Professional Documents
Culture Documents
Table of Contents
SHORT CASES IN MEDICINE ............................................................................................................................................................ 5
MEDICINE = CARDIO SHORTS................................................................................................................................................................................ 5
MEDICINE = RESPI SHORTS ................................................................................................................................................................................... 9
MEDICINE = RENAL SHORTS ...............................................................................................................................................................................14
MEDICINE = ENDOCRINE SHORTS ......................................................................................................................................................................15
MEDICINE = HANDS SHORTS...............................................................................................................................................................................16
ENDOCRINE ........................................................................................................................................................................................ 17
MEDICINE (THYROID) = PHYSICAL EXAMINATION.........................................................................................................................................17
MEDICINE (THYROID) = INTRODUCTION .........................................................................................................................................................20
MEDICINE (THYROID) = THYROID LUMPS .......................................................................................................................................................23
MEDICINE (THYROID) = MANAGEMENT OF HYPERTHYROIDISM .................................................................................................................23
SURGERY (THYROID) = HYPERTHYROIDISM ....................................................................................................................................................26
MEDICINE (THYROID) = HYPOTHYROIDISM ....................................................................................................................................................30
SURGICAL (THYROID) = THYROID CARCINOMA ..............................................................................................................................................33
SURGICAL (THYROID) = THYROIDECTOMY ......................................................................................................................................................36
RHEUMATOLOGY ............................................................................................................................................................................. 38
MEDICINE (RHEUMATOLOGY) = RHEUMATOID ARTHRITIS SONG ...............................................................................................................38
MEDICINE (RHEUMATOLOGY) = GENERAL POINTS ABOUT ARTHRITIS .......................................................................................................39
MEDICINE (RHEUMATOLOGY) = SYSTEMIC LUPUS ERYTHEMATOSUS (SLE).............................................................................................40
MEDICINE (RHEUMATOLOGY) = GALS SCREEN ..............................................................................................................................................46
MEDICINE (RHEUMATOLOGY) = RHEUMATOID ARTHRITIS ..........................................................................................................................48
MEDICINE (RHEUMATOLOGY) = EXAMINATION OF RHEUMATOID HANDS .................................................................................................56
MEDICINE (RHEUMATOLOGY) = CASE STUDY .................................................................................................................................................59
MEDICINE (RHEUMATOLOGY) = CLERKING OF RHEUMATOID ARTHRITIS .................................................................................................62
MEDICINE (RHEUMATOLOGY) = SCLERODERMA LONG CASE .......................................................................................................................63
MEDICINE (RHEUMATOLOGY) = GOUT .............................................................................................................................................................66
MEDICINE (RHEUMATOLOGY) = GOUT HISTORY TAKING .............................................................................................................................68
MEDICINE (RHEUMATOLOGY) = CHRONIC TOPHACEOUS GOUT (SHORT CASE) .........................................................................................71
DIABETES ............................................................................................................................................................................................ 72
MEDICINE (DIABETES) = HISTORY TAKING .....................................................................................................................................................72
MEDICINE (DIABETES) = DIETARY ADVICE .....................................................................................................................................................74
MEDICINE (DIABETES) = COUNSELING A NEWLY DIAGNOSED DIABETIC ....................................................................................................75
MEDICINE (DIABETES) = DIABETES MANIFESTATIONS ................................................................................................................................76
MEDICINE (DIABETES) = DIABETES MELLITUS ..............................................................................................................................................77
MEDICINE (DIABETES) = HYPOGLYCEMIA .......................................................................................................................................................79
MEDICINE (DIABETES) = DIAGNOSIS OF DM ..................................................................................................................................................81
RENAL MEDICINE ............................................................................................................................................................................. 83
MEDICINE (RENAL) = NEPHROTIC SYNDROME HISTORY TAKING...............................................................................................................83
MEDICINE (RENAL) = NEPHROTIC SYNDROME ...............................................................................................................................................85
MEDICINE (RENAL) = SECONDARY HYPERTENSION ......................................................................................................................................89
MEDICINE (RENAL) = DIALYSIS MODALITIES ..................................................................................................................................................90
MEDICINE (RENAL) = RENAL TRANSPLANT (MAJOR RISKS) .......................................................................................................................92
MEDICINE (RENAL) = ADULT POLYCYSTIC KIDNEY DISEASE (APKD) ......................................................................................................92
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MEDICINE (RENAL) = URINARY TRACT INFECTION / PYELONEPHRITIS ....................................................................................................94
MEDICINE (RENAL) = ASSESSING VOLUME STATUS .......................................................................................................................................96
MEDICINE (RENAL) = FLUID AND ELECTROLYTES (ACID- BASE DISORDERS) ...........................................................................................98
MEDICINE (RENAL) = RESPIRATORY DISORDERS........................................................................................................................................ 102
MEDICINE (RENAL) = RENAL TUBULAR ACIDOSIS (RTA) ........................................................................................................................ 103
MEDICINE (RENAL) = POTASSIUM DISORDERS ............................................................................................................................................ 105
MEDICINE (RENAL) = HYPONATRAEMIA ...................................................................................................................................................... 108
MEDICINE (RENAL) = HYPERNATRAEMIA .................................................................................................................................................... 111
GASTROLOGY .................................................................................................................................................................................. 113
MEDICINE (GIT) = HISTORY TAKING: GIT (GENERAL) ............................................................................................................................. 113
MEDICINE (GIT) = PHYSICAL EXAMINATION: GIT ...................................................................................................................................... 115
MEDICINE (GIT) = ISSUES FOR DISCUSSION ................................................................................................................................................. 119
MEDICINE (GIT) = APPROACH TO ASCITES .................................................................................................................................................. 122
MEDICINE (GIT) = ASCITES............................................................................................................................................................................. 124
MEDICINE (GIT) = CHRONIC LIVER DISEASE AND LIVER CIRRHOSIS ........................................................................................................ 128
MEDICINE (GIT) = HEPATOMEGALY.............................................................................................................................................................. 132
MEDICINE (GIT) = JAUNDICE (HISTORY-TAKING) ....................................................................................................................................... 135
MEDICINE (GIT) = APPROACH TO JAUNDICE ............................................................................................................................................... 137
MEDICINE (GIT) = ACUTE HEPATITIS ........................................................................................................................................................... 143
MEDICINE (GIT) = VIRAL HEPATITIS ............................................................................................................................................................ 144
MEDICINE (GIT) = ALCOHOLIC LIVER DISEASE........................................................................................................................................... 152
MEDICINE (GIT) = AUTOIMMUNE HEPATITIS.............................................................................................................................................. 153
MEDICINE (GIT) = METABOLIC LIVER DISEASE .......................................................................................................................................... 154
MEDICINE (GIT) = WILSON’S DISEASE (HEPATOLENTICULAR DISORDER) ............................................................................................ 156
SURGERY (GIT) = OBSTRUCTIVE JAUNDICE .................................................................................................................................................. 158
MEDICINE (GIT) = LIVER FAILURE ................................................................................................................................................................ 163
MEDICINE (GIT) = PORTAL HYPERTENSION ................................................................................................................................................ 165
MEDICINE (GIT) = CHRONIC DIARRHEA ....................................................................................................................................................... 167
MEDICINE (GIT) = INFLAMMATORY BOWEL DISEASE ............................................................................................................................... 171
REPIRATORY MEDICINE ............................................................................................................................................................. 179
MEDICINE (RESPI) = HISTORY TAKING: RESPIRATORY SYSTEM (GENERAL) ........................................................................................ 179
MEDICINE (RESPI) = PHYSICAL EXAMINATION: RESPIRATORY SYSTEM ................................................................................................. 182
MEDICINE (RESPI) = HAEMOPTYSIS .............................................................................................................................................................. 188
MEDICINE (RESPI) = DYSPNOEA..................................................................................................................................................................... 189
MEDICINE (RESPI) = APPROACH TO CHEST PAIN AND DYSPNEA ............................................................................................................. 191
MEDICINE (RESPI) = PULMONARY FIBROSIS ................................................................................................................................................ 193
MEDICINE (RESPI) = COPD ............................................................................................................................................................................ 194
MEDICINE (RESPI) = BRONCHIECTASIS ......................................................................................................................................................... 199
MEDICINE (RESPI) = COR PULMONALE ......................................................................................................................................................... 203
MEDICINE (RESPI) = RESPIRATORY INFECTIONS: TUBERCULOSIS ........................................................................................................... 205
MEDICINE (RESPI) = PANCOAST TUMOUR-UPPER LOBE LUNG CA........................................................................................................... 211
MEDICINE (RESPI) = PLEURAL EFFUSION..................................................................................................................................................... 212
MEDICINE (RESPI) =PNEUMOTHORAX .......................................................................................................................................................... 216
MEDICINE (RESPI) = RESPIRATORY FAILURE .............................................................................................................................................. 220
MEDICINE (RESPI) = SYSTEMIC APPROACH TO CXR ................................................................................................................................... 222
MEDICINE (RESPI) = MEDIASTINAL MASSES ................................................................................................................................................ 223
CARDIO VASCULAR SYSTEM ...................................................................................................................................................... 224
MEDICINE (CVS) = HISTORY TAKING: CVS.................................................................................................................................................. 224
MEDICINE (CVS) = PHYSICAL EXAMINATION: CVS .................................................................................................................................... 227
MEDICINE (CVS) = ISSUES FOR DISCUSSION ................................................................................................................................................. 231
MEDICINE (CVS) = APPROACH TO CHEST PAIN ........................................................................................................................................... 236
MEDICINE (CVS) = HO ON CALL..................................................................................................................................................................... 240
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MEDICINE (CVS) = ISCHAEMIC HEART DISEASE (HISTORY) .................................................................................................................... 242
MEDICINE (CVS) = ANGINA PECTORIS .......................................................................................................................................................... 244
MEDICINE (CVS) = ISCHAEMIC HEART DISEASE (HISTORY) .................................................................................................................... 248
MEDICINE (CVS) = ACUTE CORONARY SYNDROME (ACS) ....................................................................................................................... 250
MEDICINE (CVS) = CONGESTIVE CARDIAC FAILURE (CCF) ...................................................................................................................... 257
MEDICINE (CVS) = PATHOPHYSIOLOGY OF DYSPNOEA .............................................................................................................................. 264
MEDICINE (CVS) = PROGNOSTIC FACTORS OF HYPERTENSION ............................................................................................................... 264
MEDICINE (CVS) = HYPERTENSION............................................................................................................................................................... 266
MEDICINE (CVS) = ANTI HYPERTENSIVE MEDICATION ............................................................................................................................. 273
MEDICINE (CVS) = GUIDELINES FOR SELECTING DRUG TREATMENT OF HYPERTENSION .................................................................... 277
MEDICINE (CVS) = LIPIDS ............................................................................................................................................................................... 278
MEDICINE (CVS) = MYOCARDITIS.................................................................................................................................................................. 282
MEDICINE (CVS) = CARDIOMYOPATHY ......................................................................................................................................................... 284
MEDICINE (CVS) = TAKAYASU ARTERITIS ................................................................................................................................................... 286
MEDICINE (CVS) = VALVULAR HEART DISEASE ........................................................................................................................................... 287
MEDICINE (CVS) = VALVULAR HEART DISEASE ........................................................................................................................................... 289
MEDICINE (CVS) = PROSTHETIC HEART VALVES......................................................................................................................................... 294
MEDICINE (CVS) = INFECTIVE ENDOCARTITIS ............................................................................................................................................ 296
PRISCILLA’S MEDICINE ADD-ON .............................................................................................................................................. 300
SURGERY (THYROID) = INVESTIGATIONS ...................................................................................................................................................... 300
SURGERY (THYROID) = SHORT CASES ........................................................................................................................................................... 302
SURGERY (THYROID) = CONGENITAL ANOMALIES....................................................................................................................................... 303
MEDICINE (RHEUMATOLOGY) = APPROACH TO THE RHEUMATOLOGICAL CASE ................................................................................... 304
MEDICINE (RHEUMATOLOGY) = DERMATOMYOSITIS AND POLYMYOSITIS ............................................................................................. 309
MEDICINE (RHEUMATOLOGY) = HISTORY-TAKING ..................................................................................................................................... 313
MEDICINE (RHEUMATOLOGY) = HAND ......................................................................................................................................................... 315
MEDICINE (RHEUMATOLOGY) = HANDS & WRISTS, SHOULDER, C-SPINE, HIP ....................................................................................... 329
MEDICINE (DIABETES) = DIABETIC KETOACIDOSIS (DKA) ...................................................................................................................... 332
MEDICINE (DIABETES) = HYPEROSMOLAR HYPERGLYCAEMIC NON-KETOTIC (HHNK) STATE .......................................................... 336
MEDICINE (DIABETES) = MANAGEMENT OF DIABETES MELLITUS .......................................................................................................... 338
MEDICINE (ENDOCRINE) = CUSHING’S SYNDROME ..................................................................................................................................... 349
MEDICINE (ENDOCRINE) = ACROMEGALY .................................................................................................................................................... 354
MEDICINE (ENDOCRINE) = ADDISON’S DISEASE (CHRONIC 10 ADRENAL INSUFFICIENCY) .................................................................. 358
MEDICINE (ENDOCRINE) = HYPO-PITUITARISM .......................................................................................................................................... 360
MEDICINE (ENDOCRINE) = GYNAECOMASTIA .............................................................................................................................................. 363
MEDICINE (RENAL) = ACUTE RENAL FAILURE ............................................................................................................................................ 364
MEDICINE (RENAL) = CHRONIC RENAL FAILURE ........................................................................................................................................ 368
MEDICINE (RENAL) = CRF WITH FLUID OVERLOAD ................................................................................................................................... 376
MEDICINE (RENAL) = BALLOTABLE KIDNEYS.............................................................................................................................................. 377
MEDICINE (RENAL) = TRANSPLANTED KIDNEY .......................................................................................................................................... 379
MEDICINE (RENAL) = APPROACH TO OLIGURIA ........................................................................................................................................... 383
MEDICINE (RENAL) = APPROACH TO PROTEINURIA ................................................................................................................................... 384
MEDICINE (RENAL) = HAEMATURIA.............................................................................................................................................................. 387
MEDICINE (RENAL) = GLOMERULONEPHRITIS ............................................................................................................................................ 390
MEDICINE (RENAL) = DGIM RENAL TRANSPLANT .................................................................................................................................... 396
MEDICINE (GIT) = HEPATOSPLENOMEGALY ................................................................................................................................................ 398
MEDICINE (RESPI) = GENERAL APPROACH TO A HISTORY OF SHORTNESS OF BREATH....................................................................... 399
MEDICINE (RESPI) = ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS) .......................................................................................... 400
MEDICINE (RESPI) = SYSTEMIC APPROACH TO CXR ................................................................................................................................... 402
MEDICINE (RESPI) = LUNG CANCER .............................................................................................................................................................. 406
MEDICINE (RESPI) = INFECTIONS – TUBERCULOSIS ................................................................................................................................... 411
MEDICINE (RESPI) = PNEUMONIA .................................................................................................................................................................. 416
MEDICINE (RESPI) = ASTHMA ........................................................................................................................................................................ 421
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MEDICINE (RESPI) = PULMONARY EMBOLISM ............................................................................................................................................. 427
Acknowledgements
Written by:
Dr Priscilla Phoon & her team of original authors
Transcribed by:
YLLSOM Class of Medicine 2013
Special Thanks to the following people for helping with the add-on:
Ong Eng Hui
Chew Bao Li
Steffi Chan
Teo Yi Lyn
Lucy Davis
Grace Lum
Last Updated:
20st Febuary 2011
4
Short Cases in Medicine
Medicine = Cardio shorts
On examination of the peripheries, there are no stigmata of infective endocarditis such as clubbing, splinter
haemorrhages, Janeway lesions or Osler nodes. There is no extensive bruising seen over the arms. I looked
for but did not find any evidence of an enlarged goitre or thyroidectomy scar.
On examination of the praecordium, there was a metallic click audible to the unaided ear. A visible apical
impulse was seen in the 6th intercostal space 1cm lateral to the mid-clavicular line. The apex beat was
heaving in nature. There was no parasternal heave or thrills felt over the base of the heart. On auscultation,
the first heart sound was metallic and sharp in nature. The second heart sound was native. There were no
additional heart sounds. In addition, there was a grade 3/6 PSM heard loudest over the apex with radiation
to the axilla.
This was not associated with signs of right heart failure as the jugular venous pressure was not raised and
there was no peripheral oedema. Auscultation of the lung bases also did not reveal the presence of
inspiratory crepitations.
So in summary, Mdm XXX is an elderly chinese lady who has a prosthetic mitral valve replacement. I say this
because
(a) midline sternotomy scar with no corresponding saphenous vein harvest site
(b) metallic click audible to the unaided ear
(c) sharp and metallic first heart sound heard on auscultation
This is not complicated by congestive cardiac failure, infective endocarditis, over-anticoagulation or valve
haemolysis
Mitral stenosis
Mdm XXX is an elderly chinese lady who appears to be alert, well, comfortable and orientated at rest. Her
vitals are as follows = HR 80/min, irregularly irregular. There is no RR delay, RF delay or collapsing pulse. RR is
16/min, not tachypneic or dyspnoeic. She does not appear to be in any respiratory distress and is pink on
room air. On general inspection, there are no signs of pallor, jaundice or cyanosis.
On examination of the peripheries, there are no stigmata of infective endocarditis such as clubbing, splinter
haemorrhages, Janeway lesions or Osler nodes. There is no extensive bruising seen over the arms. I looked
for but did not find any evidence of an enlarged goitre or thyroidectomy scar.
On examination of the praecordium, there were no surgical scars or chest wall deformities. The apex beat
was not displaced. It was in the 5th intercostal space in the mid-clavicular line and was tapping in nature.
There was no parasternal heave or thrills felt over the base of the heart. On auscultation, the first heart
5
sound was loud and there was an opening snap followed by a mid-diastolic murmur heard best over the
apex which was accentuated with the patient in the left lateral position. There was no PSM heard over the
tricuspid area or Graham-Steell murmur heard over the pulmonary area.
This was not associated with signs of right heart failure as the jugular venous pressure was not raised and
there was no peripheral oedema. Auscultation of the lung bases also did not reveal the presence of
inspiratory crepitations.
So in summary, Mdm XXX is an elderly chinese lady who has mitral stenosis. I say this because
(a) presence of atrial fibrillation
(b) tapping apex beat which is not displaced
(c) opening snap with a MDM heard best over the apex and accentuated by the patient lying in the left
lateral position
This is not complicated by pulmonary hypertension, congestive cardiac failure, infective endocarditis or
over-anticoagulation
Mitral regurgitation
Mdm XXX is an elderly chinese lady who appears to be alert, well, comfortable and orientated at rest. Her
vitals are as follows = HR 80/min, regular. There is no RR delay, RF delay or collapsing pulse. RR is 16/min, not
tachypneic or dyspnoeic. She does not appear to be in any respiratory distress and is pink on room air. On
general inspection, there are no signs of pallor, jaundice or cyanosis.
On examination of the peripheries, there are no stigmata of infective endocarditis such as clubbing, splinter
haemorrhages, Janeway lesions or Osler nodes.
On examination of the praecordium, there were no surgical scars or chest wall deformities. The apex beat
was displaced in the 6th intercostal space 1cm lateral to the mid-clavicular line and was heaving in nature.
There was no parasternal heave or thrills felt over the base of the heart. On auscultation, the first and
second heart sounds were heard. There was no 3rd heart sound. In addition, there was a grade 3/6 PSM
heard loudest over the apex with radiation to the axilla. There was no radiation to the carotids.
This was not associated with signs of right heart failure as the jugular venous pressure was not raised and
there was no peripheral oedema. Auscultation of the lung bases also did not reveal the presence of
inspiratory crepitations.
So in summary, Mdm XXX is an elderly chinese lady who has mitral regurgitation. I say this because
(a) displaced apex beat which is heaving in nature
(b) grade 3/6 PSM heard loudest over the apex with radiation to the axilla
Aortic stenosis
Mdm XXX is an elderly chinese lady who appears to be alert, well, comfortable and orientated at rest. Her
vitals are as follows = HR 80/min, regular. There is no RR delay, RF delay or collapsing pulse. However, I note
that the pulse is of low-volume and slow-rising in nature. RR is 16/min, not tachypneic or dyspnoeic. She
does not appear to be in any respiratory distress and is pink on room air. On general inspection, there are
no signs of pallor, jaundice or cyanosis.
On examination of the peripheries, there are no stigmata of infective endocarditis such as clubbing, splinter
haemorrhages, Janeway lesions or Osler nodes.
On examination of the praecordium, there were no surgical scars or chest wall deformities. The apex beat is
6
not displaced and is thrusting in nature. There was no parasternal heave or thrills felt over the base of the
heart. On auscultation, the first and second heart sounds were heard. There was no 4 th heart sound. In
addition, there was a grade 3/6 ESM heard loudest over the aortic area with radiation to the carotids
which was accentuated by forced expiration.
This was not associated with signs of right heart failure as the jugular venous pressure was not raised and
there was no peripheral oedema. Auscultation of the lung bases also did not reveal the presence of
inspiratory crepitations.
So in summary, Mdm XXX is an elderly chinese lady who has aortic stenosis. I say this because
(a) low-volume slow-rising pulse (‘anacrotic pulse’)
(b) apex beat is not displaced and is thrusting in nature
(c) grade 3/6 ESM heard loudest over the aortic area with radiation to the carotids and accentuated by
forced expiration
Aortic regurgitation
Mdm XXX is an elderly chinese lady who appears to be alert, well, comfortable and orientated at rest. Her
vitals are as follows = HR 80/min, regular. There is a collapsing pulse noted but no RR delay or RF delay. RR is
16/min, not tachypneic or dyspnoeic. She does not appear to be in any respiratory distress and is pink on
room air. On general inspection, there are no signs of pallor, jaundice or cyanosis.
On examination of the peripheries, there are no stigmata of infective endocarditis such as clubbing, splinter
haemorrhages, Janeway lesions or Osler nodes.
On examination of the praecordium, there were no surgical scars or chest wall deformities. The apex beat is
displaced in the 6th intercostal 1cm lateral to the mid-clavicular line and is heaving in nature. There was no
parasternal heave or thrills felt over the base of the heart. On auscultation, the first and second heart
sounds were heard. There was no 3rd heart sound. In addition, there was a grade 2/6 EDM heard loudest
over the upper left sternal edge which was accentuated with forced expiration. There was no Austin-Flint
murmur detected.
This was not associated with signs of right heart failure as the jugular venous pressure was not raised and
there was no peripheral oedema. Auscultation of the lung bases also did not reveal the presence of
inspiratory crepitations.
So in summary, Mdm XXX is an elderly chinese lady who has aortic regurgitation. I say this because
(a) collapsing pulse
(b) displaced apex beat which is heaving in nature
(c) grade 2/6 EDM heard loudest over the upper left sternal edge and accentuated by forced expiration
7
Tricuspid regurgitation
Mr XXX is a young chinese gentleman who appears to be alert, well, comfortable and orientated at rest. His
vitals are as follows = HR 80/min, regular. There is no RR delay, RF delay or collapsing pulse. RR is 16/min, not
tachypneic or dyspnoeic. He does not appear to be in any respiratory distress and is pink on room air. On
general inspection, there are no signs of pallor or cyanosis. However, he appears to be jaundiced.
On examination of the peripheries, there are no stigmata of infective endocarditis such as clubbing, splinter
haemorrhages, Janeway lesions or Osler nodes. I did not note the presence of needle tracks in the cubital
fossae.
On examination of the praecordium, there are no surgical scars or chest wall deformities. The apex beat is
not displaced and is normal in nature. There was a parasternal heave detected but no thrills were felt over
the base of the heart. On auscultation, the first and second heart sounds were heard. There was no loud
P2. In addition, there was a grade 3/6 PSM heard loudest over the lower left sternal edge which was
accentuated with forced inspiration. I did not hear a MDM which might be suggestive of mitral stenosis.
This is associated with signs of right heart failure as the jugular venous pressure was raised till the level of the
mid-neck with giant v waves seen. There was also bilateral lower limb pitting oedema till the level of the
knees. However, auscultation of the lung bases also did not reveal the presence of inspiratory crepitations.
So in summary, Mr XXX is a young chinese gentleman who has tricuspid regurgitation. I say this because
(a) jaundiced
(b) parasternal heave but with no other signs of pulmonary hypertension
(c) grade 3/6 PSM heard loudest over the lower left sternal edge and accentuated by forced inspiration
(d) signs of right heart failure with raised JVP, giant v waves and lower limb pitting oedema
8
Medicine = Respi shorts
Bronchiectasis
(after examination) I would like to complete my examination by requesting for the vitals, sputum mug as
well as to examine the patient for a raised JVP and splenomegaly.
Mdm XXX is a middle-aged chinese lady who appears to be alert at rest. Her vitals are as follows: HR 80/min
regular and not bounding. She appears to be in respiratory distress as evidenced by tachypnoea with a RR
of 24/min, on supplemental oxygen via nasal prongs at 2L/min, use of accessory muscles of respiration as
well as the presence of intercostal retractions. However, there is no cyanosis or terminal asterixis. I also note
the presence of intravenous antibiotics hanging by the drip-stand suggesting that there is an underlying
infective process going on. There is also no sputum mug or bronchodilators by the bedside. On general
inspection, she does not appear to be cachexic. There are no signs of pallor or jaundice.
On examination of the peripheries, I note digital clubbing. However, there are no signs of tar stains, wasting
of the intrinsic hand muscles or swelling and pain over the wrist joints. There are no signs suggestive of
Horner’s syndrome. There is no displacement of the trachea or apex beat.
On examination of the chest, there are no surgical scars or chest wall deformities. The main physical
findings on examination are coarse pan-inspiratory crepitations heard throughout the posterior chest which
do not clear with coughing. This is associated with decreased air-entry and chest expansion, resonant
percussion note and a normal vocal resonance.
(infective exacerbation) In addition, there are also signs suggestive of consolidation in the right lower third
of the posterior chest. I say this because there is decreased chest expansion, dullness to percussion,
decreased air-entry with bronchial breath sounds and increased vocal resonance.
There is no cervical lymphadenopathy or signs of pulmonary hypertension. There was no parasternal heave
or palpable P2 detected. I would have liked to examine the neck for a raised JVP but I note that the
patient does not have lower limb oedema.
So in summary, Mdm XXX has features suggestive of an infective exacerbation of bronchiectasis. I say this
because
(a) digital clubbing
(b) coarse pan-inspiratory crepitations that do not clear with coughing
She is currently in respiratory distress but her condition is not complicated by pulmonary hypertension or cor
pulmonale
My differentials are
(a) infective exacerbation of COPD signs of hyperinflation, expiratory rhonchi, prolonged expiratory
phase
(b) pulmonary fibrosis dry cough, steroid toxicity, fine end-inspiratory crepitations
Pleural effusion
(after examination) I would like to complete my examination by requesting for the vitals and sputum mug.
Mr XXX is an elderly chinese gentleman who appears to be alert at rest. His vitals are as follows: HR 80/min,
regular and not bounding, RR 16/min, not tachypneic or dyspnoeic. He does not appear to be in any
respiratory distress and is pink on room air. I do not note the presence of a sputum mug or bronchodilators
by the bedside. On general inspection, he does not appear to be cachexic. There are no signs of pallor,
jaundice or cyanosis.
On examination of the peripheries, there is no evidence of digital clubbing, tar stains, wasting of the intrinsic
hand muscles or pain and swelling over the wrist joints. There are no features suggestive of Horner’s
syndrome. There is also no displacement of the trachea or apex beat.
9
On examination of the chest, I did not note any surgical scars or chest wall deformities. The main physical
findings are that of a right-sided pleural effusion. I say this because there is decreased chest expansion over
the right lower third of the posterior chest associated with stony dull percussion, decreased breath sounds
as well as decreased vocal resonance. There was no cervical lymphadenopathy.
I looked for but did not find any underlying aetiology. In particular, there were no other abnormal chest
findings, hand deformities, characteristic malar rash or stigmata of chronic liver and renal disease. I would
have liked to examine the cardiovascular system in detail but I note that there is no lower limb oedema.
So in summary, Mr XXX is an elderly chinese gentleman who has a right-sided pleural effusion. I say this
because the right lower chest
(a) decreased chest expansion
(b) stony dull percussion note
(c) decreased air entry
(d) decreased vocal resonance
This is likely to be a small effusion as there is no mediastinal displacement. He is currently not in respiratory
distress
Pulmonary fibrosis
(after examination) I would like to complete my examination by requesting for the vitals and sputum mug
as well as to examine the patient for a raised JVP
Mdm XXX is a middle-aged chinese lady who appears to be alert at rest. Her vitals are as follows: HR
80/min, regular and not bounding. She appears to be in respiratory distress as evidenced by tachypnoea
with a RR of 24/min, on supplemental oxygen via nasal prongs at 2L/min, use of accessory muscles of
respiration as well as the presence of intercostal retractions. There is also evidence of central cyanosis.
However, there is no terminal asterixis. On general inspection, she does not appear to be cachexic. There
are no signs of pallor or jaundice.
On examination of the peripheries, I note the presence of digital clubbing. However, there are no tar stains,
wasting of the intrinsic hand muscles or tenderness and swelling over the wrist joints. There are also no signs
suggestive of Horner’s syndrome. The trachea and apex beat are not displaced.
On examination of the chest, there are no surgical scars or chest wall deformities. The main physical
findings are suggestive of bibasal pulmonary fibrosis. I say this because there is dullness to percussion over
the lung bases associated with decreased air-entry and fine end-inspiratory crepitations that do not clear
with coughing. Vocal resonance is normal. There is no cervical lymphadenopathy.
So in summary, Mdm XXX is an elderly chinese lady who has bilateral lower lobe fibrosis. I say this because
of
(a) digital clubbing
(b) bibasal fine end-inspiratory crepitations which do not clear with coughing
She is currently in respiratory distress as evidenced by tachypnoea and central cyanosis. However, her
condition is not complicated by pulmonary hypertension or cor pulmonale.
My differentials are
(a) congestive cardiac failure with pulmonary oedema no clubbing, evidence of fluid overload,
crepitations clear with coughing
(b) bronchiectasis productive cough, coarse pan-inspiratory expiratory crepitations
10
Chronic obstructive pulmonary disease
(after examination) I would like to complete my examination by requesting for the vitals and sputum mug
as well as to examine the patient for liver ptosis and raised JVP
Mr XXX is an elderly chinese gentleman who appears to be alert at rest. His vitals are as follows: HR 80/min,
regular and not bounding. He appears to be in respiratory distress as evidenced by tachypnoea with a RR
of 24/min, on supplemental oxygen via nasal prongs at 2L/min and use of accessory muscles of respiration.
However, he does not appear cyanosed nor is there terminal asterixis. I note the presence of intravenous
antibiotics hanging by the drip-stand suggesting that there is an underlying infective process going on.
However, there is no sputum mug or bronchodilators by the bedside. On general inspection, he does not
appear to be cachexic. There are no signs of pallor or jaundice.
On examination of the peripheries, there is no sign of digital clubbing, tar stains, wasting of the intrinsic
hand muscles or tenderness and swelling over the wrist joints. There are also no signs suggestive of Horner’s
syndrome. The trachea and apex beat are not displaced.
On examination of the chest, there are no surgical scars or chest wall deformities. However, there are signs
of hyperinflation as evidenced by
(a) barrel-shaped chest = increased antero-posterior diameter cg lateral diameter
(b) decreased chest expansion
(c) resonant percussion note
(d) loss of cardiac and liver dullness
(e) decreased air-entry associated with expiratory wheeze and prolonged expiratory phase
(f) decreased vocal resonance
So in summary, Mr XXX is an elderly chinese gentleman who has evidence suggestive of an infective
exacerbation of COPD. I say this because
(a) signs of hyperinflation
(b) decreased air-entry, expiratory wheeze and prolonged expiratory phase
He is currently in respiratory distress but his condition is not complicated by pulmonary hypertension or cor
pulmonale
My differentials are
(a) infective exacerbation of bronchial asthma
(b) infective exacerbation of bronchiectasis clubbing, coarse-inspiratory crepitations
Consolidation
(after examination) I would like to complete my examination by requesting for the vitals and sputum mug
Mr XXX is an elderly chinese gentleman who appears to be alert at rest. His vitals are as follows: HR 80/min,
regular and not bounding, RR 16/min not tachypneic or dyspnoeic. He does not appear to be in any
respiratory distress and is pink on room air. There is an intravenous antibiotic hanging on the drip-stand
suggesting an underlying infective process. On general inspection, Mr XXX does not appear to be
cachexic. There are/are no signs of pallor, cyanosis or jaundice.
On examination of the peripheries, there is no sign of digital clubbing, tar stains, wasting of the intrinsic
hand muscles or tenderness and swelling over the wrist joints. There are also no signs suggestive of Horner’s
syndrome. The trachea and apex beat are not displaced.
On examination of the chest, there are no surgical scars or chest wall deformities. The main physical
findings are in the lower 1/3 of the right posterior chest which is suggestive of consolidation. I say this
11
because there is decreased chest expansion, dullness to percussion, decreased air-entry associated with
coarse pan-inspiratory crepitations, bronchial breathing as well as increased vocal resonance. There is no
cervical lymphadenopathy.
So in summary, Mr XXX is an elderly chinese gentleman who has evidence suggestive of consolidation in
the lower 1/3 of the right posterior chest. I say this because
(a) decreased chest expansion
(b) dullness to percussion
(c) decreased air-entry, coarse pan-inspiratory crepitations, bronchial breathing
(d) increased vocal resonance
He is currently not in respiratory distress.
Collapse
(after examination) I would like to complete my examination by requesting for the vitals and sputum mug
Mr XXX is an elderly chinese gentleman who appears to be alert at rest. His vitals are as follows: HR 80/min,
regular and not bounding, RR 16/min not tachypneic or dyspnoeic. He does not appear to be in any
respiratory distress and is pink on room air. On general inspection, Mr XXX appears to be cachexic. There
are no signs of pallor, cyanosis or jaundice.
On examination of the peripheries, there is no sign of digital clubbing, tar stains, wasting of the intrinsic
hand muscles or tenderness and swelling over the wrist joints. There are also no signs suggestive of Horner’s
syndrome. There is tracheal deviation to the right with no mediastinal displacement.
On examination of the chest, there are no surgical scars or chest wall deformities. The main physical
findings are in the upper 1/3 of the right anterior chest suggestive of an upper lobe collapse. I say this
because of right tracheal deviation, flattening of the right chest wall, decreased chest expansion, dullness
to percussion, decreased air-entry as well as decreased vocal resonance. There is no cervical
lymphadenopathy.
So in summary, Mr XXX is an elderly chinese gentleman who has evidence suggestive of a right upper lobe
collapse. I say this because
(a) right tracheal deviation
(b) flattening of right chest wall
(c) decreased chest expansion
(d) dullness to percussion
(e) decreased air-entry and vocal resonance
He is currently not in respiratory distress.
12
Lung cancer
(after examination) I would like to complete my examination by requesting for the vitals and sputum mug
Mr XXX is an elderly chinese gentleman who appears to be alert at rest. His vitals are as follows: HR 80/min,
regular and not bounding, RR 16/min not tachypneic or dyspnoeic. He does not appear to be in any
respiratory distress and is pink on room air. On general inspection, I note that he is cachexic. There are/are
no signs of pallor or jaundice.
On examination of the peripheries, I note the presence of digital clubbing as well as hypertrophic
pulmonary osteoarthropathy. However, there are no tar stains, wasting of the intrinsic hand muscles or
features suggestive of Horner’s syndrome.
On examination of the chest, there are no surgical scars or chest wall deformities. The main physical
findings are that of a collapse-consolidation over the right upper 1/3 of the posterior chest as well as a
right-sided pleural effusion involving the lower 2/3 of the posterior chest. I say this because
(a) collapse-consolidation
- tracheal deviation to the right
- dull percussion note
- decreased air-entry with no adventitious sounds
- increased vocal resonance
(b) pleural effusion
- decreased chest expansion over the right lower chest
- stony dull percussion note
- decreased air-entry with no adventitious sounds
- decreased vocal resonance
- likely to be moderate in size as the apex beat is slightly displaced in the 6 th intercostal space 1cm lateral
to the mid-clavicular line
In addition, multiple small enlarged cervical lymph nodes were found bilaterally ranging from 1-2 cm in
length. They were non-tender, firm, matted and relatively immobile.
So in summary, Mr XXX has multiple chest findings including a right upper lobe collapse-consolidation as
well as a right-sided pleural effusion. He most likely has a right lung malignancy. This is supported by the
findings of cachexia, pallor, clubbing, HPOA as well as cervical lymphadenopathy.
I would like to examine the patient for hepatomegaly, focal neurological deficits and to percuss the
vertebral column for tenderness.
13
Medicine = Renal shorts
Mr XXX is a young Chinese gentleman who appears to be alert and comfortable. His vitals are as follows =
HR ____, RR ____. On examination, he has bilateral ballotable kidneys most likely due to adult polycystic
kidney disease and is in ESRF on haemodialysis.
(confirm findings) I say this because on examination of the abdomen, I note a distinct fullness over the left
and right flanks. On palpation, there were bilateral ovoid masses measuring ___ cm by ___ cm, non-tender
and firm. I was able to get above the masses and they did not move with respiration. No splenic notch was
felt. The masses were ballotable and a band of resonance was detected on percussion.
(aetiology) I looked for but did not find any hepatosplenomegaly. There was no apparent focal
neurological deficit as Mr XXX was able to move all 4 limbs. However, I would like to confirm this by doing a
detailed neurological examination. In addition, I did not note the presence of diabetic dermopathy.
(complications) Functionally, Mr XXX is in ESRF as evidenced by his sallow appearance and conjunctival
pallor. In addition, I also note the presence of an AVF in the left cubital fossa with a palpable thrill and signs
of recent cannulation. However, Mr XXX does not appear to be uraemic as there are no signs of bruising,
scratch marks or terminal asterixis. He is also not in fluid overload as there is no lower limb oedema, ascites
and he is able to lie flat in bed with no signs of respiratory distress.
(summary) In summary, Mr XXX is a young Chinese gentleman who most likely has adult polycystic kidney
disease. I say this because of the presence of bilateral ballotable kidneys. This is complicated by end-stage
renal failure and Mr XXX is currently being managed by haemodialysis. He is not in uraemia or fluid
overload.
Transplanted kidney
Mdm XXX is a (age)(race)(gender) who has a transplanted kidney and is on immunosuppressive therapy
I say this because she has a J-shaped scar in her left iliac fossa, overlying a rounded mass x cm by x cm
which is non tender and firm to touch. There is no hepatosplenomegaly or ascites noted
In addition, she also has evidence of immunosuppression with a characteristic rounded facies, central
obesity, violaceous abdominal striae, oral thrush, gum hypertrophy, bruising and thin skin
I looked for but was unable to find any signs suggestive of the aetiology of end stage renal failure such as
bilaterally enlarged ballotable kidneys and diabetic dermopathy
Functionally, I note that she has a left arteriovenous fistula with a palpable thrill. There are no signs of recent
cannulation which suggests that the graft is functioning well. This is supported by the fact that she does not
have any evidence of uraemia. She does not appear sallow and there are no signs of bruising, scratch
marks or asterixis. She is also not in fluid overload as she is able to lie flat in bed with no signs of respiratory
distress and there are no signs of ascites or lower limb oedema
14
Medicine = Endocrine shorts
Cushing’s syndrome
Mdm XXX is a middle-aged Chinese lady who appears to be alert and comfortable at rest. On general
inspection, I note that she has Cushingnoid features as evidenced by
(a) characteristic rounded facies with facial plethora, hirsutism and acne
(b) central deposition of adiposity with thick violaceous abdominal striae
(c) supraclavicular and dorsal fat pads
(d) skin atrophy, bruising, proximal myopathy
(e) cataracts
(f) oral thrush
During the examination, I looked for but did/did not find any evidence of
(a) deforming arthropathy RA, SLE
(b) characteristic malar rash SLE
(c) clubbing or tar stains small cell lung ca
(d) expiratory rhonchi or fine end-inspiratory bibasal crepitations asthma, COPD, IPF
(e) transplanted kidney/liver
There are no hypocount scars over the finger-tips or diabetic dermopathy which may suggest the presence
of DM as a complication. However, I would like to confirm this by performing a urine dipstick to look for
glycosuria. In addition, I would like to take the BP for hypertension.
Thyrotoxicosis
I would like to complete my examination by requesting for the patient’s vitals, performing Pemberton’s sign
, checking for hyper-reflexia as well as performing a cardiovascular examination looking out for signs of
congestive cardiac failure.
Miss XXX is a young Chinese lady who appears to be alert and comfortable at rest. She does not appear to
be agitated or nervous. On general inspection, I note that she has a diffuse anterior neck swelling. This is
most likely the thyroid gland as it moves with swallowing but not with tongue protrusion. There are no
overlying skin changes, dilated veins or previous surgical scars.
On palpation, the thyroid gland measured 10cm by 5cm in dimensions. There was no increased warmth or
palpable thrill. It was non-tender, firm in consistency and had a smooth and regular surface. It was not
attached to overlying skin or underlying muscle. There was no cervical lymphadenopathy or displacement
of the carotids and trachea. Retrosternal extension is unlikely as the inferior border of the gland was well
felt. In addition, there was no dullness to percussion over the manubrium. There was an audible bruit heard
over both lobes on auscultation.
Miss XXX is likely to be in thyrotoxicosis. I say this because she is in sinus tachycardia with a HR of 120/min. In
addition, she has warm and sweaty palms, palmar erythema as well as fine tremors. I did not note the
presences of thyroid acropathy, proximal myopathy or pre-tibial myoxedema. Furthermore, Miss XXX has
also features of thyroid eye disease as evidenced by lid retraction, exophthalmos and lid lag. However,
there is no proptosis, chemosis, limitation in eye movement or lagophthalmos.
So in summary, Miss XXX is a young Chinese lady who most likely has Graves’ disease complicated by
thyroid eye disease and is currently in thyrotoxicosis.
15
Medicine = Hands shorts
The disease is likely to be quiescent as the joints are non-tender. In addition, there is no joint swelling,
erythema or increased warmth.
Functionally, there is deforming arthropathy with asymmetrical joint involvement resulting in limited ROM in
the finger and wrist joints as well as muscle wasting. However, he/she is still able to hold a cup, write and
unbutton.
I looked for but there were no xanthelasma seen on the face. In addition, the patient does not appear
uraemic as there is no sallow appearance nor are there bruises or scratch marks on the arms. There is also
no arteriovenous fistula noted.
Request
(a) presence of gouty tophi = olecranon bursae, pinna of ear, prepatellar bursae, archilles tendon
(b) feet, ankle and knee for similar changes
(c) haematological malignancy = hepatosplenomegaly, generalised lymphadenopathy
(d) signs of alcoholism = duputyren’s contracture, parotidomegaly
Differentials
1. Tendon xanthomata
- yellow (not chalky)
- stuck to tendons (not joints)
- bursa not involved
- no active arthritis
2. Rheumatoid arthritis
16
Endocrine
Medicine (Thyroid) = Physical Examination
Start
1. Ask the patient to sit comfortably at the edge of the bed or on a chair.
2. Introduce yourself and explain purpose for examination.
Inspection
1. General appearance
restless, edgy, nervous
thin/large body habitus
2. Eyes
Thyroid stare
Exophthalmos (visible sclera below lower limbus)
Lid retraction (upper limbus visible due to sympathetic overstimulation of lipopolysaccharide)
Lid oedema (chemosis, conjunctivitis, exposure keratitis, tarsorraphy)
Strabismus
3. Neck
Goiter (diffuse/nodular)
Overlying skin changes (erythema, tethering of skin)
Dilated veins (suggests retrosternal extension with thoracic inlet obstruction)
Previous surgical scar along skin creases
4. Ask patient to drink a sip of water but only swallow at your command
If neck swelling rises (due to attachment to larynx) → thyroid, thyroglossal cyst
If inferior border not visible → retrosternal extension
5. Ask the patient to open mouth and protrude tongue → thyroglossal cyst
Palpation
1. Ask the patient if there is pain → subacute thyroiditis malignant infiltration, haemorrhage into cyst
2. Move behind the patient and look over his head for proptosis
3. Begin palpation from behind with pulps of fingers over the gland. Slightly flew patient’s neck to relax SCM
4. Feel the isthmus (overlies thyroid cartilage) and then the lobes
Size = WHO grading of goiter
17
5. Palpate for cervical lymphadenopathy (infiltration by carcinoma), carotid artery (displacement/absence →
infiltration by carcinoma)
6. Move to the front and assess for trachea deviation
Percussion
1. Percuss manubrium from one end to the other (dullness may indicate retrosternal extension)
Auscultation
1. Listen over each lobe for bruit (increased vascularity)
Eyes
1. Look from side to assess proptosis again
2. Assess visual acuity
Impaired EOM (opthalmoplegia) = IR → MR → SR → LR
Diplopia
Lid lag (descent of upper lid lags behind eyeball)
3. Ask patient to close eyes → lagophthalmos
4. Grading of eye signs
Grade 1 MR palsy
Grade 2 Lid retraction and Lid lag
Grade 3 Opthalmoplegia
Grade 4 Exophthalmos and Chemosis
Legs
1. Pretibial myxoedema
Elevated symmetrical skin lesions
Well-defined
Red but not inflamed
Swollen but not edematous
Skin is shiny and has peau d orange appearance
Request
1. Pemberton’s sign (thoracic inlet obstruction → retrosternal extension)
Instructions = ask patient to lift arms over the head and wait for 1 minute
+ve sign = facial plethora, cyanosis, inspiratory stridor, non-pulsatile elevation of JVP (main
features), periorbital oedema, exophthalmos, conjunctival injection, retinal venous dilation, dilated
collateral vessels on the chest
2. Vitals = T: (subacute thyroiditis), BP (wide pulse pressure, collapsing pulse)
3. Chest = gynecomastia, CVS examination (signs of CCF)
4. Eye examination and referral
Visual field defect
18
Impaired visual acuity and colour vision
Papilloedema, optic atrophy (optic nerve compression → do fundoscopy)
Proptosis (quantified by Hertel’s exophthalmometer)
5. Associated AI disorders
Vitiligo
Conjunctival pallor → pernicious anemia
Myasthenia gravis
Glycosuria → T1DM
Hyperpigmentation of palmar creases → Addison’s disease
6. History
Thyroid symptoms
Compressive symptoms (dysphagia, stridor)
Drug history (iodine containing medications, RAI)
Exposure to radiation
Family history of goiter
19
Medicine (Thyroid) = Introduction
Anatomy
1. Consists of two lateral lobes connected by isthmus (latter lies below the cricoids cartilage)
2. Gland lies anterior to trachea
3. Lateral lobes related to oesophagus
4. Enclosed by pre-tracheal fascia therefore seen to rise with trachea and larynx during swallowing
5. Functions
Thyroid follicular cells synthesize thyroid hormones (T3 and T4)
Para follicular C cells synthesize calcitonin (promotes bone absorption of Ca2+, inhibits osteoclastic
action)
Embryology
1. Descends from foramen caecum (lies in the midline at the junction of the anterior 2/3 and posterior 1/3 of
the tongue) to normal position in the neck
2. Brings with it parathyroid glands on each side
3. Eventually rises at the level of the 2nd and 3rd tracheal rings
4. Failure to descend → ectopic thyroid tissue
Physiology
20
hypothalamus
TR
anterior pituitary gland H
TSH
thyroid gland
T3 + T4
peripheral tissues
Metabolism
1. Inactivation (minor) = deamination, decarboxylation, conjugation with glucuronide/sulphate
2. Deiodination (major) = 1/3 of T4 converted to T3
Inactivation by 5’ deiodinase to reverse T3
Activation by 5’ deiodinase to T3
Thyroid hormones
1. Principle hormone secreted is T4
2. T3 + T4 highly bound to serum thyroid hormone-binding proteins (esp thyroxine-binding globulin)
T4 (99.9%) vs T3 (99.5%) → less free T4 than T3
3. Free fraction is the active fraction
4. 80% of T3 is derived from peripheral deiodination of T4 (1/3 of T4)
5. T3 (T ½ = 1.5 days) is 4x more metabolically active than T4 ( T ½ = 9 days)
21
Functions of T3 and T4
1. binds to nuclear thyroid hormone receptor → hormone receptor complex binds to thyroid hormone
response elements in target genes → regulate gene expression
2. metabolic effects =
up regulate carbohydrate and lipid catabolism
stimulate protein synthesis
increase basal metabolic rate therefore increase heat production
3. critical for development and function of
central nervous system
skeletal muscle (growth)
reproductive tissue
4. effects are potentiated by human growth hormone
22
Medicine (Thyroid) = Thyroid Lumps
Solitary Lumps
* Benign = Thyroid Cyst
Follicular/Toxic adenoma
Dominant nodule of multi-nodular goitre
Multiple Lumps
* multinodular goitre
Diffuse enlargement
* Hyperthyroidism = Grave’s disease
* Euthyroid = diffuse non toxic goitre (endemic/physiologic)
* Hypothyroidism = Hashimoto’s thyroiditis
De Quervain’s thyroiditis
Epidemiology
* 5% of adults have palpable thyroid lumps
* but only 5% of these lumps are malignant
* females > males
* more likely to be neoplastic in = solitary nodule, younger patients (<40 years old), males, ‘cold’ nodules, history of
Head and neck radiation
Differential diagnosis
* cervical lymphadenopathy
*lipoma, sebaceous cyst, dermoid cyst
* plunging ranula
Anti-thyroid agents
* Classes
iodide trapping anions (per chlorate, thiocyanate)
oxidation thioamides (carbimazole, PTU)
Organification thioamides
iodides
coupling thioamides
Endocytosis
release iodides
lithium
23
Anions
* No longer in use
Thioamides
* MOA = interferes with oxidation, Organification and coupling (inhibit thyroid peroxidase enzyme)
* 2 main types
(a) Propylthiouracil (PTU) (also inhibits peripheral conversion of T4 to T3)
- Strong binding to plasma proteins unlikely to cross placenta and enter breast-milk
- For use in pregnant and lactating mothers
(b) Carbimazole
- Partially metabolised in liver to active metabolite (methimazole longer t1/2)
- crosses placenta and secreted in breast-milk
- preferred over PTU due to more convenient dosing (OM vs TDS)
* Indications = definitive treatment for thyrotoxicosis (1-2yrs)
Pre-operative treatment (shrink gland before surgery)
Awaiting effects of RAI
* S/E = agranulocytosis (1st sign is sore throat; Mx = stop meds, admit immediately, take blood
C/s, IV broad-spectrum antibiotics, barrier nursing)
Hypersensitivity reactions (pruritic MP rash, fever)
Cholestatic hepatitis
Arthralgia
* Advantages = reversible hypothyroidism
Can be used in children
* Disadvantages = high relapse rate once drug is withdrawn (60-80%)
Side-effects
Slow onset (requires 3-4 weeks to deplete pre-formed thyroid stores)
Iodides
* MOA = interferes with Organification and release of thyroid hormones
* Indications = pre-operative treatment for surgery (given for 10 days prior)
Treatment of thyroid storm
Prophylaxis against endemic goiter
* S/E = hypersensitivity reaction
Iodism from chronic overuse (bleeding disorders, conjunctivitis, drug fever, inflamed
Salivary glands, metallic taste, oral ulcers, rash)
* Advantages = decreases size and vascularity of gland
* Disadvantages = increases thyroid iodine stores (delays effectiveness of thioamide and RAI
Therapy
Severe exacerbation of thyrotoxicosis on drug withdrawal
24
30%)
Radiation induced cancer
* Indications
(a) Not fit for surgery
(b) failed pharmacological therapy
(c) Adverse effects from anti-thyroid drugs agranulocytosis, hepatotoxicity
(d) Relapse after previous surgery
* Contraindications
(a) Children
(b) Patients who are pregnant or intending to get pregnant within the next 6 months
(c) Lactating mothers
(d) Iodine allergy
(e) Severe thyroid eye disease
* Process = render patient euthyroid with anti-thyroid drugs
Stop medications 4 days prior to administration and restart 4 days later
* Advice to give
- Stay at home for 2-3 weeks
- avoid public places
- avoid pregnant women and children for 1/52
- Exacerbation of symptoms within first 2 weeks (esp if not euthyroid before treatment)
- Stress on importance of regular f/u and the need to report hyper/hypo-thyroid symptoms
- need for lifelong L-thyroxine
- avoid pregnancy for the next 6 months
- Condition may relapse
* Efficacy = 10-30% become hypothyroid in the 1st year
5% per year thereafter
Symptomatic control
* Sinus tachycardia = β-blockers
* AF = digoxin, β-blockers (rate control)
Warfarin (prevent embolic complications)
Surgery
* Advantages = usually results in permanent cure
* Disadvantages = will require life-long L-thyroxine
Risks of surgery (refer)
* Prognosis of the end of 1 year = 80% euthyroid, 15% hypothyroid, and 5% relapse
25
Surgery (Thyroid) = Hyperthyroidism
Thyrotoxicosis
* Hyperthyroidism (biochemistry changes) VS thyrotoxicosis ( biochemical changes + clinical manifestations)
* Hyper metabolic state caused by elevated levels of free T3 and T4
(a) Excessive release of preformed thyroid hormones = thyroiditis
(b) Extra-thyroidal source = TSH-secreting tumours, hCG-producing tumours, struma ovari
(c) Hyper functioning thyroid gland ( primary hyperthyroidism) = Grave’s disease
Toxic MNG
Toxic adenoma
(d) Drugs= amiodarone, lithium, L-thyroxine
* Clinical features result from hyper metabolic state and sympathetic over activity
Clinical Symptoms
* goitre = duration, speed of growth, pain
* neurological = restless, nervous, irritability, inability to concentrate , tremors, insomnia
* eyes= difficulty closing eyes, double vision, pain
* autonomic over activity= heat intolerant, excessive sweating
* CVS = palpitations, CCF ( chest pain, dyspnoea, ankle oedema, fatigue )
* GIT = polyphagia, LOW, chronic diarrhoea
* GUT = oligomenorrhoea
* musculoskeletal = proximal myopathy ( difficulty hanging clothes or walking up stairs)
Periodic paralysis ( after exercise or eating)
Osteodystrophy ( osteomalacia, osteoporosis)
* aetiology = recent fever and URTI ( subacute thyroiditis )
Drug history
History of radiation to the head and neck
Family history
* complications = compression ( dysphagia, stridor (tracheal narrowed to 20-30%), cough, dyspnoea, hoarseness)
Metastasis( LOA, LOW, fatigue, fever, bone pain, chest pain, SOB, haemoptysis, abdominal pain
Jaundice, change in bowel habits)
* systemic review
* management before and during current admission
* has this happened before? Describe prior episodes
* past medical history = IDDM, pernicious anaemia, vitiligo, myasthenia gravis, Addison’s disease, history of head and
Neck radiation (if suspect cancer)
* family history of thyroid lesions
Clinical Signs
* General appearance = restless/edgy/nervous, thin body habitus
* Hands= fine tremors, warm, sweaty, acropachy ( clubbing), onycholysis (Plummer’s nails), palmar erythema
* Pulse = tachycardia, AF
* Arms = proximal myopathy, hyper-reflexia
* Thyroid eye disease = lid oedema, chemosis, conjunctivitis, exposure keratitis, tarsorraphy, thyroid stare, lid
Retraction, exophthalmos, proptosis, strabismus, diplopia, restricted EOM, lid lag,
Lagophthalmos, decreased visual acuity/colour vision, optic atrophy, papilloedema ( optic
Nerve compression )
* Goitre= diffuse/nodular, warmth, tender, consistency, overlying skin changes, mobility, bruit, thrill, retrosternal
Extension, previous thyroidectomy scar
* Local effects = enlarged lymph nodes, displacement of trachea and carotid artery
* Chest = gynecomastia
Systolic flow murmurs, displaced apex beat, S3,gallop rhythm, bibasal lung crepitations
* Legs= pretibial myxoedema
* Pemberton’s sign
Decompensation
* High output cardiac failure
* Thyroid storm * Fixed opthalmoplegia = usually painful
26
Grave’s Disease ( GD )
* definition = diffuse enlargement of thyroid gland due to TSH receptor-stimulating auto antibodies which frequently
Results in Hyperthyroidism
* Commonest cause of thyrotoxicosis in Singapore (>90%)
* affects 1.28% of the population
* pathogenesis= stimulating auto-antibodies against TSH-receptor
* clinical features = diffuse and smooth goitre
Occurs in young females ( 20-40 years old )
Strongly associated with HLA-DR3 inheritance
Associated with AI disorders ( IDDM, pernicious anaemia, vitiligo, Addison’s disease, myasthenia
Gravis)
* 5 indicators of toxicity
(a) Resting tachycardia
(b) Warm and sweaty palms
(c) Fine Tremors
(d) Hyper-reflexia
(e) Thyroid bruit
*features unique to GD : Grave’s opthalmoplegia, pretibial myxoedema, thyroid bruit
*Grave’s opthalmoplegia
- increased volume of retro-orbital connective tissues and extraocular muscles
- does not depend on thyroid status
- orbital fibroblasts aberrantly express TSH receptors differentiate into adipocytes secrete
Glycosaminoglycansfibrosis and swelling
-due to = marked infiltration of retro-orbital space by mononuclear cells
Inflammatory oedema and swelling of extra-ocular muscles
Accumulation of ECM components ( glycosaminoglycans, hyaluronic acid)
Increased adipocyte differentiation leading to fatty infiltration
-factors that increase risk = age, male gender, smoking , RAI ( steroids usually given to decrease risk)
* Little evidence to suggest increased frequency of thyroid cancer in GD
* Management = anti-thyroid drugs ( PTU, carbimazole)
Β-blockers ( block sympathetic effects on CVS )
RAI
Subtotal thyroidectomy
Protective eye measures
* Grave’s disease in pregnancy = TSH-receptor Ab crosses placenta fetal hyperthyroidism
Anti-thyroid agents crosses placenta fetal hypothyroidism
Multi-nodular Goitre
* epidemiology = commonest cause of goitre in the UK
Usually in older women ( ≈ 60 years old)
* pathogenesis = occurs spontaneously or in long standing simple goitre
-reflects impaired synthesis of thyroid hormones
-results from repeated stimulation and involution of thyroid follicles
- low levels of thyroid hormonescompensatory rise in serum TSH levelshypertrophy and hyperplasia of
Follicular cellsdiffuse goitreinvolution of follicular epithelium if dietary iodine increases or demand for
Thyroid hormone decreases
-endemic goitre= due to iodine deficiency
-physiological goitre= occurs in puberty and pregnancy due to increased demands
* Clinical features
(a) usually euthyroid
(b) Hyperthyroidism/Thyrotoxicosis
- hyperactive focal nodule within long-standing goitre (Plummer syndrome)toxic MNG
- Permanent with no spontaneous remission. Therefore, anti-thyroid drugs not appropriate long-term Rx.
