Nina Cooper MedED EMQ Notes

Nina Cooper EMQ Lecture Notes

Respiratory SHORTNESS OF BREATH Case 1:

68, ex-smoker SOB on exertion, over years Wheezy for a few years Regular productive cough

COPD

Investigations: post-bronchodilator Spirometry

o FEV1 % lower o FEV1:FVC

Classic = gradual onset, smoker, productive cough

Destruction of alveolar space ! decreased gas exchange ! chronic bronchitis

COPD ASTHMA

Smoker/ex smoker Wheeze Chronic cough Regular sputum production Exertional breathlessness Frequent winter bronchitis

May/may not smoke Wheeze Chronic non-productive cough Night time waking with breathlessness or wheeze Significant diurnal variation FHx asthma FHx atopy

Case 2:

Fever Cough Weight loss Red Ziehl-Nielson Stain

TB

Long-standing cough (>2 weeks) Racial profiling in EMQs normally

Asian Systemic symptoms include

weight loss, anorexia, fever and night sweats

Investigations: o CXR: cavitatory nodules o Sputum samples o Microscopy

Culture in Lowenstein Jensen medium for 4-6 weeks

Mycobacteria, bacilli, acid-fast = appear red with ZN stain

Treatment RIPE o Rifampicin flu-like

symptoms, hepatitis, stains contacts orange

o Isoniazid hepatitis, neuropathy

o Pyrazinamide hepatitis, arthralgia, gout

o Ethambutol ocular toxicity + colour vision loss

Case 3:

Steatorrhoea, diabetes Recurrent infections Dilated airways Clubbing

Cystic Fibrosis

Autosomal recessive Carrier freq. 1 in 22 for

Caucasians Defective Cl- excretion leads to

viscous mucous Increased infections Also assoc. with diabetes and

infertility Bronchiectasis = permanent

dilation of bronchioles and elastic damage

Signet rings seen on CT Past history of infections e.g.

pertussis = bronchiectasis Case 4:

Shipyard worker End-inspiratory crackles Progressive dyspnoea Non-productive cough Clubbing

Mesothelioma

Secondary to asbestosis (ship-building/power stations) or pneumocoliosis (coal worker)

Leads to impaction ! fibrosis ! end inspiratory crackles

Also seen in idiopathic pulmonary fibrosis (cryptogenic fibrosing


alveolitis) = progressive dyspnoea and non-productive cough

Case 5:

Farmer Many flu-like illnesses over

winter Hypersensitivy Pneumonitis (EAA)

Farmer's lung - one of the most common forms. Due to exposure to mouldy hay. The major antigen is Saccharopolyspora rectivirgula

Bird-fancier's lung - one of the most common forms. Due to exposure to avian proteins, eg pigeons, parakeets

Cheese-worker's lung - exposure to cheese mould, Penicillium casei.

Malt worker's lung - exposure to Aspergillus clavatus in mouldy malt

Hot tub lung - exposure to Mycobacterium avium in poorly-maintained hot tubs

Chemical worker's lung - trimellitic anhydride, diisocyanate and methylene diisocyanate act as the antigens during the manufacture of plastics, polyurethane foam and rubber.

Mushroom worker's lung - exposure to thermophilic actinomycetes in mushroom compost

LUNG CANCER Case 1:

SOB Weight loss Oedamatous Flushed

SVC Syndrome

Blockage causes oedema of face and arms e.g. due to tumour

Facial flushing Dilated veins over arms, neck and

chest Morning headaches

Case 2:

Ptosis R arm pain

Pancoasts Tumour Impinges on brachial plexus and

sympathetic chain Leads to Horners syndrome

o PTOSIS o ANHYDROSIS o MYOSIS

Case 3:

Weight loss Cough Headaches Worse bending over

Metastases

Liver: anorexia, nausea, weight loss, RUQ pain

Bone: pain, fractures Adrenals: usually asymptomatic Brain: SOL

Case 4:

Lower back pain Tired Constipated Hypercalcaemia

Squamous Cell Carcinoma

35% of all lung cancers Arises from epithelial cells Releases PTHrP Same actions as PTH: bone

reabsorption, tubular calcium reabsorption

Hypercalcaemia: stones, moans, groans, bones

Case 5: Recent haemoptysis Dyspnoea Truncal obesity Moon face


Small Cell Carcinoma 20% of all lung cancers 2 year survival: 20-40% limited

disease, 65

Can be lobar or bronchopneumonia (patchy alveolar consolidation in both lobes)

Investigations = CXR and sputum MCS

Treatment = relevant abx: oral amoxicillin or IV clarithromycin + oral co-amoxiclav

Pathogens

S. pneumonia o Young and middle aged o 30% all CAPs o Rapid-onset o High fevers, rigors and

pleuritic chest pain o Rusty-coloured sputum o CXR shows lobar

consolidation Chlamydophila pneumonia

o Mild pneumonia in younger people

o Assoc. with sinusitis, pharyngitis and laryngitis

o CXR shows small segmental infiltrates

Mycoplasma pneumonia o Adolescents and you ng

adults


o Cause epidemics in 3 year cycles

o Few chest signs o Present erythema

nodosum, pericarditis and haemolytic anaemia

o CXR shows patchy/lobar consolidation and hilar lymphadenopathy

Staph. aureus o Complicates an underlying

pneumonia o Can arise from other foci

e.g. osteomyelitis o Abscesses on XR - Cavities

with air-fluid levels Pneumocytisis jiroveci

o Pneumocystisi pneumonia = PCP

o Most common AIDS-defining illness

o Dry cough, fever, SOB, weight loss and night sweats

o Low O2 sats o Widespread infiltrates on

CXR Legionella pneumophila

o Legionnaires disease o Localised epidemics o Dry cough, myalgia,

malaise and GI symptoms o Low sodium and low

albumin o Air conditioning units

Chlamydophila psittaci o Contracted from birds o Bacteria shed through

faeces and nasal discharges

o Fever, arthralgia, diarrhoea, conjunctivitis and headache

o Hepatosplenomegaly recognised

o CXR = patchy lower lobe consolidation

Klebsiella pneumoniae o Purulent dark sputum o CXR = upper lobe

consolidation Case 2:

70M 40 pack year history Blood in sputum

Lung Cancer NSCC = 80% SCC = 20% See above notes.

Case 3:

3 year old child Coughing up blood Happened when came back

from nursery Inhaled Foreign Body

Most common cause in young children

Case 4:

2-3 cups of coffee-like appearance

Been drinking Oesophagial Varices

Dilated veins at distal end of oesophagus

Caused by portal HTN secondary to liver disease

o Poor blood flow and high resistance ! backpressure ! tributary formation

o Also see caput meducae, varices on rectum and spider naevi

o Weak and prone to rupture

Bleeding worsened by fact that can no longer metabolise vit K due to LF!

Case 5:

20 year old male from Bangladesh

Coughing up blood for few weeks

Bilateral hilar lymphadenopathy TB

Risk factors o Hx o HIV o Travel o Homeless

Investigations: CXR, ZN staining, HIV serology

BHL can be caused by TB or sarcoid


ASTHMA Case 1:

8M 6 month history of night cough

and intermittent wheeze Small for age Mild eczema

Stepwise Management of Asthma

New diagnosis Started on step 1 = short acting

B2 agonist e.g. salbutamol, terbutaline

Step 2: step 1 + low dose inhaled steroid e.g. budesonide, fluticasone

Step 3: step 2 + high dose inhaled steroid or long acting B2 agonist e.g. salmeterol

Step 4: high dose inhaled steroids + long acting B2 agonist + other drugs e.g. theophyllines, anticholinergics (ipratropium), leukotriene antagonists (montelukast), mast cell stabilisers (sodium cromoglicate)

Step 5: step 4 + oral steroids (prednisolone)

Case 2:

16M Poorly controlled chronic

asthma Managed with long acting B2

agonist and high-dose inhaled steroids

Parents want to know if anything else can be given

Stepwise Management of Asthma See above Case 3:

23 year old man with known asthma

A&E with SOB Widespread wheeze Breathless to talk HR 115BPM RR 36

Severe Exacerbation of Asthma

Features of severe asthma

o Pt is too breathless to finish sentences

o RR>25 o Pulse >100bpm o Peak flow


Cardiology MURMURS Case 1:

Anacrotic pulse (slow-rising) Breathlessness Syncope Pain

Aortic Stenosis

Ejection systolic murmur Characteristic breathlessness,

syncope and angina on exertion Case 2:

26F Pink frothy sputum Atypical pain MI

Mitral Regurgitation

Can present acutely or chronically Acute = backflow, leading to pink

sputum Mitral valve prolapse causes

atypical pain seen in young Graham Steell murmur heard if the

regurgitation backflows through the pulmonary valve too, due to LA problem

Inferior MI can cause rupture of the posteromedial papillary muscle while anterolateral infarctions can cause rupture of the anterolateral papillary muscle

This leads to acute mitral regurgitation (RV papillary rupture is rare but can cause regurgitation of the tricuspid valve)

Complete rupture of the papillary muscle is fatal and causes wide-open MR

Those with incomplete rupture need emergency cardiac surgery with inotropic support considered for transient stabilisation prior to this

Case 3:

IV drug user Low pitch murmer Loudest in apex

Louder on inspiration Pulsating uvula

Aortic Regurgitation

Multiple signs due to collapsing pulse

o De Mussets (rhythmic bobbing/nodding of head in synchrony with beating of the heart)

o Duroziezs sign (systolic and diastolic murmurs heard over the femoral artery when it is gradually compressed with the stethoscope)

o Watson Hammer Pulse (Large volume collapsing pulse)

o Corrigans pulse (rapid upstroke and collapse of the carotid pulse)

o Quinkys sign (pulsation of capillaries in nail bed)

o Traubes sign (a 'pistol shot' systolic sound heard over the femoral artery)

Austin flint murmur = loudest in apex, mid-diastolic or pre-systolic, heard in severe aortic regurgitation

Decrescendo diastolic murmur Case 4:

30F SLE Muffled heart sounds

Pericardial Effusion

Lupus -> pericarditis Adversely affects heart function =

cardiac tamponade Transudative (congestive heart

failure, myxoedema, nephrotic syndrome),

Exudative (tuberculosis, spread from empyema)

Haemorrhagic (trauma, rupture of aneurysms, malignant effusion).

