AMC 2006 April Melbourne -GP1154, Pt EducP187

8. Contact dennatitis

Photo dorsum of hand. (Not from AMC book -scaly lesions on whole dorsal surface of hand, red).Pt is a brick layer started new job 6 months ago, comes to your GP practice

The 32 years old man came to tour surgery. Presented with hand (the picture attached: swelling with sign of dermatitis and infection between the fingers)

Take relevant history

Explain the condition to the patientManagement

Role player asked:

• How long you going to put me on antibiotic?

Should I stop working? How to prevent in the future

Hx

When and where it began?ft's distribution?Does it change overtime? Any .relationship to sun exposure or heat or cold? And any response to Tx?

How long have you had this problem?

Can you tell me more about it? How does it started? What have you done for it? _

What medication did you use? What cream have you tried? Anything that makes it worse?

Anything that makes it better?

Does it itchy? Painful? Warmth sensation? Redness? Swelling? Pus discharge, fever?

Any constitutional symptoms?

Ask if any feverlheadachelfatigurelanorexialwt loss PastHx

-rashes or allergic reactions

-Past Hx of asthma, ecze.ma and hay fever

Fhx

-Do you have FH of eczyma, asthma, or allergic skin problems?

A detailed social Hx

-Whafs your occupation? Cement contact because J'm a brick layer.

• -How long have you been a brick layer?

Smoking Alcohol Medication Allergy

Summary of hx

Role-palyer one: Rash has been there for 3 months, 3 months after he started his work, at work does everything with hands, no gloves. Rash very itchy, holidays made it better. pt loves his job. Brother has psoriasis (to confuse you).

From history the patient said it came suddenly, he doesn't have any allergy, hay fever or asthma, as well as family history of those conditions. He is a builder and recently he worked with cement

.,

Allergy skin tests (patch test) and RAST Ox: Contact Dennatitis

\

,

Mx Tell pt:

It is a skin inflammation caused by an allergic or irritating reaction to certain substances (cement most likely) coming into contact with skin.

• Tx: Refer to Dermatologist ~ .~ 1:..o.t:i Tj

• Stop contact with allergens- stop working as a brick layer, but it seems to be impossible, so advise use of gloves which there are cotton in inner layer, plastic in outer layer. (Wear protective work gloves such as cotton-lined PVC gloves)

• Antihistamines for very itchy cases.

• Avoid soap and other irritant at this point because of possible infection. i,.Uu':\.h... t.Clfh... w~ Of

• Topical corticosteroid cream s. 'F l ..... :J •

• Oral corticosteroid for severe cases (60 mg for adults)

• Give antibiotics orally if sign of infection (pus discharge, fevet)

My answer: contact dermatitis. Examiner expected to hear oral steroids as tx, not only topical steroids and gloves as protection. I told the role-player he does not have to change the job, which he liked. The examiner asked about complications. (My answer cellulitis, treat with oral FlucloxaciJlin after checking BSL and lymph nodes)

I'd read at least from Murtagh and Pt's education re: this topic

I explained to him that he had an allergy probably due to cement complicated by bacteria. I gave him prednisolone and antibiotic. I talked about referring him to allergic clinic to have a test done and avoidance to the materials that you allergiC to. Then report to your employer regarding his condition. There's possibifity that they'll move you to another department

)

2006 April Adelaide

A 17y man complaining of worsening vision over the last few months. He has difficulties with driving and cannot see the road signs clearly. His father and brother wear glasses.

Do the necessary tests. explain the results and manage the case (He had decreased visual acuity, all other tests NAD)

Examination

1. visual acuity(snellen chart}--with pinhole test

2. visual field( using red oin)

3. colour vision

4. pupil reaction(ligbt reflux. accommodation) S. eyemovement

6. fundus examination

(A complete eye test is the only sure way to determine whether your vision is normal)

(

Explain

1. myopia is short-sightedness. people who have it do not see distant obj ects clearly. It is a kind of refractive errors.

2. in a normal eye, the lens and cornea focus light into on the retina In a myopic eye, the light is focused in front of the retina and so the image is blurred

3. myopia is a very common condition which affects about 30%of Australianj

4. myopia usually begins to develop in teenage yearS: then it may progressively increase over the q following years:1Slowing in the mid to late twenti.e@in most people.

S. refractive errors ends to stabilise once a person stop growing, so that from their late 20s to their early 40s most people do not experience any major changes in their eyes.

6. . most people stop changes below 6 dioptreS~

7. ifmyopia progresses above 6 dioptres (sometimes up to over 20 dioptres) called pathological myopia. Ii is rare less 3%.

8. this has serious consequences later in life because secondary degeneration of the vitreous and retina can lead to : retinal detachment ,choroidretinal atrophy and macular bleeding

9. main causes are genetic (chromosome 18p&12q) and excessive close work in the early decades.

Management

Non-surgicaI measures

1. when reading ensure ·&000 lighting!

2. advocate ~ balan:~ .t:?f p'hysic8.I activity and readingi

3. some people also advocate doing eye exercise(known as"bates methods" ,but there is DO solid scientifid evidence)

4. ~tacIeS (~With Concave lens)

5. ·.ContaCt 1eris8

_ ...

6. for children, check their eyes every 6 month (avild over-correction as this can make myopia worse)

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Smgery

7. radial keratotomy

8. photorefractive keratotomy (PRK)

it is an entirely laser treatment where the curvature of the front of the cornea is altered by ablation of part of it using a laser

it is less predictable than lasik with some people having under-correction and others over -correction

most have good outcome but it is very painful for a few days

)

9. lasik/laser assisted in situ keratomileusis)

a thin flap of corneal tissue is created with a fine instrument known microkeratome. This flap is then lifted out of the way. The excimer laser reshapes the underlying tissue and the flap is replaced to cover the newly recontoured surface.

Serious complications are rare but trauma to I infection of the flap may result in permanent corneal scarring.

Reason for surgery

1 they can't wear contact lenses and would prefer not to wear glasses for cosmetic reasons

2 they want to engage in work or leisure activities that can not be done while glasses 01 contact lenses

medical issues to consider

1 at least more than 20 years old

·2 the refractive error should be stable

3 people with diubete/uncoutrolled rheumatic conditions/diseases of immune system/family history of keratoconus should be careful in proceeding with laser eye surgery.

4 lase. eye surgery carries extra risks if performed on patients with abnormally shaped or very thin corneas.

AMC 2006 April Adelaide

-devftP35 (very good case) in combined wfth our surgeon's note.

Case--11 (Neck lump! Warthin's tumour)

70 years old lady com to you wfth lump in front of left ear in the post 5 years (slow growing) no pain. ,

Task: take history for 3 mints, ask examination finding from examiner and examine relevant system and talk to the patient.

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HOpe (detail of the lump)

-Slow growing and painless swelling below ttis left ear (in the parotid region) for 5 yrs

-The lump has been getting slowly larger, but has not noticed any other

swelling. l:x...o""'-!'"

-No change in the size of the lump when eating nor.painful.

-No discharge or bleeding from the lump. "'-

-Only left side swelling

Associated symptoms

-He has no night sweats nor loss of weight, no coughlfever

-she had no vision problem, no headache, no teeth ache,

-and no difficulty with swallowing, no voice change.

PastHx

-In general good health

-not previous history of surgery and no hx of any trauma on the face.

Fhx: Nil Social Hx

Smoking: 20/day for 40 yrs Alcohol: Nil

Medicacation: Nil

Allergy: Nil

GA well, no pale/wt laos -V'signs: Normal

-Detail of lump exam, look for the following

-Site, size, shape, consistency, surface, edge, and

. deep/superficial attachment

-Relationship to nearby anatomical structures (mandible and pre-auricular)

-Its anatomical layer (skin, subcutaneous tissue and muscle)

-whether it impinges on adjacent structures (facial N)

-Look inside the mouth. Look for ca of tounge and deep lobe tumour

-examine for lymphadenopathy

-Check faCial nerve function

-Examine the external auditory canal.

-Comment on the other side (important)

Note:

-Skin (moved when the skin is moved) -Sebaceous cyst Epidermoid cyst Papilloma

- Subcutaneous (skin moved over the lump) Neurofibroma Upoma

fl'c--.A,<. 00.-vvl- ~t&--vl;!.. ....

- Muscle or tendon (I imit lump mobility) - Tumour

- Nerve- pressing on the lump c¥:ing pain

Summary of findings

There is a 3cm diameter smooth-surfaced swelling situated over the angle of the left jaw. It is not attached to the ovenying skin and no punctum is visible. The lump appears to be frxed to the underlying tissue and is finn in consistency. There are no other palpable neck swelling and the left external auditory meatus appears normal.

Intra-oral examination shows that the patient has good, well cared-for a~ 1",."",1,

dentition. The orifice to both parotid ducts are normal (no stone) C ()1'~"":!-<-- "fP-'-''''-

I looked for similar lumps elsewhere and checked for lymphatic field and other lymph node group. I also asked for examination of seven cranial nerves and respiratory system. Patient asked; doctor is it cancer? I reassure her; that from history and my finding you not have any cancer and I will send you for taking a biopsy for histopathology for confolTTlation of my diagnosis.

Investigation:

-CT scan, initial Ix: this ~ide a clear definition of the @f~:of ~Iesion and its<y.?sculari~ Also provide if the~ lobe is damaged.

-FNA~ 2ncl ix. C LAjt:O!.o9y)

Cx-ray, LFT, incisionaJ biopsies of the parotid are usually avoided because of the high risk of damage -to the facial nerva.

Note: Swelling of the parotid gland may be due to duct obstruction, although tumour is more common with this gland. Malignant tumours of the parotid gland may associate I facial nerve palsy.

-Warthin's tumour of parotid gland (AMC feedback)

Warthin's tumour is benign tumour and is usually in old person with ·srilokstt. About 10% is :bJlat~1 siqej and no tendency to be malignant? so usually:oq' -_Ileed to surger;y. - - ....

However, the most common parotid swelling is benign pleomorphic adenoma· (tendency to be malign9:nt) and this need to be surgical removed.

Mx

-Superfical parotidectomy

How to talk to the pt and consent for operation Explain the dx to the patient.

He has a slow-growing tumour in the parotid gland, and while it will not metastasize, it will get larger and==may:::::e¥eRttlally=undergo---malignant .tfBnsfermation.

Superficial parotidectomy, under GA, S incision and parotide cut out. Risk:

damage facial nerve palsy

Frey's syndrom: gustatory sweating, parasympathetic nerve affected Sialocele (subcutaneous accumulation of saliva)

DDX

.. Benign lesions of the parotid - 'ite'O"""O"1l....·l..- ~.~ -Warthin's tumour (~~~ft-..v~)

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- ~.~...J. ........ ~

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.. Nt#'>- ~h'd 1't.4! .............

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7

AMC march Sydney 2006 Autologous blood transfusion ~BMJ 2002, 324:272-5

12.A man in his 40's comes to your GP clinic. Few days earlier, he was seen by an orlhopedic surgeon and was scheduled to have a hip prosthesis operation in 6 weeks time. He wants his own blood to be used during the operation.

Tasks:

Explain benefits and risk of autologous blood transfusion and other blood products

Answer patient's questions

Questions asked:

How many bags of blood can be extracted from the patient? How many times can take blood from pt?

What are the advantages and disadvantages of autologous transfusion How long can an extracted blood from patient last in the blood bank? Can the patient be aI/owed to have AT?

What Ix need to be done for blood transfusion? What are the criteria for selecting qualified blood?

Note: This case is a little bit confusing as I am not sure the task is ask you to focusing on A T or normal blood transfusion, so becareful reading the task in the exam.

My approach:

Introduce yourself and show sympathy

Ask pt why she is concerned her own blood transfusion

Explain the options of blood products and the benefits/risks of each option

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Autologous blood transfusion Key points:

-decreased need for allogeneic transfusion

-Most widely used in elective surgery

-Is one of techniques used to reduce the need for allogeneic

transfusion

-3 main techniques:

-Prediposit transfusion (AT)

-Intraoperative haemodilution

-Intraoperative/postoperative salvage

-Advantage: blood is safe and less postoperative risks

-Disadvantage: more cost-effective

5% blood donated in USA is AT

Why AT--concems about the safety of blood Problems associated with allogeneic transfusIon

-'Acute haemolytic reaction: could be life threatening.

AAilergic reaction: The most common complication due to release of cytokines from wce within the blood product. Present as fever, etc ;-Oecrsasecf celfiTI-ass/occasT6ri-cii1y-tranSJenfhypotension

-lncreased risk of postoperative infection: Heptitis B & e, HIV, etc.

~f"" (I ~ ft.') 1"0 fI

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-Increased risk of mutilorgan failure

Alncreased demand for biood with a declining population of qualified willing and healthy donors.

Predeposit AT Procedure

-Entails repeated preoperative phlebotomy

.. Blood col/ection begins 3 .. 5 wks before elective surgery, depending on the numbelS of units required, usually 2-4 units (1-2 Litre).

-The last donation takes place a least 48-72 hrs before surgery to allow for re-equilibration of the blood volume.

-On each occasion, about half a litre of the patienfs own blood is taken and put into sterile plastic bags.

-Anticoagulation is maintained with citrated glucose solution blood is stored until the time of surgery.

Advantages

-Eliminates the risk of viral transmission

-Eliminates the immunologically mediated haemolytic, febiil, or allergic

reactions. +{"(!I") sfC!!> Ib...,

-Decreased risk of post-operative infection

-Decreased risk of cancer recurrence because of immuno-modulation

Disadvantages

-Up to half of the blood that is col/ected may be discarded because the amount drawn off needs to exceed the median routinely needed to avoid additional allogeneic transfusions.

-Left over blood 'can rarely be used for other patients because most AT donors do not meet the stringent health requirements for allogeneic blood donation.

-This wastage of blood and the cost of administrating autologous results in high costs of collection.

Suitability of patients

-Is only for elective surgery

-Patients must be willing and able to travel to a donation centre before

the operation, which can be inconvenient and stressful and may decreased their productivity at work.

-Perioperatlve anaemia: · ..... Slood volume, "'Venous access, 'Packed cell volume and haemodynamic stability are important determiants of who is an appropriate candidates for the procedure.

Need to check HS each time before donation.

-Children who weigh less than 30-40 kgs are cr.

-Adult pts who have severe haemodynsmic problems, active systemic

infections, or a hx of serious reactions to donation (such as seizure). -Patients with diarrhoea in the dayslweek because increased risk of bacterial contamination of their donated blood.

-:-High risk of reactions such as fainting/dizziness.

-Do same match test.

Allogeneic blood transfusion (Packed red cells) (RCH Handbook P413) Procedure

Donor should be:

0\.ge between 16 (18 in Tasmania) and 70 yrs old. Weight >45 kg. Be in good health, with normal temparature and BP.

<.:Blood donor should be screen for hepatitis Band G, syphilis and HIV/AIDs, and if donor spends 6 mths or more in England, Wales and Scotland for "mad cow disease)

-Healthy people weight> 45 kgs of all age are able to donate blood the procedure is safe and painless.

-Normal person can donate 470 ml in one time, which is 8% of the average blood volume. Body replaced the blood volume within 24-48 t!!!. and ReG within 10-12 wks needs to replace, so you can donate whole blood every 12 weeks and plasma every 2 weeks.

Benefits

-The commonest blood product for transfusion is Qacked red cells.

-Indication: acute restoration of oxygen carrying capacity is

required.

-Thus, carrying oxygen around the body, which is life saving.

Disadvantages/complications: -see above

/0

CASE 16 L--- .-J (SKIN RASHES)

2006-07 -29-BRISBANE

A young male, developed

37.8; and

of both

TASK:

""Dr. Vikraman case:

A 40 y/o male, a computer engineer come to your GP; p/w rash, fever, pain in his jOints(small joints). Being very healthy. He has a family, 3 children.

TASK: Hx regarding the Sx.;

Ask Examiner physical finding; COX;

Ix: what confirmation tests .------,1:

Fever: When was the fever started?

Do you have any SIS of upper resp. tr. Infection(URTI) such as runny nose, cough, headache, sorethorat and body ache? Are there any ass. sx such as nausea, vomiting, diarrhea, fatigue, joints pain, muscle pain?

Skin rash: Where are the skin rashes located?

What color are they? Red; purple or blue?

Does it blanches on pressure? Are they itchy? An,) b~'(..?

Joints pain: Where are your joints pain?

How many joints being affected?

Are the joints present with redness, swollen, warmth and tender? l ~"''f''-<. c f i"~wv>~i!i.m)

Are these joints limited ROM or stiffness? I' .....

Lymphadenopathy: Did you feel any lump in your neck, ann pit or groin" areas?

¥Travel Hx: I I

C: Have you been travel to other countries or interstate?

P: , I went to for for

1 week; a lot of mosquitoes over there, I got

. We came back to Melbourne 4

days ago.

I,

~: GA: Acutely ill, unwell, but no dehydration VS: BT: febrile; others normal

Head & Neck: Conj. Not anemic; Sclera not icteric Oral mucosa no petechiae

.. No Neck stiffness, no Kemig's sign No LNE; no TGE

Chest & Abd: Skin rashes; non blanching purpura rashes.

No HIS megaly Ext: Rashes as well.

Joints pain over carpal phalangeal joints; wrist & ankle joints; worst on wrist joint.

1)1'), I:

• Dengue fever

• Hepatitis g,

• Rubella

• Barmah forest fever (a mosquito barrie virus)

• Early-RA and Rheumatic fever

• Arbovirus

• Pannovirus

• Parvovirus

• Slap face = Fifth dz.

[;It do all the viral serology esp. Ab for Ross River Virus ...,1\

FB~ESR\CRP -

Blood culture

Blood film

,

, -

Antibodies - ANA; other autoantibodies Rheumatoid factor

onfirmation tes: A,....'·d·>'\J~ T~

M>,: No specific treatment

Symptomatic Tx-Bed rest

Simple analgesics - aspirin, NSAIDs Oral corticosteroids are effective but should be avoided If possible.

*GP/JM p265 IRoss River Feverl

11--

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BNE 3/05 Case 12 : G""'-:-lan--::'"dTu-rla=r"'l"'fe="""v=e-:-r . (260GP) 20-22 yo boy c/o sore throat, rash on back. Take Hx , Ask findings , make Ox.

1. H>C Ask: -The onset or duration of sore throat. -fever.

-cough.

-swollen glands.

-the jaundice

-Abdo pain.

-NN.

-loss of appetite.

- Change in bowel movements.

-Rash:

- Have you taken any meds for sore-throat such as Amoxicillin or PNC.

PHXi.: Hx of jaundice, hepatitis, blood transfusion, ear piercing, tattoos.

Meds (cause hepato toxicity) - illicit drugs , alcohol.

Any risk factors of hep A ( eating shellfish, over crowding, contaminated water or food .

III contacts (girl friend .. )- Travel overseas. Immunisation against Hep 8 Sexual fiX : There are so many problems which can be transmitted by

sexual intercourse, it is routine to ask some Qs abt your sexual activity: + Do you have sex with men, women, or both?

+00 you have a stable relationship with 1 person?

+ Have you always used condoms?

+00 you have sex with people who might be at risk for having sexual transmitted Os or HIV?

+Have you practised unsafe sex?

2. ,PEl: GA/VS

Throat Ex :(erythematous pharynx). Neck: lymph nodes.

Abdo : tenderness on R UQ ? Liver: size, Spleen: size. Respiratory.

3J>G FBC & blood film: (atvpicallymphocytes ).;abso!ute Iymphocytosi~.

LFTs. - -

Viral serology for Hep A,B,C.

Mooospot test (lgM )=Paul Bunnell test .to confirm Ox. Test for heterophil antibodies +ve{ =ve can be delayed or absent in 10% ) .

If monospot test -ve =>order Cytomegalo titers since

mononucleosis may be due to CMV.

Diagnosis confirmed (if necessary) by EaV-specific antibodies-lgM, IgG &EB nuclear antigen (EBN-A).

Culture for EBV & tests for specific viral antibodies are not done routinely.

Throat Swab: culture?

4.0x: Infectious Mononucleosis due to EBV. S.ODx: Hep A,B,C.D ,E I t.MV/ 'Tc..,.u:.r~'(,--' 1-JllI

M.,. •

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t.. 'W\.-\,... ok ioj" ~ <-- '"""'f.J.\.ON"L)

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Mx of heart ranure (Dr Hillman) -devitPl99 (very good case), GP538,

Case: 7S·y.p female. presented with 3 wks hx of SOB and ankle swelling. OlE: found to be atrial fibrillation and mitral pansystolic murmur and evidence of cardiac failure. Task: (1) explain the nature of heart failure to the pt (2) further Ix and (3) Mx

What is heartfailure?(pt Ed P215)

-The heart not function well, muscle pump, fails to pump enough bliod around the body

-due to muscle is weakened or because there is a mechanical fault in the valves controlling the flow of blood.

-Lt side pump blood with oxygen into the body. t,

-rt side pump blood into lung to get oxygen

What are the symptoms?

-SOB, esp on exertion, paroxysmal noctural dyspnoea

-tiredness/lethargy/nausea

-swelling of ankle and abdomen , ~l>,J./V"."...Q.

-weight gain or loss

What are the signs? Left heart failure

\.

-Tachycardia , Tc...J,...,~JpnO'i..Lt..

-poor peripheral perfusion (cool and muscle wasting)

-low volume pulse

-displaced apex/gallop rhythm (3n1 ht sound)

-Pleural effusion/bilateral basal crackles

Rt Heart Faliure -elevated NP

-peripherallankle/abdo oedema

-hepatomegaly/ascites

What are the causes? (Dr Hillman's note)

-ischaernic ht dx tc(..k.v. ~ ,"t- 0... 1..-/0 ant..... AMI ")

-hypertension

-valvular disease

-myocarditis (alcohol, viral)

further Ix(250 Cases) -FBEIU+ElLFTs/ R.~I

-CXR

-ECG

-Echocardiography: Assess ejection fraction/valvular dxlventricular function / di ~~Q..-n+ful-t- bit:

iffurther doubt, can do transoesophgeal echo ~w\Ji<- .... ~t,,,( . ..\·\;:'\.\L·~1

Management (GP540) . ~/. .r - .s" I ~ _ 1'!.; .

