Flashcards in Day 2 Deck (74):
Weight loss, change in appetite, fever/night sweats, fatigue, pain
Chest pain, palpitations, orthopnoea, peripheral oedema, claudication
Breathlessness, wheeze, cough, hoarseness, haemoptysis
Chest pain kay details of the history?
SOCRATES (chest pain, palpitations, orthopnia, peripheral odema, claudication, breathlessness, wheeze, cough, hoarseness, haemoptysis, fever, sweats, fatigue, pain elsewhere)
ICE and summary
PMH: Cardiac, GORD
DH and allergies
SE: Urinary symptoms, bone/joint/muscle pain, headaches/confusion, rashes or skin changes
Morphine 1-10mg IV + Metoclopramide 10mg IV
Oxygen if <94%
Nitrates: Glyceryl trinitrate 1tab/3puffs every 5 mins
Aspirin 300mg PO/450mg PR
Ticagrelor 180mg PO
>120 mins thrombolysis (alteplase)
Secondary prevention of cardiac events post ACS?
Aspirin + clopidogrel
Types of MI?
II, III, aVF: inferior RCA
I, aVL, V5, V6: anterolateral circumflex
V1-V4: anterolateral LAD
STD in V1-3: posterior RCA
Details (name, dofb, date and time of ECG, calibration speed 25mm/s)
Rate: this is a regular rhythm at (300/R-R), this is an irregular rhythm at (QRSx6). Tachy or brady
Rhythm: P waves, P waves before every QRS and every QRS proceeded by P wave = sinus rhythm
Axis: I and aVF
PR: 3-5 (0.12-0.2)
QRS: <3 (<0.12)
ST: STE, STD
T wave: inversion outwith V1 and III
Cardiac enzymes and timing of rise/decreases?
Troponin 2-4hrs, 7 days
CK 4-6hrs, 72hrs
Dysphagia, reflux, N&V, change in bowel habit, blood/mucous in stool
Dysuria, frequency, urgency, nocturia, haematuria
Fits/faints/falls/funny turns, numbness/tingling, weakness, headaches, visual changes
Joint pain, muscle pain, swelling, stiffness, rashes
Dry eyes, red eyes, visual changes
Skin lesion describing?
Count the lesions
Description (macule, patch, papule, nodule, plaque, vesicle, bulla, pustule, erosion, ulcer, fissure, wheals/hives)
Diameter & definition (mm, well defined, poorly defined)
Configiration (discrete, confluent, linear, annular)
Blush (erythematous, purpuric, hyper/hypopigmented)
Additional features (scale, excoriation, lichenification, crusting)
Gynae history taking?
HPC (Pain: abdo, pelvis, during sex, will moving bowels. Bleeding: intermenstrual, post coital. Urinary symptoms. STI symptoms: discharge, skin changes or itching)
ICE and summary
Menstrual history: Age, LMP, typical cycle, menorhagia, dysmenorhia, contraception, menopause
Sexual history: LSI, consensual, demographics, type, contraception, LSI in 3 months, HIV risk
Smears and procedures
PMH: migraine, VTE, breast Ca, bleeding disorders
DH and allergies
SE: Ca: WL, change in bowel habit, bloating. Infection: fever. Anaemia: SOB/tiredness. Hypothyroid: cold/weight gain/reduced sex drive
What are fibroids?
Benign tumours in the uterus, not cancerous
What are the signs of fibroids on abdo exam?
What are the typical symptoms of symptomatic fibroids?
Heavy and long periods
Fe deficiency anaemia
Abdo pain, urinary and bowel symptoms (mass effect)
How to diagnose fibroids and other useful tests?
Abdo exam, TVUSS
FBC (Fe def anaemia), TFTs
What do fibroids look like on TVUSS?
What is the main difference between endometriosis presentation and fibroid presentation?
Endometriosis is classically painful heavy periods with fixed retroverted uterus and deep dyspareunia
How to manage fibroids?
Myomectomy, uterine artery embolisation, hyterectomy
What are the CI for COCP?
FH/PMH of breast Ca
Migraines with aura
What is seen in Fe deficient anaemia?
MCV <80 (microcytic)
SLE key questions to ask?
General: fever, weight loss, night sweats
CNS: change in thoughts, change in mood, stroke
MSK: joint pain, rashes or skin changes
Cardio and resp: SOB, chest pain, PE
GU: blood in urine, frothy urine, urinary symptoms
Skin: malar rash, photo-sensitivity, mucosal ulcers
Haem: bruising, fatigue, recurrent infections
Obstetric: problems during pregnancies, miscarriages
Ophthalmology: Dry eyes, red eye, visual changes
Investigations in SLE?
AutoAbs: ANAs, antidsDNA, antismith, antiphospholipid
Xrays of affected joints
FBC (anaemia, thrombocytopenia, leukopenia)
Prothrombin time (prolonged)
Urinalysis (If proteinuria and haematuria: urinalysis to rule out infection, microscopy to look for casts, renal biopsy for immune deposits)
Management of SLE?