Malignant (due to fluid accumulation caused by metastasis)


Case 5: 22M Positive vasalva manoeuvre Harsh ejection systolic murmur

HOCUM

Hypertrophic Obstructive Cardiomyopathy

Disease of myocardium without known cause

Cause of sudden cardiac death Valsalva maneuver increases the

intensity of HOCUM murmurs, namely those of dynamic subvalvular left ventricular outflow obstruction (decreases AS, PS, TR)

Patent Ductus Arteriosus

Tachycardia Respiratory problems dyspnoea - shortness of breath Continuous machine-like heart

murmur Cardiomegaly Left subclavicular thrill Bounding pulse Widened pulse pressure

HEART FAILURE EMQ:

80F IHD Dyspnoea Orthopnoea PND

Upon examination, you hear fine inspiratory creps + normal ECG

Blood test = BRAIN NATRIURETIC PEPTIDE (check for LV HF)

Fine insp creps = pulmonary oedema

Her BNP is positive. What should the next test be?

GOLD STANDARD = TRANSOESOPHAGEAL ECHO

FIRST LINE = TRANSTHORACIC DOPPLER ECHO

She is admitted. What should the first line treatment be?

ACE INHIBITOR

She is discharged, but later presents with a chronic dry cough. Secondary treatment:

ANG-II RECEPTOR ANTAGONIST

6 months later, she is put on enalapril (ACE inhibitor), atenolol (B-blocker) and furosemide (diuretic)

Next = SPIRONOLACTONE Can cause gynaecomastia,

menstrual disturbances etc.


INFECTIVE ENDOCARDITIS EMQ:

22F IV Drug User Tricuspid murmur Petechiae Microvascular haematuria Janeway lesions Clubbing Splinter haemorrhages

Modified Duke criteria for Infective Endocarditis. MAJOR:

Positive blood culture o Typical organism in 2

separate cultures or o Persistently positive +ve

cultures) Endocardium involved

o Positive echo o Or new valvular

regurgitation Minor

Predisposition (cardiac lesion, IVD user)

Fever >38c Vascular/immunological signs Positive blood culture that does not

meet criteria Positive echo that doesnt meet

major criteria Diagnosis: 2 major / 1 major + 3 minor / 5 minor May show signs of septic shock. MANAGE:

ABC, fluid resuscitate FBC ECG Echo Manage w MC&S

Has MRSA = give IV VANCOMYCIN ARRHYTHMIAS Case 1:

85F Acute SOB + pain Irregular rhythm HR 190

Fast AF No discernable P waves Chaotic excitation Irregularly irregular Typical = old, palpitations, SOB,

fatigue, syncope Paroxysmal = 7 days, requires

cardiaversion Permanent = doctor and patient

have lost hope of sinus rhythm Causes can be cardiac or non-cardiac (infection, thyroxtoxicosis) Investigations

ECG Ambulatory monitoring

Case 2: 36M Palpitations 150bpm

Atrial Flutter

Narrow complex tachycardia Atrial Rate = 250-350bpm Ventricular Beat = 150bpm with a

2:1 block Saw tooth appearance on ECG Acute = shock them

Recurrent = catheter ablation Case 3:

56M Previous MI Broad complex tachycardia

Ventricular Tachycardia

Broad complex = ventricular problem (i.e. not from SAN)


Risk = previous MI or inherited syndromes

Emergency as can turn into VF -> ischaemia/infarction

Case 4:

24M Palpitations Pre-

excitation Wolff-Parkinson White

Often benign, 1-3/1000 people Non-conductive AV septum is

bypassed by an accessory pathway (bundle of Kent)

Pre-excitation, slurred upstroke = delta wave

Case 5:

84M HR 32 Broad QRS

Complete Heart Block

Broad QRS = conduction outside of normal pathways

SAN spontaneous AVN slower spontaneous

(~30bpm) See P waves in unison + QRS

randomly appearing

INVESTIGATIONS Case 1:

54 Diabetic SOB Central crushing chest pain

Suspected ACS

Do ECG first Case 2:

65M Fever

Back pain since prosthetic valve put in 4/52

Suspected Infective Endocarditis

Case 3: 72M Shoes too small Exertional dyspnoea No PMHx

Suspected Heart Failure

First line BNP for HF if no previous MI

If previous MI = stress echo Case 4:

66F Pansystolic murmer Post-MI

Suspected Mitral Regurgitation

TTE Case 5:

55M Hyperlipidaemia Central chest pain on exertion Relieved by rest


Diagnosing Stable Angina Coronary angiography Then exercise ECG/CT calcium

scoring CHEST PAIN Case 1:

70M BMI 35 Collapse running Tearing pain to back BP 190/120 ! 160/90

Dissected Thoracic Aortic Aneurysm

Higher risk in connective tissue disorders

Can cause hemiplegia, acute limb ischaemia, MI if CA involvement

Case 2: 32M Stabbing pain Worse lying down/coughing Improved by sitting upright Pericardial rub audible

Pericarditis

Positional pain Can be caused by infection, SLE,

rheumatic rever ! pericardial effusion

The classical finding on examination is a friction rub which is said to sound like walking on snow

There may be diffuse ST elevations on ECG, an effusion on echocardiography and blood results suggesting inflammation

Complications include tamponade and constrictive pericarditis

Prior viral infection is a risk factor with the most common pericardial infection being viral

Bacterial purulent pericarditis also occurs

Inflammation is due either to direct viral attack or immune mediated damage

Other risk factors include male gender, post-MI (both early and Dresslers), post-pericardiotomy

syndrome, neoplasm from local tumour invasion, uraemia and autoimmune conditions such as RA and SLE.

Case 3:

Central crushing chest pain Bradycardia

MI

Bradycardia -> inferior MI Management = MONA LISA

MORPHINE OXYGEN NITRATES ASPIRIN LOOP DIURETIC IV ACCESS STREPTOKINASE ANTIPLATELETS

Case 4:

Sharp chest pain, worse on inspiration (pleuritic)

Haemoptysis Sudden onset

Pulmonary Embolism

Antiphospholipid syndrome can cause DVTs, leading to PE

First-line = CTPA D-Dimers = non-specific

Wells Scoring

CT Calcium Scoring

Functional Imaging

Angiography

RULE OUT Low risk factors Atypical pain

INTERMEDIATE Low risk factors Atypical pain Women Includes stress echo, MPS with SPECT and cardiac MRI

RULE IN High risk Typical pain Can carry out procedure?


Case 5: 70F Similar pain to her angina, but

no relief with GTN Woke up from sleep Previous episode 1/12 ago

Unstable Angina

Episodic Has PMHx Occurs at rest


ANGINA CASE 1 A 73 year old banker complains of chest pressure which comes on predictably on exertion. It is relieved when he sits down and rests. = Stable Angina

Resting ECG is often normal Patient is asymptomatic. During exercise stress ECG (most

often the Bruce Protocol) there will be ST segment depression during exercise indicative of ischaemia and the patient will complain of chest pain

Those unable to exercise to an adequate level may need stress myocardial perfusion imaging or stress echocardiography

1st line treatment involves lifestyle changes and antiplatelet therapy with aspirin.

Anti-anginal therapy will also be given, first line being beta-blockade

Statin therapy, blood sugar control in diabetics and BP control with antihypertensives may also be necessary

Those with LMS disease, 3 vessel disease or a reduced EF may benefit from CABG

Single vessel disease may benefit from PCI

CASE 2/3 A 55 year old man is admitted to A&E with chest pain which is central in origin and came on while he was waiting for his bus. Troponin and CK-MB are not elevated. An overweight 63 year old male with a history of hypertension presents with cardiac sounding chest pain while watching TV. However, his cardiac biomarkers are not elevated. An ECG is ordered which shows ST depression and T wave inversion = Unstable Angina

Characterised by chest pain at rest ECG will typically show ST

depression and T wave inversion

Acute management includes antiplatelets and antithrombotics to reduce damage and complications

Long term management aims at reducing risk factors

Key risk factors include obesity, hypertension, smoking, hyperlipidaemia, FH, DM and positive FH

People with diabetes may again present with atypical symptoms

Cardiac biomarkers will not be elevated although in a patient who has had an acute MI days earlier, troponin may remain elevated (remains elevated up to 10-14 days after release)

All patients with presumed cardiac chest pain should in the first instance get oxygen, morphine


and GTN with antiplatelet therapy in the absence of contraindications

CASE 4 A 59 year old woman complains of chest pain. ECG shows ST segment depression. However, a subsequent coronary angiogram is normal = Syndrome X

Chest pain with usual ST segment changes associated with coronary artery disease but with normal coronary arteries

It is treated with calcium channel blockers such as nifedipine

CASE 5 A 57 year old female complains of chest pain which occurs at rest. ECG performed on A&E admission shows ST elevation but a subsequent angiogram with a provocative agent shows an exaggerated spasm of the coronary arteries = Variant Angina

Caused by coronary artery vasospasm rather than atherosclerosis

It occurs at rest and in cycles Many patients will also have some

degree of atherosclerosis although not in proportion to the severity of the chest pain experienced

ECG changes are of ST elevation (rather than depression) when the patient is experiencing an attack and a stress ECG will be negative

Patients with Prinzmetal angina are often treated for ACS and cardiac biomarkers may be raised as vasospasm can cause damage to the myocardium

The gold standard investigation is with coronary angiography and the injection of agents to try to provoke a spasm

CASE 6 A 44 year old female complains of a two week history of tight chest pain which occurs when she is lying down. = Decubitus Angina

This patient has chest pain which occurs on lying down, which is decubitus angina by definition

CARDIOLOGY DRUGS Alpha 1 agonist

Alpha 1 agonists such as phenylephrine are vasoconstrictors

Also have a use as a mydriatic They are used as nasal

decongestants as a result of their vasoconstrictor effect

Alpha 2 agonist

Used for treatment of glaucoma Decrease production of aqueous

fluid by the ciliary bodies of the eye and also by increasing uveoscleral outflow

Beta 1 agonist

Used to treat hypotension and bradycardias

E.g. dobutamine Beta 2 agonist

E.g. salbutamol Used for bronchial smooth muscle

relaxation Adrenaline

Non-selective adrenergic stimulation

Increases HR and BP Beta blocker

Lower heart rate, CO and MABP during exercise

Also act to reduce renin release as well as the release of NA

Use ranges from migraine prophylaxis, anxiety and


hypertension to thyrotoxicosis, post-MI and chronic heart failure

Also useful in arrhythmias where they act to increase the refractory period of the AVN.