(c) mass effects
(d) malignant change < 5%
* Management
(a) anti-thyroid drugs ( not useful as relapse occurs after withdrawal; autonomous nodule not responsive to
Medications)
(b) RAI = lower risk of hypothyroidism
(c) Subtotal thyroidectomy = for compressive symptoms
27
* Comparison with GD
Toxic adenoma
* Epidemiology= usually in females > 40 yrs old
* Arises from follicular adenoma ( benign neoplasia derived from follicular epithelium)
- vast majority are non-functional
- small portion undergo toxic change to cause thyrotoxicosis
- rarely precursors of cancer
* Pathogenesis= activating somatic mutations in TSH receptor signalling pathway chronic cAMP pathway
Stimulation generates cells that acquire growth advantage
* Histopathology = discrete solitary mass, well circumscribed, encapsulated, no infiltrative margins, atrophy of
Remaining gland, cut surface brown and glistening ( due to colloid), uniform follicular growth,
No areas of necrosis or haemorrhage
* Clinical features = painless mass
Mild hyperthyroidism ( 50% have isolated elevation of T3 only)
* Management
(a) Anti-thyroid drugs ( not useful as relapse occurs after withdrawal)
(b) RAI = lower risk of hypothyroidism due to compensation of remaining thyroid gland
(c) surgery
Thyroid Storm
* acute life threatening hyper metabolic state induced by excessive release of thyroid hormones in individuals with
Thyrotoxicosis
(a) Surgical = inadequately prepared thyrotoxic patient undergoing thyroid surgery
Non-thyroidal surgery in patients with undiagnosed thyrotoxicosis
(b) Medical
-sepsis ( most common precipitating cause)
-RAI
-sudden withdrawal of anti-thyroid drugs
-administration of iodinated contrast medicum
-infarction ( AMI,CVA)
-trauma
* Clinical features
- hyperpyrexia, diaphoresis, palpitations, tachyarrythmias, hypertension with wide pulse pressure, CCF, tremors,
28
delirium, agitation, frank psychosis, seizures, nausea, vomiting, diarrhoea, abdominal pain, jaundice
-complications: high-output cardiac failurehypotensive shock. Dehydration. Multi-organ dysfunction syndrome
* Burch-Wartofsky score
-scoring system = >25 (thyrotoxicosis possible)
= >45 ( thyroid storm probable)
-based on = temperature
CNS effects
Hepatogastrointestinal dysfunction
Tachycardia
Congestive Cardiac Failure
AF
History suggestive of thyrotoxicosis
* Investigations = FBC, U/E/Cr, LFT, TFT, ECG, CXR, septic work-up
* Management
-admit patient in HD or ICU
-urgent referral to endocrinologist
(a) PO PTU/ carbimazole or lithium carbonate ( if allergic to the former) = rapidly lowers T3 levels
(b) IV sodium iodide = blocks further release
Must be given at least 1 hr after PTU (or else will exacerbate thyrotoxicosis)
(c)Tachycardia= IV propranolol
(d)AF = IV digoxin
Cardioversion if unstable
Anti-coagulate if unstable
(e) IV dexamethasone = protect against shock, block peripheral conversion of T4 to T3
(f) CCF = digoxin, diuretics
(g)supportive therapy = oxygen supplementation
Monitor vitals
IV hydration ( hyperpyrexia, diaphoresis, vomiting, diarrhoea)
Tepid sponging, ice packs, anti-pyretics (do not give aspirininhibits binding of thyroid
hormones to
Binding proteins)
Sedation if patient restless (chlorpromazine)
Treat precipitating cause (antibiotics)
* should respond to above therapy within 24-48 hours
Oesophagus
*dysphagia
Trachea
*stridor=positional in nature (on neck extensionpush goitre into thoracic inlet)
*may cause trachomalaciapost operative complication
Carotids
*arteries usually resistant to tumour invasion
*drop attacks(rare)
29
Medicine (Thyroid) = Hypothyroidism
Aetiology
* Primary hypothyroidism
(a) congenital -> agenesis, dyshormonogenesis, ectopic thyroid
(b) interference with hormone synthesis
- iodine-deficiency
- anti-thyroid drugs (lithium, amiodarone, radiocontrast, KI-containing expectorants)
(c) infective -> de Quervain’s thyroiditis
(d) autoimmune -> Hashimoto’s thyroiditis, post-partum thyroiditis, Riedel’s thyroiditis
(e) post-surgical/radioactive iodine (RAI)
* Secondary hypothyroidism -> TSH deficiency
* Tertiary hypothyroidism -> TRH deficiency
Clinical features
* Cretinism = hypothyroidism in infancy or early childhood
- impaired development of skeletal system and CNS
- mental retardation, short stature, coarse facial features (wide-set eyes and protruding
tongue), umbilical hernia
* Myxoedema = hypothyroidism in adults > 40 yrs old
deposition of muco polysaccharides beneath the skin
History
# symptoms = mental sluggishness (poor cognition/dementia)
depression
fatigue
cold-intolerance
weight gain despite LOA, constipation
menorrhagia, infertility
ankle oedema
neck pain and swelling
# aetiology = drug history
fever and recent URTI
# past medical history = hyperthyroidism s/p thyroidectomy/RAI therapy
autoimmune disorders
# family history of thyroid and AI disorders
Physical Examination
# general impression = large body habitus
slow mental capacity
vitiligo, malar rash, conjunctival pallor, palmar crease pigmentation
# face = coarse facial features (preorbital oedema, thick nose and lips, macroglossia)
loss of outer 1/3 of eyebrows
dry skin and hair (‘peaches and cream’ complexion)
xanthelasma
hoarse voice (sounds like ‘jabba the hutt’)
# neck = previous thyroidectomy scar
goitre
# neurology = ankle reflexes with delayed relaxation, proximal myopathy, carpal tunnel
syndrome, cerebellar syndrome, myxoedema coma, myxoedema madness,
dementia, deafness to high tones (Trotter’s syndrome)
# CVS = bradycardia, hyperlipidemia, mild HTN (10%), CCF, pericardial effusion, IHD
# resp = pleural effusion
# abdomen = faecal masses
# lower limbs = non-pitting oedema
30
- excessively clothed (cold intolerant)
* face
- coarse facial features (periorbital oedema, thick nose and lips, macroglossia)
- loss of outer 1/3 of eyebrows
- xanthelasma
- hoarse voice (sound like ‘jabba the hutt’)
* neck
- previous thyroidectomy scar
- goitre
* peripheries
- pulse -> bradycardia
- Tinel’s test -> carpal tunnel syndrome
- finger-nose test and dysdiadochokinesis -> cerebellar syndrome
- proximal myopathy
- ankle jerks -> delayed relaxation
- abdomen -> faecal masses
Investigations
Confirm diagnosis
* thyroid function test = low fT4, high TSH
* thyroid auto-Ab panel = TSH-receptor inhibitory Ab, anti-TG Ab, anti-TPO Ab, anti-microsomal Ab
* RAI = reduced radioisotope uptake
Complications
* FBC = anaemia secondary to menorrhagia
* fasting lipid panel = increased TC and TG
Associated AI disorders
* IDDM = fasting glucose, HbA1c
* pernicious anaemia = Hb, MCV, vitamin B12 levels, anti-IF Ab, anti-parietal cell Ab
* Addison’s disease = U/E/Cr (hypo Na+ and hyper K+)
Evidence of decompensation
* serous effusions = pleural, pericardial, joint
* carpal tunnel syndrome
* cerebellar syndrome
* bradycardia/heart failure
* dyslipidaemia
* depression/psychosis
Hashimoto’s thyroiditis
* autoimmune inflammation of the thyroid gland usually in middle aged women (45-65 yrs old)
* a/w other AI disorders IDDM, Addison’s disease, pernicious anaemia, SLE, MG, B-cell NHL
* clinical features = insidious onset of hypothyroidism a/w painless enlargement of thyroid gland
* Mx = L-thyroxine replacement
monitor for malignancy (lymphoma) -> do serial neck examinations
Post-partum thyroiditis
* autoimmune inflammation of the thyroid gland occurring 2-10 months post-partum
- associated with anti-thyroid peroxidise antibodies
- very similar to Hashimoto’s thyroiditis -> cannot be distinguished on pathology specimens
- current theory = underlying asymptomatic AI thyroiditis that flares post-partum due to fluctuations
of immune function
- clinical features = silent (no pain or swelling)
short period of hyperthyroid -> prolonged but self-limiting period of hypothyroid
Riedel’s thyroiditis
* extremely rare disease
* unknown aetiology (? Autoimmune)
* clinical features = slight enlargement of thyroid gland
woody hard and fixed mass (thyroid parenchyma replaced with fibrous tissue which
filtrates into surrounding neck structures)
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* may be mistaken for infiltrating neoplasm
* a/w retroperitoneal fibrosis, sclerosing cholangitis and fibrosing mediastinitis
Myxoedema coma
* severe form of hypothyroidism
(a) defective thermoregulation -> hypothermia
(b) altered mental status -> stupor, coma, seizures
(c) precipitating cause -> sepsis
infarction (AMI, CVA)
trauma
recent administration of sedative/tranquilizer
prolonged exposure to cold
(d) other features -> hypo-reflexia, bradycardia, hypoventilation, heart failure
* investigations = FBC, U/E/Cr, glucose, TFT, serum cortisol, ABG, ECG, CXR, septic work-up
* management
~ admit patient into HD or ICU
~ urgent referral to endocrinologist
(a) thyroid hormone replacement = PO liothyronine
(b) IV hydrocortisone
(c) hypothermia = warm blankets, warm room, warmed fluids
(d) hypoventilation = supplemental O2, monitor with serial ABGs, consider mechanical ventilation
(e) treat precipitating cause
L-thyroxine
* indications = lifelong replacement therapy for hypothyroidism
TSH suppression in thyroid cancers
* pharmacokinetics
- usual starting dose = 50-100 ug OM (25 ug OM if underlying IHD)
- T1/2 = 7 days
- initial doses must be low and increased gradually (adjustments every 3 wks according to clinical
response and TSH suppression)
* start low and go slow in elderly -> rapid replacement may precipitate angina and AMI
* Cx of over-treatment = osteoporosis
* Liothyronine (T3) therapy reserved for myxoedemic coma
32
Surgical (Thyroid) = Thyroid Carcinoma
Epidemiology
Females>Males
9th most common cancer in Singaporean females
Good Prognosis (10 year survival >90%)
Aetiology
Environmental = head and neck radiation (first 2 decades of life)
Iodine deficiency -> pre-existing endemic goitre
Genetic mutations
Clinical features suggestive of carcinoma
High index of suspicion:
Family history of medullary thyroid carcinoma / MEN 2 syndrome
Rapid tumour growth
Very hard/ firm nodule
Fixation of nodule to adjacent structures
Vocal cord paralysis
Regional LAD
Distant metastasis
Pathology
2 main groups:
well differentiated (papillary, follicular, medullary) -> good prognosis
poorly differentiated (anaplastic) -> poor prognosis
Papillary Carcinoma
Most common type of thyroid carcinoma (75-85%)
best prognosis out of the 4 subtypes esp in young and female
occurs usually in young adults (30-50 yrs old)
slow-growing multicentric tumour with late lymphatic spread
history of head and neck irradiation linked to development
pathology:
o Papillary cells with nuclear grooves
o Intranuclear inclusion bodies
o Psammomma bodies (keratin pearl with calcifications)
Treatment:
o Total thyroidectomy
o L thyroxine replacement
o Radioactive iodine
Why thyroidectomy preferred?
1. Multifocal disease
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2. Possibly of using radioactive iodine = cannot be used if only hemithyroidectomy done due to uptake in
normal thyroid lobe
3. Use of TG as surveillance method to detect recurrent or metastatic disease
Follicular Carcinoma
Makes up 10-20% of thyroid carcinomas
Occurs in young and middle aged adults (40-60 yrs old)
Linked to endemic goitres
Tendency to metastasize early by homogenous route (liver, bones, lungs). Worse prognosis!
Tx
o Total thyroidectomy
o L thyroxine replacement
o Radioactive iodine
Medullary Carcinoma
Makes up 5% of thyroid carcinomas
Occurs in young and middle aged adults (40-60 yrs old)
Arises from parafollicular c (neuroendocrine) cells -> secrete calcitonin
80% arises spontaneously (in the elderly) -> unifocal; worse prognosis
20% may be familial and linked to MEN 2 syndrome (screen family members) -> multifocal; better prognosis)
# MEN 2 syndrome = medullary thyroid cancer, pheochromocytoma, primary hyperparathyroidism due to RET
proto-oncogene mutation
100% penetrance for MTV; 90% penetrance for PCC, 50% for primary hyperparathyroidism
Metastasize by local extension, lymphatic and hematogenous routes
Pathology = amyloid trauma
Tx :
o Pheochromocytoma (urinary catecholamine) and parathyroid hormone (ipTH and Ca2+)
o Screen pre op
o Total thyroidectomy (resect pheochromocytoma first, remove all parafollicular cells -> junction of
middle and lower third of thyroid gland)
o Monitor calcitonin levels
Anaplastic Carcinoma
Least common of the thyroid carcinomas (<5%)
Occurs in the elderly (60-80 yrs old)
Aggressive tumour with local extension and distant metastasis via lymphatic and hematogenous routes
Very poor prognosis (average survival is 6-9 mths after diagnosis)
Must be differentiated from lymphoma (better outcome)
Tx:
o Debulking surgery
o Palliative radiotherapy and chemotherapy
Lymphoma
Require biopsy to make diagnosis
Tx : radiotherapy and chemotherapy
34
Clinical Features
History
Lump in neck
Mass pressure effects = dyspnea, stridor, cough (airway obstruction)
Dysphagia
Hoarseness
Usually euthyroid (no symptoms of hyperthyroidism)
History of head and eck irradiation
Family history of thyroid cancer
Metastasis = LOA, LOW, fatigue, malaise, fever
Bone pain
Abdominal pain, jaundice, change in bowel habits
Prolonged cough, hemoptysis, hoarseness (infiltration into recurrent laryngeal nerve)
Physical examination
Lump in the neck = ill defined, solitary, hard, immobile, tender
o Usually spreads to the LNs in the tracheal-oesphageal groove (level 6)
o Can affect levels 2 (jugulo-digastric), 3 (mid-jugular), 4 (supraclavicular) as superior thyroid pedicle
drains in a cephalic direction
o Not commonly seen or palpable unless >1.5-2 cm in diameter
Palpable deep cervical lymph nodes (10% of cancers)
Palpable deep cervical lymph nodes (10% of cancers)
+ or – signs of hyperthyroidism
Management
Total thyroidectomy -> remove both sides + paratracheal lymph nodes +- cervical lymph nodes
Recurrence and mortality increases by 2x if not done!
RAI – ablate residual cells
Scan for metastasis in chest cavity and bone
Monitor TSH/TG regularly -> increases with recurrence (should not have any thyroid tissue left)
o No thyroglobulin
o TSH 0.1ng/ml
Monitor calcitonin levels if patient has medullary carcinoma
L-thyroxine replacement for life -> suppress TSH release (remove stimulus for remaining tirrue)
No remaining T3 + T4 synthesis
Lifelong follow up : Physical examination (cervical LAD, thyroid gland)
Thyroid Ultrasound
35
Surgical (Thyroid) = Thyroidectomy
Types:
1. Lobectomy
2. Subtotal thyroidectomy (GD)
3. Total thyroidectomy (MNG, carcinoma)
# Normal thyroid lobe is the size of distal phalanx of the thumb (4g) -> leave the equivalent behind
Indications for thyroid surgery
C – Cancer
C- Control
C – Compression (dyspnoea, stridor, cough, hoarseness, dysphagia)
C – Comesis
Pre-operative considerations
Reduce thyroid activity -> clinically euthyroid
ENT referral to check vocal cords (normal cord mobility; exclude compensated cord paralysis_
Operating Procedure
Papillary lesion ->
o Hemithyroidectomy
o Frozen section
o Total thyroidectomy
Follicular lesion ->
o Hemithyroidectomy
o Trace paraffin histology results
o KIV total thyroidectomy on a separate occasion
Specific
Early:
a) Haemorrhage
Can compress trachea very easily (limited space between strap muscles and trachea)
Clinical features = dyspnea, stridor, shock
Management = remove sutures immediately
b) Pneumothorax
c) Thyroid storm
d) Hypoparathyroidism
Inadvertent removal or injury to the parathyroid glands during surgery
Hypocalcemic tetany usually occurs POD 2-5
Clinical features =
a) Circumoral parasthesiae
b) Tingling of extremities
c) Painful carpopedal spasms
d) Laryngospasm
36
e) Chvostek’s sign (tapping of facial nerve in front of external auditory meatus will
cause hemifacial spasm
f) Trousseau’s sign (carpopedal spasms induced by tourniquet around arm)
Management: slow infusion of 10ml of 10% calcium gluconate (extravasations can cause
necrosis) and oral calcium intake
e) Recurrent laryngeal nerve damage
Lies behind the thyroid gland in the groove between oesophageal and trachea
Close to the inferior thyroid artery
Damage to 1 nerve -> slight hoarseness (weak voice)
Damage to 2 nerves -> almost complete loss of voice + severe airway narrowing
f) External branch of the superior laryngeal nerve damage
Travels with the superior arterio-venous pedicle
Damage affects high frequency speech and voice projection
Late
a) Hypothyroidism -> L thyroxine for life if total thyroidectomy
b) Recurrent hypothyroidism
c) Keloid scarring
37
Rheumatology
Medicine (Rheumatology) = Rheumatoid Arthritis Song
Mdm XXX is a middle aged Chinese lady who is alert and comfortable at rest. On general inspection, I note
that she appears to be Cushingoid as evidenced by the characteristic rounded facies (facial plethora, acne,
and hirsutism). In addition, she also has a pair of rheumatoid hands.
Pathology
I say this because there is bilateral symmetrical deforming polyarthropathy involving the small joints of
the hand namely the MCPJ and PIPJ and sparing the DIPJ. I note bilateral Z-thumb deformities, swan neck
deformities affecting joints and Boutonniere deformity affecting joints. There is ulnar deviation of the
fingers, radial deviation at the wrists, ulnar subluxation at the MCPJ and dorsal subluxation of the DRUJ
(distal radial-ulnar joint). There are no rheumatoid nodules seen over the extensor surfaces or over the
olecranon process. I note muscle wasting of the intrinsic muscles. There are no nail changes or psoriatic
plaques seen.
Stage
The disease is likely to be in a quiescent stage and there is no overlying erythema, joint
swelling/tenderness of increased warmth.
Function
Functionally, Mdm XXX is only able to hold a cup with both hands. She is unable to button her shirt, grasp
a pen and write.
38
Medicine (Rheumatology) = General points about arthritis
Definition
Pain and swelling involving joint(S)
Cf arthralgia = pain without joint swelling
Key Words
Symmetrical versus asymmetrical
Mono/oligo/poly-arthropathy
o Mono = 1 joint
o Oligo = <5 joints
o Poly = >5 joints and more
Small versus large joint
Axial versus peripheral
39
Medicine (Rheumatology) = Systemic lupus erythematosus (SLE)
Epidemiology
An autoimmune multi system disorder with a remitting and relapsing course
Strong female preponderance (approx 9:1)
Onset usually in 2nd or 3rd decade of life but may manifest at any stage
Pathogenesis
Autoimmune disorder with the fundamental defect of failure to maintain self tolerance
Type 3 hypersensitivity = immune complex formation with deposition in target organs
Involves a bewildering array of auto-antibodies
Antinuclear antibodies (ANA)
Directed against several nuclear antigens (DNA, histones, non-histone proteins)
Senstive = positive in 95% of patients with SLE
Not specific = also positive in Sjogren’s, polymyositis/dermatomyositis, RA, autoimmune hepatitis
Anti-Sm Ab
Specific for SLE. Virtually diagnostic
Anti-phospholipid antibodies (lupus anticoagulant, anticardiolipin Ab)
Present in 40-50% of lupus patients
Phospholipids required for coagulation. Therefore, prolonged aPTT that fails to correct even after
addition of normal plasma
Prothrombotic state = venous thrombosis (DVT/PE)
Arterial thrombosis (AMI/CVA)
Recurrent spontaneous miscarriages
Livedo reticularis
Predisposing factors
Genetic/family history
Non genetic factors: Drug lupus = isoniazid, procainamide, hydralazine, chlorpromazine,
minocycline
Lung and skin involvement >renal and CNS involvement
Remits once drug is stopped
Anti-histone Ab are characteristic (anti-dsDNA is almost never detected)
UV light = damages DNA and promotes cell injury
Mechanism of injury
Visceral lesions mediated by immune complexes (type 3 hypersensitivity)
Abs against RBC, WBC and platelets (type 2 hypersensitivity)
Extremely variable course
Extremely benign course even without treatment
May progress to death rapidly within months
Clinical features
Constitutional symptoms
LOW
LOA
Fatigue/malaise
Fever
40
Skin
Erythematous malar rash sparing nasolabial folds
Photosensitivity
Discoid rash
Alopecia
Nail-fold infarcts, telangiectasia
Raynaud’s phenomenon (white-blue-red)
Eyes
Dry eyes (Sjogren’s syndrome)
Red eyes (episcleritis, scleritis, anterior uveitis)
Cotton wool exudates (retinal vasculitis)
Mouth
Oral ulcers
Dry mouth (Sjogren’s syndrome)
Joints
Non-evasive arthritis involving at least 2 peripheral joints
Consists of a non-specific mononuclear infiltration in synovial membrane
Seen in 90% of patients
Deforming arthropathy may occur due to capsular laxity (jaccoud’s arthropathy)
CNS
Psychosis
CVS
Vessels = acute necrotizing vasculitis affecting small arteries and arterioles
Heart = pericarditis (serous effusion, fibrinous exudates)
Myocarditis
Libman-sacks endocarditis (non-bacterial, less common due to steroid use)
Lungs
Pleuritis = serous effusion, fibrinous exudates
Pulmonary fibrosis
Renal
One of the most commonest cause of death
Deposition of immune complexes within glomeruli -> evokes inflammatory response
6 classes (WHO classification)
Class I = normal LM, EM and FM (rare)
Class II = Mesangial lupus nephritis
o 20%
o Mild clinical symptoms
o Immune complex deposition in mesangium with slight increase in mesangial matrix
and cellularity
Class III = focal lupus nephritis
o 25%
o Mild microscopic haematuria and proteinuria
o Microscopic = proliferation of endothelial and mesangial cells
Less than 50% of glomeruli affected
Class IV = diffuse proliferative lupus nephritis
o Most serious form and also the most common, 50%
o Haematuria, moderate to severe proteinuria, HPT and renal insufficiency
41
o Microscopic = proliferation of endothelial and mesangial cells affecting entire
glomerulus
Crescent formation
o Glomerular injury eventually gives rise to glomerulosclerosis
Class V = membranous lupus nephritis
o 15%
o Severe proteinuria and nephritic syndrome
o Microscopic = widespread thickening of capillary wall
Class VI = advanced sclerosing lupus nephritis
o > 90% of glomeruli sclerosed globally
Hematological
Anaemia = hemolytic, chronic disease
Leucopenia (esp lymphopenia)
Thrombocytopenia
Anti phospholipid syndrome = venous and arterial thrombosis, recurrent spontaneous miscarriages
Generalized lympadenopathy +/- splenomegaly
Diagnostic criteria
At least 4 out of 11
1. Malar rash Fixed erythema malar eminences sparing nasolabial
folds
11. ANA
Major causes of death = renal failure, intercurrent infections and diffuse CNS involvement
42
Laboratory findings
1. FBC
NCNC anemia = anemia of chronic disease
Hemolytic anaemia -> reticulocyte count, hepatoglobin, LDH, direct Coomb’s test
Leucopenia/lymphopenia
Thrombocytopenia
2. ESR, CRP
ESR = raised
CRP = normal (consider infection if raised)
3. PT/PTT
Prolonged aPTT in anti phospholipid syndrome
4. U/E/Cr
Renal impairment
Proceed to do urine dipstick, UFEME, urine c/s , urine phase contrast, 24 hr CCT/UTP, urine PCR, renal
biopsy
5. Autoimmune markers
ANA = sensitive but not specific
Anti-dsDNA = specific
Anti-Sm = specific
Anti-Rho and anti-La (complete heart block in neonate)
anti phospholipid Ab (lupus anticoagulant, anticardiolipin Ab)
6. Monitor disease activity
anti-dsDNA = high
serum complement = low C3 and C4
High C3 degradation product
ESR = high (do CRP to distinguish lupus flare from infection)
Management
General measures
Avoid sunlight = carry umbrella, wear sun block
Wear warm socks and gloves for Raynaud’s phenomenon
Avoid drug provocation (penicillin, sulphonamides)
Pharmacotherapy
No curative therapy
Different modalities
(a) Joint symptoms = NSAIDs
(b) Skin symptoms/joint symptoms not controlled by NSAIDs = hydroxychloroquine (annual eye check for
maculopathy)
(c) Renal involvement = steroid and pulsed IV cyclophosphamide
(d) Severe episodes = high dose prednisolone, cytotoxics (azathioprine, cyclophosphamide, methotrexate)
(e) Chronic disease = low dose prednisolone
Prognosis
poor prognostic factors
(a) Renal disease (esp class IV)
(b) Hypertension
(C) male
(d) Young age
43
(e) APLS
(f) High disease activity
prognosis = 90% 5 year survival
80% 10 year survival
History taking
1. Malar rash
2. Discoid rash
3. Photosensitivity
4. Alopecia, dry eyes and mouth, oral ulcers
5. Gangrene of fingers, Raynaud’s phenomenon
6. Chest pain, dyspnoea
7. Joint pain
8. Seizures
9. Change in urinary frequency and volume, haematuria, frothy urine, loin pain
10. Anaemia = pallor, chest pain, palpitation, fatigue, giddiness, dyspnoea, jaundice
Leukopenia = susceptibility to infections
Thrombocytopenia = gum bleeding, easy bruising, menorrhagia
APLS = history of recurrent spontaneous abortion, DVT/PE, AMI, CVA
11. Constitutional (fever, LOA, LOW, malaise)
Examination
“This patient most likely has SLE as evidenced by the butterfly rash affecting the nose bridge but sparing
the nasolabial folds.”
44
Purpura (vasculitis or autoimmune thrombocytopenia)
Proximal myopathy (due to disease or steroid use)
Face
Conjunctiva pallor
Mouth ulcers
Alopecia
Chest
CVS = pericardial rub
Lungs = pleural rub, pleural effusion, pulmonary fibrosis
Abdomen
Mild splenomegaly +/-hepatomegaly
Legs
Vasculitic rash
Lower limb pitting edema (due to lupus nephritis)
45
Medicine (Rheumatology) = GALS screen
Gait, Arms, Legs, Spine => look at appearance and movement
History
1. Have you had any pain or stiffness in your muscles, joints or back?
Cardinal symptoms of rheumatic disease
2. Can you dress yourself completely without any difficulty?
ADL = assessing functional problem of UL
3. Can you walk up and down stairs without any difficulty?
ADL = assessing functional problem of LL
46
Fingers on thumb
Measurement of fine movements
Squeeze across MCP joints
Early arthritis = pain and tenderness on squeezing before other abnormalities seen
4. Legs
Inspection
Leg
Deformities
Knee
Bulk of quadriceps muscle
Loss of parapatellar fossae
Feet
Callus formation = abnormal weight bearing
Movement
Fully flex knee and hip joint
Place hand on knee joint to feel for crepitus
Internally and externally rotate hip joint
Squeeze across MTP joints
Early arthritis = pain and tenderness on squeezing before other abnormalities seen
47
Medicine (Rheumatology) = Rheumatoid Arthritis
Overview
Description
► Systemic chronic inflammatory disease affecting multiple tissues but principally attacking joints to produce a non- suppurative proliferating
synovitis that frequently progresses to destroy articular cartilage and underlying bones with resulting disabling arthritis.
Epidemiology
► Very common = ∼ 1% (higher in smokers)
► Female > Males (3:1)
► Peak incidence = 4th/5th decades of life
Pathogenesis
► Initiation by an arthritogenic antigen with subsequent autoimmune reaction in which T cells release cytokines and inflammatory mediators that
ultimately destroy the joint.
► Causative microbial triggers are unknown but suspects include EBV, Borrelia species, Mycoplasma species, retrovirus and mycobacterium.
Principles of Diagnosis
History
► Arthritis
- Classically, swollen, painful, stiff hands and feet worse in the morning
- Chronic inflammatory joint disease with relapsing and remitting course
- Insidious onset with joint pain and early morning stiffness
- Symmetrical polyarthropathy = PIPJ, MCPJ, wrist, MTPJ and knees (spares distal DIPJ)
- Joints progressively enlarge → limited ROM and complete ankylosis (stiffness due to abnormal adhesion and rigidity of the bones of the joint)
► Constitutional symptoms
- LoA, LoW, fatigue, fever, rash
- Anemia → chest pain, SOB, giddiness, palpitations, fatigue
► Extra-articular involvement
- Skin = Raynaud’s phenomenon, rash
- Head and Neck = red eyes, dry eyes and mouth (Sjögren’s syndrome)
- Pulmonary and Cardiac = chest pain, SOB
- CNs = numbness, parasthesiae, weakness
► Atypical presentations
- Palindromic = acute recurrent, relapsing, remittent arthritis usually affecting 1 large joint for a few hours, with symptom-free intervals of days
– months between attacks. (‘Was I Saw!’ → wrist, ankle, shoulder, IPJ)
- Persistent monoarthritis
- Systemic = pericarditis, pleurisy, LoW, constitutional symptoms
- Acute onset of widespread arthritis
48
Extra-articular involvement
1. Eyes
Sclera – episcleritis, scleritis, scleromalacia, scleromalacia perforans
Conjunctiva – pallor, keratoconjunctivitis sicca (Sjögren’s syndrome)
Lens – cataracts from steroid use
Extra-Ocular Muscles – mononeuritis multiplex, myasthenia 2º penicillamine, EOM tendon synovitis
Fundi – maculopathy from hydroxycholoroquine use
2. Head and Neck
Mouth – ulcers from DMARD treatment, dry mouth and enlarged parotids (Sjögren’s)
TMJ – crepitus
Neck – tenderness, muscle spasm, limited ROM (atlanto axial sublux, basilar invagination by dens protrusion,
subcervical spine)
3. Respiratory system
Upper airway – cricoarytenitis
Pleura – pleural effusion, pleurisy
Bronchioles – bronchiolitis obliterans and organizing pneumonia (BOOP)
Parenchyma – lower lobe pulmonary fibrosis, penumonitis, rheumatoid nodules
Infiltration – Caplan’s (rheumatoid nodules in periphery of lung fields a/w coal worker’s pneumoconiosis)
4. CVS
Pericarditis
Aortic/mitral regurgitation
5. Lympadenopathy
6. GIT
Splenomegaly (5%)
Felty’s syndrome (1%) = RA w/splenomegaly and hypersplenism →anemia, leukopenia, thrombocytopenia and leg ulcers (ameliorated by
splenectomy)
Methotrexate use → hepatomegaly
7. Upper Limb
Vasculitis = nail-fold infarcts, splinter hemorrhage, telangiectasia, Raynaud’s phenomenon
Subcutaneous nodules (indicates seropositivity and more aggressive arthritis, found on flexor and myocardium)
Entrapment neuropathy
8. Lower Limb
Hip – limited ROM
Knees – quadriceps wasting, synovial effusion, flexion contracture, genu valgus deformity, Baker’s cysts in popliteal fossae
Lower Leg – leg ulcers, calf swelling (ruptured Baker’s cyst), peripheral neuropathy, mononeuritis multiplex
Ankle – limited ROM, nodules on Achilles tendon
Feet – foot drop (peroneal nerve entrapment), MTPJ (swelling, subluxation)
Differentials
49
* Deforming symmetrical chronic polyarthropathy = RA
Psoriatic Arthritis
Chronic tophaceous gout
* Arthritis and nodules = RA
SLE
RHD
Amyloid arthropathy (usually a/w multiple myeloma)
Investigations
Arthritis is symmetrical Right and left joints involved for one or more of
the following: wrist, PIP, MCP, knee, MTP, elbow,
ankle
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Complications
Complications of disease
‐ Increased risk of IHD and lymphoma
‐ Ruptured tendons
‐ Joint destruction and resultant disability
‐ Cervical myelopathy
‐ Amyloidosis → proteinuria, nephritic syndrome and renal failure
Side effects of therapy
‐ Dyspepsia, BGIT, asthma (NSAIDs)
‐ Renal impairment (NSAIDs, penicillamine)
‐ Proteinuria (gold salts, penicillamine)
‐ Anemia (NSAIDs)
‐ Bone marrow depression (DMARDs)
5 causes of anemia in RA
1. Anemia of chronic disease
2. Iron deficiency anemia
BGIT due to NSAIDs use
3. Megaloblastic anemia
Increased cellular turnover (folate acid ‘deficiency’)
Methotrexate use
Pernicious anemia
4. Hypersplenism
2º to Felty’s syndrome
5. Aplastic
BM suppression due to gold and penicillamine use
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‐ Anemia
‐ Rh factor titres = correlates with likelihood that patient has extra-articular disease (not activity of arthritis)
‐ Inflammatory joint fluid = high polymorph count, low complement, fibrin
Imaging
‐ Progressive bony erosions on serial X-ray films
‐ Low bone marrow density
Sjögren’s syndrome
‐ Connective tissue disorder a/w dry eyes(keratoconjunctivitis sicca) and dry mouth (xerostoma)
‐ May be a/w autoimmune thyroid disease, MG or autoimmune liver disease
‐ Ix = Schirmer filter paper test (crude measure of tear production; <5mm, N → at least 15mm after 5 mins)
‐ Tx = artificial tears, artificial saliva and NSAIDs
Principles of Management
Treatment modalities
Symptomatic relief
Paracetamol Pain
Anti-cytokine therapy
-suppress disease activity only during treatment → relapse on discontinuation
Infliximab (against TNF) Progressive RA after 2 S/E = N/V/D, rash, infection (TB reactivation),
Etanercept (against TNF receptor) DMARDs failure neutralizing antibodies
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*drugs causing cytopenias = warn patient to stop meds and consult doctor if sore throat develops.
Clinical course
Variable
- most have fluctuating disease with the greatest progression during the initial 4-5 years
Most develop deforming and destructive arthritis after 15-20 years
Life expectancy reduced by 3-7 years
Poor prognostic factors
1. Female
2. Older age of onset (>60 YO)
3. Systemic features: LoW, extra-articular manifestations
4. Vasculitis
5. Early bone erosions
6. Rheumatoid nodules
7. Persistent disease activity > 12 months
8. Insidious onset
9. HLA-DR 4 linkage
10. Rh factor > 1 in 512
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Medicine (Rheumatology) = Examination of rheumatoid hands
Approach to RA short case
Introduce yourself
Sit patient at edge of bed, remove accessories, roll up sleeves and place hands on pillow (watch action)
General inspection – Cushingoid appearance
Hands
1. LOOK
‐ Palms down
Deformities = symmetrical polyarthropathy involving small joints of the hand (sparing DIPJ)
Z-deformity of thumb, Swan neck and Boutonniere deformity of fingers
Ulnar deviation of fingers
Volar subluxation of MCPJ
Radial deviation of wrist
Dorsal subluxation of ulna at carpal joint → prominent radial styloid process
Swelling = Rheumatoid nodules over extensor surfaces (never on IPJ)
Discoloration = Erythema (active disease)
Wasting of intrinsic muscles (guttering)
Nails = Telangiectasia, nail fold infarcts, splinter hemorrhages, nail bed pallor, longitudinal ridging, thickening, pitting, onycholysis (rule out
psoriasis)
‐ Palms up
Wasting of thenar and hypothenar eminences
Palmar erythema
Carpal tunnel release scar (over distal palmar crease)
2. FEEL
‐ Increased warmth (run back of hand across patient’s dorsum)
‐ Wrist = Tenderness (suggestive of synovitis → active disease)
Joint effusion (soft and boggy → synovitis)
Synovial thickening
Piano key sign = springs back into position when pressed
‐ MCPJ = Tenderness
Joint effusion (bulge sign)
Subluxation
‐ PIPJ = Tenderness
Joint effusion
3. MOVE
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‐ Clench fists tightly and release = trigger finger
‐ Place palms on pillow and lift fingers off = dropped finger (tendon rupture/slipped off into gutter)
‐ ‘push against wall’ position = finger drop (PIN palsy due to inflammation around wrist)
‐ Wrist flexion and extension = limited ROM
‐ Fold arms across chest = subcutaneous nodules over elbows, psoriatic skin plaques
4. NEUROLOGICAL
‐ Radial nerve = EPL, sensation over 1st dorsal web space
‐ Median nerve = FPL, FDP of index finger, APB sensation over lateral palm and 3½ fingers, Tinel’s sign (CTS)
‐ Ulnar nerve = FDP of little finger, finger abduction, sensation over medial palm and 1½ finger
5. FUNCTION
‐ Power grip
‐ Unbutton clothes
‐ Write
‐ Hold a cup of water
6. REQUEST
‐ Feet for similar changes
‐ TMJ for crepitus
‐ Neck for tenderness
‐ Eyes = Episcleritis, scleritis
‐ Lymphadenopathy
‐ Lungs = Pleural effusion, end-inspiratory fine crepitations (pulmonary fibrosis), nodules
‐ CVS = aortic regurgitation
‐ Request to look at temperature chart, offer to take BP and perform urine dipstick test
Format for presentation
a) Describe deformities
b) Disease activity → active or quiescent
c) Functional status
d) Request to examine
e) Diagnosis and differentials
57
58
Medicine (Rheumatology) = Case Study
Ang King Siang
72 Chinese Female
Has 1 son and 4 daughters, lives with eldest son and daughter with maid
Ambulates with quad stick
Background:
1) Seropositive erosive rheumatoid arthritis f/u Dr F CHia
Diagnosed in 7/2003
Manifestation: 45 years of bilateral symmetrical polyarthritis: Joint pain over bilateral wrist, MCPs,
PIPs with early morning stiffness > 1hour
- Bilateral deformities of writs, MCPs, fingers, left elbow and right shoulder with ulnar deviation
- Crepitus left knee with genus varus
Serology:
RF 98, ANA 1/320
DsDNA –ve
Markers of activity
ESR baseline ~ 30 (highest 99, lowest 17), CRP normal,
Anti-HCV and HbsAg –ve, albumin baseline 31, creatinin baseline 200
X- ray hands 12/2005: Ulnar deviation mainly in MCPs with carpal bone fusion and erosions
Treatment: No treatment btw 7/2003 till 10/2005 (burnt out RA) given glucosamine for OA knee
a) Prednisolone: 5mg om 10/2005: left knee effusion; max dose 10mg om. Current 7.5 mg om
b) Sulfasalazine: 500mg om till 11/2005: Pancytopenia (WBC 3.9 Hb 9.7 Plt 129)
Restarted 6/2/2007 at 500mg Om when left knee and ankle jts remained active in spite of IA TA.
Stopped since 20/2/07: AoCRF; also left knee inflammatory OA rather than RA flare
c) Hydroxychloroquine: 200mg om 12/2005 till 2/2006: blurred vision, feels unwell
d) IA triamcinalone 10/2005 and 12/2005 and 12/2006 left knee
Last admitted to RAI for left knee effusion 20/10/2007 – 23/10/2007 thought to be inflammatory OA
with a ddx of active RA: PNL 5mg om and 2.5mg on (7.5mg od) ; GWR imp was that of inflammatory
OA left knee, decision then to stop SSZ. Reduced PNL to 2.5mg bd Plans to refer ortho output.
Since discharge: Joints quiescent; remained on tailing dose of PNL until 30/10/07
TKR 18.10.07
3.11.07: With interval mild improvement of left foot pain and swelling. But reported right foot pain as
well. Ddx: ?Crystal arthropathy with worsening renal impairment (Cr 239-258) PNL increased
10mg/d x 1 week then 7.5mg/d; uric acid 573 -> 590 -> 632 umol/L
2) Hyperlipidemia
– On simvastatin 10mg on
- Last lipid panel 8/07: Chol 5.0 LDL 3.0 HDL 1.4 TG 1.4
3) Type 2 DM
- On tolbutamide 250 mg tds
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- Last HbA1c (10.11.07) 5.9%
4) Hypertension
- On atenolol 75 mg om, hydrallazine 50mg tds, amlodipine 10mg om
5) Osteopenia
- Last BMD 22/2/07 NOF-1.6, L2-4 -0.5
- Currently on calcium acetate
6) Hyperuricaemia
- Uric acid 20/2/07 – 590
- Previous 573, 98/06
7) Hypothyroidism
- On thyroxine 50 mg om
Last TFT (27.9.07): L Ft4 14; TSH 1.36
8) OA knees
- Fusion arthroplasty right knee > 15 years ago in TTSH
- S/p Left TKR 18/10/07
Current admission:
Admitted from clinic 11/12/07
c/o:
1) SOB with easy fatigability
2) Increased polydipsia and polyuria
3) Rigors x few days
No fever reported dysuria and freq
No chest pain
Family volunteered that pt felt unwell x 4 days
Slow drift: Hb 10-> 9.9 -> 8.5 -> 7.3
O/e:
TP 38
BP 90/60 (manual 108/60)
HR 86
Spo2 95% RA
Alert nontoxic
H: S1S2
L: Clear
A: Soft NT renal punch neg
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DRE: No malena/bld on PR
Ufeme
Urine c/s
Bld c/s
Issues:
1) Anemia for investigation: Post op vs GIT loss
Hb 6.3 MCV 99 (mild macrocytosis since May 07)
Fe sat 67% H transferring 1.3 Ferritin 512
Folate/vit B12 normal
2 pints PCT
Post transfusion FBC: Hb (12/12)
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Medicine (Rheumatology) = Clerking of Rheumatoid arthritis
Name/age/race/gender/occupation
Past medical history
Drug allergy
Date of admission
Presenting complaint » RA
1. Duration of disease
2. First presentation: initial clinical picture
- Joint pain and swelling: which joints involved
Acute/sudden onset
Character of pain (increase with rest, decrease with movement)
- Joint stiffness (morning stiffness > 1 hour)
- Constitutional symptoms: LOA, LOW, fatigue, fever, anaemia
- Initial investigations: x-rays, rheumatoid factors
- Initial treatment
3. Articular involvement
- How has the disease progressed?
- What joints are affected currently?
- Current symptoms: joint pain and swelling
Present everyday or occur in attacks
Frequency of exacerbations and management
Joint stiffness
- Medications: NSAIDs (renal involvement; BGIT)
DMARDS
Anti-cytokine therapy (TB reactivation, increased susceptibility to infection)
Any recent changes
Compliance
Effectiveness
Side-effects
- Physiotherapy/occupational therapy= any splints
- Surgeries: tendon transfers
Joint stabilization/replacement
- Deformities and disabilities: ADL
Work
Social recreation
Housework
Home modifications
4. Constitutional symptoms: LOA, LOW, fever, fatigue, anaemia, rash
5. Extra-articular involvement
- Eyes: episcleritis (red eyes)
Dry eyes
- Dry mouth
- Cervical spondylosis: neck pain/stiffness, radicular pain and weakness
Cervical myelopathy: bladder/ bowel involvement
Gait disturbances
LL numbness/ weakness
- Lungs: recent lung function test
Pleuritic chest pain, SOB
- Skin: vasculitic rash
Raynaud’s phenomenon
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Medicine (Rheumatology) = Scleroderma Long Case
History
Physical Exam
General Cachexia
Bird like facies
Hands Raynaud’s
Oatcinosis, ulcers
Telangiectasia
Arthropathy
Contractures
Arms/Skin Thick tethered skin
Pigmentation
Vitiligo
Proximal myopathy
Head Alopecia
Eyes
Anemia (chronic dz, folate and B12 def, Fe def from chronic esophagitis,
microangiopathic hemolytic anemia)
Sjogren’s
Mouth
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Microstomia: open <3cm max
Chest Roman breastplate tight skin
Pericardial rub
Pulmonary HTN
Lungs Fibrosis
Effusion
Chest infections
Alveolar cell carcinoma
Other joints Arthropathy
Flexion deformities
Other BP, urine dipstick for proteinuria
Investigations
To confirm diagnosis
To look for complications
Management
Supportive, symptomatic
Pt education
Scleroderma itself Cytotoxics
Early stages: cyclophosphamide, MTX
Late stage: penicillamine
Raynaud’s Vasodilators – CA++ blockers, aspirin
Oesophageal symptoms Antacids
PPIs
HTN Antihypertensives
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Look and proceed
1. FACE
Avian-like facies with pinched nose
Skin = tight
Puckering around the mouth (perioral tethering)
Telangiectasia
Mouth = Microstomia (can 3 fingers pass through?)
2. HANDS
Sclerodactyly (double-pinch test)
Vitiligo
Finger pulp atrophy
Digital resorption
Nails = breaking (pseudo clubbing)
Atrophic
Raynaud’s phenomenon with vasculitic ulcer
Telangiectasia
3. ELBOWS
Subcutaneous Calcinosis
4. PROXIMAL MYOPATHY
5. LUNGS
Bibasal pulmonary fibrosis → pulmonary HPT → cor pulmonale
6. REQUEST
(1) BP
(2) Assess function of hands
(3) Dysphagia
Raynaud’s phenomenon
Dry eyes & mouth
Diagnosis
1. Systemic sclerosis
2. Limited cutaneous scleroderma (extremities + face)
3. Diffuse cutaneous scleroderma (extremities + face + trunk)
4. Overlap syndrome (PMS, DMS, SLE)
65
Medicine (Rheumatology) = Gout
Introduction
Mono/oligo-articular crystal arthropathy resulting from a disorder in purine metabolism leading to
hyperuricemia and urate crystal formation.
Epidemiology: usually presents at 30-60 years old
Males affected more than females (9:1)
Affected females usually post-menopausal
Pathophysiology
Urate crystals deposited in minute clumps in connective tissues and remain inert for years
Release of crystals into joints due to trauma or local injury and causing a flare (acute arthritis)
Due to phagocytosis of urate crystals by WBCs, hence release of inflammatory mediators.
Clinical manifestations
Asymptomatic hyperuricemia (technically not gout)
Acute gouty arthritis
Chronic tophaceous gout
Urate urolithiasis
Urate nephropathy
Gout Pseudogout
Males > 30 years old Females > 60 years old
Smaller joints affected Larger joints affected
Acute severe pain Gradual moderate pain
Gouty tophi Chondrocalcinosis
Hyperuricaemia Normal levels or uric acid
Monosodium urate crystals = needle shaped - Calcium pyrophosphate dehydrate crystals
ve birefringent crystals = rhomboid-shaped weakly +ve direfringent
crystals (apple green)
Age, DM, acromegaly, haemochromatosis,
hypothyroidism, hyperparathyroidism
Natural History
3 classes of stages
(a) Acute gouty arthritis
Intense inflammatory response (clinically identical to septic arthritis)
Asymmetrical mono/oligo-articular involvement
Pain, swelling, increased warmth, erythema, decreased ROM
Lasts for around 1-2 weeks
Commonly affects = 1st metatarsophalangeal joint (podagra)
Ankle and knee joints
Finger joints
Olecranon bursa
Precipitating factors = trauma
Dietary indulgence (meat, fish, alcohol, legumes, tofu)
Starvation
Drugs (diuretics, aspirin, allopurinol)
(b) Interval gout
Asymptomatic period upon resolution of acute attack lasting for a variable duration.
Polyarticular flares = sequential (migratory) or cluster of adjacent joints
Peri-articular involvement = tendons, bursae
Bony erosions and deformities
66
(c) Chronic tophaceous gout
After recurrent attacks of acute gout (~75% affected over 20 years)
Clinical features
- Polyarticular = stiffness, chronic pain, deformity
- Gouty tophi =pinna of ear, olecranon bursa, prepatellar bursa, Archilles
Tendon, MTP of big toe can ulcerate and discharge chalky
Material
- Renal involvement = urate urolithiasis
Nephropathy
Aetiology
67
Medicine (Rheumatology) = Gout History taking
Name/age/ethnicity/gender/occupation
Past medical history
Date of admission
Presenting complaint
Acute painful and swollen joints
- pain, warmth, erythema
- swelling
- disability
- neurological symptoms
- constitutional symptoms= fever, chills, rigors, malaise, LOA
Etiology
- vascular= use of long term steroids
- infective= history of recent joint inoculation (septic arthritis)
History of recent URTI/GE, arthritis and conjunctivitis (reactive arthritis)
History of dysuria, urethral discharge, sexual history (gonococcal infection)
- trauma (haemarthrosis)
- autoimmune = rashes and other joint involvement (RA,SLE)
- metabolic= history of gout and gouty tophi (gout)
Usual triggers+ trigger for current episode
- inflammatory= history of chronic bloody diarrhea (IBD)
- neoplasia
Complications
- Joint deformities
- Loss of function
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- Urate urolithiasis= loin to groin pain, renal colic, dysuria, haematuria, FUN, obstructive
symptoms, history of stones
- Urate nephropathy= decreased urine output, history of renal impairment
Drug history
- Drug allergy
Social history
Family history
- Gout, DM, HPT, HCL, IHD
Differentials
- Septic arthritis (cellulitis, septic bursitis)
- Pseudo-gout (if elderly female)
- Haemarthrosis
- Rheumatoid arthritis (if oligoarticular involvement)
Investigations
Bloods
- FBC= increase WBC (infection, inflammation)
Highly increase WBC and blasts (haematological malignancy)
- PBF
- U/E/CR=renal function
- ESR, CRP
- Serum uric acid level= hyperuricemia
- Blood cultures (if septic)
- Associated metabolic conditions= fasting lipid panel, fasting glucose, HbA1c, ECG
Joint aspirate (diagnostic and therapeutic)
- Clinical chemistry= WBC count
- Gram-staining and microscopy
- Culture and sensitivity
- Polarized light microscopy
X-ray
- Acute gout= soft tissue swelling
- Chronic gout= punched out erosions adjacent to tophi
Interosseous tophi
Secondary OA changes
69
Management
Acute management
1. Colchicine
- Most efficacious if given within first 24 hours
- MOA= inhibits urate phagocytosis by WBC
- Side effects= diarrhea, nausea, vomiting, bone marrow suppression, renal impairment
- Dosing regimen= 1 g stat, 0.5g 2 hourly until a maximum of 4g or pain subsides.
2. Analgesic
- NSAIDS: give indomethacin (DO NOT GIVE ASPIRIN)
- Corticosteroids (oral/ IM/ intra-articular)
3. Joint aspiration
4. Joint immobilization
- Jones bandage
5. Rest in bed or at least 1 day after pain subsides
Chronic management (aim= serum urate <5 mg/dL)
1. Lifestyle modifications ( refer dietician)
- Weight loss
- Low purine diet: avoid beans, meats, seafood, legumes
- Avoid alcohol
2. Review medications
- Cytotoxics
- Aspirin
- Diuretics (frusemide, thiazides)
3. Medications ( should be covered with NSAIDs or colchicines)
(a) Allopurinol
- Indications: frequent major attacks ( >5x/year)
Radiological evidence of bony erosions (end-stage disease)
Urate urolithiasis
- MOA= competitive xanthine oxidase inhibitor
- Side effects: rash (5-10% risk of SJS esp within the 1st month), bone marrow suppression,
renal impairment
- Never start within 1 month of acute flare (to be avoided during acute attacks because might
exacerbate the flare)
- Can be used in patients with abnormal renal function
(b) Uricosuric agents (probenecid, sulfinpyrazole)
- S/E = gastrointestinal irritation (nausea, vomiting)
Aplastic anaemia
Nephritic syndrome
- can only be used if renal function normal → must encourage fluid intake (ensure urine
output > 2L/day)
(c) rasburicase
- MOA = urate oxidase enzyme that promotes conversion of uric acid into allantoin (inactive
metabolite and 10x more water-soluble)
- Does not occur in humans
- Indications = prevention and treatment of tumor lysis syndrome in patients receiving
chemotherapy for leukemia and lymphoma
- Very expensive!
4. Surgical intervention
- Indications = infection, deformity, pain, ulcerating tophi
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Medicine (Rheumatology) = Chronic tophaceous gout (short case)
(Confirm findings) This patient has chronic tophaceous gout with asymmetrical joint involvement. I
say this because there are multiple gouty tophi seen over the extensor surfaces of both hands
involving the MCPJ, PIPJ and DIPJ. These tophi vary in sizes = smallest being __cm and the largest __cm.
they are firm, immobile and non-tender. Some tophi have ulcerated and are extruding a chalky-white
substance onto the skin surface. There are no gouty tophi seen over the olecranon bursae.
(Disease activity) The disease is likely to be quiescent as the joints are non-tender. In addition, there is
no joint swelling, erythema or increased warmth.
Functionally, there is deforming arthropathy with asymmetrical joint involvement resulting in limited
ROM in the finger and wrist joints. However, he/she is still able to hold a cup, write and unbutton.
(Aetiology) I looked for but there were no xanthelasma seen on the face. In addition, the patient does
not appear uraemic as he/she does not appear sallow nor are there bruises or scratch marks on the
arms. There is also no arteriovenous fistula noted.
Request
(a) presence of gouty tophi = olecranon bursae, pinna of ear, prepatellar bursae, archilles tendon
(b) feet, ankle and knee for similar changes
(c) haematological malignancy = hepatosplenomegaly, generalized lymphadenopathy
(d) signs of alcoholism = duputyren’s contracture, parotidomegaly
(e) vitals = temperature, HPT
(f) urine dipstick = glycosuria (DM)
Differentials
1. Tendon xanthomata
- yellow (not chalky)
- stuck to tendons (not joints)
- bursa not involved
- no active arthritis
2. Rheumatoid arthritis
71
Diabetes
Medicine (Diabetes) = History taking
Name/age/ethnicity/gender/occupation
Date of admission
Presenting complaint
- Uncontrolled DM
- Hypoglycemia
- DKA/HHS
- Unrelated problem
72
Past medical history
- HPT, HCL, CRF, IHD/AMI, CVA, cancer, gestational DM
- Previous hospitalization
- Previous surgeries
Drug history
- Drug allergies
- Current medications
Social history
- Smoking
- Alcohol
- Family set up
- Main caregiver
- Type of housing
- Lift landing
- Finances
- Functional status
Family history
73
Medicine (Diabetes) = Dietary advice
Fats= Saturated fats < 10% DCI
Saturated fats not equal to 1/3 total fat
Change to olive/canola oil
Avoid fried and oily food
Sugars= Avoid simple sugars e.g. cakes, pastries, soft drinks, biscuits
Digest very quickly, therefore, rapid rise in blood sugar
Rice eat < ½ bowl
Bread < 2 pieces
Salt= Cut down especially in hypertensive patients
- Reduce use of sauces
- Eat more soupy stuff (gravy contains salt)
- Reduce junk food and preserved and canned food
- Use natural spices instead e.g. pepper
74
Medicine (Diabetes) = Counseling a newly diagnosed diabetic
Facts of DM:
- 9% of adult Singaporeans have DM
- 2 types: Type 1 (IDDM), Type 2 (NIDDM)
- Risk factors:
o Age>40
o Family history of DM
o Obesity
o Race
o Gestational DM
o History of HPT, IHD, polycystic ovary syndrome
o IGT
Pathogenesis
- Explain action of pancreas = secretes insulin that allows peripheral uptake of glucose
- Insulin=Hormone
- In a patient with DM: insufficient insulin or insulin resistance
- Therefore increased glucose left in blood= DM
- Chronic complications: Microvascular and macrovascular
i) Microvascular: retinopathy, nephropathy, neuropathy
ii) Macrovascular: IHD, CVD, PVD
- DM doesn’t kill but its complications do
Weight loss
- Decreases insulin resistance
- Measure patient’s height and weight and calculate BMI (Ideal<23)
- Advise on ideal weight
Diet
- Decrease blood sugar level and other risk factors (HPT, HCL)
- Explain food pyramid
Exercise
- Decreases insulin resistance
- At least 5x/week, 30 mins each time
- Should break out into light sweat
Medications
- Ask patient what types of medications they are on and when they take it
- Explore compliance
- If on insulin, demonstrate technique, get them to show you
Others
- Explain importance of annual screening
- Ask patient if there are any questions
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Medicine (Diabetes) = Diabetes Manifestations
1. Urogenital manifestations of DM
Kidneys :
- Nephrotic syndrome
- Renal failure
- Glomerulosclerosis (Kimmelstein-Wilson lesion)
- Chronic pyelonephritis
- Emphysematous pyelonephritis
- Renal papillary necrosis
- Type 4 RTA
- Contrast nephropathy
Genital
- Vaginal candidiasis
- Impotence
- Retrograde ejaculation
2. Skin Manifestations of DM
a) Suggestive of DM
- Acanthosis Nigricans
- Vitiligo
- Hyperpigmentation over neck, cheek, back of hands (Addison’s Disease)
- Thick greasy skin (Acromegaly)
- Papery thin skin (Cushing’s)
- Bronzed skin (Haemochromatosis)
b) Exclusive to DM
- Granuloma annulare
- Dermopathy
- Necrobiosis Lipodica Diabeticorum
- Scleroderma Diabeticorum (Thickening and hardening of skin)
c) Complications of Disease
- Xanthelasma and eruptive xanthomata
- Carbuncles, folliculitis, gangrene, ulcers, cellulitis, necrotizing fasciitis
d) Complications of treatment
- Lipodystrophy
- Jaundice (Tolbutamide)
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Medicine (Diabetes) = Diabetes Mellitus
Introduction
Metabolic disorder characterized by persistent hyperglycaemia due to relative/absolute insulin
deficiency
a/w long term sequelae resulting from damage to various organs
Epidemiology
Prevalence (Singapore) = 8.2% (2004 NHS), 8th most common cause of death
- Prevalence increases sharply with age
18-29 years: 0.5%
40-49 years: 7.9%
60-69 years: 28.7%
- Gender: Males (8.9%) > Females (7.6%)
- Ethnicity: Indians (15.3%) > Malays (11.0%) > Chinese (7.1%)
A/w considerable mortality and morbidity from chronic complications
- 3-fold increase in mortality mostly due to cardiovascular disease
Classification
Primary Diabetes
- Type 1 DM (IDDM): absolute insulin deficiency resulting from destruction of beta cells
Type 1A: Immune mediated
Type 1B: Idiopathic, not a/w AI disorders, more common locally
Associated AI disorders: Graves’ Disease, Hashimoto’s thyroiditis, Addison’s disease, myasthenia
gravis, celiac disease, vitiligo, pernicious anaemia
- Type 2 DM (NIDDM): disorder of insulin secretion and action (relative insulin deficiency)
May range from predominantly insulin resistance with relative insulin deficiency to
predominantly secretory defect with insulin resistance
Preceded by a period of abnormal glucose homeostasis (IFG/IGT)
Secondary Diabetes: Disease causing pancreatic islet cell damage
- Genetic defects: maturity onset diabetes of the young
- Genetic syndromes: DIDMOAD, Down, Turner’s, Klinefelter syndrome
- Exocrine pancreatic defects: Chronic pancreatitis, Ca pancreas, CF, haemochromatosis
- Endocrinopathies: Cushing’s syndrome, acromegaly, hyperthyroidism, PCOS, phaechromocytoma,
glucagonoma
- Drugs: glucocorticoids, thyroxine, diuretics, phenytoin, alpha-interferon
Gestational Diabetes )GDM): insulin resistance related to metabolic changes in pregnancy, increased
insulin requirements leading to impaired glucose tolerance
Pathogenesis
Type 1 DM
- Absolute insulin deficiency resulting from autoimmune destruction of islet beta cells
- Commonly develops in childhood, manifests at puberty and progresses with age. But can occur at any
age (even in 8th, 9th decade of life)
- AI markers: Islet cell Ab; glutamic acid decarboxylase Ab, insulin Ab,
Phases
(a) Prediabetes = autoAb as markers
(b) - honeymoon phase = spontaneous decrease in insulin requirement after starting treatment, may
last 3 to 6 months, exogenous insulin abates inflammatory process and allows remaining beta cells to
function
- Relapse phase = progressive increase in insulin requirements
- Permanent phase = complete destruction of beta cells
Type 2 DM
- Most common form of DM
77
- Multi-factorial: genetic, environmental
no evidence of AI defects
- Associated with metabolic X syndrome = obesity, hypertension, dyslipidaemia and DM
- 2 main metabolic defects = insulin resistance + beta cell dysfunction
Type 1 DM Type 2 DM
Aetiology Absolute insulin deficiency 1. Insulin resistance
- Genetics: - Genetics
HLA-genes no HLA-linkage
Twins = 30-70% Twins = 60-80%
concordance concordance
- AI destruction - Environment: obesity
- Viral infection? 2. Beta cell dysfunction
Age of onset Juvenile (<20 years) Adult-onset (>40 years)
Weight Normal/LOW Obese
Lab results
- Plasma insulin Absent/Low High/Normal
-Plasma glucagon High (due to low/no Low
insulin)
-Anti-islet cell antibodies Yes No
Islet cell morphology Insulitis No insulitis
Marked atrophy and Focal atrophy and amyloid
fibrosis deposition
Complications Diabetic ketoacidosis Hyperglycaemic
Hypoglycaemia Hyperosmolar State
78
Medicine (Diabetes) = Hypoglycemia
Definition:
1) Low blood sugar levels: < 3.0 mmol/L (venous blood)
2) Classical symptoms
3) Relieved upon correction of low blood glucose
Causes
Healthy patients Ill-looking patients
Medications/Drugs Sepsis; Shock
- Alcohol
- Salicylates
- Non-selective B-blockers=
attenuate adrenergic response
to stress
- Overdose with insulin/OHGAs
esp. long-acting sulphonylureas
Intense exercise: Unexpected/unusual Infection: Malaria, esp. with
quinine/quinidine (dose-dependent
increase in insulin secretion)
Insulinoma (MEN-1 associated) Starvation: Anorexia Nervosa
Missed/Delayed/Inadequate meals Liver failure
Gastroparesis Heart failure
Renal failure (impaired
gluconeogenesis and impaired
clearance of DM medications)
Endocrine: HPA-axis insufficiency
(in cortisol and GH insufficiency),
Insulin antibodies
Non-islet cell tumour: sarcoma,
mesothelioma
Congenital liver problems: Defects in
carbohydrate, amino acid, fatty acid
metabolism
Pathogenesis
- Brain requires constant supply of glucose to maintain function: uses alternative fuel (ketones)
- When hypothalamus senses the hypoglycaemia
1. Sympathetic nervous system activated @ ~3.0 mmol/L Adrenaline Autonomic S/S
2. Release of catabolic hormones: Glucagon, adrenaline released
Clinical features
- Wide spectrum of neurological manifestations
Neurogenic/ Autonomic activation - Sweating
(BSL=2.8-3.0 mmol/L) - Trembling
- Tachycardia
- Pallor
- Hunger
- Anxiety
Neuroglycopenia (BSL <2.5-2.8 Behavioural disturbances
mmol/L) - Irritable
- Aggression
79
- Confused/AMS
- In coordination
- Seizures
- Focal neuro deficits
- Speech difficulty
Drowsy ( GCS)
Non-specific - Nausea
- Headache
- Tiredness
80
Medicine (Diabetes) = Diagnosis of DM
Asymptomatic AND Random plasma glucose>11.1mmol/L Symptomatic AND RPG>11.1
OR Fasting plasma glucose>7.0 mmol/L mmol/L OR FPG>7.0mmol/L
Acute metabolic
decompensation
No Yes
Repeat
FPG
DM
FPG>7.0m
mol/L
No Yes
FPG
6.1-
<6.0mmol
6.9mmol/
/L >11.1
L
Normal FG OGTT
7.8-11.0
<7.8
81
Impaired Glucose Tolerance
12% prevalence in ages 18-69 (NHS 2004)
High risk of developing DM
- Develop complications before onset of DM
Metformin may help to retard progression
82
Renal Medicine
Medicine (Renal) = Nephrotic Syndrome History Taking
Name/Age/Race/Gender/Occupation
Past Medical History
Date of admission
Presenting Complaint
1. Lower limb oedema
When did it start?
Bilateral/unilateral?
Getting progressively worse?
Worse in the evening? Better in the morning?
2. Associated with
Abdominal distension? Can clothes still fit?
Increase in weight?
SOB? Exertional dyspnoea/Orthopnea/Paroxysmal nocturnal dyspnoea?
Periorbital/Facial oedema? (esp so in the morning)
3. Aetiology
Renal
o Frothy urine, oliguria, concentrated urine (signs of proteinuria)
o Haematuria (Nephritic syndrome)
o Fever, URTI symptoms (trigger, post infectious glomerulonephritis)
o Diarrhoea (IgA nephropathy)
o History of Hepatitis B/C infection
o Recent drug intake
o Joint pain, rashes (autoimmune)
o Polyuria, polydipsia, polyphagia, LOW (DM)
CVS
o Chest pain, SOB, palpitations, giddiness/syncope, diaphoresis, nausea/vomiting
GIT
o LOA, LOW, lethargy, jaundice, pruritus, easy bruisability (chronic liver disease)
o Mucoid/bloody stools, alternating constipation and diarrhoea (inflammatory bowel disease)
4. Complications
Spontaneous bacterial peritonitis (fever, abdominal pain)
Hypovolemia (abdominal pain, vomiting, dizziness)
2. Management
83
Followed up with whom? Frequency of follow up? Compliance to follow up? Investigations done at
every follow up? Annual investigations?
Medications?
o Steroids, cyclophosphamide, chlorambucil, levamisole, cyclosporine A
o Compliance with medications?
o Side effects: obesity, hypertension, cataracts, osteoporosis, increased susceptibility to infections,
cosmetic changes, gastritis, diabetes
Fluid and dietary restrictions
o Fluids: as desired
o Diet: no refined sugars, no fat (if patient is on steroids), less protein
Level of control
o Number of relapses? Number of hospitalisations?
o For each relapse Presentation? Triggers? Treatment?
o When was the last episode?
Monitoring
o How often?
o Records in nephrotic diary?
o Do you know what to do when proteinuria is found?
o Indications for admission?
3. Complications
Hypovolemia (abdominal pain, vomiting, giddiness)
Acute renal failure
Thromboembolism
o Was any blood clot found?
o Treatment with heparin/warfarin only if symptomatic or immobile
Increased susceptibility to infections
Spontaneous bacterial peritonitis
o History of abdominal pain of fever treatment?
o Pneumococcal vaccinations?
o Prophylactic antibiotics?
Hyperlipidemia
o On statins?
