Basics in Presentations for clerking and Mx plan Flashcards
(49 cards)
1
Q
What should be asked about a patients background with joint pain?
A
- age and sex
* e.g men > women with gout, & women with RA
* younger sexual causes of septic arthritis - Immunodeficiency
- IVDU - increase risk of septic arthritis
2
Q
Differentials for joint pain
A
Acute - SA, trauma, gout, pseudogout
Chronic - RA, Osteoarthritis, PA
RA - symmetrical
PG - knee
OA - likely knee + hand
PA - asymmetrical oligoarthritis, distal phlangeal, arthritis mutilans, psoriatic spondylitis
3
Q
What does a SOCRATES of joint pain tell you?
A
S - small joint vs large joint
O - acute vs chronic causes
C - stiff - OA, RA,PA, - Intense - G, PG, SA
R - confined
A - fever (SA), psoriasis, fatigue (RA)
T - mane (ra), activity (oa), persistent think acute
E - ra not worse on movement
S - Acute more severe
4
Q
Red flags of SA
A
Fever, systemically unwell, acute, prothetic joint
* red hot swollen, increasing tender with limited range of movement
5
Q
Obs to monitor in Joint pain
A
Temp, sepsis signs
6
Q
Examination things to look for in joint exams
A
- surgical scars
- limited range of movement
- red hot swollen
- heberdens (distal) and bouchard (proximal) nodes
- swan neck & boutonniere (flexed proximal, hyperextended distal - can see in ehlers danlos)
7
Q
SA mx and ix
A
- Infection of joint space that can cause rapid joint destruction
- Joint aspirate to microscopy needle -ve and rhomboid +ve for the gouts
- FBC & CRP & BCs before treatment
- XR - for trauma
- ABs - cluster in cocci = s.aureus
8
Q
SA antibiotics
A
2 week IV abs
4 week oral abs
ortho for arthrocentesis if prosthetic joint
9
Q
What should be asked about a patients background with cough?
A
- Older - cancer, copd, ild
- young - postnasal drip, asthma
- drugs - acei, methotrexate
- smoking
- occupation - ild, eaa, pneumoconiosis
10
Q
Causes of cough
A
- u airway - post nasal drip (mucus from nasal mucosa drips along nasopharynx into larynx)
- l airway - pneumonia, copd, asthma, lung cancer (red flags), bronchiectasis (recurrent chest infections with blood)
- parenchyma - ild (occupation), pulmonary oedema (hf)
- drugs
11
Q
Red flags with cough
A
- haemoptysis
- weight loss
12
Q
Assessment of cough
A
- observe for tachypnoeic and saturations - acute
- in chronic cases - sats may need to be scale 2
- fever
13
Q
Examination of cough
A
- lung cancer - cachetic, monophonic wheeze
- polyphonic wheeze for a, copd, bronchiectasis - multiple sounds at once
- ild - fine inspiratory crackles
- clubbing - cancer, bronchiectasis, ild
- pneumonia - coarse crackles, bronchial breathing sounds
14
Q
Ix Lung cancer
A
- FBC - haemoptysis
- CXR
- CT scan
- biopsy, bronchoscopy, image guided techniques
15
Q
Mx Lung cancer
A
- chemo + radio + lobectomy
16
Q
What should be asked about a patients background with diarrhoea?
A
- young - IBD / Coeliac
- chronic change in elderly - cancer
- lifestyle - takeaways
17
Q
Differentials for diarrhoea
A
- acute- food poisoning, gastroenteritis, infectious colitis
- talk about close contacts / travel
- IBS = younger - flucuating with constipation / bloating
- hyperthyroidism - increase MR increase motility - anxiety, sweting, tremor, heat intolerance, diarrhoea
- colorectal - ida
- fp - after food
- gastroenteritis - close contact
- infectious colitis - watery in elderly completed course of ABs, e.g. clindamycin, ciprofloxacin, co-amoxiclav and cephalosporins
- IBD - RIF pain, UC - rectal bleeding
- coeliac - wont flush away (steatorrhoea and weight loss), rash on exxtensors (dermatitis herptiformis), fhx
18
Q
Red flags diarrhoea
A
- PR Bleeding if chronic
- acute - ischaemic colitis, ibd, infection
- IBD increases around 50-60 as well
19
Q
How to assess diarrhoea
A
- assess for dehydration - tachycardia, hypotension
- fever
20
Q
Examination for diarrhoea
A
- gloves and gowns
- generalised discomfort might be ibd
- tumour may be palpable
21
Q
Mx of gastroenteritis
A
- inflammation of stomach and small bwoel due to viral infection
- ischaemic colitis is the colon
- Ix - stool culture and pcr, u&e - check pre renal AKI
- resolve, fluids, if bacterial e.g. campylobacter consider antibiotics such as clarithomycin (macrolide)
22
Q
How do macrolide act
A
- binding to the 50S ribosomal subunit of bacteria, which stops bacterial protein synthesis
23
Q
What should be asked about a patients background with iliac fossa pain?