Calcium channel blockers can increase A-V block, slowing down heart rate and worsening severe heart failure, bradycardia and sick sinus syndrome.

Calcium channel blocker

Non rate slowing e.g amlodipine - leads to arterial vasodilation by action on vascular smooth muscle cells

It can lead to unwanted ankle oedema, headache, hypotension and palpitations

Used for hypertension and angina

The palpitations a patient may experience are due to reflex tachycardia from arterial vasodilation

Rate-slowing calcium channel blockers also exist such as verapamil and diltiazem and uses for these also include arrhythmias such as paroxysmal SVT and AF

ACE inhibitor

Prevent the conversion of angiotensin I to angiotensin II by ACE

Uses o Hypertension o Heart failure o Post-myocardial infarction o Diabetic nephropathy o Progressive renal

insufficiency o Patients at high risk of

cardiovascular disease E.g. Enalapril

Angiotensin Receptor Blocker

E.g. losartan Antagonists of type 1 (AT1)

receptors for Ang II, preventing

the renal and vascular actions of Ang II

Uses: hypertension, heart failure Organic Nitrates

Uses o Angina o Acute and chronic heart

failure o BP control during

anaesthesia Mechanism of action: Release nitric

oxide (NO) in smooth muscle cells (nitrates) or stimulate guanylate cyclase (nicorandil) to cause vasodilation

Reduce preload (venous return) Venodilation

Reduce afterload (peripheral resistance) Vasodilation

Example: Glyceryl trinitrate, nicorandil

Chronic use can lead to tolerance It is also weakly antiplatelet and

has a weak direct action to vasodilate the coronary arteries

Spironolactone

Aldosterone antagonist (potassium-sparing diuretic)

Used to treat oedema Used to potentiate loop/thiazide

diuretics Loop diuretic

Used in pulmonary oedema due to LVF

Reduces breathlessness and reduces preload

Used for patients with chronic HF E.g. furosemide and bumetanide

Thiazides

Inhibit sodium reabsorption at the beginning of the distal convoluted tubule

Act within 1-2 hours Management of HTN low dose

produces maximal effects with little biochemical disturbances

E.g. bendroflumethiazide, indapamide


MISC. CAUSES OF CHEST PAIN CASE 1 A 32 year old woman has a 2 day history of intermittent attacks of a sharp pain over the lower left side of her chest. The pain is exacerbated by movements of the rib cage and the patient tells you it becomes difficult to breathe. She has also felt feverish. = Borneholme Disease

Bornholm disease is caused by Coxsackie B virus

Symptoms include the fever seen as well as the characteristic attacks of severe pain in the lower chest

Exacerbated by small movements of the rib cage, which make it difficult for the patient to breathe

CASE 2 A 22 year old woman complains of pain in her breast. Upon deep palpation, you notice tenderness over the right lower inner quadrant. = Costochondritis

Inflammation of the costal cartilage

CASE 3 A 40 year old man complains of pain and swelling over the ribs = Tietzes Syndrome

Inflammation of the costal cartilage

Similar to constochondritis but has swelling

CASE 4 A 70 year old man presents 1 month post-MI with pain on inspiration, a low-grade fever and central sharp chest pain, made better by leaning forwards. = Dresslers Syndrome

Characterised by pleuritic chest pain, low-grade fever and pericarditis, which may be accompanied by pericardial effusion

It usually presents two to five weeks after the initial episode, with pain and fever that may suggest further infarction

The pain is the main symptom, often in the left shoulder, often pleuritic, and worse on lying down.

There may be malaise, fever and dyspnoea

Rarely, it may cause cardiac tamponade or acute pneumonitis

A pericardial friction rub may be heard. The typical sound of pericarditis is described as like the sound of boots walking over fresh snow

ANTIHYPERTENSIVES


GI Medicine ANATOMY OF ALIMENTARY TRACT

Topographical Anatomy

Costal margin: Formed by the medial borders of the 7th through 10th costal cartilages

Rectus sheath: from xiphoid process and 5th through 7th costal cartilages pubic symphysis and pubic crest. Contains rectus abdominis muscle

Linea alba: A slight indentation that can sometimes be seen extending from the xiphoid process to the pubic symphysis

Inguinal Ligament: From ASIS to pubic tubercle of pelvis. Folded inferior edge of external abdominal aponeurosis. Separates abdominal region from thigh

Umbilicus: At approximate level of intervertebral disc between the L3 and L4. Marks the T10 dermatome

Oesophagus

Pierces diaphragm at T10 Stomach

Foregut structure Found in epigastric/left

hypochondriac region

Liver

Lies deep to ribs 5-11 The common hepatic artery runs

in association with the bile duct + portal vein in the free edge of the lesser omentum (the hepatoduodenal ligament part)

The common hepatic is a branch of the aorta, and then divides into the R + L hepatic (with the cystic artery supplying the gall bladder branching off the R hepatic)

Gall Bladder/Biliary Tree

Gall bladder stores + concentrates bile

Sphincter of oddi controls passage of juices through the ampulla of vater

Spleen Beneath ribs 9 through 11 on the

left side. 10th rib is axis of spleen Kidneys

Located in loin region Left kidney is higher than right

(pelvis at L1/2 on left and L2/3 on right)

Duodenum

Brunners glands found in second part of duodenum

C-shape surround head, body and uncinate process of pancreas

L2 level Blood supply = foregut (coeliac

trunk) ends at ampulla of vater


Ileum/Jejunum

Blood supply = midgut (SMA) -arterial arcades, with connecting vasa recta

The jejunum makes up the proximal 2/5 of the SI, with the ileum forming the distal 3/5

The jejunum diameter > ileum It is difficult to distinguish the

jejunum from the ileum by diameter alone, but there are other features, particularly the arterial arcades + vasa recta

o The jejunum has less prominent arterial arcades with longer vasa recta

o The ileum has prominent arterial arcades with a shorter vasa recta

Large Intestine

The large intestine consists of the caecum (most proximal), vermiform appendix, ascending colon, hepatic flexure, transverse colon, splenic flexure, descending colon, sigmoid colon + rectum

Distinguishing features: fatty tags (appendices epiploicae), ribbons of longitudinal muscle (taeniae coli) + segmented/pocketed haustra walls

2 openings: o Ileocaecal orifice acts as

valve preventing movement of substances back into small intestine

o Appendix Blood supply = midgut until

splenic flecture ! IMA/hindgut Innervation of Gut

Abdominal viscera is supplied by the autonomic nervous system

Parasympathetic sensory innervation regulated the reflex gut function:

o Vagus nerve o Pelvic splanchnic nerves

S2-S4 Sympathetic sensory innervation

mediate pain: o Thoracic splanchnic T5-

T12 (greater, lesser, least) o Lumbar splanchnic L1+L2

VOMITING Case 1

80F 2 day hx of nausea and vomiting Slightly confused PMHx: AF, osteoarthritis, HTN

(recently diagnosed) 3/52: started on low dose

bendroflumethiazide Also takes digoxin and co-

dydramol O/E: 36.8C, 56BPM, irregularly

irregular HR, BP 145/85 Mild epigastric tenderness Na 138, K 3.1, urea 8.6, creatinine

142 Digoxin Toxicity

Hypokalaemia secondary to use of diuretic (bendroflumethiazide) predisposes to digoxin toxicity

Vomiting ! further hyperkalaemia Patients are nauseated and have a

low HR Case 2

25 student 8h hx of frequent vomiting,

unable to keep anything down Cramp-like abdo pain Pale, clammy, shivering Hb 14.7, WCC 11.8, Platelet 368,

Na 135, K 3.4, urea 7.7, creatinine 70

Gastroenteritis

Secondary to staphylococcus aureus

Short history due to preformed enterotoxin from food contaminated with staph.

Vomiting starts shortly after consumption of food

Other causative organisms of vomiting-predominant food poisoning include Bacillus cereus, however the hx is typically shorter (1-2h) and symptoms start later after ingestion

Also occurs with Salmonella, Campylobacter and Shigella, but the predominant symptoms are lower abdominal pain, diarrhoea or dysentery


Case 3 4 week old baby 4/7 projectile vomiting of curdled

milk shortly after every feed 2cm palpable mass in epigastric

region Gastric Outflow Obstruction

Neonatal pyloric stenosis Occurs at 3-6 weeks old Characteristic = projectile

vomiting after every meal Disorder is due to hypertrophy of

circular muscle in pyloric region Dehydration and severe

electrolyte disturbances eventually arise

Treated surgically with a ramstedt pyloromyotomy

HAEMATEMESIS Case 1

70M 40% burns to body Several episodes of haematemesis

Gastric Erosion

Stress ulceration ! erosion of stomach is a complication of serious burns = Curlings ulcer

Other traumatic causes e.g. sepss, organ failure and intracranial lesions (Cushings ulcer)

Risk of bleeding is reduced with mucosa-protecting agent or prophylactic antacids

Case 2

32F 1 year of recurrent peptic

ulceration Taking 40mg of omeprazole Endoscopy reveals 2cm actively

bleeding ulcer in duodenum CT shows 2cm mass in pancreas

Zollinger-Ellison Syndrome

Rare disorder caused by gastrin-secreting tumour

Either found in pancreatic islet cells or duodenal wall

Large amounts of HCl produced due to gastrin secretion

Diagnosis is suspected in pts with recurrent ulceration and

persistently high serum gastrin levels

Use of PPIs can suppress secretion e.g. lansoprazole

Case 3

45M Several episodes of vomiting fresh

blood Drowsy MCV = 106 Platelets = 167 WCC = 11.7 INR 2.1

Oesophageal Varices

Massive haematemesis + bloods = likely to point to varices

Raised MCV due to alcohol-induced bone marrow toxicity

Raised INR due to severe hepatic dysfunction

Normally caused by portal htn secondary to cirrhosis

Upper GI endoscopy = confirmation

Need to correct coagulopathy ! FFP + vit K

Sengstaken-Blakemore tube can be used for balloon tamponade of bleeding in emergency situations

