Final MBBS Notes

Meningitis : Long Case

2013-07-16T10:13:00.003-07:00

CONTENTS

History
Examination
Summary
List of problems
Management plan
Possible questions that could be asked during the discussion

Meningitis is one of the commonest long case topics. It is more commonly given in Pediatrics than in Medicine. The format includes the history, examination, summary, list of problems and management. First, a proper history should be taken.

HISTORY

Introduction of the patient

Name
Sex
Age
From
Occupation
History is taken from .................... who is educated up to .................. and the history is reliable

Presenting Complaint

The typical presentation of a child with meningitis is fever with drowsiness. As usual, first the presenting complaint should be written with the duration.

History of presenting complaint

History of presenting complaint should start from the last time where the child was OK. Then the the sequence of event should be told like a story. Make sure to mention all the medications the child was given as well. Each and every presenting symptom should be analyzed thoroughly. For example, if we take fever, the following aspects should be asked.

Onset
Is it intermittent, remitent or persistent
The time it takes for the fever to rise up to the maximum level
How long the fever stays at its peak
How long does it takes the fever to settle down
How many fever spikes a day
Does the fever responds to paracetamol
Presence of any associated symptoms? (arthralgia, myalgia, chills and rigors)
Nausea, vomiting
Associated skin rash

Meningitis is common among infants and it cause a lot damage to the developing brain. Therefore, whenever an infant comes with fever, meningitis lies high in the list, because it should be identified and treated as soon as possible to minimize the damage to the brain.

If the parents say that the child is drowsy, describe the level of consciousness according to the parents. After analyzing the presenting symptoms, the next thing is to have a list of differential diagnosis. A child can have fever with altered level of consciousness for several reasons. They are,

Encephalitis
Meningitis
Drugs
Electrolyte imbalances
Dehydration
Hypoglycemia
Seizures
Toxins
Delirium due to high fever

The analysis of the presenting symptoms may give a clue to the diagnosis, but you will have to ask specific questions to find specific symptoms that could support the diagnosis. If the child is having meningitis, he will have other features of meningitis such as photophobia and phonophobia. They might have associated nausea, vomiting, etc. If the child have severely altered conscious level, he is more likely to have encephalitis more than meningitis.

Then you will have to ask questions to exclude or confirm other above mentioned differential diagnoses. Ask whether the child has access to any drugs. If the child has vomited or has had severe diarrhea, he can be having electrolyte imbalances. Ask about level of hydration. Also inquire whether the parents have noticed any abnormal movements in the child's body. Toxins are also a common cause of altered level of consciousness, so ask about the presence of toxins in the house. Sometimes the fever itself can cause altered level of consciousness. Therefore, ask whether the child had very high fever.

In the history, you should ask things that could affect your management. If the child is having meningitis he can have increased intracranial pressure as a complication. If the child is having increased intracranial pressure, lumbar puncture cannot be done to obtain cerebrospinal fluid. Therefore, you should ask for features of increased intracranial pressure such as nausea, vomiting, etc.

Inquire about all other systemic symptoms to exclude or to confirm the diagnosis. Then complete other parts of the history.

Past medical history

Specifically ask about seizures and febrile fits.

Birth history
Surgical history

History of head injury

Allergic history
Immunization history
Development
Family history

family history of fits

Social history
Dietary history

Examination

General examination

Since the child is having fever, a thorough head to feet examination should be carried out to find out whether there is any septic focus.

Temperature
Ear discharge
Skin rashes

seen in meningococcal meningitis

Neck stiffness - Meningitis is inflammation of the meninges. When the neck is flexed the inflammed meninges are stretched, causing pain. So, the child will have pain when you bent his neck anteriorly. In very little children neck stiffness is not present, therefore meningitis cannot be excluded with absence of neck stiffness.
Kernig's sign - This also checks the presence of meningial inflammation. The child is kept in the supine position. Then his hip is flexed slowly with fully flexed knees. When the hip is fully flexed, the knee is slowly extended. If the child feels pain when the knee is extended, the kernig's sing is said to be positive.
Also check the hydration level of the child by looking at the capillary refill time.
BCG scar

Cardiovascular System Examination

Do a thorough cardiovascular system examination to find out the features of septicemia such as tachycardia, hypotention, etc.

Respiratory System Examination

Tachypnea
Features of respiratory tract infection - respiratory tract is one of the commonest sites of spread of organisms to the blood.

Nervous System Examination

Especially check the fundi for papilloedema to find out the presence of increased intracranial pressure.
Look for features of focal neurological signs.

Abdominal Examination

Abdominal examination may reveal hepatosplenomegally due to septicemia in meningitis.

SUMMARY

The summary should include the most important parts of the history and examination. Important positive and negative findings should be included in the summary. Usually a summary should not be longer than 4 to 5 sentenses.

PROBLEM LIST

The aim of taking a history and examination is to formulate a comprehensive list of problems. Identify your patient's problems and categorize them as follows. Formulation of a comprehensive list of problems is the key to successful management of your patient.

Medical Problems

Acute problems
Chronic problems

Psychological Problems
Social Problems

MANAGEMENT

Address each and every problem in your problem list, through your management plan. Form a list of investigations that you would like to perform for your patient. Be prepared to justify why you are doing each and every investigation in your list. During the presentation of the case, make sure to mention the investigations along with reasons to do them before the examiner ask you.

Cerebrospinal Fluid analysis (full report and culture) - to find out the etiological organism.
CT scan of the brain to visualize the changes and to exclude increased intracranial pressure.
Full blood count to see the signs of infections. If there is a bacterial infection, there will be neutrophil lekocytosis. If there is a viral infection, there will be lymphocytic leukocytosis.
Blood culture
Random blood sugar to see whether the child is hypoglycemic
Serum electrolytes to see whether there is any electrolyte imbalances that might have given rise to altered level of consciousness.

DISCUSSION

Possible questions during discussion are,

How do you manage this patient?
How do you perform lumbar puncture in this patient?
What are the contraindications for lumbar puncture?

Cardiopulmonary instability
Focal neurological signs
Signs of increased intracranial pressure (high blood pressure, bradycardia, coma)
Coagulapathy
Thrombocytopenia
Local infection at the site of lumbar puncture

What are the things that you are going to look for in a CSF analysis report?
How do you diagnose the type of organism by the CSF report?
What are the features of CSF report in a partial treated meningitis?
What are the organisms that can be the cause of meningitis in this child?
How do you calculate the fluid requirement of the child? The child is not given all the fluid required because he is at risk of developing syndrome of inappropriate ADH (SIADH) secretion. So, he will be given only 2/3 rd of his fluid requirement.
What are the antibiotics you are going to give him? How long?
What is the role of dexamethosane in meningitis?
How do you assess the patient during daily ward round?
How do you give prophylaxis for contacts of a patient with meningococcal meningitis?
What are the complications of meningitis?

Hemophilia : Long Case

2013-07-13T08:13:00.000-07:00

CONTENTS

History
Examination
Summary
List of problems
Management plan
Possible questions that could be asked during the discussion

Hemophilia is one of the commonest long case topics. It is more commonly given in Pediatrics than in Medicine. The format includes the history, examination, summary, list of problems and management. First, a proper history should be taken.

HISTORY

Introduction of the patient

Name
Sex
Age
From
Occupation
History is taken from .................... who is educated up to .................. and the history is reliable

Presenting Complain

If you are given a patient with hemophilia, the parents or the guardians know the diagnosis. The aim of the history in a patient with hemophilia is mainly to find management difficulties, to inquire about complications of the illness and to find out other problems. The diagnosis has already been made and the parents often know the type of hemophilia the child has. Therefore, history may not be taken to diagnose the disease. Therefore, the presenting complaint can be begun as "This is a diagnosed patient with hemophilia A, present to hospital for routine factor transfusion". Sometimes, patients with hemophilia presents with episodes of bleeding.

History of presenting complaint (HPC)

Do not start the history by saying that the child is a product of consanguineous marriage as usual. Hemophilia is an X linked recessive disorder. Therefore, consanguinity doesn't have any effect on the disease. You can start the history by saying that the child is with a history hemophilia from the mothers side of the family.

Start from birth and tell what happened since then like a story. Make sure to focus on the followings.

Onset of symptoms
Sites of bleeding
Severity of bleeding
Bleeding during crawling period
Whether the bleeding occurred spontaneously or after trauma
Time taken to bleed after trauma
What was done and how the child was diagnosed
History of seizures indicating intracranial bleeding
Presence of a target joint - target joint is a joint where repeated bleeding has occurred. With repeated attacks of bleeding ultimately cause osteoarthritis of the joint and bony spike formation which ultimately lead to joint deformity.
History of muscle bleeding - disabilities and treatments taken should be explained
Spontaneous appearance of echymotic patches
History of hematuria
Also explain the treatments the child is on. Mention the frequency of factor transfusion. Most parents know if the child has developed inhibitors. If the child has developed inhibitors, say what has been done regarding them.
Then describe the present problem. If the child is presented with another attack of bleeding, describe the circumstances, severity of bleeding. Also mention what was done at home.

Past medical history

blood group
blood transfusion related complications

infections - HIV, hepatitis B and C, malaria

Past surgical history - bleeding after tooth extraction
Immunization history - bleeding after intramuscular injections
Allergic history
Social history

Hemophilia requires regular factor transfusion. This can interfere with schooling of the child.
Mention about the education level of the parents and their understanding regarding the illness.
Other siblings affected
Income
Nearest hospital
Transport facilities
Most people now know that hemophilia is a disease that you inherit from your mother. This can give rise to many social obstacles. For example, the farther's side relatives of the child can blame the mother for bringing a defective gene in to the family.

Other than hemophilia, there are other bleeding disorders that can be given as your long case. Most of the time this is the first presentation of the disease. In such situations you should take to exclude each and every diagnosis. The history will be the same but some aspects of the history should be altered accordingly. Von willebrand disease, Idiopathic thrombocytopenic purpura, liver disease and SLE are some of the common bleeding disorders that can be presented to you as your long case. Therefore, read about them and be prepared to answer the questions that can arise during the discussion.

Examination

General Examination

General appearance - depressed, in pain
Pallor
Petechiae
Purpura
Echymosis
Gum bleeding
Features of systemic lupus erythematosus
Joint swelling, deformity, contractures, level of disability
Look for any hidden sites of bleeding

Complete system examination and note down any abnormalities found. Nervous system examination is important in cases of intacranial bleeding.

Summary

A comprehensive summary should be prepared to show the main problems.

List of Problems

Categorize the problems as,

Medical problems

acute
chronic

Psychological problems
Social problems

Management Plan

Address each and every problem you have identify.