Non-pharmacological ~ includ~ ?sk fnctors.:C?nirol '''~t.;~Y\''''i ',"~~"';'r ,"I.; ve.-, " . 11,,-::

-reduce your physical actrvity ~ -;-L.{../- ;~ ~rt-(",,~ ...... ~,bv..G- ~,.. ... ~,'t-C.. '"j. v-.J~"""'cr-,J rt

-~ut.downyo~s~tintake . \-.,~.C<. ~~ &e.t """,w u-r ec.(~t

-limit your fluid intake ~ <, \ YL L/J"'--j •

-reduce your weight if overweight ...........

-avoid smoking/stop alcohol

Medications (pt ed is good English skill)

-diuretics (fluid tablets). help take the load off the heart

.. VG4.{, cl.,·l&.~ (AL~ \,.,I.--,;.I,ri i-o-.+-) ... ~ cf"'"i:} - +0 Dr-- 'i ~ flt.u---u.L ,,~ •

.. ~'r""" """"'J ~ ~.J-..-, 11'V'>y--v'-L. --f1,-..L .rlwzr- v-i- --tt.--.. h,.e.a....-t..

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DVT #11 14.05.05 Melbourne

54 y.o. female has a painful calf when goes to bathroom. She is on HRT. Diagnosis: oW-task; Management

-

Mrs. Jones, you have got a condition, called Deep Vein Thrombosis.

How much do you know about DVT?

. '-' •• t. • There is a clot in your vein and can not bring back the blood to the heart. This causes oedema

~La- n,.('.<fL'/ in the leg and pain. J

I ~. The causes can be trauma, post operation, prolonged bed rest, coagulant problem or on HRT.OU. r£ll'VlOvJ

JV!.l:JVi1j 4-00 • The symptoms are calf pain, leg oedema and pain on dorsiflexion of ankle _ Homan's sign. r l

co (I ~" ~H}'!J • This complication can be potentially threaten Iife-Pulmonary'Embollsm, if it is not treated

"" p ",If elf. i;,., appr?priately, other complication is varicose vein, esp. if it is recurrent. \_j) , . _ . _

• The Important tests we need to do for you are: ~t- 0-"- ~- 'nJ-c..".<.-I;"""

Venous Doppler study L eo ~+ "T ot.(,-t- ) Thrombophifia screen: Protein C and SI Leiden factor VI Homocysteinl AntiphosphoJipid anti body Prothombin gene mutation Venography (Contrast) ()1 g 't ,') v (( .... ,9 "lC'" rto h f"~VTG ~ L ,--~ • Lung Scan: VlQ scan c: w",l;"T"" 1I~" of. PE )

t

Treatment: . :])'" '1Yv'"!" ........... \-() yt.("...,...-",. vI- ,~ Stop HRT/ Admit to Hospital /T.(\V'f' ~ ~1-,".-.....J2 -k., :..u n M """- +t.-.... I - I

Heparin therapy:

Low molecular weight heparin -Delteparin 10Qiulkg@12hrly Advantage: More convenient Dose on weight, not require monitor Disadvantage: Can nat reverse 4_ Can not used in renal failure .. V'Unfractionated heparin -Danaparoid sooOL@ followed by 1000ulh Advantage: Rapid reverse - Protamine

Can be used for renal impairment Disadvantage: Require more frequent montor, difficult to dose

{~h\"'~+~""'I~t.r......., ..... ~r~'\.-)" Ch" \\.~.

Warfarin: Antagonise vrt K. depress factors VII IX X ~ ~c (, (Y') j1....

start with Heparin .f";6Lo ........ I, "j tl.>c.-.-~ .......

start at loading dose,§ .. 10mg for 2 days

Adjust the dosage according to the INR from the 3m day Therapeutic range 2-3

Heparin can be ceased when INR>2 for 2 consecutive days

Maintenance dose is reach by day S. INR reflects the warfarin level 48 hrs earlier • j.. k

\L JWarfarin should be continue for 3 months (PE 6 months) c;lo.,1.j ]C t to

~ompressive stockings - both legs to above knees ~"\,.

Surgery: For extensive and embolising case :r..... ... ~ ~""" ""j - Il-u.> ~ '"'" J..J......1... }<'l"

.. Advice to patient: 2. Hfl"lrry.JJC· ~

Keep to a consistent diet and ideal weight ~ ~

Take Warfarin same time each day !c"e-t..t1 )<" tt r.J

Do not take Aspirin NSAIO with Warfarin I ~\..q. L<>

Always mention that you take warfarin to any doctor, dentist or chemist you are 1-

consulting u \

R rt r f bI· ....... dl\ P' [)oj •

Jtf epa sgns 0 eeding such as black motions, blood in urine, easy bruising, unusual ,."

nose bleeds, heavy periods or purple toes I C:n. ........ ~- flVt..uJ.i'J

Remember to take tablets_strictly as directed and have your blood tests. .

Prevention:

" eany arnbulatlon <72 hrs after operation

Elastic stocking Pneumatic compression

Electrical calf muscle stimulation during surgery LMWH for orthopaedic surgery

Unfractionated for prolonged immobilized patient

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AMC resit 2006 march Sydney

Case-8 (CelVical spondylosis) 'V"-",,"'r.r- @..."&~ ....... tr·1.>-""c- Ij8

-GPP661, Davidson Med P

A middle aged man has pain in the left shoulder, radiate to forearm and fingers.

A young man came to your GP clinic wah complaints of pain at the left shoulder for the past one week.

Task: take history, examine, finding investigation result from examiner and diagnose the case.

Hx

Detail of pain ~c..-' ~7

Onset/sudden or gradullay/du rationlquality/radiation/aggreciati ng

relieving factors/daily living. Qs to be asked: I . J L

-When did you notice the pain: a few days ago - ::. n 11 t'I h S

-Can yo u describe the pain? Do you have neck pain? Yes _ J j .'1 ~ i i ~ ~ q, n ""'., J,,, ,,;,"\,

-What type of the pain? Duilibuming

-Is anything make the pain better or worse? Does the pain come on

when you have to 1I0k up for a while? Do you have trouble reversing I... ~'Or""'\ ) your car?Does the pain wake you at night?

WOJSe; in roornjog. on arising Dc lifting headf;mpCDved with waan shgwemlWorse with heaw actiVitY

-Does the pain radiate to other site? Armfforearmffingers

-What about the other side?

Associated symptoms

-Does your neck get stiff esp in the morning?

-Do you get headache or feel dizzy?

-Do you get pain or pins and needles or numbemess in your arm?Do

your hands or arms feel weak or clumsy?

-Do you have chest pain/SOB, etc?rule out MI.,. wtloss

Ht problem flou4- Au--'rU..-,t.

Past Hx: Any neck injury/RA, eet Fhx

Social Hx: Occupation t +''''-"V-',L ........ \....u ~.,f.t....-._<Z ~c,...cL .....,,-h -c, ~~"'--;f b~L.!<'tl-. lc. . .J-."., V.'N./', I r::r:C-H';h1":- )

Smoking

Alcohol

Medication

Allergy

Summary of Hx

He has shoulder pains and the pain go to lift ann and forearm. He feels the pins and needle sensation on lateral side of arm, forearm and thumb and index. No history of chest pain, SOB, not any history of previous medical illness, no muscle weakness, no history of neck injury,

On examination;

GA: well -Vsigns: normal

It

-Shoulder exam: focus on joinVNerve (axillary plexus) _

-Neck exam: Look!feeVmove/measure/test of functionlx-ray

Inspection: willingness to move - head and neckllevel of shoulder/any lateral flexion/contour of the neck from side Palpation: any tenderness/central di9Ltai and lateral digital palpation

Movement: Flexion: 45 degree/extension 50 degreellateral flexion 45/rotation 75

Neurological exam: for nerve root lesions of C5 to T1

-pain and paraesthesia - along the distribution of dematome.

-localised sensory loss

-reduced muscle power

-Hyporeflexia

Systemic review: Heartl/ung/other joints or neurological findings

)

Summary of OlE:

Shoulder and upper limb neurological findings the shoulder joint was normal

Power/sensation and reflex all reduced in bicepltriceplbrchioradial

Neck:

-restriction of neck movement,

-Flexion decreased

-Extension: normal

-Rotation: decreased

-C5, C6 tenderness

Ix

)

-FBElFilmIWcc

-ESR

-RA factor

-HLA-B27 antign

-Radilogy

Plain X-ray CT scan

CT scan and myelogram Bone scan-suspect of tumour MRI:

DDx

Cervical spondylosis

Cervical disc prolapse/Cervical dysfunction Rheumatic arthritis

Ankylosing spondylitis

Muscle strain

Ischemic heart disease

Extra information:

Shoulder (see AMC April Melb 2006 in detail)

Neck:

Localised areas of tenderness at the base of the neck may be present

in cervical spondylosis. .

There may also be 'radiation' of pain down one or both arms to the fingers. Classically in cervical spondylosis, three tender areas, representing the 'Huckstep tender triad', should be felt for.

These are:

1. At the base of the neck anterior to the trapezius

2. Over the insertion of the deltoid .

3. In the extensor mass of the forearm (not the origin of the extensors which usually suggests tennis elbow).

Osteoarthritis and cervical spondylosis

Degeneration of the disc spaces, particularly C415 and C516, is common, and is often associated with narrowing of the intervertebral foramen and osteophyte formation.

This, in tum, may cause root pressure on the C5 and 6 roots on one or both sides, more unilateral, C516, C6f7 and C415 level or C6, 7, 5 roots.

Clinical~entation

~ in the neck + radiate in the distribution of the affected nerve

roots ~

-Neck is held regidly/neck movement may exaceshate pain ~

-Parathesjalsensory loss in affected segment + UMN Signs of

decreased weakoesslwasting/reflex C . It"

ervtca roo compression
Root Muscle weakness Sensory loss Reflex loss
C5 BicepsJdeltoidlspinati Upper lateral arm Biceps
C6 Brachioradialis Lower lateral Supinator G'r
arrnlthumbfU1dex 'tr~l)~~_
finger
C7 TricepsifingerlwrisUextension Middle finger triceps )

This, in tum, may cause root pressure on the CS and 6 roots on one or both sides, more unilateral, C5/6, C6f7 and C4/5 level or CS, 7, 5 roots. Neck movements are limited, particularly rotation to the side affected, lateral flexion to the opposite side and neck extension. The 'Huckstep tender triad' (tenderness at: base of the neck, insertion of the deltoid muscle and over the extensor muscles of the forearm) is often seen. In the early stages of cervical sPQndylosis )(rays may appear normal

Mx:

-Conservative: analgesics/cervical collar J ~YICt"(I:'\

-Surgery: foraminotomyldisc excision ,c\,":) c (to p c. ( ~ ()1 ~ () ~

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AMC: 17th March, 2006 Resit Sydney

Ref pt Ed P106, also people did the recalled paper.

1) Young men came back from Philipine, concerned about HIV test Task: a) Take History

b) Counselling patient what are going to manage

Hx: -Introducation

- How long have you come back?

- Why are you concerning about HIV test? any reason? Any symptom, Flu

like sis?

- Have you had this test before?

- Have you had unprotected sex? Homo or Hetero Sexual?

- What type of sex? vaginal or anal? Multiple Partner? Any condom use?

- How long have you been there?

- Have you used any IV drugs?

- Have you had any sharing needle? Tattoo

- Have you had any blood transfusion?

- Have you notice any discharge from your penis?

- Have you lost weight recently?

- How is your general health like?

- Have you had STO before?

- What is your occupation?

- Do you smoking or drinking alcohol?

- Past Medical Problem?

- FHx of Hep B or Hep C?

- Allergic to Penicillin?

Counseling:

- Explained the situation and risk (Assessed the patient belong to high or low

risk?)

- The patient needed a full physical and genital examinations

- The Patient needed do blood test for HIV, Hep Band Hep C and STls,

MSU and urethral swabs iffind DIC

- Explained HIV testing, the initial screening and later confirmatory and need

for repeat after 3/12 in case of -ve

- Discussed the issues of reporting to public health and reassured re:

confidentiality within health system.

- Told about Partner tracing, Inx and Mx.

- Need follow up with STO clinic

- Advised safe sex. Use condom, don't share needle, etc.

- The patient may need antibiotics to treat asymptomatic Gono/Chlamy

infection

- Explained HIV is not AIDS, HIV usually need 10 years to develop to AIDS.

Only 30% will develop to AIDS

HIV screening test-Use ELISA

HIV confirm test - Use Western Blot

;'1

For Chlamydia -peR use urine sample collected in the first. r:m:iming Critical errors

-KeyHx

-sexual hx

-IV drug user

Counselling

-HIV and STDx

What does antibodies test mean Safe sex

Window periods

)

BNE 3/05 CASE 16 (362 GP, 250 Tjandra 2edn ,328 scott ,293 OHCS) HAEMORRHOIDS

46yo woman plw PR bleeding after bowel open. No FHx of bowel cancer. Second degree haemorrhoids has been diagnosed by you from proctoscopy. She is on panadein forte for her back pain for half of year.

Task: explain your Dx ,order some Ix & Mx.

(

\

Explain your Dx :

From the result ,you have condition called Haemorroids ,the other word is PILES. Draw a picture to explain

Haemorrhoids are swollen tissues that contain veins &that are located in the wall of the rectum & anus.

Haemorrhoids may become inflamed, develop a blood clot ,bleed & become enlarged & can prolapse outside the anus & hang as small grape-like lumps.

Types: External haemorrhoids are small painful haemorrhoids under the skin

arO! IOd the anus .

Internal are those that from inside the rectum near the beginning of the anus. They are 'generally not painful & often are only noticed when they bleed

Causes: Dilation of vascular channels ( such as internal haemorrhoid f1exus)

ass with long standing inflammatory cells tha may cause thrombosis.

Distension of the arteriovenous anastomosis near the anal cushion. Prolapse anal cushion.

Predisposing factors:

Constipation ( commonest) ,related to lack of dietary fibre ,due to the excessive straining at toilet.sitting on the toilet for long periods.

Long standing increased abdo preesuse : liver Ds, cough ,

Diarrhoae, prostate enlargement.

Pregnancy.

Erect posture: Bus driving. Heavy manual work.

Run in family.

How common : Are common & tend to develop between the age of 20-50. About 1 out of 4 Westemers suffer from them at some stage of life.

Sxs: Rectal bleeding is the main Sx&in many people the only Sx. The blood is bright red &appear when you defaecate. You may notice it as streaks on toilet paper or in the faeces.

Piles often cause a mucus discharge & itching around the anus Classification: 4 degrees;

I. Prominent haemorrhoids vessels, No prolapse. Ak"'{-t. c.~\-t...\-L~"" 'P .. )\ .... ~r"'\ (:p1'lW'l"-l> .... v, II. Haemorrhoids prolapse with straining but spontaneously retract.

III. Prolapsed haemorrhoids do not retract spontaneously & require manual reduction.

IV. Chronically prolapsed & despite attempts to replace them , fall out again.

Tx : Depends on the severity of the Sxs & the grade of haemorrhoid.

2-1

(

Grade I: Bowel management program (8MP) Injection sclerotherapy'( C.:T~U~~') Grade II: 8MP.

Injection slerotherapy\ L~"\h~,,-~'-) Rubber band ligation.

Grade III: 8MP

Rubber band ligation.

Occasional haemorrhoidectomy.

Grade IV: Haemorrhoidectomy.

+ Bowel management program help to decrease straining during defaecation, spending prolonged periods in the toilet, excessively using toilet paper, All activities that can exacerbate Sxs of haemorrhoids.

Frequently these simple measures alone can lead to cessation of bleeding

for grade I & II & even ameliorate Sxs for Grade III • High fibre diet 25- 30g of fibre per day.

• - Fluids: 6-8 glasses per day.

• Fibre supplements: Psyllium 1 table spoon of powder mixed in glass of fluid once or 2 daily.

• Stool softeners: Coloxyl with senna, 1 tab, 1 or 2 each day.

• Good bowel habits : not deferring bowel motions, careful perianal cleansing with moistened toweletles or baby wipes.

• The use of hydrocortisone (cream ,ointments, suppositories) has not been supported by any scientific data , but many pts report empiric benefit with their use.

+ Non excisionai technique: FIXATION PROCEDURE: Perform without sedation or anaesthesia, outpatient procedure & > 80% of Sxs can usually be controlled.

CD Injection sclerotherapy:

Sclerosing agent: 5% phenol in almond oil.

3 haemorrhoids sites can be done at the same session. Injections are repeated at 1 month & 3 month intervals,

Cx: - Accidental injection of the prostate cause dysuria & permanent impotence secondary to injection.

-Sepsis & mucosal ulceration .

These are rare.

Should inform pt : mild rectal discomfort may occur & healing requires 3-6wks.

Recurrent rate: higher compared to rubber band ligation. .

® rubber band ligation:

+ Cheap, safety, effective, standard newer method.

+ it involves placing a tiny rubber band around the base of an internal haemorrhoids ,thereby devascularising the prolapsing tissue which undergoes necrosis & sloughs within 3-10 days.

+ Elastic band is applied not> 2 bands ( at a time) in the one visit to minimise discomfort. Do another at 3-4w intervals. If >3 bandings are needed at the same time ,referral for surgeon

+ Banding should not be immediately painful but some discomfort is common in the first 24 hrs.

15% of pts experience a sensation of needing to have bowel motion. 5-10%: mild itching /sensation last few days.

+ Disadvantage: Require 2 people: an operator & an assistant to hold the proctoscope in place.

+ ex : + Bleeding: most common, usually scant

When the bands fall off ,occur 7-10 days when haemorrhoids sloughs

+ Sepsis - pelvic cellulitis: Rare ( 1;1000): c/o fever, severe perianal pain, inability to urinate or severe dysuria occurs within 24-72hrs

Urgent Tx : Hospitalisation.

Broad spectrum IV antibiotics.

Surgical debridement.

NSAIDS & Aspirin: relative contraindicated for 2wks post procedure.

+Banding should be avoided in pts with AIDS or other immunodeficiency. +15-20% recurrence rate within 5yrs , can be treated again with rubber banding with out the absolute necessity of surgery.

@nfra red photocoagulation : Not any more effective than elastic band ligation.

+ SURGICAL HAEMORRHOIDECTOMY:

Indication: + in pts with conservative methods failed consistently.

+Grade III & IV..

+Strangulated internal haemorrhoids.

+ Suffering from both symptomatic internal & external haemorrhoids.

Cx : Most are quite rare with modem technique.

Urinary retention, Pain, delayed primary haemorrhage: within 24hrs of surgery., constipation, faecal impaction.

LATE cX: SECONDARY HAEMORRHAGE (7-10 days after surgery) Anal sepsis.

. .Anal stenosis.

~r9~rnr~?T f~fr. ~ o. ~ ~~~~

*~~ ... t~~s ... ~ase :. i ~§ff ~ ~{~~ IiUffffff. (ifr ~R(9.H ~~~~?f f « ffR«~t '1~ ~I~'tt~~~ 1plnr rf .. ,.1~rf:·lr r~9l~1 ~\1r~!n~ .. ~rrl·~99yry ~n~~19 q ...

If..the pt has chronic constipation, suspect hypothyroidism, should do TFT~" also FBC look for anemia.

DDX : Rectal prolapse IBD

Any polyp & fissures Malignancy Ds

AMC 2006 Sydney May: Secondary see metastasis (Neck lump) -devitp39, Devit P239, GP651,

4:;t.

A photograph show the neck with enlarged lymph node on the left. Lymph node was already biopsies, and showed that rd squamous cell metastasis. Pt is smoker with 20 cigarettes a day for 20 yrs.

Task To do focus physical examination for the primary site and to do Ix

1st to think wlwi are dre possible primary site of Cancer Causes of Metastatic lump in the neck

-primary site originate from head and neck

-Thyroid

-Scalp: Melanoma

-Careinoma of tongue (mouth}

-primary source from elsewhere:

-Upper GI tract: Oesophagus/81omach

-Lung

-Breast

-Lymphoma/inguinal reion

working rule (GP651):

-lump in the upper neck from skin to aerodigestive tract

-Iump in the lower neck from below clavicles: lung/stomachlbreastlcolon

Focused examination

Note: As this is :ra sec metastasis, so exam should focused on skin

(scalpiface) SeC/melanoma, mouth (ca a/tongue) and Lung (SCC type). -Check mouth, pharynx, sinus, larynx

-Check scalp/skin

-Check Oesophagus

-Check Lung

Carcinoma of tongue (Devitt P40)

-surrounding cervical lymph nodes, esp in the submandibular region

-Look at mouth: persistent oral mass/ulcer/poor oral hygine

-Leucoplakia

Skin SCClMelanoma

Look for skin lesions on face, scalp or elsewhere Carcinoma of oesophagus

-usually no physical signs.

sec of Lung

May have no signs Lookfor the following -Clubbing

-TI weakness: Wasting/weakness: finger abduction/adduction (lung Ca

involve brachial plexus) (pancost syndrome: Tl weakness/horner's syndrome) -Wrist tenderness (HPO): hypertrophic pulmonary osteoarthropathy

-Homer's syndrome: ptosis, constricted pupil, no sweating of one eyebrow.

Compress the sympathetic N.

-Malignant lung disease: pleural effusion, ect.

