test - Split (1) Flashcards
(257 cards)
1
Q
abdoPainDDX
A
can be by region or by organ. GASTRO: i) Gastroduodenal (PUD, gastritis, malignancy, gastric volvulus. ii) Intestinal (appendicitis, obstruction, diverticulitis, gastroentereitis, mesenteric adenitis, strangulated hernia, IBD, inutssusception, volvulus, TB) iii) Hepatobiliary (acute/chronic cholecystitis, cholangitis, hepatitis) iv) Pancreatic (acute/chronic pancreatitis, malignancy) v) Spleen (infarct, spontaneous rupture). URINARY: cystitis, acute urinary retention, acute pyelonephritis, ureteric colic, hydronephrosis, tumour, pyonephrosis, PCK. GYNAE: ruptured ectopic, torsion of ovarian cyst, ruptured ovarian cyst, salpingitis, severe dysmenorrhoea, mittelschmerz, endometriosis, red degeneration of a fibroid. VASCULAR aortic aneurysm, mesenteric embolus, mesenteric angina, mesenteric venous thrombosis, ischaemic colitis, dAA. PERITONEUM secondary peritonitis, primary (rare). ABDO WALL: strangualted hernia, rectus sheath haematoma, cellulitis. RETROPERITONEUM: retroperitoneal haemorrhage (eg anticogaulants). REFERRED PAIN: AMI, pericarditis, test torsion, pleurisy, herpes zoster, lobar pneumonia, thoracic spin disease (eg disc, tumour). MEDICAL (all rare): hypercalcaemia, uraemia, DKA, sickle cell disease, addisons, acute intermittent porphyria, Henoch-Schonlein purpura, tabes dorsalis
2
Q
acuteAngleClosureGlaucomaEx
A
hazy, semi-dilated pupil
3
Q
acuteAngleClosureGlaucomaHx
A
photophobia, visual disturbances, seeing haloes, painful red eye
4
Q
acuteAorticDissection(AAA)Epi
A
elderly males with HTN, or younger pts with CTD (Marfan or Ehlers-Danlos or fam hx)
5
Q
acuteArterialOcclusionEx
A
6Ps: pain, pallor, pulseless, paraesthesia, paralysis, perishingly cold
6
Q
acuteArterialOcclusionHx
A
sudden, pain, can’t move, feels cold
7
Q
acuteCoronarySyndrome(ACS)-STEMIEx
A
clammy, sweaty, sob, pale, alternatively: cardiac arrhytmias, heart failure, severe hypotension w cardiogenic shock, ventricular septal rupture/papillary muscle rupture, systemic embolism or pericarditis
8
Q
acuteCoronarySyndrome(ACS)-STEMIHx
A
central, heavy, burning, crushing, tight retrosternal, lasting for several minutes, not relieved by SL GTN, anxiety, SOB, N/V, pain rad to neck/jaw/arms/back occasionally epigastrium (or may present at these sites alone) ** atypical presentations in elderly, diabetics, and females
9
Q
acuteCoronarySyndrome(ACS)-STEMIIx
A
ECG: TWI or STEMI in contigious leads. Posterior infarcts = tall R and STDep in V1-4
10
Q
acuteCoronarySyndrome(ACS)-STEMIRf
A
cig, htn, age, dm, hyperchol, male, fam hx, previous angina/heart failure
11
Q
acuteKidneyInjury(AKI)DDX
A
- Prerenal (low BP, hypovol, renal artery occlusion from mass or emboli), 2. Renal (intrinsic pathology eg GN, vasculitis, drugs), 3. Post renal (outflow obstruction, ureter, bladder, urethra, due to enlarge prostate, single functioning kidney with calculi, pelvic mass/surgery)
12
Q
acuteKidneyInjury(AKI)Dx
A
acute rise in baseline urea and cr +/- oliguria
13
Q
acuteKidneyInjury(AKI)Ex
A
volume status, BP, HR, JVP, basal creps, gallop rhyth,, oedma, palpable bladder
14
Q
acuteKidneyInjury(AKI)Hx
A
previous renal problems, comorbidities, UO, fluid intake, nephrotoxic medication? (eg NSAIDS, gentamicin, IV contrast)
15
Q
acuteKidneyInjury(AKI)Ix
A
urine (colour, hourly volume, dipstick, MCS, osmolality and sodium osmolality), Bloods: FBE (hyperK), UEC, LFT, CK, CRP, osmolality, ESR, Clotting. ABG to look for acidosis, ECG, CXR, urinary tract USS
16
Q
acuteKidneyInjury(AKI)Rx
A
IDC (to monitor UO), cause dependent (ie IDC, or fluids if shocked, or frusemide and O2 if overloaded, ins/gluc, cagluc, salbutamol if hyperK associated)
17
Q
ankleInjuryHx
A
immediate swelling and inability to WB = serious and suspicious for lig tear/fracture
18
Q
ankleSprain/Dislocation/FractureScore
A
Ottawa Foot Rule: 98% sensitive: Request foot x-ray if there is PAIN in mid-foot AND one of these: 1) tender over the base of fifth metatarsal, 2) tender over navicular, 3) unable to WB (ie 4 steps) after injury AND in ED. Ottawa Ankle Rule: Request ankle AP and LAT xray if, Malleolar pain (ie bwn medial and lateral malleolus) AND on of these: 1) bone tenderness over the post edge or tip of distal 6cm of medial OR lateral malleolus, 2) inability to WB within 1st hour and in ED.
19
Q
anorectalPainDDX
A
ACUTE: fissure-in-ano, perianal haematoma, thrombosed haemorrhoids, perianal abscess, intersphincteric abscess, ischiorectal abscess, trauma, anorectal gonorrhoea, herpes. CHRONIC: fistula-in-ano, malignancy, chronic perianal sepsis (eg crohns disease, TB), proctalgia fugax, solitary rectal ulcer, cauda equina lesions
20
Q
aorticStenosis(AS)Aetiology
A
- stenosis 2ndary to rheumatic heart disease, 2. calcification of bicuspid aortic valve. 3. calcification of tricuspid aortic valve in the elderly
21
Q
aorticStenosis(AS)Complications
A
arrhytmias, Stokes-Adams attacks (sudden death), MI, LVF. Only years to live, correlates with symptom severity
22
Q
aorticStenosis(AS)Epi
A
M>F. old. bicuspid aorta leads to presentation earlier
23
Q
aorticStenosis(AS)Ex
A
narrow pulse pressure, slow-rising pulse, thrill in aortic area, forceful sustained thrusting undisplaced apex beat, harsh ESM, rad to carotids and apex, S2 softened, bicuspid valve may produce an ejection click
24
Q
aorticStenosis(AS)Hx
A
SAD (syncope/dizzy on exertion, angina, dyspnoea and other signs of heart failure)
25
aorticStenosis(AS)Ix
ECG: LVH, LBBB, CXR showing post-stenotic enlargement. ECHO. Angio
26
aorticStenosis(AS)Rx
Surgery (replacement, balloon dilation (valvoplasty), management of LVF medically, ABX prophylaxis against infective endocarditis
27
ascitesDDX
HEPATIC: cirrhosis, hepatic tumors, MALIGNANCY: carcinomatosis, abdominal/pelvic ca (primary/secondary), pseudomyxoma peritonei, primary mesothelioma. CARDIAC: card failure, constrictive pericarditis, tricuspid incompetence. RENAL: nephrotic syndrome. PERITONITIS: TB, Spont bacterial. VENOUS OBSTRCUTION: Budd-Chiari syndrome, veno-occlusive disease, hepatic portal vein obstruction, inferior vena cava obstruction. GI: pancreatitis, malabsorption, bile ascites.