Drug History
1. Drug allergies
Social History
1. Smoking
2. Alcohol drinking
3. Family set-up? Main caregiver?
4. Finances
5. Have to miss a lot of work?
Family History
84
Medicine (Renal) = Nephrotic Syndrome
*in an oedematous patient always test for proteinuria and investigate for nephrotic syndrome if
albustick >= 2+
Definition
1. Clinical entity
2. Characterized by classical triad
Proteinuria (> 3g/1.73m3/day)
Hypoalbuminemia (<30g/L)
Oedema
3. Usually associated with hyperlipidemia and lipiduria
4. Hypertension, haematuria and azotemia are rare (characteristic of nephritic syndrome)
Aetiology
1. Primary glomerulonephritis (usually non-proliferative glomerulonephritis)
Minimal change disease
Focal segmental glomerulosclerosis
Membranous glomerulonephritis
Membranoproliferative glomerulonephritis
2. Secondary glomerulonephritis
Vascular (Henoch-Schönlein Purpura)
Infective (hepatitis B/C, malaria, HIV, post streptococcal)
Drugs (captopril, TCM, NSAIDS, gold, penicillamine)
Autoimmune (SLE)
Metabolic (diabetes)
Infiltrative (Amyloidosis)
Neoplasia (multiple myeloma, lymphoma)
Causes
1. Children
Minimal change disease (80%)
2. Adults
Minimal change disease (30%)
Focal global sclerosis (21%)
Mesangial proliferative glomerulonephritis (25%)
Membranous glomerulonephritis (12%)
Focal segmental glomerulosclerosis
Pathogenesis
1. Derangement in glomerular capillary walls proteinuria hypoalbuminemia
2. Loss of oncotic pressure generalised oedema
3. Drop in plasma volume diminished glomerular filtration rate compensatory rise in aldosterone
promotes retention of salt and water by kidneys further aggravates oedema
Clinical signs
1. Oedema (periorbital, facial, lower limb, genitalia, sacral)
2. Pleural effusion
3. Ascites
4. Xanthelasma
5. Leuchonychia
6. JVP and BP
85
Complications
1. Hypovolemia
Presents with abdominal pain, vomiting and giddiness
Pathogenesis: third space loss results in insufficient blood volume in vessels to maintain adequate
blood pressure leads to peripheral vasoconstriction and urinary Na+ retention
Indicators: decreased urinary Na+, increased hematocrit/urea/creatinine
Management: IV 20% albumin
5. Hyperlipidemia
Pathogenesis
o Lipoprotein synthesis triggered by hypoalbuminemia
o Abnormal transport of circulating lipid particles
o Impaired breakdown of lipoproteins
Usually improves with resolution of nephrotic syndrome
Increases the risk of ischemic heart disease and arthrosclerosis
Management
o Statins (if prolonged)
Investigations
1. Confirm diagnosis of nephrotic syndrome
Urine dipstick
o Proteinuria
o Haematuria
o Glycosuria
UFEME and urine cultures to rule out urinary tract infection as a cause of proteinuria
Liver function test to check for hypoalbuminemia
Fasting lipid panel to check for hyperlipidemia
Acute management
1. Fluid restriction to < 1L/day
2. Low salt and low protein diet
3. Place on I/O charting
4. Daily weights and albustick
5. Monitor vitals Q4hourly (inform if systolic BP is <100mmHg or Hr >100/min)
6. Symptomatic treatment
IV Lasix (furosemide) and PO Span K (aim for 1kg loss/day) with/without spironolactone (K+ sparing
diuretic) and IV 20% albumin symptomatic treatment for hypotension
PO ACE inhibitors/ Angiotensin II receptor blockers (ARB) proteinuria
PO statins hyperlipidemia
87
Thromboembolic deterrent (TED) stockings, anticoagulants prevent thromboembolic event
o Consider ambulatory problems/immobility
o Consider risk factors for deep vein thrombosis (DVT)
o Consider severe proteinuria with low albumin
Chronic management
1. Immunosuppression
2. PO furosemide with Span K and low salt diet only if oedematous
3. Monitoring at home with albustick and educate patient on how to escalate therapy and when to admit
4. Prevention of infections
Pneumococcal vaccination
Prophylactic antibiotics
Prompt treatment of infections
NO LIVE ATTENUATED VACCINES (especially if on steroids)
Immunosuppresants
Immunosuppressive therapy is used for minimal change disease
1. Corticosteroids
High dose prednisolone (1mg/kg/day)
80% remission rate achieved by 16 weeks
Regime
o High dose prednisolone continued for 1 week after remission is achieved
o Taper dose over 6 months, and subsequently discontinue
o Can give alternate day prednisolone during tapering to minimise side effects
Complications
o Cosmetic changes: moon-like facies, hirsutism, acne, central obesity, buffalo hump,
supraclavicular fat pads
o Metabolic: obesity, diabetes, hypertension
o Endocrine: menstrual irregularities, Addisonian crisis, osteoporosis
o Musculoskeletal: proximal myopathy, aseptic necrosis
o Posterior subcapsular cataracts
o Gastritis/Peptic ulcer disease (PUD)
o Increased catabolism: thin skin, easy bruising, abdominal striae
o Increased susceptibility to infections especially opportunistic ones
o Steroid psychosis
2. Alkylating agents
Cyclosporine A, cyclophosphamide
o Indicated in frequently relapsing, steroid dependant nephrotic syndrome (clinically significant
cataracts, difficult hypertension, diabetes, and disabling emotional disorders due to cosmetics
appearance)
3. Mycophenolate mofetil
4. Tacrolimus
88
Medicine (Renal) = Secondary Hypertension
Indications for screening
o Age of onset <40years old or >55 years old
o Severe or refractory hypertension
o Sudden rise in BP over a previously stable value
Renal artery stenosis
o Most correctable cause of secondary hypertension
o Presentation
Patients <30yo with no family history/risk factors
Patients >55yo presenting with severe hypertension
Refractory or resistant hypertension (compliant to full dosages of an appropriate 3-drug
regimen including a diuretic)
Hypertensive emergency
Acute elevation in plasma Cr after use of ACE-I or ARB
Unilateral abdominal bruit
o Causes
Atheroma (elderly male smokers)
Fibromuscular dysplasia (young females)
o Management
Balloon angioplasty
Conn’s syndrome (primary hyperaldosteronism)
o Primary hyperaldosteronism
Excess pdn of aldosterone independent of RAA system
Conn’s syndrome (aldosterone-secreting adenoma)
Primary adrenocortical hyperplasia
Adrenal carcinoma (rare)
o Secondary hyperaldosteronism
Decreased renal perfusion (RAS, coarctation of aorta)
Pregnancy (estrogen-induced increase in rennin)
Arterial hypovolemia and oedema
o Clinical presentation
Suspect conn’s syndrome in hypertensive patients with
Hypokalemia
Refractory hypertension
Severe hypertension before 40yo (esp in females)
o Investigations
U/E/Cr = hypokalemia, hypernatremia
Plasma rennin and aldosterone = raised aldosterone with low rennin levels
CT A/P
o Management
Conn’s syndrome = surgery with pre-op spironolactone
Hyperplasia = spironolactone/amiloride
Pheochromocytoma
o Composed of chromaffin cells found in adrenal medulla which synthesize and release
catecholamines
o Rule of 10s
10% rise in association with several familial syndromes (MEN 2, NF 1, von Hippel-
Lindau syndrome)
10% are extra-adrenal
10% are bilateral
10% are biologically malignant
o Clinical presentation
Abrupt onset of hypertension hypertensive emergency
Symptoms
Episodic headaches, palpitations, diaphoresis, postural giddiness
May be precipitated by sneezing, stress and smoking, etc
Physical examination
89
May have no signs
Medullary thyroid cancer
o Investigations
Peritoneal Dialysis
Types
o Continuous ambulatory PD (CAPD)
o Automated PD (APD) – fluid exchange performed by machine, usually 3 cycles per night
Process
o Hypertonic lactate + glucose solution placed into peritoneum via Tenchkoff catheter (inflow
10min; outflow 20min)
o Results in hyper filtration across peritoneal membrane
o Since lactate can diffuse into blood stream patients tested and classified into high and low
transporters of lactate
High transporters need to remove dialysis fluid after 3 hrs
Low transporters need to remove dialysis fluid after 4-5 hrs
o Lactate degradation products can cause sclerosis of peritoneal membrane compromises
hyper filtration and diffusion
Advantages
1. Simple, reliable and safe from a cardiovascular point of view (suitable for patients with low EF)
2. Convenient greater freedom of mobility
3. Pain free
4. Removes large volume of fluids
5. Greater freedom of diet and fluid intake
6. Preserves residual renal function as BP fluctuates less (BP fluctuations during HD causes
repeated renal micro infarcts)
Disadvantages
1. Patient motivation and treatment compliance required
2. Limited to patients <75kg
3. Body imagine problems catheter sticking out of abdomen
Ideal candidates
1. Elderly
2. Diabetics
a. IP insulin
b. Difficult venous access
c. Low EF
3. Stroke patients
a. Mobility problems
4. Paediatric patients
5. IHD patients
a. Low EF
b. Cannot tolerate BP variations
Contraindications
1. Polycystic kidneys = less intra-peritoneal volume available
90
2. Multiple abdominal surgery = adhesions (anatomical distortions), peritoneal fibrosis (decreased
efficacy)
3. Colostomy/ileostomy
4. Abdominal wall hernias
Other things to take note
1. EPO injections
2. Vitamin D and calcium supplements
3. Prepare AVF in case Tenchkoff catheter needs to be removed (backup dialysis modality).
Otherwise IJ catheter will be required in event of PD failure.
4. High protein diet = replace protein loss in dialysis
5. Potassium supplements = replace losses in dialysis
Complications
1. PD peritonitis
Main complication
Results in significant morbidity, catheter loss and long-term failure of peritoneal
viability for further PD
Empirical Rx with cefazolin and gentamicin for 2-3 weeks until culture results
return
Gram +ve (S aureus and S epidermidis): usually can resume PD once peritonitis
resolves
Gram =ve (E coli): usually due to fecal contaminants or diverticular disease. Catheter
removed and patient given IV antibioitics
2. Exit site infection
3. Catheter blockade or displacement
4. Protein and potassium losses
5. Abdominal wall hernias
6. Basal atelectasis
7. Pleural effusion
Peritoneal-pleural fistula = ligation
Foramen of Morgagni = pleurodesis
8. Hydrocele (patent tunica vaginalis)
9. Hyperglycemia and lactic acidosis (dialysate left too long)
Haemodialysis
Advantages
o No protein or potassium losses
o Removes large volumes of fluid
o Regular supervision and nursing intervention
o Patient free of burden of caring for self (esp for patients with poor motivation)
Disadvantages
o Bound to dialysis centre difficulties travelling abroad
o Heparin use increased risk of bleeding
o Increased CVS instability
o Requires vascular access difficult venous access. Blockade, infection, thrombosis.
AVF: longer lifespan (7-10 yrs). Fewer complications.
AVG: use of synthetic tubes or saphenous vein. Shorter lifespan (2yrs).
o B2-microglobin Amyloidosis: may cause CTS, arthralgia and bony changes. Better removed via
hemofiltration.
91
Medicine (Renal) = Renal Transplant (Major Risks)
General risks
o Risk of GA (<1%)
o Risk of death (<1%)
o Pain
o Bleeding (<1%)
o Wound infection (<1%)
o Damage to surrounding structures
Specific risks
o Early
Renal vein thrombosis (<5%)
Ureter anastomotic leak (<5%)
Acute graft rejection
Blood-borne infections
o Late
Immunosuppresants
Risk of infection (esp 1st 6mths)
Risk of cancer
Specific side effects
Chronic graft rejection & graft failure
Require HD/PD again
93
- Bladder neck obstruction
Medicine (Renal) = Urinary Tract Infection / o Urethral strictures, BPH/prostate ca,
Pyelonephritis bladder calculi, bladder tumour, bladder
neck stenosis, Neurogenic bladder,
Definitions posterior urethral valve, constipation, ca
- UTI = pure growth of >105 colony forming cervix/uterus, ca colon, retroperitoneal
units/ml OR 108 CFU/L fistuli
o Urethritis - Reflux uropathy
o Cystitis o Vesico-ureteric reflux (VUR), intra-renal
o Prostatitis reflux
o Pyelonephritis - Instrumentation
- Bacteriuria = presence of bacteria in urine o Urinary catheterization, flexible cystoscopy,
o Asymptomatic (covert) only requires TURP
further investigation and treatment if - Immunosuppression
occurring in infants, pregnant women or o DM, AIDS, steroids
urinary tract abnormalities
o Symptomatic
Organisms
- Abacterial cystitis/urethral syndrome = UTI
- E. coli (>70%)
symptoms but no Bacteriuria (1/3 of women)
- Enterococcus
- Recurrent UTI = a further infection with a new
- Enterobacter
organism
- Proteus
- Relapse UTI = a further infection with the same
- Klebsiella
organism
- Pseudomonas
Differential Diagnoses
Symptoms
- Acute appendicitis
Cystitis - Frequency
- Diverticulitis
- Urgency
- Cholecystitis
- Nocturia
- Salpingitis
- Dysuria
- Perinephric abscess
- Haematuria
- Suprapubic pain
Typical Patient Profile - Cloudy and foul
- Women = prevalence increases with age smelling urine
- Men = uncommon (usually in 1st year of life or - Obstructive
>60 y/o, a/w BPH) symptoms
o Must always rule out urinary tract Acute Pyelonephritis - Fever a/w chills and
abnormalities - Almost always a/w rigors
lower UTI - Renal colic
Classification (ascending) - Vomiting and
Upper UTI Lower UTI - Haematogenous diarrhoea
- Pyelonephritis - Urethritis route less common - Symptoms of lower
- Cystitis UTI
- Prostatitis - Acute renal failure
oliguria
Uncomplicated Complicated - Sepsis
- Normal renal tract - Male patients Prostatitis - Flu-like symptoms
- Normal renal function - Abnormal urinary - Lower back ache
- Normal host defenses tract - Enlarged & tender
- Impaired renal prostate
function - Few urinary
- Impaired host symptoms
defenses Signs
- Virulent organisms - Fever
- Signs of dehydration
Risk Factors - Abdominal tenderness/guarding
- Female - Positive renal punch
- Sexual intercourse - Renal mass
94
o Hydronephrosis, renal abscess Prostatitis trimethoprim (check G6PD
- Bladder distension status)
- Enlarged and tender prostate - Change as required when urine
o Prostatitis c/s results return
- Usually treat for 28 days
Complications - If severe: IV cephalosporin +
- Perinephric abscess gentamicin
- Pyonephrosis Advice - Drink > 2L water per day
- Necrotizing papillitis in pyelonephritis ARF - Urinate frequently
- Urosepsis - Double void if reflux present
- Wipe from front to back after
Investigations micturition
Urine - Post-coital voiding
- Urine Leukocytes, nitrites, proteinuria, Prevention - Abx prophylaxis for recurrent
dipstick haematuria UTI: trimethoprim,
- UFEME WBC, RBC, casts nitrofurantoin
- Urine c/s - Cranberry juice (inhibits
adherence of E. coli to bladder
cells)
Bloods
- FBC WBC and differential count
- ESR and Inflammatory markers
CRP Sterile Pyuria
- U/E/Cr Renal impairment a) Renal TB
- Blood c/s If patient is septic b) Inadequately treated UTI
c) Calculi
d) Prostatitis
Imaging e) Bladder tumour
- KUB Radio-opaque stones f) Interstitial nephritis
- CT KUB Highly suspicious of stones g) Appendicitis
- Renal U/S Hydronephrosis
- IVU Physiological/anatomical upper Urinary Catheters and Lifespan
tract abnormalities
a) Foley’s = 2 weeks
Radiolucent stones b) Silicon-coated = 4-6 weeks
Renal function
c) Silicon = 3 months
- Flexible Lower urinary tract abnormalities
cystoscopy
- MCU Reflux uropathy
- DMSA Renal scarring and differential
- MAG-3 renal function (recurring UTI)
Management
Lower UTI - Empirical Abx: trimethoprim
(check G6PD status),
amoxicillin, nitrofurantoin
- Change as required when urine
c/s results return
- Usually treat for 7 days
95
Medicine (Renal) = Assessing volume status
1. Cx of hypovolemia:
- Cerebral hypoxia
- ARF
- AMI
- Hemorrhagic enteropathy
- Liver failure (fatty change, haemorrhagic necrosis, impaired lactate metabolism)
2. Cx of hypervolaemia
- Pulmonary oedema
- Pleural effusion
- AMI/CCF
- Hypertension
3. Physiology
2/3 intracellular
(40%)
2/3 water 1/3 extracellular 2/3 interstitial (13%)
(60%) (20%)
Body 1/3 intravascular (7%)
1/3 solids
(40%)
6. Replacement fluids
a. Crystalloids – normal saline (limited to extracellular space), Ringer’s lactate, Hartmann’s
solution
b. Colloids – albumin, gelafundin
i. Stays within intravascular space
ii. Indications: for volume expansion in acute blood loss, hypoalbuminaemic states eg.
cirrhosis (causes intravascular depletion and interstitial fluid excess)
c. Blood
7. Dextrose
a. Distributes within both intracellular and extra cellular spaces
b. Once dextrose is metabolised, infusion is essentially free water may cause cell lysis
c. D5 consists of 50g of dextrose dissolved in 1L of water, has an osmolality of 252mosm/L
d. Can be used when treating hypoglycaemia or when keeping IV access patent in patients with
intravascular volume excess (quickly leaves intravascular space)
e. Dextrose/saline – maintenance IV fluid for patients who cannot accomplish normal oral intake
97
Medicine (Renal) = Fluid and electrolytes (Acid- base disorders)
*acidosis = right shift of oxygen dissociation curve, poor pulmonary uploading, also a/w hyperkalemia
*alkalosis = left shift of oxygen dissociation curve, poor tissue unloading, also a/w hypokalemia and
hypocalcemia free ionic calcium decreases due to increased binding to serum albumin
Normal values
1. pH = 7.40 (7.35-7.40)
2. HCO3 = 24mmol/L (22-32)
3. PCO2 = 40mmHg (35-40)
pH pCO2 HCO3
98
Step 2: Respiratory or Metabolic?
HCO3 decrease
(a) Common (esp < 12 mmol/L) = metabolic acidosis
(b) Uncommon = respiratory alkalosis + metabolic compensation
pCO2 increase
(a) common = respiratory acidosis
(b) uncommon = metabolic alkalosis + respiratory compensation
Respiratory Decrease Decrease HCO3 Acute = HCO3 decrease by 2mmol/L for every
alkalosis pCO2 10mmHg decrease in pCO2
Chronic = HCO3 decrease by 5mmol/L for every
10 mmHg decrease in pCO2
Metabolic acidosis
Primary cause = low HCO3
- Respiratory compensation = hyperventilation
Calculate anion gap = (Na + K) – (Cl + HCO3)
- Normal = 12-17 mmol/L
- High anionic gap nearly always a/w metabolic acidosis
Metabolic alkalosis
Primary cause = high HCO3
- Respiratory compensation = hypoventilation
Causes
1. Excess alkali intake = acute alkali administration, excessive acetate in TPN, exchange transfusion
(from breakdown of citrate)
2. ECF contraction = vomiting, diarrhea, diuretic therapy (K depletion)
3. Mineralocorticoid excess (Cushing’s syndrome, primary hyperaldosteronism)
Mechanisms = Acid loss (GIT, renal)
Acid shift (intracellular shift of H in hypokalemia)
Increased HCO3 intake (massive blood transfusion causing breakdown of
citration)
Contraction alkalosis (loss of HCO3 poor and Cl rich ECF)
Complications
1. CNS = mental confusion, obtundation, seizures, parasthesia, cramps
2. Hypokalemia
3. Cardiac arrhythmias
Management
(a) Identify reversible causes
(b) Saline responsive alkalosis (vomiting, diarrhea, diuretics) = NaCl infusion and KCl replacement
(c) Saline resistant alkalosis (Conn’s, Cushing’s) = treat underlying causes
(d) Severe alkalosis = arginine HCl, NH4Cl, acetazolamides (NAGMA)
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Respiratory acidosis
Primary cause = hypoventilation
- Metabolic compensation = decreased renal excretion of HCO3
Causes
1. Drugs = sedatives, opiates, anaesthetic agents
2. CNS depression = brainstem stroke
3. Neuromuscular disorder = GBS, myasthenia gravis, polio
4. Thoracic cage limitation = kyphoscoliosis, flail chest
5. Restricted lung expansion = pneumothorax, pleural effusion, hemothorax, diaphragmatic paralysis
6. Pulmonary disease = pneumonia, ARDS, pulmonary oedema, pulmonary fibrosis, COPD
Respiratory alkalosis
Primary cause = hyperventilation
- Metabolic compensation = increased renal excretion of HCO3
Causes
1. Drugs = salicylates, catecholamines, L-thyroxine
2. CNS stimulation = SAH, meningitis, stroke, encephalopathy
3. Psychogenic = hysteria, anxiety
4. Pulmonary disease = pneumonitis, asthma, pulmonary embolism, FB
5. Excessive mechanical stimulation
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Medicine (Renal) = Respiratory Disorders
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Medicine (Renal) = Renal Tubular Acidosis (RTA)
Introduction
o Condition of systemic acidosis caused by renal tubular dysfunction
o 2 types of RTA
1: Hypokalaemic hypochloraemic metabolic acidosis
2: Hyperkalaemic hyperchloremic metabolic acidosis
o Renal function usually normal
Type 1 (Distal RTA)
o Primary abnormality
Failure of H+ excretion by distal tubule (defective H+ ATPase)
Therefore…
Failure of Na+ reabsorption
Aldosterone release
o Biochemical results
K+ , HCO3- , Cl-
Normal anion gap
(Alkaline urine that cannot acidify following acid load)
o Causes
Primary (AD,AR)
Secondary
Pyelonephritis, obstructive uropathy, lithium)
o Clinical features
Growth failure
Nephrocalcinosis
Renal stones
Osteomalacia
o Management
HCO3- and K+ supplements
Type 2 (Proximal RTA)
o Primary abnormality
Failure of proximal tubule in HCO3- reabsorption (Slow H+/NA+ pump)
o More severe than Type 1 RTA
o Biochemical results
K+ , HCO3- , CL-
Normal anion gap
(Alkaline urine that can acidify following acid load)
o Causes
Primary (AD, sporadic)
Secondary
Familial syndromes (Failure of glucose, PO43- and amino acid reabsorption)
o Clinical features
Growth failure
Rickets
Polyuria, polydypsia, dehydration
No renal calcification
o Management
HCO3- and K+ supplements
Type 4
o Primary abnormality
Aldosterone deficiency/resistance
Failure of NA+ reabsorption and K+/H+ excretion
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o Biochemical results
K+ , HCO3- , CL-
Normal anion gap
(Acidic urine)
o Causes
Adrenal disorders (Addison’s disease, CAH), R A renal
Hyporeninaemic hypoaldosteronism (interstitial nephritis) R A renal
Pseudohypoaldosteronism R A
o Clinical features
Primary renal disease
Adrenal disease
o Management
HCO3- supplements
K+ reduction (Eg. Furosemide, thiazides)
Flucortisone
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Medicine (Renal) = Potassium Disorders
Physiology
K+ is the major intracellular cation
Na+/K+ ATPase involved in regulating K+ balance -> stimulated by insulin and B-adrenergic agonsits
Renal handling
1. ~90% of filtered K+ reabsorbed actively in the proximal tubule and thick ascending limb
2. actively secreted by distal nephron if GFR reduced -> avoid hyperkalemia
-mediated by aldosterone
Hyperkalaemia
1. Definition = K+ > 5.0 mmol/L (3.5 – 5.0)
2. Causes
105
3. Grading of severity
a. Mild = K+ <6.0 mmol/L
ECG can be normal or show tall tented T waves
b. Moderate = K+ = 6.0 -7.0mmol/L
ECG shows tall tented T waves
c. Severe = K+ >7.0mmol/L
Clinical presentation = parasthesia (tingling around lips/fingers)
muscular weakness (flaccid paralysis, loss of tendon jerks)
abdominal distension, paralytic ileus
cardiac arrythmias -> sudden death
ECG changes = tall tented T waves
increased PR interval
widening of QRS complex
ventricular tachycardia/fibrillation
4. Management
a. Resuscitate the patient = ABC
b. Create IV access
c. Place on continuous ECG monitoring
d. Treat reversible causes = hypovolemia, acidosis (do ABG)
e. 4-step management
i. Stabilize membrane potential = IV 10ml 10% calcium gluconate over 10 mins
Immediate onset and effects last for 1 hr
Cardio-protective function (does not reduce serum K+)
IV calcium to be used only = ECG evidence of severe K+
o Severe hyper K+
o Significant neuromuscular weakness
Use with absolute caution in patients on digoxin -> severe digitalis toxicity
Ensure IV line is working -> extravasation of calcium into subcutaneous tissue can cause
necrosis
ii. Shift ECF K+ into ICF
1. IV bolus 40ml 50%D + 10units soluble insulin over 10min (6U to renal failure patients)
2. IV 0.5mg Salbutamol in 5%D over 10 min
neubulized salbutamol: N/S = 1:3 over 10mins
Risk of tachycardia
iii. Remove K+ from the body
1. Resonium A (15 – 30g PO; 30g rectal enema)
2. haemodialysis
iv. Prevent further K+ increase
1. Medications review and advice
2. Dietary review and advice
f. Treat concomitant metabolic acidosis with 8.4% NaHCO3
5. HO on call
a. Check with sample is not haemolysed
b. Ask for patient’s vitals and symptoms (i.e. chest pain, SOB, palpitations, parasthaesiae, weakness)
c. Past medical history = ESRF
d. Order ECG if K+>5.5 mmol/L and place on contunous ECG mentoring if K+>6.0 mmol/L
e. Orders
i. K+ > 5.0 mmol/L = PO Resonium 15g stat or 30g fleet enema
ii. K+ > 5.5 mmol/L = as above
IV 10ml 10% calcium gluconate over 10mins
IV 40ml D50% + IV 10U soluble insulin
iii. K+ > 6.0 mmol/L = as above
nebulised salbutamol:N/S = 1:3 over 10 mins
iv. If fluid overloaded as well = IV Frusemide
urgent dialysis (if recalcitrant to treatment)
f. Recheck if K+ 2 hrs later
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Hypokalemia
2. Causes
3. Clinical presentations
Muscle weakness
Hypokalemic periodic paralysis (intermittent weakness lasting up to 72hrs)
Reduced intestinal motility -> paralytic ileus
Cardiac effects
o Ventricular arrythmias
o Asystole
o Potentiation of digitalis toxicity
ECG
o Flattened T waves
o Prominent U waves
o Prolonged PR interval
o Severe (ST depression, T wave inversion)
4. Management
Absolute indications for treatment
1. Digoxin therapy
2. DKA treatment
3. Respiratory muscle weakness
4. Severe hypokalaemia (<2.5mmol/L)
5. HO on call
1. Check that sample not spurious, i.e. not taken distal to drip site
2. Check patient’s vitals, PMHx, current medications = stop diuretics, insulin and salbutomol
3. Order ECG if K+ < 3.0mmol/L and place on continuous ECG monitoring if K+ < 2.5 mmol/L
4. Orders
K+ < 3.5 mmol/L
o Oral Span K+ 0.6 – 1.2g OM
o Mist KCL 10ml TDS
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K+ < 2.5 mmol/L or K+ < 3.0 mmol/L with digoxin/AMI/IHD = IV KCl replacement
o Check that patient is not oliguiric
o Calculate K+ deficit = 0.6 X BW X (4 - __)
o 1 cycle = 10mmol of 7.45% KCl solution in 100ml water given over 1 hr increases K+ by 0.1 unit
o IV K+ = maximum 20 mmol/hr, maximum 20 mmol/pint, never given as IV bolus
5. recheck K+ 2 hrs post-replacement
Spurious Non-Spurious
*Taken just distal
to drip site Step 1: Serum osmolality
(280 – 295 mosm/kg)
Low Normal/High
True Pseudohyponatraemia
hyponatraemia *Causes = ↑ lipids, ↑
Step 2: Urine osmolality proteins, ↑ glucose
*True Na+ =
<100mosm >300mosm
Fluid overload
Hypovolaemi Euvolaemia
Step 3: Urinary Na+ a
Step 3: Urinary Na+ Step 3: Urinary Na+
1. Excess
GIT Skin diuretics
1. Vomiting 1. Burns 2. Tubulopathy
2. Diarrhea 2. Excessive
3. Intestinal sweating
fistula 3. Exudative skin
disease
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3. Clinical Features
- Defined as:
a) Absolute ↓ in serum osmolality
b) Rate of development of hyponatraemia
c) Volume status
- Hypervolaemia = oedema
o ± associated features of CCF, liver disease, renal disease
- Euvolaemia = drug history
o ± associated features of Addison’s disease, hypothyroidism
- Hypovolaemia = dehydration
- Hyponatraemia = neurological, due to cerebral oedema (headache, lethargy, weakness, altered mental state,
restlessness, fits, coma)
4. Management
- Usually replacement of Na+ if Na+ <125mmol/L
- Hypovolaemia
o Cannot correct > 10mmol/day
∴ Na+ deficit = (140 – Na+) x 0.6 x body weight
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c) Chest
TB
Pneumonia
Abscess
Aspergillosis
d) Metabolic
Porphyria
e) Drugs
Narcotics
Chlorpropamide (OHGA)
Anti-depressants (amitriptyline)
Neuroleptics (haloperidol, fluphenazine, chlorpromazine)
- Management
o Fluid restriction
o Treat underlying cause
o Chronic symptomatic SIADH = demecleocycline/lithium (induces nephrogenic diuresis)
- In psychiatric patients = always think of drug-induced SIADH
- Exclusion criteria
o Normal renal/fluid/adrenal/thyroid function
- Inclusion criteria
o Plasma = ↓ Na+, ↓ osmolality
o Urine = ↑ Na+, ↑ osmolality
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Medicine (Renal) = Hypernatraemia
1. Definition
- Na+ > 145 mmol/L
- Usually treat when [Na+] > 150 mmol/L
2. Algorithm
Hypernatraemia
Impaired ADH
Inc. Salt intake Dec. H20 intake Excess H20 loss
regulation
Hereditary Acquired
1. Head Injury Hereditary Acquired
1. DIDMOAD Syndrome
2. Pituitary 1. Hypokalaemia
surgery 2. Hypercalcaemia
3. CNS Infection 3. Obstructive uropathy
4. Idiopathic 4. Nephrotoxic drugs
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3. Physiology
- Increased serum osmolality cause a reflex increase in thirst and ADH secretion
- ∴ hypernatraemia is rare unless thirst mechanism is abnormal or there is limited access to water
4. Clinical Features
- Hypernatraemia: confusion, coma, seizures, weakness
- Dehydration
- Diabetes insipidus: polyuria, polydipsia, increased thirst
5. Management
- Free H20 deficit = [ (serum Na – 140) x 0.6 x BW] / 140
- (Serum Na – Fluid Na) / [(0.6 x BW) + 1] = 1 L of fluid will correct Na by ___ mmol/L
- Fluids:
o D5% = 0 mmol/L Na+
o 0.9% N/S = 154 mmol/L
o 0.45% N/S = 77 mmol/L
o 0.23% N/S = 38.5 mmol/L
- Total fluids = water deficit + maintenance
- Correct ½ the deficit over 24 h and the remainder over the next 1-2 days
- Eg 60/C/Female
[Na] = 160mmol/L
BW = 60kg
Free H20 deficit = (160-140)/140 x 0.6 x 60 = 5.1L
If D5% given : (160 – 0)/ [ (0.6 x 60) +1 ] = 4.3 1 L of D5% will decrease Na by 4.3 mmol/L
If 0.9% N/S given : (160-154)/ [(0.6 x 60)+1] = 0.16 1L of 0.9% NS will decrease Na by 0.16 mmol/L
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Gastrology
Medicine (GIT) = History Taking: GIT (General)
Name/age/race/gender/occupation
Date of admission
Presenting Complaint
1. GI symptoms
a. Nausea + vomiting
Describe vomitus = nature (liquid, digested/undigested food)
colour (yellow bilious liquid, coffee-ground, blood)
Projectile pyloric stenosis, raised ICP
Timing = >1h after meal (GOO, gastroparesis)
early morning (pregnancy, raised ICP)
b. LOA + LOW malignancy, depression
How much weight was lost?
Duration
c. Dysphagia
Onset
Frequency (intermittent suggests oesophageal spasm)
Solids or liquids?
Progressively getting worse (suggests ca, stricture, achalasia)
Painful on swallowing (odynophagia)
Able to initiate swallowing? (inability suggests neurological disease)
Regurgitation (fluid regurgitation highly suggests neurological disease)
d. Heartburn + acid regurgitations (symptoms of GERD)
Precipitants = foods
Aggravating factors = lying supine, bending, alcohol, change in posture
Relieving factors = antacids
e. Abdominal pain
Onset, frequency, duration
Sudden/gradual onset
What were you doing at onset?
Constant/intermittent
Site and radiation
Character (sharp, dull, crampy, colicky)
Severity
Precipitating factor(s) (food, lying down, alcohol)
Aggravating factor(s) (movement in peritonitis)
Relieving factor(s) (sitting up and leaning forwards, antacids/vomiting in GERD/PUD, defecation in
colonic disorders)
f. Constipation
Diarrhoea = frequency (usually > 3x/day)
consistency of stools (watery)
fever (infection)
mucous (IBD, IBS, solitary rectal ulcer, villous adenoma)
blood (colorectal ca, IBD)
travel and contact history)
g. GI bleeding haematemesis, malaena, haematochezia
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If present other sites of bleeding (bleeding dyscrasia, coagulopathy from CLD)
If present chest pain, SOB, palpitations, giddiness, fatigue (symptoms of anaemia)
h. Fatigue (anaemia, chronic diseases)
i. Jaundice obstructive jaundice (pale stools, steatorrhoea, tea-coloured urine, pruritus, easy-bruising,
previous history of right-sided colicky abdominal pain)
Steatorrhoea = >7g of fat in a 24-hour stool collection. Stools are pale, fatty, extremely smelly, float in
the toilet bowl and difficult to flush away
j. Abdominal distension + ankle oedema
k. Easy bruising + pruritus
3. Complications
4. Systemic review
Drug History
1. Any known drug allergies
2. Long-term medications
- Types and indications for use (esp. NSAIDs, aspirin, warfarin)
- Dose, frequency of dosing
- Compliance with use
- Side-effects
3. TCM use
Social History
1. Smoking
2. Alcohol drinking
3. Family set-up (main caregiver, health of family members, finances)
4. Lift-landing
5. Functional status (ADL/iADL)
Family History
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Medicine (GIT) = Physical examination: GIT
Start
1. Examine patient on the right side of his bed
2. Introduce yourself and explain purpose
3. Lie the patien flat on bed with his head on a single pillow (relax abdominal muscles)
4. Achieve adequate exposure = nipple line to mid thigh
General appearance
1. Mental state (hepatic encephalopathy) = alert, drowsy, confused, stupor
2. Comfortable/ in distress
3. Cachexia = failure of GIT to absorb food normally, intra-abdominal malignancy
4. Obesity = fatty liver (non-alcoholic steatohepatitits)
5. Skin colour and pigmentation =
a. Haemochromatosis (due to haemosiderin stimulating melanocytes)
b. Addison’s disease (‘sunkissed pigementation of nipples, palmar creases, pressure areas and mouth)
6. Hydration
7. Abdomen: surgical scars, distension ± eversion of umbilicus, visible masses/ pulsations, moves well with
respiration, distended veins
Face
1. Eyes: conjunctiva pallor, jaundice
2. Preorbital: xanthelasma (yellowish plaques in subcutaneous tisues; hypercholesterolaemia; cholestatsis;
primary billary cirrhosis)
3. Mouth:
a. Breath (fetor hepaticus is rather sweet smelling; due to methymercaptans derived from methionine
which is not demthylated by diseased liver)
b. Freckle-like spots on buccal mucosa (Peutz Jeghers syndrome)
4. Tongue
a. Central cyanosis
b. Glossitis (smooth appearance due to papillae atrophy due to nutritional deficiencies e.g. iron, folate,
vitamin B12, ; common in alcoholics)
c. Geographical tongue (slowly changing red rings and lines, painless; comes and goes; may be a sign
of riboflavin (vit B2 ) deficiency)
d. Leucoplakia (white mucosal thickening; premalignant 5s = sore teeth (poor dental hygiene), smoking,
spirits, sepsis, syphilis)
e. Macroglossia (cretinism, Down syndrome, acromegaly)
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5. Lips
a. Capillary haemorrhages (hereditary haemorrhagic telangiectasia or Rendu-Osler-Weber syndrome)
b. Perioral freckle-like spots (Peutz-Jeghers syndrome)
c. Angular stomatitis (iron-deficiency anaemia; Plummer-Vinson syndrome)
Neck
1. Palpate left supraclavicular fossa for enlarge lymph node (Virchow’s node – indicating advanced intra-
abdominal malignancy)
Chest
1. Check for gynaecomastia (palpate area around nipple) and spider naevi
Abdomen
1. Kneel down at the right side of the bed and position yourself so that you are at eye level with abdomen and
watch for asymmetrical movement
2. Ask patient to point to site of pain (if any)
3. Determine direction of flow in distended veins (empty a distended vein below the umbilicus by flattening it
out and occluding it at both ends, release lower finger, empty vein again, release upper finger; if the flow of
blood is downwards, the cause is portal hypertension; if the flow of blood is upwards, the cause is due to
obstruction of IVC)
4. Begin superficial (? Soft/ guarding/ tender) and deep (organs and masses) palpation. Use the pulps of
fingers (flex metacarpophalangeal joints and distal interphalangeal joints) and palpate systematicall (work
all the way up from one side to the other and always begin from the non-tender area). Look at face during
palpation for signs of pain
a. Guarding = may result from tenderness, anxiety, peritonitis
b. Rigidity (wash board rigidity) = peritonitis
c. Rebound tenderness = peritonitis
5. If there is a mass, describe it interms of : size, shape, surface, tender, mobility, consistency, pulsatile
a. Try to get below it (if it is a pelvic mass, cannot get below it)
b. Bimanually palpate if (if cannont, then mass is located more anterior)
6. Examine specific organs: liver, spleen, kidneys
Liver
1. Place lelft hand on right costal margin and right hand at a similar angle to the ribs
2. Start in the right iliac fossa
3. Palpate deeply during inspiration and move fingers upwards during expieration (will feel liver edge moving
towards fingers during inspiration)
a. Normal causes of palpable liver: ptosis 20 hyperinflation (asthma, emphysema),
supradiaphragmatic collection)
4. Percuss intercostals spaces downwards until dullness occurs – upper limit of liver dullness
5. Lower limit is where you feel the liver edge/ percuss upwards until dullness occurs
6. Describe liver in terms of size, (hepatomegaly – measure liver span and length below right costal margin),
surface (smooth.nodular), pulsatile, tender, consistency, edge
Gallbladder
1. If biliary obsturtion/ acute cholecystitis suspected, examining hand should be oriented perpendicular to
costal margin and feel from medial to lateral
2. Do Murphy’s sign: ask patient to take a deep breath and press finger at angle between costal margin and
border of rectal sheath. If inspiration is arrested, there is a positive sign (suspect cholecystitis)
Spleen
1. Place left hand on left costal margin and begin palpation from right iliac fossa
a. Enlarged spleen descends obliquely across the mideline (must enlarge by 2x for it to be palpate)
b. Can also feel enlarged para-aortic lymph nodes and abdominal aortic aneurysm)
2. Palpate deeply during inspiration and move fingers obliquely upwards during expiration
3. Percuss over lowest intercostals space in left anterior axillary line and spleen (both areas should be
resonant)
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Ascites
1. Place left middle finger on umbilicus and start persussing to the other end (should be resonant out to the
flanks); dullness in the flanks means that there is at least 2L of ascitic fluid
2. If there is dullness before the flanks, ask patient to lie on right lateral position and wait for 30-60s for fluid
equilibration. Percuss form site of dullness back towards midline. If site of dullness becomes resonant in
this position, there is ascites. Percuss for new position of dullness (fluid level in this position)
3. Further test for ascites: ask patient to place right hand vertically in midline of abdomen, then place your
hand on left abdomen and flick fingers on right abdomen (can feel fluid thrill if there is ascites)
4. In this position, palpate for spleen
5. Check for sacral edema and scars (bone marrow biopsy → ? myeloproliferative disease)
Kidneys
1. Bimanual palpation; place left hand under patient and right hand on the abdomen and push left hand
upwards twice during inspiration (do 2 time on each side)
a. If kidney enlarge, the righ hand will feel something hitting it
b. Enlarged kidney bulges forwards; perinephric abscess bulges backwards; transplanted kidneys
palpable in either iliac fossa
Ausculatation
1. Listen for bowel sounds (tinkling and hyper active = IO; absent over 3min period = paralytic ileus)
2. Listen for renal bruits
3. Hepatic arterial bruit = alcoholic hepatitis, HCC, liver mets
4. Abdominal venous hum = portal hypertension
Groin
1. Palpate for enlarge inguinal lymph nodes
2. Ask patient to cough to detect inguinal hernias
3. Inspect for testicular atrophy (CLD)
Legs
1. Look for bruising, scratch marks and edema (press thumb against the back of malleolus, look at patient’s
face for pain)
2. Inspect toe nails for clubbing, cyanosis, pallor, leukonychia
End
1. Sit the patient up
a. Hepatic asterixis for 15s (hepatic encephalopathy)
b. Cervical lymphadenopathy
c. Parotid/ submandibular gland enlargement)
2. Tell the examiners that you would like to complete the examination by doing a PR exam, taking blood
pressure and temperature. If patient has hepatomegaly, should examine JVP. If ascites/ pedal edema
present, check for pleural effusion
3. Thank patient for his help and dress him up properly
Examination of the peripheries did not show any signs of jaundice, pallor cyanosis, dehydration or stigmata of
chronic liver disease such as clubbing, leuconychia, palmar erythema, spider naevi, gynaecomastia etc.
Inspection of the abdomen did not reveal any surgical scars, abdominal distension, distended vein or any
visible masses or pulsations. The abdomen was symmetrical and moved well with respiration. On superficial
palplation, the abdomen was soft and non-tender with no guarding or rigidity of abdominal wall muscles. The
liver was found to be enlarged at 3cm below the right costal margin with a liver span of 16 cm as measured in
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the mid-clavicular line. The surface of the liver was smooth with no nodules felt. It was non pulsatile and no
bruits were heard over the liver. The spleen and the kidneys were non-palpable. No ascites was detected. Bowel
sounds were normal and no renal bruits were heard.
Inguinal lympadenopathy and cough impulses suggestive of inguinal hernia were not detected in the groin.
Lower limb and sacral edema were absent. There was no hepatic flap.
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Medicine (GIT) = Issues for discussion
1. Signs of chronic liver disease
a. Hands = clubbing, leuconychia, palmar erythema, asterixis, bruising, petechiae
b. Face= jaundice, fetor hepaticus
c. Chest = spider naevi, gyanecomastia, loss of axillary hair, wasting of pectoral muscles
d. Abdomen = portal hypertension (ascites, caput medusa, splenomegaly), sacral edema
e. Groin = testicular atrophy
f. Legs= edema
2. Peutz-Jeghers syndrome
a. Autosomal dominant condition
b. Features
i. Freckle like spots (discrete brown-black lesions) around the mouth, buccal mucosa, fingers,
toes
ii. Harmatomas of the small bowel(50%) and colon(30%) →can present with bleeding +
interssusception, increased incidence of GI adenocarcinoma
3. Rendu-Osler-Weber syndrome
a. Autosomal dominant condition
b. Multiple small tenlangiectasiae present on lips, tongue, and skin
c. GI features = chronic blood loss, torrential bleeding, liver AV malformation
4. Hepatic flap
a. Refers to jerky, irregular flexion-extension movement at the wrist and MCP joints often
accompanied by lateral movements of the fingers
b. Mechanism = interference with the inflow of joint position sense information to hte reticular
formation in brainstem resulting in rhythmical lapses of postural muscle tone
c. Characteristics = usually bilateral, absent at rest, brought by sustanined posture, not synchronous
on each side, absent when coma suepervenes
d. Characteristic but not diagnostic of liver failure (can also occur in cardiac, respiratory, and renal
failure; also in metabolic encephalopathy – hypoglycaemia, hypokalemia, hypomagnesaemia,
barbiturate intoxication)
5. Spider naevi
a. Consist of a central arteriole form which radiate numerous small vessels
b. Usual distribution is the area drained by SVC→ found on the arms, neck and chest wall
c. Pressure applied with a pointed object to the central arteriole causes blanching of the whole lesion
with rapid refilling from the centre to the periphery on release of pressure
d. Differentials:
i. Campbell de Morgan spots (flat/ slightly elevated red circular lesions which occur on the
abdomen or chest wall; do not blanch on pressure)
ii. Venours stars (due to elevated venous pressure; found overlying main tributary to a large
vein; occur on dorsum of feet, legs, back and lower chest; not obliterated by pressure; blood
flow from periphery to centre of lesion)
iii. Hereditary haemorrhagic telangiectasia
6. Troisier’s sign = presence of a large left supraclavicular lymph node with gastric carcinoma
10. Liver
a. Normal liver span = <13 cm as measure in the mid-clavicular line
b. Pulsatile liver = tricuspid regurgitation, HCC
c. Tender liver = hepatitis, rapid liver enlargement, hepatic abscess, cholangitis
11. Gallbladder
a. Courvosier’s law= if the gallbladder is enlarged and the patient is jaundiced, unlikely to be
gallstones; gallbladder with stones is usually chronically fibrosed (small)
Gallbladder enlargement
With jaundice
1. Carcinoma of head of pancreas
2. Carcinoma of ampulla of Vater
3. Gallstones in CBD
4. Carcinoma of the gallbladder
Without jaundice
1. Mucocele/ empyema of gallbladder
2. Carcinoma of the gallbladder
3. Acute cholecysitits
12. Splenomegaly
Causes of splenomegaly
Vascular Portal hypertension
Infective Viral hepatitis , EBV, CMV
Bacterial (SBE)
Protozoal (malaria, kala-azar)
Trauma Haematoma
Autoimmune SLE
RA (felty’s syndrome)
Metabolic Storage disorders (Gaucher, Neimann-Pick, glycogen storage, lipid storage)
Infiltrative Amyloidosis
Sarcodosis
Neoplastic CML (invasive)
Myelofibrosis (massive)
Lymphoma
Lymphoproliferative disorders
Polycythemia ruba vera (massive)
Haematological Chronic haemolytic anemia, (spherocytosis, G6PD deficiency, thalassaemia)
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Medicine (GIT) = Approach to ascites
Ascites is the effusion and accumulation of serous fluid in the abdominal cavity.
Symptoms and Differential Diagnoses of Ascites
1. Causes of a distended abdomen:
Fat, faeces, fluid, flatus, fetus, filthy big tumour
2. Causes of ascites
Chronic Liver Disease/ Cirrhosis (Commonest Cause)
Chronic alcoholism
Viral hepatitis
Cardiac Failure
Chronic Renal Failure
Nephrogenic ascites secondary to dialysis
Nephrotic syndrome
Enlarged Lymph Nodes
Primary and Metastatic
Intra abdominal mass
Malignancy : Primary and Metastatic
Others :
Tuberculosis
SLE
Pancreatitis
Constrictive pericarditis
History
1. Past medical history : To identify the system responsible for the ascites
Any past medical history of any disorder like coronary artery disease, hypertension, alcohol abuse. Is
the patient on any drug that can cause cardiac, hepatic or renal disease? Does the patient have renal
failure or go for dialysis. If suspicious, a history of HIV and TB should be obtained.
2. Ascites: Alcohol history, Hepatitis B status, any intra-abdominal masses and their associated symptoms.
3. Past medical history : Hepatitis Vaccinations, any recent drugs used
4. Any associated early satiety and shortness of breath
Physical Examination
General Appearance
Does the patient have any stigmata of chronic liver disease?
Is the patient on oxygen?
Does the appear to be in any respiratory disease?
Vital Signs
Any tachycardia
Respiratory rate for tachypnea
Blood pressure measurement for hypertension
CVS Examination
Checking for raised JVP will provide great yield here as it would indicate heart failure
Other signs to pick up will include displaced apex beat, gallop rhythm, bibasal crepitations and any
possible aetiology for heart failure like valvular heart disease
Abdominal Examination
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Ask for site of most intense pain first. Palpate for presence or organomegaly. The live in alcoholic
cirrhosis is unlikely to be enlarged. However, other stigmata of chronic liver disease can be sought for
like caput medusae.
Percuss for ascites and shifting dullness
Palpate for any suspicious intra abdominal masses
Palpate for hepatosplenomegaly in portal hypertension
Lower Limbs
Check for presence of pitting edema
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Medicine (GIT) = Ascites
Introduction
Pathological accumulation of fluid in the peritoneal cavity = clinically detectable when > 500mls
Pathogenesis
Under filling theory = inappropriate fluid sequestration within splancnic vascular bed secondary
to portal hypertension > decreased intravascular volume > kidneys retain more Na+ and water by
activating RAA system
Overflow theory = primary renal retention of Na+ and water
Complications
a) Peritonitis
b) Dyspnea secondary to splinting of diaphragm
c) Pre-renal failure secondary to intravascular volume depletion
d) Early satiety
Aetiology
Transudate vs Exudate
Transudative Exudative
Cardiovascular Infection
Congestive cardiac failure TB peritonitis
Right heart failure
Constrictive pericarditis
IVC obstruction
Portal/hepatic vein obstruction
Renal Inflammation
Acute renal failure Pancreatitis
Chronic renal failure
End stage renal failure
Nephritic syndrome
Nephrotic syndrome
GI Intra-abdominal malignancy
Chronic liver disease Pancreatic/gastric/colonic ca
Malnutrition Ovarian ca
Protein-losing enteropathy Metastasis to liver
Metastasis to peritonium
Generalised vs Localised
Generalised Localised
Cardiovascular Vascular
Congestive cardiac failure Portal HPT
Right heart failure a) IVC obstruction
Constrictive pericarditis b) Budd-chiari syndrome
c) veno-occlusive disease
d) Liver cirrhosis
e) Portal/splenic vein obstruction
Renal Infection
Acute renal failure TB peritonitis
Chronic renal failure
End stage renal failure
Nephritic syndrome
Nephrotic syndrome
GI Inflammation
Chronic liver disease Pancreatitis
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Malnutrition
Protein-losing enteropathy
Intra-abdominal malignancy
Pancreatic/gastric/colonic ca
Ovarian ca
Metastasis to liver
Metastasis to peritonium
History
Name/age/race/gender/occupation
Drug allergy
Past medical history
Date of admission
Presenting complaint
Symptoms
1. Abdominal distension
duration
acute/gradual
quantity = how many inches? , weight gain
associated with LL edema, SOB (exertional, orthopnea, PND), faciel edema
fever and abdominal pain and diarrhea > SBP
Aetiology
1. CVS
History of heart disease
Chest pain, sob, diaphoresis
2. Renal
Urine output (oliguria, appears concentrated)
Hematuria and frothy urine
3. GIT
Chronic bloody diarrhea
LOA, LOW
History of liver disease – jaundice, easy bruising, pruritis changes in uring and stool, fatigue
4. Infection
History of TB
5. Inflammation
Acute epigasttric pain radiating to the back
6. Malignancy
LOA, LOW, fever, fatigue, abdominal pain, jaundice, recent changes in bowel habits,
haematochezia, melena, irregular menstrual bleeding
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Systemic review
Management prior and during admission
Has this happened before? Describe prior experiences
Differentials
Fat
Fetus
Flatus
Faeces
Fluid
Filthy big tumour
Investigations
ECG, Cardiac enzymes, CXR = CCF
Urine
Urine dipstick = proteinuria, hematuria
UFEME
Urine phase contrast microscopy
Urine PCR or 24hr UTP
Bloods
FBC = WBC ↑ (SBP), HCT (hypovolemia)
U/E/Cr = renal impairment
LFT = liver impairment, albumin
ESR, CRP
Imaging
U/S Hepatobiliary system (HBS)
CTAP
Microbiology
Abdominal paracentesis
Both diagnostic and therapeutic
Clinical parameters
Appearance (straw coloured; turbid = pyogenic, TB; bloody = malignant, TB; chylous =
pancreatitis)
Clinical chemistry (cell count and differential; protein; albumin; glucose; amylase)
Gram stain, microscopy, c/s, AFB smear, TB c/s
Fluid cytology
Serum-ascitic albumin gradient = serum albumin – ascitic albumin
Correlates directly with portal pressure
Transudate = gradient > 1.2 g/dl
Excudate = gradient < 1.2 g/dl
May be associated with a right pleural effusion via trans-diaphragmmatic lymphatics =
subpulmonic effusion
- Management = fluid restriction, strict I/O charting, vitals monitoring, IV albumin 20% with
diuretics
Management
Non-pharmacological
Fluid restriction (1 L/day)
Low salt diet
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Strict I/O charing and daily weights
Monitor vitals 4hourly – inform doctor if SBP < 100mmHg or HR > 100 bpm
Pharmacological
IV diuretic therapy = frusemide spironolactone
Albumin 20% only if patient is hypotensive – to bring back fluid from 3rd space
Diuretic-resistant ascites
therapeutic abdominal paracentesis with IV albumin 20%
TIPPS
Liver transplant
Approach to ascites
Abdominal masses
Epigastric mass (gastric ca)
RIF mass (ovarian ca, cecal ca)
LIF mass (desceding colonic ca, sigmoid ca)
If patient is jaundiced
a) Signs of CLD – liver cirrhosis Cx portal HPT
b) Minimal signs of CLD + smooth tender hepatomegaly = budd-chiari syndrome
+ craggy liver = intra-abdominal malignancy with liver/peritoneal mets
Feel for supraclavicular LAD
If patient is not jaundiced and no signs of CLD
a) Leuconychia – nephritic syndrome
b) Raised JVP – constrictive pericarditis or right heart failure
If all negative
a) TB peritonitis = chest examination
b) Carcinomatosis peritoneii = paracentesis + FNAC to see malignant cells
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Medicine (GIT) = Chronic liver disease and Liver cirrhosis
Chronic liver disease
Liver disease persisting >6 months based on LFT and histology
Liver cirrhosis
Strict criteria
a. Diffuse fibrosis
o Occurs in portal tracts, central veins and space of Disse
o Inflammation stimulates stellate cells in space of Disse transforms into myofibroblasts
o Extension of fibrosis from space of Disse to other parts of lobule causes sinusoids to separate
from hepatocytes
o Venulization = sinusoids converted from fenestrated endothelial channels with free exchange of
solutes to high pressures and fast-flowing channels without such exchange
o Shunting of blood directly from portan vein to central vein = no detoxification of metabolites
hepatocytes derived of nutrients
b. Nodule formation = consisting of regenerating hepatocytes
c. Disruption of tissue architecture = bridging fibrosis and shunt formation
Results in subdivision of liver into nodules of regenerating hepatocytes surrounded by scar tissue
Aetiology
Vascular
o Tricuspid regurgitation/right heart failure (cardiac cirrhosis)
o Veno-occlusive disease
o Budd Chiari syndrome
Infective
o Hep B and C infection
Toxin
o Chronic alcoholism
o Drugs (methotrexate, amiodarone)
o alfatoxin
Autoimmune
o Autoimmune hepatitis
o Primary biliary cirrhosis
o Primary sclerosing cholangitis
o Secondary biliary cirrhosis (RPC or chronic CBD stones)
Metabolic
o Wilson’s disease
o Secondary haemochromatosis (DO NOT mention HH as gene not found locally)
o Alpha1 antitrypsin deficiency
Cryptogenic
History
Aetiology
Vascular
o History of heart failure
Infective
o Personal history of Hep B/C infection
o History of Hep B vaccination
o Maternal history of Hep B infection
o History of blood transfusion, IVDA, CSW contact, tattooing
Toxin
o History of chronic alcoholism
o History of cytotoxic drug ingestion
Autoimmune
o History of rash, joint pain and swelling
Metabolic
128
o Family history of liver disease
Complications
Hypoalbuminaemia
o Lover limb edema
o Abdominal distension +abdominal pain/fever (SBP)
Bilirubin
o Jaundice
o pruritus
Coagulopathy
o Easy bruisability
o Petechiae may present like ITP
o Mucocutaneous bleeding
o menorrhagia
Bleeding varices - Haematemesis, haematochezia, melena
Encephalopathy - lethargy drowiness, confusion, sleep-wake inversion, personality change
Hepatorenal syndrome - oligouria
HCC
o LOA, LOW, fever, fatigue
o Regular f/u done? Annual U/S and AFP?
Physical examination
CLD = jaundice, clubbing, leuconychia, palmar erythema, bruising, scratch marks, fetor hepaticus, spider
naevi, gynaecomastia, loss of axillary hair, testicular atrophy, lower limb edema
Portal HPT = dilated veins, ascites, splenomegaly
Encephalopathy = terminal asterixis
HCC = hard and craggy hepatomegaly
Alcoholism = duputyren’s contracture, parotid enlargement
Hep B/C infection = tattoos, IV needle marks
Investigations
Aims
Confirm diagnosis
Look for underlying aetiology
Assess severity
Look for complications
Bloods
FBC
o Hb decrease, WBC decrease, pII decrease (hypersplenism)
o WBC increase (SBP)
o Hb decrease (folate/iron-deficiency anemia)
o MCV decrease (alcoholism)
LFT
o Bilirubin increase
o AST>ALT (alcoholic liver disease)
o GGT increase (alcohol liver disease)
o ALP increase (biliary obstruction)
o Albumin (marker of synthetic function; malnutrition)
PT/PTT = prolonged PT (marker of synthetic function)
U/E/Cr = hepatorenal syndrome
Hepatitis serology
Autoimmune screen
Tumor markers = AFP
Imaging
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U/S HBS
o Development of HCC
o Biliary obbstruction
Liver biopsy/ERCP
Assessing severity
Child’s Pugh score
Originally used to predict peri-operative morality
Now used for
o Evaluating prognosis of liver cirrhosis
o Management (determine treatment required, necessity of liver transplant)
Management
Ascites/Lower limb edema
Fluid restriction
Low-salt diet
Strict I/O charting and daily weights
IV diuretics = Furosemide +/- spironolactone
Abdominal paracentensis (intermittent peritoneal taps)
o Therapeutic = relieves SOB
o Diagnostic = rule out peritonitis
Peritoneovenous shunt
Portal HPT
Results in = varices, ascites and spleomegaly
Varices
o Portal gastropathy (watermelon stomach = strips of dark red and light red)
o Esophageal varices
o Caput medusae
o Haemorrhoids
Management
o Propanolol 20mg BD
o TIPPS (does nt reduce mortality)
o OGD with banding/sclerotherapy
Malnutrition
Vitamin D and calcium supplements
IM vit K injections
Pruritus
Ursodeoxycholic acid
Hepatic decompensation
Jaundice
Hepatic flap
Coagulopathy
Ascites
Lower limb edema
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Medicine (GIT) = Hepatomegaly
Causes of hepatomegaly
Right heart failure
Constructive pericarditis
Vascular IVC obstruction
Budd-Chiari syndrome (malignancy = myeloproliferative (PRV) and intra abdominal
(HCC, RCC); PNH, IBD, OCP, SLE/APLS)
Bacterial (Salmonella, Shigella)
Infective Viral (hepatitis, CMV, EBV)
Protozoal (malaria, amoebiasis)
Trauma Haematoma
Primary biliary cirrhosis
Primary sclerosing cholangitis
Autoimmune
SLE
RA
Fatty liver (alcohol, DM, obesity, pregnancy, Cushing syndrome, hyperthyroidism,
IBD, steroids, methotexate)
Metabolic
Storage disorders (type 4 glycogen storage disease, Wilson’s disease, cystic fibrosis,
haemochromatosis, 1-antitrypsin deficiency)
Amyloidosis
Infiltrative
Sarcoidosis
Primary (HCC, hepatic adenoma, hepatoblastoma, hemangioma)
Neoplastic
Secondary (metastasis)
Lymphoma (Hodgkin’s, non-Hodgkin’s)
Lymphoproliferative disease
Haematological
Myeloproliferative disease
Chronic haemolytic anaemia (spherocytosis, G6PD deficiency, thalessemia)
Common causes
Moderate-large liver
a) Malignancy
b) Fatty liver (esp alcoholic liver disease)
c) Myeloproliferative disease
d) Right heart failure
Hard and knobbly liver
a) Malignancy
b) Macronodular cirrhosis
c) Cystic APKD, hydatid
d) Granulomatous/gummatous syphilis
e) Amyloidosis
# glass eye + hard knobbly liver = 1° ocular melanoma with liver metastasis
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Chronic Liver disease
-thalessemia major
Short stature
Hyperpigmented
Overall
Thalessemic facies (frontal bossing, flat nosebridge,
maxillary hyperplasia)
Looks younger for age
Pituitary haemosiderosis Hypopigmented areolae
Loss of axillary hair
JVP v wave
Cardiac haemosiderosis Pulsatile liver
Lower limb edema
Hypocount marks on fingers
Pancreatic haemosiderosis
Diabetic dermopathy
Intervention Splenectomy
Request Gonadal examination
Specific conditions
Haemochromatosis
Request to examine for:
a) Arthropathy pseudogout
b) CCFcardiomyopathy
c) Testicular atrophy pituitary involvement
d) Glycosuria with urine dipstick DM
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Wilson’s Disease
Area Sign Interpretation
Overall Short stature Rickets secondary to
proximal RTA
Eyes Ptosis Penicillamine-induced MG
Pallor and jaundice Coomb’s negative
haemolytic anaemia
Kayser-Fleischer rings Copper deposits in
Descemet’s membrane of
cornea predominantly at 12
and 6 o’clock positions. Can
also occur in PBC and
cryptogenic cirrhosis. Look
out for sunflower cataract
as well
Face Malar Rash Penicillamine-induced
lupus
Upper limb Small hand joint arthritis Penicillamine-induced
lupus
Tremor/chorea Extrapyramidal syndrome
Lower limb Swollen knees Pseudogout
Request urinalysis for glycosuria (proximal RTA)
Chronic UC
CLD + pyoderma gangrenosum = chronic UC and
a) Cirrhosis
b) Chronic active hepatitis
c) Primary sclerosing cholangitis
d) Cholangiocarcinoma
e) Metastatic colorectal cancer
Request to examine
a) Joints sacroilitis, ankylosing spondylitis, peripheral large joint arthritis
b) Skin erythema nodosum, pyoderma gangrenosum
c) Mouth aphthous ulcers
d) Ocular uveitis, iritis, episcleritis
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Medicine (GIT) = Jaundice (history-taking)
Name/age/ethnicity/gender
Occupation
Date of admission
Presenting complaint
1. Jaundice
- Duration
- Onset=acute or gradual
- Skin and eyes affected?
- Progression – getting better, worsening, fluctuating (periampullary ca, gallstones)
2. Obstructive
- Tea-coloured urine
- Acholic stools
- Steatorrhoea
- Pruritus
- Bleeding tendencies (gum bleeding, easy bruising)
3. Abdominal pain (epigastric/RHC pain) = obstructive/hepatic jaundice
4. Fever (a/w chills and rigors)
5. LOA, LOW, malaise
6. Nausea/vomiting
7. Changes in bowel habit (?CRC with liver mets)
8. Melena/PR bleeding (necrosis of periampullary ca? CRC with liver mets, portal HPT)
9. Abdominal distension and lower limb oedema
Aetiology
1. Pre-hepatic = symptoms of anaemia (pallor, chest pain, SOB, giddiness, palpitations)
History of G6PD deficiency and thalassaemia
History of recent blood transfusion
2. Hepatic
#infective
- Travel history
- Contact history
- Recent shellfish/seafood ingestion
- History of Hep B/C infection
- Maternal history/family history of Hep B/C
- Sexual history
- History of blood transfusion/tattoo-ing/IVDA
#drugs
- Alcoholism/recent alcoholic binge
- Recent drug/TCM intake
#autoimmune
- Rash, joint pain and swelling
#neoplasia
- Evidence of mets chest pain, SOB, bone pain
- If primary: change in bowel habits, melena, tenesmus, haemoptysis
3. Post-hepatic
- History of gallstones
- History of epigastric pain radiating to the back (pancreatic ca)
- History of biliary surgery/instrumentation
Complications
1. Liver failure (acute/chronic)
- Coagulopathy
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- Oedema = abdominal distension, ankle oedema
- Encephalopathy – confusion, drowsy, personality changes
2. Hepatorenal syndrome
- Decrease in urine output
Management prior and during admission
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Medicine (GIT) = Approach to Jaundice
Definitions
Jaundice=yellowish skin discolouration due to excess bilirubin in the blood (>35umol/L)
Icterus=yellowish sclera discolouration
Cholestasis=systemic retention of bilirubin, bile salts and cholesterol due to impaired biliary excretion
(hepatic dysfunction; intra/extra-hepatic biliary obstruction)
Other conditions that may mimic jaundice
Hypercarotenaemia – absence of yellow scleral and mucosal discolouration, normal urine colour,
presence of yellow-brown pigmentation of carotenoid pigment in palms, soles and nasolabial folds.
