GP clinic Flashcards
(35 cards)
what exams and Ix
- Urine dip
- Abdo exam
- Pregnancy test
- Basic set of obs
ddx?
- HR borderline high
- BO normal
- Apyrexic, rr and sats normal
- High HR because struggling to lie still
Renal colic – loin to groin pain, in waves – as move into ureter = colicky type pain. N and V because so painful (can also be caused by infection) Blood in urine
UTI/pyelonephritis – no evidence of infection in urine or fever = less likely. Pain more constant
Ectopic pregnancy – want negative test
Biliary colic – would be more on R
Mx of renal colic
are there complications – complete urinary tract obstruction, infection, unable to keep fluids in – vomit = shock/dehydrate = a and e, eg fever or infection in urine
Risk of AKI because one kidney obstructed – normally other can compensate. If CKD, bilateral stones or one kidney – risk of AKI = A and E
no sign of infection, obs normal, no PMH – still need urgent ix - CT KUB in 24hr – ambulatory care
Analgesia – paracetamol and an anti-inflammatory
safety netting for renal colic
Complications = a and e
- fever
- If not passing urine/intermittent urine flow
- If persistently vomit, or cant tolerate oral fluids
qns in Hx
Other urinary sx – dysuria, anything suggest UTI but leukocytes and nitrites -ve
Freq dribbling, LUTs
Systemic – FLAWS
Is it renal colic – loin to groin pain
Urethral discharge
Any medications
FH
Social hx – RF for urological malignancy – smoke, and have they been in contact with aromatic amines – dyes, rubbers and textiles
ddx
- Bladder cancer
- Cancer in urinary tract – renal/prostate
- BPH
- Prostatitis
- Urinary tract infection
- Pyelonephritis but no sign of infection
- Transient – if exercised/sexual intercourse cause haematuria
- If female and on period might be transient cause of blood in sample
next steps
Repeat dipstick – see if persistent or transient cause –
need to be 2 out of 3 samples taken a couple of weeks apart
causes of macroscopic haematuria
malignancy - prostate, bladder or kidney
stones
infection
trauma
renal disease
BPGH
transient - vigorous exercise, menstrual blood
Ix for haematuria
depend on pt demographic, Hx and Ex
repeat dip
check BP
urine MCS
urine ACR
blood - eGFR
specialist - cystoscopy, imaging, biopsy
bp, ACR and eGFR are for glomerulonephritis
when would you consider 2ww for haematuria
age >/=45 with unexplained visible haematuria
age >/=60 with unexplained non-visible haematuria and raised WCC or dysuria
If had really high index of suspicion of malignancy – could still make a 2ww based on suspicion
what would you do now
- Examine throat
- Obs
- Check for cervical LN
- Listen to chest – because URTI
- Wouldn’t go straight to swab – might do further down line if struggling with mx
ddx
- Tonsilitis – more common
- Bacterial or viral
- Majority are viral
- Glandular fever
just tachy because of temp
Mx
Centor criteria or FeverPain score
Centor:
- age 3-14 = +1, 15-44 = 0, >=45 = -1
- exudate or swelling in tonsils = 1
- tender/swollen anterior cervical LN = 1
- temp >38 = 1
- no cough = 1
3 or 4 = AB - penicillin V or erythromycin for 7-10days
0-2 = likely viral - watch and wait/delayed prescription
after amoxicillin for sore throat:
what has happened
Glandular fever – caused by EBV – if give amoxicillin to pt with EBV – cross reactivity between Ab on EBV and AB = rash
Only happens with amoxicillin not other penicillins
Could be drug allergy but had amoxicillin before
signs of glandular fever
enlarged spleen
axillary lymphadenopathy
ix for glandular fever
- Monospot test same as heterophile Ab test
- In some cases might do serology
- Wouldn’t do swab unless monospot -ve and think you need other AB
- FBC – haemolytic anaemia, thrombocytopenia, reactive lymphocytosis
advice for glandular fever
Avoid close contact with people
Avoid contact sport for 8weeks because risk of splenic ruture
Make sure well hydrated analgesia
Sx can linger for weeks to months
ddx
- Gallstone – biliary colic, cholecystitis
- Pancreatitis
- Gord
- Peptic ulcer
- Lower lobe pneumonia
- Liver – hepatitis
Most likely is biliary colic – worse after eating, last 1hr, sick and vomiting
what Ix would you do
- Not tender and no mass in RUQ*
- If think gallstone is it biliary colic or is it cholecystitis – when stuck in tree = inflammation: constant pain, tachy, tender, temp*
- LFT
- US
- Lipid profile – if cholesterol stones
- Not XR – cant see biliary stones
- Amylase and lipase
mx of biliary colic
- Diet advice – avoid fatty foods
- Safety net
- Analgesia
- Refer to upper GI surgeons
Risk could get stuck somewhere = refer for laparoscopic cholecystectomy
asymptomatic and tree normal – don’t need referral
asymptomatic but stones in tree – need referral because high risk of complication
Acute cholecystitis/cholangitis need urgent referral
ddx
- PVD
- Intermittent claudication – vasculopathy, and relived by rest
- Chronic limb ischemia
- Diabetic neuropathy
- SE of statin – myopathy – typically wouldn’t just be in leg when walked – ask how long ago started statin
- Spinal stenosis – narrow of spinal canal mimic claudication sx – typically other neuro sx – better when bend over, sit, in foetal position – stretch the spinal canal and release pressure
- MSK
Ex
- Peripheral vascular exam
- Pulse
- Temp
- Beurgeur’s test
- Loss of hair
- Check skin for ulcers – arterial and venous
- Temp
- Muscle atrophy
- Skin change
- Cap refill in both legs
- Look for signs of acute limb ischemia
- CVS exam because of CV risk
signs of peripheral arterial disease
- Weak pulse, legs can look normal
- Think skin, tissue loss near heal and around toes, hair loss
- Beugeur’s test – arterial insufficiency – when elevate leg goes pale, when hang over bed it is more red
Mx
- ABPI – ankle brachial pressure index – make dx and determine mx based on this
- Overall cardio risk
- Smoking cessation
- Exercise
- Supervised exercise program
- Safety net for acute ischemic sx
- Make sure on med needs to be on for PVD – statin (maybe higher dose), antiplt