28
backPainAetiology
Most pts in primary care (>85%) have nonspecific low back pain, meaning that the patient has back pain in the absence of a specific underlying condition that can be reliably identified
29
backPainDisp
HOME: Home care in simple lower back pain: Address the factors that contribute (ie bad work practices and lifting techniques, poor posture, being overweight, lack of exercise, pregnancy, stress, smoking). In the first two to three days patient should aim to minimise pain and assist healing. Ice to back wrapped in towel for 20 minutes, every one to two hours when awake. Avoid ‘HARM” – Heat, Alcohol, Re-injury and Massage for the first few days. Avoid activities you do not really need to do. Sit as little as possible until the pain settles. Avoid extended car travel unless absolutely necessary. When resting, lie in a comfortable position, supported by pillows if necessary. Keep moving as much as possible. Take painkillers when necessary. Physiotherapy as soon as possible.
30
backPainEx
scoliosis, kyphosis, bony tendereness, paraspinal tenderness, reduced range of movement (especailly flexion), pain on straight leg raise, lower limb neurology in motor, sensory, reflexes, expansile abdo mass. PR exam for decreased tone or sensation
31
backPainHx
trauma/lifiting, location of pain, duration, aggrevating/relieving factors, radiation, pain in joints, pain or tingling in legs, leg weakness, bladder retention or incontinence, faecal incontinence, altered sensation on passing stool, LOW. PMH: previous, neurological problems, osteoporosis, anaemia. DH: steroids, analgesia. FH: joint or back problems. SH: occupation involves lifting or prolonged sitting
32
backPainScore
RED FLAGS: Age of onset 55 years? First presentation? Ill health or presence of other medical illnesses? Urinary/bowel incontinence? Saddle anaesthesia? Progressive neurological deficits? Disturbed gait? Malignancy? Current or history of? Fevers/night sweats? Unexplained weight loss? History of trauma? IVDU? Immune suppresed? (ie. HIV, Steroids) Symptoms worse at night? YELLOW FLAGS (psychosocial factors shown to be indicative of long term chronicity and disability) i) Negative attitude that back pain is harmful or potentially severely disabling? ii) Fear avoidance behaviour and reduced activity levels? iii) An expectation that passive, rather than active, treatment will be beneficial iv) A tendency to depression, low morale, and social withdrawal v) Social or financial problems
33
bronchialCarcinomaHx
low, smoking,
34
bronchiectasisHx
purulent long-standing sputum production
35
brugadaSyndromeDisp
Cardio for further evaluation and risk stratification
36
brugadaSyndromeHx
Fam hx of sudden death? Fever? Anti-arrhytmic? (bc ECG pattern sometimes only seen in fever or after taking anti-arrhytmic drugs (particularly 1C - flecainide, propafenone)
37
brugadaSyndromeIx
ECG: RBBB morphology, coved ST segment elevation in V1-2 with terminal TWI.
38
budd-ChiariSyndromeIx
LFT for inc transaminases. FBE, UEC, clotting, thrombophillia screen. Doppler US for flow in hepatic vein. Hepatic venogram.
39
budd-ChiariSyndromePatho
obstruction to hepatic venous outflow (from hypercoagulable state) resulting in abdo pain, ascites, jaundice, encephalopathy, variceal bleeding and hepatosplenomegaly (due to portal hypertension)
40
cardiacTamponadeEx
tachycardia, hypotension, pulsus paradoxus, raised JVP which rises on inspiration (ie Kussmaul's sign)
41
cardiovascularHx
chest pain, palpitations, soboe, PND, orthopnoea, ankle swelling, claudication
42
caudaEquinaSyndrome(CES)Aetiology
Sun et al. SR found that cauda equina syndrome was caused by prolapse of the intervertebral disc in 22.7 percent of cases, ankylosing spondylitis in 15.9 percent, lumbar puncture in 15.9 percent, trauma in 7.6 percent, malignant tumor in 7.2 percent, benign tumor in 5.7 percent, and infection in 5.3 percent
43
cellulitisAetiology
beta-haemolytic strep, S.Aureus, MRSA, Gram-Neg aerobic bacilli (minor number of cases)
44
cellulitisEx
Clinical symptoms: Erythema, oedema, warm, Entry source: toe web intertrigo, injection sites
45
cellulitisHx
slow onset (days cf erysipelas which is more accute), swelling, warmth, +/- purulent drainage. most often on lower limbs, but may also be eyes, abdo (in morbid obese)
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cellulitisPatho
DDX is erysipelas. E involves upper dermis and superficial lymphatics, whilst C involves deeper dermis and subcut fat. Therefore in E, there is a sign (milian sign) behind the ear, as this are does not have any deeper dermis. E in young and old. C in mid-age-group
47
cellulitisRf
skin disruption, preexisting skin infection, inflammation (eg eczema / radiotheraphy), odema due to venous congestion, lymp obstruction post surgery. Most important entry is perhaps the skin bwn toes (toe web intertrigo)
48
cellulitisRx
mark the area w a pen, elevation, hydrate the area to avoid cracks, treat the underlying condition if one found (tinea pedis, lymphoedema, chronic venous insufficiency), diuretics, compressive stockings, ANTIBIOTICS: empirical eTG tba
49
chestPainDDX
Life-threats: ACS, PE, Aortic dissection, TPT. Complete list: CV (angina, AMI, acute aortic dissection, pericarditis) GI (reflux oesophagitis, PUD, oesophageal spasm, oesophageal rupture, hiatus hernia, biliary colic/cholecystitis, subdiaphragmatic irritation), Pulmonary (Pneumonia, Ptx, PE, pneumomediastinum, pleurisy), MSK (fractured ribs, chest wall injuries, herpes zoster, costocohonditis, secondary tumors to rib) Emotional (Depression) Pleuritic chest pain = Ptx, PE, pericarditis, PE, pneumonia, pleurisy, rib #, costochondritis
50
chestPainDo
IV, cardiac monitor, sats, O2>94%, FBE, UEC, LFT, Troponin, ECG, repeat in 10min if 1st ECG is non-diagnostic. CXR mainly looking for APO, cardiomegaly, atelectasis. Aspirin 150-300mg, gtn SL (0.6mg tab or 0.4mg spray)
51
chestPainEx
end-of-bed-quick-look-test, vital signs, appearance (marfanoid - predisposing to aortic dissection), HEENT: xanthelasma = hyperchol, thrush associated with oesophageal candidiasis. RESP:
52
chestPainHx
site, onset, character, radiation, association, time course, exacerbating/relieving factors, severity, pleuritic, hx of heart disease, similar to previous episodes, PMH: card/respiratory problems, DM, GORD. Drugs: cardiac/resp meds. antacids. FamHx: IHD, premature cardiac death. SHx: smoking, exercise tolerance.