A
- sex - e.g. female reproduction
- ask about trans if needed
- ask about heavy bleeding / fibroid history
- previous surgical history
24
Q
Differentials for iliac fossa pain
A
- appendicitis, inguinal hernia, ibd, bowel obstruction, intestinal ischaemia
- ectopic, ovarian cyst, PID
- urinary tract calculi, uti
25
SOCRATES for IF pain
* S - right (appendicitis), left (diver), either (everything else
* O - sudden = torsion, calculi, ischaemia, cyst, incarcerated hernia - gradual = appen, ibd, diver, obstruction, pid, ectopic, uti
* C - intense - torsion, calculi, dull - appen, ibd, diver, ectopic, uti, bowel obstruction, ischaemia
* R - loin - calculi, umbili to right - appen
* A - discharge / irregular bleeding- PID, ectopic preg, dysuria - uti, calculi - diarrhoea / pr bleeding - IBD, diver, intestinal ischaemia
* Timing - wax and wane - calculi, perisistent = everything else
* E - sex - PID, eating - intestinal ischaemia
* S - Calculi and torsion = worst pain
| A - vomiting + fever
## Footnote
inguinal hernia - not reduce, vomit, not able to pass faeces or flatus
ischaemia - acute = sudden with hypotension, previous abdo surgery
- chronic - after eating due to gut claudication
- colitis = left sided with bleeding
- urine smell for uti / sti
26
Red flags for IF pain
* absolute constipation with pain and vomiting - SBO
* fever
* sudden onset of pain
* rectal bleeding / vaginal bleeding
27
Assessment and examination of IF pain
* looking for fever, tachycardia, tachypnoea
* surgical scars, distended abdomen with no bowel sounds
* guarding (voluntary contraction of muscles) / rebound tenderness (stab of pain when abdomen pushed slowly down then released suddenly) - peritonism
28
Torsion ovarian Mx and Ix
* ovary rotates among vascular pedicle
* urinalysis and pregnancy test
* speculum examination
* serum hCG
* clotting screen
* G&S
* transvaginal ultrasound scan - whirlpool sign
* iv fluids, detortion, salpingo-oophorectomy
29
What should be asked about a patients background with dysuria?
* gender - women = uti, older men - bigger prostate, youth - sti
30
Differentials of dysuria
* Lower UTI - cystitis, sti, genitourinary syndrom (atrophic vaginitis), BPH, prostatitis
* Upper - calculi, pyelonephritis
* older - urinary retention - could be caused by BPH or constipation
* urine usually smells, look for discharge, dryness of vagina / dyspareunia
* BPH - voiding symtpoms - hesitancy, incomplete emptying, poor stream, straining + storage (frequency, urgency, nocturia, dysuria)
* pain on defecation - prostatitis
* fevers
31
Red flags of dysuria
* frank haematuria and weight loss usually painless
* rigor and fever + organ hypoperfusion lead to sepsis and AKI
32
assessment and examination of dysuria
* look out for fever, hypotension, tachycardia
* lower abdo discomfort, renal angle tenderness where kidney and 12th rib meet
* enlarge bladder
* dry and inflammed genitals
33
Mx of Genitourinary syndrome
* low oestorgen levels leading to thin and fragile vaginal mucosa leading to dyspareunia, post menopausal bleeding and dysuria
* urinalysis - leucocytes and nitrites
* post void bladder scan
* FBC for any bleeding
* ultrasound with any postmenopausal bleeding
* mx - lubricants, moisturisers, topical and systemic oestrogens
34
What should be asked about a patients background with right upper quadrant pain?
