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Amir SAM > Interactive Cases in General Internal Medicine 3 > Flashcards

Interactive Cases in General Internal Medicine 3 Flashcards

1
Q

In an abdo examination what do you look for on the hands in liver failure?

A

Asterixis (liver flap)

Bruising

Clubbing

Dupuytren’s contracture

Erythema (palmar)

Leuconychia

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2
Q

In an abdo examination what do you look for on the forearms?

A

AV fistulae

Current or previous renal replacement therapy

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3
Q

In an abdominal examination when you look at the head and neck what are you looking out for?

A

Anaemia

Jaundice

Skin: jaundice, excoriation marks or spider naevi?

Oral examination:

– Pigmentation

– Gum hypertrophy (? On ciclosporine after renal transplant)

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4
Q

in an abdominal examination what do you notice on the inspection of the chest?

A

Gynaecomastia

Hair loss

Excoriation marks

Spider naevi

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5
Q

in an abdominal examination what do you notice on the inspection of the abdomen?

A
  • Abdominal distension?
  • Caput Medusae?
    • distended superficial abdominal veins
    • direction of flow in the veins below the umbilicus is towards the legs.
  • Scars?
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6
Q

What are the names of all these scars?

From what procedure do you get this scar

A
  1. Right subcostal (Kocher’s) incision (biliary surgery)
  2. Mercedes-Benz incision (liver transplant)
  3. Midline laparotomy incision (GI or any major abdominal surgery)
  4. McBurney’s (Gridiron) incision (appendicectomy)
  5. J-shaped/ ‘hockey stick’ incision (renal transplant)
  6. Low transverse (Pfannenstiel) incision (gynaecological procedures)
  7. Inguinal incision (hernia repair, vascular access)
  8. Loin incision (nephrectomy)
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7
Q

What could cause hepatomegaly?

A
  • Cancer (primary or secondary deposits)
  • Cirrhosis (early, usually alcoholic)
  • Cardiac:
    • Congestive cardiac failure
    • Constrictive pericarditis
  • Infiltration
    • Fatty infiltration, haemochromatosis, amyloidosis, sarcoidosis, lymphoproliferative diseases
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8
Q

when do you get asterixis?

A

hepatic encephalopathy

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9
Q

What is the caput medusa a sign of

A

portal hypertension

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10
Q

What are causes of splenomegaly?

A

H (portal Hypertension)

H (Haematological)

Infection

Inflammation

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11
Q

what are causes of liver disease?

A

Alcohol

Autoimmune

Drugs

Viral

Biliary disease

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12
Q

75 year old man • Epigastric pain • Back pain • PR: 130 bpm • BP: 80/50 mm Hg

What is this?

A. Peptic ulcer

B. Pancreatitis

C. Gastritis

D. GORD

E. Ruptured aortic aneurysm

A

E. Ruptured aortic aneurysm

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13
Q

What type of pain would you have in an inflammed bowel

A

Constant

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14
Q

What type of pain would you have in an obstruction?

A

Colicky

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15
Q

How do you classify adominal pain?

A

Nature: constant, colicky

Location: Epigastic, RUQ, RIF, suprapubic, LIF, general

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16
Q

What are the causes for epigastric pain? What would you ask for to narrow down to this condition?

AND THEN CONSIDER a bit below, above and to the right

A

Stomach:

  • Peptic ulcer (?NSAID use)
  • GORD (better with antacids)
  • Gastritis (retrosternal, ETOH)
  • Malignancy

Pancreas:

  • Acute Pancreatitis -(?Gallstones, high amylase)

AND THEN CONSIDER a bit below, above and to the right

Above (heart) – MI

Below (Aorta) – ruptured aortic aneurysm

Right: (liver/gall bladder) – Cholecystitis – Hepatitis

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17
Q

What are abdominal conditions where you would refer to a medical team?

A
  • hypercalcaemia
  • Addisonian crisis (ask to take of the bra - darker under the bra)
  • DKA- vomitting and abodminal pain
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18
Q

What are feature of acute pancreatitis?