53
chronicBronchitisEx
hyperexpanded chest, decrased inspiratory movement
54
chronicBronchitisHx
purulent long-standing sputum production
55
clavicle#Anatomy
Clavicle = 1st bone to ossify. The only bony connection between arm and the trunk. Articulated distally with acromion and prox with sternum by Atypical synovial joints, because (fibrocartilage not hyaline cartilage). "S" shape. The proximal half curves outward (convex) providing space for the neurovascular bundle of the upper limb. The distal half = concave. # at the junction (midshaft) between these two curves, most likely because this area i) lacks ligamentous attachments to adjacent bones and is the bone's ii) thinnest segment. Displacement = Proximal fragment superiorly (cephalad) by the pull of the SCM. Distal = inferiorly (caudad) by the weight of the arm. Shortening often occurs (because subscapularis and pectoralis muscles, which internally rotate and pull the arm towards the chest). Even though the clavicle is subcutaneous, with only a thin layer of overlying soft tissue, open fractures are uncommon. However, tenting (ie, taught stretching) of the overlying skin is relatively common. If left uncorrected, tenting may lead to necrosis of the overlying skin and conversion to an open fracture. Tenting is therefore an indication for closed reduction or surgical repair.
56
clavicle#Anticipate
scapula #, rib #, hemothorax, pneumothorax, brachial plexus injury
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clavicle#Dx
Fall on shoulder. direct violence, or FOOSH. Fractures bwn middle and outer third in adults. greenstick in kids. c/o pain. Ex: local deformity. tenderness. Look for tenting! as this is a sign of potential evolving necrosis/needing operative mx. AP X-ray shows the #
58
clavicle#Ex
crepitus, tenderness, neurovascular exam: lung exam:
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clavicle#Hx
fall on shoulder, pain, snapping, cracking, swelling
60
clavicle#Ix
AP Xray. Sometimes need a 45-degree cephalic tilt view to see midshaft clav fracture
61
clavicle#Note
69% middle 3rd, 28% distal, 3% proximal /// 87% of clav # are from fall on shoulder, 7% direct blow, 6% FOOSH.
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clavicle#Rx
SUPPORT: triangular sling, PAIN: analgesia. SWELLING: ice. OPERATIVE: if nerves/vessels compromised. F/U: Refer to next # clinic. Note: NO longer use of figure of 8 bandage as uncomfortbale and ineffective.
63
clusterHeadachesHx
retro-orbital pain
64
coffeeGroundVomitingAnticipate
melena
65
coffeeGroundVomitingDDX
upper GI bleeding
66
coffeeGroundVomitingPatho
iron exposed to gastric acid --> oxidization
67
commonFibular/PeronealNerveAnatomy
MOTOR: Innervates the short head of the biceps femoris directly. Also supplies (via branches) the muscles in the lateral and anterior compartments of the leg. SENSORY: Innervates the skin over the upper lateral and lower posterolateral leg. Also supplies (via branches) cutaneous innervation to the skin of the anterolateral leg, and the dorsum of the foot. Clinical EFFECT of damage: Foot drop, Sensory loss to the dorsal surface of the foot and portions of the anterior, lower-lateral leg. NOTE: A common yoga kneeling exercise, the Varjrasana, has been linked to a variant called yoga foot drop.
68
commonFibular/PeronealNerveRf
damaged by: fibula fracture, too tight cast
69
conn'sSyndromeHx
few sx. but HTN, may give headache and poor vision. muscle weakness, spasms, tingling sensation, xs urination. Complications with stroke, AMI, kidney fail, arrhytmia
70
conn'sSyndromePatho
too much aldosterone --> low renin.
71
conn'sSyndromeSyn
eponym for primary hyperaldosterism.
72
constipationDDX
i) Obstruction (diverticular disease, colonic carcinoma, extrinsic compression), ii) Painful anus (fissure-in-ano, perianal abscess, strangulated haemorrhoids, post-haemorrhoidectomy), Adynamic bowel (paralytic ileus, spinal cord injury), Endocrine (diabetes, autonomic neuropathy, myxoedema, hyperparathyroid), Drugs (codeine, morph, TCA, atropine, laxative abuse), Other(dietary changes, anxiety, depression, irritable bowel syndrome, generalised disease, starvation) Congential (Hirschsprungs)
73
constipationHx
what does the pt mean? abdo pain, distension, N/V, haemodynamic status, absent/tinkling bowel sounds, LOW, PR bleeding
74
costochondritisAetiology
3 I's. Idio, infection (direct or haem), inflammation (microtrauma, cough, unaccustomed upper limb movement)
75
costochondritisEpi
common. females >40y.
76
costochondritisRx
ABx not effective because cartilage has poor blood supply
77
diabeticKetoAcidosis(DKA)Hx
4 situations equal incidence. 1. precipitant (infection, stress), 2. treatment non-compliance, 3. new diagnosis, 4. no known precipitant event
78
diabeticKetoAcidosis(DKA)Patho
xs stress hormones antagonises actions of insulin, the pathogenesis requires two events: (i) increased mobilisation of FFA and, (ii) a switch of hepatic lipid metabolism to ketogenesis.
79
dvtEx
pain, tenderness, swelling, heat, oedema, Homans signs (on dorsiflexion) - to do or not do?