* age and sex - gallstone overweight, obese, over 40
* alcohol - hepatitis, increased risk of pancreatitis
* NSAID - ulcers
35
Differentials of RUQ pain
* hepatic - viral, autoimmune and hepatic hepatitis - subacute ruq pain - screen endemic, sex, ivdu
* bilary - gallstones, intermittent pain worse after fatty meal, presence = cholecystitis - blocks flow of common bile duct = ruq, jaundice and fever - charcots triad
* pancreatitis - gallstone can cause that + alcohol
* pneumonia, PE if also resp disease signs tachypnoea and cough
* righ kidney - colic and pyelonephritis
36
SOCRATES of RUQ pain
* S - if flanks = calculi
* O - rapid - calculi, subacute - hepatitis, gallstone, pud, pancreatitis, lower lobe pneumonia, pyelonephritis
* C - dull pain, pleuritic pain
* R - shoulder - hepatitis, cholecystitis, acute cholangitis, back - pancreatitis, groin - calculi
* A - bowel - gallstone (steatorrhoea), PUD (melaena), jaundice (hepatitis and gallstone), sob pneumonia, dysuria calclui and pyelonephritis
* T - persistent - hep, chole, cholangitis, lower lobe pneumonia, pyelonephritis, wax and wan - uti, bilary colic, intermittent -PUD
* E - after meals - colic, PUD - gastric worse after eating
* S - colic and pancreatitis
37
Red flags of RUQ pain
* acute cholangitis - sepsis
* radiates to back - pancreatitis
* tachypnoeic - sepsis
* haematemesis and melaena - perforated peptic ulcer
38
Assessment an examination of RUQ pain
* fever, tachycardia, hypotension
* hypoxia
* murphys sign - pain on deep inspiration
* visibly icteric (jaundice)
* rigid, tender abdomen - perforated ulcer
* renal angle tenderness
* haemorrhagic pancreatitis - grey and cullens signs
* basal crepitations
39
Mx and Ix of acute cholangitis
* biliary system infection not just gallbladder
* usually due to obstructing gall stone
* urinalysis - negative urobilinogen, bile not flowing to intestines
* vbg - lactic acidosis and bilirubin = severe infection
* fbc and crp and lft
* alp and ggt raised. = obstructive pattern
* blood cultures
* clotting screen and g&s
* amylase for pancreatitis
* abdo ultrasound = dilated bile duct
* ctap
* mrcp - mri that visualises bilary tree and ercp - is scope in - dye into tree and remove obstructing stone
sepsis 6 is needed - ercp, percutaneous bilary drainage or cholecystostomy
40
What should be asked about a patients background with confusion?
* age - old - infections
* young - drugs
* cognitive baseline / impairment
* frailty score
* alcohol excess, wernickes encephalopathy and subdural
41
Differentials for confusion
* older - delirium - acute confusional state caused by an acute health problem
* dementia
* subdural in elderly
* intoxication, CNS inflammation - seizures and reduced CNS
* brain tumours
* metabolic disturbances - hypoglycaemia, hyponatraemia, hypercalcaemia
*
42
Red flags with confusion
* altered gcs
* seizures
* focal neurology
* loss of consciousness - airway
* fever - sepsis - intracranial
* head injury
43
Assessment and examination of confusion
fever - intracranial infection
* cushings triad - bradycardia, hypertension, irregular bleeding - increase intracranial pressure
* lateralising neurology e.g. unequal pupils, highly suggestive of intracranial
* brudzinskis and kernig signs
* brud - hips and knees flex involuntarily after their neck is passively flexed.
* kernig - experiences pain or is unable to extend their knee past 135 degrees when their hip is flexed to 90 degrees.
44
Mx and Ix Encephalitis
* inflammation of brain parenchyma due to infection or autoimmune attack
* confusion, seizures, drowsiness
* HSV
* GCS, 4AT
* VBG
* FBC & CRP
* Blood cultures
* Ct head
* Mri head
* lumbar puncture
* EEG
* iv aciclovir
* strep pneumoniae, neisseria and listeria can be treated with ceftriaxone
* autoimmune encephalitis - steroids, ivig, plasmapheresis, immunomodulating drugs
* seizures - anticonvulsants
45
What should be asked about a patients background with N&V?
* previous surgery - bowel obstruction
* changes to medications
* recreational drug use e.g. cannabis
46
Differentials for N&V
GI - abdo pain / change in bowel habits - gastroenteritis, ibd etc - bo - absolute bowel obstruction
CNS - headache - tumour, migraine, infection
ENT - hearing changes, vertiginous symptoms - posterior stroke - HINTS
Metabolic - DKA - hyperosmolar hyperglycaemic state
Adrenal insufficiency - fatigue
postural hypotension / skin pigmentation
with hyperkalaemia and hyponatraemia
47
Red flags for vomiting
* absolute constipation
* abdominal distension
* previous abdominal surgery
* headache, drowsiness, confusion, seizures
48
Assessment and Ix of Vomiting
* dehydrated - tachycardic, hypotensive
* fever - infection
* check aspiration sigsn - tachypnoea, desaturation
* abdominal tenderness
* distension with vomiting = BO
* absent bowel sounds
* reduced GCS
* nystagmus
49
Mx and Ix of BO
* disrpution of normal passage through bowels due to mechanical obstruction
* DRE - confirm rectum is empty
* VBG - lactic acidosis
* e.g. tissue hypoxia in bowel obstruction
* U&E, bone profile and magnesium
* axr - CT abdomen and pelvis with contrast e.g. tumour
* Drip and suck with a ryles tube, decompress system
* + iV fluids
* gastrograffin follow through
* emergency laparotomy
* adhesiolysis
* hernia repair if needed
* flatus for large bowel