List the investigations that you will order.

Full blood count to know the degree of anemia, platelet count and white cell count

Possible Questions that could be Asked During Discussion

Does the child has a target joint?
The factor level requirement of the child.
Factor requirement of the child if the child were to undergo a major surgery
If the child presents with features of intracranial bleeding, what is your initial management?
The place of gene therapy

Thalassemia: Long Case

2013-07-13T02:53:00.001-07:00

CONTENTS

History
Examination
Summary
List of problems
Management plan
Possible questions that could be asked during the discussion

Thalassemia is one of the commonest long case topics. It is more commonly given in Paediatrics than in Medicine. The format includes the history, examination, summary, list of problems and management. First, a proper history should be taken.

HISTORY

Introduction of the patient

Name
Sex
Age
From
Occupation
History is taken from .................... who is educated up to .................. and the history is reliable

Presenting Complain

If you are given a thalassemia patient, the parents or the guardians know the diagnosis. The aim of the history in a patient with thalassemia is mainly to find management difficulties, to inquire about complications of the illness and to find out other problems. The diagnosis has already been made and the parents often know the type of thalassemia and the type of medication which the child is on. Therefore, history may not be taken to diagnose the disease. Therefore, the presenting complaint can be begun as "This is a diagnosed patient with thalassemia major, present to hospital for routine blood transfusion".

History of presenting complaint (HPC)

Start the HPC by mentioning whether the child is a product of a consanguineous marriage or not. Then, start telling the story from the birth up to the diagnosis of the disease with special emphasis on the following details. If there are other affected family members, mention about them too.

Was the child normal at birth
What were the initial symptoms and the age of onset of symptoms - children with thalassemia major show symptoms at the age of 6 months. This is the age at which most of the red blood cells with fetal hemoglobin are replaced by red blood cells with adult hemoglobin. Children with thalassemia intermedia have a late presentation.
The presenting symptoms at the time of diagnosis could be pallor, poor appetite, failure to thrive, vomiting, sleeplessness, irritability, jaundice, etc.
Then describe how the diagnosis was made and the treatment the child is on.
Describe the frequency of blood transfusion, iron levels just before each blood transfusion, the type of chelator the child is on, last ferritin level. Ideally, the hemoglobin level just before blood transfusion should be around 10 g/dl. If it is low, it indicated inadequate blood transfusion.The ferretin levels should not exceed 1000ng/ml. If it is >1000ng/ml, iron chelation should be started.

Then you should focus on the complications of the disease, complications of blood tranfusion and side effects of iron chelators.

Complications of the disease - bone deformities, growth retardation, complications of splenomegaly (discomfort in the left upper abdomen, bleeding manifestations, anemic features), complications of chronic anemia (palpitation, heart failure)
Complications of blood transfusion - presence of blood borne diseases (hepatitis B, hepatitis C, malaria, etc.)
Complications due to iron overload (the excess iron go and deposit in the hypothalamus, the thyroid, the pancreas and the heart and gives rise to following complications)

Hypothalamus - hypogonadism (ask about delayed puberty), growth hormone deficiency (growth retardation)
Thyroid - ask about features of hypothyroidism such as lethargy, cold intolerance, weight gain, increased sleepiness, etc.
Pancreas - the excess iron destroy the beta cells that produce insulin and give rise to diabetes mellitus (ask about features of diabetes such as polydypsia, polyuria and polyphagia)
Heart - the iron goes and deposits in the heart. The excess iron form free radicals which destroy the myocardium. As a result, the heart enlarges. This can even lead to heart failure.

Side effects of iron chelators

Desferrioxamine - impaired vision and hearing, reduced growth, skeletal lesions, increased risk of infections (Yersinia enterocolitica, Yersinia pseudocolitica)

Then fill the rest of the history.

Past medical history
Past surgical history - splenectomy (If splenectomy has been done, describe about immunization against capsulated organisms), pathological fracutres
Family history - family members with similar illness, any deaths involving anemia among relatives, incidence of malaria in the family (carriers of thalassemia has a certain level of protection against malaria)
Immunization history

hepatitis B
capsulated organisms

Hib vaccine
pneumococcal vaccine
immunization against meningococcus

Drug history

is the child using an infusion pump to deliver desferrioxamine
oral iron chelating drugs (deferepfone)
oral penicillin prophylaxis after splenectomy

Allergic history -

allergic reaction during blood transfusion
allergy to Desferrioxamine

Dietary history

were the parents instructed not to give any iron rich foods to the child
promote drinking tea and reduce intake of vitamin C.

Social history

Social history plays a very important part in the history. Thalassemia is a chronic disease requiring frequent hospital admissions. Sometimes more than one child can be affected by the disease. This can be a huge burden to the family. It might have caused a lot psychological, economical and physical stress to all family members. Therefore, these problems should be asked and described clearly. Also note down the following information.

Distance from the home
Transport facilities (bus fees - some examiners always ask whether you know th bus fee, because they have to come to hospital several times a month which will cost them alot)
Family income
Education level of the parents
Schooling of the child
Genetic counselling given or not
Whether the parents understand about the nature of the disease

Examination

General Examination

Height, weight - plot on a chart and comment on it. Also mention that you would like to know the mid parental height to find out whether there is growth retardation.
Dysmorphic features (prominent maxilla, frontal bossing, malocclusion of teeth, dental caries, recurrent ottitis media)
Dyspnoec or not
The child may not be pale because he is most probably transfused already, but you should look for features of chronic anemia such as angular stomatitis, smooth tongue, etc.
Jaundice - thalassemic patients are mildly jaundiced. You might not notice yellowish discoloration of eyes at first sight. Therefore, you should ask the child to turn the eye to a side to see jaundice clearly.
Look for deformities due to pathological fractures
Hyperpigmentation
Leg ulcers - common in hemoglobinopathies
Desferrioxamine mark on the abdomen
Pubertal stage

you may not be able to examine the child's genitalia during the exam, but make sure to say that you would like to examine the child's genitalia to find the pubertal stage.
Axillary hair
Pubic hair

Ankle edema

Cardiovascular System Examination

Look for features of cardiomegally

Abdominal Examination

Desferrioxamine mark
Splenomegally
Hepatomegally

Nervous System Examinatio

Consciousness
Orientation
Fundus
Focal neurological signs

Summary

In the summary you should include the important aspects of the history and examination.

List of Problems

Medical problems

Acute problems - Anemia, fractures
Chronic problems - hypothyroidism, growth retardation

Psychological problems

depression
parental understanding regarding the illness
anxiety

Social problems
Economical problems

Management Plan

Management plan should be targeted to address all the problems that you have listed above.

Arrange blood transfusion sessions to keep the hemoglobin levels >10g/dl. Frequent blood transfusion prevents bone malformation, cardiac failure, splenic complications and iron overload from increased absorption.
Types of blood for transfusion.

washed red cells
packed red cells
frozen blood

If hemoglobin level is <8 g/dl blood transfusion is necessary
Iron chelation is started when serum ferritin level exceeds 1000 ng/ml.

desferrioxamine -

administration is via subcutaneous route through a syringe pump, 3-4 times a week depending on the level of iron overload, infused at an average rate of 20-60 mg.kg
dosage - depends on the prevailing iron overload
role of vitamin C
measure serum ferritin levels every 6 months

Defereprone

side effects - hepatic fibrosis, bone marrow suppression

Splenectomy

indications for splenectomy -

hypersplenism
annual blood requirement >300ml/kg/year
spleen palpabel >6 cm from the left costal margin

Give pneumococcal vaccine 2 weeks before splenectomy
Also vaccinate against meningococcus and Hemophilus inflenza
After splenectomy, child is given life long penicillin prophylaxis
Avoid overcrowded places.

Record height and weight of the patient 3 monthly
Measure Ca levels, phosphorus levels, blood sugar levels and thyroid and liver functions 6 monthly.
Evaluate the growth, development, and iron balance yearly.
Provide psychological support.

Possible Questions that could be Asked During Long Case Discussion

Do you think the child is adequately transfused? If not why?
Do you think the child is having iron overload? Why?
Is the child is grown adequately?
What are the reasons for growth retardation in this child? It is multifactorial. Hypogonadism, frequent hospital admission, chronic anemia, depression can cause growth retardation.
What is the reason for cardiomegally in this child? What is the mechanism of cardiomegally in this child?
Does the child requires splenectomy?
Can you delay splenectomy?
What are the aspects you should consider if you are going to remove the spleen of this child?

Bronchial Asthma: Long Case

2013-06-29T22:33:00.000-07:00

CONTENTS

History
Examination
Summary
List of problems
Management plan
Possible questions that could be ask during the discussion

Bronchial asthma is one of the commonest long case topics. It is more commonly given in Paediatrics than in Medicine. The format includes the history, examination, summary, list of problems and management. First, a proper history should be taken.

HISTORY

Introduction of the patient

Name
Sex
Age
From
Occupation
History is taken from .................... who is educated up to .................. and the history is reliable

Presenting Complain

Patients often presents with difficulty in breathing with wheezing and cough. In pediatrics, the mother knows the diagnosis of asthma, so you can straightly start by saying that the child is a diagnosed patient with asthma, but still you will have to analyze the presenting symptoms to exclude other differential diagnosis.

History of Presenting Complaint

In a pediatric history with a chronic disease like bronchial asthma, it is better to start from the beginning of the illness and tell the story up to now. So, start by describing the initial attack of bronchial asthma, how it was diagnosed and what was done briefly. Then information should be gathered to identify the severity and control of asthma before this episode. The control and severity of asthma is summarized in the following table.

	Day time symptoms	Night time symptoms	PEF	PEF Variability	FEV1
Intermittent	<1 week	<=2/ month	>=80%	<=20%	>=80%
Mild	>1 week	>2 /month	>=80%	20-30%	>=80%
Moderate	Daily	>1/week	60-79%	>30%	60-79%
Severe	Daily	Frequently	<60%	>30%	<60%

According to the table, you should ask about the day time and night time symptoms with their frequency. Describe about the sleep at night. Some may only have nocturnal cough. When assessing the severity, the frequency of hospital admissions, ICU care and life threatening attacks should be mentioned.

Then the exercise tolerance of the child should be inquired. Quantify the exercise tolerance by the type of physical activity which the child is involved in. If his illness has limited his participation in a certain kind of activity, it should be mentioned. If he is engaged in any kind of vigorous exercise, it should be mentioned whether it provokes any symptoms.