Refer to rheumatology
If evidence of kidney involvement refer to nephrology Lifestyle (avoid sun, stop smoking)
Differentiating between RA and SLE joint pain?
RA is more deforming, XRAYs show erosions. ABS RF, antiCCP
Differentials of SLE?
RA, antiphospholipid syndrome, vasculitis
Differentials for haematuria?
Infection, stones, BPH, cancer, glomerulonephritis
Key questions in haematuria history?
Infection: dysuria, frequency, urgency, lumbar pain, fever/rigors
Stones: lumbar pain, colicky pain radiating to groin, N&V
BPH: hesitancy, poor flow, dribbling, incontinance
Glomerulonephritis: frothy, quantity
SE in haematuria history?
Rash, joint pain, fatigue, odema/swelling
Key features of PMH in haematuria hx?
Recent catheter, bleeding disorders, prostate problems
Key to ask in DH?
Initial investigations of haematuria?
Urinalysis (rule out infection - positive nitrites and leukocytes)
Urine microscopy (dysmorphic RBCs and casts indicated glomerular damage)
FBC, U&Es (kidney function), LFTs (albumin), GFR, lipid profile (raised in nephrotic)
If proteins are +++ what do you suspect and what are investigations?
Referal to nephrology
Investigation of choice if suspecting stones?
KUB non contract CT detects 99% of stones
What are the investigations for all macroscopic haematuria and why?
1- flexible cystoscopy
2- <50years: KUB USS
>50years: CT urogram with contrast
(look for cancer)
What is the most common type of cancer in bladder and kidneys?
Key difference between nephritic and nephrotic syndrome?
Nephritic: Proliferative damage allowing protein and RBCs to escape (Haematuria, red cell casts, protein ++, hypertension, decreased UO)
Nephrotic: Only allows protein to be filtered (protein +++, frothy urine, hypoalbuminaemia, odema, hyperlipidema
What is key difference between post strep glomerulopnephritis and igA nephropathy?
Post strep is 2-3 weeks after bacterial infection
IgA nephropathy can occur without infection or 1 or 2 days post
What is post strep glomerulonephritis and how does it present?
T3HS deposition of immune complexes in the kidneys causing local inflammation
Nephritic syndrome pattern
What are the differentials for post strep glomerulonephritis?
Vasculitidies involving kidneys (wegners, churg straus), Good pastures, IgA nephropathy, SLE
Management of glomerulonephritis?
Reduce proteinuria (ACEi)
Preserve renal function
Acute cholecystitis presentation?
Murpheys +ve, RUQ pain, fever, raised CRP, may or may not be jaundiced
What is acute cholecystitis?
Inflammation of the gall bladder most commonly due to gall stones
What are the fat soluble vitamins?
A, D, E, K
What happens to stools when bile flow is blocked?
Pale, smelly - steatorrhoea
(bile isnt available to breakdown fat so it is excreted unabsorbed)
What are the ducts in the biliary tree?
Cystic duct from gall bladder
Hepatic duct from liver joins cystic duct to form common bile duct
What is ascending cholangitis and the key symptoms?
inflammation of the bile duct usually due to stone there
Charcots triad: RUQ pain, jaundice, fever
What are the investigations in acute cholecystitis?
When does dark urin arise and what does it indicate?
CB in the blood as it is water soluble passes out in urine
Damage to hepatocytes allowing it to leak out (hepatitis, obstruction)
Investigations in query obstructive jaundice?
If not confirmed MRCP
Management of acute cholecystitis?
Management of ascending cholangitis?
IV abx, ERCP
Management of gall stones?
Assymptomatic: if in gall bladder no treatment, if in bile duct ERCP
Symptomatic (colicky biliary pain): cholecystectomy or ERCP
Presentation of pancreatic Ca?
Painless jaundice often palpable gall bladder
Investigations in suspected pancreatic Ca?
Investigations in suspected cholangioCa?
USS, MRCP or ERCP
Management of pancreatic Ca?
What are the signs of liver cirrhosis?
Portal hypertension (forces fluid out: hepatomegaly, RUQ pain, ascites, splenomegaly, portosystemic shunt causing renal vasoconstriction, osophageal varices in lower 1/3rd, caput medusae)
Decreased liver function (detox: toxins to brain causing hepatic encepalopathy - asteryxix, confusion, coma, high oestrogen causing gynaecomastia, palmar erythema and spider naevi. Decreased CFs. Decreased Albumin)
Leakage of CB into blood through damaged hepatocytes (jaundice)
Investigating liver problems?
USS of liver (hepatomegaly, fatty liver, cirrhosis, mass, ascites, portal htn)
Process of ALD?
increased fat production and deposition - steatosis, inflammation and damge to cells - alcoholic hepatitis, fibrosis and cirrhosis
LFTs in ALD?
Main marker for obstructive jaundice in LFTs?
ALP high high high
LFTs in NASH?
LFTS in acute hepatitis?
albumin normal indicating not a chronic process
Differentials for hypoechoic enlarged liver with no ductal pathology?
ALD with cirrhosis
Pancreatic Ca (CT)
Cholangio Ca (MRCP)
key feature NASH?
No history of alcohol consumption