InvestigatioJIS

Carcinoma a/tongue (Devitt P40) FBE/u+Elcoagulation profile -CXR

-biopsy of tongue lesion to confirm the dx: histologically

-CTIMRI for staging

Carcinoma of oesophagus -Barium swallow

-Endoscopy

-Biopsy

SCC is the commonest type

sec 0/ Lung (Devitt P239) Complete blood picture

I. CXR

2. CT contrast, renal ftmction should be considered

3. sputum cytology

4. lung function test and renal function test, reason for this is high risk for

bronchscopy

5. Bronchoscopy, ifnormal do

6. CT-guided biopsy

7. PET scan, both for dx and staging

8. incision biopsy

\

Carpal Tunnel Syndrome

#16 A young lady with tingling and numbness of the Rt hand. TASK: Do PE, Dx and Management

PE:

• . Approach:

Expose to elbows and ask the patient to place her hands palm upwards on a

pillow.

Vital points - Directed neurological assessment of the hand

• Look

Wasting of the thenar muscles

Scar from previous surgery over the transverse carpal ligament • Sensory assessment

i"t>tdil't>t'\. Radial-palmar aspect of the hand 3.5 fingers

Light tough - deficiency implies median nerve involvement, compare with the

other fingers '

• Motor assessment

Opponens pOllicis - oppose the patienfs thrumand the little finger and ask her to stop you pulling the fingers apart, •

Abductor pOllicis brevis - place dorsum of hand on a flat surface and ask the patient to lift her thumb to the ceiling against resistance

Special test:

• Tinel Sign - tapping over the median nerve at the wrist reproduces tingling sensation in the distribution of the nerve

• Phalanx's test - maximal flexion of the wrist for 60 sec. exacerbates symptoms which are promptly relieved when flexion is discontinued, 70% positive

• Carpal tunnel compression: 150mmHg for 30 sec elicits paraesthesia, 87%

positive .

Investigation:

Nerve conduction test - how fast nerve impulses are conducted through the nerve and test the severity of the lesion

Dx: Carpal Tunnel Syndrome

Causes:

• Anatomical abnormalities:

Bona - previous wrist fractures 8.9. Colles fracture, acromegaly Soft tissues - lipomas, ganglia

• Physiological abnonnalities

Inflammatory conditions - rheumatoid arthritis, gout

Alterations of fluid balance - pregnancy. menopause, hypothyroidism, obesity,

amyloidosis, renal failure

Neuropathic conditions - diabetes, alcoholism

Treatment:

• Non-surgical:

a. Removal of under1ying causes

b. Splinting of the wrist in a neutral position (especially at night-time)

c. Local steroid injections just proximal to the carpal tunnel

d. Anti-inflammatory medications such as Neurofen, Aspirin Surgery:

Carpal tunnel decompression - cutting the roof or top of the transverse carpal ligament under local anaesthesia

Explanation:

a. The carpal tunnel is an opening into the hand that is made up of the bones of the wrist on the bottom and the transverse carpal ligament on the top.

b. There are a number of structures running in the tunnel, including the tendons which move the fingers. The tendons are covered by synovium.

c. Any condition which causes initation or inflammation of the tendons or their synovium can increase the pressure in the carpal tunnel squeezes the median nerve.

This results in pain and numbness in the hand - Carpal Tunnel Syndrome.

LIPOMA

Melbourne 11 February 2006

#13 - A 50 y.o male patient with a swelling in his scalp (other recall - neck). Task: Examine, Ox and advice the on management

On scalp- can be Sebaceous cyst or lipoma depend on clinical features/exam.

lipoma is a common benign tumours of mature fat cells situated in any

_ situation where there is fat but particularly in the subcutaneous tissue of the trunk and limb

(especially arms). Lipomas also occur in subperiosteal, subperitoneal, subfasciai

and subsynovial planes and in the submucosa of the bowel.

Clinical features / Examination: -usually appear in adult life

-soft and maybe fluctuated

-well defined and lobulated

-ruboery consistency (j '~~ u ~ ""' .. :0v..\,-"-,,,,-.

-may be one or multiple • M,y ... ~v...~ o-Io-t......k- IN..,...;'(j

-painless, sometime a little bit discomfort R....:""'.M ....... ~ u>-v-~ ... rt...v.htJ'''-"'<-- (>Y-.I-o ·)"'e.h'V-<-

-can occur at any site c.Vvv:>IV'I Tuv-l .r~"""""~ ,

-calcification can sometime occur, but it is rare for Iiposarcomatous changes

to occur.

-no local LN involved

-no ulcer or bleeding

For subcutaneous lipomas the diagnosis can be confirmed by Ultra Sound.

DDx: ,

1.Sebaceous (Pilar) cySt - common skin less ion

- lined by epidermis and filled with keratinous debris- an offensive,

creamy, 'tooth-

paste like' material, but not sebum.

- found mainly on ~ then face. neck.Jrunk and scrotum , .

- may be a @ntmJ punctum containing keratin __ , '

- ten den c) to inflammation .

{excision s recommended for 90smetic and prevent possible complication such as

infection.

2. skin Cancers - check the lump and LN i'Lump - 3 S : site, size and shape

- 3 T : tender, temperature and translumination

- 3 C : contour, colour and consistency

- or ABCDE - Appearance, Border, Colour, Diameter, Elevation

3.Liposarcomas

rarely spread to lymph nodes. Mainly spread by e!QQ9 route to lYD9.

Management

-reassurance about benign nature

-Excision is recommended if lipomas are large and troublesome (discomfort

from pressure) and for cosmetic reasons.

Indication for removal of lipoma -Increased size/painful

-Causing pressure effect on adjacent structure

-Malignancy suspicious.

-tt .. >5 em, deep to deep facia (the most important concemi.:» ~

-Wonied feature-lipossarcomas

Critical points

-If < 5 ern, very likely lipoma

-If> 5 cm plus deep to deep facia, very suspicious of liposarcoma, do

CT/MRI, CT guided biopsy, very poor prognosis,

GP1199, T J Surgery P372, OSeE case2.

, , "---

,;

- .

-- .. ~- ... ,...

..:: __ ....-_ r __ ~

)

Disorders of the Prostate (GP, Devitt P -3 cases

Case 1 (Dr Riilman, AMC exam)

A 65 y.o man present with urinary frequency. nocturine and poor urinary stream. Your task is to: (1) Hx, (2) Exam, (3) Ix and (Dx) and MX plan.

Hx

HOPC

-3mtb. hx of "

voiding (obstructive) symptoms

-hesitancy/weak stream/terminal dribblinglrentention Storage (irritative) symptoms:

-urgency/urge incontinencelfrequency/nocturialdysuria

Associated symptoms:

-No pain include: abdo pain

-No hameturia/no colour changes

-no wtloss

-no bonelback pain

-appetite oklbowel motion ok

-no respiratory/liver symptoms

Past Hxt-nil, no DM, renal problems before.

FHX:-Nil -

Social Hx-retired officer Smoktng-Io/d; since young age Alcohol-s can beerld Medication-Nil

Allergy -Nil

Exam:

GA:WellV'signs; normalAbdominal: normal

,.. PI(: enlarged and firmed prostate Other systems unremarkable,

, - -FBEIU + ElLFTs/glucose/IFTs/CaIcium!Pbosphate?ALP -Urine MSU/culture all normal -

l\-PSA: 125 units (normal <4), >20 highly suspect of'Ca CXRI

-U/S

-Prostatic needle biopsay: confirmed prostate Ca

-CTscan ' -

-Bone scan-metastasis

-voiding flow rate < IO-15mUsec

Dx:

Prostate Ca

Involves the insertion of an aortic graft through the common femoral artery via a catheter.

Note: AAA < Scm in diameter should be treated with aggressive control of risk 'I factors and 6-mthly U/S follow-up.

JfScreen the t" degree family members.

Advice patient re: his holiday

(1) seek surgeon's opinon before go to holiday as the risk of rupture is high in his case if left untreated. Probably not to go at this stage.

(2) If pt insists doing, give advice of warning signs: if pain occurs go to hospital straightway.

Infrarenal is the most commonest

Case 2 (see Devitt P155 in detaiQ

A 75 y.o man presents with acute back pain for 18 hrs. Your task: Hx, OlE, lx, Dx and MX

Hx HOPC

-Central abdo. Pain, increasing back pain, radiates to left groin and thigh. Pain is constant, getting worse

-no obvious aggreviating or relieving factors.

-No hx of trauma

-Walking and exertion do not affect it If the pain is aggravated by

movement, suggesting neurological problems. -No other associated symptoms.

(note: pt is often collapsed at toilet if in acute rupture)

Cardiovascular risk factors:

Past Hx: 8 mths ago, he suffered Mllhypertension He smoke 20 Iday

He took antihypertension tablets regularly.

Other review of systems are unremarkable.

GA: thin and pain

Vsigns: BP 140/90, pulse 100

Cardiovascular: JVP is not elevated, apex beat 2 em displaced, no other abnormal findings.

Resp.: normal

Abdo: a tender mass in the abdomen which feels like 6-7 cm in diameter and situated in the level of the umbilicus. The mass is pulsatile. There is dullness to percussion in the suprapubic region. Lower limb exam: pulses are present/neurological exams are normal.

3Z--

-U/S '

Mx

This is vascular emergency, inform the surgeon immediately_

Insert wide bore IV catheter, send bloods for FBElU+E1cross-matching and coagulation profiles. Control BP. Also ECG monitor and insert urinary catheter.

Surgery

Ddx:

-Aortic Dissection

-Acute pancreatitis

-Ureteric Colic

-Urinary retention

-Mesenteric ischaemic arterylischaemic colitis

Complications

MI

Bleeding Ischaemia bowel High risk of death septistis

Refs:

GP. Devitt P157, GP324, TJ Surgery 487

\

Goldcoast , July 2006

REVISED

Case 12- Bladder Tumour

Pt do suddenly noticed a change in colour of urine (red) No Hx ofloss weight or pain (renal colic)

Task: relevant Hx , DDx and Manage the case

Hx:

-GA : anemia?

-VS : BP, R, PRo T

-Chest heart- atrial fibril1ation?or Sub acute endocarditis?-renal emboli

Pleural effusion? -perinephric/renal infections -Abdominal- enlarge Kidney?-renal tu, hydronephrosis, polycystic

- enlarge spleen?- bleeding disorder

- suprapubic - bladder enlargement and tenderness

- Men: do PRl- prostate (BPHlCalprostatitis?)

- women- PV~ pelvic mass?

- check urethral meatus: caruncle or prolapse?

-when it started (red urine)? With Pain? Happen before/first time?

- Have you noticed whether the redness is at the start or end of your stream or

throughout the stream?

SlHave you notice any bleeding elsewhere, such as bruising of the skin or nose

bleed? i((iil.kvfI- '8"",}um, .. in !)CL

- Any pain in the loin or lower abdomen? .., u ((, i'., (: 'j _ d~ Sur { "

-any difficulty in passing water? d ~ J b

-any.burningorfrequencyofyoururine? -vrjr I,"lc.on i .... Clt.t6 ~s6.lp,--t.rLo ((. 1"11'"

-any problem with the flow of your urine? - f f" t" t u v n ,~

-any weight loss? Appetite? _ (10 (, tv r i u

-any trauma in lower abdo or pelvic area?

-any health problems : schistosomiasis, kidney problem in the past or chronic UTI?

- Smoke? Alcohol?{

- have you been having large amount of bee trout, red lollies or berries in your diet?

-any medication : phenacetin, 9}'clophosphamicle , rifampicine ? R' \r. Ju (. ~() c

-what is the job? Any possible expose to aromatic amines (rubber industry)? _l_~_---.ll _

-any expose to radiation (pelvic irradiation)? ., 'S m 0 k ; (l 1 (rn Cj .- n >(~ 0 1.

-FHx of malignancy? " (( w C. (l 'j t '$ )

-been travel overseas recently? • i. h t m .- c 'i I

-any strenuous sport? _ i) uf"lh Ij 1 o Nl ,"'(

-sexually related? ...- ....... b b VI'" ; '") J .. "] ~ 'J

• {~(.Lo~p),.,c.lh;cI"

• ~ "" tn CI c ft ~ .. .., iT) e ~4 be

• Sch;:,.h.I50O?c" h~ l !JC(

• {.\., rD"IL- '("I"i .l-t;j~ton

.- c(.J~~,1,:,

_ th(on:c:. c"rh (~t .... _ bl"Jc1~(" -:.h,..,

PE

Iv

-Urine - Microscopic ( formed RBC in true hematuria, RBC cast & deformed. RBC in

glomerular bleeding) - culture q..s

- cytology - detect bladder,lower tract ca, but usually negative for kidney ca

- dipstICk

7L ..Ji

- Blood test: FBC, ESR., RFT, ASO titer( if glomerulonephritis suspected)

-Radiologic:

IVU - may show filling defect ± ureteric involvement. ,US-;;,... less sensitive for LUT

CT , renal angiography, retrograde pyelography - Direst imaging teclmiques

Cystoscopy with biopsyt inel muscle)- to confirm diagnosis (grade and stage)

Urethroscopy C y sh~ :11;' C p~ e b1u d dv(" w Cl~ h i 1")'\ (~ 01 d ., I-u" d.0 r d )

- Renal biopsy- if suspect glomerular ds ( found dysmorphic-ltBC on Mi )

+U(l1()lI( ('nti(~f/r> - Nf.I,P -'221 fM("I'·Il .. no'tlt, F-J)P DDx:

- Kidney : Tumours, polycystic, glomerulonephritis. hydronepbrosis,necrosis

- Bladder tumour mostly Transitional cell (urothelial) ca (Tee}- 90%

Others ( rare ): -scc ( may follow Schistosomiasis, chr UTI)- 10 % -Adeno-ca ( arise from urachal remnant in the vault of the bladder}--rare

- Prostate - ca IBPH/prostatitis

- urethritis/cystitis/stones-pain +

- Exercise induced hematuria ( young people)

- Pseudohaematuria: beetroot, berry, red lolly, porphyrin, myoglobin, drugs.

This pt has a painless terminal haematuria which is mostly from bladder and confirm by cystoscopy with biopsy-Dx: Tec

(haematuria occurring in the first part of the stream suggest urethral or prostate lesion., while terminal baematuria suggest bleeding from the Bladder, uniform haematuria has no localize features)

Management (Tee)

Depend on the stage and grades of the Tumour Grade (G) - by histology: G1- differentiated wtJ.l

G2- intermediate

G3- poorly differentiated.

Stage - complex and is vital to the prognosis and treatment:

Tis - Ca in-situ. not felt at EUA (Exam Under Anaesthesia) Ta - Tu confined to epithelium, not felt at EUA

Tl - invasion to sub epithelial connective tissue, not felt at EUA

1'2 - invasion of superficial bladder muscle, rubbery thickening at EUA 1'3 - invasion to deep bladder muscle. mobile mass at EUA

T4 - invasion beyond bladder, fixed mass at EUA

TisfTalTl:

- 80% of all pt -Diathermy via cystoscope '"'fUR£:. l"

- consider:- intravssical chemoTx ego Mitomycine C (for multiple small tumours)

- intravesical inununoTx with BCG ( for high grade Tu and Tis)

1'2-3:

- Gold standard-Radical Cystectomy + ~t- \..,-.~~""":j u.;>'I'k-...- ~a&;\f~

- RadioTx - 5 year survival rate < surgical -:

- post-op chemoTx- effective but toxic "~;"~lc.

- option: partial cystectomy/transurethral resection + systemic chemoTx-long term

result disappointing.

-Complication of cystectomy: sexual and urinary malfunction ( may use ileum to make a new bladder to avoid urostomy)

T4 1rv:-\-io..L ~+e,.."..n.:... ~~ ~ ;~Ic:.t.:Ht,...,

- usually palliative: chemo/radioTx

- chronic catheterization and urinary diversion may relieve pain.

For massive bladder haemorrhage- consider alum solution irrigation (safer than

formalin). .

FoUowup

-Hx, examination and regular cystoscopy.

-High risk tu - every 3 months for 2 years then eve.!)' 6 months

-Low risk Tu - fuSTF'U cystoscopy after 9 months then yearly

Tn spread

- Local- to pelvic structures (prostate, uterus,vagina)

- Lymphatic- to iliac and paraaortic nodes

- Haematogenous- to liver and lung

Survival-Depend on age and Tu stage :

e.g - 3 yr survival rate for- T2-3: 60% for 65-705yo 40% for 75-82 yo

- 5 yr survival rate for unilateral pelvic node inv : 6%

- 3 yr survival rate for bilateral or para-aortic inv: nil

Note :

Incidence: 1: 5000/yr , Male 4 x than femal, age -> 65 yo

Symptoms: --

painless haematuria (70%)

recurrent UTI

voiding irritability

rare- BOO or metastasis symptoms (bone pain, anaemia etc)

Adelaide april 2006

#5. A 60 y.o man with enlarge prostate was seen by the surgeon., who is planning to perform TURF on him but didn't explain him the procedure. His PSA is normal. Task - Explain to him the procedure, possible complications and answer the questions ( asked about the possible cancer now and the future)

Explain to the ptthat his prostate is ~IlJarged, and cause obstruction of the urinary flow, and may block off the urine completely and cause considerable ~,ifthe obstruction continue it may damage the bladder and possibly the kidney. The enlargement can not shrink by itself or with drugs and the enlarge tissues needs to be removed to allow the urine flow normally. This pt is going to have a TURF.

TURP Drocedure:- Most commonly done.

-Anaesthetic: either Spinal (4 brs) or General anaesthetic(check -allergy?)

-The operation is done through the penis. The urologist passes an instrument about as

wide as a pencil through the urethra to .cut away the enlarged prostate. This instrument ( a resectoscope) has a loop of wire at its tip, which can cut tissue. It has a mini camera or telescope and light to allow surgeon to see clearly to slice and nibble away pieces of prostate from inside the urethra

Possible complications:

During operation- haemorrhage and hyponatremia CTUR syndrome') result from absorption of the irrigation fluid during dilution of the blood (treated by fluid restriction).

Post-operation:

- may have urgency or incontinence for a few days

- bleeding can occur intermittently for 3 weeks

erectile fimction usuallY,unchanged ( 5% loss erectile)

- orgasm continue but no emission with ej aculation.. The semen go back to the bladder (pt must warn pre-operation).

- If obstruction recur early there may be a stricture.

- UTI and septicaemia

.. Hospital stay - 1-2 days (longer if complication happened)

..0 Put- 3 way urinary catheter ( usually for 2 days) - wash out the blood and clots in the bladder.

Advice to pt after operation:

- don't drive for 2 weeks

- no sex for 3 weeks (oxford ~2 weeks)

- 20% ofTURP needs redoing within 10 yrs (oxford)

This pt which has a normal PSA., the chance to have prostate cancer is low (5%) and needs to confirm by pathologic result post-operation(now). For the future he needs to be follow-up by routine PSA and DRE.

Notes:

LUTS (Lower Urinary Tract Symptoms)

There are multiple causes, and symptoms can be divided into voiding (obstruction) and storage (irritative). Is is not always possible to distinguish the cause from the clinical features, so special investigations are often needed.

Causes:

I.Physical obstruction:

- BOO (Bladder Outlet Obstruction): BPH, Bladder Neck stenosis, Urethral

sphincter spasm.

- Prostate carcinoma .

- Stricture: urethral/meatus

- . Penis disorder -phymosis

- Calculi: bladder/urethra

External compression: loaded colon, pelvic tumor.

2. Functional- detrusor-sphincter dyssynergia eg.: MS or atonic/underactive detrusor.

3. Other causes: UTI , change in diurnal secretion of ADH can cause nocturia

4. Drugs: anticholinergics (eg .isopropamide, phenothiazine etc), antidepressant (TCA), anti Parkinson (eg: amantadine, benzhexol, benztropine etc), beta adreno-

receptor agonist (eg: ephedrine, salbutamol .etc) .. OTe.. ~Mt.- D~ wet!'" L lO~( •

Symptoms:

Voiding -hesitancy, weak stream, terminal dribbling, urinary retention -cause : eg: prostate

For voiding dysfunction- ask the Voiding Row rate ( GP 1089) in ml I sec. A flow rate < 15 ml/sec suggest obstruction and < 10 ml/sec significant obstruction

Storage - urgency, urge incontinence, frequency. nocturia, dysuria, suprapubic pain - cause : eg. Bladder, prostate also may cause it

BPH (Benign Prostate Hyperplasia) -Commonest cause for men> 64 (40%)

- 10-15% needs surgery

-Symptoms: hesitancy, frequency, urgency, nocturia, slow interrupted flow, terminal

dribbling, acute retention (15%), haematuria -DRE: prostate enlarged.

-Investigations: urine:cultureIMSU, electrolytes, RFT, PSA, prostatic needle biopsy

with/without trans-rectal US( If ca suspected), voiding flow rate « 10-15 ml/sec), US scan for postmicturition residual urine or the presence of upper urinary tract dilatation, 24 hrs freq/volume chart recorded over 7 days with time and volume of urine passed. -Drugs may be used in mild disease or while awaiting TURP:

g- blockers (tamsulosin, prazosin, indoramin) -reduce muscle tone of the prostate and bladder.

5-a-reductase inhibitor- reduce prostate size by blocking the conversion of testosterone to dihydrotestosterone (months before it work). MManagement: consider surgery in pt with:

acute/chronic retention, renal dysfunction, complications ( stones, infections, haematuria), failed medication, incontinence. interference in life style.

-Surgery:

I.TURP - most common

2. Retropubic prostatectomy - open surgery.

3. TUNA (Trans urethral needle ablation; TUMT (Trans urethral microwave therapy); TULIP(Transurethral Laser-induced Prostatectomy);TUIP{Transuretbral Incision of the Prostate-for small prostate).

4. Prostate ballon dilatation, stenting .

Complication of the surgery - see page 1 above.

Counselling

Ask pt Q: Do you know what is prostate?