Drug compliance should be inquired. Then the response to treatment and their complications should be described. Children on steroids will have side effects of steroids such as,

slowed growth
Weight gain
Thin skin
Hyperactivity
Gastritis

After describing the illness up to now, describe the present attack,. Patients with bronchial asthma could present with,

Exacerbation of bronchial asthma
Infective exacerbation of bronchial asthma

The severity of asthma attack could be

mild
moderate
severe

The history should be targeted to find out the etiology of exacerbation and the severity of exacerbation. If the child is having an infective exacerbation, he will have fever, rhinorrhea, productive cough with yellowish sputum etc. Exposure to cold air could also aggravate the symptoms. Sometimes, the exacerbation may have resulted from an exposure to some substance such as dust, house dust mites, cockroaches, mosquito coils, and out door allergens (pollen, fungal mould, chemical irritants, fumes). Sometimes, asthma can be induced by exercise (exercise induced asthma). Allergic foods such as brinjal, prawn, crabs and cow milk and drugs such as beta blockers, NSAIDs (Non Steroidal Anti-inflammatory Drugs) and aspirin are also responsible agents.

Other differential diagnosis should be excluded before confirming this attack as an exacerbation of bronchial asthma. They are,

Bronchiactasis - Presence of copious amounts of productive cough
Bronchiolitis - very young age (less than 1 year)
Topical pulmonary eosinophilia
Gastro-esophageal reflux disease - Past history of regurgitation, burning sensation of upper abdomen
H type tracheo-bronchial fistula - Respiratory illness since birth
Foreign body - History of ingestion of a foreign body
Cystic fibrosis
Mediastinal mass

Also mention about the ward management done so far according to the mother.

Birth History

Immunization History

Past Medical History

past history of eczema, urticaria, hay fever, allergic rhinitis, allergic conjunctivitis

Past Surgical History

Allergies

Drug History

Mention if the child is on any other drugs.

Family History

Many children with bronchial asthma often have a family history of atopy (asthma, eczema, allergies etc.)

Social and Environmental History

Social and environmental history is one of the most important parts of the history. A detailed social and environmental history should be taken.

The child lives with ............
His parents are educated up to...............
Description of the house (number of rooms, ventilation, dusty area or not, cleanliness, moping or sweeping, presence of furry objects, cushions, leaking roof, kitchen etc)
Usage of mosquito coils
Passive smoking
Smoking coming from the kitchen
Bed room, bed linen
Pets
Distance to hospital
Availability of transportation - important in case of an emergency
Income of the caretakers
Other children
Difficulties in taking care of the child
Care taker's understanding regarding the illness

EXAMINATION

General Examination

General examination of a patient with bronchial asthma may not reveal many signs, but look carefully for the following features.

Height and weight of the child - height and weight gives an idea about the growth of the child. Children on steroids are at a risk of growth retardation. You will have to plot the height and weight on a growth chart and comment on the adequacy.
General appearance
Cyanosis
Dyspnoec
Presence wheezing sounds
Other routine general examination findings such as pallor
BCG vaccination scar - this is one of the most important signs that you should look for
Lymphadenopathy
Signs of skin rash or eczema
Clubbing - Cystic fibrosis

Respiratory System Examination

This the most important part of the examination. Do a thorough examination to find out the signs.

On inspection,

Dyspnoec
Respiratory rate - tachypnoec
Subcostal and intercostal recession
Usage of accessory respiratory muscles
Chest deformities

On palpation,

Position of the trachea
Position of the apex beat
Chest expansion

On percussion,

Resonant or hyper-resonant
Liver and cardiac dullness

On auscultation,

Vesicular breathing or bronchial breathing
Presence of rhonchi - In bronchial asthma, the child will have bilateral end expiratory polyphonic rhonchi, also mention about the zones of the lungs in which the abnormal sounds were herd.
Crepitations - Important in infective exacerbation

Complete the rest of the examination quickly and be prepared to present a summary.

SUMMARY

PROBLEM LIST

Medical Problems

Acute problems
Chronic problems

Psychological Problems
Social Problems

MANAGEMENT

Address each and every problem in your problem list, through your management plan.

DISCUSSION

Possible questions during discussion are,

How do you manage this patient?
If the patient presents to you in an acute attack, how do you manage this patient? To answer this question, you should be thorough with your knowledge, especially when it comes to management of emergencies. You should know the exact doses and how to give them. Through the discussion, the examiners will test whether you have seen the management of an emergency. Some of them might even ask to how to prepare the nebulizer, how to give theophiline, what the container of theophilin look like, is it a liquid or a powder etc. Be calm, think carefully and answer. If you are calm and know your way around, even you don't know the correct answer, you can get through the exam easily. If you panic, they will think that you will do the same during an actual situation.
What is the severity of asthma of this child? Why do you say so?
What is the control of asthma of the child? Why do you say so?
What are the advises you are going to give to the child and the mother?

Template - Diabetes Mellitus History

2012-06-26T05:43:00.000-07:00

Diabetes is a common illness with various presentations and complications. Therefore, many students will get a diabetic patient for their long case. In such situations it is very important to ask all the relevant symptoms and complications of the disease from the patient. The following format will help as a basic guide for a detailed history.

Identification

Name
Age

young age à more likely type 1 diabetes
old à type 2 diabetes

occupation à sedentary life style, drug compliance

Presenting Complaint

Polyuria, polydypsia, pholyphagia
Lethargy, weakness, loss of weight
Infection
Complications

microvasular
macrovascular

History of presenting complaint

When was he/she is diagnosed to be diabetic
What were the symptoms he/she had
What were the treatments given
Adherence to treatments
Problems with treatment/ side effects
Was he/she advised regarding hypoglycemic attacks
Was he/she advised about diet control
Was he/she referred to eye clinic
was he/she advised regarding foot care
How many hospital admissions since then, for what illness, what was done
Macrovascular complications

Ischemic heart disease
Perepheral vascular disease

Leg ulcers
Claudication

Strokes/Transient ischemic attacks

Microvascular complications

Visual disturbances
frothy urine, oliguria, red colored urine
Nuropathies

eripheral nuropathy - Loss of sensation, abnormal sensation, tingling of feet
Mononuropathies - Symptoms of carpel tunnel syndrome/tarsal tunnel syndrome
Autonomic nuropathy - impotence, gustatory sweating, urinary retension, incontenance, constipation, diarrhea, dizziness, recurrent nausea and vomiting
Nuroglycopenic symptoms - impaired interlectual activity, diminished psychomotor skills, severe agitation, confusion, coma, epileptiform seizures

Immunological complications

Recurrent infections
Urinary tract infections
Balanitis
pruritus vulvae

Past Medical History

strokes
Ischemic heart disease
Dyslipidemias
Fits
Bronchial asthma
Strokes

Past Surgical History

Amputations

Drug History

antidiabetic drugs, side effects, compliance

Allergic History

Drug, food, laster allergies

Family History

Diabetes, premature heart diseases, Strokes, young deaths in first degree relatives

Social History

Educated up to
Occupation
Lives with
Income
Exercise
Alcohol intake
Smoking
Nearest hospital

Dietary history

Regularity of meals
Quality of content

Fatty greasy food
Fruit and vegetable content
Sugar and sugary foods
Salt

Examination of a Diabetic Patient

Diabetes Mellitus Examination

2012-04-02T08:50:00.000-07:00

General Examination

· General built

· BMI

· Ketone odour

· Eyes

o Corneal arcus

o Xanthalasma

· Dry mouth / Mucous membrabes

· Acanthoosis nigricans

· Injection sites à lipohypertrophy, lipoatrophy

· reduced skin turgor

· Capillary refill time

· Diabetic cheiroarthropapthy (stiff hand syndrome)

· Carpel tunnel syndrome (Tinel’s sign, Phalen’s sign, thenar eminence wasting)

· Granuloma annulare

· Pustules, abscesses, carbuncle

· Necrobiosis lipoidica diabeticorum (anterior shin)

· Vitiligo

· Diabetic dermopathy

· Bullosis diabeticorum (tense blistering on the feet)

· Fungal nail infections

· Deformity

· Callus

· Ulcerations

· Nail care

· Neuropathic joint à Charcot neuroarthropathy

Cardiovascular System Examination

· BP

o Pulse

§ PR à tachycardia (dehydration)

§ Peripheral pulses

o Blood pressure

§ Hypertension

§ Hypotension à dehydration

§ Postural hpotension

o Auscultaion

§ Carotid and femoral bruits

Respiratory System Examination

· Kussmaul breathing

Central Nervous System Examination

· Eye

o Reduces pupillary response à diabetic autonomic neuropathy

o Visual acuity

o Funduscopy

§ Cataract à loss of light reflex

§ Lens for opacities

§ Green light to see microaneurysms

o Proximal motor neuropathy

§ Diabetic amyotrophy

§ Femoral neuropathy

o Mononeuropathies

§ Median nerve (Carpel Tunnel Syndrome)

§ Tarsal tunnel syndrome

§ 3^rd and 6^th nerve palsies

o Autonomic neuropathy

· Sensation

o Great toe

o Metatarsal heads

o Dorsum

o Peripheral sensory neuropathy

· Reflexes

o Loss of ankle jerk à early diabetic peripheral sensory neuropathy

Acknowledgement

2012-02-21T08:25:00.000-08:00

This post is to aknowledge all the lectureres, consultants, senior registrars, registrars, senior house officers, and house officers who taugt very well so I was able to prepare a good note with all the information. Some templated are almost entirely based on senior students' notes. I thank them for leaving behind such a comprehensive set of notes so we joniors can benifit from that. We are still using some of their notes for our studies. But, most of them are now becoming hard to read after several rounds of photo copying. So, I wish that those who after me can get a decent print out from my blog.

THANK YOU ALL!