CONSTIPATION Case 1

66M 3/12 hx of difficulty passing stool Previously opened daily Now straining, producing worm-

like stools with mucus Tenesmus

Carcinoma of Colon/Rectum

Short hx of change in bowel habit to constipation

Mucus + tenesmus are common in low rectal tumours

Case 2

28F Chronic schizophrenia Abdominal pain, bloating and

constipation Opens 2x weekly with passage of

hard stool Also complains of dry mouth


Iatrogenic Antipsychotic treatments (e.g.

chlorpromazine) have anti-cholinergic side effects

Leads to decreased motility of GIT and decreased glandular secretions ! dry mouth

Also can cause difficulty passing urine, blurred vision + others

Will see iatrogenic constipation with iron and opiate use

Case 3

92F Falls and fractures right neck of

femur Six days post-op, complains of

colicky lower abdo pain Not opened bowels for 6-days

post-op Faeces are palpable in left colon

and on DRE Faecal loading seen on AXR

Simple Constipation

Treatment = alleviate causative factors e.g. reduced food intake, low-fibre diet, lack of exercise and mobility

Common in elderly too Use of laxatives should be short-

term Case 4

56M Short hx of abdo pain and

difficulty opening bowels Not passed faeces for 6 days and

now struggling to pass urine 6/12 hx of cough with occasional

haemoptysis puts down to being a smoker

Wife thinks he has lost weight Hypercalcaemia

Likely to have carcinoma of bronchus (cough + haemoptysis)

Can get hypercalcaemia with lung cancer due to malignant infiltration of bone (osteolysis + Ca release) or due to ectopic secretion of an PTH-like hormone

Bowel can also be affected by auto-antibodies to myenteric neurones in association with SCC of the lung ! intestinal pseudo-obstruction

Groans, moans, stones, bones Abdo pain, vomiting, constipation Polyuria, polydipsia Depression, anorexia, weight loss Fatigue Hypertension Confusion Pyrexia Renal stones Ectopic calcification Causes

o Malignancy o Sarcoidosis o Primary

hyperparathyroidism Case 5

26F Constipation Struggled for a few years Topical GTN and dietary advice is

not helping Anal Fissure

Constipation due to pain Tx

o High fibre, high fluid diet o Topical lidocaine o Topical GTN ! headaches o Botox o Surgical

Case 6

8 year old Constipation Distended abdomen Normally fit Healthy and balanced diet

Aganglionosis

E.g. Hirchsprungs disease Absence of ganglion cells in GIT Therefore impaired/absent

nervous control Usually diagnosed as an infant

DIARRHOEA Case 1

93F Severe chest infection 10 days broad-spec abx, nebs +

O2 Develops profuse, offensive,

greenish diarrhoea Clostridium difficile


Antibiotic induced diarrhoea Carried by 3-5% population Treatment with oral metronidazole

or vancomycin Enterotoxin is responsible for the

diarrhoea and cytotoxin is responsible for the pseudomembrane

Case 2

22M Severe abdominal cramps,

vomiting and watery diarrhoea Several hours after eating poorly

reheated chinese takeway Stool samples confirm gram

positive, aerobi bacilli Bacillus cereus

Associated with poorly reheated rice

Takes between 1-16h for symptoms to present

Case 3

Middle aged couple 1 week hx of watery, severe

diarrhoea and foul-smelling belches

Several days after returning from Russia

Cysts and trophozoites seen on stool microscopy

Giardia lamblia

Commonly found in Eastern Europe and Russia

Causes malabsorption and watery diarrhoea

Characteristic = foul smelling flatus

Causes villous atrophy in SI Can exist in cyst and trophozoite

form Causes acute-phase IgM response Treat with rehydration and oral

metronidazole Case 4

31M HIV +ve Profuse watery diarrhoea, weight

loss and fever Dilated descending colon on AXR Oocysts present on stool sample

Cryptosporidium

Self-limiting diarrhoea for up to 10 days

Can cause toxic dilatation of colon in immunocomprimised patients

Hydration + nutrition + electrolyte support

Case 5

65F Diarrhoea Struggled with infrequent bowel

motions most of her life Overflow Diarrhoea

History of chronic constipation/obstruction

Liquid stool passes obstruction Case 6

18F Diarrhoea Recently started OCP Similar episodes in the past which

she manages with lifestyle modification

Lactose Intolerance

Drug adjuvants can cause problems too

OCP and POP both contain lactose Intolerance is due to

hypersensitivity (reproducible, adverse reaction). Non-immune mediated

Case 7

62M Bloody diarrhoea Intense abdominal pain Therapy for heart palpitations

Ischaemic Colitis WEIGHT LOSS Case 1

22F Hypopigmented patches on

dorsum of hands Weight loss, loose stools and

oligomenorrhoea Examination: onycholysis, fine

tremor, resting tachycardia + warm peripheries


Thyrotoxicosis Hypopigmentation = vitiligo

associated with many autoimmune disorders

Signs of graves disease o Acropachy (pseudo-

clubbing of the nails) o Orbitopathy (eye disease) o Pre-tibial myxoedema

Start pts on carbimazole or propylthiouricil

Case 3

51F Weight loss, anorexia and swelling

of abdomen Unwell, pale, signs of a left pleural

effusion, hepatomegaly and shifting dullness in abdomen

Multiple opacities in both lung fiels Carcinomatosis

Signs of disseminated malignancy ascites, hepatomegaly and multiple pulmonary mets

Most likely cause = ovarian cancer presents late with intra-abdo mets

DYSPHAGIA Case 1

72M 6/12hx of progressive difficulty

swallowing Now only swallows small amounts

of fluid Lost 10kg in weight Wasted appearance

Oesophageal Carcinoma

Rapidly progressing dysphagia Weight loss + hypoproteinaemia =

highly suggestive Histological diagnosis confirmed

by oesophagoscopy Size of lesion seen on barium

swallow ! apple core lesion Case 2

45M 6/12hx of progressive difficulty

with speech and swallowing Weakness of facial muscles

bilaterally Absent jaw jerk

Bulbar Palsy

Palsy of tongue, muscles of mastication/deglutition and facial muscles due to loss of function of brainstem motor nuclei

Signs of LMN disease Seen in motor neurone disease,

but also Guillain-Barr, polio and brainstem tumours

NEVER affects extraocular movements how you distinguish from myasthenia gravis

Case 3

50F Chest pain associated with

regurgitation of solids and liquids, occurring shortly after swallowing

Dilated oesophagus + tapering lower oesophageal segment

Oesophageal manometry demonstrates failure of relaxation of lower oesophageal sphincter

Achalasia

Failure of relaxation of lower oesophageal sphincter

Presents between ages 30-60 Diagnosis = beak-like tapering

on barium swallow Case 4

26M Undergone renal transplant 3 day hx of odynophagia and

difficulty swallowing Barium swallow + endoscopy

show generalised ulceration of oesophagus

DHx: oral pred + ciclosporin Oesophageal Candidiasis

Short hx of symptoms + immunosuppression

Also seen in AIDS DISEASES OF THE STOMACH Case 1

63F 2/12 hx of anorexia, weight loss

and epigastric pain Iron-deficiency anaemia


Endoscopy shows thickened and rigid gastric wall without an obvious mass lesion

Biopsies show numerous signet-ring cells diffusely infiltrating the mucosa

Adenocarcinoma

Weight loss + anorexia + iron-deficiency anaemia (chronic bleeding)

Leather bottle stomach = gastric carcinoma which diffusely infiltrates all layers of the gastric wall

Signet-ring cells = poorly differentiated adenocarcinoma

Case 2

51M 3 month hx of weight loss +

dyspepsia Endoscopy shows heavy mucosal

folds + 2cm antral ulcer Biopsy shows heavy infiltrate of

atypical lymphocytes with clusters of intraepithelial lymphocytes

MALT Lymphoma

Lymphoma of mucosa-associated lymphoid tissue

Normal gastric mucosa is devoid of lymphocytes any infiltrate signifies disease

DD lies between gastritis and lymphoma

Atypical + intraepithelial involvement + thickened folds + ulceration = infiltration is lymphomatous

MALT lymphomas are the most common type of primary gastric lymphoma and are usually low-grade B cell type

Case 3

26M, HIV +ve 2 week hx of dyspepsia and

epigastric pain Endoscopy shows purple, plaque

like lesions Biopsies show slit-like vascular

spaces surrounded by proliferating spindle cells

Kaposis Sarcoma Endoscopic + histological features

= typical Also HIV +ve

Case 4

42M Long hx of epigastric discomfort

related to meals Endoscopy shows diffuse

erythema in antrum w/o obvious ulceration

Antral biopsies show infiltrate of lymphocytes, plasma cells and neutrophils in the gastric mucosa

Staining shows h. pylori infection Active Chronic Gastritis

Caused by h. pylori infection Presence of neutrophils shows

active inflammation Nb. 90% of h. pylori infections

cause duodenal ulcers INFLAMMATORY BOWEL DISEASE Case 1

34F Known UC 2 week hx of worsening jaundice ERCP shows beading of

intrahepatic ducts Sclerosing Cholangitis

Cholestatic jaundice with relatively raised alk phos

Beading ! strictures and dilatations

Principally associated with UC Case 2

27M CD Several small bowel resections Severe right sides loin pain, rigors

and haematuria Urine microscopy shows pus cells

and red cells but no organisms Oxalate Renal Stones

Oxalate is normally bound to calcium in terminal ileum, rendering it insoluble in the colon

With multiple bowel resections, this does not occur and so leads


to hyperoxaluria and stone formation

Case 3

26M 6/52 hx of weight loss, passage of

blood and mucus per rectum associated with diarrhoea

Complains of red, watery eyes UC diagnosed

Anterior Uveitis

Related to disease activity and can be associated with presenting symptoms

Equal presentation in UC and CD Case 4

19F 4 week hx of abdo pain and

bloody diarrhoea Enlarging ulcer on left shin

Pyoderma Gangrenosum

More common in UC Seen in IBD, vasculitic disorders

and haematological malignancies JAUNDICE Case 1

74M Acute chest infection Pyrexial, icteral sclerae, RLL

pneumonia Gilberts Syndrome

Unconjugated hyperbilirubinea Associated with acute illness Autosomal dominant inheritance Acute illness + raised bilirubin No other signs of deranged LFTs