What are investigation results you might see

A
  • Pain
  • High amylase
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19
Q

What are feature of chronic pancreatitis?

What are investigation results you might see?

A

Pain, wt loss

Loss of exocrine function

Loss of endocrine function

Normal amylase

Faecal elastase

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20
Q

What are causes of RUQ pain?

And think a bit above, to the side and below

A

Gall bladder:

  • Cholecystitis
  • Cholangitis
  • Gallstones

Liver:

  • Hepatitis
  • Abscess

And think a bit above, to the side and below

  • Above (lungs)
    • Basal pneumonia
  • Below (appendix)
    • Appendicitis
  • Left (Stomach, pancreas)
    • Peptic ulcer, Pancreatitis
  • Right: (kidney)
    • pyelonephritis
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21
Q
A
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22
Q

What are causes for RIF pain?

and think a bit above, below and to the side

A
  • GI
    • Appendicitis
    • Mesenteric adenitis
    • Colitis (IBD)
    • Malignancy
  • Gynaecological
    • Ovarian cyst rupture, twist, bleed
    • Ectopic pregnancy
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23
Q

What are causes for suprapubic pain?

and think a bit above, below and to the side

A

Cystitis

Urinary retention

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24
Q

What are causes of LIF pain?

A
  • GI
    • Diverticulitis
    • Colitis (IBD)
    • Malignancy
  • Gynaecological
    • Ovarian cyst rupture, twist, bleed
    • Ectopic pregnancy
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25
Q

When does an ovarian cyst become painful?

A

if it is ruptured

torsion

haemorrhage

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26
Q

Woman comes in with abdominal pain asked to take off her bra.Why?

A

addison’s hyperpigmentation

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27
Q

What are causes of generalised abdominal pain?

A
  • Obstruction
  • Infection: Peritonitis, Gastroenteritis
  • Inflammation: IBD
  • Ischaemia: Mesenteric ischaemia
  • Medical causes
    • DKA
    • Addison’s
    • Hypercalacemia
    • Porphyria
    • Lead poisoning
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28
Q

Mesenteric ischaemia:

IF the celiac artery is obstructed which organ might be affected

A

stomach

spleen

liver

Gallbladder

duodenum

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29
Q

ischaemic mesentric artery:

IF the superior mesenteric artery is obstructed which organ might be affected

A

small intestine

Right colon

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30
Q

Mesenteric ischaemia:

IF the inferior mesenteric artery is obstructed which organ might be affected

A

left colon

rectum

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31
Q

History and EXAM

65 year old man • AAA repair 2 days ago • Diffuse abdominal pain • PR: 120 bpm • RR: 30

What are his blood tests likely to show?

A. Normal lactate

B. High amylase

C. High Bicarbonate

D. High sodium

E. High Calcium

A
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32
Q

55 year old man • Excess ETOH use • Cirrhosis • Confused • Abdominal pain • Abdominal distension • O/E: Ascites, liver flap

Which of the following is consistent with Spontaneus bacterial peritonitis?

A. Ascites neut ≥ 25 cells/mm3

B. Ascites neut ≥ 50 cells/mm3

C. Ascites neut ≥ 100 cells/mm3

D. Ascites neut ≥ 250 cells/mm3

E. Ascites neut ≥ 500 cells/mm3

A

D. Ascites neut ≥ 250 cells/mm3

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33
Q

What are causes of abdominal distension?

A

5 F

Fluid

Flatus

Fat

Faeces

Fetus

34
Q

What are clues that would point you towards ascites ?

A

FLUID

  • Shifting dullness
  • features of liver disease
    • Asterixis
      • Bruising
      • Clubbing
      • Dupytren
      • Erythema
      • Leukonychia
35
Q

What features would point you towards obstruction?

A

Obstruction

  • Nausea, vomiting
  • Not opened bowel
  • High-pitched tinkling BS
  • ?Previous surgery (adhesions)
  • ?Tender irreducible femoral hernia in the groin
36
Q

how do you classify ascites?

What are the causes?