80
dvtRf
Malignancy, Presence of a central venous catheter, Surgery, especially orthopedic, Trauma, Pregnancy, OCP, HRT, Tamoxifen, Thalidomide, Lenalidomide, Immobilization, Congestive failure, Antiphospholipid antibody syndrome, Myeloproliferative disorders (eg Polycythemia vera, Essential thrombocythemia/thrombocytosis), Paroxysmal nocturnal hemoglobinuria, Inflammatory bowel disease, Nephrotic syndrome, Inherited thrombophilia (ie Factor V Leiden mutation, Prothrombin gene mutation, Protein S or C deficiency, Antithrombin (AT) deficiency, Dysfibrinogenemia)
81
dyspepsia(Indigestion)Hx
epig pain related to hunger, eating, specific foods, time of day, bloating, fullness, heartburn. alarms symptoms = anaemia (IDA), LOW, anorexia, recent onset of progressive sx, melaena/haematemesis, swallowing difficulty
82
dysphagiaHx
1. difficulties swallowing solids AND liquids from the start (yes = motility, no = stricture benign or malignant) 2. difficult to make the swallowing movement (yes = ?bulbar palsy especially if coughing on swallowing) 3. odynophagia (yes = ca, ulcer, spasm) 4. intermittent or constant and getting worse (intermittent = oesophageal spasm, latter = malignant stricture) 5. does the neck bulge or gurgle on drinking (yes = pharyngeal pouch)
83
dyspnoea(SOB)DDX
Sudden (ptx, chest trauma, aspiration, anxiety, APO, PE, anaphylaxis) Acute (asthma, resp tract infection, pleural effusion, lung tumours, metabolic acidosis) Chronic (COPD, anaemia, valvular heart disease, cardiac failure, CF, idiopathic pulmonary fibrosis, chest wall deformities, neuromuscular disorders, pulm HT)
84
dyspnoea(SOB)Ex
cyanosis (peripheral and or central), kyphosis, conscious state, barrel-chest, pursed-lip breathing, accessory muscle use, clubbing, pulse rhythm, JVP, temperature, traceha, expansion, percussion (dull or resonant. note ptx presents initially with 'relative dullness' on unaffected side), murmurs, third heart sound, quiet heart sound in COPD, breath sound volume, wheezing, crepitations, fine inspiratory creps (IPF)
85
dyspnoea(SOB)Hx
onset, precipitants, relieving factors, associated with cough, sputum, blood stained, haemoptysis, wheezing
86
earpainDDX
Primary (OM, OE, other infections) Secondary (referred, eg neuralgia, neoplasma, odontogenic)
87
earpainEx
Otoscopy
88
earpainHx
pain, pruritus, discharge, hearing loss, any known tympanic membrane perforation, previous ear infections, any prior ear surgery, recent ear instrumentation, and water exposure
89
enoxaparinRx
DVT/PE prophylaxis 20-40mg/24h depending on renal function. DVT/PE treatment: 1.5mg/kg/24h. ACS treatment: 1mg/kg/12h. CONTRAINDICATIONS: bleeding disorders, thrombocytopenia, severe HTN, recent trauma. CAUTION: hyperK, hepatic/renal impairment. SIDE EFFECT: haemorrhage, thrombocytopenia, hyperK. INTERACTIONS: NSAIDS increases bleeding risk. effect increased by GTN
90
epiduralHaemorrhage(EDH)Anatomy
1) usually from temporal bone fracture, across the groove of the middle meningeal artery. 2) biconvex shape due to intimnate attachement of dura to inner table, which therefore inhibits soread of blood
91
epiduralHaemorrhage(EDH)Hx
lucid interval bwn trauma and appearance of symptoms
92
epiduralHaemorrhage(EDH)Ix
CTB: footbal (biconvex)
93
erysipelasEx
Miian ear sign (because there is now deeper dermis there!), butterfly involvement of the face
94
essentialHTNDDX
Renal (GN, DMNephropathy, renal art stenosis, chronic pyelo, PCKD, CTD (eg systemic sclerosis)), Endocrine(cushings, conn's, pcc, acromegaly), Drugs (Oestrogen-OCP, Corticoids (eg corticosteroids, liquorice), MAOIs and thiamine, sympathomimetics ()), CV, Pregnancy (pre-eclampsia)
95
essentialHTNEpi
>90% of HTN are essential
96
fibula#(Isolated)Ex
neurovascular. focus on common peroneal nerve (ie foot drop, lost sensation to dorsum and lateral leg)
97
fibula#(Isolated)Hx
direct blow to lateral leg, local pain, swelling, walking-difficulties
98
fibula#(Isolated)Ix
full length AP and lateral X-ray of tib and fib + ankel and knee joints
99
fibula#(Isolated)Rx
Support: firm crepe bandage with cotton-wool padding OR below-knee walking plaster, Refer: to fracture clinic
100
fissure-in-anoHx
constipation, pain on defecation, blood on paper.
101
gaitEx
initiation, festination, hesitancy, stride length, base (narrow or wide)
102
gastrointestinalHx
Symptoms: top-to-bottom. Appetite, taste, vomiting, dysphagia, reflux, abdo pain, nausea, opening of bowels, change in stool habit, bowel movement frequency, consistency, colour, pain on passing, recurrent urge, blood (bowl or paper), offensive smell, mucus. Allergies: MEDs: NSAIDs, anticoagulants, hepatotoxics drugs, opioids, laxatives. PHx: GI bleeds, gord, varices, gallstones, liver problems, jaundice, IBD, haemorrhoids, polyps. FamHx: IBD, liver disease, cancer. SHX: foreign travel, illicit drug use, IVDU, etoh.
103
gcsScore
eye (spontaneous, voice, pain, none), verbal (oriented, confused, inappropriate, incomprehensible sounds, none), motor (command-following, localises, withdrawal, decort, decerebrate, none)
104
goodpasturesSyndromeHx
haemoptysis, haematuria, renal disease
105
haemoptysisDDX
Resp (bronchial carcinoma, pneumonia, TB, chronic bronchitis, bronchiectasis, pulmonary oedema, Goodpasture's, Wegners), Vascular (PE, pulmonary HTN (mitral stenosis), hereditary haemorrhagic telangiectasia), Systemic (coagulation disorders)
106
haemoptysisDx
sob, sudden (PE, resp infection) or chronic (rest of ddx), pink stained = APO, long-standing sputum = bronchiectasis/chronic bronchitis, flecks of blood = TB, lung ca, mitral stenosis, LOW, other sites of bleeding (haematuria = Goodpastures, epistaxis = wegners and HHT), rheumatic fever, co-existing renal disease
107
haemoptysisEx
clubbing, cachexia, malar flush, small dilated blood vessels on mucus membranes, JVP, hyperexpanded chest, decrased inspiratory movement, supraclavicular lymphadenopathy, calves for dvt
108
haemoptysisIx
sputum, ecg, fbe, uec, clotting scree, cxr, bronchoscopy. Specifics (mantoux, urin analysis for red cell casts with GN due to goodpastures or wegners), antiglomerualr basement antibodies, c-ANCA, renal biopsy, tissue biopsy of lung, ct PA, tte
109
headacheAlternatives
Primary (migraine, tension, cluster, miscellaneous benign types) 2. Secondary (head injury, vascular (bleed, thrombous, malformation), non-vasc intracranial (inc CSF pressure, SOL), substance abuse or withdrawal, infection (meningitis, encephalitis), metabolic (hypoxia, hypercapnoea, hypogly, CO poisoning, dialysis), craniofacial disorder (eg referred pain), neuralgias (trigeminal, occipital, other cranial nerves)
110
headacheDDX
1. Acute (trauma, cerebrovascular (SAH, intracranial bleed/infarction), systemic infection, meningitis, acute angle-closure glaucoma). 2. Chronic or recurrent (tension, migraine, cluster, drugs (eg GTN, nifedipine, substance withdrawal (etoh), psych (inc anxiety and depression). raised ICP (from tumour, hydrocephalus, abscess, benign), temporal arteritis, pre-eclampsia, paget's disease of bone, severe HTN, CO poisoning
111
headacheDx
associated worrying features? severe and/or first? chronic unresponsive to treatment? Onset over minutes (primary headaches), hours/days (meningitis), days/weeks (raised ICP) sudden/gradual, severity, altered LOC, fever, vomiting, phonophobia, photophobia, recent LP
112
headacheEx
Vitals, Head for injury/tenderness, Eyes: VA, conjunctival infection (occurs with acute attacks of cluster headaches and angle-closure glaucoma), pupil reactions, eye movements, papilloedema. Sinuses: palpate for infection/tenderness, Ear: haemotympanum, infection. Oral cavity: infection. Skin: rash, purpura, petechial haemorrhages.