Template – Bladder Outflow Obstruction, LUTS

2012-02-18T03:58:00.000-08:00

HISTORY

1. Introduction

a. Age > 70

b. Commoner in males

c. BPH is higher in high socio-economic group

2. Presenting complaint

a. Weakness of lower limbs – impending cord compression

b. Anuria – acute renal failure

c. Pathological fracture ( vertebrae/hip)

d. Dehydration, nausea, vomiting – hypercalcaemia

e. Acute urine retention

f. LUTS symptoms

g. UTI (recurrent)

h. Chronic renal failure

i. backache

3. History of presenting complaint

a. Symptom analysis

i. Storage symptoms

1. Frequency

2. Urgency

3. Urge incontinence

4. Nocturia

5. Nocturnal enuresis

ii. Voiding symptoms

1. Hesitancy

2. straining

3. Poor stream (caliber, force, length)

4. Intermittency

5. Double voiding

6. Dribbling

7. Sensation of incomplete emptying

8. Episodes of near retention

iii. To which extent has it affected

b. Differential diagnosis

i. Testicular pain - epididymo-orchitis due to BOO reflux

ii. Suprapubic pain – prostatitis

iii. Chronic pelvic pain – gonorrhea – strictures

iv. If acute urinary retention

1. Postponement of urination

2. Beer

3. Confinement to bed due to illness

4. UTI

5. Surgery

6. Constipation

7. Drugs – TCA, anticholinergics

8. Previous episodes, what was done

v. Voiding LUTS

1. Benign prostatic hyperplasia

a. haematuria

2. Prostatic carcinoma

a. Haematuria

b. LOW

c. LOA

d. Haematospermia (blood in bed clothes – in advanced cases)

3. Bladder neck stenosis

4. Urethral strictures

5. Functional obstruction

a. Spinal cord disease

b. Stroke

c. Diabetes mellitus - Autonomic neuropathy

d. Degenerative neurological disease

e. Parkinsonism

f. Alzeimer’s disease

vi. Storage LUTS

1. Infection

a. Persistent loin pain

2. Urinary stones

a. Colicky pain

3. Overactive bladder

c. Eatiology

i. Urethral strictures

1. History of urethral discharge

2. History of urethral instrumentation

d. Complications

1. Prostatic carcinoma

a. Impotence

b. Lower limb and genital oedema

c. Constipation, alteration of bowel habits, incontinence

d. Bone pain/back pain/pathological fractures

e. Fits, early morning headache and vomiting

f. Jaundice, LOA, LOW

g. Lower limb weakness

h. Evidence of spinal cord compression

2. Renal failure

a. Uremic symptoms

e. Fitness for surgery and anaesthesia

i. Knee and hip joint – arthritis – Treatments taken

f. What was done up to now

4. PMH

a. IHD – precipitate CCF from TURP syndrome

5. Drug history

a. For any psychiatric illness – TCA

b. Aspirin

c. Anticoagulants

6. PSH

a. Instrumentation

b. Urogenital surgery

c. Spinal injury

d. Pelvic trauma, surgery

e. Vasectomy

f. B/L orchidectomy

7. Allergies – contrast

8. FH

a. Prostate Ca

b. Breast Ca (BRACA 2)

9. Social history

a. Smoking – prostate cancer

b. Alcohol – BPH

c. Completed family? Post TURP – impotence, retrograde ejaculation

d. Exposure to cadmium (in rubber industry) – prostate cancer

EXAMINATION

General Examination

1. BMI

a. Obese – BPH

b. Wasted – advanced Ca

c. Febrile

d. Icterus

e. CRF features

f. Bone tenderness – spine

Abdominal Examination

1. Distended bladder – loss of suprapubic skin crease

2. Renal angle tenderness

3. Bladder –

a. Chronic retention - above umbilicus, painless

b. Acute retention – below umbilicus, pain++

4. Loin masses – hydronephrosis

5. Hepatomegally – liver 2ries

External Genitalia

1. Meatal stenosis

2. Ballanitis

3. phemosis

4. Urethra strictures

a. Examine the urethra from end to end for a stricture/palpable thickening

b. Extensive strictures are associated with a large palpable area of scarring in the perineum

c. distended proximal part of the urethra ending in a firm fibrous stricture

d. examine membranous urethra during PRE

5. Scars on scrotum and perineum

6. Stones

7. Hard and swollen testes – recurrent epididymo- orchitis

8. Hernias

DRE

1. Sacral sensation

2. Reduces anal tone – rectal invasion of Ca

3. Constipation

4. Prostomegally

a. Median groove +/-

b. Consistency

i. Hard à malignant

ii. Smooth, soft à benign

c. Mucosa

i. Fixed – post TURP, after prostate biopsy, Ca

5. Firm mass above prostate à Ca bladder

6. Fluctuating mass above the prostate à residual urine

VE in Females

1. Uterine prolapsed

2. Cystocoele

Nervous System

1. Quada equine syndrome (S2-S4)

a. Can feel pin prick sensation beside the anus

2. Anal reflex

3. Patulous anal sphincter

4. Parkinsonism

5. DM neuropathy

6. Gait

INVESTIGATIONS

1. Urine full report to see

a. Pus cells à infections, stones, tumors

b. Red blood cells à Stones, infection, prostate carcinoma

2. Urine culture and antibody sensitivity test

3. Urine cytology à if carcinoma in situ is suspected

4. X-ray KUB

5. USS KUB

a. Oedema

b. Hydronephrosis

c. Hydroureter

d. Bladder trabeculations, diverticuli, hypertrophy, stones

e. Prostate

f. Post voidal residual volume - > 40 % of prevoidal, > 1000ml is significant

6. Renal function assessment

a. Serum creatinine

b. Serum electrolyte

c. Blood urea

7. TRUS

a. Exact size of prostate

b. Echogenicity

8. Prostate biopsy

a. Indications – malignant features, DRE, increased PSA, mets disease

b. Complications

i. Bleeding in to the bladder, rectum, seminal vescicle ( stop aspirin, anticoagulants 2 weeks prior)

ii. Infection – founier’s gangrene ( ciprofloxacine 500 mg 1 hour before, post biopsy………….)

iii. Inflammation à oedema à acute retention

9. Ascending urogram – urethral strictures

10. PSA

a. For screening in people with

i. Hard irregular prostate

ii. Obliteration of median grove

iii. Positive family history (only indication in SL)

iv. Backache with LUTS

v. Sclerotic bone lesions

vi. Afro Caribbeans at 50 years

b. To follow response to treatment

i. PSA velocity - % rise

1. Normal < 10 % within 1 year

2. > 20 % abnormal

ii. Free : total

1. BPH à increased free and total

2. Ca à reduced free and increased total

3. Cut off is 20 %

11. Early prostate cancer antigen

a. Experimental

12. Urine flow metry

a. Normal volume is >150 ml

b. Normal flow is > 15 ml/s

c. If <10 ml à treatment is recommended

d. Record 2 or 3 voids

BOO à significant symptoms + benign prostate + low maximum flow rate (<10-12 ml/s) for a good voided volume (>200 ml)

13. Pressure flow urodynamic study

a. In neurogenic bladder to identify the type

b. To distinguish BOO from idiopathic detrusor instability in males

c. Indications

i. Suspected neuropathy (Parkinson’s, dementia, DM, previous strokes, multiple sclerosis)

ii. Dominant history of irritative symptoms, urgency and frequency

iii. In patients with doubtful history and near normal urine flow rate

iv. Men with invalid flow rate measurement due to inadequate voided volumes

14. Cystourethroscopy

a. Immediately prior to the prostatectomy

b. To exclude urethral strictures, bladder carcinoma and non-opaque vesicle calculus

15. Investigation to stage

a. Liver

i. SGOP/PT

ii. Increased ALP

b. Bone – Tc 99 bone scan

c. CXR

d. X-ray abdomen

e. Monoclonal antibodies

f. CT/MRI pelvis

16. CT/ MRI if radical prostatectomy is planned

17. FBC

18. Investigations to see fitness for anaesthesia

MANAGEMENT

1. flow rate >15 and residual volume < 100 ml à safe à reassurance and review

2. Indications for treatment

a. Acute retention

b. Severe symptoms and large residual volumes

c. Chronic retention and renal impairment

i. Residual urine >200 ml

ii. Raised blood urea

iii. Hydroureter, hydronephrosis

iv. Uremic symptoms

d. Complications of BOO

i. Stone

ii. Infection

iii. Diverticulum

iv. haemorrhage

v. severe symptoms

3. Emergencies

a. Impending cord prolapsed

i. Immediate presentation – B/L orchidectomy (IV stillbsterol is not present in SL)

ii. Late presentation – neurosurgical decompression

b. Hypercalcaemia

i. IV fluids - / + Ca binding resins

c. Acute renal failure (B/L ureteric obstruction)

i. Percutaneous nephrostomy

4. Treatment

a. Watchful waiting

b. Life style adjustment

i. No alcohol, coffee, chocolate

ii. Less busy life style

c. Uropharmoceuticles

i. Alpha blockers

ii. ADR - Postural hypotension – take when going to bed

iii. Retrograde ejaculation

iv. 5 alpha reductase inhibitors

1. 6 months to take effect

2. For larger prostates

3. ½ the PSA level and shrinks the gland

d. Phytotherapy

i. Saw palmetto, pumpkin seeds

5. Monitoring treatment

a. IPSS

b. Flow rate

c. Episodes of AUR

d. Residual volume

e. Prostate size by TRUS

6. Treatment for inoperable patients

a. Prostatic stent under local anaesthsia

b. TUMT

c. TUNA

d. HIFU

e. Transurethral vaporization of the prostate

f. Indwelling urethral or suprapubic catheter

g. Self interval catheterization

7. Management of acute retention

a. IM pethidine

i. Reduce agitation à sphincter relaxes à easy to pass the catheter

b. Catheterize ASAP

i. If spasms +ve à put under sustained pressure

ii. Prophylactic gentamycin 80 mg

iii. Record date, time of catheterization, number of attempts and residual volume

c. If failed à suprapubic catheterization

d. Monitor input and output

e. If first presentation of AUR

i. >1000 ml à uropharmaceuticles are not effective

ii. <1000 ml à alpha blocker + s alpha reductase

1. If alpha 1a receptor blocker is given à peak dose in 48 hours à remove catheter and review in 2 days

2. If alpha blocker + finesteride à catheter off trial in 1 week

a. Catheter off trial

i. Remove catheter

ii. Drink fluids

iii. 1 pint N/S

iv. If passes >200 ml urine for

v. 3-4 times à normal

vi. If not à catheterize

8. Chronic retention

a. Clean intermittent catheterization

i. Males – 16 G, females – 14 G

ii. Wash hands with soap and water

iii. Introduce catheter and remove urine

iv. Wash catheter if reused

v. Complications

1. Decompression haematuria

2. Post obstructive diuresis, especially in uremic patients

9. Surgery

a. Transurethral

i. TURP

ii. TUIP

iii. Laser prostatectomy

b. Open prostatectomy

i. Retropubic

ii. Transvesicle

iii. Perineal

c. Indications

i. Uremia and hydronephrosis

d. Relative indication

i. AUR

ii. Recurrent UTI + BPO

iii. Recurrent haematuria

iv. Persistent symptoms

e. Consider surgery in

i. High IPSS score

ii. Low urine flow metry

iii. USS – high residual volume (> 1000 ml)

f. Advantages of spinal anaesthesia over GA

i. Has post-op analgesic effect

ii. No period of nill by mouth

iii. Urethra is dialated à easy access

iv. Hypotension prevents bleeding

v. Easy to identify TURP syndrome

g. Post-op management

i. 22-24 G catheter inserted and bulb inflated with 20 cc, continuous irrigation started.