Chronic renal failure – sallow
Haemochromatosis (hereditary or transfusion-related)
Haemosiderosis
Features suggestive of jaundice
- involvement of skin and sclera,
- discolouration of urine and faeces
- pruritus
- epigastric/RHC tenderness (liver enlargement stretching of Glisson’s capsule; inflammation of
biliary tree)
Bilirubin
end-product of heme degradation heme
– biliverdin
Heme
bilirubin Biliverdin
Formed outside the liver in cells of mononuclear
oxygenase phagocyte system
reductase
Bound to serum albumin
Hepatic processing
(a) Carrier-mediated uptake at sinusoidal membrane
(b) Conjugation with glucuronic acid to form bilirubin glucuronide
(c) Excreted in bile
Most bilirubin glucuronide are deconjugated by gut bacteria to colourless urobilinogens
Urobilinogens and remaining bilirubin glucuronides are largely excreted in the faeces
~20% of urobilinogens are reabsorbed in the ileum and colon and returned to the liver to be re-
excreted into bile (enterohepatic circulation)
Small amount escaping this enterohepatic circulation is excreted in urine
Causes of hyperbilirubinaemia
(a) Over-production of bilirubin haemolytic (pre-hepatic) jaundice
(b) Impaired hepatocyte uptake, conjugation or excretion of bilirubin hepatocellular (hepatic) jaundice
(c) Obstruction of bile outflow obstructive (post-hepatic) jaundice
Pathophysiological classification
Predominantly unconjugated hyperbilirubinaemia
- Unconjugated bilirubin tightly complexed to serum albumin insoluble in water not excreted in
urine
- Unbound albumin-free portion highly toxic deposited in brainkernicterus
- High affinity for basal ganglia choreoathetotic CP
Over production of bilirubin
- Haemolytic anaemia
o enzyme defects (G6PD deficiency, pyruvate kinase deficiency)
o Membrane defects (spherocytosis, elliptocytosis)
o Hb synthesis defects (thalassemia, sickle cell anaemia)
o Blood group and Rh incompatibility
o Immune-mediated (drug-induced, SLE, idiopathic)
Impaired hepatocyte uptake
- Drugs (interfere with membranous carrier systems) = rifampicin
- Gilbert syndrome (decreased uridine diphosphate-glucuronosyltransferase)
137
o Mild heterogeneous condition affecting 6% of the population
o Usually detected during recurrent illness or fasting
o No clinical consequences
Impaired hepatocyte conjugation
- Gilbert syndrome (decreased uridine diphosphate-glucuronosyltransferase)
- Crigler-Najjar syndrome s I/II (lack or deficiency of uridine diphosphate-glucuronosyltransferase)
o Type 1 more fatal than Type 2 (former is unresponsive to phenobarbitone and requires
liver transplant)
o Causes kernicterus with neurological damage
- Hepatocellular disease
o Vascular (CCF, right heart failure, hypotension, Budd-Chiari syndrome)
o Infected (viral hepatitis, EMV, CMV, HSV, dengue, leptospirosis)
o Toxin (alcohol binge, drugs – paracetamol OD, anti-TB, statins, anti-epileptics, OC, TCM)
o Autoimmune (SLE, idiopathic)
o Metabolic (fatty liver, Wilson’s disease, haemochromatosis, α1-antitrypsin deficiency)
o Infiltrative (sarcoidosis, amyloidosis)
o Neoplasia (HCC, liver mets, leukaemia, lymphoma, myeloproliferative disorders,
myelodysplasia)
Predominantly conjugated hyperbilirubinaemia
- Designated when >15% of an elevated serum bilirubin is conjugated
- Conjugated bilirubin is water-soluble, non-toxic, loosely bound to serum albumin and is excreted in
urine
- Typically associated with cholestasis
Impaired intra-hepatic excretion of bilirubin
- Dubin-Johnson syndrome
o Defect in the transport protein responsible for excretion of bilirubin glucuronides
o Darkly-pigmented liver
- Rotor’s syndrome
o Variant of DJS
o Liver is non-pigmented
- Hepatocellular disease (refer above + TPN)
Intra-hepatic biliary obstruction
- Primary biliary cirrhosis
- Primary sclerosing cholangitis
o Recurrent pyogenic cholangitis – recurrent febrile episodes of jaundice
o Vicious cycle of intra-hepatic biliary ductal stonesscarringstrictures
- Cholangiocarcinoma
Extra-hepatic biliary obstruction
- Gallstones in the CBD
- Liver abscess (amoebic, TB, meliodosis, enteric gram –ve bacilli)
- Ca head of pancreas
- Periampullary ca (cholangiocarcinoma, Ca ampulla of Vater, Ca duodenum)
- Biliary strictures
- Secondary biliary cirrhosis
- Lymphadenopathy at porta hepatis
Clinical features
Pre-hepatic jaundice
Onset Acute
Precipitating factor Usually present
1st episode Usually not the first time
Urine and stools Dark urine and stools
Anaemia Usually present, +/- splenomegaly
Progression Usually self-limiting and gradually improves once
precipitating factor is removed
Hepatic jaundice
138
Onset Viralgradual with prodromal symptoms
Drug/alcohol-inducedacute
Pain Dull and usually insignificant
Usually due to stretching of Glisson’s capsule
Fever May occur with viral hepatitis
Low-grade and non-specific
Urine and stools Dark urine and stools
Progression Usually self-limiting (die or get better)
Post-hepatic jaundice
Onset Gallstoneacute
Pain Gallstonebiliary colic (tenderness)
Ca pancreasepigastric pain radiating to the back
Hepatomegaly (Stretching of Glisson’s capsule)congestion
of intra-hepatic biliary spaces
Fever Characteristic of cholangitis (Charcot’s triad – feverRHC
painjaundice)
Spiking with chills and rigors
Urine and stools Dark urine
Acholic stools steatorrhoea
Progression Progressive and relentless
Fluctuating
- periampullary ca (necrosis of tumour may relieve
obstruction)
- Gallstones
Benign (Sx jaundice) Malignant (Sx jaundice)
Onset Gallstoneacute Usually gradual
Constitutional symptoms Usually absent LOA, LOW, fatigue, fever
Pain Acute and colicky Painless jaundice
Ca pancreasepigastric pain radiating to
back
Courvoisier’s sign: non-tender palpable gall bladder is unlikely to be caused
by gallstones, as enlargement of gall bladder is likely in Ca pancreas, not in
gallstones (- too acute).
Cholangitis More Less
- Charcot’s triad -regurgitation of small bowel -relentless tumour growth eventually leads
- Raynaud’s contents up biliary tree to complete obstruction
pentad ->90% will have infected bile -No regurgitation of small bowel contents to
cause infection
2-hit phenomenon Usually obstructs biliary tree Obstructs both biliary and pancreatic
only ductssteatorrhoea and LOW
Endocrine insufficiency Absent Worsens existing DM
Newly diagnosed DM
Migratory thrombophlebitis Usually absent Suggests Ca pancreas (esp body and tail)
Progression Self-limiting if gallstone Relentless and progressive
passes Fluctuatingperiampullary ca
Complications
1. Acute jaundice Acute liver failure
- Coagulopathy
- Ascites/LL oedema
- Encephalopathy=forgetfulness, confusion, drowsiness
- Hepatorenal syndrome – renal failure due to liver impairment
o Oliguria/anuria (urine becomes lesser and more concentrated(
o Liver unable to detoxify blood either due to porto-systemic shunting or impaired
hepatocyte function
High levels of circulating endotoxins
139
Formation and deposition of immune complexes in the glomeruli
glomerular/tubular dysfunction
- Hypoglycaemia
2. HBS sepsis
3. Malabsorption (protein, fat, vitamins A/D/E/K)
- Protein malnutritionascites, LL oedema pleural effusion
- Hypoglycaemia
- Fat malnutritionsteatorrhoea, LOW, easy bruising
4. Coagulopathy
- Mechanisms
o DIVC (HBS sepsis)
o Lack of production of coagulation factors (liver impairment)
o Lack of absorption of vitamin K (obstructive jaundice, ca pancreas)
- Clinical features
o BGIT (haematemesis, melena, haematochezia)
o Easy bruising
o ICH
o BGUT (haematuria, menorrhagia)
- Management
o correct by giving vit K if PT>3 above upper limit of normal
o Correct within 48 hrscholestasis
o Remains prolonged hepatocellular insufficiency
5. Portal hypertension
- Secondary to long-standing biliary obstructionbiliary cirrhosis
- Pathogenesis
o Accumulation of bile pigments within hepatocytes (foamy degeneration)
o Dilated bile canaliculi with green-brown plugs of bile
o Dilatation and proliferation of bile ductules (secondary to bile stasis and back pressure)
o Ruptured canaliculi leading to extravasation of bile into sinusoids
o Inflammationoedema + neutrophilic infiltrateportal tract fibrosis and cirrhosis
- Cx-ascites, splenomegaly, dilated veins (gastro-oesophageal varices, caput medusa, haemorrhoids),
portal hypertensive gastropathy: mucosal changes.
Investigations
Blood:
1. FBC
- WCC (leucocytosis in infections; leucopoenia in biliary cirrhosis and hypersplenism)
- Hb (anaemia if there is haemolysis, bleeding or underlying malignancy)reticulocyte count
- Haptoglobin assay
- PBF
2. U/E/Cr
- Renal impairment (hepatorenal syndrome)
- Serum glucose (hypoglycaemia)
3. LFT
(a) Establish if it is a predominantly unconjugated/conjugated hyperbilirubinaemia
(b) Hepatocyte integrity AST, ALT, LDH
(c) Biliary obstructionALP, GGT
(d) Synthetic function
- albumin, PT/PTT
- ALT>AST in viral hepatitis
- AST>ALT in alcoholic hepatitis
- Raised ALP/GGT in obstructive jaundice
- GGT specific for alcoholic hepatitis
4. PT/PTT
- Measure of liver function (PT affected as factors 5&7 have the shortest t1/2)
140
- Check for coagulopathy
5. Serum ammonia = measure of liver function
6. Hepatitis screen
- Anti-HAV Ig M, anti-HAV Ig G
- HBsAg, HBeA (active replication), anti-HBc Ig M, anti-HBc Ig G
- Anti-HCV, HCV RNA
7. Autoimmune markers (anti-ds DNA, ANA, anti-mitochondrial Ab, anti-Sm Ab, ESR, CRP)
8. Tumour markers = α-fetoprotein, CA 19.9, CA 125, CEA
Imaging:
1. AXR
- Gallstones
- Pneumobilia (cholecystenteric fistula, cholangitis with gas-producing organism)
2. U/S HBS
- Dilated intra-hepatic ducts (obstruction)
- Gallstones in gallbladder
- Liver cirrhosis and masses
- Ascites
3. CT AP
- Gallstones in gallbladder or biliary tree
- Liver and pancreatic masses
- Level of biliary obstruction
- Double-duct sign (dilatation of both CBD and pancreatic duct periampullary ca)
- LAD at porta hepatitis
- Ascites
4. CXR
- Lung primary or mets
5. ERCP (endoscopic retrograde cholangiopancreatography)
- If gallstones, lower CBD or pancreatic head pathology suspected
- Diagnostic
o Direct visualisation
o Obtain samples for histology/cytology (periampullary region, pancreatic fluid and bile)
- Therapeutic
o Remove gallstones
o Sphincterotomy
- Stenting of stricture at lower end
o Contraindications
o Gastrectomy (ECRP poses high risk of perforation as stomach is disconnected from
duodenum)
- Complications
o Traumatic pancreatitis
o Pancreatic/biliary sepsis
6. PTC
- If there is dilatation of intra-hepatic ducts or unsuccessful ERCP
- Diagnostic
o Direct visualisation
- Therapeutic
o Insert catheter for drainage
- Contraindications
o Coagulopathy
o Ascites (unable to tamponade liver puncture)
o HBS sepsis
7. MRCP
- If patient has contraindications to ERCP/PTC
8. Liver biopsy
- US/CT-guided core liver biopsy
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- Determine hepatic causes of jaundice/grade liver tumour
Decompensated liver cirrhosis
BGIT
Constipation
Sepsis
Drug-inducedalcohol, steroids
Hep D infection
HCC
Post-operative jaundice
(Usually occurs in first 3 post-operative weeks)
Resorption
o Haematoma
o Haemoperitoneum
o Haemolysis of transfused RBCs (shorter t1/2)
o G6PD deficiency
Impaired hepatocellular function
o Halogenated anaesthetics
o Sepsis
o Hepatic ischaemia 2° perioperative hypotension
Extra-hepatic biliary obstruction
o Biliary stones
o Injury to biliary tree
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Medicine (GIT) = Acute Hepatitis
Aetiology
Vascular: Ischemia
Infective: Viral (hepatitis viruses, CMV, EBV, HSV, dengue)
Bacterial (salmonella, shigella)
Parasitic (malaria)
Drug induced: Alcohol, paracetamol, TCM, anti-TB drugs (e.g. isonazid, rifampicin, pyrazinamide),
anti-convulsants (e.g. sodium valporate), satins
Autoimmune: Autoimmune hepatitis
Metabolic: Wilson’s disease
Infiltrative:
Neoplastic: Massive malignant infiltration
ALT-AST reversal
Most liver diseases are characterized by greater ALT elevations than AST elevations
Exception where AST: ALT ≥ 2
o Alcohol
o Drug induced
o Infections (e.g. salmonella, dengue)
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Medicine (GIT) = Viral Hepatitis
Introduction
Viral hepatitis is caused by viruses that cause inflammation to the liver
Acute hepatitis
4 phases
1. Incubation period
Peak infectivity = last asymptomatic days of incubation period to early days of acute symptoms
2. Symptomatic pre-icteral phase
Usually precedes development of jaundice by a few days to 2 weeks
Non-specific prodromal illness : headache, myalgia, arthralgia, nausea and anorexia
Vomitting, diarrhea, RHC pain
May have dark urine and pale stools
May have physical signs:
i. Liver is often tender but only minimally enlarged
ii. Occasionally, mild splenomegaly and cervical lymphadenopathy (more frequent in children
or EBV infx)
3. Symptomatic icteric phase
Mainly conjugated hyperbilirubinaemia
Common in actue HAV infection; absent in 50% of acute HBV infection; uncommon in acute HCV
Jaundice may be mild and the diagnosis may be suspected only after finding abnormal liver blood
tests in the setting of non-specific symptoms. Symptoms rarely last longer than 3-6 weeks
4. Convalescence
Chronic hepatitis
Symptomatic, biochemical or serological evidence of continuing hepatic disease > 6months with
histological evidence of inflammation and necrosis
Aetiology
o Infective = viral hepatitis (HBV, HCV)
o Drugs = chronic alcoholism, isonazid, methotrexate, methyldopa, nitrofurantoin
o Autoimmune = autoimmune hepatitis (may be associate with primary biliary cirrhosis and primary
sclerosing cholangitis)
o Metabolic = Wilson’s disease, haemochromatosis, α1 –antitrypsin deficiency
Hepatitis A virus
Epidemiology= usually found in developing world → substandard hygiene & sanitation;
prevelance of seropositivity increases with age
Caused by picornavirus (ssRNA), 1 serotpe
Mode of transmission=
o faecal oral route
o food & water borne (e.g. eating partially cooked cockles & oysters/ contaminated food & water)
o person-person (e.g. sexual oral-anal)
Incubation period = 4-6 weeks
o HAV appears in faeces before clinical symptoms (usually 2-3 weeks before jaundice & 1 week after
onset of jaundice)
Clinical presentation
o Asymptomatic (most) = subclinical & milder than HBV infection
o Acute hepatitis= usually bengn and self limiting
o Worse if superimposed on chronic hepatitis
o Does not cause chronic hepatitis or carrier state
Complications: Fulminant hepatitis (rare)
Serological picture:
o Transient viraemia → blood borne transmission rare
o IgM with acute infection → fecal shedding ends as IgM increases
o IgG for long term immunity
Prevention
Avoid eating contaminated food or drinks
Boiling 5 mins
Immunization
o Passive immunization with Ig G
IgG collected from blood of persons who have been exposed to the hepatitis A
This method of immunization is getting obsolete because of the short supply of immune
globulin and the potential risk of transmission of other infection through blood products
o HAV vaccine
Inactivated virus
145
Given in 2 doses, with the second dose being given 6 - 12 months later. Immunity after
vaccine lasts for 10 - 20 years. Protection against hepatitis A begins 4 weeks after
vaccination
People at risk of HAV
Persons travelling to or working in countries that have high or intermediate rates of hepatitis A
Persons who work with hepatitis A virus infected primates or with hepatitis A virus in a
research laboratory should be vaccinated.
Persons with chronic liver disease eg. chronic hepatitis B carriers as these patients have been reported to
have a higher mortality.
Hepatitis B virus
Epidemiology: endemic in Africa and Asia;
Microbiology
Belongs to the Hepadnavirus family
Has 3 well characterized antigens:
o HBsAg (surface) → stimulates anti-HBs
o HBcAg (core) → stimulates anti-HBc
o HBeAg (core associated) → stimulates anti-HBe
Dane particle = infectious spherical HBsAg particle containing HBcAg core
HBeAg arises from the same gene as HBcAg
o c gene has 2 initiation codons= precore and core region
o translation intitated at precore region = HBeAg → signal peptide that facilitates secretion (can be
used as surrogate marker for presence of HBcAG)
o translation initiated at core region = HBcAg → no signal peptide →not secreted into serum
Nucleocapsid
o circular partially ds DNA
o DNA polymerase with reverse transcriptase activity
o HBcAg → remains in hepatocytes for complete assembly of virions, only detected in liver biopsy
samples
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Serology
HBV mutants
Pre-core mutant: variant C gene fails to produce HBeAg (–ve HBeAg viraemia); still infections because of
HBcAG
o HBV DNA necessary to detect presence of disease activity
S mutants: mutation at ‘a’ epitope (HBsAg –ve viraemia) → vaccine not effective; low frequency in
Singapore
Treatment
Anti-virals: lamivudine, adefovir
Interferon-α
Vaccination
Hepatitis C virus
Caused by Flavivirus, ssRNA
Transmission: blood-borne, sexual intercourse
Incubation period: 6-12 weeks
Clinical presentation
o Mainly asymptomatic
o Acute hepatitis = general milder than HBV; no effective immunity
o Chronic hepatitis = hallmark of HCV infection
60-80% develop chronic hepatitis
20% go on to develop liver cirrhosis
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Acute infection with recovery
HCV RNA detectable for 1-3 weeks
during active infection,
HCV RNA frequently persists
despite neutralizing antibodies (Abs
present in 50-70% of acute
infection; 30-50% have anti-HCV
Abs after 3-6 weeks)
Chronic infection
Persistence of HCV RNA despite
neutralising Ab
Episodic elevations of HCV RNA
and transminases
Treatment
Ribavirin and IFNα combination therapy → partial efficacy
No vaccine available; difficult to cover agains the 6 major genotypes
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Hepatitis D virus
Defective ssRNA virus → requires HBsAg coat to infect cells
HBV serves as helper virus
Clinical presentation
1. Super infection: chronic HBV carrier exposed to HDV → severe hepatitis
2. Co-infection: exposed to HBV & HDV at the same time
a. HBV must become established first to provide HBsAg required for HDV virion production
b. Chronic hepatitis rare
c. Higher rates of fulminant hepatitis (3-4%)
Serology
HDV RNA appears just before and during early acute symptomatic infection
IgM anti-HDV = recent HDV exposure
To differentiate co-infectin and super infection = correlate with HBV markers
Hepatitis E virus
Calicivirus, ssRNA
4 genotypes, endemic in India and the Middle East
Transmission: faecal-oral, water borne
Incubation period= 4-6 weeks
Clinical presentation
Acute hepatitis
o Usually self-limiting and benign
o Abs are non-protective
No chronic state or chronic hepatitis
High rate of fulminant hepatitis in pregnant women (25% fatal); foetal mortality also high
No vaccines
Serology
HEV RNA and HEV virions present in stool and liver before onset of symptoms
IgM anti-HEV present with rising transaminase → IgG
Hepatitis Screen
HAV=
o Anti- HAV IgM (acute)
o Anti- HAV IgG (previous infection)
HBV=
o HBsAG, HBeAG, anti-HBc, IgM (acute)
o Anti-HBs IgG, anti-HBe, anti-HBc IgG (previous infection)
HCV=
o Anti-HCV IgM (acute)
o Anti-HCV IgG (previous infection)
CMV = anti-CMV IgM
EBV = anti EBV IgM
HSV = anti-HSV IgM, HSV PCR (if patient presents with acute liver failure)
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HAV HBV HCV HDV HEV HGV
Agent Icosohedral capsid, Enveloped dsDNA Enveloped ssRNA Enveloped ssRNA Unenveloped ssRNA ssRNA
ssRNA Calicivirus
Picornavirus Hepadnavirus Flavivirus Flavivirus
Transmission Faecal-oral Parenteral, close Parenteral, close Parenteral, close Waterborne Parenteral
contact, vertical contact contact
Incubation period 2 – 6 weeks 4 – 26 weeks 2 – 26 weeks 4 – 7 weeks 2 – 8 weeks Unknown
(superinfection)
Carrier state None 0.1 – 1% of blood 0.2 – 1% of blood 1 – 10% of drug Unknown / none 1 – 2% of blood
donors; 90 – 95% of donors; <1% are addicts, donors
those infected at healthy carriers haemophiliacs
birth (vertical
transmission); 1 –
10% infected as
adults (esp. If
immune-
compromised)
Chronic hepatitis None 5 – 10% of acute >60%; half then <5% if co-infection None None
infections (adults); progress to cirrhosis with HBV; 80% upon
90% in infected super infection with
neonates HBV
Fulminant hepatitis 0.1 – 0.4% <1% Rare 3 – 4% in co- 0.3 – 3% Unknown
infection 20% in pregnant
females
Hepatocellular Ca No Yes Yes No increase above Unknown, but None
HBV unlikely
Vaccine available Yes Yes No No No No
Others Acute hepatitis Fulminant hepatitis At present, not
(symptomatic, almost never occurs considered
asymptomatic) with HCV pathogenic
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Medicine (GIT) = Alcoholic Liver Disease
*clinical spectrum*
1) fatty change/hepatic steatosis
Clinical features – asymptomatic, mild increase in serum bilirubin & ALP
Pathology – soft, greasy hepatomegaly
Fat accumulation within hepatocytes
(micro macro-vesicular)
Seen within days of ingestion on U/S
Initially reversible
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*investigations*
FBC – raised MCV
LFT – raised ALP, GGT, AST > ALT, raised conjugated bilirubin, decreased albumin
PT/PTT
Hepatitis serology
U/S liver
*causes of death*
BGIT – haematemesis
Hepatic encephalopathy
Hepatorenal syndrome
Sepsis
HCC
*epidemiology
females > males (3:1)
Premenopausal females
*clinical presentation
acute hepatitis with autoimmune symptoms (fatigue, arthralgia, myalgia)
chronic hepatitis
incidental finding with signs of chronic liver disease
*associated with autoimmune disorders – RA, thyroditis, scleroderma, IBD, pernicious anaemia, IDDM,
AIHA, PSC
*investigations
FBC – decreased Hb, decreased WBC, decreased platelets (w/ hypersplenism)
LFT – raised AST
Hyperglobulinaemia – raised IgG
Autoimmune screen – ANA, anti-SMA Ab, anti- LKM1 Ab
Hepatitis serology – negative
Liver biopsy – mononuclear infiltrates of portal and peri-portal areas,
piecemeal necrosis fibrosis cirrhosis
*treatment
(a) immunosuppression – prednisolone, azathioprine (steroid-sparer)
(b) liver transplant
*prognosis – if untreated severe disease:
40% die within 6 months,
40% of survivors develop cirrhosis
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Medicine (GIT) = Metabolic Liver Disease
2) Haemochromatosis
*excessive iron accumulation with subsequent deposition in various organs esp. liver and pancreas
*primary haemochromatosis (hereditary haemochromatosis)*
Autosomal recessive inheritance
Males > females (6:1)
Females diagnosed later (menstruation offers protection)
Pathogenesis: unregulated intestinal Fe absorption excess Fe direct toxicity via free radical
formation/lipid peroxidation/Fe-DNA interactions
Usually presents at around 20-30yrs old
*secondary haemochromatosis*
Repeated blood transfusions – Thalassemia major, aplastic anaemia, sickle cell disease, myelodysplastic
syndrome, leukaemia, lymphomas
Increased Fe intake – Fe-dextran injections
*investigations*
Iron studies – high transferring saturation? High ferritin levels?
U/S liver – HCC is the commonest cause of death (200x greater risk of getting HCC)
Liver biopsy (diagnostic) – measure liver stores
Genetic testing
*management*
Early venesection – beneficial especially in those who have not developed DM/cirrhosis
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prolongs life and reverses tissue damage
prevents progression of hepatic disease
3. a1-Antitrypsin deficiency
*autosomal dominant disorder
*pathogenesis – abnormally low levels of a1-antitrypsin (protease inhibitor)
*clinical features
childhood and adult cirrhosis HCC
COPD
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Medicine (GIT) = Wilson’s disease (Hepatolenticular Disorder)
*History*
Hx of consanguinity Wilson’s disease has an autosomal recessive inheritance
Considered in any patient younger than 40yrs with unexplained disorder of CNS, hepatitis, chronic
active hepatitis, haemolytic anaemia, unexplained cirrhosis, or has a relative with Wilson’s disease
*Physical Examination*
Kayser-Fleischer rings: greenish yellow to golden brown pigmentation at the limbus of the cornea due
to deposition of copper in Descemet’s membrane
Proceed to look for:
o Jaundice
o Sunflower cataracts
o Hepatomegaly
o Signs of liver failure
o Neurological manifestations: tremor, chorea, mask-like
facies
*Presentation*
Hepatic – 50% of patients (usually presents in 2nd
decade/children)
1) Acute hepatitis – self limited
2) Parenchymal liver disease (chronic hepatitis) – may follow acute hepatitis or develop
insidiously without prior disease
Indistinguishable from chronic active hepatitis and cirrhosis
3) Cirrhosis – may develop insidiously after a lapse of decades
4) Fulminant hepatitis – generally fatal, characterized by progressive jaundice, ascites,
encephalopathy
2) Chronic
-marked proximal ‘wing-beating’ tremor
-dysarthria, dystonia and rigidity
-choreoathetoid movement
-psychosis, behavioural disorders and
dementia
-if untreated death in 10yrs
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*Discussion*
Inheritance
o Autosomal recessive; chromosome 13
o A/w family history of consanguinity
Pathophysiology
o Excessive absorption of Cu from the small intestine with decreased excretion by liver
o Increased tissue deposition esp in brain, cornea, liver and kindey Fanconi’s Syndrome
(glycosuria)
o Cavitation and neuronal loss occurs within the putamen and globus pallidus (basal ganglia)
Biochemical changes
o Decreased serum ceruloplasmin
o Serum Cu concentration might be high, low or normal
o Increased urinary Cu excretion
o Increased liver Cu content
Diagnosis
o Kayser-Fleischer rings + serum ceruloplasmin levels < 20mg/l
o Serum ceruloplasmin level < 200mg/l + Cu concentration in liver biopsy sample > 250 µg/g
o MRI (T2) shows thalamic and putaminal hyperintensity
Clinical stages
o Stage I: asymptomatic accumulation of Cu in liver
o Stage II: asymptomatic or manifests with haemolytic anaemia or liver failure
o Stage III: Cu accumulates in brain
o Stage IV: progressive neurological disease
Treatment
o Low Cu diet
o Chelating agent, eg. penicillamine.
-side effects: anaphylaxis, skin rash, bone marrow suppression and glomerulonephritis
alternate treatment: trientine.
-penicillamine has anti-pyridoxine effect, thus pyridoxine given together
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Surgery (GIT) = Obstructive jaundice
A. Intrahepatic biliary obstruction
*Primary biliary obstruction*
*epidemiology:
Predominantly affects middle-aged women (~50yrs old)
*pathology
chronic granulomatous inflammation that destroys interlobular bile ducts fibrosis liver cirrhosis
*clinical presentation
fatigue
pruritus (main presenting complaint, may precede jaundice by mths/years)
occasionally jaundice, RHC pain, diarrhoea/steatorrhea
*complications:
Osteopenia/osteoporosis (due to malabsorption of fat-soluble Vitamin D)
Coagulopathy (due to malabsorption of fat-soluble Vitamin K)
Liver cirrhosis portal HTN HCC (relative risk=20)
Increased risk of cancer overall
*clinical signs:
Stigmata of chronic liver disease: palmar erythema, leukonychia, bruising, scratch marks, spider naevi,
gynaecomastia
Digital clubbing
Xanthelasma and xanthomata (over joints, skin folds and trauma sites)
Signs of portal HTN: dilated veins, hepatosplenomegaly (early stages), ascites
Request to examine for: proximal muscle weakness (osteomalacia)
peripheral neuropathy
*clinical presentation
L.O.A, L.O.W, fatigue
Insidious development of jaundice and pruritus
Intermittent RHC pain
*investigations
LFT
PT/PTT
Autoimmune screen (AMA –ve; ANA and ANCA may be +ve)
ERCP
Liver biopsy (fibrous obliterative cholangitis w/ onion skin appearance)
*management
Conservative (corticosteroids, cholestyramine)
Surgical (endoscopic stenting, t-tube drainage, liver transplant
*epidemiology
Found almost exclusively in S.E.A.
No gender predilection
Peak incidence in 3rd and 4th decades of life
*clinical presentation
Recurrent bouts of cholangitis
Pancreatitis
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*complications
Cholangitis liver abscess HBS sepsis
Pancreatitis
Biliary obstruction liver cirrhosis portal HTN
Increased risk for cholangiocarcinoma
*investigations
U/S HBS
CT A/P
ERCP/MRCP
*management
Treatment of acute cholangitis
o Take blood cultures start on IV empirical broad-spectrum antibiotics definitive antibiotics
once results available
o Biliary drainage – open vs. percutaneous
Prevention of long-term complications
o General approach:
- removal of stones with regular surveillance (ERCP, percutaneous, surgery, laser)
- surgical resection of affected hepatobiliary segment with biliary-enteric anastomosis
*Cholangiocarcinoma*
* arises from epithelial cells of the intrahepatic and extrahepatic bile ducts
Histological subtypes: adenocarcinoma (95%)
squamous cell carcinoma (5%)
*classification
Intrahepatic (10%)
o Least common
Extrahepatic (90%)
o Peri-hilar (65%) confluence to upper border of pancreas
o Distal (25%) upper border of pancreas to ampulla of Vater
^peri-hilar cholangiocarcinoma:
Most common
Also called Klatskin tumours (occur at bifurcation of right and left hepatic ducts)
Bismuth classification: Type 1 (below the confluence)
Type 2 (reaching the confluence)
Type 3 (occluding common hepatic duct and either right/left hepatic duct)
Type 4 (multicentric)
*clinical presentation
Diagnosis usually made in the 7th decade
Males > females
Usually presents late metastatic at time of presentation
Insidious onset of jaundice, pruritus, RHC pain
May present with cholangitis
*associations
Inflammatory conditions (ulcerative colitis, primary sclerosing cholangitis, RPC)
Fibropolycystic liver conditions (choledochal cyst, Caroli’s disease)
Parasitic infections (oriental liver fluke, chronic typhoid carrier state)
160
Toxin exposure (thorotrast)
*management
Curative surgery (rarely possible) wide resection and reconstruction of biliary tree
o Indications:
inrahepatic tumour confined to 1 lobe of liver
Extrahepatic tumour
Patient fit for surgery
o Contraindications:
bilateral/multifocal intrahepatic disease
Invasion of portal vein/hepatic artery
Nodal involvement
Distant metastasis
Palliation
o Stenting
o Surgical bypass – cholecystojejunostomy, choledochojejunostomy
Adjuvant therapy
o Radiotherapy
o Chemotherapy
*Biliary strictures*
*aetiology
Others (5%): impacted gallstone
Post-traumatic (95%):
o Causes:
Surgical
Blunt abdominal trauma
o Classification:
Early vs. late
Early: due to technical problems
Late: due to vascular insufficiency and problems with healing and fibrosis
Anastomotic vs. non-anastomotic
Anastomotic
o Due to post-operative oedema and inflammation
o Management: endoscopic balloon dilatation and stenting
o Require life-long surveillance as high recurrence rate
Non-anastomotic
o Due to vascular insufficiency or recurrence of underlying disease
o More difficult to treat:
-endoscopic balloon dilatation with sphincterectomy and stenting
-surgery (choledochoduodenostomy, choledochojejunostomy, end-to-
end bile duct anastomosis)
*clinical presentation: intermittent cholangitis
*investigations: PTC/ERCP (depends on level of narrowing)
*complications
161
Cholangitis liver abscess HBS sepsis
Secondary biliary cirrhosis liver cirrhosis portal HTN
*Periampullary carcinoma*
*includes: cholangiocarcinoma (involving distal common bile duct)
ampulla of Vater tumour
duodenal adenocarcinoma
*Mirizzi syndrome*
*rare cause of obstructive jaundice
*due to lodgement of gallstone in cystic duct/Hartmann pouch causing extrinsic compression of
common bile duct
*aetiology
Acute/chronic inflammation causing constriction of gallbladder which fuses with and causes secondary
stenosis of common bile duct
Cholecystocholedochal fistula secondary to direct pressure necrosis of adjacent duct walls
*classification
Type 1: no fistula present
Types 2-4: fistula present (depending on size of defect w.r.t. diameter of common bile duct)
*investigations
U/S HBS
CT A/P
ERCP/PTC
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Medicine (GIT) = Liver Failure
Introduction
- Most severe clinical consequence of liver disease
- Large hepatic reserve 80-90 % of hepatocytes destroyed before liver failure sets in
- Pathogenesis
a) Sudden massive hepatic destruction (‘Fulminant hepatitis’)
o Progression of hepatic insufficiency to hepatic encephalopathy within 2-3 weeks
o Subfulminant hepatitis= less rapid course within 3 months
b) End point of progressive hepatic damage
o Usually tipped into decompensation by = sepsis, BGIT, heart failure
- Management
o MARS (membrane adsorbent recirculating system)
o Liver transplant (if not 70-90% mortality)
Aetiology
Fulminant Hepatitis
- Vascular = Ischemia (shock, hypoxia)
- Infective = Hep B > Hep A, HSV
- Drugs = Paracetamol, anti- TB drugs, MAOIs, Carbon Tetrachloride,
Halothane, TCM, Anti- cummisants
- Toxin = Amanita Phalloides (mushroom)
- Metabolic = Wilson’s Disease
- Neoplastic = Massive malignant infiltration (leukaemia)
- Idiopathic
Progressive Hepatic Damage (similar aetiology for cirrhosis)
Hepatic dysfunction without overt necrosis = Hepatocytes viable but unable to
perform normal metabolic function
- Reye syndrome
- Tetracycline toxicity
- Acute fatty liver of pregnancy
Clinical features
Hepatic dysfunction
- Jaundice
- Fetor hepaticus
- Hypoalbuminaemia lower limb pitting oedema, ascites, pleural effusion
- Hypoglycaemia
- Hyperammonaemia hepatic encephalopathy
- Hyperoestrogenaemia palmar erythema, spider naevi, gynaecomastia,
testicular atrophy, loss of axillary hair
Portal hypertension
- Ascites
- Splenomegaly
- Porto-systemic shunts haemorrhoids, caput medusae, gastro-oesophageal varices
Complications
- Coagulopathy (inadequate synthesis of clotting factors2,7,9,10 or DIVC)
- Hepatic encephalopathy
- Hepato-renal syndrome
- Multiple organ failure = cardiovascular collapse, ARDS
- Sepsis
- Fluid electrolyte and acid base disturbances
Hepatic Encephalopathy
- Life threatening disorder of neurotransmission in CNS and NM system
- Reversible if underlying liver condition corrected
- Pathogenesis = Hepatocellular insufficiency leading to decrease in
163
detoxification of ammonia
Intra-hepatic shunting (venulization)
Extra-hepatic collaterals that bypass liver and enter into
systemic circulation
- Results in elevated blood ammonia levels Neuronal function impaired
Generalised brain oedema
- Triggers
a) Excess protein/urea load = excess dietary protein, constipation, BGIT,
uraemia
b) Infective = sepsis, HDV infection
c) Drug-induced = alcohol binge, sedatives, narcotics, anti-depressants
d) Trauma = surgery, paracentesis (>3-5 L), porto-systemic shunts
(non-selective)
e) Metabolic = hypokalaemia
f) Neoplastic = HCC
- West Haven Classification
o Stage 0
Minimal hepatic encephalopathy lack of detectable changes
o Stage 1
Mild confusion
Decreased attention span
Disordered sleep (hypersomnia, insomnia or sleep-wake inversion)
o Stage 2
Lethargy
Moderate confusion
Disorientation
Personality changes and disinhibition
ASTERIXIS present
o Stage 3
Drowsy but arousable
Marked confusion
Disorientated to TTP
o Stage 4
Comatose
ASTERIXIS absent
- Clinical features
a) Impaired consciousness
b) Limb rigidity and hyper- reflexia
c) Asterixis
d) Seizures
e) EEG changes
- Management
o Treat precipitating cause
o Restrict protein intake
o Ensure adequate bowel movement (fleet enema)
o Liver transplant
Hepato-renal syndrome
- Life-threatening renal failure in patients with severe CLD no intrinsic renal causes
- Renal function improves with correlation of underlying liver failure
- Pathogenesis = imbalance between systemic vasodilation and renal vascular vasoconstriction results in
decreased renal perfusion pressure decreased GFR
- Clinical features
o Oliguria
o Rising BUN and creatinine
o Concentrating ability of kidney maintained= hyperosmolar urine; low urinary NA
- Poor prognosis median survival 2 weeks (rapid onset form) to 6 months (insidious-onset form)
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Medicine (GIT) = Portal Hypertension
Introduction
- Increased pressure within portal system such that there is increased resistance to portal blood
floe
- Defined as portal pressure > 5-10 mmHG OR
portal pressure gradient ≥ 12mmHg (pressure difference between
portal and hepatic veins)
- Anatomy of portal system
1) Portal vein drains from = small and large intestines
stomach
spleen
pancreas
gallbladder
2) Superior mesenteric vein + splenic vein unite behind neck of pancreas = portal vein
3) Divides into 2 lobar veins = right branch drains cystic vein
left branch drains umbilical and paraumbilical
veins
4) Coronary vein runs along lesser curvature of stomach = receives distal
oesophageal veins
Aetiology
Pre-hepatic
- Portal vein
o Extrinsic compression = malignancy, LAD
o Thrombosis =malignancy , peritoneal sepsis, pancreatitis
- Splenic vein
o Thrombosis
o Shunting of excessive blood secondary to massive splenomegaly
Intra-hepatic
- Liver cirrhosis
Post-hepatic
- Hepatic vein obstruction (Budd –Chiari Syndrome)
- Veno-occlusive disease
- IVC obstruction
- Right heart failure
- Constrictive pericarditis
Clinical features
- Porto- systemic venous shunts
o Develops wherever systemic and portal circulations share capillary beds
o Principle sites
Portal gastropathy (watermelon stomach =strips of dark red and light red)
Cardio- oesophageal junction oesophageal varices
Falciform ligament of liver (periumbilical veins) caput medusae
Rectum haemorrhoids
Retroperitoneum
- Ascites
o may be complicated by peritonitis
- Splenomegaly
o may be complicated by hypersplenism
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- Encephalopathy
Veno-occlusive disease
- Aetiology
a) Toxic alkaloids (‘brush tea’ from Africa)
b) Cytotoxic drugs
- Results in toxic endothelial injury to hepatic vein thrombosis and fibrosis
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Medicine (GIT) = Chronic Diarrhea
Introduction
Classification
a. secretory (faecal osmotic gap < 50mOsm)
b. osmotic (faecal osmotic gap > 50mOsm)
5 typical causes
a. radiation
b. ischaemic colitis (self-limiting)
c. IBD
d. TB
e. enteroinvasive infection
Steatorrhea
Aetiology
Complications
Investigations
1. Bloods
-LFT (biliary obstruction)
-autoimmune screen (ANA, anti-SMA, anti-LKM1 Ab, IgG, IgM)
167
-amylase (pancreatic disease)
2.Stool studies
-stool fat
-stool elastase/chromotrypsin (pancreatic disease)
3. Imaging
-AXR (pancreatic calcifications)
-CT A/P (ca pancreas)
-U/S HBS or ERCP (biliary obstruction)
Treatment
1. fat restriction
2. supplementation of pancreastic enqyme extracts
3. medium-chain triglycerides
4. treat cause (e.g antibiotics for bacterial overgrowth, steroids for CD)
Non-bloody, Non-steatorrhoeic
Aetiology
1. Infective
-giardiasis
- HIV
2. Drug-induced
-laxative abuse
-pseudomembranous colitis due to use of broad spectrum atibiotics e.g. clindacysin,cephalosporins &
ampicillin
-rarely antacids, anti-hypertensives, diuretics, chemotherapeutic agents
3. Metabolic
- DM with autonomic neuropathy (causing nocturnal diarrhea)
-thyrotoxicosis
-lactose intolerance
168
History
Name/age/race/gender/occupation
Drug allergy
PMH
Presenting Complaint
Symptoms
1. Diarrhea
-duration
-baseline & current frequency
- onset (acute/ gradual/ congenital)
- description of stools ( volume, presence of blood, watery or bloody, floating, foul-smelling or hard to
flush)
2. Mucoid stools
3. Urgency (any incontinence?)
4. Abdominal pain (ask SOCRATES, relieved on defecation?)
Aetiology
1.infective
-fever,abdominal pain, LOW
-recent travel & contact hx
-sexual orientation & CSW contact
2. drug-induced
-laxative abuse
-antibiotic usage
-drug hx (recent & current)
3. metabolic
- hx of diabetes, gastroparesis, postural hypotension, urinary retention, impotence,numbness/peripheral
neuropathy
-polyphagia, LOW, insomnia, irritability, heat intolerance, swetating, palpitaitons, beck swelling, personal &
family hx of thyroid disease
4.lactose-intolerance
-recent change in diet
Complications
-dehydration
-electrolyte imbalance
Systemic Review
Physical Examination
1. General inspection
-general condition (goiter, thyroid eye disease)
-vitals
169
-hydration status
2. Peripheries
-eyes (thyroid eye disease)
-abdomen (tenderness, guarding, distension)
-PR examination (anal tone)
- LL (diabetic dermopathy)
Investigations
1.FBC
-WBC & differential count (chronic infx)
-incr HCl (in dehydration)
2. U/E/Cr
-incr urea > incr Cr (in dehydration)
-electrolyte abnormalities
3.LFT
-albumin (protein-losing enteropathy)
4.TFT
-thyrotoxicosis
5.BSL & HbA1c
-DM
6.Stool studies
-stool OB
-stool pH (<5.6 indicated carbohydrate intolerance)
-gram staining
-microscopy for ova, cysts & leukocytes
-culture/ sensitivity
-C. difficile toxin
7.AXR
-spurious diarrhea form fecal loading
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Medicine (GIT) = Inflammatory Bowel Disease
Epidemiology
-young adults or middle age
-no gender predilection
-uncommon in asia (more common in Indians locally)
Aetiology
1.Genetic
-mutaton in NOD2 gene increases risk of crohn’s disease
-evident in Jews & Caucasians
-higer rates in monozygotic twine & first-degree relatives
-assoc. with SLE,Hashimoto’s thyroidiits & ankylosing spondylitis
2.Immunological
-profound derangement of mucosal immunity (T cells being the main driving force) where there is
abnormal host immunoreactivity, hence failure of downregulation
3. Environmental
-gut microbes likely provide antigenic trigger to dysregulated immune system
Pathogenesis
-inflammation is final common pathway
-activation of inflammatory cells (neutrophils & mononuclear cells), leading to non-specific tissue damage
a. mucosal destruction (loss of mucosal epithelial barrier & absorptive function
b. activation of crypt epithelial cell secretion
- resulting in characteristic intermittent bloody diarrhea
Pathology
Ulcerative Colitis
-diffuse inflammatory disease affecting colonic mucosa from rectum to caecum (rectum is always involved ,
while ileal involvement is present in backwash ileitis)
- course of disease
a. relapsing & remitting (70%)
b. continuous (10%)
c. single episode (10%)
d. fulminant episode requiring surgery (10%)
-typically presents in young adults with intermittent chronic bloody diarrhea assoc. with
a.fever
b.malaise
c.LOW
-triggers
a.stress
b.intercurrent infections
c.GE
d.antibiotics
e.NSAIDS
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-patterns of disease (according to site of colonic involvement)
-complications
a.primary sclerosing cholangitis (4%), hence incr risk of cholangiocarcinoma
b.incr risk of colorectal carcinoma, risk incr with duration & extent of disease (overall RR=8% ; for pancolitis
there is a 3% risk @ 15 yrs, 5% risk @ 20yrs & 9% risk @ 25 yrs)
* do yearly colonoscopy & biopsy ( @ every 10 cm of colon & @ raised/ulcerated areas) in pancolitis or 8
or more years duration
c.toxic megacolon (transverse colon diameter >6cm on AXR)
Crohn’s Disease
-recurrent inflammation that can affect any level of the GIT (but usually involves terminal ileum & colon)
-characterised by
a.sharply-demarcated transmural involvement of the bowel
b.skip lesions
c.non-caseating granulomas
d.fissuring with fistulae formation
-variable presentations of acute pain, diarrhea, LOW, malabsorption, I/O, appendicitis
-2 patterns of disease
-complications
a.fistulae formation (entero-enteris,entero-vesical, entero-vaginal)
b.strictures (hence I/O)
c.lower BGIT
d.malignant change (lower risk than UC)
e.perianal disease (leading to perforation, acscess formation & peritonitis)
f. malabsorption syndromes (protein, Fe, vit B12)
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Differences between UC & CD
UC CD
1.Gross pathology
a. location Isolated to large bowel Any part of GIT
-small bowel + colon (50%)
-small bowel (30%)
-colon (20%)
b. skip lesions Absent Present (cobblestone mucosa)
c.stricture formation Absent Present
d.toxic megacolon Present Absent
e.fistula/sinus formation Absent Present
f.pseudopolyps Present Absent
2.Microscopic Pathology
a. inflammation Mucosa & submucosa Transmural
b.non-caseating granulomas Absent Present
c.ulceration Superficial Deep,linear serpentine
d.fibrosis Less more
e.glands Gland destruction, crypt abscess Intact glands
3.Clinical
a. bloody diarrhea Very common Uncommon
b.abdominal pain Pre-defecation urgency Post-prandial
c.palpable mass Uncommon Frequent (RIF)
d.perianal disease Less common More common
e.fat/vitamin malabsorption Absent Present (in small-bowel involvement)
f.malignant change Greater Lesser
e.recurrence after surgery Rare Common
Complications of IBD
Extraintestinal
Urinary calculi (esp oxalate in CD)
Liver (fatty liver, cirrhosis,PSC)
Cholelithiasis
Epithelium (oral aphthous ulcers
Retardation of growth & sexual maturation
Arthralgia (arthritis, AS, sacroilitis)
Trombosis (DVT, portal/mesenteric vein thrombosis)
Iatrogenic (steroids, blood transfustion, surgery)
Vitamin deficiencies
Eyes (uveitis,epicleritis,iridocyclitis,conjunctivitis)
Intestinal
Cancer
Obstruction (rare in UD, unless due to CRC. Common in CD)
Leakage (perforation)
Iron deficiency due to hemorrhage
Toxic megacolon (more in UC)
Inanition (severe wasting due to malabsorption & LOA)
Strictures, fistulas (enter-enteric, entero-vesical,entero-vaginal), perianal disease (CD)
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History-taking
Name/age/race/gender/occupation
Drug allergy
Past medical history
Presenting complaint
Symptoms
1. Bloody diarrhea
- Duration = chronic if persists more than/equals to 4 weeks
- Baseline and current frequency
- Acute/gradual/congenital onset
- Describe stools = watery
volume of stools
Aetiology
Infective = fever, abdominal pain, LOW
recent travel and contact history
history of TB
history of antibiotics usage (use of broad spectrum antibiotics = clindamycin,
ampicillin, cephalosporin)
Trauma = history of radiation
Autoimmune = oral ulcers, joint pain, back pain, unilateral red and painful eye
Neoplastic = LOW, LOA, fever, fatigue, nausea/vomiting, abdominal pain, abdominal
distension, recent changes in bowel habit, preceding constipation, jaundice
Complications
Dehydration = decreased urine output
Protein losing enteropathy = LL oedema
Systemic Review
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Management prior and during admission
Has this happened before?
1. History of IBD
- Duration of disease
- Presenting complaint investigations management
- Currently on follow-up? Compliance
- Current medications = types
recent changes
compliance
side effects
- Control of symptoms = frequency of bloody diarrhea
frequency of exacerbations requiring admission
blood transfusion required
usual precipitating factors
- Triggers for present relapse = stress
intercurrent infections/GE
antibiotics/NSAIDs use
non-compliance to medications
- Complications= red eyes, oral ulcers, back pain, joint pain
toxic megacolon perforation
history of CRC on regular colonoscopy
liver problems (obstructive jaundice)
Drug history
Social history
Smoking
Alcohol drinking
Family set-up and main care-giver
Sexual orientation and contact = HIV can present as diarrhea
Type of housing
Lift-landing
Financial status
Functional level
How has illness affected your life?
Family history
Physical examination
General inspection
General condition = in pain and distress
toxic-looking
pallor
cachexia
Cushingnoid features
Patient’s vitals
Hydration status
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Peripheries
Hands = digital clubbing, palmar crease pallor
Eyes = conjunctival pallor, episcleritis, iritis, conjunctivitis
Oral cavity = angular stomatitis, oral ulcers
Abdomen = tenderness, guarding, peritoneal irritation, distended (toxic megacolon),
abdominal mass (thickened bowel loops/intra-abdominal abscess), rectal mass
on PR (CRC)
Perianal disease = sentinel tags, fistulae, fissures, abscess
Lower limbs = ankle oedema (protein-losing enteropathy), erythema nodosum, pyoderma
gangrenosum
Differentials
Inflammatory bowel disease = ulcerative colitis
Coorectal cnacer
Infective colitis = amoebiasis, TB
Radiation colitis/proctitis
Ischaemic colitis
Antibiotic-associated colitis (pseudomembranous colitis casued by C. difficile)
Investigations
Blood
FBC = low Hb (anemia a/w iron deficiency)
WBC and differential count (chronic enteric infection)
Low platelet (bleeding diasthesis)
Elevated hct (dehydration)
U/E/Cr = elevated urea > elevated creatinine (dehydration, BGIT)
Electrolyte abnormalities (hypokalaemia and metabolic acidosis)
LFT = Albumin (LOW, LOA, protein-losing enteropathy)
Elevated conjugated bilirubin + ALP + GGT (primary sclerosing cholangitis a/w IBD)
PT/PTT = BLEEDING DIASTHESIS
GXM
ESR and CRP = raised in acute UC
Blood c/s (especially in febrile patients with known colitis/CD)
Stools
Stool studies = gram-staining, culture /sensitivity
Microscopy for ova, cysts and leukocytes
C. difficile toxin
Imaging
AXR = colitis (toxic megacolon, mucosal oedema aka ‘thumb-printing’, perforation)
Colonoscopy and biopsy
- UC = confluent lesions most severe in rectum and distal colon
No strictures
- CD = skip lesions, apthoid ulcers and strictures, rectal sparing, perianal disease
- NSAID = microscopic colitis (scope may look normal but still biopsy)
Barium study/Barium enema/Barium meal (if colonoscopy cannot be done)
- UC = shortened colon, loss of haustrations, lead pipe appearance, featureless colon
- CD = strictures (string-sign), skip lesions, cobble stoning of mucous, deep fissured
ulcerations, fistula, loss of haustrations
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Management
Acute exacerbation
(a) Stabilize patient’s vitals esp circulation
- Set 2 large-bore IV cannulas
- Take bloods for investigations esp GXM
- Fluid resuscitation if in shock = crystalloids colloids PCT
(b) Keep NBM and maintain on IV hydration. Start I/O charting
(c) IV empirical antibiotics if febrile = Ciprofloxacin or Metronidazole (cover against E. coli)
(d) IV high-dose hydrocortisone x 5/7
If refractory IV cyclosporine (much faster onset than azathioprine)
(e) Monitor vitals q4hrly = inform doctor is SBP <100mmHg or HR>100/min
Place on stool charting
Long-term management
(a) Pharmacotherapy
1. 5 ASA (5-aminosalicyclic acid)
- prototype = sulfasalazine (5 ASA + sulfapyridine)
- MOA = blocks arachidonic acid metabolism to prostaglandins and leukotrienes
- Routes of administration = oral
suppository (proctitis covers 10-15cm from anal verge)
enema (proctosigmoiditis)
- Topical = very effective for distal disease (up to splenic flexure)
better than steroids
oral = effective for pancolitis
- S/E = nausea, vomiting, headache, rashes, haemolytic anaemia, agranulocytosis
Introduction of remission
Mild disease Oral 5 ASA
5 ASA/steroid enema
Moderate disease Oral prednisolone 40mg OM
Severe disease IV hydrocortisone x 5/7
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Maintain remission
Ulcerative colitis or Sulphasalazine (usu Proven benefit in colitis = not for
Crohn’s colitis 2g) small bowel CD
Decreases relapse risk from 60%
to 15%
Crohn’s ileal disease Steroids
Immunosuppressants
(c) Surgery
- Indications = impaired quality of life
failure of conservative treatment
Prognosis
Life expectancy same as general population
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Repiratory Medicine
Medicine (Respi) = History Taking: Respiratory System (General)
Name/age/race/gender/occupation
Date of admission
Presenting complaint
1. Respiratory symptoms
(a) Fever = when did it happen
acute/gradual onset
T max? associated with chills and rigours?
symptoms of raised ICP = vomiting, headache, photophobia, neck stiffness
pattern (constant, swinging, spiking)
relieved with anti-pyretics?
progressively better or getting worse?
Management before coming into hospital
(b) Cough = productive/dry
colour of sputum? amount? Smell?
haemoptysis (exclude haematemesis and trauma)
character (barking/brassy/hollow)?
- Barking = epiglottitis
- Brassy = tracheal compression by tumor
- Hollow = recurrent laryngeal nerve palsy (vocal cords are unable to close
completelybovine cough)
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progressively worsening or getting better
severity (must rest for how long)
precipitating, aggravating and relieving factors
effort tolerance (walking on level ground, climbing up stairs)
3. Aetiology
4. Complications
5. Systemic review
Drug history
1. Any known drug allergy
- If yeswhat kind of drug? Drug reaction (angioedema, anaphylaxis, urticaria)
2. Long-term medications
- For what medical conditions
- Type, length of use
- Dosage, frequency of dosing
- Side-effects
- Compliance with use
3. TCM use
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Social history
1. Smoking (20 cigarettes/day for 1 year = 1 pack year)
2. Alcohol
3. Occupational history = exposure to dust/animals
duration of exposure
use of protective devices
Family history
1. Asthma, AR, allergic conjunctivitis, food allergy
2. Bronchial carcinoma
3. TB
181
Medicine (Respi) = Physical Examination: Respiratory System
Start
1. Examine the patient on the right side of his bed
2. Introduce yourself, and explain to patient what you are about to do to and the purpose, note hoarseness
of voice (sore throat/RLN involvement)
3. Position the patient at 45°
4. Achieve adequate exposure by removing shirt
Hands
1. Take radial pulse for 15s (rate rhythm)
- Tachycardia=fever, hypoxia, treatment with β2-agonist
- Pulsus paradoxus: severe asthma, tension pneumothorax
- Bounding pulse= CO2 retention
2. Check hands for
- Clubbing (lung ca, bronchiectasis, empyema, lung abscess, pulmonary fibrosis, cystic fibrosis)
- Cyanosis
- Pallor of nail beds and palmar creases in anaemia
- Tar stains (cigarette smoking, tar is colourless)
- Guttering of small muscles of the hands
- Weakness of finger abduction-lung Ca involving the lower trunk of brachial plexus
- Palpate wrist for tenderness- Hypertrophic pulmonary osteoarthropathy
- Flapping tremor-patients to stretch out arms, dorsiflex wrists and spread out fingers CO2
retention
Face
1. Eyes- partial ptosis, papillary constriction, loss of sweating (horner’s syndrome with apical lung ca)
182
2. Sinuses= palpate frontal and maxillary sinuses (tender=sinusitis)
3. Lips and tongues= central cyanosis
4. Oral cavity (teeth, gums, tonsils, pharynx)= URTI, lung abscess, pneumonia
Neck
1. Palpate for tracheal tug-signs of respiratory distress
2. Palpate for tracheal deviation (warn patient first)- deviated to same side in upper lobe collapse and
fibrosis, pushed to the other side in pleural effusion and tension pneumothorax
Chest
2. Palpate
- Apex beat (displaced in middle lobe or lower lobe pathologies)
- Parasternal heave of RVH
- Palpable p2 of pulmonary hypertension
- Symmetry of chest expansion and if it is reduced bilaterally. (place hands parallel to ribs with
thumbs meeting in midline and measure the distance moved during inspiration at least 5 cm)
3. Tell examiners that you would want to do tactile fremitus but acknowledge the fact that it is only useful
in cases of large pleural effusion or consolidations
- Place palms on either side of the chest while patient says 99, increased in consolidation, decreased
in pleural effusion
4. Percuss = apices, clavicles, anterior intercostal spaces and axillae
- Loss of cardiac and liver dullness 2° to hyperinflation in asthma/COPD/emphysema and
pneumothorax
- Dull: consolidation and collapse
- Stony dull: pleural effusion
5. Ascultate the apices (bell), anterior intercostal spaces, axillae
- Determine air entry and if expiratory phase is prolonged
- Breath sounds: Vesicular (2/3
inspiration, 1/3 expiration with inspiration louder and with gap)
Bronchial (1/2 inspiration, 1/3 expiration, expiration louder, and hollow and blowing and with
audible gap in between, heard over areas of lung consolidation and just above a pleural effusion.
- Adventitious sounds like rhonchi, crepitations, pleural rubs
6. Vocal resonance= ask patient to say 99 and listen with stethoscope
- muffled in normal lung (low pitched components heard with booming quality, high pitched
components are attenuated
-increased in consolidation (clearly audible, aegophony with bleating quality; whispering pectoriloquy-
whispered speech is distinctly heard
- decreased in pleural effusion
Sitting up
1. Get patient to sit up, hug a pillow and fold hands across chest
2. Inspect chest for shape and symmetry: check for increased AP diameter and barrel shaped chest in
hyperinflation in diseases like severe chronic asthma, and COPD
3. Kyphoscoliosis
4. Anklysing spondylosis
5. Examine back for scars, radiotherapy changes, asymmetry of chest expansion
6. Measure chest expansion
7. Tactile fremitus (usually not done)
8. Percussion
9. Auscultation and vocal resonance
10. Check submental, cervical and supraclavicular LNs
183
Legs
1. Check lower limbs for oedema and cyanosis of Cor pulmonale
End
1. Request for sputum mug, blood pressure and temperature chart
2. Look for pulmonary HPT (Palpable p2, Parasternal heave, loud p2)
3. RHF (Raised JVP, hepatomegaly, sacral oedema
4. Lung metastasis (hepatomegaly, lymphadenopathy)
Thank the patient for his help, help him button his shirt
186
Presentation
Mr ___(name)___ is a pleasant-looking ___(age/race/gender)___ who appears to be alert, well, comfortable and
orientated at rest. His vitals are stable with a HR of ______, regularly regular and not bounding in nature, RR of
______ and currently afebrile. He does not appear to be in any respiratory distress: he is pink on room air and is
not on any supplemental oxygen. He also does not appear cachexic. There were no signs of cyanosis, pallor,
jaundice or dehydration.
On examination of the peripheries, there were no signs of clubbing or wasting of the small muscles of the hand.
There were no tar stains or flapping tremor seen. Tracheal tug and deviation were absent.
On inspection of the chest, I did not observe any surgical scars or chest wall deformities. Chest wall movement
was equal bilaterally. There was no displacement of the apex beat or signs of pulmonary hypertension. Chest
movement was adequate on deep inspiration and equal on both sides. Percussion note was normal. On
auscultation, normal vesicular breath sounds were heard with no adventitious sounds. Vocal resonance was
normal.
No lymphadenopathy was found. There was no peripheral oedema which could indicate right heart failure. I
would like to end my examination by requesting for the sputum mug as well as the temperature and BP charts.
187
Medicine (Respi) = Haemoptysis
1. Definition
Expectoration of blood >200 mls over 24h
Results in death by asphyxiation (rather than exsanguination) 80% mortality
Haemoptysis = blood is coughed out, frothy, alkaline, bright red, no food particles
2. Aetiology
Respiratory V = pulmonary embolism, Wegener’s granulomatosis, Goodpasture’s syndrome, AVM
I = bronchitis, pneumonia, TB (ask for contact/travel hx, sexual hx, h/o HIV or AIDS, h/o DM,
steroids use), bronchiectasis, lung abscess
T = mucosal trauma after vigorous coughing
A
M
I
N = lung cancer
CVS Severe mitral stenosis
Acute left ventricular failure APO
Bleeding diatheses
3. Investigations
Bloods
a) FBC
b) U/E/Cr
c) PT/PTT
d) GXM
e) ABG
f) Cardiac enzymes
g) D-dimer for pulmonary embolism
ECG
PE = sinus tachycardia, S1Q3T3, right axis deviation, right BBB, p pulmonale, S1S2S3
Imaging
a) CXR = lung abscess, bronchiectasis, consolidation, TB, lung ca, APO
b) CT thorax = locate site of bleeding
c) Bronchial/ pulmonary artery angiogram = locates site of bleeding, allows for embolisation
d) Bronchoscopy = locate site of bleeding, allows for endobronchial tamponade
Specific
a) PE spiral C/T, V/Q scan
b) Wegener’s granulomatosis ESR, CRP, ANCA
c) Goodpasture’s syndrome anti-GBM antibodies
d) Chest infection sputum gram-staining, c/s
4. Management
Airway = head tilt and chin lift (if bleeding profusely left lateral position)
Breathing = ensure that patient is breathing spontaneously, give supplemental oxygen, obtain
saturation and monitor SpO2
Circulation = obtain ECG (r/o PE), HR, BP, large bore IV access fluid resuscitate if in shock, obtain
bloods for investigation
Monitor in MICU/HD
Monitor vitals closely
Correct coagulopathy
Definitive management
Bronchial artery embolisation
Surgery = lobectom
188
CCF
Medicine (Respi) = Dyspnoea
Mitral/aortic valve disease
Dyspnoea = subjective feeling of discomfort a/w breathing Cardiomyopathy
Pericardial effusion/constrictive pericarditis
Respiratory Airway Neuromuscular Guillain-Barre syndrome
Asthma Myasthenia gravis
COPD (chronic bronchitis, emphysema) Others Anemia
Bronchiectasis Hyperventilation
Foreign body obstruction Acidosis
Cystic fibrosis
Laryngeal/pharyngeal tumor History taking
Bilateral vocal cord palsy
Tracheal obstruction/stenosis Name/age/ethnicity/gender/occupation
Tracheomalacia/ laryngomalacia Date of admission
190
Medicine (Respi) = Approach to Chest Pain and Dyspnea
Parenchyma
Pneumonia
Pneumothorax
Lung cancer
Circulation
Pulmonary embolism
History
Name/age/race/gender/occupation/drug allergy
Date of admission
Presenting complaint
1. Chest pain
Mode of onset
Frequency
Duration
Triggers (exertion, palpitations, anxietyCVS, food GIT etc)
Constant/intermittent
Increasing in frequency/severity
Site and radiation
Character
Pain score/severity
Aggravating factors (coughing, deep inspiration, movement respi, sitting up and leaning forward
CVS, lying down, alcohol GIT)
Relieving factors (GTN, rest CVS, bronchodilatorsrespi)
2. Dyspnea
Mode of onset
Frequency
Duration
Acute/gradual onset
Progressively worsening/getting better
Severity (able to speak in full sentences, phrases or words?)
Triggers (exertion, rest. Quantify the effort tolerance!)