113
headacheIx
temp
114
hereditaryHaemorrhagicTelangiectasiaEx
small dilated blood vessels on mucus membranes
115
hereditaryHaemorrhagicTelangiectasiaHx
haemoptysis, epistaxis
116
herpesZosterDisp
postherpatic neuralgia occurs after the acute episode and is difficult to treat. get expert help
117
herpesZosterHx
unilateral dermatomal distribution of chest pain for 2-3days, then rash. Rash = redening, maculopapular evolving into vesicular lesions. How long since vesicle eruption
118
herpesZosterRx
opioids and steroids for pain releif. Aciclovir 800mg PO five times per day for 7days (or famciclovir 250mg PO TDS for 7days if seen within 72 hours of vesivle eruption)
119
hyperKalaemiaDDX
1) Pseudo (Delay in separating red cells, haemolysis, Severe leucocytosis/thrombocytosis), 2) Excessive intake (Exogenous: IV or oral KCl, massive blood transfusion, Endogenous/Tissue necrosis Burns, Ischaemia, Trauma, rhabdo, Tumour lysis) , 3) Decrease renal excretion (Drugs interferring w excretion (ie K-sparing diuretics (spirnolactone, amiloride), ACEi/ARBs, NSAIDs, Calcineurin inhibitors, trimethoprim, pentamidine), Renal failure, Addison’s, Hyporeninaemic hypoaldosteronism, 4) Compartmental shift (acidosis, insulin deficiency, digoxin OD, Succinylcholine, Fluoride poisoning, Hyperkalaemic periodic paralysis)
120
hyperKalaemiaDx
Conscious state, chest pain, palpitations, dizzy, abnormal ECG, breathlessness (due to acidosis), paraesthesia, areflexia, wekaness, abdo pain, hypoglycaemia, hyperpigmentation (ie addisons)
121
hyperKalaemiaEx
haemodynamic unstable, pulse irregular, stigmata of renal failure
122
hyperKalaemiaIx
Repeat UEC, dig levels (bc dig toxicity will worsen hyperK), ABG for acidosis if renal fail, ECG (Peaked T, prolonged PRI, broad QRS, flat P, VF), FBE for haemolysis, CK for crush, cortisol (which will be down in addisons)
123
hyperKalaemiaPhys
K is excreted main (95%) by kidney, rest by gut. excretion is slow. hormonal and acid-base systems shifts K into cell.
124
hyperKalaemiaRx
1) Stop the cause and nephrotoxics, 2) CaGluconate 10% IV 5-10ml or 15g PO (protects), 3) Salb nebulized 10-20mg, Insulin20U with Dextrose 50g, or IV Sodium Bicarb 50-200mmol (move into cells), 4) Frusemide+resonium, refractory or acidosis --> dialysis (inc excretion)
125
hyperTensionEx
comfortable/distressed/critical, BP bilat, HR? (brady+htn = increased ICP, tachy+htn = catecholamine), Lungs (Crackles = APO) Note: atheroscleosis/obese measured with small cuff may read facticously too high,
126
hyperTensionHx
1. An emergency? (Aortic dissection, chest pain, arrhytmia, SOB (APO, AMI), sudden headache, vomiting, confusion, seizure) 2. MAOI antidepressant (Isocarboxazid (Marplan), Phenelzine (Nardil), Selegiline (Emsam), Tranylcypromine (Parnate)) 3. AntiHTN meds normally taking
127
hyperTensionRx
O2>94%,
128
hypoCalcaemiaDDX
1) Major cause is hypoPTH (form surgery, thyroid dis, autoimm, developmental abn of PTH gland.
129
hypoCalcaemiaDisp
Calcium-vitD tablet, Complications: seizures, arrhytmias, cataracts, bone #
130
hypoCalcaemiaDx
dec GCS, chest pain, palpitations, dec BP, abn ECG
131
hypoCalcaemiaEx
hyperreflexia, tetany, Trousseau's (ie spasm of hand from inflated BP cuff for 3-5min), Chovstek's (uni and ipsilat twitch of face from tapping the facial nerve 2cm anterior to audiory meatus), dec BP, bradycardia, arrhytmia, concern is tetany --> laryngospasm
132
hypoCalcaemiaHx
carpopdeal spasm, twitching of muscle, tingling around mouth, distal paraesthesia, fatigue, depression, dry skin, coarse hair,
133
hypoCalcaemiaIx
UEC, CMP, Albumin, ALP, PTH, VitD, ECG: prolonged QT, ST abn, arrhytmias
134
hypoCalcaemiaPatho
loss from ECF is greater than replacement from intestines and bones. Concern is laryngospasm!
135
hypoCalcaemiaPhys
albumin binds 40% of ecf Ca, so need to correct. Levels controlled by vitD and PTH
136
hypoCalcaemiaRx
if severe tetany: 10ml 10% ca gluc over 10min. correct other elec deficiencies, if mild/asymp - monitor. **Need to correct hypoCa before acidosis if that is present, bc correcting acidosis w bicarb will make the ca fall even further
137
hypoKalaemiaDDX
Decreased intake (K-free IV fluids, reduced oral intake). Excessive loss from Renal, GI, Endocrine. Renal (diuretics, renal tubular disorders). GI (diarrhoea, vomiting, fistulas, laxatives, villous adenoma). Endocrine (cushing's syndrome, steroids, hyperaldosteronism, alkalosis)
138
hypoKalaemiaHx
chest pain, palpitations, muscle weakness, myalgia, constipation, paralytic ileus, cardiac arrhytmia (ranging from ectopics to serious arrhytmias), hypotonia
139
hypoKalaemiaIx
UEC, BSL for DKA. ABG for metabolic alkalosis. ECG (flattened T, ST dep, U waves, prolonged QT). CMP (look for decrease, as magneisum is required for adequate processing of K+). Plasma aldosterone (raised in Conn's syndrome). Plasma renin (low in Conn's). Cortisol (diurnal cariation lost in cushings). Urinary free cortisol (elevated in cushings). ACTH
140
ketoacidosisAetiology
starvation, alcoholic, diabetic
141
ketoacidosisHx
starvation, chronic alcoholic has binge then stops dirnking AND eating, GI sx (NV, abdo pain, haematemesis, melaena), magnesium low
142
ketoacidosisPatho
ketoacidosis = high anion gap metabolic acidosis due to xs keton bodies (ie keto-anions) in the blood. these ketone bodies (acetiacetatem beta-hydroxybutyrate, acetone) are released into blood from liver when hepatic lipid metabolism has changed to increasing ketogenesis. Always either relative or absolute insulin deficiency
143
leftAnteriorFascicularBlock(LAFB)Dx
LAD, ‘qR complexes’ in leads I and aVL, ‘rS complexes’ in leads II, III, aVF, QRS duration normal or slightly prolonged (80-110 ms), Prolonged R wave peak time in aVL > 45 ms, Increased QRS voltage in the limb leads
144
legPainDDX
trauma (#, disloacations, crush injuries), inflammatory (RA, Reiter's, ank spond), Infective (cellulitis, septic arthritis, myositis, osteomyelitis), degenerative (OA, meniscal lesions, baker's cyst), vascular (intermittent claudication, DVT, acute arterial occlusion), Neurological (sciatica, peripheral neuropathy, neurogenic claudication), Metabolic (Gout), Neoplastic (osteogenic sarcoma, secondary deposits), Other (cramp, PMR, strenous exercise)
145
legSwellingDDX
1. Local swelling. 1a) Acute (trauma, DVT, cellulitis, RA, Allergy) 1b) Chronic. Varicose veins, venous obstruction (eg pregnancy, pelvic tumor, post-phlebitic limb), Dependency, lymphoedema, congential malformation (eg AVfistulae), paralysis (failure of muscle pump) 2. General swelling (CCF, hypoprotein(eg liver fail, nephrotic syndrome, malnutrition), renal failure, fluid overload, myxoedema)
146
legSwellingDx
pain, trauma, recent pregnancy, abdominal or pelvic malignancy, prev surgery, radiotheraphy to lymph nodes, thyroid disease, failures (heart, liver, renal), malnutrition, poliomyelitis in childhood, nerve lesions
147
liverFunctionTests(LFTs)DDX
1. AST/ALT 2:1, normal ALP, inc GGT, macrocytosis = alcoholic liver disease. 2. AST inc +++, ALT + = acute viral hepatitis 3. AST, ALT LDH increase = ischaemic hepatitis 4. ALP and GGT ++ = cholestasis
148
maisonneuveFractureAnatomy
This is a combination of spiral fracture of the proximal fibula and ankle injury which could manifest by widening of the ankle joint due to distal tibiofibular syndesmosis and/or deltoid ligament disruption, or fracture of the medial malleolus. It is caused by pronation external-rotation mechanism.