ii. KUO for bleeding

iii. Input output chart

iv. Continue bladder input

v. IV gentamycin stat dose

vi. Monitor pulse, BP, RR

vii. IV N/S over 6 hours

viii. Pethidine 50 mg

ix. Phenagon 25 mg

x. Diclofenac sodium 100 mg suppository SOS

xi. Diclofenac sodium 50 mg bd

xii. Omeprazole 20 mg bd

xiii. Dulcolax to prevent straining

xiv. Irrigate with N/S until urine is clear ( 1 hr, 500 ml)

h. On ward round D1

i. Colour of urine

ii. Stools passed?

iii. PR,BP

iv. Advise not to strain

v. Cough syrup if cough present

vi. Strict bed rest

i. D2

i. Mobilize the patient

ii. If urine colour is normal, stop irrigation

iii. If urine becomes dark, increase oral fluid intake up to 2 l

j. D3

i. Remove catheter

ii. Measure each void and record

k. Open prostatectomy à remove catheter in D7

l. Complications

i. Immediate (1-2 %)

1. TURP syndrome à convulsion, arrhythmias, pulmonary oedema

a. To prevent –

i. Pre-op correction of electrolytes

ii. Use of isotonic fluids

1. 5% dextrose

2. Glycine

iii. Do not resect beyond the capsule

iv. Limit duration of surgery

b. Treatment

i. HDU

ii. Restrict water

iii. Osmotic dieretics

2. Local haemorrhage

3. Perforation of prostate capsule

4. Sepsis

ii. Early

1. Secondary haemorrhage

a. Treatment - Rest and increase fluid

b. Clot retention

i. Treatment – bladder irrigation

2. Sepsis

iii. Late

1. Strictures and bladder neck stenosis 10%

2. Urinary incontenance 1%

3. Erectile dysfunction 5%

4. Retrograde ejaculation 50%

Carcinoma of the Prostate

1. Watchful waiting

a. For elderly patients with low grade, low volume disease

2. Localized disease

a. Brachytherapy

b. Radical surgery

3. Locally advanced disease

a. Radical radiotherapy

b. Hormonal therapy

4. Metastasis

a. Androgen deprivation

i. B/L orchedectomy

ii. Medical

1. Antiandrogens

2. LHRH agonists

5. Curative surgery – radical prostatectomy

a. Retropubic

b. Laparoscopic

ACKNOWLEDGEMENT

Template – Bleeding PR

2012-02-18T03:34:00.000-08:00

HISTORY

· Age

o Crohn’s disease – 2 peaks (20-40, >70)

· Gender

· Presenting complaint

o Bleeding PR

· History of presenting complaint

o Previously well

o Color –

§ black/tarry – upper GI bleeding

§ red wine – proximal large bowel

§ bright red – anal, low rectum

o Amount of bleeding

o association with defecation

§ mixed with feces à higher than sigmoid colon

§ on surface of feces à lower sigmoid colon, rectum, anal canal

§ following defecation à haemorrhoids

§ blood passed by itself à rapidly bleeding Ca, IBD, diverticulosis, severe upper GI bleeding

§ blood on toilet paper – haemorrhoids, anal fissures

o Mucus

o Pain during defecation à fissure, anal Ca, rectal Ca obstructing the lumen

o Tenesmus – intense, painful, fruitless effort to defecation à space occupying lesion in the rectum

o Previous bowel habits

§ Constipation

§ Frequent diarrhoea

§ Consistency of stools

§ Incontinence and soiling

o Abdominal pain

o DD

§ Haemorrhoids – pruritis, lump coming out

§ Colo-rectal Ca –

· Cecal tumor à RIF pain

· Mucus à mucus producing adenoma

· Caecal tumor à RIF pain

· Ca rectum à

o increased frequency with scanty amount

o PR bleeding

o Tenesmus

· Ca at amula of rectum à early morning bloody diarrhoea

§ Fissure in ano

§ IBD – mucus, joint problems, conjunctivitis

§ Solitary rectal ulcer

§ TB – cough, fever, night sweats

§ Bleeding disorders

§ Angiodysplasia

§ Bleeding disorders

§ Diverticular disease

o Aetiology

o Complications

§ Obstruction à constipation, abdominal distension, vomiting, abdominal pain

§ Anaemia à Faintishness, lethargy

§ Spread

· Local à

o recurrent UTI

o Vaginal discharge in females

o Back pain radiating along the thigh (sacral plexus)

o Faecouria, pneumaturia, haematuria à bladder

o Haematospermia à

o Fistula

o Lymphadenoma

· Metastases

o Liver à history of jaundice, RHP, LOW, LOA

o Lungs à chest pain, SOB, persistent dry cough, wheezing, haemoptesis

o Adrenals

o Brain à headache, visual disturbances, early morning vomiting, drowsiness, fits

o Bone

o Fitness for surgery and anaesthsia

§ Exertional dyspnoea, chest pain, orthopnoea, PND

§ Urinay habits

§ Lower limb joint problems

· Positioning for APR

· NSAIDS

· IBD – extraintestinal manifestations

o PMH

o PSH

§ Colonic polyps, Ca, Haemorrhoeids, colonoscopy and biopsy

§ Cholecystectomy à increased risk

§ Uretero-sygmoidostomy à increased risk of stump Ca

o Drug history à aspirin, heparin, warfarin

o Allergies à foods, drugs and plasters

o Family history

§ Polyposis coli

§ Bowel Ca

§ Breast Ca

§ Ovarian Ca

§ DM

§ HT

§ Prostate Ca

o Dietary Histtory

· High fat

· Low fibre

o Social history

§ Level of education

§ Details of the family

§ Income

§ Family support

§ Smoking

§ Alcohol

§ Toilet - ? public

§ Nearest hospital

§ Transport

§ Consent for colonostomy and surgery

EXAMINATION

General

· BMI

· Ill/well looking

· Pale

· Jaundice

· Conjunctivitis, joint swelling (IBD)

· Features of nutritional deficiencies

· Supraclavicular lymph node

· Ankle edema

Abdominal Examination

· Sister Mary Joseph’s node

PR Examination

· Anal scars

· Perineal tears in females

· Skin tags

· Skin excoriation

· Prolapsed haemorrhoids

· Genital and perianal warts

· External opening og sinus/fistula

· Sphincter tone/soiling

· Sever pain à anal fissure, abandon the procedure

· Anal canal à mass, polyp, ulcers,

· If growth à

o distant from anal verge

o upper margin

o contact bleeding

o fixed to sacrum

o circumference

o consistency

o tenderness

· prostate

· VE – masses in the pouch of Douglus

Anoscopy/proctoscopy

· Haemorrhoids à position

· State of mucosa

· Anal polyps

· Anal growths

Biopsy

· Yeoman’s Forceps

INVESTIGATIONS

For Diagnosis

· Rigid sigmoidoscopy (25-30 cm)

o Visualizes the anal canal and the rectum

o Bowel preparation à Micro-enema

· Flexible sygmoidoscopy (70 cm)

o Up to splenic flexure

· Colonoscopy and biopsy

o Preparation

§ Informed consent

§ Low fibre diet for 3 days

§ Liquid diet on the day

§ Polyethylene glycol (klean prep) 4 packets in 4 liters

· 1 L in 1 hr à 1 L clear water for 1 hr à ………………..

§ IV cannulae

§ Iv midazolam 2-3 mg à microenema in morning Hiscosin bromide

· Double contrast Ba enema

o Determines the level of obstruction

o Ca of colon

o Ulcerative colitis

o Diverticular disease of the colon

o Familial adenomatous polyposis

o Assessment of anastomotic leak

For Staging

· USS abdomen

o Liver 2ries

o Lymph node enlargement

o Ascites

· Transrectal ultrasonography

· CXR

o Lung mets

o Pleural effusion

o Osteolytic lesions of the ribs

o Mediastinal lymph nodes

· CT abdomen

o Better soft tissue enhancement

o Liver mets, liver enlargement

o Tumor

o Level of invasion

· Bone scan

· CT Brain

To Assess Fitness for Anaesthesia

· FBC with Hb

· FBS

· BU

· SE

· PT/INR

· Serum proteins

· ECG à echo, exercise ECG

· CXR

MANAGEMENT

SEVERE PR BLEEDING

· Assessment and resuscitation

o ABC, IV fluids, blood transfusion

· History, examination

· Monitor à PR, RR, BP, input/output, CVP

· UGIE

· Colonoscopy

· If colonoscopy cannot be done à angiography, radio-isotope scan (radio-labelled RBCs)

HAEMORRHOIDS

· Exclude

o Colorectal malignancy

o IBD

o Diverticular disease

o Adenomatous polyposis à loose stools, lower abdominal pain, weight loss, blood and mucus diarrhoea

· Stool softners

· Bulking agents

· Increased intake of fluids

· 1^st degree à

o Sclerotherapy

§ 2-5 ml of 5% phenol in olive oil is injected above each haemorrhoids

§ If injected too superficial à mucosal sloughing (a white wheel)

§ If injected too deep à

· Males – chemical prostatitis, impotence

· Females – ano-vaginal fistula

§ Bradycardia

· Leave the patient for sometime and ensure that PR is normal

· No nausea, vomiting, light headedness à can go

§ Allergic reactions à anaphylaxis

· 2^nd degree

o Elastic band ligation

· 3^rd and 4^th degree

o Hamorrhoidectomy

o Stapled haemorrhoidoplexy

EXTERNAL PLEXUS HAEMATOMA

· Perianal haematome

· Maximum severity of pain – 2-3 days

· May take up to 2 weeks to resolve

· Tense dark blue swelling at the anal margin

· Reassurance and analgesia

· If large/ extremely painful à excision under LA

FISTULA IN ANO

· Anal fistlectomy

ANAL FISSURE

· Stool softners

· Bulking agents

§ Peutz-Jegher’s polyps

§ Juvenile polyp

o Neoplastic

§ Adenomas à tubular, tubular villous, villous

§ Adeno Ca

§ Carcinoid tumor

CA COLON

· Columnar cell adeno carcinoma

· Clinical features

§ Left side

· Stenoting variety

· Features of intestinal obstruction

· Pain – suprapubic coloc, constant ache (advanced)

· Alteration of bowel habits – episodes of constipation followed by attacks of diarrhoea