Aggravating factors
Relieving factors (bronchodilators, rest)
191
Orthopnea or Paroxysmal nocturnal dyspnea
3. Etiology
CVS= nausea/vomiting, diaphoresis, palpitations, giddiness, syncope, ankle edema, fatigue,
intermittent claudications
Respiratory tract= fever, cough, hemoptysis, recent URTI, hoarseness, noisy breathing, chest pain,
night sweats, LOA, LOW, malaise, history of trauma, history of immobility, recent travel, major
surgery, OCP/HRT
GIT= epigastric pain, nausea/vomiting, reflux symptoms, dysphagia
Others= anemia (pallor, chest pain, SOB, giddiness, palpitations, fatigue, PR bleed, menorrhagia)
Drug history
Drug allergies
Current medications
Recent drugs = B-blockers, NSAIDs, aspirin, thyroxine
Social history
Smoker (significant smoking history more than 10 pack years)
Alcohol, occupational history, family set up, main caregiver, type of housing, lift landing, finances, functional status
Family history
TB, lung cancer, asthma, DM, HTN, HL, AMI/IHD
Investigations
1.ECG and cardiac enzymes= angina, ACS, pulmonary embolism
2.FBC (low Hb anemia, high WBC leukocytosis during infection)
3.U/E/Cr electrolyte disturbances
4.ABG alkalosis/acidosis, type 1 or 2 respiratory failure
5. CXR hyperinflation, rib fracture, pneumothorax, consolidation, pleural effusion, mass, cardiomegaly, CCF
6. D-dimer if PE is suspected
Management
Secure airway patency give supplementary O2 (COPD/smoker O2 28% by venturi mask). Start pulse oximetry
Ensure patient is breathing spontaneously= auscultate lungs
Haemodynamically stable= look for signs of shock, HR/RR/BP, ECG monitoring, set large bore IV access, obtain
bloods for investigation
Resuscitate patient if necessary
Obtain history and perform physical examination once patient is stable
192
Medicine (Respi) = Pulmonary Fibrosis
Clinical features
Symptoms
Progressive exertional dyspnea
Chronic dry cough
Right heart failure (ankle edema, ascites)
Etiology
History of RA (joint pain, swelling, deformity)
History of SLE (rash)
Occupational history
Drug history
History of Ankylosing Spondylitis (back pain)
History of Allergic Broncho-Pulmonary Aspergillosis (history of chronic asthma not responding to
treatment)
History of radiotherapy in the thorax
History of TB infection (chronic cough, hemoptysis, fever, LOW, night sweats, contact and travel
history)
Signs
Digital clubbing
Central cyanosis
Bilateral basal fine crepitations
Tachypnea
Hands rheumatoid arthritis, systemic sclerosis
Face malar rash (SLE), heliotrope rash (dermatomyositis), bird like facies (systemic sclerosis)
Pulmonary hypertension (parasternal heave, loud and palpable P2)
Cor pulmonale (raised JVP, peripheral edema)
Investigations
Bloods (ESR, CRP, anti-dsDNA, anti-ANA, rheumatoid factor, ABG)
Imaging (CXR, lung function tests restrictive lung disease pattern FEV decreased and FEV1/FVC
normal, high resolution CT thorax)
Others (bronchoalveolar lavage, lung biopsy)
Management
Corticosteroids (monitor with symptoms, CXR, lung function tests, consider
cyclophosamide/azathioprine in non-responders)
Single lung transplant
Complications
Type 2 respiratory failure
Cor pulmonale
Increased risk of bronchogenic carcinoma
Secondary polycythemia
Differential diagnosis
Bronchiectasis
Pulmonary edema (CCF)
193
Medicine (Respi) = COPD
Definition: Progressive and irreversible airway obstruction( 7th leading cause of death locally)
Chronic Bronchitis= persistent cough and sputum production for at least 3 consecutive months each year for at
least 2 consecutive years. (Clinical diagnosis)
Emphysema= irreversible dilation of air spaces distal to terminal bronchioles due to destruction of alveolar
walls in the absence of fibrosis (histological diagnosis)
Aetiology
1) Genes- alpha1 antitrypsin deficiency
2) Environment: Occupation- dust, coal, farming
Pollution
3) Smoking(significant if >10 pack years)
Clinical features
History:
1) Current symptoms: dyspnoea, chest tightness, wheezing, increased cough and sputum, change in
sputum colour, fever, LOA, malaise
2) Travel and contact history
3) History of previous episodes: presentation, investigations, management
4) Current management: bronchodilators, long term oxygen therapy, lung surgery
5) Current control: frequency of symptoms, frequency of SAB use, frequency of exacerbations requiring
hospitalisations
6) Baseline status: effort tolerance, ankle edema, LOW( probably due to increased TNF production a/w
chronic hypoxia)
7) Past Medical Hx: pTB, atopies (food allergy, drug allergy, asthma, AR, eczema, allergic conjunctivitis)
8) Social Hx: Smoking (significant if> 10 pack years)
Physical Examination:
Peripheries
1) Signs of respiratory distress: tachypnoea, dyspnoea, use of accessory muscles, pursed lip breathing,
tracheal tug, suprasternal/intercostals/subcostal retractions, paradoxical breathing NB: patients with
emphysema are more breathless (pink puffers)
2) Peripheral and Central cyanosis (in chronic bronchitis-> blue bloaters)
3) Palmar erythema (secondary to polycythemia)
4) Signs of CO2 retention: altered mental state, bounding pulse, asterixis, papilloedema
5) Nicotine/ tar stained fingers
Chest examination
1) Inspect for barrel chest, signs of hyperinflation
2) Chest expansion: decreased
3) Percussion: resonant/ hyperresonant, loss of liver and cardiac dullness
4) Auscultaion: decreased air entry, prolonged expiratory phase, expiratory rhonchi, inspiratory creps,
(chr bronchitis-> mucous plugging; absent in emphysema)
5) Vocal resonance: decreased
Complications
1) Abdominal examination: liver ptosis
2) Signs of cor pulmonale: raised JVP, parasternal heave, loud and palpable P2, hepatomegaly, peripheral
edema
194
Complications
Chronic Bronchitis Emphysema
Type 2 respiratory failure: low paco2 due to v/q Type 1 respiratory failure: low po2 and low/normal
mismatch from mucous plugging. paco2
Differentials:
1) Bronchial asthma
2) Bronchiectasis
3) Obliterative bronchiolitis
4) CCF
Investigations
Bloods:
1) FBC: Hb for polycythemia, WCC
2) U/E/Cr: electrolyte imbalances
3) Blood cultures (if pt is septic)
4) ABG (FEV1 < 40% predicted, spo2 <92%, signs of respiratory failure)
5) Alpha1 antitrypsin assay (esp if pt has never smoked and has emphysema)
Imaging:
1) ECG: right heart strain (cor pulmonale)= R ventricular hypertrophy (R>S in lead V2), P pulmonale (tall p
wave)
2) CT/ HRCT thorax
3) CXR:
a) hyperinflation-> more than 6 ant ribs/ more than 9 post ribs seen above right hemidiaphragm in
mid clavicular line, horizontal ribs, flattened hemidiaphragm, thin and slender mediastinum, decreased
vascular markings.
b) consolidation
c) Pneumothorax
d)Bullae
195
Classification of Severity
Global Initiative for Chronic Obstructive Lung Disease(GOLD) Staging:
Stage/Severity FEV1/FVC FEV1 Treatment
I=mild <70% ≥ 80% Short acting bronchodilators:
1)SABA(salbutamol,fenoterol,terbutaline)
2)SAC(ipratropium bromide)
3)Combivent (SABA+SAC)
Management
Acute Exacerbations:
1) Supplemental O2
a) Controlled oxygen therapy=ventimask (start from Fio2 28% and monitor before escalating, ensure
paco2 does not increase)
b) Keep spo2 >92% (Aim 90-95%)
2) Nebulised salbutamol + Ipratropium bromide + N/S (1:2:1) for symptomatic relief
- use air driven nebuliser (less o2)
3) Assisted ventilation
a) Aim is to rest respiratory muscles and restore gas exchange
b) Types
-Non invasive ventilation(BiPAP-> Bilevel positive airway pressure; CPAP)
Advantages=reduced mortality, need for intubation and length of hospitalisation
Contraindications= facial trauma, drowsy patient
Indicated in the presence if all the following depite 2-3 nebulisations:
Tachypnea(>25 breaths/min)
pH <7.35
PaCO2 >45mmHg
-Endotracheal intubation
Indications:
If NIV fails
pH<7.25
respiratory arrest
somnolence
severe hemodynamic instability
c) Cut offs=
-pH< 7.35 (consider NIV)
-pH<7.30 (must use NIV)
-pH<7.25 (consider intubation)
-pH<7.20 (must intubate)
196
4) Steroid Therapy= oral prednisolone (0.5mg/kg/day), IV hydrocortisone (100mg q6hrly)
-only useful in acute exacerbations
-does not influence course of chronic bronchitis
5) IV antibiotics
a) Indications: worsening dyspnoea, cough and increased sputum volume+ purulence
b) should cover against S.pneumoniae, H influenzae, and M catarrhalis (if recurrent->
Pseudomonas)
c) Start with amoxicillin, if no response proceed with augmentin + Klacid
d) Possible agents: rocephine, cipro, ceftazidine
Chronic Management:
NB: The ONLY 2 things that improve mortality= smoking cessation and LTOT
1) Non pharmacological
a) All stages:
- Smoking cessation= reduce sputum production and bronchospasm. Can use bupropion
SR, nicotine gum, nicotine inhaler and nicotine patch
- Pneumococcal (ever 5 years) and Influenza vaccinations
- Refer to dietician if malnourished a/w decreased respiratory muscular function and
increased mortality
- Encourage ambulation and weight reduction
- Chest physiotherapy
- Patient education
b) Moderate-Severe COPD:
- Pulmonary rehabilitation:
Consists of nutritional therapy, pulmonary exercises and chest physio
Does not improve survival but improves quality of life
c) Long term oxygen therapy
- Indications: clinically stable COPD with pao2 < 55mmhg; COPD cx by polycythemia/
pulmonary htn/ cor pulmonale with pa02 < 60mmhg/ terminally ill patients with pao2
<55mmhg
- Regimen=continuous O2 for at least 15 hrs/day
- Advavntages=symptomatic relief, improve QoL and prognosis
- Disadvantages= expensive(oxygen concentrator), explosive (cannot smoke at home,
cannot put in kitchen, dangerous)
- Reassess every 3 months with ABG-> expensive
d) Treat depression
e) Discuss end of life issues
2) Pharmacological
a) Mucolytics
b) Bronchodilators
- MOA= relax bronchial smooth muscles and relieve bronchospasm
- Does not improve mortality or influence decline in lung function
197
Inhaled SABA -Examples=salbutamil,terbutaline,fenoterol
-Fastest onset ~15 min (DOA 4-5 hours)
-May be ued up to max of 4-6times/day
-S/E: tremors,palpitations,hypokalemia
c) Inhaled Corticosteroids:
- Examples=beclomethasone, budesonide, fluticasone
- Recommended for patients with FEV1 <50% predicted value and experience freq
exacerbations
- Only a modest effect on lung function in COPD as compared to asthma
d) Combination of ICS and LABA
- Examples=seretide (salbutamol+ fluticasone) , symbicort (budesonide + formoterol)
3) Surgical
a) Indications: recurrent pneumothorax (from emphysema), isolated bullous disease
b) Types:
- Bullectomy
- Insertion of endobronchial valves
- Lung volume reduction surgery (thoracoscopic resection of 20-30% of poorly
functioning lung tissie in each lung -> reduce thoracic volume)
- Lung transplant (only if patient is <65y/o and has no serious co-morbidity)
198
Medicine (Respi) = Bronchiectasis
Definition
- Chronic necrotizing infection of the bronchi and bronchioles leading to permanent dilatation due to destruction
of muscles and elastic supporting tissue.
- Main organisms= H. influenzae, S. pneumoniae, S. aureus, P.aeruginosa
- Not a primary disease
- More common in females
Predisposing conditions
- Congenital
(a) Cystic fibrosis= viscid secretions tend to block passages (mucoviscidosis); also decrease clearance
(b) Hypogammaglobulinaemia= decrease in all types of antibodies; hence increased susceptibility to recurrent
bacterial infections
(c) Kartagener’s syndrome (often in relatively young patients, look for left cholecystectomy/appendidectomy
scar) =
1. Ask for history of subfertility, sinusitis +/- otitis media, dextrocardia/ situs inversus, urinalysis for
amyloidosis
2. Autosomal recessive triad of situs inversus (50% have situs inversus totalis), chronic sinusitis and
bronchiectasis
3. Pathogenesis: immotile cilia decreased mucociliary clearance infections
4. may occur in young people but never present at birth sinuses not formed yet
- Acquired
(a) Bronchial obstruction
- tumour
- lymphadenopathy
- foreign body
- TB granuloma
(b) Post infective
- In children= measles, pertussis, bronchiolitis
- In adults= influenza, TB, S. aureus, Klebsiella, mixed infections
(c) Allergic bronchopulmonary aspergillosis (ABPA) = type 3 (complex-mediated) hypersensitivity affecting
mainly proximal bronchi; to suspect in pt with chronic asthma resistant to therapy and productive cough
investigations: eosinophilia, high IgE levels, aspergillus in sputum c/s, skin prick test
- Idiopathic (up to 50%)
Pathogenesis
- Obstruction or chronic persistent infection (either one may come first)
Chronic cough
199
(c) chronic cough leads to rise in bronchial pressure
- Localised bronchiectasis= mechanical obstruction, childhood bronchopulmonary infection
- Generalised bronchiectasis= inherited/ acquired impairment in host defences
Morphology
Macroscopic features
- cystic, smooth, glistening honeycomb appearance of cut surface of lung
- bronchi= grossly dilated up to 4 times the usual diameter , can be traced to pleural surface (normally can
only trace till 2-3 cm from pleura), thick fibrous walls, most severe distally
- obliteration of intervening lung parenchyma
- affects bilateral lower lobes
Microscopic features
- intense acute and chronic inflammatory exudates within bronchial and bronchiolar walls
- capillary congestion, interstitial oedema and hemorrhage
- +/- squamous metaplasia
- Hyperplasia of goblet cells increased mucous secretion
- Destruction of elastic tissue
- Fibrosis
Reid’s classification
(a) cylindrical= uniformly dilated bronchi that end abruptly instead of tapering
(b) varicose = dilated bronchi with irregular bulging contours that end in bullae
(c) cystic =most severe form where dilated bronchi end in cystic pus- filled cavities
Clinical features
History
- Current symptoms= severe persistent cough with copious purulent sputum, haemoptysis, fever, dyspnoea,
pleuritic chest pain, wheeze, precipitated by URTI
- Aetiology = fever, LOA, LOW, night sweats, history of TB, travel and contact history, history of chronic cough
and purulent sputum since childhood (CF, Kartagener’s syndrome)
- Management of current episode= chest physiotherapy, antibiotics, bronchodilators
- History of prior episodes = treatment given, investigation conducted (CT chest, bronchoscopy)
- Past medical history = hypogammaglobulinaemia, COPD, asthma, allergies
- Drug history
- Social history = chronic smoker
- Family history
Physical examination
- fever, clubbing, central/ peripheral cyanosis
- coarse pan- inspiratory/ late inspiratory crepitations that does not clear with coughing
- rhonchi (mucous plugging/asthma/COPD/ABPA)
- sputum mug (voluminous, purulent, foul-smelling, blood- stained, layering of sputum)
- severe disease= cor pulmonale (raised JVP, parasternal heave, palpable and loud P2, peripheral oedema),
amyloidosis (splenomegaly)
- Presentation of findings:
200
“In summary, this patient most likely has an infective exacerbation of bronchiectasis. I say
this because:
(a) presence of IV antibiotics
(b) bilateral coarse pan-inspiratory crepitations that does not clear with coughing
(c) digital clubbing
The patient is currenly not in any respiratory distress and his condition is not complicated
by pulmonary hypertension or cor pulmonale. “
Request to examine:
(a) anterior chest
(b) temperature chart
(c) sputum mug
(d) raised JVP for cor pulmonale
(e) splenomegaly 20 amyloidosis
Differentials:
1. Pulmonary fibrosis- distinguishing features
Pulmonary fibrosis Bronchiectasis
Dry cough Productive cough
Fine end-inspiratory creps Coarse pan-inspiratory +/- expiratory
creps
Steroid toxicity Splenomegaly
Investigations
- Bloods= FBC, ESR, CRP, blood c/s, ABG
- Sputum = gram stain, c/s, AFB stain, TB c/s
- CXR = cystic shadows, thickened bronchial walls (tramline and ring shadows), air fluid levels
- High resolution CT (HRCT) thorax= assess extent and distribution of disease; slices are 1-2 mm thick CF
standard CT (10mm)
- Bronchoscopy = locate site of haemoptysis and exclude obstruction; largely superceded by HRCT
- Spirometry = obstructive picture
Management
Acute
- Give supplementary 02
- If rhonchi present nebulized salbutamol
- Start IV antibiotics
- Chest physiotherapy = aid sputum expectoration and mucous drainage
201
- Massive haemoptysis bronchial artery embolisation
Chronic
-Smoking cessation
- Pneumococcal and influenza vaccination
- Bronchodilator therapy
- Chest physiotherapy
- Long term 02 therapy
Surgery
- Indication= localized disease which has failed medical therapy
- Options= lobectomy
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Medicine (Respi) = Cor Pulmonale
Pulmonary hypertension
- Primary pulmonary hypertension (much less than 5%)
- Most common in females (20-30 years old)
- Marked by fatigue, exertional dyspnoea and chest pain
- Pathogenesis = pulmonary endothelial dysfunction Decreased prostacyclin and NO
Vasoconstriction
Cor pulmonale
- right heart failure cause by chornic pulmonary hypertension due to disorders in the lung, chest wall or
pulmonary circulation
- Aetiology:
Lung diseases Chronic severe asthma
COPD
Bronchiectasis
Pulmonary fibrosis
Lung resection
Pulmonary circulation Recurrent pulmonary embolisms
Pulmonary vasculitis
Primary pulmonary hypertension
Acute respiratory distress syndrome
Chest wall disorders Neuromuscular Myasthenia gravis
Poliomyelitis
Motor neurone disease
Duchenne muscular dystrophy
Chest wall Kyphoscoliosis
Obesity
Hypoventilation Obstructive sleep apnoea
Cerebrovascular accident
Clinical features
Symptoms
- exertional dyspnoea
- chronic productive cough
- ankle oedema
- Abdominal distension
Signs
- respiratory distress= Tachypnoea
Central cyanosis
- tar stains on fingers
- pulmonary hypertension = parasternal heave,
Loud and palpable P2
Pulmonary and tricuspid regurgitation
- cor pulmonale= as above plus raised JVP (prominent a and v waves)
Hepatomegaly (pulsatile liver in TR)
Ascites
Ankle oedema
- Aetiology = COPD (hyperinflation, expiratory wheeze, prolonged expiratory phase, inspiratory crepitations),
pulmonary fibrosis (bibasal fine end- inspiratory crepitations)
203
Complications
(a) right heart failure
(b) respiratory failure
(c) secondary polycythaemia
Investigations
Bloods
- FBC= raised Hb and hematocrit (hct)
- ABG= hypoxia +/- hypercapnia
ECG
- p pulmonale (relatively narrow P wave with increased amplitude indicating R atrial dilation), RAD, RBBB, RVH+/- strain
CXR
- enlarged right atrium and ventricle
- prominent pulmonary arteries
Management
(a) treat underlying cause
(b) treat respiratory failure
- Give supplementary 02 cautiously if Pa02 < 60 mmHg
- Start at Fi02 = 24% and monitor with ABG 30 mins later
- Escalate oxygen if PaC02 remains stable
- If PaC02 increases give doxapram (a respiratory stimulant)
- Consider assisted ventilation
(c) treat cardiac failure
- fluid restriction
- diuretics
(d) venesection if hct >55%
(e) heart- lung transplant in young patients
Prognosis
Very poor (50% mortality within 5 yrs)
204
Medicine (Respi) = Respiratory Infections: Tuberculosis
Epidemiology
Communicable disease
Causes 6% of deaths worldwide, making it the most common cause of death from a single infectious
agent (WHO)
Developing countries
Incidence is increasing in developed countries as well, due to increasing prevalence of AIDS (most
important risk factor for development of TB) and migration
Common in poverty stricken, overcrowded areas, malnutrition
Common in those with chronic illnesses eg DM, chronic lung disease, elderly or immunocompromised
(AIDS)
Notifiable disease
Aetiology
Mycobacterium tuberculosis (M. bovis from unpasteurised cows’ milk is rare)
Transmission: direct person-to-person transmission via airborne droplets from an active case (latent
disease is not transmissible unless it reactivates in times of immunosuppression). Significant exposure
of 6-8 hours in a confined space.
Pathogenesis:
o Mycobacterium enter macrophages -> inhibit microbicidal activity -> uncontrolled proliferation
of mycobacterium -> bacteremia and seeding of multiple sites
o Recruitment of monocytes whch differentiate into epithelioid histiocytes that characterise the
granulomatous response
o Also results in delayed type tissue hypersensitivity
Pathology
Primary Tuberculosis
Develops in previously unsensitised individuals.
Usually asymptomatic
Elderly persons may lose their sensitivity to MTB and hence develop primary TB more than once
Source of organism is exogenous
Bacilli deposit near the pleura proliferate in macrophages -> form tubercles with caseous necrosis
(Ghon focus)
Bacili drain to the regional LN which also undergo caseous necrosis (Ghon complex = parenchymal
lesion + nodal involvement)
Effective cell-mediated immune (CMI) response develops 2-6 weeks after infection
Failure to develop CMI results in progressive destruction of the lung -> progressive primary TB
Complications
Foci of scarring may harbour viable bacilli for years, and thus be the nidus of reactivation in times of
immunosuppression.
Progressive primary tuberculosis: disease develops without interruption in immunocompromised
individuals eg. AIDS patients with CD4+ counts <200/mm3
o Inability to mount immunological reaction to contain the primary focus
o Absence of characteristic caseating granulomas (non-reactive TB)
o Miliary TB: multiple tubercles evenly distributed throughout the lung
Latent TB
Stage in between primary and reactivation TB
Secondary TB (reactivation TB)
Arises in previously sensistised host, from reactivation of dormant bacilli when host resistance is low
(only 5% of those with primary disease develop secondary TB)
Classically localised to the apex of one or both upper lobs (may be due to high oxygen tension)
205
Due to hypersensitivity, bacilli excite a prompt and marked tissue response that tends to wall off the
focus (hence the regional LN are less prominently involved in early secondary TB compared to in early
primary TB)
Cavitation occurs, erosion and dissemination along the airways -> sputum positive, person can spread
the disease.
Complications
Progressive pulmonary tuberculosis: apical lesion enlarges, erodes into surrounding tissue
o Erosion into bronchus creates a ragged irregular cavity
o Erosion of blood vessels leads to hemoptysis
o Dissemination by blood or lymphatics
Miliary pulmonary disease
Pleural involvement: effusions, tuberculous empyema or obliterative fibrous pleuritis
Lymphadenitis: the most common form of extrapulmonary TB
o Typically occurs in the cervical region (“scrofula”)
Endobronchial, endotracheal and laryngeal TB
Intestinal tuberculosis
Pott disease: TB abcesses in the vertebrae (may spread along tissue planes to form “cold abscesses”
which present as a pelvic lump)
Systemic military tuberculosis
o Hematogenous spread to other organs esp liver, bone marrow, spleen, meninges, adrenals,
kidneys -> fatal without treatment
Clinical features
Pulmonary TB
Symptoms
o Fever, persistent cough, hemoptysis, pleural pain, spontaneous pneumothorax, non-resolving
pneumothorax, lethargy, LOW, night sweats
Signs
o Crepitations, signs of consolidation, +/- signs of fibrosis, +/- signs of pneumothorax, +/- signs of
effusion
Miliary TB
Persistent cough, SOB, crepitations, tachycardia, anaemia, hepatosplenomegaly, choroidal tubercles on
opthalmoscopy, fever, LOW, night sweats, lymphadenopathy
Extrapulmonary TB
GI (intestine or peritoneum)
o Diarrhoea, malabsorption, I/O, ascites
o Management: Peritoneal fluid for AFB
Pericardium
o Pericardial effusion or tamponade, constructive pericarditis due to post-infectious fibrosis
o Management: Requires steroids to reduce need for pericardiectomy
GU
o Haematuria, frequency, dysuria, sterile pyuria, salpingitis, tubal abscess, epididymal TB-
swelling/sinus formation
o Management: 3 early morning urine for AFB, renal U/S, IVU
CNS
o Headache, meningism, altered mental state, vomiting, neurological deficits
o Management: CSF for AFB – fibrin web, mononuclear cells, cell count 10-1000, decreased
glucose, normal or increased protein
Lymph node
o Usually cervical lymph node, swelling and sinus formation
Bone/Joint
o Vertebral collapse, pyrathrosis, osteomyelitis, cold abscess formation, bone marrow: anaemia,
thrombocytopenia
o Management: X-ray, MRi to determine extent of involvement, culture biopsies
Others
o Adrenal gland destruction -> Addison’s disease
206
o Skin: lupus vulgaris, erythema nodosum
o Eyes: Phlyctenular keratoconjunctivitis, iritis, choroiditis
Symptoms of compression by lymph nodes eg. Monophonic wheeze, bronchiectasis, lung collapse
Symptoms of affected organ systems eg. Headaches and seizures for TB meningitis, paraplegia for Pott
disease
Risk factors: contact/travel history, crowded living conditions, HIV/immunocompromise, malnutrition,
alcoholism, steroid therapy, DM, previous TB
Investigations
CXR
o Cavitation in the apices of the lung
o Calcification
o Reticulonodular shadowing (for military TB)
o Fibrosis (“scarring”) with traction
o Enlargement of hilar and mediastinal lymph nodes
o Cavity with aspergilloma: air crescent sign
(CXR does not give indication of the activity of the disease; it is not diagnostic)
FBC
LFT
CRP
Sputum AFB smear: MTB binds to Ziehl-Neelson stain and resists decolorisation (acd fast)
o Positive AFB smear makes a presumptive diagnosis of TB in a high risk patient, although a
positive stained smear is not specific for M. Tuberculosis
o 50% of AFB positive locals have MOTT (Mycobacteria other than TB)
o Most AFB positive foreign workers have MTB
o If the patient is not able to produce sputum, sputum induction with nebulized, hypertonic 3%
saline in a negative pressure isolation room is an alternative before more invasive procedures
(bronchoscopy)
Sputum culture is the gold standard (culture on Lowenstein Jensen media requires 12 weeks; PCR can
provide faster results) *only culture can provide info on drug sensitivity
Early morning gastric aspiration: most useful in young children where sputum is more difficult to
obtain, and is best performed following at least nine hours of fasting
Nucleic acid amplification tests (NAAT), can provide rapid diagnostic information to the clinician,
generally within 24 to 72 hours
Tuberculin skin test: TB antigen is injected intradermally and the cell mediated response at 48-72 hours
is recorded. A positive test indicates that the patient has immunity (ie, previously exposed or
vaccinated). A strong positive test suggests active disease. False negatives occur in immunosuppression
eg. Miliary TB, AIDS
In HIV patients, atypical features include sputum smear negative for AFB; false negative tuberculin test
cos of tuberculin anergy, lack of granulomas in tissues
Management
Notify CDC, refer to TBCU
Contact tracing
o Household contacts of sputum smear positive PTs
o 2/3 step contact tracing
Week 0: Do Mantoux, read at day 2-4
If >15mm, means seroconvert – give prophylaxis
If <15mm, repeat Mantoux
Week 2: Do Mantoux
If increase of week 0’s test by >10mm, means that first Mantoux reactivated
previously exposed immune system, now pt is displaying competent immune
response – don’t need prophylaxis
If <10mm, do third Mantoux
Week 12: Do Mantoux
207
If increase >10mm of week 0, means pt has seroconverted. Pt has LTBI, give
prophylaxis
If increase <10mm, no need prophylaxis
Advise HIV testing
Isolation whie infectious
Ishihara colour vision testing before initiating therapy with ethambutol
Give anti-TB drugs (directly observed therapy to improve compliance) + monitor liver function
Monitor CXR weekly during treatment, monthly sputum AFB smear and cultures till two consecutive
negative cultures
Most persons diagnosed with TB are begun on specific treatment before the diagnosis is confirmed by
the laboratory.
TB drugs
Aims of therapy
o Successful treatment requires more than one drug to which the organisms are susceptible
o Sufficient dose
o Sufficient duration
o Compliance -> DOT (polyclinic DOT) – directly observed therapy
TB drugs
o First line:
Isoniazid (H): 15mg/kg PO 3x/week
RIfampicin (R): 600-900mg PO 3x/week
Pyrazinamide (Z): 2.5g PO 3x/week
Ethambutol (E): 30mg/kg PO 3x/week
Streptomycin (S): 0.75-1g/day IM
Amikacin
Kanamycin
o Pyridoxine is given to reduce peripheral neuropathy induced by isoniazid
o Pyrazinamide is given for the first 2 months to kill intracellular bacilli
o 6 month treatment
o Titrate according to body weight
o Initial drug regimen is based on knowledge of the likely drug susceptibility
o Four drugs are used in the initial phase of treatment when the total duration of treatment is 6
months, because of the high incidence of isoniazid-resistant organisms in most communities
o Usually RHZ or RHEZ for 2/12 followed by RH for 4/12
Drug resistant TB
o Initial drug regimens need to be modified in areas with a known high prevalence of MDR-TB
o Development of drug resistance after initial drug sensitivity (secondary drug resistance) occurs
in patients who do not comply with treatment regimens, occurs mainly in HIV patients
o Nosocomial transmission significant
o Use 4 drugs, treat for 2 years
o Follow up for 1 year after eradication
o Second line drugs: Ofloxacin, Ciprofloxacin, Cycloserine, Ethionamide, Azithromycin
Drug side effects
o Rifampicin
Induces liver enzymes -> caution in drugs and OCP
Stop if liver enzymes are more than 3x elevated
Orange tears, sweat, sputum, urine
o Isoniazid
Peripheral neuropathy
Skin rash
Hepatitis -> stop drug
o Pyrazinamide
Precipitates gout
Liver toxicity
o Ethambutol
208
Dose related optic retrobulbar neuritis, presents with colour blindness, central scotoma,
reduction in visual acquity
o Streptomycin
Irreversible damage to the vestibular nerve
Allergic reactions are more common
TB and HIV
TB in an HIV patient is an AIDS defining condition
4 drugs are used instead of the usual 3
Adverse reactions are common and the prognosis is poor
Multiple drug resistance occurs in 6%
M. avium intracellulare is another mycobacterium that can cause pulmonary infection in AIDS patients
Negative Mantoux test
Positive reactivation of TB
Atypical presentation
Negative smears for AFB
Atypical CXR
Extrapulmonary and disseminated disease common
Increased toxicity from anti-TB and anti-RV therapy
Immune reconstituition inflammatory response = anti-RV therapy reconstitutes CD4 count and immune
function. Therefore paradoxical worsening of TB symptoms
Absence of caseating granulomas
Prevention
BCG vaccination: live attenuated vaccine -> only protects against childhoos military and CNS TB. Repeat
vaccination in adolescence not found to affect outcome/ risk of TB, and is no longer indicated
Contact tracing: CXR, Mantoux test
Chemoprophylaxis for contacts and for HIV patients
o Isoniazid 200mg/day PO for 9 month/ rifampicin 4 months if Mantoux positive as descrbed
Mantoux test
Used to identify patients with latent TB (useful for screening)
Positive tuberculin test indicates infection with M. tuberculosis; it does not diagnose active disease
Intradermal injecion of 0.1 ml of PPD (type 4 hypersensitivity reaction)
Interpreted 48-72 hours after intradermal administration = wheal and flare reaction
Transverse diameter of wheal should be measured and recorded in millimetres
False negatives: newly diagnosed TB, HIV, TB meningitis, malnourished, immunosuppressed,
lymphoma, sarcoidosis, military TB
Children who have received the BCG vaccine generally demonstrate PPD skin test reactions of 3-19mm
several months after vaccination. Most of these reactions wane significantly with time. Responses
indicative of a new infection include: >10mm induration in persons less than 35 years of age or >15mm
induration in >35 years old.
209
10 mm or
< 5mm of 5 to 9mm of
more of
induration induration
induration
Initiate
treatment of
latent
tuberculosis
infection
Pulmonary TB
Sputum culture after 2 months of antibiotic treatment
o Decrease if positive
o Increase: continuation phase to 7months (therefore total treatment 9 months)
Unable to tolerate pyrazinamde
o 2 months of RHE
o 7 months of RH
Patient taken out of isolation once sputum culture negative
Extrapulmonary TB (10%)
6-9 months regimens
12 months = military TB, bone/ joint TB, TB meningitis
Adjunctive treatment
o Corticosteroids = TB pericarditis/ meningitis
o Surgery = constructive pericarditis, spinal cord compression
210
Medicine (Respi) = Pancoast tumour-Upper lobe lung CA
General inspection
- Cachexia
-Radiotherapy marks
-SVCO=Unilateral UL edema, facial plethora
Peripheries
-Digital clubbing and Hypertrophic pulmonary osteoarthropathy
-Tar stains
-Horner’s syndrome= Partial ptosis, constricted pupil, facial anhydrosis, enopthalmos
-Compression of brachial plexus=weakness of finger abduction, wasting of intrinsic hand muscles, numbness
over T1 dermatome
-Cervical lymphadenopathy
Lung
-Trachea deviation
Away=pushed by mass
Towards=Collapse
-Consolidation= Decreased air entry, inspiratory creps, increased vocal resonance, dull percussion in
supraclavicular fossa, upper 1/3 of chest
1. Differential diagnosis
-upper lobe consolidation and lymph nodes a) Neoplastic Lymphoma, b)
Infective-TB, pneumonia, lung abscess, aspergillosis, hydrated cyst
2. Request to examine- Vitals, sputum mug, posterior chest-pleural effusion, pemberton’s sign, abdomen-
hepatomegaly, vertebreal column-mets, paraneoplastic syndromes->Pigmentation of palmar creases,
gynacomastia, cerebellar syndrome, peripheral neuropathy
211
Medicine (Respi) = Pleural Effusion
Definition
*Excessive accumulation of fluid in the pleural space
-Detectable on CXR when fluid > 300ml
-Detectable clinically when fluid > 500ml
*5 major types= Exudate, transudate, empyema, haemothorax, chylothorax
Pathogenesis
Transudate
*Increased hydrostatic pressure
(a) Cardiac = Congestive cardiac failure, Constrictive pericarditis
(b) Renal = ARF, CRF, ESRF, nephritic syndrome
*Lymphatic obstruction
Tumour compression
Post-radiotherapy
SVCO
*others
Hypothyroidism
Meig’s syndrome = Benign ovarian fibroma a/w right-sided pleural effusion
Exudate
*Increased vascular permeability
Inflammation due to RA, SLE, pulmonary embolism, pancreatitis
Infections like pneumonia, TB, Bronchiatasis
Malignancy = Lung primaries or mets, mesothelioma lymphoma
Drugs= Ergotamine, carbegeline, bromocriptine, methotraxate, nitrofurantoin, amiodarone
Clinical features
History
-asymptomatic
-pleuritic Chest pain
-Dyspnea
-Fever, LOA, LOW, Night sweats, cough, haemoptysis
Physical exam
-Usually would be asked to examine the back
-Trachea deviation away from side of effusion
-Decreased chest movement/expansion
-Stony dullness
-decreased/absent breath sounds -> Bronchial breath sounds may be heard above the effusion
-Decreased vocal resonance-> Aegophony may be heard above the effusion
-Aetiology
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Transudate (usually bilateral) Exudate (usually unilateral)
Cardiac failure Malignancy
-raised JVP -Radiotherapy marks
-Displaced apex beat(heaving) -Mastectomy
-S3 heart sound -cachexia
-Gallop rhythm -clubbing
-nicotine stains
-HPOA
-Cervical lymphadenopathy
Chronic liver disease Inflammation
-Stigmata of Chronic Liver Disease -Rheumatoid hands(RA)
-Malar Rash(SLE)
Renal Failure Infective
-Stigmata of ESRF -Toxic looking, sputum mug, IV antibiotics
-Vascular access
Investigations
1. Erect CXR(PA and lateral)
-Findings on PA CXR =Blunting of the costophrenic angles, meniscus sign
-Findings on Lateral CXR =Obliteration of posterior costophrenic angle then hemidiaphragm
-If column of fluid visible and 5cm in height from posterior costophrenic angle of contralateral lung Lateral
decubitus view not required
-Subpulmonic effusion Raised hemidiaphragm
-Loculated pleural effusion Accumulation of fluid between major/minor fissures or along lateral chest wall
(With obtuse angles of interface)
*may be mistaken for tumour
*Invx = U/S
3. Pleural tap
-Both diagnostic and therapeutic
-Procedure= Infiltrate skin, periostuem of rib and pariatal pleural with 1% lignocaine
Insert needle into 1-2 intercostal space below level of dull percussion note
-dry tap=absence of fluid, incorrect needle placement, inappropriately short needle
-Investigations
(a) Clinical chemistry
Protein, albumin, LDH, Glucose, cholesterol
Empyema =pH (taken in a ABG tube and sent in ice)
Pancreatitis, malignancy, oesophageal rupture = Amylase
Autoimmune =Rh factor, ANA
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4. Aetiology
CT thorax=useful for visualizing underlying lung parenchyma obscured on CXR by large pleural effusions
Video assisted thoracoscopy(VAT)
-Indications=Unknown etiology, lung malignancy, mesothelioma, pleural malignancy, TB
Closed pleural biopsy(CT or US guided)
-Indications=malignancy, TB pleurisy, pleural tap inconclusive
Transudate vs Exudate
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Management
* Important to distinguish transudate from exudates
- transudate = treat underlying cause
- exudate = investigate aetiology and treat
* General measures
- Ensure close monitoring of vital signs
- supplemental O2
- large-bore IV excess and GXM (if haemothorax suspected)
- antibiotics for parapneumonic effusion and empyema
* Principles of treatment
1. Removing pleural fluid
- Indications for urgent drainage of parapneumonic effusions = frank pus
Pleural fluid pH <7.2
Loculated effusions
Positive bacterial cultures
- Complications = pneumothorax, haemothorax, re-expansion pulmonary oedema
(a) Thoracocentesis (pleural tap) = alleviate dyspnoea in symptomatic effusions
Prevent ongoing inflammation and fibrosis in exudative effusions
~ ensure that platelet count, PT/PTT are satisfactory
(b) Chest tube insertion
2. Prevention of recurrence → pleurodesis (tetracycline, bleomycin or talc)
- Indications = recurrent effusions (malignant effusions); >2x
* Surgical
- indications = persistent effusions
Increasing pleural thickness (on ultrasound)
Monitoring
* Monitor
(a) patient’s vitals
(b) amount of fluid drained
(c) quality of fluid drained
(d) air-leak (bubbling through water seal)
* Repeat CXR when drainage <100ml/day = evaluate if effusion has been fully drained
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Medicine (Respi) =Pneumothorax
Definition
Pneumothorax = air in pleural space
Haemothorax = blood in pleural space
Chylothorax = lymph in pleural space
Empyema = pus in pleural space
Aetiology
Spontaneous
(i) Primary
- No underlying lung disease
- Usually due to connective tissue defect in pleural wall → bleb formation and rupture
- a/w Marfan’s syndrome and Ehlers-Danlos syndrome (↓ collagen)
- Epidemiology = young tall and thin males (alveoli at lung apices subjected to greater
distending pressure cf to those at lung bases → more likely to develop sub-pleural blebs)
(ii) Secondary
- Due to underlying lung disease = COPD, asthma, TB, CF, lung cancer, bronchiectasis
Traumatic
Types of pneumothorax
Open
- Open communication between airways and pleural space (broncho-pleural fistula) →
persistant air-leak
Closed
- No communication
- Air is reabsorbed at a rate of 1.25% of the total radiographic hemithoracic volume per
day
Tension
- Valvular mechanism develops such that air is sucked into the pleural space during
inspiration but not expelled
- Results in = mediastinal shift, tracheal deviation
Increasing respiratory and cardiac embarrassment
Clinical features
History
- Asymptomatic
- Acute pleuritic chest pain
- Sudden onset/rapidly progressing dyspnoea
- Triggers = trauma, IJ (internal jugular) line insertions, recent H&N surgery
- Underlying lung disease – asthma, COPD, TB, CF, lung cancer
- Previous episodes of pneumothorax
- History of Marfan’s or Ehlers-Danlos syndrome
Physical examination
- Vital signs = tachycardia, tachypnoea, hypotension, pulsus paradoxus (inspiration: ↑ VR
(systemic venous return causing ↑ lung pooling) ∴ ↓ systolic BP → missing radial pulses;
seen in tension PTX)
- Signs of respiratory distress
- Decreased chest expansion, hyper-resonant percussion note, decreased breath sounds
- Subcutaneous emphysema
- Tracheal and mediastinal deviation if tension PTX
Investigations
Erect CXR
- Radiological findings
(a) Ipsilateral lung edge seen parallel to chest wall
216
(b) No lung markings in pleural space
(c) Contralateral mediastinal and tracheal shift if tension PTX
(d) Deep sulcus sign = costophrenic angle is significantly lower than that on
contralateral side
(e) Contralateral lungs gets entire cardiac output and vascular markings become
more prominent
From:
http://www.meddean.luc.edu/lumen/MedEd/Radio/curriculum/Mechanisms/Atelecta
sis1.htm
- Assess rotation → obscure PTX and mimic mediastinal shift
- Side of PTX
(i) Small = apex-cupola distance < 3cm,
Visceral-parietal pleural separation < 2cm (BTS)
(ii) Large = apex-cupola distance ≥ 3cm,
Visceral-parietal pleural separation ≥ 2cm
- Evidence of underlying lung disease e.g. bullae, hyperinflation
ABG
Management
Supportive
- Supplementary O2 = 100% oxygen by NRM → creates concentration gradient → N2 diffusion
from PTX into alveoli → decreases size
Tension pneumothorax
- Immediate needle decompression in the 2nd intercostals space along mid-clavicular line (14
gauge needle)
- Followed by chest tube insertion
Primary spontaneous pneumothorax
- Small = observe at EMD → repeat CXR
Discharge if no progression of PTX
F/u CXR within 2 days
Observe at 2-weekly intervals until air is reabsorbed
- Large / unstable = chest tube inserted at EMD
Admit and observe
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(i) Simple Aspiration
- Infiltrate with lignocaine
- Push 16 F gauge cannula into pleural space
- Connect cannula to three way tap and 50ml syringe
- Aspirate up to 2.5 L of air slowly → stop if there is resistance or patient coughs excessively
- Repeat expiratory CXR film
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Collapse > 72 hours Sudden re-expansion
Practical points
1) Indications for chest tube insertion
(a) Pneumothorax = large, tension, traumatic, failed aspiration
(b) Haemothorax
(c) Symptomatic pleural effusion
(d) Rib fractures and mechanically ventilated patients
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Medicine (Respi) = Respiratory Failure
1. Definition
a. It occurs mainly when gas exchange is inadequate – resulting in hypoxia
b. Defined as PaO2 < 8kPa – subdivided into 2 typees according to PaO2 levels
2. Type 1 respiratory failure
a. Defined as hypoxia (PaO2 < 8kPa) with a normal/low PaCo2
b. Caused primarily by V/Q mismatch
i. Pneumonia
ii. Pulmonary oedema
iii. ARDS
iv. Pulmonary embolism
v. Asthma
vi. Emphysema
3. Type 2 respiratory failure
a. Defined as hypoxia (PaO2 < 8kPa) with hypercapnia (PaCO2 > 6kPa)
b. Caused by alveolar hypoventilation -> respiratory acidosis
i. Drugs – opiates, sedatives, anaesthetic agents
ii. CNS depression – brainstem stroke
iii. Thoracic cage limitation – kyphoscoliosis, flail chest
iv. Neuromuscular disorders – GBS, Myasthenia gravis, Polio
v. Restricted lung expansion – pneumothorax, pleural effusion, hemothorax, diaphragmatic
paralysis
4. Clinical features
a. Hypoxia = cyanosis, dyspnoea, restlessness/agitation, confusion
i. Long standing
1. Polycysthaemia
2. Pulmonary hypertension
3. Cor Pulmonalae
b. Hypercapnia = headache, drowsy, confusion, stupor, bounding pulse, flapping tremor, galilloedema,
peri – pleural vasodilatation, dilated retinal veins
5. Investigations
a. FBC = WCC (infection)
b. CRP
c. D-Dimer
d. ABG
e. Cardiac Enzymes
f. ECG = pulmonary embolism
g. CXR
h. Sputum & Blood Cultures
6. Management
a. Type 1 respiratory failure
i. Treat underlying cause
ii. O2 Via facemask (35-60%)
iii. Assisted ventilation (NIPPV = non – invasive +ve pressure ventilation) if PaO2 < 8kPa
despite PaO2 = 60%
b. Type 2 respiratory failure
i. Treat underlying cause
ii. Controlled O2 Therapy = start at PaO2 24%
1. Respiratory center may be relatively insensitive to Co2
a. Respiration driven by hypoxia – cant give O2 so quickly as a result
iii. Recheck ABG 20mins later
1. if PaCo2 remains steady/decrease = Increase PaO2 to 28%
2. if PaCo2 increase = respiratory stimulant (doxapram) + assisted ventilation (NIPPV)
iv. if all else fails = intubate & reventilate
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Medicine (Respi) = systemic approach to CXR
1. Name, date and projection
a. Check that it is the correct patient
b. Check the left/right marker to prevent missing dextrocardia (apex on the right and stomach bubble on
the left)
c. AP and supine films are second-best of PA films
i. AP -> heart appears enlarged (cannot comment accurately on heart size)
ii. Supine -> distension of posterior vessels = lung fields appear plethoric
1. Heart appears enlarged
“This is the erect AP/PA chest x-ray of Mr/Mdm __________ taken on the _______.”
2. Rotation, penetration, degree of inspiration
a. Rotation = medial ends of clavicles should be equidistant from the midline spinous processes
i. If one clavicle is nearer than the other -> lung on that side will appear whiter
b. Penetration = vertebral bodies should only just be visible through the cardiac shadow
i. Too clearly visible = over-penetration
ii. Cannot see at all -> under-penetration
c. Inspiration = 6th anterior rib should cut the midpoint of the right hemidiaphragm in the midclavicular
line
i. Poorly inspired film -> heart appears enlarged, basal shadowing, trachea deviated to the right
“The quality of the film is good = with no rotation, good penetration and taken on full inspiration.”
3. Mediastinum
a. Trachea = should lie in the mid-line
i. Comment on the presence of ETT
ii. Pushed away by large pleural effusion, pneumothorax, mediastinal mass or tumour
iii. Pushed by lung collapse or fibrosis
b. Thin and slender mediastinum = COPD
4. Hilum
a. Characteristics = mostly formed by the pulmonary arteries with the upper lobe veins superimposed +
left hilum slightly higher than right
b. Hilar enlargement = lymphadenopathy, large pulmonary artery
5. Heart
a. Characteristics
i. Straddles mid-line with 1/3 to the right and 2/3 to the left
ii. Right heart border formed by right atrium; left heart border by left ventricle
iii. Transthoracic diameter -> widest diameter above the costophrenic angles
iv. Cardiac diameter -> draw a vertical line from the trachea to the heart (assuming no deviation)
1. Sum of the 2 greatest lengths from the vertical line to both heart borders
b. Cardiomegaly = cardiothoracic diameter >50%
6. Diaphram
a. Characteristics = right hemidiaphragm should be higher than the left (due to liver)
b. Loss of costophrenic angle with meniscus = pleural effusion
c. Loss of diaphragmatic outline = lower lobe consolidation
d. Low and flat hemidiaphragms = COPD
e. Air below the diaphragm = free peritoneal gas (likely perforation)
7. Lung fields
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a. Division
i. Apices – lie above the level of the clavicles
ii. Upper zone – include the apices to the level of the 2nd costal cartilage
iii. Middle zone – lie between 2nd and 4th costal cartilage
iv. Lower zone – lie between 4th and 6th costal cartilage
b. Loss of cardiac silhouette – middle lobe consolidation
c. Increased translucency – hyperinflation
8. Bone and soft tissue
a. Rib fractures
b. Bone metastasis
c. Subcutaneous emphysema
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Cardio Vascular System
Medicine (CVS) = History Taking: CVS
Name/Age/Race/Gender/Occupation
Date of admission
Presenting complaint
1. Cardiovascular symptoms
(a) Chest pain
Onset, frequency, duration
Sudden/gradual onset
What were you doing at onset
Progressively better/worse
Site and radiation of pain
Character of pain
Severity
Precipitating (none, exertion, palpitations, emotions -> cardiac symptoms)
(food, alcohol, lying down - > reflux symptoms)
Aggravating (inspiration, coughing, movement of shoulders)
Relieving factors (rest, GTN, antacids)
Effort tolerance (level ground and climbing up stairs) -> significantly different from last time?
224
Any learned manoeuvres (valsalva, carotid massage, coughing, swallowing cold water/ice cubes)
(g) fatigue (reduced cardiac output and poor blood supply to skeletal muscles)
(h) intermittent claudication (PVD with poor blood supply to affected muscles)
areas affected
claudication distance
must rest for how long
2. Aetiology
(a) Trauma = musculoskeletal injury
(b) Fever and productive cough = pneumonia causing pleurisy
(c) Preceding URTI = viral mycarditis/pericarditis
(d) Nausea, vomiting, epigastric pain, acid regurgitation, dysphagia = GERD
(e) Triggers = anaemia (PR bleeding), sepsis, hyperthyroidism
3. Systemic review
225
4. Management prior and in hospital
226
Medicine (CVS) = Physical Examination: CVS
Start
1. Examine the patient on the right hand side of the bed
2. Introduce yourself and explain purpose (shake hands)
3. Position the patient at 45 degrees with adequate exposure
Hands
1. Pulse rate: hold patient’s hand with your right hand and take pulse with your left hand (15s)
Rate, rhythm, volume, character
Irregularly irregular = atrial fibrillation, multiple ectopic beats
Regularly irregular = second-degree heart block, ventricular bigemini
Regular = normal rhythm, sinus arrhythmia (increases with inspiration, decreases w expiration)
2. Radio-radial delay (aortic arch aneurysm, aortic dissection)
Radio-femoral delay (coarcation of the aorta)
3. Collapsing pulse: ask if there is shoulder pain, lift up patient’s hand and feel an increase in volume (AR)
4. Check fingers for:
Cyanosis (R->L shunt)
Clubbing (IE)
Splinter haemorrhages in nail beds (IE, Vasculitis)
Tendon xanthomata (familial hypercholesterolaemia)
Osler’s nodes (IE) = red raised tender nodules on finger pulps, thenar and hypothenar eminences
Janeway lesions (IE) = non-tender erythematous maculopapular lesions containing bacteria
Head
1. Check eyes:
Look down and pull up upper eyelid – jaundice (mechanical haemolysis by prosthetic valve; congestive
cardiac failure; hepatic congestion)
Look up and pull down lower eyelid – pallor (anaemia)/spinter haemorrhages (IE)
Xanthelasma (hyperlipidaemia)
2. Check mouth: lips and tongue – central cyanosis; teeth, gums, pharynx – IE
227
Neck
1. Check for raised jugular venous pressure
>3cm above sterna angle is abnormal
Abdominojugular reflex: compress the abdomen over the liver to see if there is an increase in JVP
+ve if rise in JVP persists throughout 15s compression
Reflects RVF (inability to eject the increased venous return)
Chest
Palpation
1. Palpate for the apex beat (feel with the whole hand and localise with 1 finger). If cannot find on the left side,
check the R side for dextrocardia
position: displacement in cardiomegaly/LVH
character
heaving = pressure loaded e.g. HPT,AS -> forceful, sustained, not displaced
trusting = volume loaded e.g. MR, AR -> forceful, not sustained, displaced downwards and laterally
tapping (MS)
double impulse (HOCM)
if apex beat is non palpable: thick chest wall, emphysema, pericardial effusion, dextrocardia (palpable to
the right of the sternum)
2. Parasternal heave for RVH (place hand vertically over sternum for 3-5s – PS, pulmonary hypertension
3. Palpable tap of P2 over pulmonary area -> pulmonary hypertension
4. Thrills for palpable murmurs (place hand horizontally over base of heart) – systolic/diastolic
Auscultation
-If patient is hairy, use bell instead of diaphragm
-Bell is good for low pitched sounds and should be applied gently to the skin (if not -> becomes a
diaphragm)
- Diaphragm filters out low-pitched sounds and makes higher-pitched murmurs easier to detect
1. Auscultate mitral area first (left 5th intercostals space)
- Palpate carotid pulse to identify S1,S2
- PSM for MR -> radiates to axilla
- Get the patient to lie on the left lateral position: palpate for the apex beat (tapping in MS); Use bell to listen
for MDM of MS
2. Auscultate left sterna edge for PSM (VSD,TR) or EDM (AR)
3. Auscultate pulmonary (left 2nd intercostals space) and aortic (right 2nd intercostals space) areas
- Manoeuvres
a. Full inspiration for right sided murmurs (PS, PR)
b. Full expiration for left sided murmurs (AS, AR)
c. Inspiration -> -ve intra-thoracic pressure increases venous return to the heart; increased blood flow
through the right side of the heart
d. Expiration -> +ve intra-thoracic pressure increases outflow from the heart; increased blood flow
through the left side of the heart
- Valsalva manoeuvre for systolic murmurs -> decreases preload (squatting has opposite effects)
a. Accentuates -> MVP (apex), HOCM (LLSE)
b. Softens -> MR, AS
- Sit up in full expiration and auscultate -> LLSE for EDM (AR); aortic area for ESM (AS)
- Sit up in full inspiration and auscultate -> pulmonary area for ESM (PS) and EDM (PR)
228
4. Ask the patient to hold his breath and auscultate the neck for carotid bruits and radiation of AS
- Radiation = same intensity as the original murmur
- Transmitted = lower intensity than the original murmur
5. Auscultate lungs
- Decreased air entry
- Crepitations
- Stony-dull percussion
6. Check sacral oedema
Mitral Loud S1
stenosis Low-pitched mid-diastolic murmur
In general:
Low-pitched murmurs indicate turbulent flow under low pressure
High-pitched murmurs indicate high velocity flow
Non-valvular murmurs
Pericardial Superficial scratching sound not confined to systole or diastole
fiction rub Caused by movement of inflamed pericardial surfaces
Can vary with posture and respiration (louder when patient is sitting up and in full
expiration)
Heard in pericarditis
Continuous Present throughout systole and diastole (permanent pressure gradient)
murmurs Communication existing between both parts of the circulation
Heard in PDA, AVF, ruptured sinus of Valsalva into right atrium/ventricle
Aortopulmonary connection (congenital, Blalock shunt)
Abdomen
- Lie the patient flat
1. Palpate liver: hepatomegaly (CCF); pulsatile (TR -> ask patient to hold his breath in full inspiration for 3-5s and
time with carotids)
2. Renal bruits
229
Legs
1. Pedal oedema (look at patient’s face when doing it
2. Check R/L dorsalis pedis
3. Check for cyanosis and clubbing of toes
4. Thickening of Achilles tendon (hyperlipidaemia)
End
1. Tell examiners that you would like to complete the examination by checking for hepatomegaly, chest (pleural
effusions and crepitations), blood pressure, temperature, fundoscopy (roth’s spots in IE = retinal infarcts) and
urinalysis (haematuria in IE)
2. Thank patient for his help and help him button up shirt
3. Shake his hand before you go
230
Medicine (CVS) = Issues for discussion
Clubbing
Examination
- Inspect fingernails from the side to determine loss of angle between nail bed and finger
- Compress nail bed and rock it from side to side (increased sponginess of proximal nail bed)
- Hold nails of both hands together facing each other (clubbing present if no gap is seen)
Pulses
- Radial pulse -> assess rate and rhythm
- Brachial/carotid pulse -> assess character and volume
231
Blood pressure
Pulse pressure
- Defined as the difference between SBP and DBP
- Narrow = AS; wide = AR
Postural hypertension
- Defined as a drop in SBP>20mmHg and DBP>10mmHg on standing
Korotkoff sounds
Korotkoff 1 = pressure at which a sound is first heard over the artery (SBP)
Korotkoff 2 = sound increases in intensity
Korotkoff 3 = sound decreases in intensity
Korotkoff 4 = sound becomes muffled
Korotkoff 5 = pressure at which sound disappears (DBP)
Measuring height
Procedure = Observe the patient at 45 degrees with his head turned slightly to the left
Right IJV lies medial to the clavicular head of the SCM
Measure the vertical height of the pulse above the sterna angle (raised JVP >3cm)
Recognising waveform
232
a. Raised JVP with abnormal waveform = fluid overload, RHF
b. Raised JVP with absent pulsation = SVCO
c. Raised JVP on inspiration (kussmaul’s sign) = constrictive pericarditis, cardiac tamponade, right ventricular
infarction (best elicited with patient sitting up at 90 degrees) – normally would flatten instead
d. Large a wave = pulmonary hypertension, pulmonary stenosis
e. Cannon a wave (right atrial systole against a closed tricuspid valve) = complete heart block, atrial flutter
ventricular arrhythmias/ectopics
f. Absent a wave = atrial fibrillation
g. Large systolic v wave = tricuspid regurgitation
Heart sounds
233
Cardiac murmurs
LL oedema
234
Presentation
Mr (name), a pleasant looking age/gender/race appears to be alert, well, comfortable and orientated at
rest. His vital signs are stable: HR is ___, regularly regular, RR is ___ and he is currently afebrile. He does
not appear to be in any respiratory distress and is pink on room air. He does not appear cachexic. On
inspection, there are no signs of cyanosis, jaundice, pallor, dehydration or peripheral oedema.
On examination of the peripheries, there was no clubbing observed or stigmata of infective endocarditis
such as splinter haemorrhages, osler nodes or janeway lesions. There was no radio-radio or radio-
femoral delays. Collapsing pulse was absent.
On inspection of the praecordium, there were no signs of surgical scars or chest wall deformities. The
apex beat was not displaced = it was in the left 5th intercostals space. There was no parasternal heave or
thrills were felt over the pulmonary or aortic areas.Palpable P2 was not felt. On auscultation, normal
S1S2 was heard. Loud P1 was not heard. There were no additional heart sounds or murmurs detected. No
bruit was heard over the carotids
There was no evidence of right heart failure = JVP was not raised and there was no sacral or pedal
oedema. Air-entry was good on auscultation of the lung bases. Normal vesicular breath sounds were
heard and there was no inspiratory crepitation sor wheeze detected.
I would like to end my examination by requesting for the temperature and BP charts.
235
Medicine (CVS) = Approach to chest pain
1. Angina
a. Usually a central dull ache in the retrosternal area
b. May radiate to the jaw or left arm
c. Characteristically occurs with exertion and relieved by rest or nitrates
d. GTN is not specific as it can also relieve esophageal spasm
2. Myocardial infarction
a. Often comes on at rest
b. Pain is more severe and lasts longer (>30mins)
c. Associated with dyspnoea, sweating, nausea, giddiness
3. Pleuritic pain
a. Made worse by inspiration, coughing and movement of shoulders
b. Due to pleurisy (pneumonia) or pericarditis
c. Often relieved by sitting up and leaning forward
4. Musculoskeletal
a. Sharp pain localised to a small area of the chest wall
b. Associated with respiration, coughing or movement of shoulders
5. Dissecting aneurysm
a. Shearing pain greatest at onset
b. Radiates to back (distal to left subclavian artery)
c. Think of this if patient presents with chest pain suggestive of AMI but with neurological symptoms as
well
6. Massive pulmonary embolism
a. Pain of very sudden onset
b. Associated with collapse, dyspnoea, cyanosis
7. Spontaneous pneumothorax
a. Sharp and localised pain
b. Associated with severe dyspnoea
8. Oesophageal spasm
a. Rare and difficult to distinguish from angina
b. Precipirated by food, alcohol and lying down
236
c. Associated with dysphagia
d. Relieved by GTN (but time to relief is not as quick as for angina)
9. GERD
a. Burning sensation radiating to the neck
b. Associated with dysphagia and acid regurgitation
c. Precipitated by food, alcohl and lying down
d. Relieved by antacids
10. Oesophageal rupture
a. Chest pain followed by violent vomiting
b. Usually no haematemesis
c. CXR shows pneumomediastinum
History taking
Name/age/race/gender/occupation
Date of admission
Presenting complaint
1. Cardiovascular symptoms
Triggers = Anaemia,
a. Chest pain, sob, palpitations, ankle oedema, nausea, vomiting
Sepsis, Hyperthyroidism
b. Diaphoresis, giddiness, syncope, fatigue, intermittent claudication
2. Management prior to hospitalisation
3. Aetiology
a. History of trauma (muscular strain, rib #, oesophageal rupture)
b. Fever, URTI, productive cough (viral myocarditis, pneumonia)
c. Nausea, vomiting, epigastric pain, acid regurgitation, dysphagia (GERD)
4. Systemic review
5. Current management in hospital
6. Details of previous similar episodes
237
*if well localised -> unlikely to be cardiac cause
Radiation = shoulder, either/both arms or neck/jaw
*can be epigastric pain as well
Precipitants = exercise, palpitations, emotion, food
*if brought on by food, lying flat, hot drinks, alcohol -> oesophageal spasm
Relieving factors = within mins by rest or GTN -> angina
GTN relieves oesophageal spasm more slowly
Antacids -> Gerd
Sitting up and leaning forward -> pericarditis
Aggravating factors = inspiration, coughing, movement of shoulders -> pleuritic
Features of non-cardiac chest pain
a. Sharp or stabbing in nature
b. Lasts <30s
c. Pleuritic component
d. No history of angina/AMI
e. Pain reproducible by palpating chest wall
Physical examination
1. Vitals
- Heart rate
a. tachycardia (tachydysrhythmia -> AF; sinus tachycardia -> pain; SVT; VT)
b. Bradycardia (AV nodal ischaemia 2o AMI, B-Blockers, CCB)
- BP
a. Usually normal
b. Hypertension – must treat if a/w AD(aortic dissection) or AMI
c. Hypotension – AMI, massive PE, tension pneumothorax, AD resulting in cardiac tamponade
d. Wide pulse pressure – proximal AD -> aortic insufficiency
e. Pulsus paradoxus – pericardial effusion/cardiac tamponade 2o AD, constrictive pericarditis, TP
- RR
a. Tachypnoea – usually a/w chest pain
- SpO2
2. Body habitus = tall, thin, patient with long limbs and arachnodactaly – AD
3. CVS examination
- Radio-radio delay/radio-femoral delay = AD
- Diminised femoral pulses = AD
- Unequal carotid pulses = AD
- Raised JVP = RVF 20 AMI, RVF 20 PE, tension pneumothorax (TP)
- Right ventricular heave = RVF 20 PE
- Left ventricular heave = CHF
- Displaced apex beat = TP
- Loud P2 = acute cor pulmonale 20 massive PE
- S3, gallop rhythm = CHF
- PSM = MR 2ndary to papillary muscle ischaemia/infarction (mitral valve prolapsed)
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- AR = proximal AD
- Pericardial rub = pericarditis
- Peripheral oedema = CHF, RVF, DVT
4. Chest examination
- Tender costal cartilage, erythema, swelling = costochondritis
- Localised rib pain = rib #
- Deviation of trachea = TP
- Unequal chest expansion = TP
- Hyper-resonant percussion note = TP
- Decreased air-entry = pneumonia, TP
- Bronchial breathing = pneumonia
- Crepitations = CHF 2ndary to AMI, pneumonia
- Pleural rub = PE, pneumonia
- Pleural effusion = PE< pneumonia
5. Abdominal examination
- Guarding and rebound = perforated ulcer
- Epigastric tenderness = PUD
- Generalised abdominal pain = mesenteric infarction from AD
6. CNS
- Hemiplegia = AD involving carotid artery
7. Skin
- Herpes zoster = unilateral maculopapular rash/vesicles in dermatomal pattern
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Medicine (CVS) = HO on call
# questions to ask over phone
1. Is the patient stable (obtain vitals)
2. What is the patient currently admitted for? Diagnosis?
3. Past medical history
- Any history of angina or AMI? If yes is the pain similar?
- How bad is the pain?
- Any recent ECG or cardiac enzymes done?