A

Transudate

  • Cirrhosis
  • Cardiac failure
  • Nephrotic syndrome

Exudate

  • Malignancy (abdominal, pelvic, peritoneal mesothelioma)
  • Infection: e.g. TB, pyogenic
  • Budd–Chiari syndrome (hepatic vein thrombosis), portal vein thrombosis
37
Q

50 year old man • Jaundice • RUQ pain • Dark urine • Pale stool

What is the cause of his pale stool?

A. Low biliverdin

B. High unconjugated bilirubin

C. High conjugated bilirubin

D. Low urobilinogen

E. Low stercobilinogen

A

E. Low stercobilinogen

38
Q

how do you classify jaundice?

What are the cuases of jaundice within those classicifications?

A

Pre-hepatic

  • Haemolysis, defective conjugation

Hepatic

  • Hepatitis

Post hepatic

  • CBD Obstruction
39
Q

Describe the metabolism of billirubin and what can go wrong in pre hepatic janudice?

A

RBC are lysed - unconjugated bilirubin - becomes conjugated in liver by Glucuronyltransferase.

Haemolytic anaemia - increased unconjugated billirubin enzyme saturated

Gilbert’s syndrome- decreased amount of Glucuronyltransferase

40
Q

Describe the metabolism of billirubin and what can go wrong in hepatic janudice?

A

Hepatitis

  • Alcohol
  • Autoimmune
  • Drugs
  • Viruses

Hepatocytes are damaged and therefore have difficulty conjugating the billirubin

41
Q

Describe the metabolism of billirubin and what can go wrong in post hepatic jaundice?

A
  • Gallstones in CBD
  • Stricture
  • Ca of head of pancreas

Dark urine and pale stools

42
Q

Why do you get pale stools in post hepatic jaundice

A

low stercobillinogen

43
Q

50 year old man • Painless Jaundice • Wt loss • Dark urine • Pale stool • O/E

His blood tests are most likely to show elevated:

A. ALP, CA19-9

B. AST, CA 125

C. ALP, alfa-fetoprotein

D. ALT, alfa-fetoprotein

E. ALP, CEA

A

A. ALP, CA19-9

44
Q

Why do you get blood diarrhaea (desentry)?

A

(loss of epithelial integrity

45
Q

What are differentials for bloody diarrhoea?

A

Infective colitis

Inflammatory colitis

Ischaemic colitis

Diverticulitis, Malignancy

46
Q

What feature in the history would point you towards an inflammatory colitis?

A

young person

extra- GI manifestation: ask about joint problems, eye problems

47
Q

What is you typical patient with ischaemic colitis?

A

elderly

previous cardiovascular incidents

48
Q

What are the organisms that cause infective collitis?

A

CHESS organisms

Campylobacter

Haemorrhagic E coli

Entamoeba histolytica

Salmonella

Shigella

49
Q

What does this abdominal X ray show?

A

thumb printing - inflammation- thickening of bowel wall

50
Q

What does this abdominal x ray show?

A

UC

51
Q

What does this abdominal x ray show?

A
52
Q

This patient presented with diarrhoea

What does this abdominal X ray show?

A

Overflow (spurious) diarrhoea due to faecal loading

53
Q

What is the management of a patient with acute GI bleeding?

A
  1. ABC
  2. IV access
  3. Fluids
  4. G&S, X-match blood
  5. OGD
54
Q

How do you treat a variceal bleed?

A

Variceal bleed

Antibiotics

Terlipressin

55
Q

How do you manage an acute abdomen?

A
  1. NMB
  2. Fluids
  3. Analgesic
  4. Anti-emetics
  5. Antibiotics
  6. Monitor vitals & UO
56
Q

What are investigations you would like to do in an acute abdomen?

A
  • FBC, U&Es, LFTs, CRP, Clotting, G&S, X-match
  • Erect CXR
  • CT
57
Q

Someone presents with jaundice what investigations would you like to do?

A
  • Bloods: FBC, LFTs, CRP
  • Abdominal USS
    • after a fast (gallstones better visualized in a distended, bilefilled gallbladder)
58
Q

Someone presents with dysphagia and weight loss

what investigations would you like to do?