· Distension – relieved by passage of flatus

· Palpable lump

· Sigmoid – tenesmus, bladder symptoms

§ Right side

· Anaemia – severe, unyielding to treatment

· Mass in RIF

· Intussusceptions – features of intermittent obstruction

· Treatment

o Remove the 1ry tumor and its draining locoregional lymph nodes

§ Right hemi-colectomy

§ Extended right hemicolectomy

§ If no obstruction à 1ry anastomosis

§ If obstruction à stoma

o Inoperable tumors

§ Ascending colon – bypass using a iliocolic anastomosis

§ Upper part of the left colon – transverse colectomy

§ Pelvic colon – LIF colostomy

o Adjuvant therapy

CA RECTUM

· Clinical features

o Can occur in youth

o Adult presentation 55 years

o Bleeding

§ Earliest and most common symptom

§ Stimulates haemorrhoids

o Sense of incomplete defecation

§ Tenesmus

o Alteration of the bowel habits

o Ampulla of rectum à early morning bloody diarrhoea

o Pain

§ Late symptom

§ Due to some degree of intestinal obstruction/local invasion

TREATMENT

· Surgery

o Sphincter saving AR

o Removal of rectum with permanent colostomy APR

o Endo-anal excision

o =>3cm from the anal verge à APR

o =>5 cm from anal verge à AR

o =>2 cm from anal verge à ultra low AR

o Fit enough to surgery + small tumor à curative surgery

o Fit enough to surgery + metastasis à palliative surgery, colostomy

o Fit enough to surgery + features of obstruction à defunctioning ileostomy/colostomy

o Fit enough to surgery + extensive local spread à neo-adjuvant chemotherapy =/- small amount of radiotherapy à if done surgery should be done within 2 weeks à Downgrade the tumor (2-3 months) à surgery à chemoradiation (5-flouroucil + folinic acid

Template – Gastric Carcinoma (Epigastric Mass)

2012-02-18T03:09:00.000-08:00

HISTORY

· Age – 7^th decade

INVESTIGATIONS

1. To confirm the diagnosis

a. Esophago-gastro-duodenoscopy

i. Direct visualization of the lesion

ii. Site and size of the lesion

iii. Brush cytology to improve diagnostic yield

iv. Vital dye spraying (indigo carmine) – accentuate early gastric cancer and facilitate target biopsies

b. Barium meal follow through with double contrast medium

2. For staging (TNM staging)

a. USS abdomen

i. Liver secondaries

ii. Para aortic lymph node

iii. Ascites

b. Endoscopic USS

c. Contrast enhanced CT

i. Expensive

ii. Irradiation

iii. Better soft tissue enhancement

iv. Assess distant disease

d. Laparoscopy

i. Tumor deposits < 5 cm in peritoneal surface

ii. Can take biopsies

3. For assess fitness for surgery and anaesthesia

a. Hematological

i. Hb%

ii. PCV

iii. WBC/DC, platelet

b. Biochemical

i. FBS

ii. BU

iii. SE

iv. Serum proteins

v. PT/INR

vi. SGOT/PT

vii. ALP

viii. CXR

ix. SD echo

x. Lung function tests

MANAGEMENT

1. Treatment

a. Curative

i. Early gastric carcinoma – endoscopic mucosal resection

ii. Advanced –

1. total gastrectomy and roux-en-y oesophagojejunostomy

2. Bilroth 1 partial gastrectomy + gastroduodenostomy

3. Polya partial gatrectomy

b. Palliative

i. Gastro jejunostomy

ii. Laser therapy for obstruction

iii. chemotherapy

2. Pre-op preparation

a. Informed written consent

b. Optimize cardiopulmpnary functions

c. Nutrition optimization if

i. BMI < 18.5

ii. Body weight < 90% of predicted

iii. > 10 % weight loss

iv. High protein/calorie diet + vitamins + minerals

d. Dentist for oral hygiene

e. In gastric outlet obstruction – NG and aspiration/ gastric wash

f. Chest physiotherapy

g. Steam inhalation

h. Breathing exercises

i. Hg at least > 8 mg/dl

j. Correction of PT/INR

k. Refer to consultant anaesthetist

l. Shower

m. Overnight fasting

n. Grouping and DT for 2 pints of blood

o. On the day of the surgery

i. Make sure all the investigations are ready

ii. Stomach wash

iii. 16 guage cannula

iv. NG

v. Catheter

vi. Antibiotics

3. Post op management

a. PR, RR, BP, T

b. Hourly UOP

c. Bleeding PR

d. Abdominal girth

e. Dressing

f. Epidural analgesia or IM pethidine 75 mg + promethazine 25 mg

g. IV fluids 2 pints N/S and 3 pints dextrose for 24 hours

h. Metronidazole 500 mg IV 8 hourly

i. Gentamycine 80 mg IV 8 hourly

j. Prop up

k. Steam inhalation

l. Chest physiotherapy

m. Early mobilization

n. Jejunostomy feeds from 2^nd post op day

o. Remove drains and catheter when the indication is over

p. Gastrography on 10^th post op dayto know the intergrity of the GIT

q. Oral feeds

r. Remove sutures

4. Complications

a. Early

i. Local

1. Bleeding – primary and reactionary

2. Anastomotic leakage – gastric/ duodenal fistula, peritonitis, intra-abdominal abscess

3. Haematoma

4. Seroma

5. Bburst abdomen

6. Incisional hernia

ii. General

1. Hypostatic pneumonia

2. MI

3. DVT

4. Pulmonary embolism

b. Late

i. Mechanical

1. Small stomach

2. Early morning bilious vomiting

3. Dumping syndrome

4. Intestinal hurry

ii. Nutritional

1. Fe deficiency

2. Vitamin B 12 deficiency

3. Fat malabsorption

4. Vitamin D deficiency

5. Immunodeficiency

5. Prognosis

a. Early gastric carcinoma – 5 year survival rate is > 90%

b. Late gastric carcinoma

c. Overall in Sri Lanka is 5%

Format of Surgery Long Cases

2012-02-18T03:06:00.000-08:00

1. History and examination

a. Introduction

b. Previously well patient/ patient with co-morbidities

c. DD

d. Eatiology

e. Complications

f. Fitness for surgery

g. Social factors

2. Summary and problem list

3. Discussion

a. Management

b. Theory

4. Investigations

a. For diagnosis

b. To assess severity

c. To assess fitness for the surgery

5. Treatment

a. surgical

i. Curative

ii. Palliative

b. medical

6. Pre-operative preparations

a. Consent

i. Why/what surgery

ii. Type of anaesthesia

iii. What will happen after surgery

iv. Complications

v. Long term outcome

b. Pre-operative assessment

c. Optimize the patient for surgery

i. Diabetes mellitus

ii. Cardiovascular disease

1. IHD

2. HT

d. Alter/modify drugs

i. Stop –

1. antiplatelet drugs – clopidogrel 14 days prior to surgery

2. warfarin – 72 hours prior to surgery and converted to heparin, UFH – 4-6 hrs prior to surgery, LMWH – 12 before

3. oral hypoglycaemics

ii. Continue –

1. Antihypertensives

2. other cardiac drugs

3. antiepileptics

4. asthmatic

e. Special preparations for the surgery

i. Patient preparation

ii. ICU bed

f. Premedications

i. Antiemetics

ii. PPI

iii. Anxiolytics

iv. For bowel preparations

v. Prophylactic antibiotics

g. Fasting and pre-op fluid balance

i. 6 hours for solids and 2 hours for liquids

7. Post operative management

a. Post op monitoring

i. ICU/HDU/ward

ii. PR/RR/BP/IP OP chart

iii. Drains

iv. Active bleeding

b. Management of pain

c. Managing co morbidities

d. Fluid and electrolyte

e. Nutrition

f. Complications

i. Bleeding

1. Iry

2. 2ry

3. Reactionary

ii. Atelactasis, pneumonia

iii. IHD, Heart failure, arrhythmias

iv. DVT, Pulmonary embolism

v. Wound

1. Haematoma

2. Seroma

3. Wound infection

vi. Fever

vii. Nausea and vomiting

Note - Chronic Pancreatitis

2012-02-18T02:58:00.000-08:00

· Severe pain, exocrine and endocrine pancreatic insufficiency

· Pain for months/ years

· Eased by sitting upright or drawing knees up to the jack knife position

· Aggravated by meals

· Local effects – biliary obstruction, duodenal obstruction, gastric compression

· Mean age of onset – 49 years

· Damage to cells, metabolic abnormalities, Obstruction àRecurrent attacks of acute pancreatitis à fibrosed duct à obstruction à chronic pancreatitis

· More in males (1:4)

· Causes

o Hereditary pancreatitis

§ Autosomal dominant disorder with 80% penetrance

§ Mutations in the cationic trypsinogen gene or chromosome 7

o CF

o Infantile malnutrition

o Idiopathic

§ 30%

§ Early onset and late onset

§ In people in warm climates

· Increased risk of pancreatic cancer, specially with tobacco smoking

· Clinical features

o Pain

§ Dull

§ Gnawing

§ Affects sleep and work

o Nausea

o Vomiting

o Weight loss

o Steatorrhoea

o Diabetes

· Analgesic abuse

· Complications are similar to acute pancreatitis

Investigations

· Increased serum amylase in early stages

· Pancreatic function – pancreatic insufficiency (>70% of gland destruction)

· Abdominal X-ray à pancreatic calcifications

· CT

· MRI

· MRCP – biliary obstruction

· ERCP

· EUS

o Presence of stones

o Visible side branches

o Cysts

o Lobularity

o Irregular main pancreatic duct

o Hyperechoic foci and strands

o Dilation of main pancreatic duct

o Hyperechoic margins of the pancreatic duct

o 4 or more are highly suggestive

Treatment

· Medical measures

o Treat addiction

o Alleviate abdominal pain

o Nutritional and digestive measures

o Treat Diabetes Mellitus

· Endoscopic pancreatic sphincterectomy

· Placement of stent – only for 4-6 weeks

· Extract stones by ERCP

· Extracorporeal shock wave lithotripsy

· In patients with a mass in the head of pancreas à Beger procedure (duodenum preserving resection of pancreatic head)

· If duct is markedly dialated à Frey procedure longitudinal pancreatojejunostomy)

· If in the duct à distal pancreatectomy

· Intractable pain and diffuse disease à total pancreatectomy, operative mortality is 10%

· Radiological, surgical

Note - Acute Pancreatitis

2012-01-16T08:51:00.000-08:00

Pancreatitis

o Acute

o Chronic – due to fibrosis within the gland

o Acute on chronic

o Injury to acinar cells / impairment of secretion of zymogen granules of Premature activation of pancreatic enzymes à auto-digestion à Local effects (oedema, hemorrhage, necrosis), systemic effects (hemodynamic instability, bactaraemia, ARDS, Pleural effusion, GI hemorrhage, renal failure, DIC)

Acute Pancreatitis

· Mortality – 10 -15 %

· Mild – oedema, minimal organ dysfunction , Mortality rate – 1%

· Severe – Pancreatic necrosis, SIR, multi organ failure, Mortality rate – 20-50%