#orders to be given over the phone
1. ECG stat
2. O2 by facemask or nasal prongs (2L/min)
- Keep SpO2 > 95%
3. S/L GTN 0.3-0.6mg every 5 mins (keep SBP >90mmHg; CI = hypotension)
#investigations to order
1. 4 blood tubes = FBC, GXM, U/E/Cr, PT/PTT
2. Cardiac enzymes (CK, CKMB, troponin-T) and bedside trop-T
3. ABG
4. ECG = normal ECG does not rule out angina or AMI
- NSTEMI/STEMI
- Inferior MI = do right sided leads to exclude RV MI
- PE (sinus tachycardia, S1Q3T3, RAD, RBBB, RVH, cor-pulmonale)
- AD (normal, LVH from longstanding HTN, electrical alternans from pericardial effusion)
- Pericarditis (ST elevation in all leads, low voltages)
5. 2D echocardiogram is helpful to confirm AMI if ECG changes are equivocal
- Assess LV function
- Exclude mechanical complications (VSD, MR)
- Screen for AD
6. CXR
- Pulmonary oedema – upper lobe diversion, pulmonary congestion
- Cardiomegaly
- Widened mediastinum and prominent aortic knuckle (AD)
- Peripheral PE
- Pneumothorax
- Pneumonia
- Rib #
- Pneumomediastinum (osesophageal rupture)
Specific management
1. AMI (MONA)
- CRIB
- Supplemental O2 (keep SpO2 >95%)
- Aspirin 300mg stat followed by 100mg OM (CI = asthma, BGIT, anaemia)
#give Ticlid 250mg OM if aspirin cannot be given (S/E = myelosuppression)
- S/L GTN stat and ISDN 10mg TDS (CI = hypotension, tachycardia; relative CI = inferior MI with possible RV
involvement)
- Atenolol 100mg OM (CI = asthma, COPD, complete heart block, severe heart failure)
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- Captopril 12.5mg BD if anterior AMI 9CI = CRF, bilateral renal artery stenosis)
Major AMI = IV morphine 5mg + maxolon
IV atenolol 5mg over 5 mins
IV ISDN 2-10mg/hr
Urgent cardio r/v if good premorbid status (PTCA, fibrinolytics)
- General measure = input/output chart
Fluid restriction (<1L/Day)
Soft diet/diabetic diet/low-salt diet
Stool softener (senna 2 tablets ON)
2. Angina
- CRIB
- Supplemental O2 (keep SpO2 >95%)
- S/L GTN stat
- Serial ECGs and cardiac enzymes (q8h x 3)
- Review precipitating cause, adjust anti-anginal medications, assessment by ICU/CCU staff if angina
occurred at rest or 1st episode of angina
3. Aortic dissection
- Arrange for CT thorax or TEE
- Trans-thoracic echocardiogram if neither can be arranged within the next house
#detect dilated aortic root, aortic regurgitation, pericardial effusion
- Refer cardio-thorax = confirm diagnosis with MRI or aortography
4. Pericarditis
- Non-urgent echocardiogram = pericardial effusion, haemodynamic compromise
- PO Idomethacin 25-50mg TDS/aspirin 650mg q4hrs
a. CI = samter’s syndrome (aspirin sensitivity, asthma, nasal polyps), BGIT, on anti-coagulation
b. Used with caution = CHF – sodium retaining properties
CRF – inhibit renal prostaglandins which maintain perfusion in those with pre-renal
conditions
5. Pneumothorax
- Order erect inspiratory and expiratory chest films
- Chest-tube insertion
- Tension pneumothorax = immediate needle decompression, chest-tube insertion
6. GERD
- Antacids = magnesium-containing ones cause diarrhoea; aluminium-containing ones cause constipation
- Elevation of head of bed
- Avoid night time snack
- H2 – receptor blocker
- PPI
- OGD KIV biopsy if PUD suspected
7. Costochondritis
- NSAID e.g. naproxen
8. Herpes zoster
- Unilateral chest pain in dermatomal distribution may precede typical skin lesions by 2-3 days
(maculopapular rash that rapidly evolves into vesicular lesions)
- Neuritis = narcotic analgesia, amltrityline HCL, steroids
- Antivirals (acyclovir) may reduce severity and duration
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Medicine (CVS) = Ischaemic Heart Disease (History)
Name/Age/Race/Gender/Occupation
Date of admission
Presenting complaint
Symptoms
1. Chest pain
- Mode of onset
- Duration
- Frequency
- Sudden/gradual onset
- Constant/intermittent
- Progressively worse/better
- Site and radiation
- Character
- Pain score and severity
- Triggers
CVS -> exertion (quantify), cold exposure, emotion, palpitations, rest
GIT -> food
- Aggravating factors
RT -> deep inspiration, coughing, moving of shoulders
GIT -> alcohol, lying down
- Relieving factors
CVS -> rest, GTN
GIT -> antacids, food
2. Dyspnoea
- Mode of onset
- Duration
- Frequency
- Sudden/gradual onset
- Progressively worse/better
- Severity
- Triggers = exertion (quantify and ?decrease in ET), emotion, rest
- Reliving factors = rest
- a/w orthopnoea and PND
3. Nausea vomiting
- Diaphoresis (excessive sweating)
- Palpitations, giddiness, syncope (loss of consciousness)
- Ankle oedema
- Intermittent claudication
Aetiology
1. Triggers
- Anaemia = chest pain, SOB, giddiness, palpitations, fatigue, pallor, BGIT, menorrhagia, gross haematuria
- Sepsis = fever
- Hyperthyroidism = goitre, fidgety, insomnia, increase in appetite, LOW, diarrhoea
242
2. History of recent trauma = pneumothorax, rib #
3. Fever, URTI, productive cough = viral myocarditis/pericarditis, pneumonia with pleurisy
4. Nausea, vomiting, heartburn, acidbrash, waterbrash, epigastric pain, dysphagia = GERD
Complications
Systemic review
Drug History
Drug allergies
Current medications
Social history
Smoking
Alcohol
Diet
Physical activity
Family set-up
Main caregiver
Finances
Lift-landing
Functional status
Family history
IHD/AMI, DM, HTN, HCL, CVA
243
Medicine (CVS) = Angina Pectoris
Pathogenesis
- Imbalance between myocardial oxygen supply and demand
- Causes
Reduced coronary blood flow = atheroma, thrombosis, embolus, vasospasm, arteritis
Decreased oxygenation = anaemia, CO poisoning, V/Q mismatch
Increased myocardial demand = ventricular hypertrophy, HOCM, thyrotoxicosis
- Accumulation of metabolites from ischaemic muscles -> stimulate cardiac sympathetic nerves -> pain
(patients with cardiac transplants who develop CAD do not feel angina as heart is denervated)
Types of angina
1. Typical angina = Central crushing chest pain
Triggered by stress (emotional, exertion)
Relieved by rest
2. Decubitus angina (severe coronary disease) = on lying down
3. Nocturnal angina (critical coronary disease) = vivid dreams at night
4. Prinzemetal/variant angina = rest angina triggered by coronary vasospasm
Higher frequency in women
5. Unstable angina = angina of recent onset, at rest or change in character/worsening symptoms (frequency)
Pathology
- Stable angina = ischemia due to fixed atheromatous stenosis of 1 or more coronary arteries
- Prinzemetal angina = ischaemia due to coronary vasospasm
- Unstable angina = ischaemia due to plaque rupture with superimposed thrombosis (dynamic
obstruction)
Risk factors
Modifiable Non-modifiable
Smoking Gender (men)
- Risk of Ami same as non-smokers
after 2 years
- Risk of angina same as non smokers
after 10 years
Alcohol Ethnicity (Indians)
Obesity Age (older)
Physical inactivity Family history of IHD/AMI
Hypertension Personal history of IHD/AMI
Hyperlipidaemia Homocysteinaemia
Diabetes mellitus
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Clinical Presentation
History
1. Chest pain
- Location = central substernal chest pain
- Character = crushing
- Radiation = left jaw and arm
- Duration = 5-10mins (AMI -> 30mins)
- Triggers = exertion, cold exposure, emotional stress, palpitations
- Relieved = rest, GTN
- ? recent changes in character of pain
2. Exertional dyspnoea (due to elevated end-diastolic pressure 2ndary to ischaemia
- Not a/w orthopnoea and PND
- ? decrease in effort tolerance
3. Intermittent claudication
4. No symptoms of nausea, vomiting, diaphoresis, giddiness/syncope, ankle oedema, fatigue
5. Triggers = anaemia -> recent BGIT/menorrhagia/gross haematuria
Recent illness/sepsis
Hyperthyroidism -> palpitations, fidgety, insomnia, increased appetite, LOW, diarrhoea
6. Risk factors
- Hypertension
- Hyperlipidaemia
- Obesity
- Smoking
- Alcohol
- Sedentary lifestyle
- Family history = 1st degree relatives (women <65 years old; men<55 years old)
- Personal history
Physical Examination
1. General inspection = obese
Signs of thyrotoxicosis (goitre, thyroid eye disease)
2. Peripheries = anaemia, tar stains, xanthoma, xanthelesma, carotid bruit
3. CVS = cardiomegaly, valvular heart disease, cardiomyopathy
4. Lower limbs = signs of PVD
Investigations
Immediate
1. ECG
- Normal
- Previous AMI (pathological Q waves, LBBB)
- Ischemia (T wave invesion, ST segment depression)
- Left ventricular hypertrophy
2. Cardiac enzymes = not raised in stable angina
3. CXR = cardiomegaly
4. Underlying conditions
- FBC = Hb (anaemia); WBC (leucocytosis)
- TFT = hyperthyroidism
Later
1. Stress test
- Exercise ECG = planar/down-sloping ST segment depression indicative of ischemia
- Dobutamine
245
- Nuclear medicine
- MRI
2. 2D-echocardiogram
- Left ventricular ejection fraction
- Valvular heart disease
3. MIBI perfusion scan
4. MUGA functional scan (multiple gated acquisition scan)
5. Coronary angiogram (delineate exact coronary anatomy in patients going for revascularisation)
Management
Acute
1. Stabilise patient if necessary
- Ensure patent airway
- Ensure spontaneous breathing -> Give supplemental O2
Place on SpO2 monitoring (keep SpO2 >95%)
- Ensure good circulation -> Obtain vitals
Obtain ECG
Place on continuous ECG monitoring if necessary
2. S/L GTN
- MOA = relieves coronary vasospasm & pulmonary congestion; vasodilation
- Absolute contraindications = hypotension; tachycardia (SBP<90mmHg)
3. B-Blockers
- 1st line therapy (not GTN)
4. Aspirin
- MOA = anti-platelet
- Contraindications = anaemia; BGIT; Asthma
#other anti-platelets (e.g. clopidogrel, ticolpidine, Gp2b/3a inhibitors) given only when patient is going
for interventional procedures
5. ACE inhibitors
6. CCB (if pain is not relieved by above measures)
Long term
1. Patient education
2. Control risk factors
- Lifestyle modifications = quit smoking, drink less alcohol, exercise regularly, lose weight, healthy diet
- Hypertension
- Hyperlipidemia
- Diabetes
3. Medical Treatment
- Symptomatic relief = S/L GTN
- Prophylaxis
Anti-platelet therapy = aspirin 75-150mg OM/Clopidogrel 75mg OM
Anti-anginal therapy
B blockers = atenolol 50-100mg *drug of choice in previous AMI)
LA nitrates = ISMN (vasodilatation, relaxes coronary arteries)
CCB = amoldipine (vasodilatation, relaxes coronary arteries, decreases contractility, slows
HR
ACE inhibitors
4. Surgical treatment
- Percutaneous trans-luminal coronary angioplasty (PTCA)
Ideal for a single and discrete lesion
246
Use of balloon dilatation to relieve arterial obstruction (KIV stent placement ot prevent
re0obstruction)
# stent coated with sirolimus -> prevents proliferation of endothelial fibroblasts -> reduces risk of
stenosis
Effective symptomatic treatment for chronic stable angina
No evidene that it improves survival
Acute CX = occlusion of target vessel/side branch by thrombus or loose intimal flap -> ischemia
Long term CX = re-stenosis
- Coronary artery bypass graft (CABG)
Ideal for patients not suitable for PTCA or severe triple vessel disease
Use of alternative arteries to bypass proximal stenosis
#left internal mammary artery (LAD) aka internal thoracic artery
Right internal mammary artery (RCA) aka internal thoracic artery
Reversed segments of saphenous veins
- Operative mortality = 1.5%
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Medicine (CVS) = Ischaemic Heart Disease (History)
Name/Age/Race/Gender/Occupation
Date of admission
Presenting complaint
Symptoms
1. Chest pain
Mode of onset
Duration
Frequency
Sudden/gradual onset
Constant/intermittent
Progressively worse/better
Site and radiation
Character
Pain score and severity
Triggers = CVS exertion (quantify), cold exposure, emotion, palpitation, rest
GIT food
Aggravating factors = RT deep inspiration, coughing, movement of shoulders
GIT alcohol, lying down
2. Dyspnoea
Mode of onset
Duration
Frequency
Sudden/gradual onset
Progressively worse/better
Severity
Triggers = exertion (quantify and ?decrease in ET), emotion, rest
Relieving factors = rest
a/w orthopnoea and PND
3. Nausea/vomiting
Diaphoresis
Palpitations, giddiness, syncope
Ankle oedema
Intermittent claudication
Aetiology
1. Triggers
(a) Anaemia = chest pain, SOB, giddiness, palpitations, fatigue, pallor, BGIT, menorrhagia, gross haematuria
(b) Sepsis = fever
(c) Hyperthyroidism = goitre, fidgety, insomnia, increase in appetite, LOW, diarrhoea
2. History of recent trauma = pneumothorax, rib #
3. Fever, URTI, productive cough = viral myocarditis/pericariditis, pneumonia with pleurisy
4. Nausea, vomiting, heartburn, acid brash, water brash, epigastric pain, dysphagia = GERD
Complications
Systemic review
248
Management prior and during hospitalization
Social history
-smoking
-alcohol
-diet
-physical activity
-family set-up
-main caregiver
-finances
-lift-landing
-functional status
Family history
-IHD/AMI, DM, HTN, HCL, CVA
249
Medicine (CVS) = Acute Coronary Syndrome (ACS)
Pathology
Unstable angina = ischemia due to plaque rupture with superimposed thrombosisDynamic obstruction, no
myocardial damage
Myocardial infarction = myocardial necrosis caused by acute occlusion of a coronary artery by plaque rupture
and superimposed thrombosis
NSTEMI = subendocardial infarct
STEMI = transmural infarct
Clinical Presentation
History
1. Chest pain
-location = central substernal chest pain
-character = crushing
-radiation = left jaw and arm
-duration = prolonged (>30 mins)
-triggers = exertion, cold exposure, emotional stress, palpitations
# DM and elderly patients can present atypically epigastric pain
Painless AMI
2. Dyspnoea (due to heart failure or elevated end-diastolic pressure)
3. Nausea, vomiting
Diaphoresis
Giddiness, syncope
Ankle oedema
4. Triggers = anaemia recent BGIT/menorrhagia/gross haematuria
Recent illness/sepsis
Hyperthyroidism palpitations, fidgety, insomnia, increased appetite, LOW, diarrhoea
5. Risk factors
- Hypertension
- Hyperlipidaemia
250
- Obesity
- Smoking
- Alcohol
- Sedentary lifestyle
- Family history = 1st degree relatives (women < 65 yrs old; men < 55 yrs old)
- Personal history
Physical examination
1. General inspection = dyspnoeic and tachypnoeic
sweating
2. Cardiogenic shock = altered mental state
Hypotensive
Thin and thready pulse
Pale, cool and clammy extremities
Reduced capillary refill time
Reduced urine output
3. Hands = tar staining, peripheral cyanosis
4. Face = xanthelesma, central cyanosis
5. Neck = raised JVP
6. Praecordium = cardiomegaly
Additional heart sounds (S3, gallop rhythm)
Systolic murmurs (new onset VSD, MR)
7. Lungs = bibasal inspiratory crepitations
8. Abdomen = tender hepatomegaly
9. Lower limbs = bilateral ankle pitting oedema
PR = BGIT
Management
Acute
1. Stabilize patient
- Ensure patent airway
- Ensure spontaneous breathing Give supplemental O2; place on SpO2 monitoring (keep SpO2 > 95%)
- Ensure good circulation Obtain vitals (HR, BP, RR); Obtain ECG; place on continuous ECG monitoring if
necessary; create venous access and take bloods for investigations
- Resuscitate if patient is in cardiogenic shock (papillary muscle dysfunction/rupture, septal rupture, cardiac
tamponade)
# call cardiologist and CT surgeon
# start inotropic support = IV dobutamine/dopamine 5-20 g/kg/min
# catheterize patient to monitor urine output
2. IV morphine for pain relief
- Give with IV maxolon (anti-emetic)
3. Nitrates
- S/L GTN = relieve coronary vasospasm
- IV GTN = for ongoing chest pain, HTN and pulmonary congestion
Absolute CI: Hypotension (SBP <90mmHg), tachycardia
Relative CI: Inferior AMI with possible RV involvement
4. Aspirin 300mg stat followed by 100mg OM (can also give clopidogrel, ticlopidine, LMWH)
- Anti-platelet effect starts 1hr after ingestion
- Decreases mortality and re-infarction rate
- CI: asthma, anaemia, BGIT
5. -blocker atenolol 100mg OM
251
Carvedilol ( -blocker of choice for large infarcts)
- Reduces HR, BP and contractility
- To be given only if patient is euvolemic
- CI: asthma, COPY, complete heart block, severe heart failure, urinary retention, bradycardia
6. ACE inhibitors captopril 12.5mg BD
- Given in suspected STEMIs
- CI: hypotension, CRF, bilateral RAS
7. CCB amlodipine
- If pain is not relieved with above measures
Specific measures
1. STEMI
- Consider myocardial salvage therapy in those presenting <12 hrs from onset
(a) Thrombolysis = tPA or streptokinase
(b) Percutaneous transluminal coronary angioplasty
# preferred reperfusion strategy if performed promptly (door-to-ballon time < 90 mins)
# indications = anterior MI, inferior MI with RV involvement, cardiogenic shock in patients < 75yo
Thrombolysis PTCA
Advantages Rapid administration Better clinical efficacy
Widely available # superior vessel patency
Convenient # reduced re-occlusion rates
Does not require expertise Less haemorrhagic risk
Early definition of coronary
anatomy
# allows tailored therapy
# more efficient risk stratification
252
Contraindications
Do not administer thrombolytics if the answer to any of the
following is yes
Suspected AD
Previous CVA
Known intracranial neoplasm
Recent head trauma
Other intracranial pathology
Severe hypertension (BP>180/110)
Hypotension (SBP<90)
Acute peptic ulcer
Acute internal bleeding
Recent internal bleeding (<1 month ago)
Recent major surgery (<1 month ago)
Current use of anticoagulants
Known bleeding diasthesis
Prolonged CPR (>5 mins)
Previous administration of thrombolytics
Pregnancy
Diabetic retinopathy
LBBB on ECG
No contraindications
2. NSTEMI
(a) LMWH
-superior to UF heparin = no need to monitor PTT, greater bioavailability, less risk of bleeding
-can also use Gb2b/3a inhibitors = proven benefit in high-risk NSTEMI +UAP as well as PTCA for STEMI
(b) PTCA
-indications = high-risk patients (persistent ST-depression and/or raised trop-T)
253
General measures
1. Monitored in CCU for at least 2 days
-short term complications of AMI = arrhythmias, CCF, cardiogenic shock, pericarditis
-monitor vitals q4rly
-I/O chart
-fluid restriction < 1L/day
-low-salt diet
-stool softener
Investigations
Immediate
1. ECG
-a single ECG cannot rule out AMI
Serial ECGs can rule out STEMI but not NSTEMI
-unstable angina = normal, ST depression, T wave inversion
NSTEMI = ST depression, T wave inversion
STEMI = ST elevation of >2mm in 2 or more contiguous leads
New-onset BBB
Posterior AMI (ST depression in leads V1+V2)
-do right-sided ECG in inferior AMI to exclude concomitant RV infarct (GTN is contraindicated)
(a) Myoglobin = detected within 1-2 hrs, peak at 6-9hrs, normalized by 24-36hrs
-earliest marker to rise in AMI
Useful in ruling out AMI early (raised in nearly all AMIs at 6hrs)
Disadvantages = not specific for cardiac muscle (skeletal muscle injury, NM disorders, renal failure, IM
injections, strenuous exercise, post-coronary bypass surgery
(b) Creatine kinase (CK-MB)= detected within 4-6hrs, peak at 18-24hrs, normalized by 48-72 hrs
-serological gold standard of AMI
-disadvantages = not specific for cardiac muscle, false positive values in CRF patients (renal failure),
narrow diagnostic window, failure of total CK to rise to abnormal values in all AMI
-relative % index = CKMB/total CK x 100% (≥ 5% suggestive of AMI)
(c) Troponin T = detected within 4-6hrs, peak within 12-120 hrs, normalized by 10-14 days
-useful for late presenting AMI
-Prognostic indicator in unstable angina
-Specific for cardiac muscle
-false positive values in CRF and dialysis patients
(d) Troponin I = detected within 4-6 hrs, peak at 12-36 hrs, normalized by 7-9 days
-the most cardiac-specific marker
-no false positive values in renal failure patients
-prognostic indicator in unstable angina
-not very widely available
3. CXR
-cardiomegaly
254
-acute pulmonary oedema
-upper lobe diversion
-congestive cardiac failure
-Kerley B lines
4. FBC = Hb (anaemia can ppt AMI)
WBC (infection/sepsis can ppt AMI)
U/E/Cr
PT/PTT = esp if patient needs to go for interventional procedures later
GXM
5. 2D-echocardiogram = LV ejection fraction
Complications of AMI (VSD, MR)
Later
1. Stress test = identify presence of residual ischemia
- ECG
- Dobutamine
- Nuclear medicine
- MRI
2. MIBI perfusion scan
3. MUGA functional scan (multiple gated acquisition scan)
4. Coronary angiogram (delineate exact coronary anatomy in patients going for revascularization)
Long-term management
1. Patient education
2. Control risk factors
- Lifestyle modifications = quit smoking, drink less alcohol, exercise regularly, lose weight, healthy diet
-hypertension
-hyperlipidemia
-diabetes
3. Medical treatment
-symptomatic relief = S/L GTN
-prophylaxis
(a) anti-platelet therapy = aspirin 75-150mg OM
Clopidogrel 75mg OM
Ticlopidine
Gp 2b/3a inhibitors
(c) Anti-anginal therapy
# β-blockers = atenolol 50-100mg (drug of choice in previous AMIs)
# LA nitrates = ISMN (vasodilatation, relaxes coronary arteries)
# CCB = amlodipine (vasodilatation, relaxes coronary arteries, decreases contractility, slows HR)
4. Surgical treatment (choice depends on technical difficulty, patient’s condition)
(a) Percutaneous trans-luminal coronary angioplasty (PTCA)
-ideal for a single and discrete lesion
-use of ballon dilatation to relieve arterial obstruction (KIV stent placement to prevent re-obstruction) #
stent coated with sirolimus prevents proliferation of endothelial fibroblasts reduces risk of stenosis
-effective symptomatic treatment for chronic stable angina
-no evidence that it improves survival
-acute Cx = occlusion of target vessel/side branch by thrombus or loose intimal flapischaemia
Long-term Cx = re-stenosis
255
(b) Coronary artery bypass graft (CABG)
-ideal for patients not suitable for PTCA or severe triple vessel disease
-use of alternative arteries to bypass proximal stenosis
# left internal mammary artery (LAD)
Right internal mammary artery (RCA)
Reversed segments of saphenous veins
-operative mortality = 1.5%
Complications
Early
Arrhythmia
-most common complication due to formation of re-entry circuits at junction of necrotic and viable
myocardium
-sudden death, VF, AF, heart block, bradycardias
Contractile dysfunction
-CCF
-LVH with pulmonary oedema
-cardiogenic shock
-papillary muscle dysfunction valvular regurgitation
Extension of infarct
Rupture
-rupture of papillary muscle (D3) severe MR
-rupture of septum VSD
-free wall rupture (D10) haemopericardium cardiac tamponade
Pericarditis (D3)
-onset of different pain = position, worse on inspiration
-pericardial rub and pericardial effusion may be present
-Dressier’s syndrome (post-MI syndrome) = persistent fever, pericarditis, pleurisy
# Mx = wait and see
High-dose aspirin, NSAIDs, steroids
Mural thrombus embolus
Late
Ventricular aneurysm
-due to bulging of non-contractile fibrous myocardium during systole
Recurrent AMI
Prognosis
Prognostic indicators = age of patient, extent of infarct, residual LV function
50% mortality within 24 hrs of onset (25% die before arriving at the hospital)
40% mortality within the 1st month
1st year survival rate = 80%
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Medicine (CVS) = Congestive Cardiac Failure (CCF)
Definition
Structural or functional heart disorder that prevents adequate cardiac output for tissue perfusion OR only at an
elevated filling pressure
Acute heart failure = present de novo acute decompensation of chronic heart failure
Epidemiology
Accounts for 4.5% of all hospital admissions and 2.5% of overall mortality in the elderly
Common condition = lifetime incidence is 20%
No gender predilection
Main risk factors
coronary artery disease (DM, HCL, obesity, smoking)
hypertension
valvular heart disease
cardiomyopathy
other risk factors = previous AMI, arrhythmias, family history
poor prognosis = many die suddenly due to malignant ventricular arrhythmias or AMI
Pathophysiology
arises from either systolic or diastolic dysfunction
(a) Systolic
- Reduced systolic dysfunction leads to 4 compensatory mechanisms
1. Increase pre-load by activating RAAS. # Starling’s law = cardiac output depends on preload (EDV),
afterload (arterial resistance) & myocardial contractility
2. Increase pre-load by ADH release
3. Sympathetic activation by releasing catecholamines
4. Local changes = ventricular hypertrophy (pressure load), ventricular hypertrophy and dilatation
(volume load)
(b) Diastolic
- Ischaemia muscle fibrosis decreased relaxation/elastic recoil or ventricle elevated LV end-diastolic
pressure decreased stroke volume
- Classically caused by hypertension and HOCM
- Normal LV ejection fraction
causes of pulmonary and peripheral oedema
(a) high arterial pressures
(b) impaired renal perfusion secondary aldosteronism salt and water retention
- CCF causes increased venous pressure which transmits to renal venous system
- Decreased pressure gradient between renal arterial and venous system results in decreased renal
perfusion
Aetiology
Pump failure
(a) Heart muscle = coronary artery disease (ischaemiafibrosis), cardiomyopathy, myocarditis
(b) Restricted filling = constrictive pericarditis, cardiac tamponade, restrictive cardiomyopathy
(c) Inadequate heart rate = negative inotropic drugs (anti-arrhythmics, β-blockers), arrhythmias (fast AF,
heart block), post-AMI
Excessive preload
(a) Fluid overload
(b) Regurgitant valvular heart diease = MR, AR
Excessive afterload
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(c) Right-sided
LV failure (most common cause)
Cor pulmonale
Pulmonary stenosis
Pulmonary embolism
(d) Left-sided
Hypertension
Aortic/mitral stenosis
High-output states
(a) Severe anaemia
(b) Thyrotoxicosis
(c) Large AV shunts
(d) Pregnancy
Clinical presentation
Name/age/ethnicity/gender/occupation
Drug allergy
Past medical history
Date of admission
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Aetiology
Recent AMI
Sepsis = fever, RTI (productive cough), UTI (FUN, dysuria, haematuria)
Anaemia = PR bleeding
Non-compliance with fluid and salt restrictions
Non-compliance with medications
Compliance
Systemic review
Drug history
Social history
Smoking
Alcohol
Family set-up
Main caregiver
Lift-landing
Type of housing
Financial status
Functional level
Family history
Physical examination
Vitals = HR, RR, BP, T, SpO2
General condition = mental state, anasarca, respiratory distress (tachypnoea, dyspnoea, use of accessory
muscles of respiration, pursed lip breathing, intercostals/subcostal retractions, cyanosis), midline sternotomy
scar with saphenous vein harvest site (previous CABG)
Peripheries = pulse (tachycardia, AF, weak and thready), cold and clammy skin, prolonged capillary refill time,
conjunctival pallor
Signs of fluid overload = facial oedema, raised JVP, pleural effusion/pulmonary oedema, tender hepatomegaly,
ascites, sacral oedema, bilateral lower limb pitting oedema
Praecordium = displaced and heaving apex beat, S3/4 heart sound, gallop rhythm, heart murmurs (valvular
heart disease)
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Differentials
1. Pulmonary embolism
2. Fluid overload = renal (nephrotic syndrome, ESRF), GIT (liver cirrhosis, protein-losing enteropathy, IBD)
3. Cor pulmonale
4. COPD
Investigations
Heart failure is principally a clinical diagnosis!
Bloods
Cardiac enzymes = AMI
FBC = Hb (anaemia), WBC (sepsis)
U/E/Cr = hypokalaemia from RAAS activation and K+-losing diuretics, hyponatraemia (fluid overload), renal
impairment from hypoperfusion
LFT = hepatic congestion, cardiac cirrhosis
Serum NT-pro-BNP
- Peptide hormone secreted by ventricular myocytes play key role in volume homeostasis
- Plasma concentration reflects ventricular pressure raised in heart failure
- Actions = increases GFR, decreases renal sodium reabsorption
- High negative predictive value = useful in excluding diagnosis of heart failure in patients with dyspnoea/
fluid retention
ABG (if SpO2 < 92%)
Blood c/s if in sepsis
Imaging
ECG
- MI(old infarcts pathological Q waves; new infarcts ST hyperacute changes)
- Arrhythmias (AF, heart block)
- LVH
- Goldberg’s triad for dilated CMP (poor R progression, small limb voltages, large chest voltages)
- Electrical alternans (cardiac tamponade, pericardial effusion)
CXR
- Cardiomegaly, upper lobe diversion, peri-hilar bat’s wing shadow (alveolar oedema), Kerley B lines
(interstitial oedema), pleural effusion, pneumonia
2D-echo
- Assess cardiac morphology
- Global and regional function
- Identify causes of heart failure (myocardial, vascular or pericardial origin)
Identify underlying ischaemia and myocardial viability revascularization
(a) 2D-echo = treadmill, dobutamine
(b) Radionuclide studies = MIBI (perfusion), MUGA (multiple gated acquisition scan) functional
(c) MRI = useful for quantifying myocardial necrosis, perfusion and function; usually indicated in cardiac
masses, complex congenital heart disease or pericardial disease
(d) CT = calcifications (coronary artery, pericardium)
(e) Coronary angiogram and cardiac catheterization = indicated in patients with angina, history or MI or at
high risk for coronary artery disease.
Acute management
Acute decompensation of chronic heart failure
Stabilize patient’s vitals
(a) Secure airway if unconscious
(b) Ensure that patient is breathing spontaneously
- Place on continuous pulse oximetry monitoring
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- Sit in upright position with legs hanging down to reduce venous return
- Give supplemental O2 via non-rebreather mask non-invasive positive pressure ventilation
(BiPAP/CPAP)
- IPPV if patient is in respiratory distress and acute heart failure-induced respiratory muscle fatigue
(c) Obtain patient’s vitals = HR, RR BP, T
- Place on continuous ECG monitoring
- Examine for signs of shock = altered mental state, cold clammy peripheries, weak thread pulse,
prolonged capillary refill time, reduced urine output
- Set IV cannula = take bloods for investigation
- CXR, ABG
Specific measures
(a) Diuretics = IV Lasix (40-80 mg bolus; onset in 20 mins; lasts for 6 hrs)
- Catheterize patient
- Monitor vitals and urine output to avoid volume contraction
- Achieve negative balance of 1-2L/day
(b) ACE inhibitors = captopril
- Monitor for hypotension (esp postural), hyperkalaemia and worsening renal function
(c) Nitrates = IV GTN (lower LV EDVrelieve symptoms of pulmonary congestion)
- IV nitroglycerine/nitroprusside
- Contraindicated in inferior/right ventricular infarct or hypotension (SBP must be >90mmHg)
- Continuous BP monitoring needed
(d) Digoxin if hypotensive
(e) - Complete rest in bed
- Fluid restriction (<1L/day)
- Low-salt diet (<2g/day)
- Strict I/O charting and daily weights
- Monitor vitals q4hrly (inform doctor if SBP < 100mgHg or HR > 100/min)
Long-term management
Conservative
Control risk factors = HPT, HCL, DM
- Obesity (weight loss, exercise, healthy diet)
- Stop smoking and drinking alcohol
Fluid restriction only if oedematous
Salt restriction (<2g/day)
Influenze immunisation
Monitoring = daily weights (avoid > 2kg/wk), symptoms and signs
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(b) Second-line therapy
1. ARB
- Mechanism of action = reduce afterload by preventing RAA axis and sympathetic activation
- Indications = patients cannot tolerate dry cough
- Agents = losartan
- Advantages = no dry cough
2. Vasodilators
- Mechanism of action = nitrates reduce preload, arterial dilators (hydralazine) reduce afterload
- Agents = nitrates (ISMN, ISDM), hydralazine
- Usually given together
- S/E = hypotension
3. Digoxin
- Mechanism of action = controls ventricular heart rate and small positive inotropic effect
- Indications = symptomatic patients despite ACE inhibitors + diuretics + β-blockers
Patients with NYHA class 3/4
AF
- No survival benefit
- Advantages = improves symptoms, reduces hospitalizations
Further management
Qn = Will patient benefit from revascularization (PTCA/CABG)?
Complications
Hypokalaemia K+-losing diuretics
Hyperaldosteronism (due to RAAS activation)
Impaired aldosterone metabolism due to hepatic
congestion
Hyponatraemia Diuretics
ADH secretion
Failure of cell membrane ion pump due to ischaemia
Impaired liver Hepatic venous congestion
function Ischaemic hepatitis
Thromboembolism Low cardiac output
Immobility
Arrhythmias and AF
Intracardiac thrombus due to MS or LV aneurysms
Arrhythmias Electrolyte changes
Structural heart disease
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Medicine (CVS) = Pathophysiology of dyspnoea
1. Cardiac dyspnoea
- Typically chronic and occurs with exertion
- Failure of left ventricular output to rise with exercise acute rise in left-ventricular EDV raised
pulmonary venous pressure interstitial oedema reduced lung compliance
2. Orthopnoea
- Definition = dyspnoea that develops when a patient is supine
- Supine = increased venous return to the right side of the heart and to the lungs
Left ventricular failure rise in left ventricular EDV raised pulmonary venous pressure
interstitial oedema reduced lung compliance
- Upright = redistribution of interstitial oedema lower lung zones become worse and upper zones
better allows for overall blood oxygenation
4. Presence of orthopnoea or PND is more suggestive of cardiac failure than lung disease
B. Decisions about management of patients with hypertension should not be made based on their BP levels alone,
but also on the presence of other risk factors, target organ damage, concomitant disease such as diabetes and
cardiovascular or renal disease, as well as other aspects of the patient’s individual and medical circumstances.
Levels of systolic and diastolic BP (Grades 1-2) Total cholesterol > 6.2 mmol/L (240 mg/dL)
Age (Men > 55 yrs; Women > 65 yrs) Reduced HDL-C < 1.0 mmol/L (40mg/dL)
Smoking Raised LDL-C > 4.1 mmol/L (160 mg/dL)
Family history of premature CVD (Men < 55 years; Diabetes mellitus
Women < 65 years) Obesity (BMI > 30 kg/m2) (BMI > *27.5 kg/m2)
* commensurate Asian BMI cut-point for action
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Coronary revascularization arteries
Congestive heart failure Haemorrhages or exudates
Vascular disease Papilloedema
Dissecting aneurysm Atherosclerosis
Symptomatic arterial disease / PVD Ultrasound or radiological evidence of
atherosclerotic plaque (carotid, iliac, femoral
and peripheral arteries, aorta)
Risk assessment
Besides the level of BP, it is also important to assess the overall cardiovascular risk of a patient prior to definitive
therapy in order to optimize risk-benefit ratio. Adding the numbers of traditional, documented risk factors in a
person is one such way. The use of well tested and accepted risk tables, charts or formulae to estimate a patient’s
absolute risk is encouraged. In individuals such as those with known or established coronary heart disease (CHD),
atherosclerotic disease, diabetes mellitus, familial hypercholesterolemia or malignant hypertension, the overall
cardiovascular risk assessment may not be necessary as the risk is already high and treatment should be started as
soon as the diagnosis of hypertension is confirmed.
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Medicine (CVS) = Hypertension
Definitions
Hypertension = 3 or more elevated BP readings taken on 3 or more different settings separated by at least 2
hrs
Hypertensive crisis
o Hypertensive emergency
Life-threatening and severe hypertension (diastolic BP ~ 120-130 mmHg) associated with
acute progressive end-organ damage
Characterized by accelerated microvascular damage with fibrinoid necrosis in vessel walls of
small arteries and arterioles resulting in intravascular thrombosis
Clinical features
# CVS = Hypertensive left ventricular failure (APO)
Acute aortic dissection
Acute myocardial infarction
# CNS = Stroke } needs to be differentiated as BP lowering is contraindicated to stroke
Hypertensive encephalopathy
# Renal = acute renal failure
#eyes = papilloedema
# eclampsia
Requires prompt BP reduction (ICU setting)
o Hypertensive urgency
Severe hypertension without acute end-organ damage
Clinical features
Hypertensive retinopathy
Chronic renal failure
Pre-ecampsia
Accelerated hypertension = grade 3 hypertensive retinopathy
Malignant hypertension = grade 4 hypertensive retinopathy
BP should be reduced within 24 hrs (outpatient basis)
Patients with accelerated/malignant hypertension should be admitted
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Epidemiology
Local prevalence rate = 24.9% (Singapore NHS 2004)
Males > females
Chinese > Indians > malays
Aetiology
Primary Hypertension
Accounts for 95% of the cases
No underlying cause found
Possible aetiology
o Increased sympathetic neural activity with enchances beta-adrenergic responsiveness
o Increased angiotensin II activity and excess mineralcorticoids
o Genetic factors = strong family history, ethnicity
o Environmental influences = obesity, smoking, excessive alcohol consumption, lack of physical
exercise, diet
Secondary hypertension
Accounts for 5% of the cases
Must investigate for the following causes in a young hypertensive patient (<40 years old)
Labile = Pschogenic
Stress-related
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Complications
Cardiovascular
‐ Heart failure
‐ Ischaemic heart disease/coronary artery disease
‐ AMI
‐ Cardiac arrhythmias
‐ Peripheral vascular disease
CNS
‐ CVA
‐ TIA
‐ SAH
‐ Hypertensive encephalopathy
Renal
‐ Chronic renal failure -> hypertensive nephrosclerosis -> ESRF
# can directly cause renal failure eand accelerate disease progression
Eyes
‐ Blindness
Hypertensive crisis
History
Name/age/ethnicity/gender/occupation
Drug allergy
Past medical history
Presenting complaint
Symptoms
Cardiovascular = chest pain (radiating to the back), SOB, palpitations, ankle oedema, intermittent claudication,
fatigue, giddiness, nausea/vomiting, diaphoresis
CNS = headache, nausea/vomiting, giddiness, blurring of vision, focal neurological deficits, seizures
Renal = haematuria, oliguria/polyuria
Eye = decreased visual acuity
Aetiology
Renal
‐ Haematuria, proteinuria, polyuria/nocturia, flank pain, ankle oedema
‐ History of renal impairment
‐ GN = vascular (childhood rash on legs)
Infective (Hep B, Hep C, HIV)
Toxin (recent drug intake)
Autoimmune (rash, joint pain and swelling, SLE)
Metabolic (DM)
‐ History of DM
‐ History of long-term analgesia
‐ History of urinary stones causing obstruction
‐ History of APKD
‐ History of reflux disease (recurrent UTI)
‐ History of kidney infection
‐ History of renal artery stenosis
Endocrine
‐ Conn’s = muscle weakness (hypokalaemic periodic paralysis)
‐ Cushing’s = weight gain around abdomen and face
‐ Pheochromocytoma = episodic headaches, palpitations, diaphoresis, postural giddiness
‐ Hypothyroidism = neck swelling, constipation, weight gain, fatigue, oligomenorrhoea, cold intolerant
‐ Thyrotoxicosis = neck swelling, diarrhea, polyphagia, LOW, palpitations, irritable, insomnia,
amenorrhoea, diaphoresis, heat intolerant
‐ Toxaemia of pregnancy = Last menstrual period
Symptoms of pregnancy
‐ Recent ingestion of OCP and steroids
Neurogenic
‐ OSA = snoring, daytime somnolence
Aortic
‐ History of coarctation of aorta
Labile
‐ Stressed recently
Systemic review
Drug history
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Social history
Smoking
Alcohol consumption
Occupation -> stressful
Diet
Physical activity
Family history
Physical examination
Blood Pressure
Procedure
- Refrain from smoking or ingesting caffeine 30 mins preceding BP measurement
- Ensure that patient is well-rested and not anxious -> white coat hypertension
- Use appropriate cuff = bladder within cuff should encircle at least 80% of arm
- Place sphygmomanometer at heart leavel
- Measure BP in both arms at first visit -> Coarcation of aorta
Aortic dissection
Patent ductus arteriosus
Thoracic outlet syndrome
- Take 2 or more readings separated by 2 mins and obtain average measurement (obtain more
readings if differ by >5mmHg)
Take BP in both standing and supine positions for elderly and DM
- Increase DBP on standing = Primary HTN
- Decrease DBP on standing = secondary HTN
Postural hypotension 2ndary to anti-hypertensive medications
General inspection
Sallow appearance, AV fitula/tenchkoff catheter, bruises and scratch marks = ESRF
Round-like facies, central obesity, violaceous abdominal striae = cushing’s syndrome
Prognathism, frontal bossing, large hands and feet = acromegaly
Café au lait spots = NF-1 (renal artery stenossis, pheochromocytoma, coarctation of aorta)
Peripheries
Pulse
Radio-radio delay and radio-femoral delay = coarctation of aorta
CVS examination
Raised JVP
Displaced apex beat – LV hypertrophy
Mitral regurgitation
S4 heart sound
Bibasal inspiratory crepitations
Peripheral oedema
Carotid bruit
Abdomen
Bilateral ballotable kidneys = APKD
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Adrenal mass = cushings
Renal bruit = renal artery stenosis
Lower limb
Neurological examination = deep tendon reflexes, focal neurological deficits
Evidence of peripheral vascular disease = trophic skin changes, temperature gradient, capillary refill time,
pulses
Fundoscopy
Grade 1 = silver wiring of arteries (sclerosed vessel wall reduces transparency -> central light streak appears
broader)
Grade 2 = arteriovenous nipping
Grade 3 = flame-shaped haemorrhages
Soft exudates (cotton wool spots due to ischaemia)
Hard exudates (lipid residues from leaky vessels)
Grade 4 = papilloedema
Hypertensive crisis
History
Physical examination
Mental state
Takes BP on both arms
CVS = heart failure, AR
CNS = focal neurological deficits, confusion, coma, seizures
Eyes = fundoscopy
Investigations
Bloods
FBC
U/E/Cr
Cardiac enzymes
Urine
Urine dipstick
Imaging
ECG
CXR
CT head = hypertensive encephalopathy, stroke, SAH
2D-scho/CT thorax = ? New onset AR (aortic dissection)
Causes
Poor control of pre-existing hypertension = not detected
Inadequate treatment
Non-compliance with medications
Secondary causes of hypertension
Management
Stabilize patient’s vitals
o Secure airway if patient unconscious
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o Ensure patient is breathing spontaneously -> give supplymental O2, monitor pulse oximetry
o Obtain patient’s vitals (HR, RR, BP, SpO2)
o Obtain Ecg and place on continuous ECG monitoring
o Set IV canula -> take blood for investigation
2 most urgent indications for immediate BP reduction = Hypertensive encephalopathy
Aortic dissection
Hypertensive emergency
Target
Lower MAP by 20-25% or DBP to no less than 100-110 mmHg within a few hours
Aim for 160/100 mmHg over the next 2-6 hrs
Esmolol Indications
o Use with nitroprusside for thoracic aortic dissection
o Used with phentolamine (alpha – blocker) for pheochromocytoma
crisis
Disposition
Admid ICU/CCU
Hypertensive urgency
Target
Lower DBP to 100mmHg over 24-48hrs
Oral Felodipine
PO Captopril
Disposition
If BP improves in monitored area -> discharge with review in next 1-2 days
If BP does not improve -> admit
Malignant/accelerated hypertension -> admit
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Medicine (CVS) = Anti Hypertensive medication
1) Classes of anti-hypertensives
a) Ace inhibitors/angiotensin 2 receptor blockers (ARB)
b) B-Blockers
c) Calcium channel blockers
d) Diuretics
3) Ace Inhibitors
a) Rennin – angiotensin – aldosterone axis
Angiotensinogen
Renin
Angiotensin I
Angiotensin II
Aldosterone Vasoconstriction
275
- Metabolic alkalosis ii) Short T1/2 = 10 mins
- Auditory and vestibular toxicity Bioactive metabolite (canrerone) has longer T1/2 = 15 hrs
- Venodilatation and hypovolaemia iii) Side effects
- Hyperglycemia - Hyperkalaemia
- Hyperuricaemia - Metabolic acidosis
- Hyperlipidemia - Anti-androgenic effects = gynacomastia/testicular
vi) Indications atrophy/menstrual disorders/hirstrusim
- CCF iv) Mild diuretic used together with other diuretics
- Oedema f) Osmolar diuretics
- Acute hyperkalemia and hypercalcemia i) Examples = mannitol, urea
d) Thiazides ii) Characteristics = small inert molecules that are filterable &
i) Example = hydrochlorothiazide non diffusible
ii) Distal tubule = active NaCl reabsorption/impermeable to Poor oral absorption
water Not metabolized
iii) Mechanism of action = inhibits NaCl cotransporter Excreted unchanged
Reduces peripheral resistance with Given IV
chronic use iii) Mechanism of action
iv) Side effects = hypo Na, hypo K, hypo Cl, hypo Mg - Act in segments that are freely permeable to H20 = PCT,
Reduced urinary Ca2+ descending limb
Metabolic alkalosis - Increases urine volume
Photodermatitis - Increases urine flow rate
Venodilatation and hypovolemia - Decreases contact time between fluid and tubular
Hyperglycemia, hyperuricaemia, epithelium
hyperlipidaemia - Decreases Na+ reabsorption
e) Aldosterone antagonists (K+ sparing) iv) Side effects
i) Examples - Dehydration and hyper Na+ (inadequate hydration;
- Spironolactone excessive use)
- Amilonide - ECF volume expansion & Hypo Na+ (may cause Heart
Mechanism of action = decreases synthesis of aldosterone Failure)
sensitive proteins – involved in Na+/K+ ATPase & apical Na+ v) Indications
channels - Increased ICP
*aldosterone = Stimulates Na+/H+ exchange - Cerebral oedema
Stimulates K+ excretion - Increased IOP
Acts on cytosolic and membrane
receptors
276
Medicine (CVS) = Guidelines for selecting drug treatment of hypertension
Friedwald Formula
LDL – C = TC – [HDL – C + (TG/2.2)]
*formula cannot be used if TG > 4.5 mmol/L
6. Risk stratification
- Catagories
Low-risk = 10 year CHD risk < 10%
Moderate – risk = 10 year CHD risk 10-20%
High risk = 10 year CHD risk > 20%
Algorithm
7. Management
- Lifestyle changes
Stop smoking
Reduce weight
Exercise regularly
Dietary restrictions = reduce alcohol consumption if TG raised
(may encourage alcohol if HDL – C low)
- Medical therapy
Recommend drug therapy
Side effects
- Transaminitis ( increase AST/ALT)
Check LFT before and 2-3/12 after starting statin therapy -> annually
Stop when AST/ALT > 3x upper limit of normal
Restart at lower dose when liver function returns to baseline
- Myopathy and rhabdomyolysis
Both likely to occur with high dosages of statins
#prescribe with caution in elderly, impaired renal function & when statin is combined with
fibrates/nicotinic acid
Maybe due to depletion of mevalonate
Stop when serum CK > 5x-10x upper limit of normal associated with muscle pain
Severe rhabdomyolysis may precipitate ARF -> fatal
- Others = headache, nausea, vomiting, diarrhea, rash
#preferably given in evenings -> coincide with cholesterol biosynthesis
# Contraindications = pregnancy/lactating females
Children < 12 years old
Ezetimibe
- Mechanism of action = selectively inhibits intestinal absorption of cholesterol and related plant steroids
Fibrates
- E.g. fenofibrate, gemfibrozil
- Mechanism of action = lowers VLDL and TG
Increases HDL – C
- Side effects
280
Transaminitis
Myopathy
Gasllstone disease
- Usually started when TG > 4.5 mmol/L
- Gemfibrozil should never be combined with a statin***
- Principles of combination therapy
Start the 2nd drug at a lower dosage & increase gradually until goal level achieved
Avoid high doses of statins
Monitor LFT & serum CK before and 6-8 weeks after initiation of therapy
Advise patient to report to doctors if got muscle pain/tenderness/weakness
Nicotinic acid/Niacin
- Mechanism of action = lowers TC & TG
Increases HDL – C
- Side effects = intense cutaneous flush & pruritus over face & upper body
Nausea, vomiting, diarrhea, dyspepsia
Transaminitis
Hyperuricaemia Avoid in these
Hyperglycaemia patients
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Medicine (CVS) = Myocarditis
Aetiology
Infections
o Viruses = coxsackieviruses A & B, adenoviruses, influenza, HIV, CMV
o Bacteria = diphtheria, meningococcus, Lyme disease, clamydia, rickettsia
o Fungi = candida
o Protozoa = Trypanosomiasis, toxoplasmosis
o Helminthes = trichinosis
Immune-mediated reactions
o Post viral
o Post streptococcal
o SLE
o Drug hypersensitivity reaction = methyldopa, sulfonamides, doxorubicin
o Cardiac allograft rejection
Unknown
o Sarcoidosis – non caseating granulomas
o Amyloidosis – amyloid protein depositions
Pathology
Gross morphology
Acute onset -> heart usually of normal size (esp if patients die soon after onset)
Chronic onset -> dilated chambers
Flabby and pale myocardium with small areas of haemorrhage -> mottled appearance
Endocardium and valves unaffected
Clinical features
History
Range from asymptomatic to severe CHF
Fatigue, dyspnea, chest pain, palpitations
Physical examination
Signs of heart failure
Tachycardia
Soft S1
S4 gallop
Investigations
ECG = ST segment elevation/depression, T wave inversion, atrial arrhythmias, transient AV block
Serology
Endomyocardial biopsy
Management
Treat underlying cause
Supportive measures
282
Outcomes/complications
Outcomes = usually recover without sequelae
Some may develop intractable chronic CCF
Complications = arrhythmias, dilated CMP, sudden death
283
Medicine (CVS) = Cardiomyopathy
Dilated cardiomyopathy
Epidemiology = may present at any age (usually between 20-60 years old)
Most common form of CMP (90%)
Inheritance = usually sporadic but some are familial
Aetiology
- Post-viral myocarditis
- Alcoholism
- Toxins = cobalt, doxorubicin
- Peripartum CMP
- Genetic mutations involving cytoskeletal proteins
Pathology
- Progressive cardiac hypertrophy and dilatation of all chambers
- Results in contractile dysfunction -> ineffective contraction (EF < 25%)
- Substantial dilatation and poor contractile function -> mural thrombus formation -> emboli
Clinical presentation
- CCF
- Ventricular arrhythmias
- Thromboembolism
Management
- CCF = diuretics, ACE inhibitors, nitrates, digoxin if hypotensive, anticoagulation
- Heart transplant
284
Anticoagulation
Implantable cardio-defebrillator, biventricular cardiac resynchronizing therapy
- Septal myomectomy
Restrictive cardiomyopathy
Epidemiology = least common
Pathology
- Primary decrease in ventricular compliance -> impaired diastolic filling
Aetiology
a) Idiopathic
b) Infiltrative = amyloidosis, sarcoidosis, scleroderma
c) Radiation-induced fibrosis
d) Endomyocardial fibroelastosis
e) Endomyocardial fibrosis
285
Medicine (CVS) = Takayasu Arteritis
Definition
Granulomatous vasculitis of medium and large arteries
o May result in fibrous thickening of aortic arch -> obliterate origins of distal branches
o Absence of pulses in upper extremities
Unknown aetiology (? Immune mechanisms)
Clinical features
Management
Symptomatic treatment
Treat complications
Large vessels
Small vessel
Takayasu’s arteritis
Henoch–Schönlein purpura
Giant cell arteritis
Wegener’s granulomatosis
Medium vessels Infective endocarditis
Polyarteritis nodosa Cryoglobulinaemia
Kawasaki’s disease
286
Medicine (CVS) = Valvular heart disease
288
Medicine (CVS) = Valvular heart disease
Mitral stenosis
Aetiology:
o Congenital: congenital parachute valve (rare)
o Acquired: rheumatic heart disease, calcification of mitral annulus & leaflets, CTD (e.g. RA, SLE) ,
malignant carcinoid
History:
o Asymptomatic
o May be symptomatic during pregnancy esp 2nd trimester → significant increase in blood volume
and raised pulmonary pressures; improves in 3rd trimester as blood volume decreases
o Dyspnoea = exertional, orthopnoea, PND (pulmonary congestion)
o Chest pain (pulmonary hypertension)
o Palpitations (atrial fibrillation)
o Fatigue (low cardiac output)
o Haemoptysis (pulmonary congestion, pulmonary embolism)
o Cough (pulmonary congestion)
o Features of right heart failure = peripheral edema (LL swelling, abdominal distension)
Investigations:
o ECG → atrial fibrillation, p mitrale (broad bifid wave)
o CXR → cardiomegaly, pulmonary congestion, pulmonary oedema (Kerley B lines → horizontal lines
in costophrenic angels)
o 2D-echocardiography → severity (thickened immobile cusps, reduced valve area, reduced rate of
diastolic filling of LV)
o Cardiac catheterization → assessment of coexisting coronary artery disease and mitral
regurgitation
Complications:
o Elevated LA pressure → LA dilation → atrial fibrillation → mural thrombosis → systemic emboli
o Pulmonary congestion → pulmonary hypertension → pulmonary edema → right heart hypertrophy
& failure
o Infective endocarditis
o Tricuspid regurgitation
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Management :
o Asymptomatic:
Anticoagulants (warfarin)
Antibiotic prophylaxis against IE before surgery and invasive procedures (amoxicillin)
o AF:
Rate control (digoxin, beta-blockers, CCB)
Warfarin
o Mild
Diuretics (reduce LA pressure)
o Moderate- severe pulmonary HPT
Percutaneous mitral balloon valvuloplasty
Mitral valvotomy (open/closed)
Valve replacement
# Ortner’s syndrome = hoarseness due to left RLN palsy a/w enlarged left atrium
Mitral regurgitation
Aetiology (MITRAL):
M – mitral valve prolapse
I – infective endocarditis
T – tensor apparatus dysfunction ( papillary muscle rupture/ dysfunction in AMI, ruptured chordate teandinea)
R – rheumatic heart disease
A – autoimmune (CTD: e.g. RA, SLE, ankylosing spondylitis, Marfan’s syndrome)
L – Large heart (cardiomyopathy – dilated, restrictive & hypertrophic; aortic regurgitation)
History:
o Asymptomatic
o Dyspnoea (pulmonary venous congestion)
o Palpitations (AF, increased stroke volume)
o Fatigue (reduced cardiac output)
o Edema, ascities (right heart failure)
o History of AMI
Investigations:
a) ECG → LVH, atrial fibrillation
b) CXR → cardiomegaly, pulmonary congestion, pulmonary edema
c) 2D-echocardiography → severity & etiology
d) Cardiac catheterization → dilated LV/ LA, mitral regurgitation, pulmonary HPT, coexisting coronary
heart disease
Complications:
o Left ventricular hypertrophy → LA dilation → Atrial fibrillation * MR can cause CCF
o Left heart failure → pulmonary edema → pulmonary hypertension CCF can cause MR
o Infective endocarditis
Management:
o Asymptomatic = antibiotics prophylaxis before surgeries (amoxicillin). Follow up 6 monthly with
2DE
o AF = rate control, anticoagulant
o Heart failure = diuretics, inotropes
o Surgery: if moderate symptoms persist despite medical therapy and ejection fraction (EF) is adequate
Valve repair or replacement if LV EF <55% or LV end systolic diameter more than 45mm
290
Aortic stenosis
Aetiology:
o Rheumatic heart disease
o Infective endocarditis Features indicating severity:
o Degenerative calcification Small volume an slow rising pulse
o Calcification of congential bicuspid valve (narrowed pulse pressure)
History: Heaving apex beat, systolic thrill
o Asymptomatic Soft S2 with narrow/ reverse split
o Syncope during or immediately after exercise Long ESM
o Fatigue (due to reduced cardiac output) S4, left heart failure
o Dyspnoea = exertional, orthopnoea, PND Narrow pulse pressure
o Extertional angina
o CVA
Differential: HOCM
Investivgations:
a) ECG → LVH
b) CXR → cardiomegaly
Post-stenotic dilatation of the ascending aorta
Calfcification of the aortic valve
c) 2D-echocardiograpy → severity, etiology
a. Grading = mild (valve area >1.5cm2)
Moderate (1.0 cm2 < valve area < 1.5cm2)
Severe (valve area <1.0cm2)
d) Cardiac catheterization → raised right heart pressures
Complications:
a) Left ventricular hypertrophy and failure → pulmonary edema
b) Infective endocarditis
c) Syncope (due to electro-mechanical dissociation/ cardiac arrhythmia/ marked peripheral vaso dilation
w/o concmitnat increase in CO)
d) Angina
e) CVA (due to embolisation from disintergrated vavle apparatus)
f) Sudden death (due to conduction abnormality: ventricular arrhythmia, heart block)
g) Microangiopathic haemolytic anemia
h) Associated with angiodysplasia of the colon → PR bleeding
Management:
a) Asymptomatic = antibiotic prophylaxis (amoxicillin)
b) Symptomatic = balloon valvuloplasty or
valve replacement (indicated if valvular gradient > 50mmHg or valve area less than
0.8cm2)
Aortic regurgitation
Aetiology:
o Intrinsic valvular disease= Congential bicuspid valve
Infective endocarditis
Rheumatic heart disease
Rheumatoid arthritis
o Aortic root disease= calcific AS (degenerative aortic dilation)
Aortic dissection
Syphilis
Seronegtive spondylosis (ankylosing spondyloarthritis, psoriasis, Reiter’s
syndrome)
Marfan syndrome
History:
o Asymptomatic
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o Dysponea = exertion, orthopnoea, PND
o Exertional angina (less cf AS)
o Palpiataions
Features indicating increased severity: Detect isolated AR:
o Wide pulse pressure Eyes (Argyll-Robertson pupils)
o Collapsing pulseECG Hands (stigmata of IE)
o Signs of LVF Deviated apex beat Back
o Soft S2
o Long EDM Request BP:
o Austin Flint murmur (MDM with no opening snap) Wide pulse pressure
o Presence of S3 Severe HPT → functional AR
o Hill’s sign (higher SMP in leg than in arm) UL & LL discrepancy
Investigations
a) ECG → LVH
b) CXR → cardiomegaly (chronic regurgitation: dilated LV, dilated ascending aorta), pulmonary edema
c) 2D ecoocardiograpy → severity, aetiology
d) Cardiac catheterization → severity, anatomy of arotic root, LV function, CAD
Management:
o Treatment of underlying conditions (e.g. endocarditis or syphilis)
o Asymptomatic = Antibiotic prophylaxis (amoxicillin)
Long term vasodilator therapy (e.g. nifedicine or ACEi) to control SBP
o Symptomatic = valve replacement (if LVEF <55% or LV end systolic diamension >55mm)
Tricuspid regurgitation
Aetiology:
o Primary:
Rheumatic heart disease
Infective endocarditis: assoc with IV drug abusers; check for needle marks & damaged veins
Congenital – Ebstein anomaly
Carcinoid heart disease
o Secondary:
Cardiomegaly (producing ‘functional TR’)
Cor pulmonale due mitral valve diseases or lung pathology (COPD, bronchiectasis,
fibrosis)
Cardiomyopathy associated with MR
AMI with papillary muscle infarct; IHD
Usually a/w mild mitral stenosis
History:
o IV drug abuser
o Right heart failure = peripheral edema (LL swelling, abdominal distention)
o h/o COPD
Complications:
a) Right heart hypertrophy & failure → peripheral edema + raised JVP ± pulsatile liver
b) Infective endocartitis
Management
a) If cause is due to RV dilation → correct cause of RV overload (e.g. diuretics + vasodilators in CCF)
b) Surgery: valve repir/ valve replacement
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o MR + MS
o Severe Mr with functional MS. No opening snap is heard in this case
If there is concurrent MR and MS, determine which is predominant by the clinical signs:
Rheumatic fever
1. Jones criteria for the diagnosis of rheumatic fever
AND
Evidence of preceding streptococcal infx:
Recent scarlet fever
Raised antistreptolysin O or other
streptococcal antibody titre
Positive throat culture of group A
2. Pathophysiology strep
Due to pharyngeal infection with Group A beta-haemolytic streptococci (S. pyogenes) which triggers
rheumatic fever 2-4 weeks later
Results in molecular mimicry: Ab to carbohydrate cell wall of streptococcus cross reacts with heart valve
tissues
Also causes acute glomerulonephritis (1-2 weeks later)
3. Epidemiology
Peak incidence = 5 – 15 years old
2% of the population
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Mitral – 70% Incompetent lesions develop during
Aortic – 40% attack
Tricuspid – 10% Stenotic lesions occur years later
Pulmonary – 2%
5. Investigations
Evidence of systemic illness (non-specific)
o FBC for leukocytosis, raised ESR and CRP
Evidence of preceding streptococcal infection (specific)
o Throat swab culture: group A beta haemolytic streptococci
o ASOT: rising titres or levels of >200 U (adults) or >300U (children)
Evidence of carditis
o CXR: cardiomegaly; pulmonary congestion
o ECG: first- and rarely second-degree AV block; features of pericarditis; T-wave inversion; reduction
in QRS voltage
o Echocardiography: cardiac dilation and valve abnormalities
6. Management
Single does benzyl penicillin 1.2million U i.m. OR oral phenoxymethylpenicillin 250mg 6 hourly for 10 days
o If penicillin allergic give erythromycin or cephalosporin
Carditis: symptomatic treatment for CCF + aspirin
Arthritis:
o Analgesia (aspirin/ NSAIDs)
o Immobilization in severe cases
Chorea: haloperidol/ diazepam
Secondary antibiotic prophylaxis for dental or other surgery
General guidelines
Mitral valve prostheses:
o Metallic S1 with opening snap
o Normal S2
o Systolic murmur (normal → does not indicate valve malfunction)
Aortic valve prostheses:
o Metallic S2
o Normal S1
Mitral & aortic valves prostheses:
o Metallic S1 and S2
o Systolic murmur (normal → does not indicate valve malfunction)
o If EDM heard → aortic valve malfunction
Complications
1. Thromboemoblism (esp with mechanical valves → req anticoagulation; INR usu kept at 2.5-3.5)
2. Valvular dysfunction (esp with bioprosthetic valves)
a. Leaking
b. Dehiscence
c. Fracture
d. Stiffening/ calcification → stenosis
e. Perforation → regurgitation
3. Haemolysis (esp with mechanical valves)
a. Haemolytic jaundice
b. Anemia
4. Infective endocarditis (involves suture line and adjacent perivalvular tissue)
a. Systemic emboli
b. Valvular destruction/ regurgitation/ obstruction
5. Complications of anti-coagulation
a. BGIT → anemia
b. Intra-cranial bleed → stroke
Causes of anemia
1. Bleeding from anticoagulation
2. Haemolysis with the mechanical valves
3. Bacterial endocarditis
Physical examination
“I say this is a prosthetic heart valve because of”
(a) Audible metallic click
(b) Midline sternotomy scar
(c) Metallic S1/S2 on auscultation
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Medicine (CVS) = Infective Endocartitis
Definition
Microbial infection of cardiac valves or endocardium resulting in the formation of adherent bulky mass of
thrombotic debris and organisms (vegetations)
Usually affects left-sided valves (turbulent flow)
o 25-30% mitral valve
o 25-30% arotic valve
o 10% mitral and aortic valves
o 10% tricuspid valve
o 10% prosthetic valve
o 10% congential heart disease
Classification
Acute:
High virulence organisms (e.g. S. aureus)
Can infect structurally normal valves
Rapidly progressive infection
Little host reaction
Subacute:
Lower virulence organisms
o Α-hemolytic streptococci (viridians)
o HACEK organisms
Haemophilus aphrophilus
Actinobacilus actinomycetemcomitans
Cardiobacterium hominis
Eikenella corrodens
Kingella kingae
Infects structurally abnormal valves
Slowly progressive infection
Greater host reaction
o Inflammation
o Granulation tissue
Predisposing factors
Native valve
o Underlying abnormality = rheumatic heart disease, VSD, PDA, coarctation of the aorta
o Normal valve = IVDA (usu right sided endocarditis affecting tricuspid valve; S. aureus, streptococci,
gram –ve rods, fungi)
Prosthetic valves = S. epidermidis (coagulase negative staphylococci)
Pathogenesis
Derangement of blood flow due to underlying cardiac abnormalities
Increased trauma to endocardial surfaces
Formation of sterile platelet-fibrin deposits
Seeding b blood-borne organisms during episodes of bacteraemia
o IVDA
o Dental or surgical procedures (e.g. urinary catheterization, cystoscopy, IV cannulation)
o Occult sources (e.g. brushing teeth)
o Clumping of gacteria due to agglutinating antibodies
Complications
Valvular destruction, regurgitation or obstruction
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CCF
Extension of infection into adjacent myocardium → ring abscess → conduction disturbances
Embolism → brain, kidneys, lungs, spleen, bowel
Entrapment of infected emboli in walls of blood vessels → mycotic aneurysms
Metastatic seeding of distal organs → cerebral abscess
Glomerulonephritis (deposition of immune complexes and subsequent complement activation)
Clinical features
History
Non-specific symptoms = fever a/w chills & rigors, malaise, symptoms of anemia, LOW, LOW
Heart failure = dyspnoea, LL swelling, abdominal distension
Symptoms suggesting embolism= to large vessels (e.g. brain, lungs) or small vessels (e.g. kidney with
haemturia or loin pain)
Risk factors = IVDA, childhood RHD, cardiac abnormalities (ostium primum ASD, VSD, TOF), prosthetic
valve replacement
Precipitating factors = recent dental/surgical procedures (time between procedure and diagnosis may be
up to 3 months)
? history of other major disease, esp those assoc with immune suppression (e.g. renal transplantation or
steroid use)
Drug history= ?antibiotic allergies, use of antibiotics for prophylaxis
How diagnosis was made (if known case) – including number of blood cultures, use of transthracic or
transoesophageal echocardiography (TOE)
Management since admission to hospital, including the names of antibiotics used, the duration of treatment
and whether possibility of valve replacement has been discussed
Physical examination
1. Examine peripheral stigmata of endocarditis
Hands:
o Clubbing (late sign)
o Splinter haemorrhages in nail beds
o Osler’s nodes on the finger pulp (always painful and palpable; prob an embolic phenomenon and
are rare)
o Janeway lesions (non-tender erythematous maculopapular lesions containing bacteria on the palms
or pulps; rare)
Eyes:
o Roth spots in the fundus (retinal infarcts)
o Conjunctival petechiae
Abdomen:
o Splenomegaly (late sign)
Urine analysis: for haematuria and proteinuria
Neurological signs of embolic disease
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3. Examine for sings of cardiac failure. Look for signs of a prosthetic valve and for scars that may present from
previous valvotomy or repair operations
4. Look for source of infection and take patient’s temperature
Investigations
1. 3-6 blood cultures over 24 hours at least 1 hour apart(98% of culture positive cases will give positive
results in the first 3 bottles)
2. FBC, ESR, CRP= NCNC anemia, neutrophilia, raised ESR, raised CRP.
a. ESR may remain elevated for months even after treatment has been successful but CRP levels falls
quite quickly→ useful in assessing the effectiveness of treatment
3. Urine dipstick= microscopic haematuria
4. ECG= atrial fibrillation in the elderly; conduction defects may occur but are not specific
5. Chest xray= cardiomegaly, pulmonary edema
6. Echocardiography= vegetations (negative study does not rule out IE as vegetations must be larger than
2mm to be detected)
Diagnostic criteria
Pathological criteria
1. Positive microbial culture = vegetation, embolus, intra-cardiac abscess
2. Histological confirmation = vegetation, intra-cardiac abscess
Management
IV antibiotics: benzylpenicillin (for S. viridians) and gentamicin (for enterococcus) + cloxacillin (for S.
aureus)
Follow progress by looking at temperature chart, serological results and haemoglobin values
Indications for surgery:
o Resistant organisms (e.g. fungi)
o Valvular dysfunction causing moderate-to-severe cardiac failure
o Persistent positive blood cultures despite treatment
o Invasive paravalvular infection causing conduction disturbances or
o Paravalvular abscess or fistula
o Recurrent major embolic phenomena
Prognosis
30% mortality with staphylococci
14% mortalitiy with enteric gram –ve rods
>70% with endogenous infection survive
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50% with prosthetic valve survive
IVDA good prognosis
Libman-Sacks endocarditis
Sterile vegetations in patients with SLE or anti-phospholipid syndrome
Not along lines of valve clousure
Uncommon due to steroid therapy for SLE
Usually a post-mortem finding
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6. Radioisotope scan
Only done in hyperthyroid patients
Priscilla’s Medicine Add-on Procedure:
Radioactive iodine (131I) injected intravenously
Surgery (Thyroid) = Investigations Thyroid gland scanned with a detector to map out areas of
1. Serum fT4 high or low uptake
‘hot’ nodule hyper-functioning area; almost never malignant (<5%)
2. Serum TSH
Decreased in hyperthyroidism; increased in hypothyroidism ‘cold’ nodule non-functioning area; 20% are malignant
If TSH low and T4 normal request for T3 levels (T3
thyrotoxicosis)
neutral same as remaining thyroid gland
3. Serum thyroglobulin
Used to monitor recurrence of carcinoma
Detect factitious hyperthyroidism (self-medication = T4 + diffuse uptake Graves’ disease
TSH + T3 + thyroglobulin)
Interpretation of tests
TSH + T4 TSH-secreting tumour
thyroid hormone resistance
Diffuse goitre
Mdm XXX is a middle-aged chinese lady who appears to be alert and comfortable at rest. She does not
appear restless. On general inspection, I note a diffusely enlarged goitre measuring __cm x __ cm in size
which moves with swallowing but not with tongue protrusion. It is non-tender, smooth, firm and not fixed
to the overlying skin or underlying muscles. There is no evidence of retrosternal extension, increased
vascularity or cervical lymphadenopathy. There is also no tracheal deviation or involvement of the carotid
arteries.