A

OGD & Biopsy

59
Q

Someone presents with PR bleed and weight loss

What investigation would you like to do?

A

Colonoscopy

60
Q

How do you treat a patient with Ascites?

A

Conservative: dietary sodium restrictions, fluid restrict (only in patients with hyponatraemia), monitor weight

Medical: Diuretics (spironolactone +/- furosemide)

Surgical: Therapeutic paracentesis (with IV human albumin)

61
Q

What does the Serum Albumin - Ascites albumin tell you about the cause of ascites?

A

>11g/L: – Cirrhosis, Cardiac failure

<11 g/L: – TB, Cancer, (Nephrotic syndrome)

62
Q

How do you treat hepatic Encephalopathy?

A

Lactulose

Phosphate enemas

(because increase the GI motility so less time things (e.g. toxin) toxin can be absorbed - and doesn’t overwhelm cirrhotic liver) - NOT ON SLIDES

Avoid sedation

Treat infections

Exclude a GI bleed

63
Q

Someone is coming out of surgery and they have

  • Erythematosus
  • Discharge

What is the complication?

A

wound infection

64
Q

Someone is coming out of bowel surgery and they have

  • Diffuse abdo tenderness
  • Guarding, rigidity
  • Hypotensive/tachycardic

What does this indicate?

A

Anastomotic leak

65
Q

Someone is coming out of bowel surgery and they have

• Pain, fever, sweats, mucus diarrhoea

What is this indicative?

A

Pelvic abscess

e.g. post-appendectomy

66
Q

What are feature to be expected in a post patient with a wound infections

A

Erythematosus • Discharge

67
Q

What are feature to be expected in a post patient with a anastomotic leak?

A
  • Diffuse abdo tenderness
  • Guarding, rigidity
  • Hypotensive/tachycardic
68
Q

What are feature to be expected in a post patient with a pelvic abscess?

A

Pain, fever, sweats, mucus diarrhoea

69
Q

What are post op complication that can happen in bowel surgery?

A

wound infection

anastomotic leak

pelvic abscess

70
Q

What are presentation and treatment of perianal abcesses?

A

Presentation: Tender, red swelling

Treatment: Incision & drainage

71
Q

What are presenting feature and treatment of anal fissures

A

Presentation:

  • Rectal pain (defaecation)
  • Stool coated with blood

Treatment:

Conservative: Advice re diet (fluids, fibre)

Medical: GTN cream, botox injections into the sphincter

Surgical: cutting some of the anal sphincter muscles

72
Q

What is the pathology?

What is the treatment?

A

Perianal abscess

Incision & drainage

73
Q

What is this pathology?

what is the treatment?

A

ANAL Fissures

Treatment:

Conservative: Advice re diet (fluids, fibre)

Medical: GTN cream, botox injections into the sphincter

Surgical: cutting some of the anal sphincter muscles

74
Q

How do IBS present?

What feature are not usually presentß

What do you need to exclude?

What is the treatment?

A

How do IBS present?

  • Recurrent abdo pain, bloating
  • Improves with defecation
  • Change in the frequency/form of stool

What feature are not usually present?

  • No PR bleed, anaemia, wt loss or nocturnal symptoms,

What do you need to exclude?

exclude Coeliac

What is the treatment?

Conservative: Diet & Lifestyle modification

Medical: Symptomatic treatment:

  • Abdo pain: antispasmodics
  • Laxatives for constipation
  • Anti-diarrhoeals
75
Q

What liver enzymes go up in an obstructive picture?

A

ALP, GGT

76
Q

What enzymes go up in a hepatitic picture

A

AST, ALT

77
Q

If someone has diarrhea, what do you always do ?

A

send off a stool sample for C diff for MCSU

78
Q

In what condition do you get a rasied ca 125?

A

gynecological cancers

79
Q

what blood test would be abnormal in an ischaemic bowel?

A

lactate and CK

80
Q

if someone has deranged LFT’s what investigation do you request?

A

abdominal ultrasound

81
Q

How do you differentiate between IBS and IBD in the history?

A

IBS will not wake up at night to go to the toilet

Amir SAM (7 decks)

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