Tell pt: Here is diagram (see GP P1087 very good picture), Prostate (gland) situated below/behind the bladder. If it is enlarged can cause urinary problem If enlarged can be due to the old age, which the most cases are, unfornately can be due to malignant, But that not mean you will be going to die. A lot of'tx are available. The next thing I will refer you to an urologist for CT/biopsy and to see ifhas spread, and further Mx.

Critical errors:

-Key Hx: not asked BOOlHameturialmetastatic spread symptoms- bone pain

-PR: enlarged andfirmed prostate

-PSA: 12.5 unitstnote: if you don't do PSA, the examiner won't tell you the

results ofother Ix)

Case 2: See Devitt P150

A 70 yr old man with painful hip

Hx

Case 3: Mx and counseling of prostate cancer (See paul's note)

\

AMC Sydney 09/05

AMC: Abdominal aortic aneurysm

65 y 0 Pt comes to you a GP for follow up of his recent U/S. You had previously felt a pulsatile mass in his abdomen and the U/S report now shows a infrarenal AAA of 5.5 em. The Pt has also planned a trip around Australia in his caravan for 3 months.

• Discuss the U/S result

• Discuss therapy options

• Advise Pt re his holiday

• Mx

Talk to the patient re: U/S result

Tell patient that U/S shows a large abdominal aortic aneurysm in the belly area.

Explain to -patient what is AAA and possible causes: permanent localized dilation of an artery (dtaw a picture). Tell patient that AAAs are most common in: (1) men, (2) Aged> 60 yrs, (3) smokers, (4) hypertensive patients

and (5) often strong family hx. ! (, I c...v..o·~ ~ '1-u-'t .. i··\L- die ~ c--(.. V\At...v'k-..-' .... Ov t-h..l,........ _ '1:b-r ",:\nl.J'YU"""""';

Tell patient the likely outcome if untreated (risk of AAA): rupture or leaking. -Normal; < 3 cm.

->5 cm the risk of rupture is high ..

5-yr risk of rupture: 5-6 em, 25% 6-7cm, 35% >7 em, 75%

." T~ ~'h-) ~....,. c.... ~t~ 4A

~ ~/. :..v';'h..-,... ~t '}-«.,,("·i~ ~1"J

k~ +!.--t.."j CA-.-- ~ ~ ~ •

Management

(1) Refer to surgeon immediately. 0 ('\I\.t;, \(" .. t:c •. e.i r-.., "'rt..J-e..- -tvv- 1LLt.....c. .. i'-"L

(2) Further Ix: <;~.

Blood tests: FBEIU + ElLipid profiles /. .

CT scan: to assess the size of aneurysm and its relationship to the renal arteries. Whether it has leaked or rule out other causes.

Spiral CT angiography: reconstruction, give infonnation if it is patency /stenoses of renal and iliac arteries. This ix is indicated for surgery

(3) Non-pharmacological intervention; Control risk factors

(4) Medications: control hypertension (5) Surgery

Indication for surgery >5 cm(as in this case)

A: open repair is the gold standard (Dacron tube graft): Invofves a laparotomy, clamping of the aorta and sewing in a prosthetic arterial graft to replace the aneurysmal aorta.

~", ~ <e. ~ rv-vvv....t- b-e; """'-<:o....d~ +v .' <t 1";0: AA.4 b1- ~t~ U--t...:...u..--..<... •

B: Endoluminal stent graft repair if in eldeny and high risk patient.

..f1.,t.~t-.:..-e-.il.>"",,"

~~. to

a-

~I-u~.:... ~ r~ ,'-t,... "~"'1) it'"\... I,..'.j(......, • ....-l--- C-LA-~ j

~ ?--t..... d/.;-..rc~,;., I ..,u--ih...-- (D r-L1lYI:;>~'~ Q;) Atxfo''- "JK-" ......

Fracture of'the clavicle

.-

#16-2006 Feb 11 \h Melbourne' -

A m,iddle aged patient fell of his motor bike and fractured his clavicle, - Task: management

Patient aslie4:

Can I ride my motor bike? Can I drive my car then?

- .

How can I have a shower?

lj::tanJ.iner asked: '

What are YOQ going to do for him? How to do the sling? .

, For how long should the p"atient use the sUng?

fCiU -on ~o l~~ -tAHt(~td .~~ot-.ldt:'" 'C'b-:+".) ., ':}.'!. cl .... H-~ 1010"" ; G'~ 1&.U· .0(')

ou J--"~<'fl-d" h· 1. Q:loSt( 94%) of 'clavicular . injyries. result. from' a direct blow on the point of the

. abgllJder .generally from a fall on the Side. Less co~oqly' , force may be .tr~tted up the

arm from a fall oh the outstretched han4 "-', -' . . . : -' - n,;td.

2. Fracture is co.nimo~est at-the-- jun¢o:n ~fthe.Ipidcile'~ outer: thirds, or in the middle third. (~;'J-~\" .' 1_-

3. Consider-the possibility of neurovascular injury (brachiBI plexus or axillary ~) . _ .-

4. In adults, immy fractures are undisplaced and are comparativi?lystable iIriinies-, with symptoms - settling rapid! y and mjDi~al treatment being required,

Diagnosis

L tendern:ess ';u the:fracture site.

'2. obvious deforrcity with l~ swelling -~d later bruising, _ '

3. the. patient may support the injured limb with the ~ li8n~

- 4. - a sinSIe A: P X-ray usually show the :l!acture deai:iy"eoDfirm the diagnosis,

, .

Management - ..

• • r Q..'\1YI. '. ~. . - .

-}, support the weight of the .!Iii; in a triangular sling (broad lif'A-'Sling) fod weeks.

l>additional fixation may be obtained by wearing the sling under the clothes. -' '.1u;..-..J-i~1'I khv~ 2> no o~er treatment is needed in gr~ck'. or undisplaccedfraoyure. (c..;~~h".:..u.. =-' ~J.dl't. .l. 6~ ~ )

2. analgesics: such as 1> paracetamol 500mg and codeine phosphate 8mg(panarleine} 2 tablets .qds during he first 3 'daysor so.

3. refer the patientto the next fracture - clinic.

4: figure of eight bandage: used mainly for marked displacement l>aim to- correct the anterior .drift of the scapularound the ch~ wall i> although i~ comparatively ineffective in terms 'of reduction, if helpful in red ucing pain 3> elderly 'patients tolerate clavicular bracing meth~ . poorly, and' support with a s~g' alone may ne preferable 4> Dr Anthony' fT -Brown think:(eoieriency p191) the traditional figure-of-eight bandage hasgenerally been abandoned

as it is uncomfortabie and clliticrilt to keep tight . '

5. if rarely. comminuted fractures or. fractures causing- compression of underlying nerves or vesselsmay be treated, operatively and should be referred immediately to the orthopaedic team._

6. if fraoture at the lateral.end ofthe bone, this fracture ~ often subject to delayed Or non-union, ~nSidet referral fOrqxm reduction,

Fracture of the clavicle

7. healing.time: _~weeks·

- follow-up - ' - _ .

- }. ' clavicular m-aces of all types require .careful supervision and 'at least initially, ~y 'require]'l' ,

, inspection-and possible tightening every 2-4 days.. -". .

-. _ 9. ==.braees are used in ~nj.unction with a sling, the sling may usually be dis~dedafter 2· _

~ ali sup~~ may ~ removed. as s~n as tenderness 'disappears from the fracture si~.

@ :::ea:~::::~;::~:::yst:;::;:: . .: '- - .

. W physiotherapy-is seldom require except in the ~Y patient who has developed shoulder . stiffness.

-'""'

.M.),.

Foot and anlde exam _

, -De Chris Jones, also see Qin-Exam P238, OSCE P GP754-

- Key skills:

Introduce yourself. '; '. , _

Hello, I am Dr ~ Do Y:Du mind if r examine your foot? '.

Look/walk in staniling positioll . .

- - -front: CB:n you stand up' and .face to me please'iPut your knees together:

Look ~ sCars/deformity/swelling 11V")/~ wo--<..+i~ . . - .

-Side: 'Can you face to the wall please? Put right foot forward, look at arch

from.side, Comment on if pis planus present (flat foot) .

-Back: Can- you face 't9' the. window please? _ Look at heel pay attention to

ligaments.. - ' . , -

-Ask patient to stand on toes, look the bottom of the foot .

-Can you walk to the door and back to 'me please? -(repeat 2-3 times if needed)

Note:

-any gait abnormalities

-Any deformities, claw toes ,

-Swelling

-Muscle wasting .

-Skin changes and signs of ischaemia

. Feel

-Systemic palpation is very useful,

-Ask pt does it burt? -

-Feel for tenderness, Is there ahy sore in anywhere?

-Can you point one.finger around foot(plantar faciatis, pain in medial ankle)

- '.

(

Movement

Ask pt in sitting position ' ~

-Plantar flexion {norm.al50 degree) and dorsiflexion (20 degree) of'foot

-Inversion and eversion of hindfoot (mainly" subtalar joint): hold beel and

abduct and adduct

-Inversion and eversion of forefoot (midtarsaljoint): (see GP754 fro detail)

- - T~ other jointsindividually . '

Special tests _ . .

'-Acliiners tendon, including calf squeeze (Thompson's test), -Compress M1;'P joints ('f1-'1.A.C- ')

-Check pulses of dorsalis pedis' and posterior tibial pulses. .

-Neurological exam: L4,5 and 81

zs" Febuary 2006 Brisbane (GP, EM)

" .

#12-(#FIBUlJ\. WITH SUBTAlAR DISLOCATION)"

.' .

, 18 ,yr old boy, ,fell down and presented in EDjGP with pain and swelling in his left . ankle. You 'sent him for X-:ray's has arrived and the patient is waitingJor you

JASK: Read the X-ray. .

Exp'lain theconditon to the patient

Manage the 'case & answer patient's questions

a) Read X-raY: (X-ray found fibula fracture 'with displaced from lateral position)

. b)' Explained to patient that-you had pain, swelling, tenderness and non weight bearing; also ~- . ray confirmed that you had fracture of fibula with displacement. '

c) Management:

• Rest

• Analgesics to control pain ,

• Refer to orthopaedics surgeon, need operation to fix.

• Then Put Plaster

,. . Most likely it will take 6 weeks

.• Need follow up:

Plaster follow up: pay 1 in plaster Day 7,.10

Week 6

X-ray /~ 6)

2 X-ray: bone hasn't moved ,

POP 0:tI: no x-ray, use hand, to' exam '

~- -

Clinical Signs. for fracture:' Pain/Swollen/Tenderness/Non weight bearing

, If one line - notdisplaced =-Plaster of Paris .

If two lip.e-.dlsplaced, -- Plate Operation to fix,

• ~ +

Sydney 3/06 Case 8 HODGKIN'S LYMPHOMA

You saw this lady tv,. before with a swollen Win her neck & do leiliargy,wt loss & pruritis .. You sent her to a _ specialist who did aFNA of the LN. He gave her a Ox ofHodgkin'lymphoma., On-further Ix Jt ~ found that there is no involvement of any other groups ofLN & no spread to any organs. The specialist advised chemo & radiotherapy. - Today she has come to youto talk: about her illness.

Answer her Qs

, Greeting: hello, Ms I'm glad to -see you again .

. I'm very sorry about the bx of'Lymphoma .It's big shock for you 1 understand that .

Ho'Y much do you know about this disease.as well as the-method of treatment such as chomo & radiotherapy?

. Note; if you first see the patient ,you haven't had herHx, shonldask: some Qs:

Have you had any health prb in the past? Heart lung, breast tumour, ovary tumour,DM, HIN ..

Allergy to any drugs? ' .

AnyFHx? "

Do you smoke?

Dink: alcohol? .

Diet? Exercise? "

Are you married? How many children do you have?

Do you still have period? Do you wish to have children? Who do you live with

Any support from your family. -

What do you do for living

Lymphoma are CA1!cers of the lymphatic system.

( Lymphatic system carries a specialized type of white blood cells called lymphocytes thra a network gflymph vessels

to all parts of the body, mcluding the bonemmrow. .

Lymph vessels connect to lymph nodes which are clustered in areas where the lymphatic vessels branch off, such as

neck, armpit , groin..) .

The majority ofIymphoma are ofB cell origin.

Lymphoma can be oonfin~ to a smale LN 2! can spread tbm oUt. the body to almost any org¢. . ~: Hodgkin & non-Hodgkin lymphoma

Hodgkin's Ds-is a type oflymphomadistinguished by ~ particular kind of Cancer cell called a Rred-Stem~ cell ~ ,i- c.. r t- ,;..-e.

( "Which are large cancerous lymphocytes that have more than 1 nuclius ) that has a distinctive appearance er .

. microscope. ...,;h,.,. 2-",,") ~_l.."..I..,...u..·L

The cause is lmknown." .. Most-common in well educated & small family, 3 times more with PHx of Glandular Fevet, but no link between Hodgkin's Ds (lID) & EBY.

Male 1 female - 21 L ~: young adult (IS & 34 YfJ) & elderly but can occur at any age . - The Ds does:n't appear to be contagious.

4 types ofHD: .

• Lymphocyte predominant: 3% , slow progression

.• Nodular sclerosing: 67%, moderate progression, most commoninyoung & female.

• Mixed cellularity : 25% , .somewhat riipjd, most common in elderly. .

• Lymphocyte depleted 5% , rare, ~pid progression.

~ .... ~.-u\WL.'- i~'",,", J1.;L.

_~i.;'. P-~':"'~"""

--l.,,;;~, ....-v:.'W'"", (~ ~ ~~ c-....'c.r ...... l-O "'fI~ .

Staging:

1) : confined to- single LN region ( ex ; R side of neck ). " ,

·-2) : involvement 0[2 or more regions on the sSme side of the diaphmgnf{ ex: some in neck & some

inannpit).. .

3) : IN QQth;:ide of the diaphragm, ( ex ; some in neck & some in groin ) .

4) .: Spread beyond the LN & other parts oftbe ~ ( bone" marrow ,lung, liver).

Each stage sub4ivide stage A : no: Sx thati other pruritus. _ B : more extensive Ds :

Weiihtloss> I-{)OIo in preceding 6m. Un explained fever> 38 . ,:v~l·N1ght sweats'.

_Likelihood of cure; survival for IS y with no further Ds ;

o Stagel: > 95% ; -

-~

,r

",

."

~ ~ ~d~~. Md- t.:t

~ \~""I.J"'I\. o~

o Stage-2 : 900/0..

o Stage 3 : 80"/0

o Stage4: 60 ~70 5

Ts:: '.: Radio: IA ~ llA ( < or = 3 areas involved) : good result . . _ Clieiiio: IlA( > 3 areas involved) fum to IVB .

Radio + cherno : any stage B Cherno with combination; ABVD :

• co Adriamycin

• Bleomycin MOPP:

co Vinblastin

• Dacarbazine _

_. Mustin • Procarbazine

• Oncovin . • Prednisolone .

Airtologus'marrow transplants: 'for relapsed Ds (peripheral stem ~ll transplantation) .

. . . .

.Cheme : Is the modality ofheatment in which special drus are used to destroy fast growing cells . '. -

They are normally given viaN inj in a series 'of 4 -6 Courses ( sometimes 6 -8 courses ). each separated by abt 3 - 4w

to allow-the body 10 recover between admission, . , -

- J'4ey are usually used in combination drugs that studieshave s~uwn to get the best effect .

. Because cancer cells replicate faster than normal cells • chemo is preferentially directedto those cells. Unfortunately some normal cells take up those-drugs which.results in their death. This occurs in normal cells which also replicate _ . . quickly such as h!iir> bone marrow used in blood production & gonads . However > they MUB.llY recover abt 6 fnth af'tt:r

cherno. . -

sE of cliemo in Lymphoma:

1. Nausea & vomiting: Most feared ofpts _ .

Can be prevented & controlled by antiemetic drugs: ondansetron.

2. Hair loss : justtemporarily ,can be reversible after stoppin'g Tx , use wig ,

3. Infertility in'-Men-: should advice sperm storage if Wish fa have children ..

. -Women: Iowerrisk, obtainingovarian tissue before starting Tx .

"4. Premature menopause : Tx with HRT .

5. Infection :Chemo will suppress immunity system in body ,it prone to Infection which presents early if sore throat or fever, Seek attention.( neutropenia most common Seen in 10 -14 dafter chemo ) .

6. Loss lipide - - . .'

- 7. . Secondary malignancies : low risk , It happens. 10 y 1atar after Tx .

8. Extravasation of'chemo agents: insite of infusion : pain, burning , swelling .. sekk attention . . ,:In MOPP regime Prednisone- cause avascular necrosis of bone t femoral head).

. ,. , -. . -

-,::;RadioTl: : ,Involvesbigh energy beams to act on DNA, - No Pam or nyection, similar to X my . . Requires production of marks ltattoo on slcirl Doesn't stmt immediately, begins in 3w .

Frequency cfradiation is once daily> 5d.a week it takes seconds to a minute ._ Oricologist is seen weekly. to monitor progress ,__ .

SE ofRadioTx ;Noneare~tbut~Ylastforupto 6m-.., Eady" reaction;

.;. Tn general : - feel tired ,anorexia,N I V .

• :. In local. ; - Skin reaction; redness > itching > decrease sweating ,dry .

_ Tx.: moisturized,

-Mucositis : inflammation of mouth ,lips .

'- Dental check up before starting Tx .

Avoid smoking, alcoh!>l , spicy food, Hygien mouth .antiseptic mouthwashes'. "

. '-- Others : Diarrhoea- ,C:ysti~ , dysphagia .

,. Late reaction: numbness , wcalmcss,painful arm afte.'l1xillnry ~rlio'IX .

M~tutasis to lung , mediastinum. bone .hrain ,liver. GI .' - - ,

NOTE: In this easels Stage IB & Tx is Radio'Ix + Chemo toredrice the risk of relapse • but cerriesa greatest risk

oflong term complications, ' . - -

Apart from medical Tx remember: . _. _

- . - The pt needs ~ lot of sUpport from family & coimnunity . Anti cang¢r council inAustalia has ~ that give

information that.can help pt understand ing the Ds by specialized trainingnurses, _ . '. ' . _.

• • _ ~ _ r_

AMC resit,March Sydney 2006

Chronic Diarmoea of rton-specffle symptoms (Coeliac D);

. ~ A 54 year old man has diarrhoea like off and on for the pasta-6 months. .

Task: take, history, examination ask for investigation and'(!ive 'your deferential diagnosis.

On investigation: - . '

FBG, serum amylase, blood for anti endomyseal antibodies, anti gliadin. antibodies, small intestinal biopsy.

DIJDx- .' .

Coeliac di$ease, chronic pahpreatitis _and i~able bowl syndrome •. -

. JtA 40 yJrold men has diarrhoea on ana off for 3 mths .

. Task: (i) Hx (iiJ/x, (iii) explain to pt why you order the tests-

. .

Dr Hillman's case, .

. ~ Case.:_ 45 y.o. . mare, 3 mtlis lei hardy., wt looss of 4 kgs, mild diarrhoeq-3 .; 4 losse. motiQns

. of normal colour ·daily. _ No PI:{ bleeding, norma" appetfte. No other sumptoms, no. cough

orqysfXJne~. . -

Task: Hx, exam! Ix anq diagnosis.,

Hx

- -ctutmic: diarrf1oea: Key questions need to ask See GP47~ .

HOpe' " ,

-When that started? . , .

-Askthe character ot stools: watery, loose • fat , blood. mucus etc

. Have you noticed any blood. and mucus in the motion? _ -Ask the frequency of stools:

How many bowel motions' do you have each day?

Do you get diarrhoea during the night?" . _

-Ask iffae~s diffiCult to flush down to toilet. . ':.' -' ,

Do you have trouble flushing your motions down the toilet? .

'J" -Ask if bulky,offensive faeces - '-. ~. . -

Associatedfeatures '( ""F,~>'\-,_® • ..v1.~( ~fV~.<,,,~·rvJL-'f..~ :l Ci,~ooL). . -Ask if associated with abdo pSin? Do you have abdo pain or is it-relieved. by

- openinq your bowels or passing winds? . .

-Ask if tir€dness and lack of energy (anaemia} ,

-Any wt loss .

-Ariy fever? Have YQu notlcedtever, chins or night. sweats?

- -Extra-bowel 'symptoms; Ask have _ you had trouble with. pain in your joint~lPack

pain, eye trouble or mouthulcerations? - - , .

-Any symptoms related to hy~hyroidism ,

Ask about appetite., diet and fo,od intake t ~\\t. ,tl,. .... -~, '~lt.u,...,....t ).

- Past HXlFhXlSociffl Hx?medication .

-Have you. had any previous atta~k? -H ~ YiJ-'.'-: ~_ "'"'J. ~~ PV: ~ -o<-kxfV·. -re.~H ...

-Have you travelled overseas recently? _ _

-Does anyone else in your family have diarrhoea? r..c--v..;~, c...vu ........ ' \,. J ~ 'ft-h'<- - R ~ . 2 .b.;,u, .... L

-What medications are you taking?" , . - : - -'. ' - - - _ -

-Are you takin'9 -antibiotics? Or any other medications, ask Ocp in female? \itt ' t,.? ~ve.A

-Are you under a lot of ~ess~ ,. -

-Do .you smoke?/aicohol?

- &f...u..t -

- r,wv.:h. t.

C-!W.

~

".,,:.y......,....-~..v:1

f'f'S

-HIV infection?

Summary of Hx

. . No bloodfn stool,

Explosive 'diarrhoea, 3 - 4 times! day. Lomotil not

helped- with diarrnoea . . -

No history' of overseas travel

Weight rest about three kg in the post S months _ Difficult to flush down, offenslve smell

No -family of colon cancer. - . .