Mdm XXX is clinically euthyroid and there are no signs of thyroid eye disease.
Multinodular goitre
Mdm XXX is a middle-aged chinese lady who appears to be alert and comfortable at rest. She does not
appear restless. On general inspection, I note an asymmetrically enlarged goitre which moves with
swallowing but not with tongue protrusion. On palpation, the thyroid gland is nodular with the right lobe
larger than the left lobe. It is non-tender, firm and not fixed to the overlying skin or underlying muscles.
There is no evidence of retrosternal extension, increased vascularity or cervical lymphadenopathy. There
is also no tracheal deviation or involvement of the carotid arteries.
Mdm XXX is clinically euthyroid and there are no signs of thyroid eye disease.
Graves’ disease
Mdm XXX is a middle-aged chinese lady who is thin and restless on examination. On general inspection, I
note a diffusely enlarged goitre measuring __cm x __cm in size which moves with swallowing but not with
tongue protrusion. It is non-tender, smooth, firm and not fixed to the overlying skin and underlying
muscles. This is associated with signs of increased vascularity such as prominent dilated veins, increased
warmth, palpable thrill and bruit. There is no tracheal deviation or displacement of the carotid arteries. No
cervical lymphadenopathy was detected.
Mdm XXX is clinically hyperthyroid. I say this because she has fine tremors associated with sweaty and
warm palms. In addition, she is also in sinus tachycardia. However, there is no thyroid acropathy,
onycholysis, proximal myopathy, hyperreflexia or pretibial myxoedema. There are also no features
suggestive of thyroid eye disease.
So in summary, Mdm XXX most likely has Graves’ disease and is clinically hyperthyroid.
Thyroid nodule
Mdm XXX is a middle-aged chinese lady who appears to be alert and comfortable at rest. She does not
appear restless. On general inspection, I note a hemispherical swelling in the anterior triangle of the neck
which moves with swallowing but not with tongue protrusion. This is likely to arise from the thyroid
gland. On palpation, the nodule is non-tender, firm and not fixed to the overlying skin or underlying
muscles. There is no evidence of cervical lymphadenopathy.
Mdm XXX is clinically euthyroid and there are no signs of thyroid eye disease.
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Surgery (Thyroid) = Congenital anomalies
Lingual thyroid
thyroid gland fails to descend patient presents with a lump at the foramen caecum
asymptomatic OR interferes with speech and swallowing
Thyroglossal cyst
usually occurs in young adults
presents as a fluctuant swelling in the midline of the neck
remnant tract left behind by the thyroid gland as it descends
from the foramen caecum to its position in front of the trachea
tract usually reabsorbs → results in thyroglossal cyst or fistula
formation if it persists
characteristics = moves on swallowing (attachment to larynx
by pretracheal fascia)
moves upwards when tongue protrudes out
(attachment to hyoid bone)
Tx = Sistrunk’s operation (cyst, thyroglossal tract, body of hyoid
bone)
Cx = infection abscess formation
thyroglossal fistula
- presents as a discharging area in the midline
- follows rupture or inadequate excision of a thyroglossal
cyst recurrent inflammation fistula intermittently
discharges mucous
- Tx = fistulectomy
malignant change is rare
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Medicine (Rheumatology) = Approach to the Rheumatological Case
GALS Screen
.
Appearance Movement
Gait
Arms
Legs
Spine
History
1. Pain / Stiffness in muscle / joints / back
- Cardinal symptoms of rheumatic disease
2. Ability to wash and dress completely without difficulty
- ADL: Assessing functional problem of UL
3. Ability to get up and down stairs easily and ability to squat
- ADL: Assessing functional problem of LL
Physical Examination
Gait
1. Ask patient to stand
Ease of transfer from chair / lying position to standing position
2. Get patient to walk and turn around
Smoothness and symmetry of leg
Pelvis and arm movement
Normal stride length
Ability to turn quickly
Without pain
Spine
1. Inspection (from back and from sides)
Start from back
Abnormal scoliosis curvature of spine
Symmetry of paraspinal muscles and girdle muscles
Symmetrical pelvic position, level iliac crests
Inspect from sides
Normal curvature in the neck and thoracic spine
Normal lumbar lordosis
Symmetry of paraspinal muscles
From front
Lateral cervical flexion ('Place your ear on your shoulder’)
Hyperalgesic response of fibronyalgia (Squeeze over midpoint of supraspinatus
muscle) If tender proceed to other sites, e.g. below medial epicondyle
2. Movement
Put finger at spine along 2 lumbar vertebrae and ask patient to 'Bend forward and touch
toes'
Finger to floor distance less than 15cm, lumbar expansion >6cm
Arms
1. Inspection
Arm:
From front: Normal girdle muscle bulk and symmetry
From back: Normal acromioclavicular sternoclavicular and glenohumeral joints; Full
elbow extension
Examine dorsal surface. Squeeze at carpal region
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No swelling, deformity
Turn over to palmar surface.
Supination movement (Arms and elbow)
Palmar surface.
Redness over palms in inflammatory arthritis, swelling, deformity
Squeeze acoss MCP joint
Early arthritis: pain and tenderness on squeezing before other abnormalities seen
2. Movement
Make a fist. Spread out.
Detection of power grip
Pinch in pincer manner
Impt for fine movements
Spread elbows straight out
Test shoulders. Put arms behind head and elbows back.
Putting elbows back test full degree of external rotation
Legs
1. Inspection
Leg
From front: No knee, forefooting or mid foot abnormalities
Knee: Bulk of quadriceps muscle, normal concavities on each side of the patella (
concavities lost with effusion at knee joints)
Feet
Pay special attention to soles of feet. Deformity change pressure points
thickening of skin
2. Movement
Bend leg up and twist
Internal rotation first to go in hip disease
Hand on knee joint feels for crepitus
Look at knees and feel across lateral border
Back of hand sensitive to temperature changes
Squeeze across MTP joints
Early arthritis: pain and tenderness on squeezing before other abnormalities seen
History
History of Presenting Complaint
Pain
Aspect Differential
Distribution and Joint Acute monoarthritis
Involvement Septic arthritis, traumatic, gout/pseudogout, haemarthrosis
N.B. arthralgia = presence of Chronic monoarthritis
joint pain wout swelling; Chronic infection e.g. TB, sero-ve spondyloarthritis,
arthritis = pain + swelling pigmented villonodular synovitis
Acute / chronic Acute polyarthritis
Getting better / worse Infection, onset of chronic polyarthritis
Chronic polyarthritis
RA, sero-ve spondyloarthritis, OA, gout, pseudogout, CTD e.g.
SLE, infection
Effect of exercise or rest RA – symptoms worse aft rest
OA – symptoms worse aft exercise
Sequence of onset of joint RA/OA – symmetrical
involvement Sero-ve spondyloarthritis – asymmetrical
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Type Subset Characteristics
Mechanical Well localised
Aggravated by mvt, coughing, straining
Spinal cord lesion Pain in dermatomal distribution
Non-mechanical Osteoporosis Progressive and unremitting pain
Osteomalacia
Malignancy
Metastasis
Leukaemia
Myeloma
Limb Pain – Where, Onset, Aggravation
Type Subset Characteristics
MSK Polymyositis Aching pain in muscles ard region a/w weakness
Polymyalgia Older pts, pain with stiffness
rheumatica
Bone dz e.g. OM,
osteomalacia,
osteoporosis
Tenosynovitis
Vascular Arterial occlusion Acute. Severe pain of sudden onset
PVD Chronic. Calf pain on exercise relieved by rest
Nervous system Entrapment and
neuropathy
Morning Stiffness
Classically in RA and other inflammatory arthropathies
Deformity
Instability
Described as “giving way” or “coming out”
Due to dislocation or muscle weakness / ligamentous problems
Change in sensation
Functional capacity
Systemic symptoms
Fatigue
Wt loss
Ulcers
Dry eyes & mouth
Stiffness
Fever
Past Medical History
Treatment history + SEs
H/o trauma or surgery
H/o recent infection inc hepatitis, streptococcal pharyngitis, rubella, dysentery, gonorrhoea, TB
Social History
Family History
Physical Examination
General Principles
Impt in assessing pt’s functional disability and gaining clues about diagnosis
Can get pt to transfer to side of bed / sit out in chair / expose and in doing so observe for
functional ability
Look, feel, move, measure, compare with opposite side
- Look
Compare left VS right
Inspect front, back, sides
Skin: look for erythema, scars, rashes
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Joint/bone: swelling, deformity, subluxation
Muscle: wasting
- Feel
Warmth
Tenderness (say “please let me know if this is uncomfortable for you”): Grade I – pt c/o
pain, Grade II – pt c/o pain and winces, Grade III – pt c/o pain, winces and withdraws,
Grade IV – pt does not allow palpation
Synovitis (soft and boggy swelling)
- Move
Passive movement
Active movement
Stability – tested by attempting to move joint gently in abnormal directions
Crepitus
Examination of individual joints
Examine this patient’s hands
Introduction - Nails
Sit the pt over the side of the bed and Psoriatic changes – pitting,
place hands on the pillow with palms ridging, onycholysis,
down hyperkeratosis, discolouration
General Inspection Feel and Move
- Cushingoid - Wrist MCPJ PIPJ DIPJ
- Weight Synovitis, effusiuon, ROM,
- Iritis, scleritis etc Crepitus
- Obvious other joint disease - Dorsi/Palmarflex
Look - Radial/Ulnar deviation
- Dorsal palmar - Palmar tendon crepitus
- Wrist - CTS tests
Skin Joints/Bone Muscle - Active mvt
- MCPJ - Wrist ext / flex
Ulnar deviation (= deviation of - Thumb ext / abd / add / opp
phalanges at MCPJ towards - Fist (intrinsics)
medial (ulnar) side of hand), volar Hand Function
(anterior) subluxation - Grip strength
- PIPJ, DIPJ - Key grip
Swan neck (hyperextension at - Opposition strength
PIPJ and FFD at DIPJ), - Practical ability
boutonniere (FFD at PIPJ and Others
extension at DIPJ), Z deformity - Elbow
(hyperextension of IPJ and FF and Subcutaneous nodules
subluxation of MCPJ) Psoriatic rash
DIPJ – Heberden’s nodes Other joints
PIPJ – Bouchard’s nodes Signs of systemic diseases
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o Gottron’s sign – Erythematous, violaceous smooth or scaly
Medicine (Rheumatology) = Dermatomyositis and Polymyositis patches over the dorsal IPJ, MCPJ, elbows, knees, medial
Definition malleoli
A number of conditions in which muscles become damaged by a non- o Erythema spares the phalanges (cf SLE – phalanges involved,
suppurative lymphocytic inflammatory process knuckles spared)
Polymyositis – inflammation of muscles, Dermatomyositis – skin + o Erythematous rash may be present on the neck and upper
muscles chest (often in the shape of a V), shoulders (shawl sign),
Etiology and Pathophysiology elbows, knees, malleoli
Polymyositis – CD8 cell-mediated muscle necrosis, found in adults o Cuticlies may be irregular, thickened, distorted
Dermatomyositis – B-cell and CD4 immune complex-mediated o Lateral and palmar areas of the fingers – rough and cracked
perifascicular vasculitis with irregular “dirty” horizontal lines, resembling those in a
mechanic’s hands
HISTORY Neurological examination of the UL/ LL
Adult form usually occurs after the 40 yo o Main findings are in the power testing
Progressive symmetrical weakness of proximal muscles evolving over Proximal muscle weaknes and tenderness of muscles
weeks/ mths (muscle wasting absent/ minimal)
o Difficulty in getting up from low chair/ squatting position Weakness of neck flexors in 2/3 of cases
o Difficulty in climbing stairs Intact/ absent deep tendon reflexes
o Lifting and running Requests
o Inability to raise head (lift head off pillow) o If the patient > 40yo, tell the examiner that you would like to
o Inability to get up from bed look for an underlying neoplasm
Dysphagia (due to weakness of the muscles of the pharynx) Summary
Dysphonia o Depends on the stem
Muscle pain and tenderness o If asked to examine UL or LL , say that this is a ___ yo ___ who
Raynaud’s phenomenon has a pattern of proximal myopathy on neurological
Rash worsened by sunlight (photosensitivity) examination of the UL or LL, with weakness of shoulder
abduction/ adduction/ of power grade __. There is also muscle
PHYSICAL EXAMINATION (stem – usu examine this patients UL/ LL) tenderness etc.
General inspection o In addition I also noticed cutaneous features suggestive of
o Cushingoid features? dermatomyositis as evidenced by the presence of _____.
Skin o Functionally he/ she is able/unable to stand from the
o Heliotrope rash or purplish-blue rash around the eyes, back of squatting position/ get up from lying positon/ unable to
hands swallow (NG tube) etc etc.
o Dilated capillary loops at the base of fingernails
o Gottron’s papules – pink, violaceous, flat-topped papules
overlying the dorsal surfaces of the IPJ
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CUTANEOUS MANIFESTATIONS
310
INVESTIGATIONS Resistant cases – methotrexate, azathioprine, cyclophosphamide,
Confirm diagnosis cyclosporine, high-dose IVIg
o Serum CK – elevated. Levels mirrors disease activity Malignancy surveillance (regular f/u)
Also in DMD, drugs (statins, chloroquine, o Detailed history and physical (breast, pelvic, rectal exam)
colchicines, px on chronic haemodialysis) o CXR, abdominal and pelvic u/s, FOBT, Pap smear,
o EMG – myopathic changes (spontaneous fibrillation, salvos of mammogram
repetitive potentials, short duration of polyphasic potentials of Those with underlying neoplasm may remit after treatment of the tumour
low amplitude)
o Muscle biopsy – necross and phagocytoss of muscle fibres,
interstitial and perivascular infiltration of inflammatory cells. Classification of polymyositis-dermatomyositis (Bohan)
o Myositis specific auto-antibodies - the aminoacyl–transfer RNA Group I Primary idiopathic polymyositis
(tRNA) synthetases (anti-Jo-1), the nuclear Mi-2 protein, and Group II Primary idiopathic dermatomyositis
components of the signal recognition particle (SRP). Group III Dermatomyositis (or polymyositis) a/w neoplasia
o CXR Group IV Childhood dermatomyositis (or polymyositis) a/w vasculitis
o Serum aldolase, LDH, ALT, AST, FBC, ANA/ENA, U/E/Cr Group V Polymyositis (or dermatomyositis) with associated collagen
o Urinalysis, urine myoglobin vascular dz
Prognosis
Dermato/polymyositis a/w malignancy
o risk of malignancy if age > 50, DMY> PMY, normal CK,
refractory disease
o 2.4-6.5 fold risk of underlying malignancy usu in internal
organs
Drug history
any known drug allergies
current medications
steroids, aspirin, NSAIDs, warfarin
Social history
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Medicine (Rheumatology) = Hand
Permission (& presence of Pain)
Position Sitting
Exposure Exposed elbows
Examination
The hand is a complex instrument with intricate function. There are 14 joints in the hand excluding the carpus.
The carpus itself is a complex articulation which comprises eight bones linked by ligaments which provide
three degrees of motion. The approach to examination of the hand is thus different and must be preceded by a
hand screen. The hand screen is still based on the basic principles of an orthopaedic examination, namely look,
feel and move.
Look
Skin
Swellings - ganglions and other lumps
Scars - surgical (esp carpal tunnel)
Nerves
Attitude - ulnar claw, median benediction
sign, wrist & finger drop
Vessels Venous
Arterial - atrophic skin changes
Lymphatic
Feel
Skin
Temperature - red, dry skin
Characterise swellings
Effusion
Nerve
Thickening - ulnar at elbow
315
Gross sensation
Vessel
Pulse - capillary refill
Pitting edema
Move
Special tests
Stability
Anterior/ posterior
Lateral
Impingement - Finkelstein’s
Fixed deformity
Neurovascular assessment
Peripheral nerve
Motor - *see special tests for nerve
Sensory
Reflexes
Functional assessment
prehension
316
Hand Screen
1. Palms up
1 3
Zones
1. thenar- wasting, crease
scar
2. fingers- attitude
3. hypothenar- wasting
4. wrist- scars
2
2. Finger flexion
Zones
1. joint ROM
2. trigger
317
3. Dorsum up
3
Zones
1. 1st web &
intermetacarpal
spaces- wasting
1 2. fingers-
arthropathy
3. wrist dorsum-
ganglion
Zones
1. subcutaneous border
of ulna and elbow-
rheumatoid nodules
318
Nerve screen
Median nerve
Ulnar nerve
Radial nerve
319
Vessel screen
Pulses
Cap refill
320
Allen’s test- hand
321
Allen’s test- finger
322
Nerve examination
Once a neuropathy has been identified, one must determine the level and the severity. Nerves have
essentially two functions, sensory and motor. As such, deficits from both these areas must be actively
sought.
Median
Look
1. wasting of the thenar eminence
Feel
2. light touch (median three and half fingers vs thenar eminence)
Move
3. Test for the FPL and FDP to index with ‘O’sign
4. Test the power of the APB
Provocative tests
5. Tinel’s test
6. Phalen’s test
Ulnar
Look
1. ulnar claw
2. wasting of hypothenar eminence
Feel
3. light touch (ulnar one and a half vs dorsal ulnar aspect of hand)
Move
4. FDP to little finger
5. Abductor digiti minimi
6. Finger crossing (palmar interossei)
7. Froment’s test
Provocative tests
8. Tinel’s at the elbow
9. elbow flexion test
Radial
Look
1. wrist and finger drop
2. wasting of triceps and forearm extensor compartment
Feel
3. light touch (1st dorsal web space)
Move
4. elbow extension
5. extension of the wrist
6. EPL
Provocative
7. Tinel’s at the spiral groove
323
Wrist
Permission (& presence of Pain)
Position Sitting
Exposure Elbows on the table, exposed
Examination
Look
Skin
Swellings - ganglions (volar and dorsal)
Scars - volar and dorsal
Nerves
Attitude
Vessels Venous
Arterial
Lymphatic
Feel
Skin
Temperature - radiocarpal joint
Characterise swellings
Nerve
Thickening
Gross sensation
324
Vessel
Pulse
Pitting edema
Move
Special tests
Stability
Impingement - Finkelstein’s
Fixed deformity
Neurovascular assessment
Peripheral nerve
Motor
Sensory
Reflexes
Functional assessment
Grip strength
325
Wrist
Permission (& presence of Pain)
Position Sitting
Exposure wrist on the table with elbows exposed
Examination
Look
1. Look for discrete and diffuse swellings over the dorsal and volar surfaces.
2. Look scars over the dorsal and volar surfaces.
3. Look dinner fork deformity.
Feel
*change position to elbows on the table with wrists off the table in neutral.
Move
Special tests
9. Finkelstein’s test
326
Wrist
Examination
1. swellings-
discrete and
diffuse
2. scars
Look
4. temperature-
radiocarpal joint
327
Wrist
6. radiocarpal joint
tenderness
Feel
7. tenderness- FCR,
FCU, ECU, 1st extensor
comprtment
8. ROM- extension/flexion,
Move ulnar/radial deviation,
pronation/supination
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Medicine (Rheumatology) = hands & wrists, shoulder, C-spine, Hip
RA hands & wrists
Pathology
Synovitis of proximal joints & tendon sheaths
Bone and tendon erosions
Joint instability & tendon rupture deformity, loss of function
Clinical features
Bilateral symmetrical involvement of the wrist and proximal joints of the hands
Patient c/o progressive pain, stiffness, swelling, deformity & disability (bathing, dressing, holding a
pen/utensils, cup, combing hair)
O/E
Hands
Ulnar deviation of the fingers
Subluxation/dislocation at the MCPJ
z-deformity of the thumb
swan-neck deformity (hyper-extension at PIPJ; flexion at DIPJ)
o inbalance of extensor vs flexor action
Boutonniere deformity (flexion at PIPJ; hyperextension at DIPJ)
o Mixture of central slip of extensor tendor & separation of lateral slips
Dinger-drop (extensor tendon rupture or subluxation into gutters)
Wrists
Swelling of DIPJ
Radial deviation
Piano-key sign (laxity/instability of DIPJ)
Volar subluxation with prominent ulnar styloid process
Look
Characteristic features in hands & wrists
Muscle wasting
Feel
Swelling, increased warmth
Piano-key sign
Move
Hand examination (ROM)
Assess function (grip strength, pinch gripm dressing, holding a cup, writing)
Examine
Knees for genu valgus
Elbow for rheumatoid nodules
C-spine (atlanto-axial subluxation, basilar invagination by dens protrusion, sub-cervical spine)
X-rays
Early stages
Soft-tissue swelling
Periarticular osteoporosis
Later
Narrowing of joint space + periarticular erosions
Last stage
Joint deformity & dislocation
Zig-zag deformity (ulnar deviation of fingers & radial deviation of wrist)
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Management
1. Central synovitis 2. Prevent deformity
NSAIDs Splintage
Low-dose corticosteroids Tendon repairs/transfers
2nd-line drugs Joint stabilization
H&L injections synovectomy Physiotherapy
Physiotherapy
3. Reconstruction 4. Rehabilitation
Arthrodesis Physiotherapy
Arthroplasty Occupational therapy
Osteotomy
RA shoulder
Acromioclavicular joint, shoulder joint and various synovial pouches around the shoulder are
frequently involved in RA
Chronic synovitis rupture of rotator cuff muscles, progressive joint erosion
RA C-spine
Severely affected in 30% of patients with RA
Types of lesions
1. Atlanto-axial subluxation
Erosion of atlantoaxial joints & transverse ligament
3. Subcervical spine
4. Erosion of facet joints subluxation
Clinical features
Middle-aged/elderly female with RA
c/o neck pain & stiffness
decreased ROM
signs & symptoms of nerve root tension: UL numbness, parasthesiae & weakness
cervical myelopathy (cord compression)
cervical spondylosis
X-rays
1. AP
2. Lateral
3. Flexion & extension news reveal subluxation/cervical instability
Treatment
Serious complications are uncommon!
Cervical collar (pain relief)
Spinal fusion (persistant & severe pain; a/w neurological deficits)
RA Hip
Hip joint is frequently affected in RA
Hallmark: progressive bone destruction bilaterally
Osteophyte formation (unless 2 OA)
330
Clinical features
Rheumatoid disease affecting many joints
Insidious onset of pain in the groin
Limp
Difficulty getting out of chair
Marked muscle wasting of buttock & thigh
Limb is held in fixed flexion and external rotation
Movements are restricted & painful
Treatment
1. Conservative
If disease has not caused bone/articular erosion
General treatment to arrest progression of RA can slow down hip deterioration
Once bone/cartilage has been eroded, treatment can stop joint destruction
2. Surgical
Total hip replacement
Even in younger patients (polyarthritis has already limited activity that implants will not be
unduly stressed even after op)
X-ray
Early Stages Later Stages
osteoporosis (loss of radiological density; Erosion of femoral head & acetabulum
rarefaction) Gross bone destruction
Loss of joint space Can resemble TB arthritis
Bilateral involvement
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Medicine (Diabetes) = Diabetic Ketoacidosis (DKA)
Introduction
Caused by absolute/relative decrease in insulin levels in the presence of excessive catabolic hormones
(eg. Glucagon)
More common in Type 1 DM
Diagnostic criteria
i. Hyperglycemia = BSL>14mmol/L
ii. Metabolic Acidosis = arterial pH <7.3
HCO3- <15 mmol/L
iii. Ketonemia/Ketonuria = [total ketones] > 5 mmol/L
Or urine ketone <3
Aetiology
Idiopathic (40%)
Infections = UTI, URTI, skin
Intercurrent illness
Insulin errors
Infarction = AMI, CVA
Pathogenesis
Insulin deficiency
i. Absolute lack newly diagnosed Type 1 DM
ii. Relative lack in known Type 1 DM reduced insulin dose or maintain normal dose during
intercurrent illness
iii. Relative lack in Type 2 DM 00> insulin resistance overwhelms -cell reserves
High plasma glucose osmotic diuresis Na+ & H2O loss dehydration (4-6 L)
Hypovolemia
Hypotension
Hypoperfusion
Shock
Clinical Features
SYMPTOMS
Hyperglycemia = polyuria, polydipsia, LOW
GIT = nausea, vomiting, abdominal pain
Dehydration = postural giddiness, weakness
Metabolic acidosis = AMS (drowsiness, lethargy, confused, stuporous, seizures)
Underlying aetiology = infection (fever and localizing symptoms)
Infarction (chest pain, SOB, nausea/vomiting, diaphoresis, palpitations,
giddiness/syncope, focal neurological deficits)
Insulin errors (compliance, no increase in dosage during illness)
SIGNS
Level of consciousness
Vital signs = HR, BP, RR (Kussmaul’s breathing), temperature
Dehydration
respiratory exam
CVS exam
Neurological exam
Complications
DKA
Fluid, electrolyte and acid-base disturbances
Congestive cardiac failure
332
Acute renal failure
Thromboembolism (2° dehydration, occur on D3) DVT, PE, AMI, CVA, DIVC
From treatment
Cerebral edema
Aetiology = over-rapid correction of fluids
Use of hypotonic saline
Rapid correction of hyperglycemia
Clinical presentation = early irritable, stuporous, drop in GCS
Late raised ICP
Usually occurs 6-12 hours after DKA Rx
Mx = elevate head of bed
Intubate and hyperventilate
IV mannitol
Hypoglycemia
Hypokalemia (serum K<3 : arrhythmia, death)
Hypophosphatemia
Management
The principles of treatment can be divided into 5 main areas – the ‘diabetic pentathlon’ –
1) Water and Na replacement
2) K+ replacement
3) Correction of acid-base imbalances
4) Insulin administration
5) Prevention of treatment complications
Supportive measures
1. Assess patient vitals and resuscitate when necessary
2. A = ensure airway patent
B = ensure spontaneous breathing
Oxygen supplementation
Monitor SpO2
C = obtain ECG and place on continuous monitoring
Create 2 large-bore IV cannula
Obtain bloods for investigation
Fluid resuscitation if in shock (ensure good cardiac function first)
3. Monitor
(a) strict I/O charting = catheterise if necessary
(b) urine dipstick
(c) BSL
(d) Vital parameters
4. Investigations
(a) Confirm diagnosis = plasma glucose
Urinary and serum ketones
ABG (metabolic acidosis)
(b) Assess severity = U/E/Cr (dehydration, electrolye abnormalities, glucose, Ca/Mg/PO4)
(c) Underlying etiology = ECG, cardiac enzymes (AMI)
CXR (pneumonia)
FBC (leukocytosis, raised Hct)
Blood c/s if septic
UFEME and urine c/s (UTI)
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Specific measures
1. IV volume replacement
1st hour = 0.9% N/S @ 5-20ml/kg/hr (change to colloids if still hypotensive)
Aim to correct estimated water loss (4-6L) within 24 hours
2nd-4th hrs = 0.45% N/S @ 10-20ml/kg/hr
Monitor urine output hourly
Check U/E/Cr every 2-4hrs till stable
Beware of over-rapid correction (esp in elderly, CCF) = serum osmolality not to ↓ >3
mOsm/kg/hr (may ppt cerebral edema)
DKA HHNK
Plasma glucose > 14 mmol/L >33mmol/L
Na + <135 (pseudohypoNa+) 135-145
K+ Normal/↑ Normal
Urea Increased Very Increased
Creatinine Increased Very Increased
Osmolality (mOsm/kg) 300-320 >330
pH < 7.3 > 7.3
HCO3 <15 >15
Ketonuria ++++ + or ++
Fluid loss 4-6 L 6-10L
Mortality risk Increased Markedly Increased
334
IV insulin sliding scale
335
Medicine (Diabetes) = Hyperosmolar hyperglycaemic non-ketotic (HHNK) state
Diagnostic criteria
BSl > 33 mmol/L
Serum total osmolality >330mOsm/kg H20
Absence of ketonuria/ketonemia (due to presence of insulin in type 2 DM)
o Arteria pH > 7.3
o HCO3- > 15 mmol/L
Salient points
Longer disease course = days (vs hrs in DKA)
More severe dehydration = fluid loss (6-10L)
Greater K+ loss
Patients are more sensitive to insulin less insulin required
a/w higher mortality
Causes
Infection
Intercurrent illness
Infarction
Insulin errors
Dehydration = impaired thirst (elderly, immobility), excess diuretics, extensive burns
Clinical features
Commonly occurs in elderly patients with type 2 DM
SYMPTOMS
Hyperglycaemia = polyuria, polydipsia, increased thirst, LOW
Dehydration = postural giddiness, weakness
Altered mental state
Underlying aetiology
o Infection (fever and localizing symptoms)
o Infarction (chest pain, SOB, nausea/vomiting, diaphoresis, palpitations, giddiness/syncope,
focal neurological deficits)
o Insulin errors (compliance, no increase in dosage during illness)
SIGNS
Level of consciousness
Vital signs = HR, BP, RR, temperature
Dehydration
Sits of infection = skin, lungs
CVS exam
Neurological exam
Complications
HHNK
Fluid and electrolyte disturbances
Congestive cardiac failure
Acute renal failure
Thromboembolism (secondary dehydration, occurs on D3) DVT, PE, AMI, CVA
From treatment
Cerebral oedema
336
o Aetiology = over-rapid correction of fluids, use of hypotonic saline, rapid correction of
hyperglycaemia
o Clinical presentation = early irritable, stuporous, drop in GCS, late raised ICP
o Usually occurs 6-12 hours after Rc
o Mx = elevate head of bed, intubate and hyperventilate, IV mannitol
Hypoglycaemia
Hypokalemia
Hypophosphataemia
Management
Supportive measures
Assess patient’s vitals and resuscitate when necessary
o A = ensure airway patent
o B = ensure spontaneous breathing, oxygen supplementation, monitor SpO2
o C = obtain ECG and place on continuous monitoring, create 2 large-bore IV cannula, obtain
bloods for investigation, fluid resuscitation if in shock (ensure good cardiac function first)
Monitor
o Strict I/O charting = catheterize if necessary
o BSL
o Vital parameters
Investigations
o Confirm diagnosis = plasma glucose, serum osmolality, urinary and serum ketones, ABG
o Assess severity = U/E/Cr (dehydration, electrolyte abnormalities, glucose)
o Underlying aetiology =
ECG, cardiac enzymes (AMI)
CXR (pneumonia)
FBC (leukocytosis, raised hct)
Blood c/s if septic
UFEME and uring c/s (UTI)
Specific measures
1. IV volume replacement more important of DKA due to greater fluid loss
Ensure good cardiac function
Rapid bolus of 2L N/S fast (1 pint over 30 mins) 1 pint q4hrly
Monitor urine output
Check U/E/Cr every 2-4 hrs till stable
Beware of over-rapid correction (esp in elderly, CCF) = serum osmolality not to ↓ >3 mOsm/kg/hr (may
ppt cerebral oedema)
2. Restoration of electrolyte balances
K+ replacement
3. Insulin administration
Bolus dose not needed as patients are sensitive to insulin
Continuous low-dose insulin infusion of 0.1 U/kg/hr
o Adjust infusion rate to obtain drop in BSL of 3-4mmol/L/hr
o Monitor BSL hourly
o Adjust until BSL < 14 mmol/L halve infusion to 0.05 U/kg/hr, add D5% into fluids
4. Treat possible complications
Thromboembolism = subcut LMW heparin until mobile
5. Treat precipitating factors
Sepsis Abx
AMI MONA
337
Medicine (Diabetes) = Management of Diabetes Mellitus
Management
1. Patient education
2. Lifestyle modifications for 2-4 months unless patient is symptomatic or severely hyperglycaemic (random BSL >
15
mmol/L or fasting BSL > 10 mmol/L)
- quit smoking = nicotine promotes both macro- and micro-vascular disease
- stop alcohol consumption
- exercise regularly
- lose weight
- eat a healthy diet
- reduce stress levels
- control HPT and HCL
338
Oral hypoglycaemic agents (OHGA)
Classes of OHGA
(a) insulin secretagogues promote insulin release
- sulphonylurea
- meglitinide
(b) insulin sensitizers improve tissue response to insulin
- biguanides
- thiazolidinediones
(c) insulin release sparers reduce amount of insulin required
- -glucosidase inhibitors
Sulphonylureas
mechanism of action = inactivate ATP-dependent K+ channels depolarisation opening of voltage-gated
Ca2 channels influx of Ca2 triggers insulin release
(a) 1st-generation
Tolbutamide
- well-absorbed orally
- rapidly metabolised in liver to inactive carboxytolbutamide
- short t½ = 4-5 hrs ( need for TDS dosing)
- advantage = safest sulphonylurea to be used in elderly due to short DOA
- S/E = nephrotic syndrome, hypothyroidism, hepatotoxicity, teratogenicity
Chlorpropamide
- extremely long-acting sulphonylurea (t½ = 36 hrs)
- S/E = severe hypoglycaemia, SIADH, cholestatic jaundice, blood dyscrasia, rash
(b) 2nd-generation
Gilbenclamide (Daonil)
- metabolised in liver to 3 major hydroxylated metabolites (1 has 15% hypoglycaemic effect that of parent drug
and accumulates in liver failure)
- long t½ = 6-12 hrs (given as OM dose)
- S/E = hypoglycaemia not given to elderly who live alone
- CI = hepatic and renal impairment
Glipizide
- metabolised in liver to inactive compounds
- short t½ = 2-4 hrs
- fastest onset and shortest DOA of all the 2 nd generation drugs
- S/E = less likely to cause hypoglycaemia
GIT effects (LOA, nausea, vomiting)
rash
(c) 3rd-generation
Glimepiride
- most potent of all the sulphonylureas!
- metabolised in liver to inactive compounds
- short t½ = 4-5 hrs
- long DOA given as OM dose
- S/E = allergic reactions (due to sulphur content urticaria, cardiorespiratory failure)
GIT (LOA, nausea, vomiting, abdominal pain, diarrhoea)
less likely to cause hypoglycaemia
Meglitinides Repaglinide
mechanism of action = act on binding sites distinct from that of sulphonylureas inactivate ATP-dependent K+
channels depolarisation opening of voltage-gated Ca2 channels influx of Ca2
triggers insulin release
prandial glucose regulator = only to be taken 30 mins before a meal (no meal no need to take)
pharmacokinetics
# well-absorbed orally
# metabolised in liver and excreted in bile
339
# very fast onset of action (within 1 hr of ingestion)
used cautiously in patients with hepatic/renal impairment
S/E = hypoglycaemia
advantage = can be used in patients with sulphonylurea/sulphur allergy no sulphur content
Thiazolidinediones Rosiglitazone
mechanism of action = nuclear regulation of genes involved in glucose and lipid metabolism
- act by binding to PPAR (peroxisome proliferator-activated receptor) found in fat, muscle and lvier
pharmacokinetics
# metabolised in liver
# slow onset and offset of activity involved gene regulation
S/E
(a) hepatic impairment
- contraindicated in patients with liver impairment (ALT > 2.5x above upper limit of normal)
- monitor LFT every 2 months
- stop if ALT > 3x above upper limit of normal
(b) fluid retention
- contraindicated in patients with CCF
- results in weight gain and low Hb/Hct/WBC (dilutional effect)
(c) ovulation in pre-menopausal/anovulatory women
- consider OCP
advantages = can be used singly or combined
decreases TG levels
decreases LDL/HDL ratio ( HDL > LDL)
role in disease prevention
Insulin therapy
indications
(a) type 1 DM
(b) failure of lifestyle modifications and OHGAs in glycaemic control of type 2 DM after 6 mths (i.e. 2 consecutive
HbA1c values 8%)
(c) during acute illness/stress in type 2 DM
manufactured by recombinant DNA technology
plasma t½ = 10 mins
insulin preparations = (a) rapid-acting Aspart (NovoRapid)
Lispro (Humalog)
(b) short-acting Regular/soluble insulin (Actrapid/Humulin R)
(c) intermediate-acting Neutral protamine (Insulatard/Humulin N)
Lente (Humulin L)
(d) long-acting Ultralente (Humulin U)
Insulin glargine (Lantus)
(a) + (b) dispensed as clear solutions at neutral pH contain small amount of zinc to improve stability and shelf-life
(c) + (d) dispensed as cloudy suspensions at neutral pH except insulin glargine (clear, pH 4)
insulin glargine is the only soluble long-acting insulin
routes of administration = SC (injection, Novopen, continuous subcutaneous insulin infusion/insulin pump)
IM, IV, IP, aerosol
current regimes use intermediate/long-acting insulins to provide basal coverage with rapid/short-acting insulin
analogues to meet mealtime requirements
# twice-daily administration (OM and ON) of one of the following regimens
~ rapid-/short- acting insulin analogues with intermediate-acting insulin
~ pre-mixed regular and NPH insulins
~ pre-mixed rapid-acting and their protaminated intermediate-acting analogues
# basal-bolus regimen
~ intermediate-/long-acting insulin ON with rapid-/short-acting insulin analogues before meals
~ BIDS (bedtime intermediate-/long-acting insulin and daytime sulphonylureas) for selected DM type 2 patients
insulin regimens
- arbitrary dosage = I unit/kg/day
- usually given 30 mins before meals (Lispro and Aspart can be given with or just after meals)
- commonest regimen is twice-daily dosing based on 2/3 : 1/3 rule
# 2/3 total dose given OM before breakfast
# 1/3 total dose given ON before dinner
# each time 2/3 intermediate or long-acting
1/3 short-acting
Insulin lispro
- insulin analogue = inversion of proline-lysine amino acid sequence at positions 28 and 29 on -chain
- features = rapid onset within 15 mins
peak within 1-2 hrs
duration of action 4-6 hrs
- advantages = very useful in toddlers
may improve compliance with adolescents
reduce nocturnal hypoglycaemia
- disadvantages = higher unit cost
frequent injections
Actrapid
- recombinant human insulin
- features = onset within 30 mins
peak within 2-4 hrs
duration of action 6-8 hrs
341
Insulin glargine
- insulin analogue
- features = slow and prolonged absorption (soluble at pH 4 micro-precipitates at physiological pH releases
small amounts of insulin slowly)
peakless
duration of action 24 hrs
- better than ultra-lente = less variability in PK profile
Monitoring
indications = patients on insulin therapy (type 1 DM 3-4 times daily; type 2 DM 2-3 times/day on 2-3
days/week)
pregnant women with GDM or pre-gestational DM
patients who failed to achieve glycaemic control
markers
(a) blood glucose levels
(b) HbA1c= measure of glycaemic control over the previous 3 months
(c) fructosamine (glycated plasma protein) = reflect control over the previous 2-3 weeks
useful in pregnancy to assess short-term control and in
342
haemoglobinopathies which interfere with HbA1c
advantage = patient can interpret results and modify treatment accordingly
better understanding of own disease
self-monitoring of blood glucose = pre-meal hypocount 4.0-6.0 mmol/L
post-meal hypocount 6.0-8.0 mmol/L
- visual method not recommended
- glucometer recommended
self-monitoring of glucosuria not recommended
- inaccurate as raised renal threshold for glucose might mask persistent hyperglycaemia
- only for patients unable or unwilling to perform hypocount
self-monitoring of ketonuria recommended in type 1 DM and pregnant women with GDM or pre-gestational DM
- indications = acute illness/stress
persistent hyperglycaemia > 14 mmol/L
symptoms of ketoacidosis (nausea, vomiting, abdominal pain, acetone breath)
Chronic complications
microvascular complications retinopathy, nephropathy, neuropathy
macrovascular complications CVD, CVA, PVD
relation to tight glycaemic control
~ DCCT = tight glucose control lowered the risk of a cardiovascular disease event by 42% and the risk of a serious
event (i.e. AMI, CVA) by 58%
~ UKPDS = 1% decrease in HbA1c value correlated to a 35-60% reduction in risk for microvascular complications;
intensive therapy with either sulphonylureas or insulin reduces overall incidence of microvascular
complications by 25% compared to conventional therapy; reduction in mean HbA 1c by 0.9% (from 7.9% to
7.0%) translates into a corresponding reduction in the risk of microvascular complications by 37%
Cardiovascular disease
importance
- type 2 DM is a major risk factor for atherosclerotic disease
- metabolic changes in DM = hyperglycaemia, HPT, dyslipidaemia, obesity, pro-thrombotic state, endothelial
dysfunction, pro-inflammatory state prone to CVD
- DM is a coronary heart disease risk equivalent (risk of DM patient suffering an AMI is the same as a non-
diabetic
patient who has already suffered a previous AMI)
- epidemiology = AMI 3-5 times more common in diabetics (also likely to be silent)
~ 60% of DM patients die as a consequence of CVD
case-fatality higher in DM patients (as many as 50% of those suffering their first AMI die)
CVA 2 times more common in diabetics
- main goal of therapy is primary prevention of CVD
investigations lower incidence of AMI and CVA if LDL-C < 2.1 mmol/L
(a) annual LFT for dyslipidaemia but total mortality is similar in both groups
(b) annual resting ECG and BP
(c) examine for PVD, femoral bruit & carotid bruit
management
- lifestyle modifications = smoking cessation, medical nutritional therapy, physical activity
- control risk factors
Hypertension
Aim < 130/80 mmHg
Rx Choice of drug depends on additional benefits
- ACE inhibitors are reno-protective
Dyslipidaemia
Aim Total cholesterol 6.2 mmol/L
343
LDL-C = very high-risk < 2.1 mmol/L
high-risk < 2.6 mmol/L
intermediate-risk < 3.4 mmol/L
low-risk < 4.1 mmol/L
TG < 2.3 mmol/L (too high at increased risk of acute pancreatitis)
HDL-C 1.0 mmol/L
# priority = LDL-C HDL-C TG
LDL HMG-CoA reductase inhibitor (statin)
- S/E = liver transaminases (check CK and LFT 2-3 mths after starting Rx, stop if ALT/AST >
3x
upper limit of normal or CK > 10 x upper limit of normal)
myopathy
rhabdomyolysis
- should not use gemfibrozil when combining with fibrates adversely alter PK of statin
increased risk of rhabdomyolysis
TG Fibrates/Nicotinic acid
- S/E = cholesterol gallstone disease
myopathy
rhabdomyolysis
liver transaminases
- severe TG = combination of fibrates with omega-3 PUFA
HDL Fibrates/Nicotinic acid
Cardiovascular events
macrovascular dz low-dose aspirin (100-300 mg/day)
no macrovascular dz DM is a CHD risk equivalent low-dose aspirin in patients > 45 yrs old
Diabetic foot
foot ulcers and amputations are major causes of disability & mortality in diabetic patients
5% of all diabetics develop foot ulcers eventually
approximately 700 lower extremity amputations performed in diabetic patients annually
2 types = ischaemic foot (painful, cool peripheries)
neuropathic foot (painless punched-out ulcer, normal skin temperature)
indications for amputation = dead, dangerous, ‘damn’ nuisance
Signs
diabetic dermopathy
pale and cool peripheries
loss of hair, shiny/dry skin, muscle atrophy, trophic nail
changes
absent/reduced peripheral pulses
positive Buerger’s test
reduced ABPI
Peripheral neuropathy Symptoms
numbness and parasthesiae over palms and soles
burning sensation in soles
Signs
foot deformities = calluses
bunions
hallux valgus
pes cavus
pes planus
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hammer toes
clawed toes
charcot’s joint (rockerbottom feet)
loss of ankle jerks (1st thing to go)
negative monofilament sensation (‘glove and stocking’
distribution)
negative pin prick sensation
negative turning fork sensation
loss of proprioception
Poor footwear open-toe shoes = slippers, flip-flops, thong
tight or ill fitting shoes
management
- optimize glycaemic control
- smoking cessation will worsen PVD
- footcare education
~ inspect feet daily for cuts and injuries especially in between toes
~ dry feet properly after bathing
~ apply moisturizer if skin is dry
~ cut toenails straight across
~ do not use corn plasters or cut calluses
~ f/u with a podiatrist regularly
~ proper footwear = do not go barefooted
wear wide-toed covered shoes
~ do not walk on reflexology footpaths barefooted
~ if a cut is found ( wash with saline and cover with light dressing
see doctor if it does not start to heal within 2 days
Diabetic retinopathy
leading cause of blindness in Singaporean adults
pathophysiology
cataracts
- increased metabolism of glucose to sorbitol via polyol pathway
- increased osmotic pressure within the lens accumulation of water lens swells cataracts
retinopathy
- hyperglycaemia increases retinal blood flow damages retinal endothelial cells and pericytes
- results in impaired vascular auto-regulation and uncontrolled blood flow
- increased production of vasoactive substances and endothelial cell proliferation
~ capillary occlusion
~ chronic retinal ischaemia stimulate production of growth factors increases vascular permeability
stimulates angiogenesis
risk factors for progression
- duration of DM
- glycaemic control = poor glycaemic control in type 1 DM patients increases risk of retinopathy by 8x
intensive glycaemic control reduces risk by 50-75%
1% reduction in mean HbA1c leads to 37% reduction in risk of retinopathy
- HPT = 10mmHg reduction in BP leads to 13% reduction in risk of retinopathy
- HCL = treatment may retard progression of retinopathy
- microalbuminuria and proteinuria = presence should allude to the presence of retinopathy
no clear evidence that treatment has any impact on retinopathy
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- pregnancy
- anaemia = treatment may retard progression of retinopathy
- smoking
long-standing poor glycaemic control = intensive insulin therapy and rapid normalisation of blood glucose a/w
worsening retinopathy; especially if retinopathy is past pre-proliferative
stage
- Mx = laser photocoagulation first followed by intensive treatment
usually develops 10-20 years after onset of DM type 2
eye examination = fundal photography
indirect ophthalmoscopy with slit-lamp
direct ophthalmoscopy through dilated pupils
classification
Non-Proliferative Mild microaneurysms only
Retinopathy Moderate more than just microaneurysms but less than severe NPDR
(NPDR) Severe Any of the following (4-2-1 rule)
> 20 intra-retinal haemorrhages in each of the 4 quadrants
venous beading in 2 quadrants
prominent intra-retinal microvascular abnormalities (IRMA)
in 1 quadrant and no signs of proliferative retinopathy
Proliferative 1 or more of the following
Retinopathy (PDR) neovascularisation
- at the disc
- elsewhere e.g. rubeosis iridis (may obstruct draining angle of eye 2 glaucoma)
vitreous/pre-retinal haemorrhage
Clinically Mild some retinal thickening or hard exudates in posterior pole
Significant Macular but distant from macula
Oedema Moderate retinal thickening or hard exudates in posterior pole
approaching the centre of the macula
Severe retinal thickening or hard exudates in posterior pole
involving centre of the macula
management
- refer ophthalmologist with annual eye screening
- lifestyle modifications = smoking cessation, medical nutritional therapy, physical activity
- optimal glycaemic control
- control risk factors = HPT, HCL
# Focal/Grid laser treatment for macular oedema results in at least 50% reduction in risk of visual loss
# Laser photocoagulation should be instituted for severe NPDR and proliferative DR as it results in 50%
reduction
in risk for severe visual loss and need for vitrectomy
~ destroy areas of retinal ischaemia = prevent release of growth factors that stimulate angiogenesis
~ seal leaking microaneurysms
~ obliterate new vessels directly on retina
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DM nephropathy
leading cause of ESRF in Singapore (> 47% of cases in 2000)
stages of DM nephropathy
- stage 1 = glomerular hyperfiltration (increased GFR)
- stage 2 = microalbuminuria (30-299 mg/day)
- stage 3 = proteinuria (irreversible from here onwards)
- stage 4 = renal impairment (Cr > 200)
- stage 5 = ESRF (Cr > 900 start preparing for dialysis when Cr ~ 600-700)
pathophysiology
- hyperglycaemia increases renal blood flow = afferent arteriole vasodilates
efferent arteriole vasoconstricts
- increased intraglomerular pressure increased single nephron GFR glomerular hyperfiltration and
hypertrophy microalbuminuria
- nephrotic range proteinuria lasts ~ 14 yrs
- vessel walls get damaged thickening of basement membrane, glomerulosclerosis, hyaline arteriosclerosis,
tubular atrophy ESRF
Dipstick test
Type 1= annually after 5 yrs
Dipstick + Dipstick –
24h UTP Urine PCR (protein:creatinine
Positive Negative
Repeat 2x over 3 mths Repeat test yearly
Monitor every 6-12 mths * Dipstick only detects > 200mg/L albumin
not microalbuminuria
management
- tight glycaemic control = may be better in ESRF (reduced insulin breakdown in PCT may have to reduce
insulin and OHGA dosage)
- control HPT = aim for BP < 125/75 mmHg
ACE inhibitors preferred as 1st-line drug (vasodilates efferent arteriole reduces intraglomerular
pressure; slows rate of GFR decline; reduces proteinuria)
renoprotective effects are independent of BP control
check U/E/Cr 7 days after starting worsening Cr function, hyperkalaemia
alternative can be non-dihydropyridine CCB (diltiazem, verapamil)
- control HCL = reduces proteinuria and slows rate of GFT decline
- stop smoking
- low-protein diet (0.8 g/kg/day)
- refer nephrologist
DM neuropathy
can affect sensory, motor and autonomic nerves
(a) sensory
- ‘glove and stocking’ distribution of sensory loss
- parasthesiae and burning sensation in soles
- impaired monofilament sensation, pinprick sensation, vibration and proprioception
- loss of distal reflexes (ankle jerks first to go)
- Charcot’s joint (damage to joint due to impaired sensation)
(b) motor
347
- muscle wasting and weakness only in advanced cases
- clawed toes with wasting of interosseous muscles pes cavus
- increased pressure on metatarsal heads with callus formation
- loss of plantar transverse arch pes planus
- diabetic amyotrophy = severe and progressive weakness and wasting of proximal muscles of lower limb
severe pain, parasthesiae and loss of tendon reflexes
due to acute infarction of LMN of lumbosacral plexus
(c) autonomic
- CVS = postural hypotension
- GIT = dysphagia (oesophageal atony)
gastroparesis (abdominal fullness, early satiety, nausea and vomiting)
nocturnal diarrhoea
- GUT = erectile dysfunction impotence
neurogenic bladder (obstructive symptoms and overflow incontinence)
management
- neuropathic pain = paracetamol TCA gabapentine
- postural hypotension = fludrocortisone
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Medicine (Endocrine) = Cushing’s syndrome
Start
1. Examine the patient on the right side of the bed
2. Introduce yourself and explain purpose
3. Position the patient at 450 with adequate exposure
Inspection
1. Cushingnoid facies = characteristic rounded face, plethora, acne, hirsutism
2. Central deposition of aadiposity
Hands
1. Clubbing and tar stains → small cell lung CA
2. Rheumatoid hands → RA
3. Hypocount marks → DM
4. Skin atrophy (double-pinch tst)
5. Bruises
6. Proximal myopathy
Face
1. Malar rash → SLE
2. Eyes → posterior sub-capsular cataracts
3. Mouth → oral thrush
Neck
1. Supraclavicular fat pads
Back
1. Inspection = dorsal fat pads (‘Buffalo hump’ → fat deposition over interscapular area)
Gibbus/ kyphoscoliosis
2. Palpate spine or bony tenderness and step-deformity → osteoporotic compression fracture
3. Auscultate chest for rhonchi → chronic severe asthma, severe COPD
Fine end-inspiratory crepitations → idiopathic pulmonary fibrosis
Abdomen
1. Thick violaceous abdominal striae → active disease (disruption of collagen fibres in dermis leading to
exposed vascular subcutaneous tissues)
2. Transplanted kidney/liver
3. Splenomegaly → autoimmune haemolytic anaemia
4. Adrenal mass → adrenal adenoma/carcinoma
Legs
1. Diabetic dermopathy
2. Proximal myopathy → squat repeatedly
Request
1. Visual fields for bitemporal hemianopia → pituitary adenoma
2. Fundoscopy → posterior subcapsular cataract
Hypertensive retinopathy
Diabetic retinopathy
Papilloedema/ optic atrophy (raised ICP)
3. Blood pressure → HPT
4. Hypocount for BSL → DM
5. Urine dipstick for glycosuria → DM
Issues for discussion
349
1. Physiology
Adrenal cortex produces androgens, glucocorticoids (e.g. cortisol) and mineralcorticoids (e.g. aldosterone)
Cortisol is excreted as urinary free cortisol
Etiology
90% exogenous steroid use 10% endogenous steroid production
350
Complications
Abnormality Clinical features History
Fat metabolism Moon-like facies, central obesity, dorsal fat pads, Inappropriate fat deposition
supraclavicular fat pads Weight gain
Protein catabolism Thick violaceous abdominal striae, skin atrophy, Easy bruising
bruising, proximal myopathy Proximal muscle weakness
Carbohydrate DM (increased hepatic gluconeogenesis + anti- History of DM
metabolism insulin effect) Hyperglycemia (polyphagia,
polydipsia, polyuria, LOW, fatigue)
Recent BSL
Others Hypertension History of HPT
Recent BP reading
Management (diet, medications)
4. Investigations
a. Screening tests
i. Overnight dexamethasone suppression test
1. Give PO DExamethasone 1mg at midnight
2. Check serum cortisol before and at 8 am
3. If cortisol suppressed → no Cushing’s syndrome
ii. 24 hour urinary free cortisol
1. Most reliable and practical
2. Accounts for circadian rhythm → lost in Cushing’s
3. Positive test = 3x upper limit of normal (>280nmol/24hr)
4. If raised but < 3x upper limit of normal → measure serum cortisol in late evening
a. If normal → no further testing
b. Mildly raise → re-evaluate in several weeks
b. Localization tests
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Plasma
ACTH
Undetectabl Detectable
e
Plasma ACTH Undetectable: likely adrenal tumor → ultrasound/ CT/ MRI adrenals
Detectable: distinguish pituitary causes from ectopic ACTH → high-dose
DST or CRH test
High dose DST PO dexamethasone 2mg/6h x 2 days
Measure cortisol (plasma + urine) at 0 & 48h
If cortisol suppressed = Cushing’s disease
If cortisol not suppressed = ectopic ACTH production
CRH test IV 100g bovine CRH → follow cortisol for 2 hrs
If rise in cortisol = Cushing’s disease
If no rise in cortisol = ectopic ACTH production
Inferior petrosal Distinguish Cushing’s disease vs ectopic ACTH
sinus sampling
352
5. Management
(a) Cushing’s disease:
Surgical resection resection of pituitary adenoma (trans-sphenodial/ frontal approach)
Pituitary radiation (in children)
Bilateral adrenalectomy (primary evacuation not possible)
(b) Adrenal tumors:
Surgery (curative for adenomas; rarely so for carcinomas → chemo + RTx)
(c) Ectopic ACTH:
Surgery
(d) Exogenous steroids:
Taper corticosteroid therapy while managing primary pathology
(e) Medications to reduce plasma cortisol
Ketoconazole
6. Pseudo-cushing’s syndrome = increased 24hr urinary free cortisol + absent circadian rhythm + cortisol
suppressed positive DST
D= depression, drugs
O= obesity, OCP
A= alcoholism, acute illness
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Medicine (Endocrine) = Acromegaly
Introduction
Clinical syndrome resulting from excess of growth hormone production after puberty (i.e. after fusion of
epiphyseal growth plate)
(before puberty → giangtism)
Epidemiology: 30-50 years old
Aetiology
Excess GH secretion (GHRH independent)
o Pituitary microadenoma
GH-secreting (commonest cause)
Mixed GH an prolactin-secreting
o Pancreatic islet cell tumor
Excess GHRH secretion (GHRH dependent)
o Central = GHRH secreting hypothalamic tumor
o Ectopic secretion =
Bronchial carcinoid tumor
Small cell lung Ca
Medullary thyroid Ca
Pathophysiology
Due to high levels of GH and GH-dependent insulin-like growth factor-1 (latter produced by the liver)
Somatic Metabolic
Stimulate growth of tissues Nitrogen retention
Skin Insulin antagonism
Connective tissue Lipolysis
Cartilage
Bone viscera
History
Somatic effects
o Excessive sweating (hyperhydrosis)
o Acral and facial changes =
Increased dental problems (malocclusion)
Enlarged face, jaw, hands and feet
Outgrowing wedding ring, dentures, shoes
o OSA = snoring, morning somnolence
o Musculoskeletal=
Numbness and parasthesia (carpal tunnel syndrome)
Chronic back ache, radicular pain (spinal stenosis)
Urinary and bladder problems (spinal cord compression)
Joint pain (20 OA, chondrocalcinosis)
Metabolic effects
o Hypertension
o DM = polyuria, polyphagia, LOW, fatigue
Local pressure effects = headache, visual field defects
Hypopituitary effects = menstrual disturbances, galactorrhoea, impotence
Tumors = uterine leiomyomata, colonic polys, CRC
354
Signs/physical examination
Request to examine
Visual fields = superior bitemporal hemianopia
Fundoscopy=
o HPT/DM retinopathy
o Papilloedema/ optic atrophy
o Angioid streaks (degeneration + fibrosis of Bruch’s membrane)
Blood pressure = HPT
Urine dipstick = glycosuria
Macroglossia
Hypocount = DM
Acromegaly
Genitalia = testicular atrophy
Hypothyroidism
Look at old photographs
Amyloidosis
Indicators of acitivity Down’s syndrome
1. Skin tags
2. Hypertension
3. Glycosuria & hyper glycemia
4. Increase goiter/ tumor (with headache, visual field defect)/ hands, feet, mandible
5. Increased sweatiness
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Algorithm for diagnosing acromegaly
Investigations
Diagnostic Serum IGF-1 Raised in acromegaly, puberty and pregnancy
OGGT with GH measurement Normal = GH suppression
Acromegaly= indadequate GH suppression
Etiology MRI pituitary fossa
Serum Ca (hyperparathyroidism a/w MEN1
syndrome)
CT chest/ abdomen
Complications ECG, CXR Cardiomegaly
U/E/Cr Hyperglycaemia (DM)
TFT, LH/FSH, testosterone, prolactin, short Hypopituitarism:
synacthen test (ACTH def), triple Sequence:
stimulation test o ↓gonadotrophins
o ↑prolactin
o ↓TSH
o ↓ACTH
Skull x-ray Large skull
Unusually large frontal sinuses
Frontal bossing
Thick skull table
Occipital prominence
OA c-spine
Prominent jaw
Malocculusion
Dental fillings
Enlarged pituitary fossa
Hand x-ray Large spade like hands
‘turfting to terminal phalanx)
Knee x-ray Chondrocalcinosis, OA
Feet x-ray Large feet, thickened heel pad (lat view)
356
Differentials for GH excess
MEN 1 syndrome = hyperparathyroidism, pituitary tumors, GIT tumors
McCune-Albright syndrome = polyostotic fibrous dysplasia, precocious puberty, café-au-lait macules
Carney syndrome
Management
Trans-sphenoidal surgery
Pituitary radiation
o Failed surgery
o Older patients
Conservative
o Growth hormone antagonist (Pegrisomant)
o Dopamine agonisits (bromocriptine, carbageline) → inhibits prolactin secretion in tuotrs that co-
secrete prolactin
o Somatostatin analogues (octreotide) → inhibit GNRH secretion
Treat complications = DM, HPT, hypopituitarism (steroids, lifelong thyroxine)
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Medicine (Endocrine) = Addison’s disease (chronic 10 adrenal insufficiency)
Eitiology
1. Primary adrenal insufficiency
Autoimmune adrenalitis
o ↑ adrenal antibodies
o a/w Graves’ disease, Hashimoto’s thyroiditis, MNG, vitiligo, pernicious anaemia
tuberculous adrenalitis
AIDS = CMV adrenalitis
Adrenal hemorrhage =
o Anticoagulants
o Meningococcal septicaemia → Waterhouse-Friederichs Syndrome
o Anti-phospholipid syndrome
Clinical symptoms
LOW, LOA
Fatigue
Dizziness (may be postural related) → syncope
Weakness
GIT = nausea vomiting, diarrhea, abdominal pain
Depression, psychosis
Addisonian crisis (see later)
Clinical signs
Hyperpigmentation (palmar creases, buccal muscosa)
o Due to high ACTH levels 20 decreased cortisol feedback
Craving for salt
o Due to ↓ aldosterone levels
Postural hypotension
Vitiligo
Goiter
Investigation
Bloods
o FBC =
↓ Hb (mild hemolytic anemia)
Leukocytosis (infection)
o U/E/Cr=
358
Hypokalemia
Hyponatremia
Hypoglycemia
o Plasma ACTH ↑, renin ↑, aldosterone ↓
Imaging
o AXR, CXR (if suspecting TB)
o CT abdomen = adrenals
Management
Patient education
o Warn against stopping steroids abruptly
o Give glucocorticoids IM/suppositories in cases of vomiting
o Medik Awas card
o Double/ triple dose of hydrocortisone during episodes of febrile illness/ injury
Pharmacotherapy
o Fludrocortisones
Postural hypotension
Hypo Na+
Hyper K+
↑ plasma renin
o Hydrocortisone replacement
Addisonian crisis
Acute adrenocortical failure characterized by nausea, vomiting, hypotension, shock
Triggers in unknown patient = infection, trauma, burns, surgery
o 1st presentation = bilateral adrenal haemorrhage
Rare in patients with 20/ 30 adrenalcortical insufficiency
o Pituitary apoplexy
o Sheehan’s syndrome
o Withdrawal of chronic glucocorticoids suddenly
Clinical evaluation
o Known patient with Addison’s disease = infection, trauma, burns, surgery
o Signs of Cushing’s syndrome = sudden withdrawal of glucocorticoids
Investigations
o FBC
o U/E/Cr
o Cortisol
o ACTH
Management
o IV hydrocortisone 100mg start then every 6 hours
o Fluid resuscitation with IV 0.5 % N/S
o Correct hypoglycaemia
o Treat precipitating cuase
o Start mineralocorticoid therapy = fludrocortisones
o Refer endocrinology
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Medicine (Endocrine) = Hypo-pituitarism
Discussion
360
Etiology
Brain damage Pituitary tumors are classically the most common caus e of hypopit but new findings imply that causes like
brain damage might outnumber pituitary adenomas in causing hypopituitarism
Traumatic brain injury
SAH
Neurosurgery
Irradiation
Stroke
Pituitary tumors Adenomas
Others
Non-pituitary tumors Craniopharyngiomas
Meningiomas
Gliomas
Chordomas
Ependymomas
Metastases
Misc Infection – abscess, meningitis, encephalitis
Infarction --- apoplexia, Sheehan’s syndrome
Idiopathic
Clinical presentation
o May be subclinical or present acutely
↓ACTH, TSH, ADH are potentially life-threatening
↓ gonadotropin and GH cause chronic morbidity
o Signs and symptoms of underlying diseases
Tumor in sellar region
Bitemporal hemianopia
Headace
Signs of culomotor nerve impairment/ damage to CN 3,4,5,6 in cavernous sinus
o Clinical features/ investigative findings
Management
o Treatment of cause
Non-functioning pituitary adenoma → Transsphenoidal or transcranial surgery
Craniopharyngioma difficult to access
Prolactinoma → medical treatment with dopamine agonist
o Hormone substitution
o Follow-up
Adequate hormone replacement should be monitored at regular intervals
Tumor → regular ophthalmological f/u & MRI
Prognosis
o Generally, hypopituitarism is chronic and lifelong, unless successful surgery or medical treatment of
the underlying disorder can restore pituitary function
o Increase mortality
Always replace steroids first before L-thyroxine or else patient can die!