149
malignancyHx
b-symptoms (night sweats, fevers, LOW), LOA, fatigue, malaise, TBA
150
meningitisEx
petechial haemorrhages, kernig's sign (pain on extending knee whilst hips flexed)
151
meningitisHx
photophobia, neck stiffness
152
meningitisIx
CT urgent and prior to LP if suspicion of inc ICP
153
metastaticCancerToBoneNote
The bone is one of the most common sites of metastasis. A history of cancer (excluding nonmelanoma skin cancers) is the strongest risk factor for back pain from bone metastasis. Among solid cancers, metastatic disease from breast, prostate, lung, thyroid, and kidney (BPLTK) cancers account for 80 percent of skeletal metastases
154
migraineHx
preceeding aura, unilateral, throbbing headache, photophobia, precipitants (cheese, red wine, chocolate), flashing lights, NV,
155
mitralStenosisEx
malar flush, arrhytmia, mitral area reveals loud first heart sound, mid-diastolic rumbling, accentuated by expiration in left lateral position
156
mitralStenosisHx
sob
157
mitralStenosisRf
rheumatic fever
158
nephroticSyndromeDx
Def: proteinuria (>3g/24h), hypoalb (
159
nephroticSyndromeEpi
Oedema (periorbital, peripheral, genital). Ascites (Fluid thrill, shofting dullness)
160
nephroticSyndromeHx
SWELLING face, abdo, limbs, genital. Symptoms of UNDERLYING disease (eg SLE). Symptoms of COMPLICATIONS (renal vein thrombosis, loin pain, haematuria)
161
nephroticSyndromeRf
fam hx of renal disease / atophy
162
nephroticSyndromeRx
Oedema (FR 1L/day, Na restriction, diuretics, oral/IV). Cause (minimal change GN = steroids, immunosup). Monitor (BP, UEC, FBalance). VTE prophylaxis (Heparin/Clexane)
163
nephrotoxicDrugsNote
tba
164
neuroCNEx
1 - not tested. no subjectively reported anosmia / decreased taste sense, 2-
165
normalRangeOfMovement(ROM)Note
tba
166
oesophagealSpasmHx
pain worse with swallowing
167
opioidConversionRx
tba
168
OSAHx
day-time sleepy, morning headache, snoring, breath-gasping during night / nocturnal choking, disturbing partner during sleep, silence followed by loud snoring
169
OSARf
age, male, obese, craniofacial/upper airway soft tissue abnormalities, OTHER (smoking, nasal congestion, menopause, fam hx, comorbs(pregnancy, end-stage renal dis, CHF, chronic lung disease, stroke)
170
otitisExternaDisp
ENT clinic for formal Aural toilet. Direct ENT referral if severe and painful occlusion.
171
otitisExternaEpi
Any age group. 10% in lifetime. 5-14years commonest. More likely in summer.
172
otitisExternaEx
pinna pulling worsens pain, erythema, oedema, debris and drainage in the canal, desquamation. Otosocpe: The tympanic membrane may be erythematous in external otitis and only partially visible due to canal edema.
173
otitisExternaHx
pain, pruritus, discharge, oedema, hearing loss
174
otitisExternaIx
clinical dx, consider malignancy only if persistent case or otalgia out of proportion (CT/MR)
175
otitisExternaPatho
Infectious (commonest), allergic, dermatologic. P. aeruginosa (38 percent), S. epidermidis (9 percent), and S. aureus (8 percent). Swimming RF because excess moisture --> skin maceration and breakdown of the skin-cerumen barrier, changing the microflora of the ear canal to predominantly gram-neg bacteria.
176
otitisExternaRf
Recent water exposure, Instrumentation of the auditory canal (eg cotton buds), trauma, canal occluding devices (hearing aids, earphones, or diving caps), allergic contact dermatitis, psoriasis, atopic dermatitis, prior radiation therapy (as it may have cause ischaemic ear canal), any known tympanic membrane perforation, previous ear infections, any prior ear surgery.