No stress, normal sleep, not change mood and normal appetite No history-of taking antibiotic and vitamin C-

No smoking and no alcohol _ -

A, L r-n /l:n J.' _ .. i"I'L'~ h1 r: - I} - id., .~ I ~ . ~ '---' .L . ~·f-toV'v"jL J.c,...."... ••

Exam:·(J) rv>&J-. 1...';:1 'rfL'ld/ ~"""'" 1'1 ,..,... __ ~- 1""" ~- Jr--

all -system were normal, ._

abdomen bloated, no hepatosplenomeqaly, PR: normal' rectal examination ..

Explain to pt your provisional Ox -

-~.

Investigations: (GP is :very gOod)_ ,.FBE!U+E1LFTs/ESRlfFTs .

-M/C/S DC? -

... 72 hrfaecal fats conllection: crystal

-Coeflac antibodies (4.4 o.vI..~~~-"J.., .48 - ~ '7l]OX r'h~ L ~·ftl..<..) - ~ wa;,...

-colonscopy normal .

-Duodenal biopsy show evidence of subtotaJ"vilious atrophy L tl..u) Tv.t)

-Blood film: hypochromia of Macrocytosis ,(due to both Fe and folate deficiency)'

Coeliac Ox -. 'Ix a.~.t- T...,·c...L

- '* Ddx of chronic diarrhoea. * ' . I r - A. ~ ,~) ,,'

Colonic ceuse« ' lo1l" n i kate. ,.\ " "--M r/ d'rt7,..-YI?. 1 - \.. <"Lj f C'fO'if () q -(..~ ::-

_ -Infective colitis / I. - . . - My _ -:_

- - -180: 'ulcerative colitis/crohn's disease ':

- lifin old' people, think of . • '}-J.-e.t-- ~ ..... f--.,C,L _. h.icf'-, w'h~ L.t+c> 1:lw-k

-Ischaemic colitis -. - f=~L. ,-~o.:-- ;:j;, )

-Divertlculltls ~""""';I:>~- d-"c-,...~ \..). • ......., ~ " .ci~ -.~

-Turnours

-Malabsorption' ,

-Srnall bowel dx Coeliac dxlcrO.hnsJs dx

-Pa ncreatic: Ca/chronic pancretitis

-Bile saltdeficiency: bacterial overqrowth

Medications .:

-antlblotics ti1. }<-c. h'\T\Jo

- - - I .

Endocrine disorder

-hyperthyroidism Non-organ causes -IBS' __ -s\(- ir"» .

":- ~ j'>"L 1: 1>11\1

" .~kt.-~-W:-i_I:-z..,..-.....tr-

.~ ~cL4.''''':~

, /\:ic.*-.... "' - ~ l"", ... ",........-.G. ~,L-' D.1

to ~~ 01.;1 GI-r.- ~ cd!:- ~'=' '(f-'. (,.' Cx.:f-.u.,~ .

• ::r;r. * U>1"k~ ~~dr~~; OJ,,, rWH+- ~-er.4i-. r=» Wtft.... ~-&u'-77f**"

~ C+ tid~.

.''- i. L .... .... _ LL. _ a.

Dr. Hillman's comments

Systemic analysis of chronic diarrhoea (see note as weI!) 1st to think large bowel disorders (colon)

, - -;l- -. .

.-?do conloscopy and stool M + c. -;t

look for (infectious, colltls, tumor, :diverticulisis, carcinoa) ,r. If (~) ve .

thin~ malabsorption

Stnell! bowel: celiac; crohn's, '

_ Chronic pancreatic and Ca. (pain + jaundice)

. -1-

Bacterial overgrowth .

- -1-

Endocrine disorder -1-

If all (-) then consider [BS (no wt loss)

Dr. Newell's comments How to ask diarrohea Hx:

-the- charterac of stools, watery, loose, fat , blood, mucus etc

-" -assoclated pain and distension· -

-rnedlcatlon -

-traveling

-stress - <;e.,S

-diet' ,

.-~{...., 'Ht _. Cb-t.£!',- } Gvvt....,...' ... } ~'- A'~

. . J 0

,) ,.". ~ . ",

.......".,.- • .:-<-/(:;,...."..1.._ • ~ i . .'1."_ •

~ .......... ~~ ----f>'

rr= H~i. (~ ~~ ~~_h'- _, ~' ... ~~ <>y ~!Y'lovht:..- 1Z-..wf>""l~1-6r·'- rtr+-.

-s-i :

"' - Ac.v...8-L Ap~'i:.;,/-'--L ~D A;'£.-- ,7) ''ho.... -1-(0.-

, CRe:-~ c--r- r~'t-- ~''-<'h1,.):

. fr bb 'rpR..'-~:

s- ~~ -0 ~jrv>-~"c--('.' e: ~'''''''''''''''.]} '''r.r~ .

, -

_-'i>

r

\

2006 February 25 Brisbane

11. 30 yt oJd woman presentS to ED complaining of severe pain abdomen since today morning. (Ret. GP328.' T J surgery ~ 1 t-_~

TASK: Perform, an abdominal examination

Ask examiner what investigations you would like to ,do. Give differenb·aJs·and your provisional diagriois. Explain management to patient.

->>>>>(ACUTE I(8DOMEN-PERFORA PEPTIC ULCER},

. -.

" .

,Abdominal examination Inspect

3.Constraction of abdomen

4. Ncabdominal distensiorr; and abdominal respiratory movement, t - ")

Palpate

5.Board-likerigidity

6.General;seci tenderness - .

. 7.Guardirig and rebollndtendemess

a.Maximum signs at polntot perforation percuss1o(\-"

9.S.hiffing dullness my be present '

Auscuiate

10.Bowel sound reduced 11.PR:pel~ic- tenderness _

51

PR: pelvic tenderness:

Investigation

. 1.FBE, UIE , BGL, Calcium , 2.LFT

. 3,Amylasell.ipase 4.Troponin

S.serum Beta HCG .

e; Dipstk:k urinalysis . . . 7.ECG·

8 ChesiX-ray: maY'sh~w~ee,airunder.diap~ragm(i~75Yo)-ne·edto sit up right (or prior 15 ininutes imited gastogratin meal can .con.firmdiagnosis

• • - j. •

s.abcorntnat X.,ray .' ". . .". .' .

?10.U/S

?11.CT

. M~tn~gement

~'''' ~;U--

1.Avoid g'iving morphine pr pethidine until diagnosis confirm,' once a defif\itive

diagnosis is made, the patient should. be given parenteral opiates for pain relief. 2. Treat shock with W saJine(drip)

3~Pass a nasogastric·tu.be(su~on)-:-ro <Iu..o~ -fi.-,. f.~ . To OVLJ(.>\'d ~~

4.Broad-spectrum autibiotics " w,..,+c..""' .... n~ol') .

ampicillin .1.9

.. gentamicin Smglkg

. metronidazde SOOmg .

'.' 5.Refef the patient immediately to the 'surgicai team 6.lmmediatelY lapt!rotomy after resuscitation

7. The operation of choice is a simple 'patch. repair.' . .

8.1ffacllities and a surgeon experienced i~ laparoscopic surgery are available. it

is can be perfonned laparoscopically.·' .

·9.~nservatiVe 'treatment may 'be. possible(e:g. later presentation. and gastrogratin swallow indicates sealing of perforation) ."

Critical.eirors

-See above,highlights·

~,.' "

. ..

I 'I . . . .

,~,... -\.. ~">i..\o~, gO' ~L I . Cf"-'-l '. s~."·k.," ~ ~t'9>h'~' I~~

·yw~tL -k6. .' "tt~ -. u.low . " .'

.'

#14 11.02:06 Mel.bourn~ .

_Mesenteric artery occfusiqr:t/ lschaemic coli~f?/

~ -, ... -_... ~

· 65 y.o.ladyhad pain for 3 hours in the mcmlnqand bloody diarrhoea; nausea.

· Hx of AF.and appendicectomy Task: Hx and DO

RetS: See my notes. r: J surgery GP all v~1Y good . ?:r 1&9

Hx:

. When' did pain start? .

Painquestlons: site/ radiationl character/ gradually OF suddenly! constantly or

inte~itter'lV better or-worse /. Yl!-~'~ .

Associated Wlth N + V + T I content

Bloody stool questions: freS:h brigl1V dark redl top on stool/ rrnxed with stool Any mucus

Howmany times you open your bowel today?

'What is your normal bowel movement? Any blo6d or mucus?

How is your urine? ....

Did you._ have this kihd of pain betor-e?

. You-have AF before, how is your heart condition now?

Do you have chest painl"heart racingl SOB? , Do you have swolleri Jegs?

~ you on any. medication for AF? Digoxin! waterin? .How tar can you walk normally?-

How. many pillows do you sleep on?

.~ ,

(,

Mow is your general health? 'HTI CHFI OM! blood clotting problem Do you navepostprandlal abdominal pain?

i~.; What is your .appetite?

Have you lost any weight?

_When did you have appendicectomy? Any complication after op Doyou smokel drink? How much? On anymedlcation / Al~_

·Nuk. .

opE:

GA: Very sick! Dehydration VS:

. .

Abd: Distension! Tenderness! Rigidity and rebound '

.¥Abs,ent bowel sound

Groin

Cardiac: Irregular beating

· Respiratory: _ -f PR:

,

_ ,7'",-,.,,,; 1l.""~";\"·U~ r+: L ~'D >-;t-,..

c<-bt- r !;" r ~ b ........,,.., "'4 e...,J-{ (J .

~ rv)* ~ov.1. ~ c;»:

~~~~.

Ix:

. -

51 .

.J '

FBE ESR UtE LFT

CXR _ .

:AXR: free g_;;1.sl fluid! "Thumb Printing" . L ~~ ~~) Abd. CT: wall thickness

Mx:

Early surgery

DDH:

Perforated vlscus lntestinal obstruction

. Aodornlna] aortic aneurysm -Aortic diss~ction .

IBD.

. Strangulated hernia DiverticuHtis

. -

- -

.- ,

, S'L.{

Iron 'Deficiency Anaemia _ ' (include 4 cases and 'consent for colonscopy)

~AMC April 2006 Melbj: A 48 y.o menopausal woman came to your clinic to -

get results from-her bloodtest/results attached). - , - -

Your task is to: _' -

. Take relevant history, (it) I?Plain the condition te: the patient, and (iii) Management

Key points ~ .

- -proper hx related to 01 tract blood loss --: '~PRexam

- -Ix: .Fe studies, gastroscopy and- colonscopy to findthe source of her anaemia

PCV (packet Cell volum)
HB- 130-180g/L , ' 105
Mev' 80-100fL . , 75
MCHC 31O-360gIL _' 298,
WEC '3;S-1l-x lO!I/l.· 5.5
Platelets .- 150-450 x lO!l1L 200 ..
- .
Electrolytes Normal
Urea, - creatinine Normal
LFTs normal - -.,;,

Tell Patient your concerns and establish rapport. '

_ History/limy indicidethe nature of anaemia) - Hope

/ \

-Ask symptoms associated with anaemia and when that started Tiredness/fatigure,

-Headaehe/dizziness -

-dyspnoea.on exertion

-palpitations . '

-Ask dietary Hx, like inadequate meat ~ ect _ - _. - .

_-Ask symptoms 'associated witlJ.tnims~~ b~ss' , - - -Menorrhagia: ask when menopause start .an ,- assoc~ated _With heavy menstrualloss. If'pt say yes, then need to decide if this -is O{}.G case or'

. Hypothyroidism., - . - -

-ask upper Gr and lower GI symptoms_:

. -epigastric pain/heartburn/reflux/vomit blood; etc

. -bowel motions/black stool/blood in -s.1001· .

- , -any weight loss -, .'

.. Ask 'symptoms associated with malabsorption: celiac dx ' , : -ask if haematuria c§) . . . .

PastHx ' .' , '

-peptic ulcer ilisease,tmalabSorption/-l,w'J!.j} /1-1 ~t-criJ ...

-COPD/heart problems, ect, ..

-any surgery, gastric operation, 'etc. C. ~~,""""':1 ).

FhX

-bowel cancer/bleeding disorders, etc .. " -thalassaemia

'-

Social Hx/smoking/alcohol - Medications . . _ .

-ask if use NASIDS ulcerogenic drugs

-ask if using anticoagulant drugs like warfartne»:

Allergy: No '

Examinations

-GA.: conjuctival pale,

-vital signs normal, .

-no oiganmegaiIy, in the abdo, no lymphadenopathy

.If -PR (very important): no blood ·and ·mass. on rectal exam

. _ -respiratory/cardiovascUlar/neurological exams all normal

- note: also ask.examiner the (allowing: .

. tachycardia/systolic flow murmur -ankle oedema/cardiac failure Sunwl!l!V: .

Patient has no symptoms with only mild anaemia

- . - - .

.. You now look at the-results and eA"Plain10 the patient

The blood film (lower HB, lciw MCV & .MCRe) shows that lIB is.lower and . roo blood cells appear small and pale in your blood, which we call hypochromic microcytic anaemia, which is most 'likely due to iron deficiency anaemia, The likely . causes are mostly due to inadequate diet, menstrualblood loss and chronic gastrointestinal blood loss, or malabsorption in 1he intestine. I will do further tests to C9nfin;n what type of anaemia ana to find the source of your anaemia, .

- Managenumt

- Further investigations

Initially to confirm the iron deficiency anaemia

. -Iron studies - - -

. -Serum folate and .serum Vit B 1 2: normal _-red cell folate: normal

. TeSt: Noma! range Result ' -
Iron 5-30 j.gII.ollL . 3.4*'
Transferrin . L9-2.8gIL 3*
lion saturation 16-51 % 15*
Ferritin 15-200 Jlg/L . 14* . ' . Note: eferntin level < 15 IS a strong indicator of iron deficiency anaemia, _ but the

. "gold standard" test is bone marrow biopsy , ,-

, ,

,

Gas.troscofty and colonscoT;Y -hu..v-~ _ . _ _ _

- You should now tell pt that she has iron deficiency anaemia (pt may ask why I got . this).' and this is not. due to. malabsorption or inadequate dietary intake of iron (all.

j normal),

_ You also need to tell pt that chronic gastrointestinal blood' joss is the most

common cause of iron deficiencyanaemiain adults. This SQUIce is upper 01 bleeding in 20-40% of cases awl colonic in loS -30% of cases, In 1 0-400/0 cases, the source is not

found. '. .

You should talk to the. consultant to arrange colonscopy for. the pt (need

consent, see next) - -

Iron replacement therapy should be commenced -ferrous sulphate 2()0 mg tds (0) - . _ . - - _._

-tell the pt side effect: naus~ diarrhoea or coristipated . B~ t.O~ ~L-

-tell her to expect arise in HB of 19lUday. . ,

Note:_ usually needs 10 talee 6 mths, r 3 mths, replace, :?d 3 mths [or storage.

Refer- to dieticim:- (esp. vegetarian diet)

A week later; pt undergone 'gastroscopy (normal) andcolonscopy (mass lesion). ' -Biopsy demonstrate colorectal cancer in the ascending colon. .How you are going to

break bad news and management .

- irate:·· the above case is mainly basedon 'common case to internship page- 281-287.

Other sources: - .

,.GPP2i4 -

- -ClinExam

-Davidson ,

P Devitt P247

-' '-1 Case 2} a 63 y.o -"man present to your clinic wtth shortness ~fbreath on exertion jar 2mths (iron deficiency anaemia due to don cancer) ---:see Devitt P 247

'ICase 31 AMC exam, anaemia-due to peptic ul~r

- [~4~AMC exam i200~) Anaemia caused by ~CUnl i:an~ (Dr Hmmiin)

a 6S-yr oldwomen presentes with 3 mthstiredness andpalor. -Bloodftlm show Hii: .

85 and microcytic hypochromic anaemia: .

Task; Hx, examination, Ix and diagnosis -

'Hx Taken: :'-' HOpe

- Tiredness/fatigure over the last 3 mths

-Shortness of breath on exertion. .

-Ask dietary Hx, like inadequate meat intake, ect: good appetite

-ask upper GI and lower GI symptoms: .' -

- -no epigastric pain/heartburn/reflux/vomit blood, etc

-no lower abdo pain, bowel motions/black stooJlblood in stool

-lost 5 kgs oyer the last 3 mths

-Ask symptoms associated With'malabsorption: celiac dx: nil

-ask if haemaruria: nil' .

-no depression, good sleeping

. -no ankle swelling' .

Past Hx .

-no peptic ulcer disease/malabsorption

-no copnlheart problems, ect. .

- .

-no .any surgery, gastric operation; etc ..

Fhx , -no Fhx ~fbowel cancer/bleeding disorders, f.11~ •. -no thalassaemia

-general appreance: palor

-vital signs, BF higher.iotherwise normal

-abdo normal ,

-ht, aortic ejection murmur, no evidence ofht failure -

. -PR dark stool' with.blood

Investigi:ltions

-FBE, U & E, LFTs

-FOB:(+) ve

-CXRnormal

- -EeG: normal

-Fe study: confirm -iron deficiency anaemia

-Endoscopy: gastrtis _ .

-Colonscopy/biopsy; demonstrate 'eaecum cancer

Caecum cancer

Mx '

. -

.'

-.

- UIS for liver_ metastases

-CT,scan for staging

Dr Hillman IS comments-

3 main causes of Iron deficiency Anaemia' -diet Fe deficiency

-blood loss

-coeliac disease--dued~ biopsy

For Fe deficiency anemia, the most commonest Cause inthis age is Gl blood Ioss:

. Upper and lower Gl bleeding .. If sigmoidscopy is 'normal then shouldgo for .

coloscopy~ will detect caecum cancer (the most common cause for anemia

Dr Newell's comments:

If FOB is (+) ve, very rare - for causes by upper Gl, IIJt look-colon, then look small 'bowel (celiac), Very severe gastric reflux can-cause Feanemia,

Consent for Colonscopy

. -OSCEs P260, Common case P285, Walter's note

Explain the procedure/or alternative procedures

- The dietary prepration .

, -

.. bowel motions: constipatedlblack stoDl/blood in stool

-urinary ok/no hameturia - .

-Iost 5 kgs over the fast 3 rnths

-No symptoms associated with malabsorption: celiac dx

-no ankle sw?lHngl -

-no heart/lung problems

-No use NASIDS ulcerogenic drugs:

-No using anticoagulant drugs like, warfarin_etc.

Examinations. ' .

.. GA: conjunCtival pale/well,

-vltal sign;'- normal, . .

-- -no organmegalfy, in the abdo, nc.lymphacenopamyrmass at RIF

-PR (very impo.rtant): no blood and mass on rectal exam. .

-respiratoryicardiovascu ta r/neurological exams all nonnal

note: a/soJ3sk exeminertne foJ/owing:. ' -'

tachycardi8lsystollc flow murmur'

-anlde oedema/cardiac failure

ProviSional Ox ' .

The likely causes of ariaemla are most likel·;y and 'chronic gastrointestinal blood loss. I 'Will do further tests to confirm what type of anaemia and to find. the source of your anaemia.

Investigations

.. FBE, blood film: to connrm if anaemia

-U & E, LFTs . .

\ -ir.on studies: confinn iron deficiency anaemia "

. -Sarum folate and serum Vit 812: normal/red cell folate: normal _-FOB; {+) ve

-Gastroscopy: gastrtis . .

-Colonscopylbiopsylbarium enema: demonstrate caecum cancer

"-CX~CG - -

Management .

Counselling _ _

. You should explain the Ox and Mx to the patient, who needs to understand that she, has -8 cancer of the boWel. At this stage, you want to refer to surgeon. The surgeon will 'do further assessment to define if tumour has spread outside the bowel.' Explain that slie 'requires surgery -to prevt;tnt

total obstruction and attempt to cure her of the disease. '

TxHollow up .

(1) Surgical referral: Resection of right hemicolectomy. (2) Iron replacement therapy. should" be commenced '(3) Further Ix for Staging/metastasis: "

. ..;U/S for Ifver metastases/CXR/LFTs _ --

-CT·scan for staging': TNM or Duke A ~ to staging

~~~--------~----~-~--- .~.-~.--~.~ - .. -- ~~ -~. - .. ~.--.-

5-yr survival (%): Dukes' A 99%, B: 80%, C: 50%, D (distant metastases): 10% (4) Chemotherapy if regional lymph nodes involved.

(5) After surgery, she should be reviewed by her surgeon every 3 mths for

2yrs

(6) She should has a colonscopy every 3-5 yrs. (7) CAE for follow up

(8) Implication for family and check coionscopy

Critical errors

-Key hx eliciting GI tract blood loss

-PR exam

-Ix: confirm Fe deficiency anaemia, gastroscopy and colonscopy to find

the source of her anaemia

-Good counseling ;,~.",

-Mx: staging and follow-up \:. c..,~P'1

C--Af3; Other related topics for AMC cases

1. Counselling for family members for check

2. How to get consent for colonscopy (See another case of Fe deficiency anaemia)

3. How to get consent for surgery of colon cancer

Consent for c%n cancer operation (Devit P138)

Explain to the patient in simple language what the operation will involve and the risks and benefits of the proposed treatment.

Procedure of operation:

(1) The surgery will be done under GA

(2) She is likely to be in hospital for at least 7 days

(3) The bowel will need to be prepared for operation, ie drink a solution and empty her bowel.

(4) She will be placed on antibiotics to reduce infection.

(5) She might need prophylaxis for protecting deep vein thrombosis and PE I :DVT

(6) The surgeon will look to see if there is evidence of tumour spread outside the bowel.

(7) The surgeon will cut out the tumour and adjacent colon and then ideally will join the two ends back together.

(8) If this were not possible she would require a colostomy or ileostomy.

This is when a piece of the bowel is brought out through the abdominal wall to drain into a bag.