· 3% of all abdominal pain

· Peak – young men, older women

· Causes

o I – Idiopathic, iatrogenic, inborn (mutation of cationic trypsinogen gene à acute pancreatitis in teen ages à chronic pancreatitis in next two decades à pancreatic cancer in 70 Years of age)

o G – Gall stones ( commonest cause in west)

o E – Ethanol ( commonest cause in east)

o T – Trauma ( commonest cause in children)

o S – Steroids

o M – Malnutrition, Mumps, CMV, EBV, Coxsackie B

o A – Autoimmune (SLE,PAN)

o S – Scorpion bite

o H – Hyperlipidaemia, Hypercalcaemia, Hypothermia

o E – ERCP – 1-3 %

o D – Drugs

§ S – Steroids

§ A – Azathioprim

§ N – NSAIDS

§ D – Diuretics

Diagnosis/ investigations

· Clinical

· Biochemical

o Serum amylase

§ Rises within 12 hours and remains elevated for 2-3 days

§ High up to 14 days

§ Three to four times above normal

§ Normal levels does not exclude the disease

o Urine amylase

o Serum lipase

§ Slightly more specific and sensitive than amylase

· Radiological

o Contrast enhanced CT

· To find out complications

· To find the etiology

· To assess the fitness for surgery

Local Complications

· Phlegmon – abscess or an inflammatory mass in the pancreas

· Acute fluid collection

o Sterile

o Most resolves

o Intervene only when large collections cause pressure effects – percutaneous aspiration under US or CT guidance

o Transgastric drainage under EUS guidance

o Can become a pseudocyst or a abscess if become infected

· Sterile and infected pancreatic necrosis

o Sterile – should not interfere

o Infected necrosis – 50% mortality

o If the patient is septic – CT or US guided aspiration of the fluid à if aspirate is purulent – percutaneous drainage à send for microbiology à start antibiotics

o If sepsis worsens à pancreatic necrosectomy

· If head is involves à Midline laparotomy

· If body and tail are involved à retroperitoneal approach through a left flank incision

· Feeding jejunostomy

· Cholecystectomy if gall stone pancreatitis

· Also laparoscopic surgery is performed

o Closed continuous lavage

o Closed drainage

o Open packing

o Closure and relaparotomy

o Nutritional support

· Pancreatic abscess

o Acute fluid collection or an infected pseudocyst

o Percutaneous drainage

· Pancreatic ascites

o Turbid fluid

o High amylase level

o Drainage via wide bore draine

o Suppress pancreatic secretion by parenteral and Nasojejunal feeding and ocreotide

o ERCP – identify the duct disruption and placement of a stent

· Pancreatic Effusion

o Encapsulated collection of fluid in the pleural cavity

o Percutaneous drainage under image guidance

· Haemorrhage

o Diagnosis by CT angiography and MR angiography

o Treatment – embolisation or surgery

· Portal or splenic vein thrombosis

· Pseudocyst

o Collection of amylase rich fluid enclosed in a wall of fibrous or granulation tissue

o Forms after 4 or more weeks after an attack of acute pancreatitis, in chronic pancreatitis or after trauma

o More than half have communication with pancreatic duct

o DD –

· acute fluid collection

· abscess

· cystic neoplasm

o EUS and aspiration of fluid

o Fluid is tested for carcinoembryonic antigen level, amylase level and cytology

o Can resolve spontaneously

o Intervene only if symptoms, complications develops or have to distinguish from tumor

o Complications

· Infection

· Rupture in to the gut or peritoneum

· Enlargement causing pressure effect and pain

· Erosion into a vessel

o Drainage

· Percutaneous transgastric cystgastrostomy

· Endoscopic

· Surgical

Systemic Complications

· CVS – shock, arrhythmias

· ARDS

· Renal failure

· DIC

· Hypocalcaemia, hyperglycaemia, hyperlipidaemia

· Ileus

· Visual disturbances, confusion, irritability, encephalopathy

· Subcutaneous fat necrosis, arthralgia

Fine Needle Aspiration Cytology

2011-12-30T23:52:00.001-08:00

· Preparation

o stop NSAIDS 1 week before the procedure

o suspend anticoagulant drugs

o No foods few hours before the procedure

o Investigations –

§ FBC

§ Clotting profile

o Antibiotic prophylaxis

· Instruments

o 22 to 25 gauge needles

o 10 or 20 ml syringes (+/- "pistol-grip" device)

· Procedure

o +/- topical local anesthetic (1% lidocaine)

o minimum of two passes be made into various portions of the nodule to decrease sampling error

o Slides are rapidly fixed and stained

o Other slides are air dried and fixed in alcohol

o Cell blocks

o Slides sent to cytopathologist with clinical and examination findings

Fine Needle Aspiration – 23-25 G needle

Large Needle Biopsy – 16 -18 G needle

Core Needle Biopsy – 14 G needle

Submandibular Gland – Sialadinitis and Tumors

2011-12-30T23:48:00.000-08:00

SIALADENITIS

· Inflammation of the submandibular gland

· Acute, Chronic, or Acute on chronic

· Causes

o Acute submandibular sialadenitis

§ viral

· mumps

§ bacterial

· commoner

· occurs secondary to obstruction

· usually becomes chronically inflamed and requires excision

o Chronic submandibular sialadenitis

· Obstruction within the gland

o due to sialothiasis, trauma, overextend flange of lower denture impinging on lingual papilla and causing inflammation and finally leading to stricture formation

o 80% of salivary gland stones occur in the submandibular gland due to high viscosity, antigravity drainage, and longer duct

o 80% of stones are radio-opaque

o stones are usually at the opening of the duct

o partial obstruction occur when the stone lies with in the hilum of the gland or within the duct in the floor

· History

o Acute painful swelling below the jaw

o lump increases in size and become painful during meals

o swelling resolves spontaneously over 1–2 hours after the meal is completed (usually seen in complete obstruction)

o pain in between

o abnormal taste – due to pus

· Examination

o firm

o tender on bimanual palpation

o stone may be felt in the floor of the mouth

o intra-oral examination - pus (chronic and non-specific bacterial infection) draining from the sublingual papilla (either side of the frenulum linguae)

· Investigations

o intra-oral X-ray

· Management

o For infection –

§ Amoxycillin 500 mg 8 hourly

§ Metronidazole 400 mg 8 hourly

o For pain - paracetamol 1 g 8 hourly

o remove the stone

§ If it is in the duct in the floor of the mouth anterior to the point at which the duct crosses the lingual nerve (second molar region)

§ Under local anaesthesia

§ Through a longitudinal incision

§ do not suture, left the duct open

§ stricture will form if sutured

§ If proximal to the lingual nerve – simultaneous submandibular gland excision and stone removal and ligation of the duct under direct vision

SUBMANDIBULAR SIALADENECTOMY

· Indications

o Sialadenitis

o Salivary gland tumors

o < 6 cm incision is made 3-4 cm below the lower border of the mandible to avoid marginal mandibular branch of facial nerve

Inflammatory conditions – intracapsular dissection

o Tumors – extracapsular dissection

o The superficial lobe of the submandibular gland is 1^st mobilized by retracting superiorly with Allis’s forceps.

o Platysma muscle is sutured with continuous reabsorbable sutures

o Skin is sutured with subcuticular non-reabsorbable sutues whoch are removed on the 7^th post-op day

o At the end a vacuum suction drain is inserted and kept for 24 hours

· Complications

o Haematoma

o Wound infection

o Damage to

§ Marginal mandibular branch of the facial nerve

§ Lingual nerve

§ Hypoglossal nerve

§ Nerve to the mylohyoid muscle producing submental skin anaesthesia

TUMORS

· Salivary gland tumors

Location	Frequency	Malignant
Parotid	Common	10-20%
Submandibular	Uncommon	50%
Sublingual	Very Rare	85%
Upper aero-digestive	Rare	90%

Submandibular Gland Tumors

· Uncommon

· Slow growing

· Painless

· 50% are benign

· Clinical Features

o Rapid enlargement of the swelling

o induration and/or ulceration of the overlying skin

o Facial nerve weakness

o Cervical lymph node enlargement

· Investigation

o CT

o MRI

o Fine needle aspiration biopsy – 18G needle

o Open surgical biopsy is contraindicated because that can seed the tumor to surrounding tissues.

· Surgical excision

o small intra-glandular tumor – intracapsular submandibular gland excision

o Large tumor – suprahyoid neck dissection preserving marginal mandibular branch of facial nerve, lingual nerve and hypoglossal nerve

o overt malignancy – modified neck dissection or radical neck dissection, which also removes lingual and hypoglossal nerves

References:

Bailey and Love’s Short Practice of Surgery 25^th edition

Pulmonary Hypertension

2011-12-04T10:14:00.001-08:00

· Mean pulmonary artery pressure = 12 +/- 2 mmHg

· Mean pulmonary capillary wedge pressure = 6 +/- 2 mmHg

· Cardiac out put = 5L/min

· Pulmonary vascular resistance = (mPAP – mPCWP) / CO = 1.5

PULMONARY HYPERTENSION

· mPAP > 25 at rest or >30 during exercise

· Associated with

o pulmonary vascular disorders

§ acute pulmonary thromboembolism

§ 1ry pulmonary hypertension

§ Multiple pulmonary artery stenosis

§ Pulmonary veno-occlusive disease

§ Chronic pulmonary thromboembolism

§ Parasitic infection (Schistosomiasis)

o lung parenchyma diseases

§ COPD

§ Pulmonary fibrosis

o Musculoskeletal disorders

§ Kyphoscoliosis

§ Poliomyelitis

§ Myasthenia gravis

o Disturbance of respiratory control

§ Obstructive sloop apnoea

§ Morbid obesity (Pickwickian syndrome)

§ Cerebrovascular disease

o Cardiac disorders

§ Mitral stenosis

§ Left ventricular failure

§ Left atrial myxoma

§ Congenital heart disease with Eisenmenger’s reaction

o Other

§ Appetite-suppressant drugs

§ Type 1 glycogen storage disease

§ Lipid storage disease

§ Rheumatic autoimmune disease (SLE)

§ Hepatic cirrhosis

§ Sickle cell disease

· Causes

o Precapillary

o Capillary

o Postcapillary

· Outcome

o Right ventricular dilatation

o Right ventricular failure

o Death

· Management

o Treatment of primary cause

§ Chest physiotherapy

§ Good nutrition

§ Early antibiotics in patients with cystic fibrosis and bronchiactasis

§ Surgical and medical therapies to optimize cardiac lung functions

§ Owygen

§ Anticoagulation

· Adverse factors

o Right ventricular dysfunction

o Reduced 6 minutes walk distance

Primary pulmonary hypertension

· Increased PAP

· Increased PVR

· Normal PCWP

· More in females (3;1) – 3^rd decade

· Men – 4^th decade

· 6-12% familial origin (autosomal dominant)

· Related to some drugs

o Aminorex fumaratre

o Amphetamine-like appetite suppressants

o Talc inhaled with cocaine

o Fenfluramine and Phenteramine in combination (weight loss drug)

· Other similar conditions

o Plexogenic pulmonary arteriopathy

o SLE

o Hepatic cirrhosis

o Eisenmenger’s reaction

· Clinical presentation

o Insidious onset

o RVF

· Investigations

o CXR –

§ Enlarged pulmonary arteries and branches

§ Pruning of peripheral arteries

§ RA or RV enlargement

o ECG

§ RVH

§ RA enlargement (P Pulmonale)

o Echocardiography

§ RVH

o Normal pulmonary function test

o Diagnosis is by CT pulmonary angiography

· Treatment

o Warfarin, oxygen, Calcium channel blockers

o Oral endothilin receptor antagonists

o Prostanoid analogues

o Sildenafil

Chronic cor Pulmonale

Enlargement of the right ventricle due to increased afterload.