Case 2

41M Acute jaundice, nausea, vomiting,

diarrhoea 3 weeks after returning for SE asia

o Bilirubin 43 o AST 432 o ALT 522 o Albumin 35 o INR 1.2

Acute phase IgM response demonstrated

Hepatitis A RNA virus spread by faeco-oral

route Causes acute illness associated

with jaundice, diarrhoea and fever Anti-HVA IgM response seen and

later IgG seen Case 3

61F Known polycythaemia rubra vera

admitted with worsening pruritis and jaundice

Icteric, tender hepatomegaly, ascites, peripheral oedema (marked sacral pad)

Budd-Chiari Syndrome

Hepatic vein obstruction secondary to thrombosis as a result of polycythaemia rubra vera

Disorder is known as Budd Chiari Syndrome

Arises secondary to thrombogenic disorders

Rarely can be due to congenital web within HPV

Diagnosis confirmed by USS/venography of HV and IVC

Treament: anticoagulation and treatment of underlying cause

Case 4

52F 6 week hx of worsening jaundice,

pruritis and weight loss Spider naevi, hepatomegaly,

jaundice Antimitochondrial antibodies

strongly positive Anti-smooth muscle antibodies

and anti-LKM antibodies - negative Primary Biliary Cirrhosis

Signs of chronic liver disease associated with acute jaundice

Autoantibodies are highly suggestive of PBC

Heralded by onset of pruritis + antimitochondrial antibody

Liver biopsy to determine stage + prognosis

Prognostic markers include albumin, bilirubin, PT, evidence of cirrhosis and portal HTN

Liver transplantation may be considered


Case 5 Obese 71m 2 week hx of worsening jaundice,

dark urine and pale stools Dilated CBD and gallbladder, no

gallstones Carcinoma of the Head of the Panreas

Symptoms of obstructive jaundice Painless therefore ASSUME

pancreatic cancer Other causes include

cholangiocarcinoma, herpatic tumours and obstructing tumours at ampulla of Vater

Diagnosis confirmed by ERCP/CT DISEASES OF THE LIVER Case 1

42M African LFTs abnormal high

transaminases Moderate-severe inflammation

seen on biopsy with mild fibrosis Special stains identify antigens

from a dsDNA virus within the cytoplasm of many hepatocytes

Chronic Hepatitis B

dsDNA = hepatitis B Not often preceeded by an acute

hepatitic illness Leads to hepatocyte damageby

causing expression of viral antigens on the cell surface ! destruction by immune system

Case 2

51M Pain in right hypochondrium Hepatomegaly 2cm below costal

margin Darkened skin compared to before LFTs show markedly raised

transaminases Biopsy shows cirrhosis and heavy

deposition of haemosiderin within the cytoplasm of hepatocytes and bile duct epithelium

Genetic Haemochromatosis

Defect in chr 6, near HLA-A locus Excessive absorption of iron in SI

Deposited as haemosiderin ! fibrosis ! cirrhosis

Can deposit in pancreas ! DM and heart ! HF

Darkened skin is due to raised levels of melanotrophin

Case 3 17M Symptoms and signs of chronic

liver disease High transaminases Chronic inflammation in portal

tracts + moderate fibrosis on biopsy

Prominent accumulation of copper-associated protein in periportal hepatocytes

Low serum caeruloplasmin + Cu Wilsons Disease

Inherited autosomal recessive disorder

Cooper accumulates in liver and basal ganglia of brain

Chr 13 defect ! abnormal copper-transporting ATP-ase and failure of liver to excrete Cu in bile

Accumulation leads to chronic hepatitis and cirrhosis

In the brain ! neurological disability

Children present with hepatic problems, adults present with neurological disease

Pathognomonic sign = Kayser Fleischer ring = Cu deposition in cornea

Causes of Ascites

Abdominal trauma Acute pancreatitis (high serum

amylase) Alcoholic cirrhosis (high yGT) Bacterial peritonitis CCF Hepatic vein occlusion Malignant mesothelioma Nephrotic syndrome (assoc. with

hypercholesterolaemia) Ovarian carcinoma (see

adenocarcinoma cells in ascitic fluid)

Tuberculosis (granulomas in ascitic fluid)


HEP B SEROLOGY

sAg: surface antigen; eAg: e antigen; eAb: e antibody; cAb: core antibodu

DNA virus Signs: fever, malaise, jaundice,

hepatomegaly, arthralgia, urticarial, deranged LFTs

Long term consequences: o Fibrosis o Cirrhosis o Hepatocellular carcinoma

DISORDERS OF THE PANCREAS Case 1

36F Long hx of gallstones 12hr hx of severe abdominal pain

radiating to back Tachycardic, tachypnoeic,

hypotensive Mildly raised bilirubin 6x serum amylase level USS shows stone in CBD

Acute Haemorrhagic Pancreatitis

Sudden onset abdominal pain + signs of shock

Common causes = alcohol and gallstones

Diagnosis depends on serum amylase

Raised amylase is also seen in other abdo emergencies (e.g. perfed DU) but if >5x normal = likely to be acute pancreatitis

Case 2

75F Painless obstructive jaundice 5cm mass on head of pancreas Malignant glandular cells on

aspirate Adenocarcinoma

Aspirate = diagnostic

Most common pancreatic neoplasm and occurs in the elderly

Presents with painless jaundice Weight loss + anorexia also occur

Case 3

56M, chronic alcoholic Repeated attacks of abdo pain

precipitated by bouts of heavy drinking

Loose, pale, greasy stools Calcification in peritoneal cavity

Chronic Pancreatitis

Upper abdo pain which develops gradually after meals/drinking

Pain radiates to back and is relieved by sitting rowards

Calcification = chronic calcifying pancreatitis ! intraductal calculi

Can lead to pancreatic insufficiency

Case 4

20M Fainted during rugby match Dizzy, palpitations then blacked

out Previous episodes related to

sport/exercise Insulinoma

Pancreatic islet-cell tumours than secrete insulin

Hypoglycaemia associated with exercise/fasting

Mostly cytologically benign DRUG SIDE EFFECTS

sAg eAg eAb cAb Resolved Infection

- - - +

Acute infection

+ +/- +/- +/-

Vaccinated + - - - Low infectivity

carrier + - + +

Naive - - - -

Drug Side Effect Isoniazid Ethambutol Rifampicin Pyrazinamide Streptomycin

Peripheral neuropathy Colour blindness Hepatic enzyme inducer, liver toxicity, OCP failure Liver toxicity Ototoxicity


GI Surgery UPPER GI DISEASE Case 1 (Gallstones)

41F Fever, abdo pain, nausea RUQ pain Intense shaking Icteral sclera

Jaundice

Increase in serum bilirubin Heme in RBCs broken down by

macrophages in spleen/bone marrow ! unconjungated bilirubin

Conjugated in liver Excreted into GI tract via biliary

tree Converted into urobilinogen in

terminal ileum Excretion: kidneys (via blood),

sterabilogen (via faeces) and re-excreted by liver

Causes

Pre-hepatic: unconjugated hyperbilirubinaemia e.g. hereditary spherocytosis

Hepatic: mix ! problem with liver excretion e.g. hepatitis, cirrhosis, drugs, humours

Post-hepatic: conjugated hyperbilirubinaemia ! obstruction; gallstones/tumours/infection

Gallstones/Biliary Colic

Contraction of gallbladder against an obstruction

Triggered by eating fatty foods Severe pain radiating to back Associated with nausea Positive murphys sign Tachycardia, non guarding Female, fat, fertile, forty

Stagnant bile ! ASCENDING CHOLANGITIS

Charcots triad (fever, rigors, jaundice)

Gram ve (e.coli) Urgen investigations watch BP

Cholecystitis can occur in absence of gallstones

Investigations include USS and ERCP

Treat via interventional elective cholecystectomy

Case 2

21 Severe burns Vomiting blood Pyrexial

= Curlings Ulcer Case 3

73 Persistent unexplained

dyspepsia Dysphasia Melaena

= Gastric Carcinoma Red flags = anorexia, melaena, progressive symptoms, age >55 Case 4

56 Hyperpigmented skin in left

axilla (acanthosis nigrans) Progressive anaemia and

dyspepsia

= Gastric Carcinoma Acanthosis nigricans Microcytic anaemia Dyspepsia, nausea, anorexia,

weight loss, satiety Virchows node Persistent unexplained dyspepsia Vomiting of fresh blood Leather bottle stomach, rigid thick

gastric wall CT/MRI staging Signet ring cells on biopsy Treatment: partial/complete

gastrectomy


Case 4 32 CLO test positive Abdominal pain after meals

= Peptic Ulcer Case 5

45 GI surgeon (?stressful) Raised INR Haematemesis after stag night

= Oesophageal Varices Oesophageal Carcinoma Progressive, rapid dysphagia, weight loss, cachexia

Low serum protein Diagnosis via oesophagoscopy Size assessed via barium swallow

apple core appearance Achalasia

Lower oesophageal sphincter failure

Food regurg Looks like beak line on swallow

Barretts Oesophagus

Metaplasia of distal oesophageal mucosa, consequence of GORD

Diagnosis with endoscopy, biopsy Treatment with regular

surveillance, PPI or mucosal ablation

Can progress to gastric carcinoma (30-40x more likely if untreated)

Peptic vs. Duodenal Ulcer Peptic Duodenal Pain immediately after meals

Pain 2-3h after meals/at night

Chronic Gastritis vs. MALT

Lymphocytes in stomach is bad Chronic gastritis = h. pylori,

plasma cell and lymphoid follicles, differentiated, erythematous, typical lymphocytes

MALT = B cell type lymphoma, intraepithelial involvement, thickened folds, atypical lymphocytes

Malignant vs. Chronic Ulcers Malignant ! ulcerating, heaped

up epithelium around crater, rolled, raised, everted

Chronic ! boundaries, fibrous scar tissue, inflammation, necrosis

Kaposis sarcoma ! AIDS, purple plaques/lesions in fundus, spindle cells

Pyloric Stenosis

Projective vomiting Succession splash Hypokalaemia Metabolic alkalosis Seen in babies