(9) Given the site of her tumour and that the operation is not an emergency, she is unlikely to require a colostomy

(10) Should such precedure be necessary, the colostomy or

ileostomy will be temporary and only required for about 12 weeks. f.ln..v..f't..-Wi,--- e.'t-IL

Risks of operation < $t,v..h ~k

(1) Anastomic leakage -

(2) Infections

(3) Bleeding

- _. -.-:=----=----.---~--.=-.-.-------- -.------.~:--,-~:'--=-:-~----- .. - ------_ .. __ . -- ---- -~---- _ .... ---- -----------_.-.- ... _-_._.- ---------

(4) Oamage surrounding organs (duodenal for Rt sider . (5) Qther risks: DVTtpE?pneumonia et~

. Ben~fits·

(1) If untreated, develop total obstruction. . {2} Potential cure of her conditon

(3) TeU her prognosis

. Refs:

GP, TJ surgery P191, DevitP138, common case P281 .

-,

-- --~....,..........- .. - - -~~. -_ .. -----~~--~-.~._.- .~~~~......--.--.....-,-

----~~.---~ .. -.----~~ --~~-~~

~~~~~-~. ~~ -- ~ -"--- - -~-- - -~~

#12 04.06 Adelaide'

Hepatitis C Counselling (Lady is iv drug user in the past)

Refs: Dr Hillman's'" notes -

FolloWing ihe order: _ .

• Further History: 'This lady found out she was positive for Hep C when she. went to give a blood donation. Sh.e tested neg~tive -~t the same time for

. HIV and Hep B. .'

• Needs furij1er ~nvestigation - is hepatitis. active or is she a carrier? (see adamfs note): Do PC~ if (-J ve, clearance,

-. Advise-on safe sex practices - she-has a husband, he also needs to-be

. tested. Both will require repeat testing in three months .

• Counseling re long temi prognosis and outcomes/co-nsiderations. Does she have children? Is she planning to fall pregnant"i

Hx

Open .0: What you are concemea and how did you find you have C?

Ask- how did she getit? .-

Dld you- ever have blood transfusion?' Dialysis?

r ; • Did you ever have - tattoo?

· Did you use drugs?

.. Did you share needle with other people?

Have cheeked' Hep Band HiV?

- .Did you have needle injUry? . _ .

Did any one in you~ family have Hap C positive as well? _DQ you have regular partner? - .

Are you sexual active?

Ask any bqnst;tutiona~ symptoms: feverlt!rdnessly~/low skin/joint pain etc.

How much do you knoW about· Hep C?

• 'It is a viralinfection in your' liver~

• It is the comrqonest.vlrus causing hepatitis, about 9:1000 inAustralia.- - • . 6 major geriotypes and more than 50 subtypes

• Genotype 2 and 3 more likely to respond to the medtcatlcn: a- interferon

.• No vaccination currently available for Hep C .

• . Many infections 'are mild. but unfortunately, tfiere is a high chance (alrnost 70%) of developing a chronic hepatitis

How does it transmitted?

• .Blood anq blood products '--main caliSe

• Drug .uS91"$ - sharing needles

• Needle stick injury

, -

------ -~-~----- .... - .. --- .. -- ~-- ,.~-

- • Infant born to Hep .C positive mother

• Tattoclnq -

• Very sm8.J1 risk of spread during homosexual or heterosexual intercourse

~. . -

What are the syinptoms? • It can be asyrrptomatlc

•. Symptoms may take 50-180 days. Such as: .

-Ge'neral:" fatiguel nausea, RUQ ciscomtort, anoreedarnusde and joint

pain '.

Liver sign'-of cirrhosis and. complication if! the. later stage. .

EXtrahepatic: skin rashes, renaldisease, neurological disor.ders-and' - . setonegaave arthritis, Sjogren syndrome and lymphoma

What further tests: we ~n do? GP-,,638- See note of Adam:

• ·Hep CAb +ve _= exposure

• Hep C- RNA- peR +ve=chronic viraemia

• HIVand Hep B

-. . C0411-i1V~viral load

-. Hap C genotype::::;determines treatment -

• ALT rai~ecJ. implied disease activity

• Uver biopsy: confirm liver cirrhosis

.- .

What happen to chronic Hep C?

• 15% progress to cirrhosis over 2-0 year's period'

• 4- ~ 0% of these will- develop hepatocellular carcinoma over a further 10.

years ,

.• At least 10% will progress to 'liver failure _

< -. If LFT abnormal for more than 6' 'months, liver biopsy should be considered - . • _ If HepC :RNA present, genotype testing help~1 as guide to antiviral "t!'terapy'

Management:

• Lifestyle change:

Health diet, low fat No alcohol

No drug use

No smoking

. GO.D.d exercise

Use progesterone} Depo provera as contraception'

.• - Prevent transmission:

Do not donate blood Do not share needles

Advice health-oare worker. including dentist

Do not share personal things (tooth brush, razors)

---~- .. --.-" --.-----------~- .. -.,,-. ..

Wipe up blood with bleach

Cover cuts arid wounds with firm dressing - , Safe sex use condom

_ • Treatment:

1. Regular visit doctor, 'regular check up'

2. Bed rest if you feel unwell .

3. Medications: Ribavirin IAlpha Interferon

a. SE: Alpha-Interferon:

Common: flu-llke 'symptom, anorexia; nausea, weight Joss,

- - anaemia,- hyperlhypotension, myalgia, headache

Infrequent: di~y, confusion, depression,' raised LFT, abn .. TFT.

lowplatlet

. Rare: liver failure, visual problem, seizure, renal lrnpeirrnent,

cardlcmyopathy respiratory problem

Ribavirin:

Respiratory effect, cardiac arrest, hypotension

b.lndication:- HepC RNA.+ve .

RaisedALT

Chronic HepC on liver Bx c. CI: Decompensate <?irrhosis NormalALT

Organ transplant recipient Severe depression

Other psychiatric .disorders Autoimmune disease

4. Liver transplant

.. FoUowup:

ALT testing ·every. 3 months. Alpha-Fl> every 3 months

If AL T constantly elevated >6months, refer to liver specialist vaccination for HepA and HepS

-. Give HepC help line number '(' .

, '.

Question:

·1 have agirl fiend, will she catch .HepC? _ _ .

. Need test for ser%g'y as well.' Low chance, but safe _sex and usecondom is

Suggested. -. '-. ,

•• __ .~ ~._._ _ _or __ , ~-~.~. --.- • ~ .~~~---.- .~ -.~ - --- --

---~~.~~ .--~ •• ~ -~~---.~-. ~& •• ---------. ~ ••• ~ ~.~ .~-~~~-~ -- --"- - -~-~-~ - ~-~. ~ -~. -- - -~.~~- ---~ ~~~~~

lP'!

AMC nth March ~06 Sydney

# 5 Physical examination of a diabetic fo.otl Give eemmentery as you go :along. After PE, you'

.. . . ~ .

are asked about further management 'of the patient. .

PE: - Before exam, ask patient do you have any pain?

Inspection: - looking for any deformity. . .

Skirrcolour/ulcer/gangrene (between the toes)/hair loss/muscle waste

~ Joint: swelling -

Palpation: - Temperature (compare both leg)

Peripheral pulses (present or absent?); capillary return?

Sebsation; ~ _ Light touch painlsensary loss: dermatomal distributionJIevel - Deep sensation vibration/reflex

Management.'

.;. Education (Keep your Diabetes under good control and do not smoking) Check you feet daily. Report any sores, infection or unusually signs

- Wash your feet daily .

- use 'lukewarm water (beware of scalds)

- Dry thoroughly, especially between the toes _

- - soften: dry skiD, especially around the heels, with lanoline

- apply methylated spirits between the toes to help stop dampness,

attend to your toenails regularly:· - Clip them straight across

- Don't cut them deep into corners ciI: tooshort across -

Wear clean cotton or wool socks daily; avoid socks with tight dame tops Exericse the feet each day to help the circulation in them '

Avoid pressure soresfmjnry/infection _-

_., . The foHowing from Victor's Dote

Diabetic foot is one of the most popular topics,

., Management

1. /patient education(including all the above notes)

2. radiograph of the foot '. .

3_ removal of callus skin { best done by a specialist (podiatrist»

4. treat infection ( antibiotic) -

5_ removal of weight-bearing and friction from ulcerated areas '_ (appropriate foot wearsuch as mould insoles or plaster cast or Crutches)

( 6. ensure good hyperglycaemia control . .

- .'- 7. control oedema' .

8. chiropody

9. surgical opinion ana arteriograhy if reconstructive vascular surgery or arigioplasty is co~idered.

Reference: Davidson p676, GP196, <case250>pS,S, 'I'alley connor p275

~--~~----'-.-'--------- --- ----~--- -- - ---- --.-----~-." -----_ .. _-._ .. _- .... ---- - -------~--~'

What implements do you require for this examination:

• Cotton wool balls

• Neurology pin

• Tuning fork (128 Hz, not 256 Hz which you use for bearing tests!

• Reflex hammer

EXAMINATION: (LOOK. LISTEN. FEEL !!!!):

• Inspection:

SKIN: hairless and atrophic because of smaIl vessel disease and ischaemia.

Ulcers: on toes or pressure areas! (combination of macro and micro vascular disease and peripheral neuropathy)

Infection: superficial infections are common, e.g. boils, ceIlulites and fungal infections (due to ischaemia and high tissue glucose providing ideal environment for bacterial growth.

Pigmented scars / diabetic dermopathy, small rounded plaques with raised borders lying in a linear fashion over the shins.

Necrobiosis lipoidica diabeticorum: rare, striking localized skin atrophy with lipid deposits over shins. Starting as flat red or yellow plaques which later ulcerate. Very hard to treat.

Gangrene: advanced macro vascular problems ("pulseJess foot) or peripheral neuropathy problem ("painless foot"). It can also be due to micro vascular changes where pulses are still palpable! The tissue becomes necrotic with black skin either dry or moist!

Injection sites: usually on thighs

Charcot's joint: due to loss of sensation (proprioception) the knee joint is exposed to frequent injuries which the patient does not even notice, leading to joint deformity,

...-..

( .

• Palpation:

Injection sites: possibly atrophy or hypertrophy in the area of the thigh ifpatients have injected for years .

Pulses!

Temperature

Capillary return

• Neurological Examination:

Peripheral neuropathy: distal, symmetric loss of sensation (stocking paraesthesia)

with numbness and tingling. ~

Mononeuropnthy: acute mononeuropathy most commonly affects the femoral or

sciatic nerve following an occlusion vessels' supplying the nerve. '

Reflexes: reduced

1-6. SpirometrrfLung Function Tests

Dr Ryan Hoy, Also see Davidson P493 Case: AMC exam Melboure April 2006

A 28 y.o man with a history of asthma came to you. He has symptom free for 2 yrs. He}1CISrl 't been using ventolin in the past 2 yrs.

Your task isto

Do spirometry

Explain to the patient the result compare to the expected value

Instruaions of Spirometry to pt

-read the questions carefully and understand the purpose for the test

-check pt name and age

-Measure height and weight

Introduction (slow and clearJ

-My name is DR _. I've been asked by your insurance to perform- lung functiontest today.

Reason for test

-the name of the test: lung function -test

-the reason for the test: we have been asked to -perfonnlung function test for

your medical insurance because you have asthma This test will help us assess -your current -status of the asthma and the severity of asthma

Risk ofthe test

-Reassure and relax the pt this is a very simple test, take a few minutes, it doesn't-hurt-you,' and shouldn't cause -any distress .

.',

Instmct the pt (Clear and'slow)

-take a deep breath to fill up your lung, put the mouth piece onto your mouth, "Close your-tips, blowout and-push as -bard as you can. and keep going, keep going until to "the end.

-repeat in 31imes

Interpret the test a will insert the figure result later) -look at data and calculate "the results

-explain the result to the pt

-pt need to be "StII"e'ifthey are ok

-ask pt do you understand the explanation?

if it is obstructive, can tell pt the following:

Breath out at the early. stage is little bit slow, the airway is a bit narrower.

Asthma -is -a common 'cause of-airflow limitation. 'The reversibility of 'the airways obstruction is usually assessed by spirometry before and after a bronchodilator aerosol. An increase of 10% or more in either vital capacity ·or -FEYl is taken to indicate significant reversibility.

.---~.------ ..... _ ... - .... _.- .-- - .- ... _-.- _ ..

Volume(l}

4.5

4

3.5

3

o

2 3

Time {Sec)

4

5

Simple measurement ofbmgjimi:Jion

Ventilatory capacity (Spirometry) Measurement before bronchiodilators -FEVI

-FVe

-Ratio = FEVIIFVC (ntmlUll value =70%)

Thenormal range of -FEVI and FVC are based on age, -height. weight, gender and ethnicity,

Measurement after inhaled salbutamol -FEYl

-FVC

-Ratio =FEVfFVC

This is to testing the reversibility of airway obstruction Full reversible is the Dx of asthma. If FEV1/FVC < 70%, indicote airway ObstruetiolL

Normal

VC within the nonnalrange for height, weight and gender. FEVIIFVC>70%

Obstructive FEVINC <10%. VC may also be below normal Tange

l() 100

. -Restrictive FEV'l NC ·is higher than -normal and may be 100%.· Both FEVI and VC below normal range,

Mixed obstructive VC below normal and FEVINC <70%. & restrictive

Flow volume curves

_" t

. ,

- t~ • • .. r~

___ ._----'---~ _J::r~_"._~ .: ---.-------,~._:__:==----- .. ~: =--=-_=~_=---:-

. __ ~ - ~~~--------~~-. -----~---~~~.--~__=~-~.- ~_r ~~~ ~~ --- ---~-.~- ~ ... -

~- ..... ----.--. --~" - -~-'"---

.'-

==>~-1 ~~ T-=rc:::r ::;:~

Ix for Dx and staging purposes (Lung Cancer)

L CXR.

2. CT contrast, renal function should be considered

3. sputum cytology

4. lung function test and renal function test, reason for this is high risk for

bronchscopy

5. Bronchoscopy

6. CT -guided biopsy

7. PET scan, both for dx and stagingS.- incision biopsy

Asthma,.!

Dr Ryan Hoy, acute astlllltll see Devil P256 / 2 'I-o

Case: A 35 y.o. woman presented with recurrent shortness of breath. Task: (i) Hx, (ii) Exam (iii) Ix, (iv) Mx

c h;1 d( lin w:lh (tt (.( .. 1( r ent (\ oc. ILl( n e; I WU(II?

ax 1 ft I -l I. \ ~r {i'rltl'l\(~~, <?'>p" "u. ese ec ("5

HOpe Ptop!~ wilh ;()H(N"l~ "-:f1\- 0t.jSfnocrl' Or (rll!'.:.J 1"

-shoter of breath over the last yr, recently become worse during daily acti vity

-no chest pain, no sputum, occasionally dry cough

-wake up during the night

-puffer make it better, no other aggreviating or relieving factors

Associated features

-wheeze (this question can be asked in hx taken??, not sure) Past Hx

-Hx of asthma Medications

-puffer SociaZHx

Smoke: 20ld for 10 yrs Alcohol: Nil

Fhx

-mother died of asthma, father OK Allergy:

-Aspirin

Dr Hov comments

Typical clinical presentations

-breathlessness, tightness of chest, wheeze and coughing (esp at night)

need to assess how bad the dyspcnea (the severity of asthma) -short of breath. on wa1klrunninglshower/rest?

-what make it worse or better?

-How often do you wake up at night?

-Have you been to the hospital?

-Did you go to the intensive care unit?

-How did you know tbediagnosis of asthma?

Exam

-key physical signs: Wheeze

Investigations

-FBE, mainly look for anaemia, Dot necessary

-CXR.: mainly look for serious lung problems, infection, pulmary hypertension

-Lung function test: spirometry, assess airway obstruction

-Inhalation challenge test

-primary pulmonary hypertension for this age

-Anemia

Mx (Devitt is pretty good)

-explain to the pt the nature of asthma

- ~_ •• __ ~. _. ••• ~ ~_~ __ ~I __ " _. ~-~ - _.__ •• __ •• _. _~~_~ •• ~." ••• • ~_. ~-~-- ~. • •• -~-- ••• 0" _ ,.,"- ~~- ~-- • _ _ - - --_ •• -, ---- .--~. ~~~ ~ • - .-

--_ .. -- -- -1;'--

-1 puff at one time (1 puff one deep breath)

-washing is very important

;0

(

II

-principles of treatment

-puffer, 3-4 time-aday

-steriods start with high dose, slowly down for 2 mths

Explain 10 the pt the ntituTe of asthma (patient. education)

. =tell the pt "you have asthma" It is very -coomon condition, take this disease-

seriously as it may be fife threatening, " ",

-asthma involes inflammation and narrowing of the airways.

-it is a chronic condition and there is no known cure

-the disease can be life threatening, but there is effective treatment available.

-two main type of medication: reliever and preventer "

'_ Two maiit type of itzedicaJion (dejil.e the ai~ of treatment)

- V entolin, relieving medication to relieve the symptoms like tightness, wheeze

and shrt of breath, advice use spacer, 4 puffs _, .

-inhaled steroids: preventer medications, anti-inflammation. ,250-50G ug twice a- day. Long acting, aimed at reducing swollen and try to preventjo get it again.

" . , ~..,.....

Very 'important to wash out, infection in your mouth

Monftoru,.g and a plan of liumageRumt (fitrihe': consilltatio.n "a.~ folluw-up) -home PEF peak flow meter

-acute asthma management plan

. -prolonged consultation

."

._--, -~----.,-. -.-------- -'" - - --~---- -- --- - -----~-.- ....... -- _ .. _--_ .. ""- - .. -------~-.---

j.i-

AMC Re-sit June Melb Z0d6

2. A young student presents with dry cough, -mOstly in the morning or a( night, general health ok; non smoker. (or. A young man has recurrent cough in -the past 3 mths. Dry cough worse -in the morning, no fever. He has past fix of eczema)

Tasks:

1. Do a respiratory examination.

2. Report your finding to your examiner. -

3. Answer examiner's questionand interpret the test results.

_ Again, followthe textbook's instruction. It was a medical student with no positive finding. I told the

examiner that there was no positive finding. Then she asked me what was the diagnosis- asthma. - ,

Immediately she asked me what else I Wanted to do. I-said spirometry.· - _

She handed over 8. spirometry result: FEVl decrease, ·FVe decrease, after bronchodilator. - FEVl . increase but lower than. normal. FvC increase but lower than normal. I said, it was Consistent with the -

diagnosis with asthma. - '.

- ' -

:;.-.

Respiratory Exaftt

Introduction: _

Hello., I am J?r._' . Do you mind if I examine your chest/Lung please? -. Good exposure & Position the' patient

Patient was asked to-sit on the edge of the bed.

General inSpection of the room

Standing back, look around the room, check if followingpresent:

-Pt was nebulized oxygen therapy (2 Uminute}, flow rate/IiaSal or

mask/concentration/intubation .

-Sputum CUP .. check for colour/thick/green, yellowlblood . (Haemoptysis)

-Spacer and medications for AstlnnaiCOPD, and -

-A wheel chair and walking frame around the room

General inspection of the pt -Sitting position - ~

-Comfortable or distressed (SOB)

-Type of cough -

-Rate of respiratory/breathing pattern at rest .

-Cyanosis -

-Accessory muscles of respiration -

Hands -

-Clubbing

-Peripheral cyanosis

-Nicotine staining

-palmar: pal~anaemia. .

-Skin: thin and atrophy, hair loss/bruising due to long term steroid use

-Wastinglweabiess: finger. abduction/adduction (lung Ca . involve brachial

~ . plexus)

-Wrist tenderness (HPO): hypertrophic pulmonary osteoarthropathy .

-Pulse rateIBP (a!ik BP front tke -examiner, please- don't forg(Ji it):

tachycardia, pulsus paradoxus

-Flapping tremor: long term use of vento lin, or hpercarpania

-Pemberton's sign .

-EIbownode

. -Horner's syndrome: ptosis. constricted pupil, no - sweating of one eyebrow, Compress the sympathetic N:

------~---- .... ------- ... ---.~~---, -- ----.---- ... ---.------~-~~-.-.---- ---_._.- --~-" ..

-Central cyanosis - -

-Voice: hoarseness

-Facial plethora

Trachea - .

-Displaced

-Very tenderbe.careful

-Tug

-Scar .

Chest Posterior (sitting on ;lde 0 f bed) ..

. Inspection

-Kypboscoliosis (shape of chest and Spine)

-Chest wall movement/chest expansion

-Scars

-Prominent veins

Palpation {mainly lower lobe)

-Cervical lymph nodes .

-Bxpansion and symmetrical: note-asymmetry and reduction of movement

-Vocal fremitus (ask the pt to bring his elboWs tog¢ter in thi front)

Percussion '(sounds + feeling) -Supraclavicular region

-BaCk

- -Maxillae.

-Tidal percussion

Auscultation

. -Breath Sounds: .

-Intensity; normal/reduced/increased . -Character: bronchial or vesicular -Adventitious sounds: crackles and wheeze

-Vocal resonance .

Chest anteriorly fbrini doWn tri 45· dEw-ee) Inspection _

. -As above

.. -Radiotherapy marks

Palpation' .

- .' -supractavtcular 'nodes-