· Clinical features

o Chest pain

o exertional dyspnoea

o syncope

o fatigue

o sudden death

o symptoms due to pulmonary hypertension

· signs

o cardiovascular system

§ prominent a wave

§ parasternal heaves

§ loud pulmonary component to the second heart sound

§ right ventricular fourth heart sound

§ systolic pulmonary ejection click

§ mid systolic ejection murmur

§ early diastolic murmur (pulmonary regurgitation – Graham steel murmur)

§ pansystolic murmur, large jugular ‘cv’ venous wave (tricuspid regurgitation)

· investigations

o CXR –

§ Right ventricular enlargement

§ Right atrial dilation

§ Prominent pulmonary artery

§ Peripheral pruning

§ Oligaemic peripheral lung fields

o ECG

§ Right axis deviation dominant (R wave in the V1 and inverted T waves in right recordial leads)

§ Right atrial abnormality ( tall P waves in L11)

o Echocardiography

§ RVH/dialation

· Treatment

o Diuretics for right ventricular failure

o Oxygen therapy

Pulmonary Embolism

· Most emboli come from pelvic and abdominal veins

· Some come from femoral deep venous thrombosis, axillary thrombosis

· Clots form as a result of

o Sluggish blood flow

o Local injury

o Compression of vein

o Hypercoagulable state

o Tumor

o Fat amniotic fluid

o Foreign material

· Clinical features

o Sudden onset of unexplained dyspnoea

o Pleuritic type chest pain, Haemoptesis - infarction

· Small medium pulmonary embolism

o Haemoptesis in 30%

o Tachypnoea

o Localized plural rub

o Coarse crackles over the area

o Exudative plural effusion

o +/- fever

· Massive PE

o Sudden collapse

o Severe central chest pain

o Shock

o Pale

o Sweaty

o Tachycardia

o Peripheral shut down

o Hypotension

o Increased JVP with prominent a wave

o Right ventricular heave

o Gallop rhythm

o Widely split second heart sound

· Multiple recurrent pulmonary emboli

o Increased SOB over weeks

o Weakness

o Syncope

o Exertional angina

o Right ventricular heave

o Loud P2

· Diagnosis

o The presentation is nonspecific, so PE is pulmonary embolism is suspected if no other cause can be found.

· Investigations

o Small/medium pulmonary emboli

§ CXR

· Normal

· Linear atelactasis

· Blunting of costophrenic angle

· Raised hemidiaphragm

· Wedged shaped pulmonary infarct (rarely)

§ ECG

· Normal

· Sinus tachycardia

· Atrial fibrillation

· Tachyarrhythmia

· Right ventricular strain

§ FBC

· Polymorphonuclear leukocytosis

§ Elevated ESR

§ Increased lactate dehydrogenase

§ Plasma D dimer

· Exclude PE if undetectable

§ Radionuclide ventilation/perfusion scan

§ USS – find clots in pelvic or iliofemoral veins

§ Contrast enhances CT angiograms

§ MR angiography

o Massive PE

§ CXR –

· Pulmonary oligaemia

· Pulmonary artery dilatation in the hila

§ ECG

· Right atrial dilation

· Tall peeked P waves

· Right ventricular strain

· RV dilation

· Right axis deviation

· RBBB

· T inversion in right precordial leads

· S1, Q3, T3

§ Blood gases

· Arterial hypoxaemia

· Low arterial CO₂

§ Echocardiography

· Vigorously contracting left ventricle

· Dilated right ventricle

· Clot in right ventricular outfoe tract

§ Pulmonary andiography

o Multiple recurrent PE

§ CXR –

· Normal

· Enlarges pulmonary arterioles

· Oligaemic lung fields

§ ECG

· PHT

§ Leg imaging

· Thrombi

§ V/Q scan

· Pulmonary infarct

· Multidetector CT

o Small emboli

· Treatment

o Acute management

§ High flow oxygen

§ Bed rest

§ Analgesics

o Severe

§ IV fluids

§ Inotropic agents

o Fibrinolytic therapy

§ Streptokinase 100 000 units IV for 12-72 hours

§ Surgical embolectomy

· Prevention of further emboli

o LMWH

o unfractionated heparinoral anticoagulants are begun immediately and continued for 6 weeks – 6 months, sometimes lifelong

o IVC filter

References:

Kumar P, Clark M, 2009, Clinical Medicine, 7^th edition, Saunders Elsevier, pp 781 -786

Notes - Infective Endocarditis

2011-12-03T23:51:00.000-08:00

AETIOLOGY

· Dental disease or procedure

o Alpha haemolytic Streptococcus viridians

· Prosthetic valves –

o Early < 60 days –

§ Staphylococcus aureus

§ Staphylococcus epidermidis

o Late > 60 days

§ Streptococcus viridians

§ Staphylococcus aureus

· Intravenous drug abuse, long standing IV cannulae and soft tissue infections (DM)

o Staphylococcus aureus

o Candida (rare)

· Cardiac surgery

· Permanent pacemakers

· Genitourinary disease or procedure

o Enterococcus faecalis

· Bowel malignancy

o Streptococcus bovis

· Rare causes – HACEK Group

o Haemophilus species

o Actinobacillus actinomycetemcomitans

o Cardiobacterium hominis

o Eikenella corrodens

o Kingella kingae

· Culture negative BE

o Prior antibiotic therapy

o Fastidious organisms

§ Coxiella burnetti (Q fever)

§ Chlamydia species

§ Bartonella species (trench fever and cat scratch disease)

§ Legonella

SYMPTOMS

· Fever – Pyrexia of unknown origin

· Malaise

· Features of cardiac failure

o Ankle swelling

o Shortness of breath

· Arthralgia

· Abdominal discomfort (splenomagally)

· Strokes

· Haematuria

SIGNS

EXAMINATION

GENERAL EXAMINATION

· Eye –

o Roth spots - retinal hemorrhages with white or pale centers composed of coagulated fibrin.

o Conjunctival splinter haemorrhages

· Poor dental hygiene

· Venipuncture marks

· Tattoos

· Petechiae - on the legs & the chest wall

· Clubbing

· Splinter haemorrhages

· Osler nodes - On pads of fingers & toes, and thenar & hypothenar eminences.

· Janeway lesions - Hemorrhagic raised lesions in palms & soles

· Ankle swelling

CARDIOVASCULAR SYSTEM EXAMINATION

· Murmur

INVESTIGATIONS

1. Confirm diagnosis

2. To identify the organism

3. Monitor response to therapy

Tests

· Blood cultures

a. Three sets (6 bottles) from three sites

· Serological tests

a. When blood cultures are negative

b. Coxiella, Bartonella, Legionella, Chlamydia

· FBC

a. Mild normochromic normocytic anaemia

b. Polymorphonuclear leukocytosis

c. Thrombocytopaenia

d. Thrombocytosis

· Blood urea - sepsis

· Serum electrolytes – sepsis

· Liver biochemistry – Increased ALP

· CRP & ESR –

a. increased

b. CRP – to assess response to therapy

· Urine full report

a. Proteinuria

b. Haematuria

· PCR – culture negative IE

· Echocardiogram

a. Transthoracic

i. Visualize vegetations

ii. Valvular dysfunction

iii. Abscessed

b. Transoesophageal

i. Higher sensitivity and specificity for abscess formation

· Chest X-ray

a. Evidence of heart failure

b. Multiple pulmonary emboli – right sides endocarditis

c. Pulmonary infiltrates

· Electrocardiography

a. MI

b. Conductive defects

DIAGNOSIS

1. Microorganism positive in culture of a specimen of a vegetation, embolism or intracardiac abscess

2. Active endocarditis seen in histology of vegetation or intracardiac abscess

3. 2M + 1m

4. 1M + 3m

5. 5m

· 5 Major Criteria (M)

1. A positive blood culture for infective endocarditis – Typical microorganisms in 2 separate blood cultures

2. A persistently positive blood cultures –

§ In 2 samples obtained 12 hours apart

§ In all 3 or majority of 4 or more separate samples with 1^st and last taken at least 1 hour apart

3. Positive serological test for Q fever

4. Echocardiographic evidence of endocardial involvement

5. New valvular regurgitation

· 6 Minor Criteria (m)

1. Predisposing heart condition or IV drug use

2. Fever ≥ 38⁰C

3. Vascular phenomena

4. Immunologic phenomena

5. Microbiological evidence

6. Endocardiogram

TREATMENT

· Antibiotic treatment for 4 – 6 weeks

1. No suspicion of Staphylococci – Penicillin, Gentamycin

2. Suspected Staphylococci – Vancomycin, gentamycin

3. Streptococcal – Penicillin, gentamycin

4. Enterococcal – Amlicillin/ amoxicillin, Gentamycin

5. Staphyloccocal – Vancomycin, Flucloxacillin, Benzylpenicillin + Gentamycin

· Monitor serum levels of Gentamycin and vancomycin to ensure adequet therapy and prevent toxicity

· Penicillin allergy – vancomycin or teicoplanin

Response to treatment

· Should respond within 48 hours

o Resolution of fever

o Reduction of ESR and CRP

· If not,

o Perivalvular extension and abscess formation

o Drug reaction

o Nosocomial infection

o Pulmonary embolism

o Take cardiothoracic opinion

Surgery

References:

· Kumar P, Clark M, 2009, Clinical Medicine, 7^th edition, Saunders Elsevier, pp 769 - 773