177
otitisExternaRx
1) Clean thoroughly (eg remove debris) 2) Treat inflammation and infection (eg abx ear drops, and wick to ensure in the canal, +/- steroids) - fluoroquinolones ofloxacin and ciprofloxacin good cover of both pathogens P.aeruginosa and S.Aureus 3) Analgesia, 4) Avoid promoting factors, 5) Follow-up and culture recalcitrant cases / consider DDX
178
otitisExternaSyn
Swimmer's ear / external otitis
179
otitisMediaEx
Otoscope: Air-fluid level along the tympanic membrane is indicative of a middle ear effusion and underlying otitis media
180
paget'sDiseaseOfBoneIx
ALP increased
181
painDx
site, onset, character, radiation, association, time course, exacerbating/relieving factors, severity
182
palpitationsDDX
Sinus Tachycardia (anxiety, emotional stress, caffeine, nicotine, etoh), Cardiac Arrhytmias (ectopic beats, PVCs or PACs, AF, SVT, VT)
183
palpitationsEx
ideally done during attack, listen for HR - not just palpate radially, BP, screen for underlying cardiac disease (eg MVP which is assoc w SVT and Afib)
184
palpitationsHx
what was felt (pounding, galloping or fluttering), frequency, regular or irregular (think ectopics or afib), precipitants, onset and offset (abrupt = SVT. Arrhythmia upon standing up straight after bending over and ending when lying down = AVNRT. Terminating post carotid sinus massage or other vagal maneuvers (eg Valsalva) = SVT, AVNT), tap out the rhythm on table/bed, light-headedness, dizzy, syncope (assoc w serious arrhytmias), chest pain, sweating, sob, age of first onset,
185
palpitationsIx
Bloods: rule out anemia and hyperthyroidism. ECG: for conduction defects or enlargement or ischaemic changes, ambulant ECG monitoring if high risk
186
palpitationsNote
DEF: Palpitations are a sensory symptom. They are defined as an unpleasant awareness of the forceful, rapid, or irregular beating of the heart
187
pancreatitisScore
Ranson: On admission WBV>16, age>55, BGL>10, AST>250, LDH>350 48hours into admission: Hct drop>10% from admission +++
188
pericarditisAetiology
Assocxiated with AMI, 2-6weeks post AMI = dressler syndrome, viral (coxsackie B virus, HIV), bacterial (pneumonia and/or septicaemia), TB (especially in HIV pts), locally invasive carcinoma, rheumatic fever, uraemia, collagen vascular disease (SLE, polyarteritis nodosa, RA), after cardiac surgery or radiotheraphy, drugs (hydralazine, procainamide, methyldopa, minoxidil)
189
pericarditisAnticipate
pericarditis and myocarditis goes together often. Determine the cause of the pericarditis
190
pericarditisDx
chest pain, low grade fever, pericardial friction rub
191
pericarditisHx
sharp, retrosternal, radiating to the back, worse on inspiration, pain can be worse with swallowing, pain worse on deep inspiration/lying flat/raising both legs (ie inc venous return), releaved by sitting up, but may be transient
192
pericarditisIx
cardiac monitor, bloods, card enzymes, viral serology, ECG (tachy, concave ST elevation, PRi depression, later: T wave flattens, becomes symmertrical inverted. Decreased voltage = effusion. electrical alternans suggests pericardial effusion), CXR (but need >250mls of effusion to see card enlargment)
193
pericarditisRx
NSAIDs (colchicine 1mg BD +/- Pred 50mg PO or Dexamethasone4mg PO/IV for pain control)
194
pneumoniaAetiology
1. CAP (s.pneum, h.inf, mycoplasma.pneumonia. remainder = s.aureua, legioneela, moraxella catarrhalis, chlamydia). viruses = 15%. 2. HAP (gram Neg enterobacteria ro s.aureus. Also consider pseudomonas, klebsiella, bacteroides, clostridia) 3. aspiration (stroke, myasthenia, bulbar palsies, dec GCS, oesophageal disease, poor dental hygiene can aspirate oropharyngeal anaerobes 4. immunocompromised pts ( s.pneumo, h.inf, s.aureus, m.catarrhalis, M.pneumo. G Neg bacilli, pneumocystis jiroveci. Others = fungi, viruses, mycobacteria
195
pneumoniaDx
acute LRTI + fever + chest symptoms + abn CXR
196
pneumoniaHx
Where and who (as determines pathogen) - cap, hap, aspiration, immunocompromised
197
pneumoniaScore
SMART-COP (age cutoff at 50 alters scoring slightly): SBP25 in young and >30 in old = 1, HR>125 = 1, acute confusion = 1, oxygen low sats or PaO2 or PaO2/FiO2, 93 or 90% = 2, pH 7mmol/l, RR >30, Low BP (
198
pneumoThorax(PTx)Disp
advice as per BTS guidelines, which consists of i) Patients should be advised to return to hospital if increasing breathlessness develops, ii) Follow up by respiratory physicians until full resolution, iii) Air travel should be avoided until full resolution or 6weeks, and iv)Diving should be permanently avoided unless the patient has undergone bilateral surgical pleurectomy and has normal lung function and chest CT scan postoperatively.
199
porphyriaHx
Acute attacks precipitated by drugs (barbituates, oestrogens, progesterones, etc). Other precipitants = etoh, smoking, sudden dieting, stress, abuse, pregnancy. Abdo pain. Peripheral neuropathy (predominanetly motor). Tachycardia, HTN, Postural hypotension. Hyponatraemia, psychiatric manifestations (eg agitation, depression, mania, hallucinations)
200
porphyriaIx
hyponatraemia, fresh urine sample protected from light to test for amino laevulinic acid and porphobilinogen concentrations. In acute attack, the urine goes dark red/brown, if exposed to light
201
porphyriaPatho
haem biosynthesis disorders in which enzyme deficiencues > porphyrin accumulation and their precursors.
202
porphyriaRx
supportive. CHO intake. careful attention to antiseizure mx as many drugs as CIed in acute attacks
203
pulmonaryEmbolismEx
inc JVP, tachypnoea,cardia, hypotension, RV heave. pleural rub
204
pulmonaryEmbolismHx
sob, pleuritic chest pain, haemoptysis, dizzy, leg pain
205
pulmonaryEmbolismIx
ECG (tachy, RBBB, TWI in V1-4, S1Q3T3). D-dimer Wells=
206
pulmonaryEmbolismScore
Wells score (DVT signs - ie leg swelling and pain on deep vein palpation = 3, PE most likely dx = 3, HR>100 =1.5, >3d immob/surgery in last 4/52 = 1.5, prev DVT/PE = 1.5, Haemoptysis = 1, malignancy (current rx, palliated) = 1.
207
pulmonaryOedemaHx
pink sputum, sob recumbent,
208
radiculopathyDx
Radiculopathy = Sx or impairments related to a spinal nerve root. May be due to degenerative changes in the vertebrae, disc protrusion, and other causes. As the root varies, the sx varies, but >90% are L5 and S1 radiculopathies
209
raisedIntraCranialPressure(ICP)Aetiology
tumoru, hydrocepahlus, cerebral abscess, benign intracranial HTN
210
raisedIntraCranialPressure(ICP)Ex
papilloedema (on fundoscope), loss of retinal nerve pulsation
211
raisedIntraCranialPressure(ICP)Hx
bursting pain, worst in morning, changes with position/cough/sneeze
212
RBBBIx
M in V1, W in V6
213
refeedingSyndromePatho
biochemical dysfunction aw the reinstitution of calorific intake in malnourished pts. may present in numerous ways. decreased electrolyes (mg, ca, glucose, thiamine), usually within 4days of startin refeeding. shift from fat to CHO metabolism --> inc insulin secretion. ins leads to cell uptake of phosphate and K cauing the serum levels of these to drop. decreased ATP in the metabolic pathway and decreased 2,3DPG in erythrocytes = tissue hypoxia and impairement of myocardial contractility
214
refeedingSyndromeRx
prevent, measure K, phos, mg, ca, replace electrolytes, thiamine, multivitamine, calories gradually
215
refluxOesophagitisDisp
endoscopy for H.Pylori testing
216
refluxOesophagitisHx
pain worse with swallowing
217
reitersDiseaseHx
conjunctivits, urethritis
218
salicylatePoisoningHx
V, tinnitus, deafness, sweating, vasodilation, hyperventilation, dehydration. Severe=coma, convulsions. Rare features=non-card APOD, cerebral oedema, renal failure
219
salicylatePoisoningIx
hypokalaemia. hyperpyrexia and hypoglycaemia (particularly in children)
220
salicylatePoisoningPatho
aspirin = 300mg acetylsalicylic acid. 150mg/kg =mild toxicity. 500mg/kg = severe/possible fatal toxicity. Can get poisoning from absorption through the skin
221
sickleCellCrisisHx
preceeded by hypoxia/ischaemia situations (eg infection, dehydration, etc) or de novo.