-Expansion and symmetrical: put fingers on Upper and' lower lobes

-Apex beat

Percussion (sounds. + feeling)

Auscultation -

Car.diovasCular system ~JVP (right side) -RHF

-oedema

·,.last asktemparature chart, oxygen' saturation, peak: flow rate

-Nom- for Exain

-key physical signs for asthma: Wheeze

Ou.estions (rom examiner

Before examine him, what dx is in your mind?

, -Asthma -

Now the physical exam was normal, can you rule out asthma?

'-No .

What tests do yoP want to order?

. -FaE. mainly look for anaemia (usua not necessary)

-eXIt mainly look for serious lung problems, infection, pulmonary hypertension. Nothing help for ast:hmil..

-Lung function test (key Ix): spirometry, assess airway obstruction

-Inhalaiion challenge test .

lfthe CXR Was normal, do you still think it is asthma? '-Yes

.Can you interpret the lung function test result? (FEV1-65%, clear improved after,

ventolin) ,

-".

Weight: 78-kg

, Height 170 em "

Predicted FEYI : 2496 Predicted-.FVC: 3508 ml Before bronchodilator

FEY1: 1650 ml (66% of predicted) FVC: 2500ml (72% of predicted)

, FEVIIFVC: 66% (nollIU31>70%)' - , After bronchodilator .

FEVl: 2100,ml (increase 450 ml, 20% increased) . . FVC: 2800 ml (increase 300 ml, i2% increased) FEVIIFVC: 62% (norm.a1>70%)

Obstructive .airway, consistent with asthma -,

-primary pulmonary hypertension for this age

-Anaemia

, -pneumonia

What is your management? (Devitt is pretty good) Explain to the pt the nature Of asthma (patient education)

-tell the, pt "you have asthma". . It is a very common condition, take this disease seriously as it may be life threatening.

-asthmainvolves inflammation and harrowing of the airways,

-it is a chronic condition and there is no known cute

-the disease can be life threatening, but there is effective treatment available.

-two main typ~ ol'medication: reliever and preventer '

1Wo main type of 'medtcation {define Ih~ ui(!J of treatment)

-Yentolin, relieving medication to-relieve the_ symptoms like tightness, wheeze _aDd slut of breath, advice use spacer', 4 puffs

. - -inhaled steroids: preventer medications, anti-inflammation. '250-500 ug twice a day. long acting, aimed at reducing swollen and try to prevent to get it

again. ';

. Yery important to wash out, infection in your mouth

----- ••• ~. - -~---~ ~ ~~- ~ --~~~ -~-- - -- --- - ••• ~ ~ --- ---- ---. & •• ' --- -- - -.-- • ~ ~ - --------~- --- -~-- •• ~ "- - -".'- --~----~ •• ~~~

--- -~----. ,-".,._. -, -_. - -- .-.-._-------

-75

Monitoring and a plan of management (fUrther consultation and fo1!ow-up)

, -home PEF peak flow meter -acuteasthnia management plan

-prolonged consultation,

.- Identification of allergic/trigger Jactors (type of allergic conditions)

.)6

AMC CIin Exams"":' chronic l~g'd~~

...... -......~".

COPD & Asthma (The differences)

tOPD (emphysema) - .'_

-allold age, all smoker - ' _ _

-not recorfunend long term Corticosteroids treatment due to increased .risk of

malnutrition and osteoporosis .

-Ifbronclrial spasam present, that means treatable by bronchidilators

-only way for treat is lung transplantation or partial lung' volume reduction

surgery - ..

Asthma ,

.. -in the AM"C exam, 'usually' presented -'in, young ~. with atopic hayfever;

eczema May just present with cough ,

_ -If present _in old age, must distinguish it is - purely asthmatic patient or' coinbined asmatidCOPD·

-asthmatic pt in later life, after-infection" confirm to have cough and wheeze,

. hx of asthma in childhood: - - ,

In the Physical exam if present with ronchi, must ask (i) dp you have wheezeing

'(COPDlAsthma)?, (ii) ask sputum: colour and quantif)' .

Pulmonary Fibrosis

Primary pulmonary fibrosis '-

-the most important in clin exam, real. patient presents with Clubbing. central cynosis and decreased 02 sats, Mx: Iung txis the only .hope, corticosteroids -

pd cause of 'pulmonary fibrosis "

-RA Lupus.systolic sclerosis (most important to find the cause)

--~-- -- - --- ---~~-~- - ---------~~ . - - -. -

77

AMC 2006 Melb Feb . .

case·10~· TlA:(no-re: most TlA PW present e!fher ann weakness or . visional disturbance, so ner« are. two cases in details)

case 10. One houraqo a 67 yrs old lady had a difficulty in speaking and . weaknessm right arm. When shewas in the waiting room the symptoms

resolved. Patients mother had a stroke: '

Task: examine the relevant systems.

Case 2: a 65-yr-old man, ·complained of episodes of funny vision .. Task: (1) HX, (2) exam, (3) management

Hxtaken .

K~y's of TIA: (1) sudden onset usually affect either vision/or ani1/leg weakness, (2) completely clinical recovery in le~s than·24 hrs·, an·d (3)

average duration of 5 minutes. .

-see GP.1337, 250cases~.119, DevittP30S

Hope

-Present symptoms and location are keys fpr neurological hx taken

sudden onset of blurred vision since last. night in the right eye -How many epidosdes OCCUlTed and how long for each episode: 3 episodes since last night, He described the sensation of a black curtain suddenly dropping in front of the ee.~ lasting just under 5 minutes, . '

. ·-If you suspect TIA, make sure ask pt Whether the symptoms· resolve.d completely or nqt as TIA last less than 24 hrs, ask pt: Is your visionlwal~speech back to normal now? Pt answered" I am cornpeletly resolved now)

-also ask pt if irs single event (only vision disturbance) Qr milltjple events (vison, sppsch, arm weakness, etc). this imply the sources of the. lesions in the brain (different locations).

Associated symptoms (aimed for DDX)

. -obtain hx of headache, setzures and loss of conciousness (exclude.

SAH. bleeding and epilepsy) ..

-Pain in-the eye and temporal artery: temporal art~ritis

-obtain hx of speech defects, sensory loss and weakness of faces ·a.r:ld

limbs . . . . .

-Aura or warning signs-exclude migirane

-any nausea .and vOl}liting

-Hx.of fu notional status: swallowing, mobility

Past Hx (focu~ed on risk of factors) -Hypertsnts lon

'-smoking -DM .

-hyperlipidaemia . /' . /'

-eardiac disease: ask pt any chest pain or racing fast (AF)

7'1

Fhx Medications

Exam

Keys: exam focus on cardiovascular risks. -Neurological exams

-Cardiovascular exam IOQking for sources of emboli

. -at end ask for v'signs chart and Ix. EsppufSe and BP.

Neurological examinations:

. Lower IimQ exam: . start from galt 4pper Ihnb exam

Speech exam

Cranial nerve exam

Upper limb .examination .

· -ask pt: Do you have any pain? .

-Inspection: muscle wasting, asymmetry, fasciculation, spasm, arm. weakness and shoulder scars.

-Tone: normal, increased or decreased . .

. -power: Shoulde"f, elbow: put towards you and push away. .

. -Reflexes: usually ii1crease,d in.the affected side.· How to differenctlate the rt and It arm normal, 'hyp~ and hyper-reflexes: Check legs.

· -sen$ory '. -coordi nation

-properceptlon

e neuroloqlcal examinations will teU you where is the lesion

• Is it any' particular group of muscle weaker?

• Cortical weakneSS:affect antigravity muscles

• Sensory loss-ftsplna' cord lesion, more nerves involved, '.usually due . to bralnstern, can be performed by crinal. nerve and language test.

(UMN) .

Careful cardiovascular exam is essential (Devitt P3.07) " .

Wnen evaluating a pt with TiA: ·.a careful cardiovascular examination is very important and essential, including measurements o(pulse' and BP, examination of cardtid and temporal arteries and assessmEmt of the hearl." -pulse ·-PAFo"..r

-blood pressure -.

-carotld bruit ~ .

-temproal arteries .

-heart "

· -tundoscopy-s

-urtne dipstick test glucose .If .

. .

At end ask Ix such as' carotid uis, CT scan MR..L Investlg~tions

-FB~ .

•• __ • __ •••• , _0. 0 ••• _~ ~. .:...

77

·-urianaylysis and fasting blood glucose

. -fasting serum lipid profile .

• -TFT

-f.-C)(R and 'ECG .

-ESR .

fC.,-carotid dapple U/S .' .

4r-Ech.o- .

: -OT '(contrast): exclude bleeding, ·ear1y changes in hypertensive :-MRI-is very good. Acute meddulary, DWR, very good in' different 'structure

.Manage~nt of acute stroke (iscJlea.mic stroke)

1st make sure the dx (rule out bleeding) -1-.

Resusciatation .J,

tPA.

(giVen within 3 hrs of onset;.

indication: I}gt too mild not too severe, J:i.$.k.ofbleeding)

'.J, - ".

Aspirin' (2nd_ prevention) . _

300- rng bonus then 150 mg(jf >30pmg, .more risk .of bleeding) - don't using heparin; no evidence improve benefit

-!-, .

~en to start ~spidn • (atleast 24 hrs after tpAl

.J,-- "-

If pt presented stroke and With aspirin, them using clopidogrel (75 mg oral)

.' -.J..

If, using both anti-platelet drug, still have stroke, then no evidence of what to . - do is the. best, don't using doubletherapy as no benefit

.J..'

I "

When to using Warfarin Atrial' fibrilationj -

How long to use warfarin (based onJ1sk of bleeding asses~inent

.J.. . '.

~- carotid en~arterectomy,

. > 7Q% stenosis go for surgery .J..

Control-BP

.Don't crop BP too quickly (for example' 240/140, drop to 2201120)

. .J..' . '_ .

Using combination treatment Priandopel (ACEI) and indapemide (Quritic)

<!- - .

. lower cholesterol (no- evidence that lower' cholesterol is associated with .

_ ' , , reduced risk of stroke) _ --

. .J..: .

--.

Reh abilitation As early as. pcssible

Questions:' .

Q... ---J)- Can you have-the double vision of cortex? 'No, double vision is due to cranial'

. nerve damage

. Q ~ How to ask loss of conciousness? ~Co~.What was your last memory? '1

.What can. you rember? J .

Q-"i> How to.dlnerennate demetia and delirium? .

By standard hx: dementia-chronic hx, dellrum, acute hx

Stroke .

. -lschaemi-85%, includes: cortical, subcortex and brain stem

TIA: . .'

less than 24 hrs, signifiCant further risk of stroJre esp in the first week. Pt with TIA should admit to hospital fot furthi3f Ix and rnx.

- ~.~

(

p'

Speech etalni.nation:(Dr Henry· Ma)

. . .. - ,~ .

-see , 250casesP149, elin ~ P~9, Zhong wenP634)

Case..A IlU\D. with recent onset of speech problem . Task: Speech examination

1 d: to identify whether it is due to mechanical problem (articulation) or language

problem .'

J,

Dysarthria (beag-beag) (difficulty with articulation)

Dysphasia/aphasia. . (Language, . left hemisphere-dorminant)

TeSt Dysphasia J.

Fluency

Ask: Can you describethe roometc ..

J-_

. Comprehension , ".

Ask: can you put your hand on your right ear?

. -!, -

Repetition"

(say 3. nouns; bread.coffee, pens or No ifs, ands and buts)

. , " '- ' -!, -

Writing

'I :'I' - \' r, ~(.;:1flO~-IoIlJfcf;knJ, Jh"

~ '" ~'(. ~pflV ~ - .. ' ',' ,

Naming 5 po lc ~"'l w rit}",.., , ...... o.rtJ.

DysjJhasia _ c II ,,1>\ (,\ ck,~' _ (~.., no,} (' re.p ((~ ~ S"~~(Jf-,t:"r~ Is

_1st to Test·the l)!pe o(apnaSias C' r II ~lY"I rob llr [. rs ~

Fluent speecn (receptive, conductive or nominal aphasia) Cr,.." fU U~ i. 0 fY' m{ln d ,"

--see'cUnExam-P289table (o}(Ol1ot;:y- p~ ~':iO' . .

. The speech is fluent but conveys information with paraphasic errors. '. •

No.~..jluentspeecJ:z(expressivea'pluisia) : . N~ivY1I"A'\ ~ o\'lF'lAt~ !')l<tYlt"j obJ ,

The speech IS slow, hesitant and non-fl~en.t· r t J L. A hlo. ~ ('r. ... n.c~

. \:f~P(h")II&t-- ut\(\tnr""", . \--

Next is to determine where is the1esion,(see 250·eases and Chinese book) 0 "l )w,,"cC.Yfro'f,("" "~'Broca's: exp~essive. frontal:lobe, due to rightOsided stroke (:.~'pn.~ .,i\,·"

Wernic~e:s: receptive, posterior/temporal (visual-field cut) R. _"" 6f l-f'v'"

-Conductton: -"

Dysarthria .

-no disorders of content of speech -but a difficulty with articulation

-Canses:

. -Pseudobulbar palsy/bulbar palsies. _ -Extrapyramidal disease

, -cerebellar disease

" '

Also remember to examine: -recurrent paraagel nerve

-cranial nerves .

"tone: to differentiate UMN/LMN

,SA,I;IrSubarachnoid Haemorrhage .

-see GP620, DevittP323, EMP56, Cpmmon case PISS

Epidemiology (devitt) . -50% mortality Keys:

- Alwa.ys ·consider S~ for a headache when pi consider sienificant mough to

the Hospital. , .. .

-S~ Can be present with fever (low grade) . ,

Risk factorS .

8.5%'0£ cases due toberry anuresym

_lut degree of relative with SAlf . -hypertension

-smoking

-heavy alCohol smoking

-previous hx .'

other uncommon causes

, ConwlicoJions ofSAH .

, -r~leeding. ,. , . ' ~~ "n~d: (: &!-v,.;.~) """.1:le....,.:tt... .

. -vasospasm -9 ~. ~ --tI .

-hydrocephalus .

-electrolyte disturbances ('4'Jr'~~"....,A"", dlf+- ~1A.1)1·.()

-pulmonary oedema

Case 1: Dr newell 2 cases (see notes)

Case 2 (common case book) . . .

Key Hx.: A 50 y.o man presents to '"the Emergency dept with severe headache for 2 .hrs,

r· , He tells you he is. on mildhypertension and is on ACEi He is fine this morning and was doing garden work allthe morning. 2 hrs a~o while digging in the garden. he developed sudden seVere headache which he described never had this headache

before.' " .

_ Case 3 (Devit): A 48 y.o woman came to the Bmertgency dep-artment presenting with

severe headache for S·hrs. - .. . .

Your Task: (1) Hx, (2) exam, (3) provisional Dx, (4) Ixand management -

Hxtaken

HOpe ,

- -Sudden onset severe headache for' 8 hrs: "like being hit over. the back of the

head . " - ,

::never had headache like this before .. _ .

-It started at the back of her head and radiated down the neck. -

-On exertion: the headache. occurs suddenly when she was Playing tennis

-sponraneoua improvement after 2'lrrs of sudden onset -

-She felt nauseated. and vomited bnce - . ' .

- -She WllS dischargedar home dx as mirgiane and collapsed and unconscious

after 24 hrs. . -,. _ . :. - , .

-prodromal episodes of~d({fuble vis§ may be present due to

"warning leakage' _. _ -. ,

_r~ - __ - ~_~ - __ ~_~_~ __ ~-. ~~ ~--~~~. ~ ~ ._. ~"- ~. I --- ---

No ot~ Associatedsymptoms (ainze4for DDX)~ esp rule out irau~ , :

, . _ Rule out epileps-1:bead' trauma, febril illness, -6ligraine and -arcbohQl and drug

-. abuse '

. Past Hxtfocused an risk offactors)

- , -Hypertentsion . - .

-smoking' ,

'-DM-

-hyperlipidaemia , _.

-cardiac disease: ask pt any chest pain or racing fast (AF) _

, t

-Bxam ..

--, -GA: drowsy, irrnable ani contused

-V'signs: BP l3ono, otherwise normal .

-Focal neurological signs. ,

Aeckstiffi:iess (+) ve, Kemig sign (+) ve -

_3rd ¢l'aniaI nerve paisy: 11 side ptosis.tdilatedpupil, and does not

•• - J •

- J:>. adduct fully . - l"'" c..l~.:...- r-L"w...--t-o...L ''1>' _~~.;,...,...V(... 4- ~(".:>r--..Q.."""-- ':'b_

J-Fundoscopy: subhyaloid haemorrhage and papilloedema ,- . s.".,

-_ -full general exam isnormal.rule outinfectionand'other cause of collapse ."

Provional Dx -SAB

Investigations

-FBEIU & Et fasting blood glucose ILFIs _ -fasting serum lipid profile -

-CXR. and EeG

CIBrain .

. : -If CT is normal but the history is convincing. a lumbar puncture should be.'

done. -RequestxanthOehromla in ,CSF to differentiate trauma (absent) -and .

haemorrhage:.. . ~ ~- uLf..Ll -, ,- ""- . - . .

- -further imaging will be-with angiography or (CTAfMB.A)~~·":'I?v .. t:,,~tA.. 4v{O~Jv.~")/ .

. /Management(EM is go~d)

Oxygen and, nurse head upwards -!.-.

Check ABC ,1..-

N-acess and send b100d fOT Ix

.!:"

" Give diazepam Smg iv for fits;

tar~~amolSOO mg and codeine a mg two tabs (o)~inorphin~ for pain reliefe Antiemetic ineI.Qclul'Huuhll:llOnig Iv.,

J

. :refer to the medical team or neurosurgical unit

m....,... ~ 1i~of ~~,'""'"'- I;""'" c-y ~

-4- Surgical intervention (within 3ds): Intraoperative clipping.

. Endovascularcoiling teChniques .

. ' .J,.

strategies to' reduce the 'risk of complications (ischemia) .

consider nimodipiile '(Ca blocker} infusionat I '

. '~-T .

AUo.T&~·c~ e~'~~ r~fc.,<"I--. ?o-t1-.~.~.

rio' ~'~.'

r+'

! .

.. ''2Lf

Ov\.. CL..8 c J1J;~?,'~ J

h "'.~'h; '0+ ~wuJl-~

'.

- PeripIleraJ. ~jpa:th~(Dr Henry'Ma) _

-see , 25CkasesP164, Clin ExBm P349, Davidson P_

Case: ~:~ present recent problem of'upper and lower limbs.

Task: Upper limb examination (lIeny, said this is usually lower limb exam)

Exam Findings:

:..,Ask pi if any pain: Nil ,

-Inspecticns; no scars, no muscle weakness/no fasciculanons, weakness of

" fuittds - - .

-:Tone:normal

-powec reduced, but more severe in distal than proximal Symmetrical

reduced.

Grade: 3 ( antigravity) -Refl,exes: absent, esp the wrist reflexes

=Coordication; normal -

-Sensory; glove -sensory .loss at both hand and wrists (sharp to- dullI from

-. proximal to distal)

.~.

palpate lhickened peripheral nerves :. !~ ~ ~UJ&-I.... Svl----.I--t -.l-wk.- ~ ~J"!-'"'tIt- ct'- !-v{~~) " 'i)A-.D RUM

Sunmru¥y: . .

-Bilateral symmetrical motor weakness, more distal than proximal

-Bilateral symmetrical sensory loss~ glove distribution- (distal glove and_ -

stockillg sensory ~ss.to all nwdizJities) 'JI i...... _ ~ ~i,.kt... ~- ~tV'J~.",--

(..pejler£s~ tfWvt- s: ~d ~ 6,J,.w-, , ~t... -n..- €J- ~ <D

k~11-t... ~.........,.; . .........:.- ~ ",-",.....td. t..;!....-<- +co de. .ft....L. ,bu.o.""""'j ~ u..,.......~ ~"",,--.k..- ~

Dx. _ . _ '_ _. "T~ ?-v: c.J....-v·o =~. /..

Perip~till Neutopatlw (these 3 signs' mentioned above are the keys). ~ is ....

. ~J. - . - O<.~~_

Hx. taken .

-Progressive (usually 3-4 iiitli§) and symmetrical numberness - in the hands and

feet which spreads proximally in a glove and stocking distribution. -

-distal weakness - . .

- Triggors: (see 250 eases and elin exam for details). Most important is DAD

RUM and viral infections -

T~o llnportant diSeases.causing peripheral neuropathy Guillain-Barre Syndrom rGBS) (see note for detail) -aCute/chronic

-most important .clinical signs; start in the lower limber, reflexes absent

-progressive respiratory muscle paralysis

-Dx: cfinicallCSF~ increased proteinIN conduction study

-Tx: don't using steroids .

DM

-.~ ~ - ~ - - - - -- _. -_.- ---.:---- -, - "-- - - --~~ - - ~ .. -- .. --- - _. -. - ~ ~ ,.

_z.5"O~.

Parkinson~, '

-Dr Henry'Ma & Dr Hiillman's (two- 63sesj'" Cpt edcation is very good for this

topiejP94 - . .

, .

Case: A 70 y.o. man brought on your GP by his wife, complaining of slowness and

. tremor, - - -

Task (i) HX.(ii) examination (iii) Management, (iv) counseling

Hx

Hope (, lt~!) . '

-Presenting symptoms 'start a yr ago, gradually worse, previously healthy

-slowness: took a lot of time doing things, pt told always slow of dQing things

-tremor: hand shaky' more on the' right hand, always there but improved by -

Using hand. '.' - .'

-How bad the Pes: ask: how much does it affect daily life

Associated(eatures L 'bt-1M.~S)· - - _ _

· -not interested in doing anythings (indicated d@ressiop.)

:-MemoIY: pt told forget to pay pills; lunch.with daughter, key left in doors, etc

-others: sp~ falls .

PasfHx:

Medications: antipsychotic drogs are causes Social Hx

Fhx

Allergy

.Dx

tiaid: J!Iemor + rIgidity + brad.ykiri~sia = Parkinson diseas3

. -Parkinsoaism

· _Tt'I"lt-i"l", <nrctPTt1 ",h-nnhv -

... t...I...,U.oI;,:I .......... !".&V ""JillJwa .... .I. u.'W. ...... y~J

-euperenucleer palsy

-DOB: diffuse Iewy body-disease?

Complications .

· -Depression is the most commonest ' ~Falls

-Dementia later stage

Exam (also see elin-'Exam P360)

- Gait (always stand with pt to protect against falling over)

- .-Hardly raisingfrom the chair - . -

-slow to start walking

. -shortened stride

- -rapid, small steps, tendency tQ running (festination)

: -reduced arm swing '. ." . -

-impaired balance on turning

-hard to stop

Face

-mask-face

-drooling of saliva

-glabellartap

- -speech: monotoryous, soft and f~t _ _

-weakness of upward gaze: Ddx: supranuclear palsy-both loss of upward and

-downward gaze (loss of verticalgaze).

-feel the brow for greasiness

-echolalar, repeat speech •

Hand

-pill-rolling

-rest tremore (Differentiate purely essentiai tremot)