Oesophageal Stricture

Impact pain Regurgitation Barium swallow; benign ! PPI,

dilatation; malignant ! resection Oesophageal Varices

Haematemisis + macrocytic anaemia (direct effect on bone marrow)

Raised INR (liver toxicity) Seen in alcoholics portal HTN

secondary to liver disease Mallory Weiss Tear

Students, beer race Tear in mucosa at G-O junction Repeated retching and vomiting Bloods normal Self-limiting

Acute Erosive Gastritis

NSAIDs, alcohol, chemotherapy, stress

Melaena and anaemia seen Burns ! curlings ulcer Intracranial lesion ! cushings

ulcer Zollinger-Ellison Syndrome

Recurrent peptic ulceration Haematemsis Gastrin-secreting tumour from the

G cells of the pancreas (also in the stomach and duodenum)

Increased HCl in gastric antrum Multiple ulcers throughout upper

GIT Distal ulceration ! diarrhoea


Investigation Raised gastrin levels in serum US, CT, angiography 60% malignant; mets to local LNs,

liver Treatment

Lansoprazole, surgical resection MEN1 = multiple endocrine

neoplasia 1 (ZES presents as part of it)

Case 5

40 banker LUQ pain Radiating to back Hypotensive and tachycardic

= Acute pancreatitis Triad = HTN, low BP + resp failure Single best marker of prognosis? = Serum urea Amylase = raised 5x ! likely to be pancreatitis but can be duodenal ulcer Case 6

52 chronic alcoholic Presents with fullness,

epigastric pain and nausea Jaundice Palpable GB

= Pancreatic Carcinoma Causes = IGETSMASHED Acute Pancreatitis

Alcohol abuse Epigastric pain, radiates to back,

relieved by sitting forwards Clinical dehydration !

hypokalaemia Haemorrhagic ! anaemia Retching Inv: bloods and USS of liver WCC: raised, neutrophilia Modified Glasgow criteria =

prognostic (PANCREAS) A score >= 3 indicates Acute Severe Pancreatitis A score < 3 indicates Acute Mild Pancreatitis

PaO2 < 8kPa (60mmhg) Age > 55 years Neutrophils: (WBC >15 x109/l Calcium < 2mmol/l Renal function: (Urea > 16mmol/l) Enzymes: (AST/ALT > 200 iu/L or LDH > 600 iu/L) Albumin < 32g/l Sugar: (Glucose >10mmol/L) Pancreatic Pseudocyst

Possible complication of pancreatitis

Fever from infection and haemorrhage into lesser sac

Symptoms of pancreatitis and fullness

Insulinoma

Pancreatic islet cell tumour Hypoglycaemia upon

fasting/exercise Mostly benign Palpitations, dizziness, fainting,

diplopia, confusion Your typical young athlete

Pancreatic Adenocarcinoma

Painless, progressive jaundice Bad prognosis Risk factors: DM, smoking, alcohol 5th most common cause Courvoisiers law: if the gall

bladder is palpable and the patient is jaundiced, obstruction of the bile duct is unlikely to be a stone (i.e. a tumour!)

Stone ! inflammation ! fibrosis ! non-distensable GB

Older population, dark urine, pale stools, ALP>AST (obstructive)

Inv: tumour marker CA19-9 (also increased in biliary tract malignancies), CT

Palliative treatment Whipples

pancreatoduodenectomy: resection of head of pancreas + CBD + GB + distal stomach + duodenum

Abdominal Masses Case 1

60M


Severe acute onset abdo pain BP 90/60, HR 150 Expansile umbilical mass

AAA

Screening for men >65 5.5cm o Growth >1cm/year

Case 2

30M, Nigerian Abdominal mass and high fever Mass in LUQ Moves with respiration Cannot palpate above it

Splenomegaly

Haematological e.g. CML Portal HTN e.g. cirrhosis Storage diseases e.g. Gauchers

disease Systemic diseases Infections

Case 3

72F RIF mass Firm, irregular and 5cm in

diameter Lower edge is palpable Hb 9.5, WCC 5, MCV 70, Pk 150

Caecal Carcinoma

Caecal lesions = weight loss and anaemia

Sigmoid colon/rectal lesion change in bowel habit/PR bleed

Be suspicious if >40yo presenting with acute appendicitis

Case 4

45M, Indian Tender swelling below right

inguinal ligament Right hip held in flexed position Complains of excrutiating pain

despite taking paracetamol earlier

Psoas Abscess

Secondary to lumbar TB

Presents with abdo pain, fever, mass

If caused by spinal TB, also back pain

Differential = femoral hernia Affected hip often held in flexed

position Case 5

65yo alcoholic Epigastric tenderness Palpable mass CT shows fluid filled round

mass in epigastrium Pancreatic Pseudocyst

Late complication in 20% pancreatitis, especially alcoholic

Typically 6-8 weeks after episode Thick wall surrounding fluid Can occur in pancreas or lesser

peritoneal sac Complications: abscess, vessel

erosion, duodenal obstruction, rupture

CT/US guided drainage if large Case 6

50M 2 year history of dyspepsia Sudden onset, severe

epigastric pain Worse on movement One episode haemetemisis O/E = cold, sweaty, shallow

breaths Abdo is rigid and bowel sounds

absent CXR shows air under the

diaphragm Perforated Peptic Ulcer

Free air under diaphragm = perforation

Patient is shocked with abdo pain + worse with movement

If diaphragmatic irritation, referred pain to shoulder tip

Do erect CXR Immediate treatment = drip and

suck, analgesia, antibiotics, PPI Case 7

28M Hx of UC


Acute abdo pain, nausea, vomiting and bloody diarrhoea

Febrile, tachycardic and distended abdomen

AXR shows transverse colon with diameter of 6.5cm

Toxic Megacolon

Can lead to perforation, sepsis and shock

>6cm dilatation = diagnostic Toxic megacolon can be treated

with intravenous fluids, antibiotics and steroids

Colonoscopy contraindicated Appendicitis Clinical Diagnosis

Inflammation of vermiform appendix

Causes = faecolith, lymphoid hyperplasia, infection (parasitic/viral)

Tx: non operative vs. operative McBurneys point Rovsings sign

Case 8

65M Referred by GP with altered

bowel habit and rectal bleeding over 8 weeks

Blood is bright red and painless Reports tenesmus and weight

loss Investigation: Flexible sigmoidoscopy Colorectal Cancer

Predisposing factors: IBD, FAP, polyps, smoking, low fibre diet

Genetics: 1st degree relative 1:17, two 1st degree relatives = 1:10

Tx: must stage (TNM) ! chemoradiation/surgery

Flexi sig visualisation rectum and sigmoid, allows for biopsy

Case 9

83F Tiredness and weight loss over

6 weeks Mass in RIF Loss of 10kg

Investigation: colonoscopy (likely bowel cancer) Haemorrhoids

Disrupted and dilated anal cushions

3, 7, 11 oclock when in lithotomy position

1st degree - internal 2nd prolapse on defecation,

spontaneously reduce 3rd prolapse but require digital

reduction 4th persistent prolapse Tx: conservative, sclerosing

agents, banding, haemorrhoidectomy

Case 10

75M Hx of AF Abdo pain, vomiting and rectal

bleeding Blood is dark with altered

constituency O/E: pale, tachycardic, cold

peripheries Tender abdomen Bowel sounds difficult to here

Mesenteric Ischaemia

Hallmark: persisting abdo pain that is out of proportion for the clinical findings in high-risk patients

Mesenteric angiography to differentiate between occlusive/non-occlusive causes

Treatment: surgical, revascularisation or thrombolysis

Embolus ! embolectomy Thrombus ! aorto-mesenteric

bypass Case 11

45F RUQ and R shoulder pain Fever Murphys sign positive

Investigation: USS Case 12

23M


Abdominal pain Started over umbilicus and now

in RLQ Tachycardic, tender RIF and

Rovsings sign postive Investigation: Predominantly clinical, USS in females

GI##INFECTIOUS#DISEASES#

CAUSATIVE#ORGANISM# SPECIES# IDENTIFYING#FEATURES#Bacteria## Clostridium+difficile+++Salmonella+typhi+++++Bacillus+cereus+++Campylobacter+jejuni+++++Cholera+++Listeria+

Caused+by+antiobiotics+Plaques+on+colonoscopy++TYPHOID+Diarrhoea+Rose+spots+on+chest+Dry+cough++Diarrhoea+Reheated+rice++Diarrhoea+Unpasteurised+cheese+Ascending+weakness+(GBS)+Spiral+shaped+organism+on+LM++Rice+water+diarrhoea++Spontaneous+abortion++Virus# Noro/rota+virus++ Diarrhoea,+rapid+spread+Parasite## Giardia+(protozoa)++++Enteramoeba+histolytica+++Cryptosporidium+++Toxomplasmosa+Gondii+

Pasty,+bulky+diarrhoea+Flatulent++Ukraine++Diarrhoea+Liver+cysts++Diarrhoea+in+immunosuppressed++Toxoplasmosis++Kitten+faeces+Encephalitis,+brain+abscess,+diarrhoea+


Neurology Case 1:

Left sided weakness Unable to move arm 2hrs since onset

Management of Stroke

Consider thrombolysis until 4.5h AFTER onset of symptoms: alteplase or streptokinase

Contraindicated in o Haemorrhagic stroke o Improving symptoms o Severely impaired or

altered mental state o At high risk of bleeding o Pregnancy o Recent trauma, surgery or

lumbar puncture Alteplase = recombinant tissue

plasminogen activator If contraindicated use aspirin

Case 2

Able to speak, but sentences make little sense

Types of Stroke

Middle cerebral artery affected Wernickes area =

UNDERSTANDING Brocas area = speech formation

broken speech Receptive vs. Expressive Dysphasia

Receptive: o Wernickes aphasia o Left tempero-parietal

damage o Can speak fluently but

doesnt make sense o Grammatical mistakes o Jumbled sentences o Potential inability to

comprehend language Expressive:

o Brocas aphasia o Left frontal lobe o Cannot initiate language o Few disjointed words o Unable to construct

sentences

Artery Regions and Symptoms MCA

Very common Contralateral weakness Greater face/arms than legs Dysphasia Neglect

ACA Rare Contralateral weakness Greater in legs than

arms/face PCA

Varied visual defects Vertebral Artery

More common than PCA Causes lateral medullary

syndrome AKA Wallenbergs syndrome DANISH Acute vertigo (damage to

VESTIBULAR NUCLEUS) Cerebellar signs ataxia/past-

pointing/dysdiadochokinesia = damage to cerebellar penduncle

Ipsilateral horners syndrome o PTOSIS o ANHIDROSIS o MIOSIS

Posterior Inferior Cerebellar Artery

Less common than VA


Lateral medullary syndrome Acute vertigo Cerebellar signs Ipsilateral horners syndrome