222
sickleCellDiseasePatho
mutation > Hgb abnormality. deoxygenation and acidosis > sickling > increased blood viscosity > sludging > stasis (stasis is again the basis)
223
socialHxHx
home: who live with, kind of house, any help, own ADLs (eg cooking, dressing, washing), mobility: walking aids, exercise tolerance, climb stairs, lifestyle: occupation, etoh, smoking, rec drugs
224
spinalEpiduralAbscessHx
Initial symptoms (eg, fever and malaise) are often nonspecific. over time, localized back pain may be followed by radicular pain and, left untreated, neurologic deficits
225
spinalEpiduralAbscessRf
Risk factors include recent spinal injection or epidural catheter placement, injection drug use, and other infections (eg, contiguous bony or soft tissue infection or bacteremia). Immunocompromised patients may also be at higher risk.
226
spleenAnatomy
1×3×5×7×9×11 rule. The spleen is 1" by 3" by 5", weighs approximately 7 oz, and lies between the 9th and 11th ribs on the left hand side
227
spleenPhys
large lymph node, blood filter, red blood cells (removes old ones and holds reserve), immune system, recycles iron
228
spleenRuptureEx
tachycardia, hypotension, abdo tenderness, pain referred to Left shoulder/shoulder tip
229
spleenRuptureHx
rib fractures recently, enlarge spleen recently (eg EBV, malaria, leukaemia) + trauma to the area. Acute rupture versus Delayed (up to 2/52 post trma)
230
spleenRuptureIx
CXR (for ?fractured ribs ?basal pleural effusion). Abdo US and/or CT. AXR is not helpful. (although if done, may see displaced stomach bubble to the right, and enlarge soft-tissue shadow in splenic area)
231
spleenRuptureRf
left lower rib injuries following trauma (associated with splenic damage in 20% of cases). Occasionally there can be injury to an already enlarged spleen (ie from glandular fever, malaria, leukaemia, etc)
232
subarachnoidHaemorrhage(SAH)Hx
neck stiffness
233
subarachnoidHaemorrhage(SAH)Rf
berry aneurysm
234
subduralHaemorrhage(SDH)Ix
CTB: most common in parietal region. crescent along the inner table of the skull, effacement of ipsilateral ventricle, midline shift
235
subduralHaemorrhage(SDH)Rf
elderly (given decreased resilence of bridging veins), cerebral atrophy (ie elderly and alcoholics - given the increased tension on veins)
236
syncopeDisp
SFSS: (San Francisco Syncope Score) to determine risk of serious adverse outcomes. CHF, Haematocrit
237
syncopeEx
postural BP
238
syncopeHx
presyncopal sx (palpitations, )
239
systemsReviewHx
CVS: CP, palp, SOB, ankle swelling, orthopnoea. RESP: Cough, sputum, wheeze, SOB. ABDO: pain, NV, bowel habits, stool colour and consistency, distension, dysuria, frequency, urgency, haematuria. NEURO: headache, photophobia, neck stiffness, weakness, change in sensation, balance, fits, falls, speech, changes in vision/hearing. SYSTEMIC: appetite, weight loss / gain, fever/night sweats, malaise, stiff/swollen joints, fatigue, rashes/itch, sleep pattern
240
temporalArteritisEx
tender along course of superficial temporal artery, absent pulsation
241
temporalArteritisHx
localised pain over artery, jaw claudication, throbbing headache
242
temporalArteritisIx
ESR raised
243
tensionHeadacheHx
tight band
244
transientIschaemicAttack(TIA)Rf
ABCD2 score (admit if 5 or more) to predict risk of stroke in short-term. Age > 65 (1 point) BP >140/90 (1 point) C symptoms = Hemi = 2 points, Dysphasia (2 points) Duration - >1hour (1 point) Diabetes (1 point)
245
tuberculosisEx
nail clubbing,
246
tuberculosisHx
LOW, LOA, flecks of blood on sputum, night sweats, cough, fever, chills,
247
tuberculosisPatho
infection (pulm or extrapulm), usually caused by mycobacterium tuberculosis, latent and active stages
248
urinaryTractInfection(UTI)Aetiology
75-90% E.Coli. Next is Staphylococcus saprophyticus... klebsiella...proteus mirabilis CLASSIFICATION: Simple (typically young and not pregnant with normal urinary tract) vs complicated (abn anatomy, urinary obstruction or incomplete emptying (eg due to instrumentation/catheter/pregnancy/underlying disease eg diabetes)
249
urinaryTractInfection(UTI)DDX
CYSTITIS (lower tract) = dysuria, freq, suprapub discomfort, +-/ macro haematuria, no vag discharge. PYELONEPHRITIS: loin pain, fever, chills, urinary symptoms. URETERIC CALCULUS + INFECTION: severe pain++. Be suspiscious as this could lead to sepsis + permanent injury to the kidneys.
250
urinaryTractInfection(UTI)Epi
Femals: by 32 years of age, 50% of women will report at least one UTI. Males: bacteruria beyond infancy = 0.1%. increases to around 3.5% with prostatic disease. 15% in hospitalised men >70yo. Homosexual at increased risk
251
urinaryTractInfection(UTI)Hx
dysuria, frequency, haematuria, suprapubic tenderness, discharge. IN ELDERLY:, institutionalised pts, non-specific sx + decline correlates POORLY with UTI despite pyuria and bacteriuria --> find another cause. IN MEN: the most common cause of recurrent lower tract UTI = prostatitis, so look for evidence like chills, dysuria, prostaic tenderness.
252
urinaryTractInfection(UTI)Ix
for most outpatient women with typical symptomatology, cultures not needed
253
urinaryTractInfection(UTI)Rf
sexual activity is the most important RF in young women, previous UTIs, cathether, homosexual men
254
urinaryTractInfection(UTI)Rx
ONLY treat asymptomatic bacteriuria in pregnant women and those about to have significant urological procedures
255
wegnersGranulomatosisEx
loss of nasal bridge, saddling of nose
256
wegnersGranulomatosisHx
haemoptysis, epistaxis, renal disease
257
wegnersGranulomatosisIx
c-ANCA