-cog-wheel rigidity' .. _

-writing-micrographia (small" writing)

_ Postural hypotension- + Pupil size

: Management

Side effect of treatment-

Visual hallucinations, How are Y9U going to manage it? '.

15t to exclude the reversible causes. like infections, medication, alcohol. etc, Add antipsychotic medications (the new one has Jess side effect)

After a while a/treatment (3-5 yrs), fluctuation "on-off phenomenon" or "peak dose

phenomenon ,,-. .

_ Small but more frequent dose

Also ask family members to have a movement diary

Counselling

Dr Hillman's case: Daughter brought on his father on your GP, father have Parkinson

- arid early stage dementia .' . -

What is It?

Neurological degenerative disease _ of brain. Caused by a lack of a special chemical in the' cells of brain called dopamine.ibecause these cells are not functionally properly •. leading to. the various body movement are impired, like slow of movement.

. - .

It. usually occur in the elderly or later middle age. It is progressively, we do not know Why it happened, but it can be caused by some drugs and toxic fumes.

W1foI is the treotment?

Self-help: caring family and other friends, particulllary.for falls prevention.

. -No .drugs. will cure the problem.. .' But there are modem drugs that can do

much to relieve the symptoms, particulary stiffness and .poor mobility, We. can give . you father the dopmine producing drugs which can improve the. symptoms. -

W1tot is'the. side effed of drug treatment

. .

. . . Side effa:t.in the body. include nausea and 'vomiting, we ~ pr~ ~~u another <lrng:' ~qf carbidopatorovercome the pto&rems. The drugs alSo. ~!W~ postural '"-",. -~'p.gteP.sjor and cardic problems, so we need to do BeG to do the follow-up chec.k"'-'- -

'U~; -,» - -.,

- This is Frogr~s,v~ disease, need. long term monitoring .

~> : ;l .~.~_. . -

: Whf!t ~,-~~,~~ fir CfJHtp/fcations?' . ' . - - .

- ". ::~ Oi~ase' is not 'life-threatening because it does not affect nerves- that

s.upply th611eart or.other vital·organs.. - - -'

. -falls, thus home care. is very important

~Depr~onfficonunon.

-in future, p~ is more and more depdent, memory could be.imp~ l~.Jo. _ dementia,

What is the outCome?

- -follow-up to CheCk up your father

-as it is progessive disease.drugs don't change 1he-C9:t¥se - .

· -. -life expectancy may decreased. Howver, it's ~'~low progressive, amny. people may have normal life expectancy,

Neurologi~ ~ (~l",~pl~ SfIeroslS) . . . '.

. ~als~.·s~GP303,.oxford.E3.&..4" Devitt elf Problem P318 (very good)

!_r ... _

Peter, a 35,..yr~to..S·ee GP, presented.with 2=days histOry...oJ4rroblem

with·w~ . _.. . '-. . . -

""'ask:~:foousea'bistory, perform physical examination. investigation; make

i .-._ .- ', ~is and management, - . - .-

'. ~ r. __ _. ~ . :; ~ ~.-

" SummariSed-history:-

,.P.~r, a35-yr,-9ld electrician" previously healthy with no-any past history, presented

- $1th ~.:day history of subacute bilateral and asymmetrical leg weakness With impaired

. "inetor arid sensory symptoms. No upper limbs abnormalities were found.. .

, .

:5 .

. '

Physical examiitations Neurological findings

-upper limbs: normal _ ._

. -Lower limbs: Tone increased in hath sides, Reflexes: anklejerk reflexes loss in both sides, knee jerk = presented (TIO damaged),

Where is the lesion cause this problem?' -

--spinal cord at 'Ii 0 level (not brain, not neck)

-MRJ Is 1he best to find the site of leis ion-

Whv YOU want to order Mri inimediately? (aimed at looking for the reasgn)

. -artery malformation (cause bleeding - -, - . . .-

-releive the compression

-tumour .

. . -disc prolapse _ _

. -. , The most impartanris taruie: 0111 the acUte l~al9fnwress_iffit (fmergency)

. _ . . .-_ .~_ 1... . _ _'

Dr Henry Ma said MRI showed 5 white spots leisionsin the Brain and suspect this is-

due to MS. -

Dirum.osis ofMS .

-Clinical history and 'MRI .

AS MS is a disease charterized by-plaques of demyelination scattered throughout the

- centralnervous System and "dis~eitiinated in tiOle and space" (m.eaos mutiple). -Thus_ the diagnosis is mainly based on clinical history and MRI findings: -

- . Jf'the MRI show mutie1e 'lesiOns (multiple white plari;es) in the brain'and-the'clinical historyshow.a few clinical events occurrtngd/l.ringa periodQ.{time, then the .

diagnosis is likely. -'

. .

What other investigations you need to do? ,:

, c'. -CSF: showed mononuclear eells' arid oligo clonal proteins (IgO)

-Serum IgG proteins: increased put can be normal

-Evoked visual response testing

Types of MS (see'a figure of my ~Qte book)

'.

"

-Relapsing and remitting MS ..

:-2ud.primary SPMS: tend to be in old age .and.in men' -Primary progressive MS .

Clinical featur~ -Opti c neuritis

. .

. -Ataxia .

'. .-braiD: stem Ieision: Internuclear opthalmoplegia (INO). ~F leision (see' . .

figure in note). nystagmus .' .

-Fatigure. .

-Vertigo: this is rare" most presented With dizziness . and ataxia

-depression

Management". . .

(1) 8teriods: initial short period tratment for 3'-5 days. Recovery quickly but does '. .n6t alter the degree of recovery or the long term prognosis.' . .. .' . . (2) In!erferon: thisis indicated for esyahlished relapsing and remitting MS. This

ahs been shown to reduce the rate of relapse by- 300/0, MRIalso showed to

- reduce the severity and number of leisions on -MRI, but does 'not to reduce the . -

disability, Injection once a week. . .

Side effect: de.pr~~ffiH f!Il4 lP-yroid:. Check thyroid function.re~arly

\?} q~~ -s~ GP or OXford, Devitt '.

\~) chemotherapy . ". . . . ....

. i

,

.. \.

all

2006 MAY 20 Sydney-'

Case-10 (lateral-Medullary .SYr) 'Wo<"\LQr)~:J 'i. ~'.

. . ~

A 50 yr lady got . severs dizziness whil~-,eating in th~ moring.

'Vl?mited.1 time. Now she is feeling fine unless .sne moves herself a lot, but _ having numbness. of ,left face and RT side the body, .

She has hyper-tension'and hypercholesterolemia and on medication.

- . - .

History

1. roUtine' question

2. 'severe nausea vomiting 1 ~~ vu..+f~- ~< ;""':"'Vl~

3. nystagmus, dizziness J '"

4. lirobataXia, .---4 .,''1:...--.f.~ ~~1'Lv---r' ~..",......d,-t..'.

5. intractable hiccups :~ .Ii., .f1.,.... ._ • -

'6. dysphagia - J :" It:' : c..» - l"V'OL~

7~ painorte.mperature sensory loss

......

examination

1·· n¥~tag~us. '. -.' ~~~~ ~ ~. ",'-' .

. -2, IOsllat~~~'!ry?:!y~~ent of D:;D,od. cranial ne~e '- - ,

3. - bulbar palsy: Impaired gag, sluggish palatal movenmnet(D, D)

4)f-honner's syndro~e(ipsitateral), .

others

S. cerebellar signs on the same side

. 6. palnandternperature sensory loss on the opposite side, 7. contralateral hemiplegia(upper motor neurone) -

- main feafures: 4 qrJd 6

.' - . r I .~.' ~t g. A~;_. ~0t'1. •

_~~~t.o..,~ ~Is. .~~~....-.. 4 .~d ~ ... <f--~_ .' 'J

dia-gnosis fatelCJ'l medulla'ry syndrome - .

~he:e isthe lesion . , . . ,

the syndrome results from infarction of a. wedge-s:haPe<ii area of the lateral' aspect Of .the medulla. and infe~or surface _ of ~e-! cerep~!!l;:Jfl1" The deficit .are cause by involvement of one sideofthe nucleus ain6Igum$7"'trlgeminal nucleus, ves~bular - nudel; :cerebefl~r .peduncle.' 'sPi~6thalamic . tract and' autonomic fibres.

Which vessel Is occluded

Any of the 'f~lIowi~9 five \;~ssles: _

1 .. posterior inferior cerebellar artery' 2. ,Vertebral artery

3 ... superior lateral medullary arteries 4, middle lateral medullary 'arteries 5. _ inferior lateral med~Jlary arteries

.. ColYW"'--Vn ~_Oo"\ or- ~~e.v;,t:-.

- ~J..:l'~ Ovcw..1- ~ ~'c)o) C0 , ~ lo..k-v-.x..Q '. ~,;" • L.on~ \.e..u- 0-+"- r'Y!- .t..

~c>..-,.

, - .

Management

1. admit to a stroke' unit

2. oxygen

3. cardiac, monitor _ -

4. pulse oximeter

5. nil orally _ .

6. if unconscious: NGT , endotracheal intubation,

7. IV fluid; eiectrolyte and nutritlonal support

8. investigation

send blood for: FBe UIE BGL LFT

Coagulation

ESR

. Chest X-ray ECG

Car9tid and vertebrobasjtar Doppler U/S

. Hr{l,nl Qt or MRI

9. give 59,",1 of ~~%.dextrose ifglucostix·is low

·1 o. ~tmf"rt~, tn~ ~l~~,r"j J ':::." •

11. rtffr. ~. m~ . m,glotl tt.m for further management

.... ~ • .J •

. ... _. : ~'; ~! ; 1 !: !!" 11 n:' T; . :

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q)

Epilepsy ~(DrHenry Ma) :

, :.-- - -see GP ,250cases~240,_Devit1Jl'

. .

Epidemiology

3-S' in 100

. . . .

Case: A 23 y.o man brought on your clinic- (GP seting) by his motlrerwith 0IIe"

episode of seizure, and Joss of consciousness at home. - .

Task: (1) Hx, (2) exam, (3) dx (4) management and counsellinig

..

Hx taken (250 cases book is good)

Keys: (i} aura -_and trigger factors (2) events-eye Witness describtion is' very - important, and (3) post-ictal symptoms (4) type of seizures

HOPC

Slagel-onset (triggers & aura) (GP1275)

. -askthe pt about the triggering factors, includes: . -excess alcohol

-stress

-lack of sleep: ask did you go to night club?

-Infections

-Fatigure

-physical exhaustion

-photosensitive: watch TV. play g.ime" .

in this Case, pi compIained tlUIt Ore seizure occurred when. he watched TV.. '" TV induced seizure almost are generalized epilepsy (oxfordP378)

-drug associated: clozipine?

-Aura (ask pt about the aura)

-abnormal feeling

-visual hallucination

_ -lip_/finger tipping

_ Siage 2 - event

-ask pt the following questions .

. -did you have a convulsion/or blackout

-Did you bit your tongue? .

_ -Did you have any iIicontinentfor lost control ofume during attack?· -Isthis the ll1t time seizure (recurrent)?

-fisk eye-witness (criticaI important):

-descrihtion of the seizure: eye shut/or open: epilepsy usually eye open

-trothing at the mouth .

-rmconcious/or incontinent "

-how long the whole "episode" lastedrcan ask mother what "was TV

show at thattime? Or ask clock time?

-how long she was unconscious after the attack?

Stage 3 - jJost-idal feotures .' . .

-Ask pt : did you feel your arm stiff (tonic-clonic)? .

-Ask the pt or mother the regaining conscious or confusion after event, Ask:

Did you try to speak to your sop? How long back: to noimal?

"_:...-"

They are often confusedafterwards

.ksociated symptoms (aimed for DDX}-nulinlJ,.,Jiffentiate- sjnu:ope (paul's irote) -ask the pt about sycopal related cardiovascular ' symptoms, like dizzinessllightheadednesslsweaty/nau.seaJvomitingi

-ask wether pt had fever/hypogilycacimealDWI1A/compmised migirane

A.u,U....k1'\jf) .

Past Hx (GP1272) MwL..o t .

(focused.on ~ causes esp. the seizure presented for the iit time after age 25) -trauma; head injmy _ / H 'Cj'L - Q,~....t.lM-

-Brain infections: ask did you have any sick in hospital previously?

-fibril convu1sions/meningitis!

-brain tumors + structural abnormalities

-metabolic disease

-certain medications

Fhx

-very important Mediazt10ns

-ask certain drugs SocJaJHx'

- -University student

, -living condition: ask: did you cook at home? -sports activity

-drugs/smoke/alcohol

Allergy

DX

-generalised tonic-clonic seizure

Summary: pt is triggred by TV watching, the muscles (arm and legs) suddenly stiffen . and become unconscious, the pt falling down en the ground, muscles jerking follows .. . ' - The pt bite heS" tongue and become incontinent, pt goes confused afterwards,

,-

Type of epilepsy

. -generlised/partial

-simple/complexed

-padeatric seizure (usually poor school performance)

Investigations

-serum ca and electrolytes

-fasting glucose '

-LFTs:. baseline LFTs is very important,

-BEG: when.to pick up? As soon as possible <24 hrs, still can pick up 30%

-MRI. better than CT: a lot of things you_can pick up fromMRI not Ct

Mana'gement (GP is very good)

Whatis it? (better health & Pt ed) .

Epilepsy is a condition in which a person has a tendency to have recurrent seizures. The brain controls the body's actions. sensations and emotions through nerve cells that carry messages between the brain and the body. These brain -cells-

. .

communicate each other at- a proper .level through the electricity discharge. In _ epilepsy .. there is a fault in the "electrical" discharge of the ~lls. resulting in the brain being' unable. to work properly for a' brief period-the various symptoms depend on

what part of the brain is affected. -

- In your case, it is called generilised seizure, whole of brain is affected (iffocal -

- say that due to frontal area). We don't know what happened but medications can-

(educe the seiZures.' "

. - Some genetic problem like running infamily has been reported, .

PI 0: wu: I have another one?

. ...... 40% if untreated in _ 3 yrs, If you have another - one, then the diagnosis of -

epilepsy is likely. At present, you are at low risk group, however, we have to follow

you yp- for 2 yrs to see what happened, .

What is the principle and mx 0/ epilepsy?(GP)

- . -Individualization (vary 'from patient to patient) .

. -the basic aim is to prevent seizurerecurrence and minimize adverse effect .

-the choice of drugs depends on the seizUre type' _

-Generalised: sodium valproate, 500 mg daily for 7~ then bd, _

-partial (focal): carbamazepine .

. phenytoin is the not the first Choice now

. .

Side effects of the drugs (GP) -loss of concentration

_-Vltg$ :. -nausea/vomiting

-liver toxicity' .

-cerebreal problem; ataxia, visual disturbance.

LFTs should be performed every 2 mths .

HaW to monitor?

-check blood drug level, only for interaction and compliance purpose

What about well-controlled, high level but no side effect? the serum drug level . doesn'tcorrelate well with the side effect

Drug interattons

-IQ. female: - . _

-barrier contraception is the best, (interact QCf) .

-planed pregnancyistablize the pt before pregnancy

-In old person and stroke pt . '.

-can affect warfarin

. -also interact an1obiQt:iQs

. Tlre.outcome .

Not Cured, hopefully reduce the chance of recurrency, if it happened, start new medications ~ less side effect (see GP for new drugs)

What about driving?

- -depend on risk profile and alscindiviulization

-ar least 2 yis for commecial drivers

-tell pt that continu monitoring for a period of time and then determine if ok for drive

Swimming

-after stabilizing and no more seizures, can go for

Home advice

-take shower Dot bathal, large room area,

-turn the cold water first for shower (not the hot)

-good sIeeo

-alcohol: maxium 1 drink/d. advice stop drinking

heizure diary: record onset/how long/what happened/frequency v-bracelet

Establish good relationship with pt -onging assessment

I am the mother what I need to do? -don't move the person

-don't force anything into the person's mouth

-don't try to stop the fit

-lay the pt on his/her side

-call for ambulance if seizure >5 minutes

Epilepsy fundation

lor

Acute DeBriuu,J

. , .,:

#9 20.05.06 Sydney

Ayoung man got 20% partial thickness bum on both forearms bas been in hospital for 36 hrs, Last night. he was restless, unable to sleep whole night, and said bearing things. He is on morphine infusion lmglhr.

TASK: Take a history

Mental state examination

Tell the examiner how YOll will manage the pt

E

Can you tell me why you can not sleep? (hIe be bad bad dream of the fire and pain)

How bad is you pain?

Can you describe from 1 to 10? Is it constantly pain?

Did you have trouble to fall sleep or you woke up in the morning?

Since the fire happened, have you been troubled by the bad memories of it? Have you been having nightmare?

Have you had trouble with your memory? Are yon jumpy?

Do you feel down/loss interest/less concentrated on things! loss appetite? Do you have any thought to harm yourself? Any plan?

Do you hear any voice, when no one is around? What does the voice say?

Do you see any thing when other people can not see? Do you think any one can read your mind?

r

t

Do you know where you are now? Do you what the day is today?

Do you why you are here now?

Do you ever on any street drugs/ alcohol! smoke?

How much do you spend on the drug! how much do you drink everydayl bow much do you smoke everyday?

How is your general health? Are you on any medication? Are you allergy to anything?

Appearance: dressfbebaviourl movement Speech: tone! volumnl speed

Mood: agitate/ depressed

.Perception: hallucination-auditory! vision! tactile! gustatory! olfactory Inside! Judgment

m Blood: FBE UIE LFT Glu TIT Vit B 12 and Folate Blood culture Oximetry Arterial blood gas

MSU

CXR

EeG

CT head scan

Non-Pha.nnacological

• Nurse pt in the quiet room.

• Frequent prompts concerning orientation and communication

• VIsitors of close relatives encouraged

• Vital signs must be monitored carefully

Phannacological:

• Oxygen

• Set up wide bore iv line and correct electrolyte and dehydration

• Increase Morphine dose and antibiotics

• Use Diazepan for the short period time (one or two days), if still insomnia

• Wound dressing

• Escharotomy if necessary

(

--

J~

Heart Murmur ;,::.

06.06 MelboJme Resit

A man has been found to have a heart murmur previously, now has come to have a chick up before the holidays.

Task: Do cardiovascular examination (do not to do abdominal and leg examination)

Management

I would like to ask a few questions before examination, as I would like to check your heart function.

How is your general health? Can you walk up stairs?

How many levels can walk? How bus stops can you walk? Can you lye flat on the bed? Do you have S.0.8?

Physical Examination

Management:

( '.

Mitral Regurgitation Aortic Stenosis
Causes Chronlc- Degenerative senile calcific
DegenerationlRheumatic aortic stenosis
Mitral valve prolapse Rheumatic
Papillary-muscle-dysfunction calcific bicuspid valve
Connective-tissue-disease:
RAlankylosing ~E.0ndylitis
Congenital:
endocardial-cushion-defect (ASO)
Acute-
Infective endocarditis! MV Surgery
!Trauma
Clinical Enlarged LV Plateau pulse
Pulmonary HT Aortic thrill-important sigh of
sever stenosis
S3t Pansystolic Munnur#1 Length, harshness and
lateness systolic murmur
Early diastolic rumble 84
Smail-volume pulse LVF
LVF Radiate to carotid artery
Radiate to axillary
Ix-ECG P mitraJet AFI Right axis deviation Left ventricular - SystoliC
,
Left venbicular .. diastolic overload overloSd ) (J Lj

CXR Large L atrium and ventricular L Ventricular hypertrophy
Mitral annular calcification Valve calcification
Pulmonary HT (Rare)
ECHO Thickened leaflets - Rheumatic Doppler: Gradient
Prolapsing leaflet Valve cusp mobility
L. Atrial size L. Ventricular hypertrophy
L. Ventricular size and function L. Ventricular dysfunction
Doppler. Regurgitant jet! jet size and
flow in pulmonary vein
Others:ASD
Calcification of Mitral annulus - Old
pt
Surgery Chronic: Class III or rv Exertional angina
L ventricular dysfunction Exertionaldyspnoea
progressively
Acute: Hemodynamic collapse Exertional Sycope (urgent)
Sever L. ventricular
hypertrophy
Valve Normal: 1.5-2.0 x 1.5-2.0 em
area:
Sig. Stenosis: <1x1em
CriticaJ: <0.7xO. 7cmOr
gradient> 70mmHg Hypertrophic Cardiomyopathy (HOCM) - AD

e variable myocardial hypertrophy, most common - interventricular septum cardiac myocytes and myofibrils

• 25% L. ventricular outflow tract obstruction - pansystolic murmur

Sympto.m: Chest paint dyspnoea! syncopel pre-syncope, cardiac arrthymia and sudden death.

PE:

• Pulse: typical sharp, rising and jerky, owing to rapid ejection by a hypertrophied ventricle earty contraction

• Double apical pulse, owing presystolic ventricular expansion + atrial

contraction

• Pansystolie murmur and ejection

• JVP: Prominent a wave, owing to forceful atrial contraction

• Aus: Late systolic ejection murmur (L. sternal edge) Pansystolic murmur/ 84

• Ix: CXR ECG ECHO Exercise ECG

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