Case 3:

57yo M T2DM Confusion, dizziness, anxious,

loses consciousness Regains consciousness after 5

minutes Most likely to be HYPOGLYCAEMIA Autonomic Signs:

Sweating Anxiety Tremor Palpitations Tremor Dizziness

Neuroglycopenic signs

Confusion Drowsiness Visual problems Seizures Coma Hemiparesis (rare)

Case 4: Who should you anticoagulate? CHA2DS2-VASc SCORING 0 = no therapy

1 = moderate risk: warfarin (INR 2-3) or novel drug treatment (dabigatran) >2 = high risk: DABIGATRAN (or warf) CHF or LVEF 75 = 2 DIABETES = 1 STROKE/TIA/THROMBOEMBOLISM = 2 VASCULAR DISEASE = 1 AGE 65-74 = 1 SEX CATEGORY: FEMALE = 1 HEADACHE Case 1:

18F 2/12 pain above eye since

started revising Feels sick Lies in dark room to recover

Migraine >2: Unilateral/bilateral headache Pulsating Worsened by physical activity + >1 Nausea/vomiting Photophobia/phonia 1/3 occur with aura

Visual Sensory Speech

Triggers: stress, depression, menstruation, menopause, food Tension Headache

Band across forehead Associate with stress Classically EMQ of student doing

exams Case 2:

74M Recent onset, severe headache Fatigue Weight loss Sore throat Red face


Temporal Arteritis Granulomatous infiltration of small -> large size arteries

Most common in ELDERLY Decreased pulsatility of temporal

pulse ESR >50 New onset of headaches See abnormal

MULTINUCLEATED GIANT CELLS

Jaw claudication Scalp tenderness Associated with polymyalgia

rheumatic Rarer manifestations

10% show respiratory symptoms Weight loss Fever Fatigue Bruits of subclavian, axillary and

brachial arteries Temporal redness

Case 3:

58M Indian Electric shooting pain when

brushing teeth Thinning beard

Trigeminal Neuralgia

Paroxysmal attacks, varying in 2-20 minutes in length

Sharp/intense/burning/stabbing sensation

Trigger factors in trigger area e.g. brushing teeth in V3

Tic douloueux Caused by compression of the

trigeminal nerve root (15% tumour)

Case 4:

82F Progressively worsening

headache Too much alcohol More forgetful than usual

Skull = middle meningeal artery (extradural) Dura Mater = venous (subdural) Arachnoid Mater

Pia Mater Extradural Haemorrhage

Sharp Bang Loss consciousness > lucid period

> compression of brain > coning of brainstem > vomiting > drowsiness > neurological symptoms > death

Subdural Haemorrhage

Seen in ELDERLY and ALCOHOLICS brain shrinks, veins stretch and can rupture

Slow bleeding Symptoms progressively develop

over weeks/months Classic = fall, progressively

worsening headache > neurological deficits

Also more likely in anticoagulated patients

Case 5:

34M 45 minute headaches every

night Bangs head on floor to relieve

severe pain Cluster Headaches Severe orbital, supraorbital or temporal pain

Lasts 15min-3hr Occurs in clusters Often wakes people up at night Agitations

Cranial Autonomic Features

Ipsilateral lacrimation Ipsilateral conjunctival infection Ipsilateral rhinorrhoea Ipsilateral ptosis Ipsilateral oedema of eyelid

Case 6:

19M Pakistani parents 2 months of weight loss and

headaches Worse since getting a cold Waking in the night with pain

Space-Occupying Lesion

Progressively worsening over time


Progressively worsening neurological signs

Heaches which is present on waking

Worse on coughing, sneezing, defaecating, bending over

DEMENTIA Case 1:

65M, HTN Severe memory loss and

slowness of thought over weeks

Wife reports memory problems for one year

Marked deterioration 2/12 = Vascular Dementia Case 2:

85F Increasingly forgetful over past

few years Deteriorated fails to

recognise immediate family on occasions

Often doesnt make sense when speaking

= Alzheimers Case 3:

61M Recently become increasingly

aggressive Shouting inappropriate remarks

in public Increasingly cold and irritable

towards own family = Picks disease (fronto-temporal dementia) Case 4:

72F Rapid decline in cognitive

function over days Memory/speech affected Jerky myoclonic movements of

her limbs

Passed away 3 months later = CJD

Rapidly progressive -> death within months

Myoclonus Memory loss, personality change, hallucination PRION proteins -> sponge-like

degeneration of brain tissue Commonly sporadic (sCJD) but

can be variant (vCJD) due to eating contaminated meat (mad cow disease)

Case 5:

Wife of 75M reports frequent episodes of slowness and inattentiveness for hours

Patient tells you he has been experiencing vivid visual hallucinations

Patient has increased tone in both arms

Slow to follow motor instructons

= Lewy body Dementia (Parkinsonian features)

Case 6:

Ex-American Football player Deterioration in memory

Alzheimers Vascular Dementia

Picks Disease (Fronto-temporal)

Lewy Body

Memory loss Impaired speech/verbal ability Loss of executive function Visuo-spatial symptoms (gets lost)

Disinhibition Personality change Inappropriate behaviour Memory often preserved

Hallucinations (visual) Sleep disturbance Resembles Alzheimers Memory, language and understanding all affected

Gradual Stepwise Earlier onset (


Poor mood Struggles to find right words

when speaking Continues to worsen over years

= Chronic Traumatic Encephalopathy

Athletes e.g. boxers, football players who experience recurrent head trauma

Develop features of alzheimers in their 40s

COLLAPSE Case 1:

21M Large amounts of dilute urine Tremor and dizziness after

sport, then collapses = Hypoglycaemia

DIABETICS Incorrect medication dose, missed

meals or exercise Tremor, sweating, dizziness

Case 2:

36F Collapse after finding out about

death of close family member Unconscious for a few minutes Limbs continue to move,

making frequent, erratic movements

= Vaso-vagal syncope

Emotion/pain/fear/standing for too long

Nausea, going pale Clonic jerking (no stiffness)

Stokes-Adams Attacks

ARRHYTHMIA -> reduced CO and LOC

Pale, slow/absent pulse -> flushing upon recovery

Drop Attacks

Elderly woman Weakness of legs -> fall with no

LOC or confusion

Carotid Sinus Syncope Shaving, head turning -> dizziness

and syncope Epilepsy

AURA Tonic-clonic sequence Tongue-biting, incontinence Post-ictal confusion

Generalised Seizures

No localizing features Tonic-clonic = loss of

consciousness, increased tone and jerking

Absence = brief pause mid-sentence

Myoclonic = single sudden jerk of limb/trunk

Simple Partial Seizure

Restricted to one part of brain, no LOC

Can vary from motor disturbance (Jacksonian) to a funny turn or strange sensation

No post-ictal confusion or amnesia Case 3:

28F Smacking lips and strange

chewing movements at work Stares blankly at colleagues

during episodes Patient confused afterwards

with no recollection Felt dj vu earlier in the day

= Complex partial seizure

Typically start with an aura, which is the simple partial component

-> Automatisms such as lip smacking, wandering around

Awareness is impaired Case 4:

16M Stiff and shakes violently Right arm was shaking before

collapse = Partial seizure with secondary generalisation

Begins as a partial seizure (sensory/motor/automatism)

Develops into LOC and convulsions


Status Epilepticus Seizures lasting >30 minutes with

no consciousness regained inbetween

Tonic-clonic Treatment

Open and maintain airway, 100% O2

IV Lorazepam bolus + 50% glucose

o Rectal diazepam or oral midazolam if IV access impossible

If seizures continue, IV Phenytoin

If still no response -> general anaesthetic

WEAKNESS Approaching Weakness: categorise into

UMN and LMN, or Brain/SC/PNs/NMJ/muscle

UMN

Spasticity Hyper-reflexia Babinksi

LMN

Muscle wasting Floppy paralysis Fasciculations

Brain

UMN signs Focal signs according to lesion

e.g. hemiparesis, haemianopias General signs e.g. headache,

vomiting Spinal Cord

E.g. MS, transverse myeltitis, trauma, malignancy

UMN signs Focal lesions e.g. vision (optic

neuritis, nystagmus), bladder/bowel incontinence, bulbar signs (swallowing, speech)

Peripheral Signs

Spinal root compression, plexus injuries

Look for LMN signs

NMJ E.g. myasthenia gravis, Lambert-

eaton syndrome, organophosphate poisoning, botulism

Affects multiple muscle groups LMN signs

Muscle

E.g. muscular dystrophy, hypothyroidism

Tend to result in muscle wasting and specific functional difficulties relating to proximal weakness

Signs of proximal myopathy include difficulty in getting out of chairs and difficulty climbing stairs

Case 1:

65F Sudden-onset right sided

weakness of face and arm History of HTN takes

amlodipine Right arm is rigid and hyper-

reflexic = CVA Case 2:

50M Smoker 6 month hx of SOB and 2 day

hx of haemoptysis Weight loss of 1 stone in 1

month Peripheral nerve examination

shows weakness in arms/legs, but improved when repeated later

= Lambert Eaton Syndrome

Paraneoplastic (assoc. with small cell lung cancer) or autoimmune

Antibodies against presynaptic calcium channel

Proximal muscle weakness and gait abnormalities

Case 3:

40F Droopy eyelids Hard to swallow, cannot

complete meal


Hyperthyroidism Voice trails off at end of

sentences = Myaesthenia Gravis

Antibody against ACh receptor Oculomotor/bulbar signs

predominate

LE MG

Improves with exercise Less Ca in cleft, therefore requires multiple APs before muscle moves

Worsens with exercise More weakness over time as need Ache to break down the ACh to free up receptors

Case 4:

4M Not able to run like peers Waddle when walks Falls over frequently Difficulty climbing stairs Positive Gowers sign

= Muscular Dystrophy Case 5:

30F 2 day hx of pain and loss of

vision in left eye

Happened 6 months ago but resolved spontaneously

Reduced fine touch sensation in both feet + weakness

= Multiple Sclerosis

Optic neuritis is most common presentation

Weakness Fatigue Paraesthesia Paralysis Relapsing-remitting, secondary

progressive, primary progressive RR: get better, then relapse, then get better Eventually can progress to secondary progressive PP: death at 5-10 years ALCOHOL Impacts on

Brain Liver Nutrition Trauma Social Other substance abuse Immunosuppression

Case 1:

45F Post-op (gall bladder) Agitated, shouting incoherently

and convinced she is covered in spiders

= Delirium Tremens

Alcohol withdrawal state Agitation, confusion, fluctuating

consciousness, seizures, arrhythmias, visual/tactile hallucinations

Treat with benzodiazepines (CHLORDIAZEPOXIDE)

Case 2:

Known alcoholic Slurred speech, cannot walk

straight, floppy sat in chair Blood alcohol level = 0


= Cerebellar Syndrome

DANISH Dysdiadochokinesia Ataxia Nystagmus Intention tremor Slurred speech Hypotonia

Case 3:

39M 40 units a week for 5 years Numbness/tingling in toes for 4

months Impotence

= Peripheral Neuropathy

Commonest cause are DIABETES and B12 DEFICIENCY

Glove & stocking distribution Usually symmetrical Can also cause impotence and

autonomic dysfunction (B12 def) Case 4:

60 year old publican Increasingly confused over

weeks Vomiting for few days Intermittent consciousness

= Subdural haemorrhage

Cerebral atrophy (alcohol!) Frequent falls (drunk!) Clotting disorder (liver failure!) DD: CVS, other intracerebral

bleed, SOL, meningitis, encephalitis)

Case 5:

50M, Irish Mumbling incoherently Not sure where he is Complains of double vision Recalls the prime minister as

Bertrand Ebstein Claims came on moped which

he borrowed from Robbie = Wernicke-Korsakoffs Syndrome

Due to untreated Wernickes Anterograde amnesia Confabulation

Alcoholics also get other types of dementia (10% causes)

Wernickes Encephalopathy

Confusion Ataxia Opthalmoplegia TX: IV Pabrinex (thiamine

[B1], riboflavin [B2], nicotinamide [B3], pyridoxine [B6], ascorbic acid [vit C]

Case 6:

60M Reducing GCS Swollen abdomen Yellow sclera Sickly sweet smell of breath =

FETOR HEPATICUS = Decompensated Liver Failure

Leads to hepatic encephalopathy Inverted sleep-wake cycle = first

sign Due to ammonia and other waste

substances crossing BBB Lethargy, personality change Worsening confusion and LOC Signs of liver failure e.g. fetor

hepaticus, jaundice Cure = transplant

NERVE INJURY

Nerve Feature Median Nerve (C6-T1) Ulnar Nerve (C8-T1) Radial Nerve (C5-T1) Klumpkes Palsy Erbs Palsy Common Peroneal Nerve (L4-S1) Tibial Nerve (L4-S3)

Wasting of thenar eminence Loss of sensation in lateral palmar surface of 3 and a half digits Test for weakness in abductor pollicis brevis Frequently affected in carpal tunnel syndrome Wasting of hypothenar eminence Sensory loss over medial one and a half digits Test for weakness of abductor digiti minimi Claw hand Weakness of wrist extension ! wrist drop Anaesthesia over fist dorsal interosseous muscle Paralysis of intrinsic muscles of hand Loss of sensation in ulnar distribution Horners syndrome sometimes present Loss of shoulder abduction and elbow flexion Arm held internally rotated Waiters tip Weakness in dorsiflexion and eversion of the foot Sensory loss over dorsum of foot Hit in side of knee Inability to invert food or stand on tip-toe Sensory loss on sole of foot

Stroke: Symptoms and Signs

Site of Stroke Symptoms/Signs Anterior Circulation Posterior Circulation Dominant Frontal Lobe (Brocas Area) Dominant Temperoparietal Lobe (Wernickes Area) PICA Thrombosis (Lateral Medullary Syndrome)

Unilateral weakness/sensory deficit Homonymous hemianopia Higher cerebral dysfunction e.g. dysphasia/neglect Cranial nerve palsy/cerebellar signs Vertigo, dysarthria, ataxia, choking Isolated homonymous hemianopia Patient can understand you Replies in broken speech = Brocas (expressive) dysphasia Patient has impaired comprehension Speech is fluent with jargon = Wernickes (receptive) dysphasia Vertigo, vomiting, dysphagia Ipsilaterally: ataxia, Horners, nerve V/VI palsy Contralaterally: loss of pain/temperature/sensation in face

! ! CAUSES!OF!MENINGITIS!!

!!Management:!1st!line:!blood!culture,!gold!standard:!LP!

ORGANISM! SPECIES! CNS!FLUID!! ! Treatment!

Bacterial! S.!pneumonia!N.!meningitides!H.!influenzae!Listeria!!M.!tuberculosis!Neutrophilia!Low!Glucose!High!protein!!!Lymphocytosis!Low!glucose!High!protein!!

! Ceftriaxone/cephalosporin!(IV)!Benzylpenicillin!!!Give!dexamethasone!(steroid)!for!streptococcus!and!in!children!Fungal! Cryptococcus!neoformans! Lymphocytosis!Low!glucose!High!protein!!

! Varies!!Viral! HSA! Lymphocytosis!Normal!glucose!Normal!protein!!

! Acyclovir!!

HEADACHES: SUMMARY Name Site Character Severity Time Associated

Symptoms Predisposing Factors

High Risk Groups

Migraine Unilateral or bilateral

Can be pulsation Moderate severe

4-72 hours Nausea, vomiting, photophobia, photophonia

Caffeine, chocolate

Women

Tension Headache

Temporal Band Band-like Mild N/a None at all Stress Students

Temporal arteritis

Temporal General pain Moderate - severe

New onset Polymyalgia rheumatica, respiratory symptoms, jaw claudication

Parvovirus B19 >50 years old

Trigeminal Neuralgia

V2/3 Sharp, stabbing, burning

Intense 2s-20min Caused by shaving, brushing teeth, wind on face etc.

None 15% have tumour

Cluster Headaches

Unilateral, orbital or supraorbital

Hot metal poking into eye

Extremely severe 15min 3hrs Running, red and swollen eye Runny nose

None All ages

Subdural General General Progressively worsens

Worsens over weeks/months

Worsening neuro signs

Fall or head injury

Elderly, anticoagulated, EtOH

Extradural General General Severe Worsens over hours

Worsening neuro signs after lucid interval

Large head injury

SOC General General Increases in severity can be very painful

Progresses over months

Worsening neuro signs

Worse in morning, coughing, sneezing, bending over


Renal Medicine PHYSIOLOGICAL KIDNEY FUNCTION Main role is waste removal

Occurs in glomerulus Mainly creatinine, urea and drugs Also involved in reabsorption of

Na and H2O Rapid exchange of Na and K in the

DCT Renin-Angiotensin-Aldosterone Axis

Involved in regulating BP Renin coverts ang ang I Then converted to ang-II by ACE Results in water retention via

aldosterone Vitamin D Regulation

Kidney controls how much Ca is reabsorbed

Phosphate

High phosphate ! PTH secretion Therefore must regulate

phosphate excretion to stop bone reabsorption and high blood Ca

Acid-Base Balance

H+ and HCO3- regulated by kidney

RBCs

EPO produced by kidney Influenced RBC formation (and

some platelets) CHRONIC RENAL FAILURE Case 1

17 child Chronic renal failure Severe anaemia Iron studies within normal

limits Most appropriate treatment

Recombinant erythropoietin injection

Case 2 54M Stage 3 CRF Bone pain Ca low Alk phos high

Test to confirm pathology

DEXA scan Diagnosis = renal osteodystrophy

Renal Osteodystrophy

High phosphate due to inadequate excretion

Low Ca due to low calcitriol and poor renal reabsorption

Increased PTH Increased bone reabsorption Osteoporosis on DEXA = bone

density scan Give Ca and Vit D supplements to

reduce PTH levels Case 3

35F Kidney transplant 6 months

ago Swelling in neck Constipation, low mood Calcifications in kidney GFR normal

Diagnosis

Tertiary hyperparathyroidism Hyperparathyroidism

Primary = problem with parathyroid (adenoma) autonomous secretion of PTH

Secondary = physiological reaction to low Ca or high Phos ! high PTH

Tertiary = prolonged secondary hyperparathyroidism, so parathyroidism becomes autonomous ! inappropriate PTH secretion

o Used to being in CRF therefore gland doesnt know what to do after transplant as Ca is normal!


She has stones + groans + moans = hypercalcaemia

Swelling in neck suggests a thyroid/parathyroid problem it is hyperplasia

CRF Overview Drugs contraindicated in renal failure

Potassium sparing diuretics NSAIDs Gentamicin

CRF

GFR 3 months 5 stages End stage is


Likely diagnosis Schistosomiasis Key is terminal = lower down in

urinary tract (malaria causes haemolysis therefore blood would be present throughout)

Schistosomiasis

Lots of different species S. Haematobium causes urinary

schisto (commonly in Africa and the Middle East)

Transmission: drinking/swimming in water with schisto eggs

Increased risk of squamous cell carcinoma of the bladder

Case 4

35 year old man comes to A&E with severe left flank pain

Comes in waves Most appropriate next step

CT KUB Renal Colic

Ask about o Loin to groin pain

(writhing in agony!) o Haematuria o Frequency o Dysuria o Rigors o Fever o Hx of stones or recurrent

UTIs Abx: nitrofurantoin, ciprofloxacin,

augmentin (if infection present) Differentials for Renal Colic

Biliary colic Pyelonephritis Acute

Documents

Nina Cooper MedED EMQ Notes