362
Medicine (Endocrine) = Gynaecomastia
Definition
Abnormal amount of breast tissue in males
Due to increase in estrogen/androgen ratio
Aetiology
1. Liver cirrhosis
2. Drug induced
Cimetidine
Spironolactone
Digoxin
Others: androgens, estrogns, ACE inhibitors, CCB, chronic alcoholism, isoniazid, ketoconazole
3. Endocrinopathies
Thyrotoxicosis
Acromegaly
Hypopituitarism
Addison’s disease
4. Hyperestrogenism
Testicular failure
o Kallmann’s syndrome
o Trauma
o Viral orchitis
o Castration (medical, surgical)
o Klinefelter’s syndrome
Paraneoplastic syndrome (Ca Lung)
5. Uraemia
6. Physcological
Pubertal
Senile
363
Recent drug intake NSAIDs
Medicine (Renal) = Acute Renal Failure Aminoglycosides
A sudden decrease in renal function resulting in an inability to maintain fluid Contrast
and electrolyte balance and to excrete nitrogenous wastes Urinary obstruction LUTS
Signs and Symptoms
Haematuria
Uraemia Nausea
Vomiting Backpain
LOA Constipation
Fatigue Urinary instrumentation
Pruritus Glomerulonephritis Rash
Skin Bruising haemoptysis
Uraemia oesophagitis/gastritis/colitis
Pericarditis
Pleuritis Lab findings to suggest ARF
Seizures Increased Urea and Cr above baseline
Encephalopathy Increase K+ (impaired renal excretion)
Peripheral neuropathy Increased PO4 (secondary to decreased secretion from tubule
Oliguria Urine output < 400ml/day damage)
Fluid overload Lower limb oedema Decreased CA2+
Ascites
Pleural effusion/pulmonary oedema Causes of ARF
Facial oedema Pre-renal (40%)
Intrinsic renal (up to 50%)
Aetiology
Post renal (5-10%)
Sepsis
Dehydration Vomiting
Diarrhea
Poor fluid intake
Fever
Use of diuretics
CCF
Haemoptysis/melena/haematemesis
Uncontrolled HPT Compliance with medications
Fluid and salt restrictions
364
Pre Renal Post Renal Intrinsic Renal
Aetiology Decreased renal Urinary Tract Obstruction within the Acute tubular necrosis Acute interstitial nephritis Acute GN
perfusion lumen Ischaemia Drug RXN Post strep GN
Sepsis Bladder calculi Nephrotoxins (penicillin/NSAIDs) IgA nephropathy
Dehydration Bladder tumour o Aminoglycosides Rapidly progressive GN
Shock Papillary necrosis o Contrast
Uncontrolled HPT Crystalluria o Chemo RX
Urinary tract obstruction within the o Rhabdomyolysis
wall
Urethral stricture
Bladder neck stenosis
Neurogenic bladder
Urinary Tract obstruction outside the
wall
BPH
Prostate CA
Constipation
CA Cervix/uterus
CA colon
Retroperitoneal fibrosis
Clinical Sepsis = Fever, Toxic LUTS (storage and voiding symptoms
features looking
Haematuria
Dehydration =
increased thrist, dry Distended bladder
mucous membranes
Decreased skin turgor, Enlarged prostate
prolonged capillary
refill time, altered
mental state
Shock = tachycardia,
hypotension
Urine Na <20 (can concentrate Variable >20 (cannot concentrate urine) <20 >20
(mmol/L) urine)
Urine >500 <350 <350 >500 <350
osmolality
(mosm/kg)
Sediment Benign/hyaline casts Normal/RBC/WBC Granular casts RBC casts WBC casts with
eosinophillia
365
Investigations
Urine Bloods Imaging Bladder catheterization
UFEME FBC KUB or CT KUB Rule out urethral
Haem -> rhabdomyolysis Hb (distinguish from CRF) obstruction
Casts Eosinophillia (acute IN) Renal U/S
o Granular (acute TN) CKMM Small atrophied kidneys (CRF)
o RBC (acute GN) Rhabdomyolysis Hydronephrosis (post-renal)
o WBC + Eosinophillia (acute IN) U/E/Cr
Urine Osmolality and urine Na+ Urea > creatinine (pre-renal)
High/low (pre-renal + acute GN) Electrolyte abnormalities
Low/High (post renal + acute TN + acute IN) Autoimmune screen
ANA
Anti-dsDNA
Complement levels
ANCA
Anti-GMB Ab
Complications
Electrolyte imbalances Fluid overload Uraemia
Hyper/hyponatraemia Hypertension Pericarditis
Hyperkalaemia Pleuritis
Metabolic acidosis Encephalopathy
Hypermagnesaemia Peripheral neuropathy
Hyperphosphataemia Platelet dysfunction
Hypocalcemia Pruritus
Oesophagitis/gastritis/colitis
366
Management
(a) Treat underlying cause (especially if post renal obstruction)
(b) Catheterize and monitor hourly urine output
(c) Fluid replacement – must be balanced against volume status of the patient and ability to PU
367
Medicine (Renal) = Chronic Renal Failure
History
Presenting complaint
Symptoms of renal failure
Complications of renal failure
Unrelated problem
Etiology:
Extrarenal
Systemic sclerosis
Multiple myeloma
Amyloidosis
Investigations done
o U/S – anatomical malformations
o Biopsy – GN
EPO injections
368
Hemodialysis – AV fistula/graft, frequency per week, duration per session, weight gain in between HD
sessions, complications (bleeding/thrombosis/infections/problems with vascular access), fluid and dietary
restrictions, compliance
Peritoneal dialysis – type of PD (CAPD/APD), type and volume of dialysate used, complications (infections,
catheter blockade), fluid and dietary restrictions, compliance
On the transplant waiting list?
Renal transplant – when (year), where (local/overseas), type (cadaveric/living related transplant), recent
graft function (graft pain and swelling, proteinuria, creatinine levels), rejection episodes and treatment,
immunosuppressants (steroids = diabetes, HPT, HCL, obesity, easy bruising, cataracts, proximal myopathy,
osteoporosis, AVN, susceptibility to infections, SCC)
Current symptoms – urine output, fluid overload, uremia
Complications of disease
369
Physical examination
370
Investigations
Management
Discussion
A)
Chronic renal failure = substantial, irreversible and usually long-standing loss of renal function, KDOQI
defines CRF as GFR < 60 ml/min/1.73m2 for 3 or more months
Azotemia = raised level of urea and creatinine without symptoms (GFR 20-35% of normal)
Uremia = raised level of urea and creatinine with symptoms (GFR < 20% of normal)
C) Stages of CKD
372
D) Complications of CRF
373
F) Anemia in CRF
374
G) Ca/PO4 metabolism in CKD
CKD
Decreased
hydroxylation of
Decreased GI Ca Vitamin D
absorption
375
1. Diuresis with IV frusemide
Medicine (Renal) = CRF with fluid overload 120-240 mg/8hrly (if serum Cr > 400 μmol/L)
Causes 80-120 mg/8hrly (if serum Cr < 400μmol/L)
1. CVS event = AMI, CCF If no response, step up to maximum OR infusion at 30 mg/hr
2. Anaemia Urinary catheter if no urine output > 6hrs
3. Sepsis
4. Non-compliance to fluid and salt restrictions 2. Exclude cardiac event
5. Non-compliance to medications Check baseline ECG
# diuretics If pt has IHD = do CK/CKMB/Trop T and repeat ECG x 3
# anti-hypertensives
3. Consider acute dialysis (if APO, severe fluid overload, acidosis or
Investigations hyperkalaemia)
serial cardiac enzymes and ECG = exclude AMI PT/PTT, GXM
CXR = cardiomegaly, APO If for dialysis = trace Hep/HIV status
-natriuretic peptide = exclude CCF If results > 6mths = order HBsAg, Anti-HCV, HIV
FBC = Hb (anaemia)
WCC and differential count (sepsis) 4. (Day 2) Referral plan
U/E/Cr = worsening renal function (AoCRF) If Cr > 400 μmol/L assess ADL
Ca/Mg/PO4/albumin/iPTH = renal osteodystrophy cannot do any one ADL refer MSW
GXM = blood transfusion can do all refer renal coordinator and vascular surgeon
LFT = exclude liver pathology If Cr < 400 μmol/L refer renal coordinator, MSW and vascular
co-morbidities = hypocount, HbA1c, fasting lipids surgeon
urine dipstick, UFEME, urine c/s = proteinuria Others = dietician, pharmacist, PT/OT as required
exclude UTI
Inspection
Distended abdomen -> ascites
Grossly enlarged kidneys
Fullness over 1 or both flanks
Vascular access (IJ, subclavian, femoral) -> ESRF
Nephrectomy scar -> hyperfunctioning of solitary kidney
J-shaped scar in iliac fossa overlying rounded mass -> transplanted kidney
Palpation
Describe characteristics of mass = size, shape, surface, edges, tender, consistency
Able to get above the mass
Does not move with respiration
No splenic notch felt
Ballotable
Percussion
Band of resonance due to overlying bowel loops
Auscultation
Bowel sounds
377
Determine Etiology
RCC = cachexic looking
APKD = hepatomegaly, splenomegaly, signs of ESRF
DM = diabetic dermopathy
Renal abscess = positive Murphy’s sign, tenderness
Signs of ESRF
AVF/AVG -> palpable thrill, signs of recent cannulation
Sallow appearance, conjunctival pallor
Uraemia -> bruising, scratch marks, asterixis
Fluid overload -> able to lie flat, ascites, lower limb oedema
Request
Vitals = temperature, BP, HR, RR
Fluid overload = Raised JVP, bibasal inspiratory crepitations
FUndoscopy = diabetic and hypertensive retinopathy
Urine dipstick = glycosuria, haematuria
APKD = CVS (MVP) + Neurological examination ( 3rd nerve palsy, focal neurological deficits, craniotomy)
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Medicine (Renal) = Transplanted Kidney
Approach to the Short Case Examination
Aims
Confirm presence of transplanted kidney
Graft rejection and failure = tenderness, signs of fluid overload
Assess for immunosuppressant toxicity
Determine aetiology and renal failure
Abdomen
o Inspection
Distended = ascites
J-shaped transplant scar in iliac fossa overlying a rounded mass
Presence of tenchkoff catheter
Surgical scars
o Palpation
Mass under J-shaped scar -> transplanted kidney
Determine characteristics of mass = size, shape, surface, edges, tender, consistency, bruit
Bilateral ballotable kidneys -> aetiology
Hepatomegaly -> methotrexate induced cirrhosis
Transplant-related hepatitis reactivation
Hepatosplenomegaly -> transplant related hepatitis B/C induced cirrhosis
Hands
o Hypocount marks -> DM from long term steroid therapy
o Leukonychia, Terry’s Nails, scratch marks, bruising -> ESRF
o Gouty Tophi -> cyclosporine A
o Thin skin (double pinch test) -> steroids
o AVF/AVG -> signs of recent cannulation? (may suggest graft failure)
o Proximal myopathy
H&N
o Eyes
Conjunctival pallor and penguinculae –ESRF
Posterior subcapsular cataract -> long term steroid therapy
o Oral cavity
Oral thrush -> steroid therapy
Gingivial hyperplasia -> cyclosporine A
o Raised JVP -> fluid overload
o Buffalo hump, supraclavicular fat pads -> long term steroid therapy
Back
o Kyphoscoliosis, step deformity, bony tenderness -> long term steroid therapy
Lungs
o Crepitations -> infection/fluid overload
Lower limbs
o Oedema -> fluid overload
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o Diabetic dermopathy -> aetiology
Request to
o Measure BP for HPT -> long term steroid therapy
o DO bedside hypocount and urine dipstick -> aetiology (DM)
o Fundoscopy -> aetiology (DM, HPT)
Presentation
Mdm XXX is a (age)(race)(gender) who has a transplanted kidney and is on immunosuppressive therapy.
I say this because she has a J-shaped scar in her left iliac fossa, overlying a rounded mass x cm by x cm, non
tender and firm to touch. She also has evidence of immunosuppression with a characteristic rounded facies,
central obesity, violaceous abdominal striae, oral thrush, gum hypertrophy, bruising and thin skin.
Otherwise, on examination of her abdomen, there is no hepatosplenomegaly or ascites noted.
I looked for but was unable to find any signs suggestive of the aetiology of end stage renal failure such as
bilaterally enlarged ballotable kidneys and diabetic dermopathy.
Functionally, I note that she has a left arteriovenous fistula with a palpable thrill. There are no signs of recent
cannulation which suggests that the graft is functioning well. This is supported by the fact that she does not
have any evidence of uraemia. Her appearance is not sallow, there are no visible bruising or scratch marks and
there is no bilateral lower limb pitting oedema.
Discussion
Criteria for transplant
Surgical processes
Retrieving the doner kidney
o Structures removed = kidney, renal arteries, renal veins, ureter
o Kidney immersed in iced saline or Ringer’s lactate solution while being prepared for
implantation (cold ischemia time)
o Time between retrieval and perfusion of doner organ with cold preservation solution = 1st
warm ischemia time
Implantation
o Kidney transplanted heterotopically (cf transplanted heart, lung and liver which are
transplanted orthotopically)
o Anastomosis = renal vein to external iliac vein, renal artery to external iliac artery
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o If external iliac vessels too small to allow implantation e.g. paediatric pation -> aorta and IVC
used
o 2nd warm ischemia time = time taken to perform vascular anastomosis after removal from cold
perfusion solution
Location
o Usually in RIF/LIF
o Easy surgical/biopsy access
o Attached to femoral/common iliac vasculature
o Note that the original kidney is usually left in the abdominal cavity
Complications
Steroid toxicity
o Cosmetic effects
o Increased protein catabolism = proximal myopathy, paper thin skin
o Endocrine = HPT, DM, obesity, Addisonian crisis, menstrual irregularities
o Cardiovascular = premature coronary artery disease
o Bone = osteroperosis, aseptic necrosis
o Immunosuppression = opportunistic infections, lymphoma, SCC
o Others = gastritis, posterior subcapsular cataracts, steroid psychosis
Cyclosporin toxicity
o Hepatomegaly
o Hirsutism
o Hyperplastic gums
o Hypertension
o Hypercholesterolaemia
o Hyperkalaemia
o Hyperuricaemia
o Hypomagesaemia
o Haemolytic uraemia syndrome
o Osteoporosis
o Hiccupping
o Neurological
o Nephrotoxicity
o Neoplasia – lymphoproliferative
Graft rejection
o Acute or chronic -> falling urine output, rising creatinine levels
o P/E = tender graft, signs of fluid overload, presence of Tenchkoff/vascular catheter
o Invx = graft biopsy
Gradually increasing Cr level -> cyclosporine toxicity? Chronic rejection?
Influences management -> either stop cyclosporine or increase immunosuppression
Recurrence of GN = FSGS, IgA nephropathy, Goodpasture’s syndrome, MPGN, Alport’s
syndrome, HUS, TTP
Mx = methylprednisolone, monoclonal antibody, azathioprine
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Investigations
U/E/CR
o Rising creatinie trend (slightly elevated level is acceptable in patients on cyclosporine A
o Electrolyte disturbances
FBC
o Leucocytosis
Infection
Steroids (increased release of mature neutrophils from BM)
o Leucopenia
Azathioprine (dosing adjusted according to neutrophil count)
LFT (may be deranged with use of cyclosporine A and steroids)
Urine dipstick/UFEME/urine c/s
U/S Kidneys
Prognosis
2 year renal graft survival from LRDT -> 85% cadaveric transplant -> 70%
Poor prognostic indicators for post transplant survival
o Previous rejection
o Host vs Donor disease
o Delayed graft function -> usually presents with oliguria
o Hep B & C infection -> need to treat Hep C with interferon for a year before transplant is carried
out. Treatment not available for Hep B
o Paid donor transplant (e.g. China, India) -> due to higher rates of Hep B, Hep C and HIV
infections and tendency for over immunosuppression
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Medicine (Renal) = Approach to oliguria
You have been informed that a patient post TURP in the ward has only passed 10ml today
DDX: Oliguria vs Catheter related problems
Blockage
o Kinking of tubing
o Clot/tissue fragments – esp post TURP or TURBT
o Sediment/stones –esp with chronic IDC
Malpositioning
Questions
1. Is the patient stable?
a. Oliguria may indicate patient in shock/impending shock/malignant HTN
2. Is the catheter draining? How has the urine output been?
a. If progressive less U/O -> may be oliguria
b. If sudden -> most likely cath blocked
3. Is there any haematuria/clots?
a. Clot blocking catheter
4. Is there any pain?
a. Peritonitis
b. Bladder distension with obstruction
c. Bladder spasm
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Medicine (Renal) = Approach to Proteinuria
Introduction
normal protein excretion is < 150 mg/day
earliest sign microalbuminuria (30-300 mg/day)
types of proteinuria
(a) glomerular proteinuria = mostly albumin and detected on urine dipstick
severity correlates with renal prognosis (cf haematuria)
(b) tubular proteinuria = LMW proteins (2-microglobulin, Ig light chains)
decreased proximal tubular reabsorption leads to increased excretion
not detectable by urine dipstick require 24hr UTP
(c) overflow proteinuria = overproduction of Ig light chains in multiple myeloma
exceeds proximal tubular reabsorptive capacity
excreted Ig light chains are also toxic to tubules further decreases reabsorption
not detectable by urine dipstick require 24hr UTP
Causes of proteinuria
V = hypertension
Henoch-Scholein purpura
I = urinary tract infection
Ig A nephropathy, post-streptococcal GN
T = drug-induced
A = SLE
M = diabetes
I = amyloidosis
N = multiple myeloma (UTP +ve, dipstick –ve)
lymphoma
Others = orthostatic proteinuria, fever, exercise
History-taking
name/age/ethnicity/gender/occupation
past medical history
date of admission
Presenting complaint
Presentation
- positive dipstick result
- frothy urine
- haematuria
- lower limb oedema (r/o CCF, CLD, protein-losing enteropathy and malnutrition)
Aetiology
(a) Vascular = purpuric rash in childhood (HSP)
(b) Infective
urinary tract infection
- frequency, urgency, nocturia
- haematuria, dysuria, urethral discharge
- hesitancy, intermittent and weak stream, double voiding, terminal dribbling
- loin to groin pain, nausea, vomiting, diarrhoea
history of Hep B/C infection
recent fever, URTI and GE
(c) Drug-induced = TCM, NSAIDs, captopril, gold, penicillamine
(d) Autoimmune = rash, joint pain and swelling
(e) Metabolic = history of DM and symptoms of hyperglycaemia
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(f) Neoplasia = back pain, LOA, LOW, fatigue, fever
Complications
- oliguria
- lower limb oedema, abdominal distension, dyspnoea, facial oedema
- hypertension
Systemic review
Management
Drug history
drug allergies
current medications
gold and penicillamine secondary membranous GN
NSAIDs and penicillin allergic interstitial nephritis
Social history
Family history
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Investigations
Urine
urine dipstick = proteinuria, haematuria, glycosuria
UFEME
urine phase contrast microscopy = dysmorphic/isomorphic RBC
urine c/s (mid-stream catch) = UTI
24hr UTP/CCT or urine PCR = nephrotic syndrome
Bloods
FBC = anaemia/leucopenia/thrombocytopenia (SLE)
U/E/Cr = renal impairment
Ca/PO4/Mg = renal impairment
LFT = hypoalbuminaemia
ESR and CRP
Hepatitis screen = HBsAg, HBeAg, anti-HCV Ig G
AI screen = anti-ds DNA, ANA, C3/C4, anti-GBM, ANCA
fasting glucose and HbA1c = diabetes
myeloma screen (for those > 45 yrs old) = serum and urine protein electropheresis
Others
Renal U/S
Renal biopsy
Management
orthostatic proteinuria (a/w upright position and in adolescents) = good renal prognosis
no follow-up required
intermittent isolated proteinuria (a/w stress and exercise) = favourable prognosis
follow-up till proteinuria resolves
persistent isolated proteinuria = follow-up indefinitely with monitoring of BP and U/E/Cr
combined microscopic haematuria and proteinuria = most common presentation of GN (esp Ig A
nephropathy)
fluid overload = fluid restriction
low-salt and protein diet
strict I/O charting with daily albusticks and weights
monitor vitals q4hrly
diuretic therapy (PO Lasix 40mg OM with PO Span K 0.6mg OM)
ACE inhibitors/ARB (PO Losartan 25mg OM)
386
Medicine (Renal) = Haematuria
Introduction
Microscopic haematuria (≥3 RBC/hpf) should undergo evaluation to exclude renal or urinary tract
pathology
Evaluate for presence of
o Proteinuria = 24hr urinary protein, urine PCR
o Hypertension = BP
o Renal impairment = U/E/Cr
Differentials
o Medications = ibuprofen, nitrofuratoin, chloroquine, rifampicin
o Food dye = beets, food colouring
o Metabolites = bile, porphyria, urate, tyrosinosis
Causes of haematuria
Renal – microscopic haematuria
Vascular = Henoch-Scholein purpura, Wegener’s granulomatosis, Goodpasture’s syndrome
Infective = post-streptococcal GN, Ig A nephropathy, UTI
Trauma = blunt abdominal trauma
Autoimmune = SLE
Neoplasia = renal cell carcinoma
Familial = adult polycystic kidney disease (APKD), thin BM disease, Alport’s syndrome (X-linked)
Systemic
Bleeding diasthesis = thrombocytopenia
HISTORY
Name/age/ethnicity/gender/occupation
Past medical history
Drug allergy
Date of admission
Presenting complaint
Haematuria
o Microscopic = cloudy/smoky
o Gross = Beginning of flow (urethra)
End of flow (bladder)
Throughout flow (renal)
o Present every time
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o Presence of blood clots
o Amount of blood loss symptomatic anemia (pallor, exertional chest pain, palpitations, SOB,
giddiness, fatigue)
o Painful/painless (dysuria, flank/loin pain)
Proteinuria = frothy urine
Renal impairment = amount of urine (oliguria, polyuria)
Fluid overload (lower limb oedema, abdominal distension, dyspnoea, facial oedema)
Aetiology
Renal
o Vascular = purpuric rash over lower limbs, lower limb oedema, joint pain, abdominal pain (HSP)
Haemoptysis (Goodpasture’s syndrome)
o Infective = recent fever and URTI (post-streptococcal GN)
Ongoing fever and URTI/GE (IgA nephropathy)
o Autoimmune = history of SLE
Rash, joint pain and swelling
o Neoplasia = fever, flank pain, palpable abdominal mass (RCC)
o Familial = personal and family history of APKD
History of deafness (Alport’s syndrome)
Urinary tract
o History of TB
o Infective/stones = frequency, urgency, nocturia, dysuria, urethral discharge, obstructive
symptoms,
loin to groin pain, fever, nausea, vomiting, diarrhea
o History of trauma = history of urinary catheterisation, flexible cystoscopy, TURP
o Tumour = LOA, LOW, fatigue, back pain
Systemic
o Bleeding diasthesis = gum bleeding, epitaxis, menorrhagia, easy bruising
Systemic review
Management
Menstrual history
Last menstrual period could be menstrual blood
Drug history
Drug allergies
Current medications = penicillamine, rifampicin, hydralazine
Anticoagulants = TCM, NSAIDs, warfarin, aspirin
Social history
Family history
388
Adult polycystic kidney disease
Hypertension
Renal disease
Deafness (Alport’s syndrome)
Urolithiasis
Physical examination
Skin = purpuric rash, digital vasculitis
Mouth = injected pharynx, tonsillitis
Fluid overload = raised JVP, lower limb oedema, hepatomegaly, bibasal inspiratory crepitations
Enlarged ballotable kidneys
PR = prostate enlargement
Vitals = temperature, BP
Investigations
Urine
Urine dipstick = proteinuria, haematuria
UFEME
Urine phase constrast microscopy
o Predominantly dysmorphic glomerular origin
o Predominantly isomorphic or mixed isomorphic/dysmorphic urinary tract origin
Urinary c/s = rule out UTI
Bloods
FBC = WCC (UTI)
Hb (anemia)
Platelet (thrombocytopenia)
U/E/Cr = renal impairment
Glomerular origin
24hr UTP/CCT or urine PCR if urine dipstick ≥ 2+ proteinuria
ESR, CRP
AI screen = anti-ds DNA, ANA, C3/C4, ANCA, anti-GBM Ab
Renal U/S = polycystic kidneys, RCC
Renal biopsy = glomerulonephritis
Non-glomerular origin
KUB
U/S or CT KUB (without constrast)
IVU
Urine cytology
Flexible cystourethroscopy
389
Medicine (Renal) = Glomerulonephritis
Glomerulus
consists of an anastomosing network of capillaries invested by 2 layers of epithelium
(a) visceral epithelium incorporated into and part of the glomerular capillary wall
(b) parietal epithelium lines Bowman’s space
glomerular capillary wall is the filtering membrane
(a) fenestrated endothelium of capillaries
(b) glomerular basement membrane
- negatively-charged layer prevent charged solutes from passing through e.g. proteins
- intersecting fibres limit size of solutes passing through
(c) epithelial slits of visceral podocyte epithelium
- foot processes (pedicels) interdigitate to form filtration slits
glomerular tuft supported by mesangial cells lying between capillaries = contractile
synthesize collagen and ECM
allows for plasma ultrafiltration high permeability to water and small solutes
impermeable to large and charged solutes
charges on GBM changes in diseased states proteinuria
Glomerular diseases
2nd leading cause of ESRF accounts for 1/3 of cases
leading cause is diabetic nephropathy
hallmarks of glomerular disease = haematuria and proteinuria (HPT, renal impairment, oedema)
major clinical syndromes = isolated microscopic/gross haematuria
isolated proteinuria
asymptomatic haematuria and proteinuria
acute nephritic syndrome
nephrotic syndrome
nephritic-nephrotic syndrome
rapidly progressive GN (acute nephritis that results in rapid loss of renal function
over
weeks to months Goodpasture and Wegener’s)
principles of treatment
(a) acute/immunological phase (immune complexes/cytokine/antibody-mediated injury) =
immunosuppressants
(b) chronic phase (injury due to glomerular hyperfiltration proteinuria, HPT, azotemia)
- ACE inhibitors/ARB = blocks angiotensin-2 mediated vasoconstriction of efferent arteriole
- dietary protein restriction = reduces macromolecular traffic and afferent arteriolar vasodilatation
reduces intra-glomerular HPT and glomerular hyperfiltration less
endothelial
cell and platelet damage
- dipyridamole and warfarin = reduces intra-glomerular coagulation
390
(c) toxins = NSAIDs, captopril, gold, penicillamine, TCM
(d) autoimmune = SLE, Goodpasture syndrome
(e) metabolic = DM
(f) infiltrative = amyloidosis
(g) neoplasia = multiple myeloma, lymphoma
(h) hereditary disorders = Alport syndrome, Fabry disease
Nephrotic syndrome
Focal segmental GS
pathogenesis
~ primary (idiopathic)
~ secondary = reflux nephropathy, Ig A nephropathy, Alport’s syndrome, neoplasia, HIV, drugs
LM sclerosis affecting some but not all glomeruli (i.e. focal)
involves only segments of each glomeruli (i.e. segmental)
foam cells (monocytes filled with lipid)
increased mesangial matrix
hyalinosis (deposition of hyaline masses)
FM granular pattern of Ig M and C3
EM loss of visceral epithelial foot processes
epithelial cell detachment from GBM
clinical features = non-selective proteinuria
higher incidence of microscopic haematuria and hypertension (> 50% each)
50% progress to ESRF within 10 years of diagnosis if left untreated
recurs in 50% of renal-transplant patients (highest rate)
391
poor response to steroid therapy
Tx = high-dose prednisolone
cyclophosphamide/cyclosporin A (latter preferred as 2nd-line therapy)
mycophenolate mofetil
tacrolimus
plasmapheresis (but results are disappointing)
Membranous GN
pathogenesis
~ primary membranous GN in-situ immune complexes
~ secondary membranous GN circulating immune complexes
causes = idiopathic (85%)
infective, drugs (gold, penicillamine, NSAIDs), SLE, neoplasia
LM enlarged glomeruli but normocellular (no proliferation)
diffuse thickening of GBM
multiple projections from GBM forming spikes (close over deposits to incorporate them)
FM granular pattern of Ig G and C3
EM subepithelial electron-dense deposits
loss of visceral epithelial foot processes
clinical features = non-selective proteinuria
may not respond to steroid therapy
Membrano-proliferative GN
pathogenesis
(a) Type 1 MPGN = presents as nephrotic syndrome
- due to circulating immune complexes
- associated with Hepatitis B/C infection and SLE
(b) Type 2 MPGN = presents as either nephrotic or nephritic syndromes
- due to circulating immunoglobulin (C3 nephritic factor)
- C3 nephritic factor reacts with C3 convertase activates alternative complement pathway
- lab findings = low serum C3 levels
LM large glomeruli with proliferation of mesangial cells
thickened GBM (double-contour BM)
FM type 1 MPGN = granular pattern of C3 and Ig G
type 2 MPGN = granular pattern of C3 (no Ig G)
EM type 1 MPGN = subendothelial electron-dense deposits
type 2 MPGN = subendothelial extremely electron-dense deposits dense-deposit disease
poor prognosis = no complete remission
50% progress to ESRF
type 2 MPGN has a worse prognosis and recurs in renal transplant patients
Clinical Histological
severity of proteinuria chronic tubulo-interstitial fibrosis
renal impairment extensive crescents (> 30-50%)
mean arterial pressure advanced glomerulosclerosis (>
(hypertension) 20%)
medial hypertrophy of arterioles
393
(c) some degree of oliguria and azotemia
(d) mild proteinuria and oedema not as marked as in nephrotic syndrome
pathogenesis
- inflammation capillary wall damage haematuria and reduction in GFR
- reduced GFR oliguria and sodium retention increased plasma volume decreased renin
activity
- HPT, raised JVP, hepatomegaly
causes = primary glomerular causes Ig A nephropathy
secondary causes V (HSP, PAN, Wegener’s granulocytosis)
I (Hep B, Hep C, post-streptococcal GN)
T (penicillamine)
A (SLE, Goodpasture’s syndrome)
management
- monitor vitals q4hrly (esp BP)
- fluid restriction in oliguric patients
- low-salt diet
- protein restriction in uraemic patients
- strict I/O charting
- daily weights
- diuretics and anti-hypertensives in mild-moderate HPT
394
(g) drugs = penicillamine, rifampicin, hydralazine
Gross pathology = kidneys are enlarged and pale
petechial haemorrhages on the cortical surfaces
glomeruli may show focal necrosis and thrombosis
LM presence of crescents (proliferation of parietal epithelial cells and leukocyte infiltration in
Bowman’s
space)
crescents eventually obliterate Bowman’s space and compress the glomeruli scarring
EM subepithelial electron-dense deposits
distinct ruptures in GBM
clinical features = loin pain, haematuria, oliguria, non-specific symptoms (malaise, LOA, fever)
death may result from renal failure if untreated
management = methylprednisolone pulse, high-dose corticosteroids,
cyclophosphamide/cyclosporin A,
plasmapheresis, dialysis, renal transplant
must be treated aggressively! (delay in diagnosis and treatment increases risk of
ESRF)
poor prognosis = esp if initial serum Cr > 600
may be related to the number of crescents
395
Medicine (Renal) = DGIM Renal Transplant
ESRD
50% are due to diabetes – patients are usually not suitable for transplant due to comorbidities
other 50% due to other causes suitable for transplant – patients usually do better, have lower mortality and is
cheaper to treat
ESRD
396
Management pathway for transplant recipient
397
Medicine (GIT) = Hepatosplenomegaly
Causes
Vascular Chronic liver disease with portal hypertension
Viral (hepatitis, IMS, CMV)
Infective
Protozoal (malaria)
Trauma Haematoma
SLE
Autoimmune
RA
Storage disorders (Gaucher = type 1 subtype; Niemann-
Metabolic
Pick)
Amyloidosis
Infiltrative
Sarcoidosis
Myeloproliferative disorders
Neoplastic Lymphoma
Lymphoproliferative disorders
Chronic haemolytic anaemia (spherocytosis, G6PD
Haematological
deficiency, thalessemia)
-thalessemia major
Short stature
Hyperpigmented
Overall
Thalessemic facies (frontal bossing, flat nosebridge,
maxillary hyperplasia)
Looks younger for age
Pituitary haemosiderosis Hypopigmented areolae
Loss of axillary hair
JVP v wave
Cardiac haemosiderosis Pulsatile liver
Lower limb edema
Hypocount marks on fingers
Pancreatic haemosiderosis
Diabetic dermopathy
Intervention Splenectomy
Request Gonadal examination
398
Medicine (Respi) = General Approach to a History of Shortness of Breath
Differentials
Cardiac
Respiratory
Anemia
Psychological
System Subset Question
Cardiac Any chest pain? Character?
Any PND?
Any Orthorpnoea?
Leg swelling?
Respiratory Parenchyma Cough?
Phlegm?
Haemoptysis?
Fever?
Airway Wheeze?
Stridor?
Pleura Trauma?
Acute pain followed by SOB?
Vasculature Prolonged immobility?
Haematological Anemia Palpitations
Giddiness / Light headedness
Bleeding – PR, Menses
Neuromuscular Generalised weakness?
Psychological Hyperventilation Association with certain situations
Tingling in hands / feet?
Cramps?
Severity
NYHA Score / Effort Tolerance
Impact on ADL
399
Medicine (Respi) = Acute Respiratory Distress Syndrome (ARDS)
Definition
Clinical syndrome characterised by acute onset of respiratory distress either caused by direct lung
injury or secondary to severe systemic illness
worst end of the spectrum for acute lung injury
Criteria for diagnosis
1. Acute onset
2. Bilateral infiltrates on CXR
3. P/F ratio < 200 [P/F ratio < 300 = acute lung injury]
4. Exclude left heart failure
Mortality of ARDS ~ 30-50%
Aetiology
Pathogenesis
due to diffuse alveolar damage (epithelial endothelial damage)
lungs particularly vulnerable to inflammatory injury = mediators released into bloodstream and
lungs receive entire cardiac output
pathology = hyaline membrane formation
increased capillary permeability and oedema
interstitial inflammation and fibrosis
damage to type 2 pneumocytes (surfactant abnormalities and alveolar collapse)
results in hypoxia due to V/Q mis-match and reduced lung compliance
3 stages
1. Exudative stage (0 – 7 days)
- capillary congestion, oedema (increased permeability) and haemorrhage
2. Proliferative stage (1 – 3 weeks)
- proliferation of interstitial fibroblasts and type 2 pneumocytes to replace sloughed type 1 cells
3. Resolution
- diffuse interstitial fibrosis interspersed with dilated distorted air spaces (honeycomb lung)
Complications
Reduction in lung compliance (stiff lungs) = diffuse interstitial fibrosis
Respiratory failure = V/Q mismatch
Pulmonary hypertension = hypoxic vasoconstriction
vascular compression by positive airway pressure
lung parenchymal destruction
Cor pulmonale = rare but associated with increased mortality if present
Death
400
Clinical features
History
- Acute onset of breathlessness
Physical examination
- Cyanosis
- Tachypnoea
- Bilateral fine end-inspiratory crepitations
Investigations
FBC
U/E/Cr
LFT
PT/PTT
CRP
ABG
Bld c/s
Amylase
CXR
- diffuse bilateral fluffy alveolar infiltrates with prominent air bronchograms
- absence of heart failure
Pulmonary artery catheter to measure pulmonary capillary wedge pressure
Management
Admit to ICU
Respiratory support = mechanical ventilation
Rescue therapy
- Recruitment of alveoli = PEEP
- Prone positioning
- High frequency ventilation
Circulatory support = haemodynamic monitoring, inotropic support, vasodilators, blood
Treat underlying cause e.g. sepsis
401
Medicine (Respi) = Systemic approach to CXR
”This is the erect AP/PA chest x-ray of Mr/Mdm ______ taken on the_____..”
“The quality of the film is good = with no rotation, good penetration and taken on full inspiration.”
3. Mediastinum
trachea = should lie in the mid-line
- comment on the presence of ETT
- pushed away by large pleural effusion, pneumothorax, mediastinal mass or tumour
- pulled by lung collapse or fibrosis
thin and slender mediastinum = COPD
4. Hilum
characteristics = mostly formed by the pulmonary arteries with the upper lobe veins superimposed
left hilum is higher than the right
hilar enlargement = lymphadenopathy, large pulmonary artery
5. Heart
characteristics = straddles mid-line with 1/3 to the right and 2/3 to the left
right heart border formed by right atrium; left heart border by left ventricle
transthoracic diameter → widest diameter above the costophrenic angles
cardiac diameter → draw a vertical line from the trachea to the heart (assuming no
deviation)
sum of the 2 greatest lengths from the vertical line to both heart
borders
- cardiomegaly = cardiothoracic diameter > 50%
6. Diaphragm
characteristics = right hemidiaphragm should be higher than the left
loss of costophrenic angle with meniscus = pleural effusion
loss of diaphragmatic outline = lower lobe consolidation
low and flat hemidiaphragms = COPD
air below the diaphragm = free peritoneal gas (likely perforation)
402
7. Lung fields
division = apices → lie above the level of the clavicles
upper zone → include the apices to the level of the 2nd costal cartilage
middle zone → lie between 2nd and 4th costal cartilage
lower zone → lie between 4th and 6th costal cartilage
loss of cardiac silhouette middle lobe consolidation
increased translucency hyperinflation
The heart
lateral film
- posterior border of heart shadow made up of left ventricle
- anterior border of heart shadow made up of right ventricle
- mitral/aortic valve = draw imaginary line from apex of heart to hilum
# above line aortic
# below line mitral
Lung collapse
PA film
(a) lung fields smaller on the side of collapse
(b) elevation of hemidiaphragms left may be higher than the right if there is left lung collapse
(c) horizontal fissure (runs from centre of right hilum to level of 6th rib in the axillary line) pulled up
in right
upper lobe collapse; pulled down in lower lobe collapse
(d) mediastinal deviation heart should straddle midline with 1/3 to the right and 2/3 to the left
(e) heart borders blurring of right heart border (right middle lobe collapse)
blurring of left heart border (lingular collapse)
(f) tracheal deviation
lateral film
(a) displacement of horizontal and oblique fissures
Consolidation
radiological features
(a) heterogenous shadowing = gets denser and more clearly demarcated at lower border (fluid sinks)
(b) air bronchogram
(c) demarcated by horizontal fissure in right upper lobe pneumonia
Coin lesion
discrete opacity situated within a lung field
causes
(a) benign tumour = hamartoma
(b) malignant tumour = bronchial carcinoma, single secondary
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(c) infection = pneumonia, abscess, TB, hydatid cyst
(d) rheumatoid nodule
description
- location
- edges = speculated/irregular/lobulated edge malignancy
well-circumscribed benign
- nature of shadowing = if centre darker than periphery cavitation
- calcification (present unlikely malignant)
- air bronchogram
- air-fluid level
- other coin lesions (likely mets)
- mediastinal LAD or bone mets
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Bronchiectasis
ring shadows
- ‘bunches of grapes’ appearance
- represent diseased bronchi seen end on
tramline shadows
- seen at lung peripheries
- consists of 2 thick white parallel lines
separated by black
- represent diseased bronchi seen side on
tubular shadows
- solid thick white shadows
- represent bronchi filled with secretions
seen side on
glove finger shadows
- represent group of tubular shadows seen
end on
Pulmonary fibrosis
radiological features
(a) fine reticulonodular shadows
extending into axillary aspect of
each hemithorax
(b) decrease in lung volume
(c) early ground-glass appearance
late honeycomb appearance
(d) mediastinal shift towards
shadowing
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Medicine (Respi) = Lung Cancer
Epidemiology
most common cancer in Singaporean males
2nd most common cancer in Singaporean females
very strong association with cigarette smoking
Risk factors
1. Smoking
- increases risk by 10-30x
- pathogenesis = genetic damage squamous metaplasia dysplasia CIS invasive
- cessation of smoking es risk = drops to 2x the risk of a non-smoker if abstain for 10-15 years
- passive smoking doubles the risk of lung cancer
- a/w small cell lung carcinoma and squamous cell carcinoma
2. Genetic predisposition
- cyt p450 polymorphism increased metabolism of pro-carcinogens higher risk
- p53 mutation
3. Occupational factors
- radioactive materials
- asbestos
- arsenic
Classification
Primary lung cancer usually a single lesion
- Small cell (oat-cell) carcinoma
- Non small cell carcinoma = squamous cell carcinoma
adenocarcinoma (most common)
bronchioalveolar carcinoma
large cell anaplastic carcinoma
Secondary lung cancer metastasis
- more common than primary lung cancer
- usually multiple, well-circumscribed “cannonball” lesions on CXR
- exhibit characteristics of primary tumour e.g. mucin-producing GIT tumour
Histological subtypes
1. Small cell carcinoma (20%)
- most aggressive
- metastasise widely very early due to rapid growth
- surgically incurable mets present at time of presentation
- sensitive to chemo/RT
- derived from neuroendocrine cells Kulchitsky cells
- paraneoplastic syndrome ADH (SIADH), ACTH (Cushing’s syndrome)
Clinical features
History
- presenting complaint = chronic productive cough, haemoptysis, dyspnoea, pleuritic chest pain,
hoarseness
- constitutional symptoms = fever, LOA, LOW, fatigue, night sweats
- local effects = dysphagia
- metastasis = bone pain, jaundice, confusion, seizures, focal neurological deficits
- paraneoplastic syndromes = hypercalcaemia (constipation, renal/ureteric colic)
HPOA (pain around UL/LL joints)
Physical examination
- General appearance = cachexia
- Hands = clubbing
tar stains
palmar crease pallor
wasting of intrinsic muscles and weakness of finger abduction (Pancoast tumour)
hypertrophic pulmonary osteoarthropathy
- Head and neck = ipsilateral Horner’s syndrome (Pancoast tumour)
conjunctival pallor
supraclavicular or axillary lymphadenopathy
SVCO (Pancoast tumour)
hoarse voice (RLN palsy)
- Lungs = localised and fixed monophasic wheeze
malignant effusion
consolidation collapse
- CVS = pericardial effusion (soft heart sounds)
- Metastasis = bony tenderness
hepatomegaly
neurological examination
- Paraneoplastic phenomenon = pigmentation of palmar creases
gynaecomastia
cerebellar syndrome
peripheral neuropathy
proximal myopathy
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Complications
Local growth and spread
(a) Bronchial obstruction bronchiectasis, lobar collapse, pneumonia
(b) Erosion of vessels haemoptysis
(c) Parapneumonic pleural effusion
(d) Rib destruction
(e) Dysphagia (oesophageal involvement)
(f) Cardiac involvement pericardial effusion, pericarditis, tamponade
(g) Pancoast tumour compression of lower brachial plexus (C8, T1)
ipsilateral Horner’s syndrome
SVCO
(h) Hoarseness (recurrent laryngeal nerve involvement or vocal cord invasion)
(i) Hemidiaphragmatic palsy (phrenic nerve involvement)
Metastasis
(a) Lymphatic spread to regional LN
(b) Haematogenous spread to distant organs brain, bone, liver, adrenals
(c) Transcoelemic spread to pleural space
Paraneoplastic syndrome
# clinical syndrome due to ectopic production of humoral substances from a malignancy of non-
endocrine origin
(a) Endocrine = ACTH Cushing’s syndrome
ADH SIADH
pTH related-peptide hypercalcaemia
hCG gynaecomastia
(b) Neuromuscular = cerebellar degeneration
peripheral neuropathy
proximal myopathy
Lambert Eaton myasthenic syndrome
(c) Connective tissue = clubbing, HPOA, scleroderma, dermatomyositis, acanthosis nigricans
(d) Haematological = polycythaemia, anaemia, DIVC
(e) Vascular = migratory thrombophlebitis (Trousseau’s syndrome)
Investigations
Bloods
1. FBC = Hb (NCNC anaemia)
2. U/E/Cr = hyponatraemia (SIADH)
3. Ca/PO4/Mg and serum acid phosphatase = hypercalcaemia
bone metastasis
4. LFT = liver metastasis
Imaging
1. CXR = primary or secondary lung carcinoma
location
complications (pleural effusion, consolidation, collapse, bony secondaries)
hilar LAD
# If pleural effusion present thoracocentesis or chest tube insertion
- drain before doing CT
- send fluid for = gram staining, culture/sensitivity, AFB, TB culture, cytology
2. CT thorax = determine exact location and features of lung ca
staging (LN involvement, local spread, distal mets)
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3. Bronchoscopy = direct visualisation
tissue biopsy
assess operability (inoperable if tumour is within first 2 cm of either bronchus as it
does not allow for sufficient resection margins or
pneumonectomy)
4. Video-assisted thoracoscopy = therapeutic (if need to drain pleural effusion)
direct visualisation of adenoca or bronchioalveolar ca
pleural biopsy
TNM Staging
Primary tumor (T)
TX = malignant cells in bronchial secretions, no other evidence of tumour
Tis = carcinoma in situ
T0 = none evident
T1 = < 3cm in size, in lobar or more distal airway
T2 = > 3cm in size and > 2cm distal to carina
or any size if pleural involvement/obstructive pneumonitis extending to hilum but not all the lung
T3 = < 2cm from, but not at carina
or involves the chest wall, diaphragm, mediastinal pleura, pericardium
T4 = involves the mediastinum, heart, great vessels, trachea, oesophagus, vertebral body, carina or a
malignant effusion is present
Regional nodes (N)
N0 = none involved (after mediastinoscopy)
N1 = peribronchial and / or ipsilateral hilum
N2 = ipsilateral mediastinum or subcarinal
N3 = contralateral mediastinum or hilum, scalene or supraclavicular
Management
Non small cell lung cancer
1. Surgery = lobectomy and pneumonectomy
- excision is the treatment of choice for peripheral tumours with no metastatic spread
- contraindications = metastatic carcinoma
malignant pleural effusion
FEV1 < 1.5 L
severe pulmonary hypertension
uncontrolled cardiac arrhythmias
recent AMI
- neoadjuvant chemotherapy can downstage tumour shrink to operable size
2. Radiotherapy
- alternative for patients with inadequate respiratory reserve
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- S/E = radiation pneumonitis
pulmonary fibrosis
Palliation
1. Radiotherapy = bronchial obstruction
SVC obstruction
haemoptysis
dysphagia
bone pain
cerebral mets
2. Pleural drainage = cope loop, chest tube, pleurodesis
3. Pain relief = morphine
4. Discuss end of life issues = comfort measures / intensive resuscitation
Prognosis
Overall 5-year survival = < 15%
Non small cell without mets = 50% 2yr survival
Non small cell with mets = 10% 2 yr survival
Small cell (treated) = 1 year median survival
(untreated) = 3 months median survival
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Medicine (Respi) = Infections – Tuberculosis
Principles of Diagnosis
Know when to suspect tuberculosis.
Know how to make/confirm a diagnosis of tuberculosis on clinical, radiological and bacteriological grounds.
Principles of Management
Explain the basic principles of TB treatment, including the role of DOT, drug resistance.
Describe the common drugs required for treatment of TB including their significant adverse effects.
Describe how to monitor response to treatment.
Prevention
Discuss the public health aspects of Tuberculosis (including the basic principles of TB control), contact tracing,
treatment of latent TB.
Outline the pathogenesis of TB ie TB infection, TB disease, TB relapse.
Outline the protective effect of BCG and the use of the mantoux test.
Describe the basic epidemiology of TB in Singapore and globally.
Epidemiology
Communicable disease
Causes 6% of deaths worldwide, making it the most common cause of death from a single infectious
agent (WHO)
Developing countries
Incidence is increasing in developed countries as well, due to increasing prevalence of AIDS (most
impt risk factor for devpmt of TB) and migration
Common in poverty stricken, overcrowded areas, malnutrition
Common in those with chronic illnesses eg. DM, chronic lung disease, elderly or immunocompromised
(AIDS)
Notifiable disease
Aetiology
Mycobacterium tuberculosis (M. bovis from unpasteurised cows’milk is rare)
Transmission: direct person-to-person transmission via airborne droplets from an active case
(latent disease is not transmissible unless it reactivates in times of immsuppression)
Pathogenesis:
- Mycobacterium enter macrophages inhibit microbicidal activity uncontrolled proliferation of
mycobacterium bacteremia and seeding of multiple sites
- Recruitment of monocytes which differentiate into epithelioid histiocytes that characterise the
granulomatous response
- Also results in delayed type tissue hypersensitivity (T lymphocytes)
Pathology
Primary tuberculosis
- Develops in previously unsensitised individuals
- Elderly persons may lose their sensitivity to MTB and hence develop primary TB more than once
- Source of organism is exogenous
- Bacilli deposit near the pleura proliferate in macrophages form tubercles with caseous necrosis
(Ghon focus)
- Bacilli drain to the regional LN which also undergo caseous necrosis
(Ghon complex = parenchymal lesion + nodal involvement)
- Effective cell-mediated immune (CMI) response develops two to six weeks after infection
- Failure to develop CMI results in progressive destruction of the lung progressive primary TB
Complications
1. Foci of scarring may harbour viable bacilli for years, and thus be the nidus of reactivation in times
of immunosuppression
2. Progressive primary tuberculosis: disease develops without interruption in immunocompromised
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individuals eg. AIDS patients with CD4+ counts <200/mm3
- Inability to mount immunological reaction to contain the primary focus
- Absence of characteristic caseating granulomas (non-reactive TB)
- Miliary TB: multiple tubercles evenly distributed thru’out the lung
Latent TB
- Stage inbetween primary and reactivation TB
Complications
1. Progressive pulmonary tuberculosis: apical lesion enlarges, erodes into surrounding tissue
- Erosion into bronchus creates a ragged irregular cavity
- Erosion of bld vessels leads to hemoptysis
- Dissemination by blood or lymphatics
2. Miliary pulmonary disease
3. Pleural involvement: effusions, tuberculous empyema or obliterative fibrous pleuritis
4. Lymphadenitis: the most common form of extrapulmonary TB
- Typically occurs in the cervical region (“scrofula”)
5. Endobronchial, endotracheal and laryngeal TB
6. Intestinal tuberculosis
7. Pott disease: TB abscesses in the vertebrae (may spread along tissue planes to form “cold abscesses”
which present as a pelvic lump
8. Systemic military tuberculosis
- Hematogenous spread to other organs esp liver, bone marrow, spleen, meninges, adrenals,
kidneys fatal without treatment
Clinical features
History
- Symptoms: low grade remitting fever, lassitude, anorexia, night sweats, chronic cough, hemoptysis,
pleuritic chest pain, erythema nodosum
- Symptoms of compression by lymph nodes eg. monophonic wheeze, bronchiectasis, lung collapse
- Symptoms of affected organ systems eg. Headaches and seizures for TB meningitis, paraplegia for Pott
disease
- Risk factors: contact/travel history, crowded living conditions, HIV/immunocompromise
Physical examination
- Consolidation in apices is possible
- Effusion
- Wheeze if there is compression
Investigations
CXR
- cavitation in the apices of the lung
- calcification
- reticulonodular shadowing (for military TB)
- fibrosis ("scarring") with traction
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- enlargement of hilar and mediastinal lymph nodes
- cavity with aspergilloma: air crescent sign
(CXR does not give indication of the activity of the disease; is not diagnostic)
FBC
LFT
CRP
Sputum AFB smear: MTB binds to Ziehl-Neelson stain and resists decolorisation (acid fast)
- positive AFB smear makes a presumptive diagnosis of TB in a high-risk patient, although a positive
stained smear is not specific for M. Tuberculosis
- 50% of AFB positive locals have MOTT (Mycobacteria other than TB)
- most AFB positive foreign workers have MTB
- if the patient is not able to produce sputum, sputum induction with nebulized, hypertonic 3% saline in
a negative-pressure isolation room is an alternative before more invasive procedures (bronchoscopy)
Sputum culture is the gold standard (culture on Lowenstein Jensen media requires 12 wks; PCR can
provide faster results) * only culture can provide info on drug sensitivity
Early morning gastric aspiration: most useful in young children where sputum is more difficult to
obtain, and is best performed following at least nine hours of fasting
Nucleic acid amplification tests (NAAT), can provide rapid diagnostic information to the clinician,
generally within 24 to 72 hours
Tuberculin skin test: TB antigen is injected intradermally and the cell mediated response at 48-72 hrs
is recorded. A positive test indicates that the patient has immunity (ie, previously exposed or
vaccinated) A strong positive test suggests active disease. False negatives occur in
immunosuppression eg. Miliary TB, AIDS
In HIV patients, atypical features include sputum smear negative for AFB, false negative tuberculin test
cos of tuberculin anergy, lack of granulomas in tissues
Management
- Notify CDC, refer to TBCU
- Contact tracing
- Advise HIV testing
- Isolation while infectious
- Ishihara colour vision testing before initiating therapy with ethambutol
- Give anti-TB drugs (directly observed therapy to improve compliance) + monitor liver function
- Monitor CXR weekly during treatment, monthly sputum AFB smear and cultures till two consecutive
negative cultures
- Most persons diagnosed with TB are begun on specific treatment before the diagnosis is confirmed by
the laboratory
TB drugs
Aims of therapy
- Successful treatment requires more than one drug to which the organisms are susceptible
- Sufficient dose
- Sufficient duration
- Compliance DOT (polyclinic DOT)
TB drugs
- First line: Isoniazid (H), Rifampicin (R), Pyrazinamide (Z), Ethambutol (E), Streptomycin (S), Amikacin,
Kanamycin
- Pyridoxine is given to reduce peripheral neuropathy induced by isoniazid
- Pyrazinamide is given for the first two months to kill intracellular bacilli
- 6 month treatment
- Titrate according to body weight
- Initial drug regimen is based on knowledge of the likely drug susceptibility.
- Four drugs are used in the initial phase of treatment when the total duration of treatment is six
months, because of the high incidence of isoniazid-resistant organisms in most communities.
- Usually RHZ or RHEZ
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Drug resistant TB
Initial drug regimens need to be modified in areas with a known high prevalence of MDR-TB
Development of drug resistance after initial drug sensitivity (secondary drug resistance) occurs in
patients who do not comply with treatment regimens, occurs mainly in HIV patients
Nosocomial transmission significant
Use 4 drugs, treat for 2 years
Follow up for 1 year after eradication
Second line drugs: Ofloxacin, Ciprofloxacin, Cycloserine, Ethionamide, Azithromycin
TB and HIV
TB in an HIV patient is an AIDS defining condition
4 drugs are used instead of the usual 3
Adverse reactions are common and the prognosis is poor
Multiple drug resistance occurs in 6%
M. avium intracellulare is another mycobacterium that can cause pulmonary infection in AIDS patients
Prevention
BCG vaccination: live attenuated vaccine protects against miliary and meningeal TB
Contact tracing
Chemoprophylaxis for contacts and for HIV patients
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Mantoux test
- used to identify patients with latent TB
- positive tuberculin skin test indicates infection with M. tuberculosis; it does not diagnose active
disease
- intradermal injection of 0.1 ml of PPD
- interpreted 48 to 72 hours after intradermal administration
- transverse diameter of induration should be measured and recorded in millimetres
- False negatives: newly diagnosed TB, HIV, TB meningitis
- Children who have received the BCG vaccine generally demonstrate PPD skin test reactions of 3 to
19 mm several months after vaccination. Most of these reactions wane significantly with time.
Responses indicative of a new infection include: > 10 mm induration in persons less than 35 years
of age or > 15 mm induration in >35 years old
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Medicine (Respi) = Pneumonia
Definition
Clinical definition
Pneumonia = acute lower respiratory tract illness associated with fever, symptoms and signs in the chest,
and abnormalities on CXR
Pathologic definition
Pneumonia = inflammation of lung parenchyma characterised by consolidation due to exudate in
the alveolar spaces
[ Distinguish from pneumonitis: inflammation affecting the interstitium, which presents clinically
as “atypical pneumonia”]
Causative organisms
CLASSIFICATION BY ACQUISITION
Community acquired typical (usually bacterial) Pneumococcus, H influenzae
Community acquired atypical Mycoplasma, Legionella
Nosocomial (usually bacterial) Pseudomonas, Staph aureus
Aspiration
CLASSIFICATION BY AGENT
Bacterial: Strep pneumoniae
Staph aureus: usually 2o, following viral infection, IVDA (assoc w abscesses)
may be 1o in patients with underlying lung disease
H influenzae: usually 2o, following viral infection
most common cause of acute exacerbation of COPD
Klebsiella: affects debilitated patients esp chronic alcoholics
characteristic thick gelatinous sputum (redcurrant jelly)
Legionella: from water storage systems (chlorination and temp control impt)
affects debilitated patients
diarrhoea is a prominent symptom
Pseudomonas: nosocomial infection in patients with CF, on mech ventilation or
neutropenic (can cause pulm artery invasion and h’rhage/infarction)
Mycoplasma (causes atypical pneumonia)
Viral: Influenza, CMV (cause atypical pneumonia)
Fungal: Aspergillus: colonise cavities to form aspergilloma; invasive allergic reactions eg. asthma
Candida: causes lung disease in those with chronic lung disease/immcompromise
hematogenous spread
Cryptococcus: opportunistic infection
localised lesion in the lung which can spread to LN and then to other parts
Histoplasma: affects immcompromised, causes granulomatous inflammation
PCP: when CD4 count < 200/mm3 in AIDS patients
perihilar shadowing, dry cough
BAL and immunofluorescence
Parasites: cause eosinophilic pneumonia: amoeba, paragonimus
Drugs/chemicals: cause interstitial pneumonitis
Aetiology
CLASSIFICATION BY SITE
Lobar pneumonia
Etiology/epidemiology
- Causative agent usually Strep pneumoniae (90%), Kleb, Staph, H influenzae (high virulence)
- Can occur at any age in healthy people without underlying lung disease
- Usually follows viral infections
- Pneumococcus is associated with rusty colored sputum
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Bronchopneumonia
Etiology/epidemiology
- Causative agents: Staph aureus, H influenzae, Strep, Pseudomonas (low virulence organisms)
Predisposing factors
- Extremes of age
- Immunosuppression/immunocompromised eg. Chronic disease
- Loss of cough reflex eg. Coma, anaesthesia
- Injury to mucociliary apparatus eg. Smoking, viral disease, genetic disease (CF)
- Interference with phagocytosis or bactericidal action eg. Alcohol, smoking
- Splenectomy
- Pulmonary congestion eg. Cardiac failure
- Accumulation of secretions eg. Bronchial obstruction, prolonged bed rest
- In hospital (nosocomial infections)
Atypical pneumonia
Etiology/epidemiology
- Causative agents: mycoplasma, chlamydia, viruses (influenza, parainfluenza, RSV, adeno)
- Affects school going children and young adults
Clinical features
- Presents as first as URTI eg. pharyngitis and flu-like symptoms laryngitis tracheobronchitis +
pneumonia (LRTI)
- May have headaches and malaise (typical of mycoplasma), erythema multiforme, arthralgia,
autoimmune haemolytic anaemia, myocarditis, hepatitis, DIC
- Cough, fever, modest sputum production, non-specific CXR changes (transient, ill-defined patches),
WBC count only moderately elevated, non-response to antibiotics
- Because the edema and exudatation are both in a strategic position to cause an alveolocapillary
block, there may be respiratory distress out of proportion to the physical and radiologic findings
- Cold agglutinins, rising antibody titre
Complications
- ARDS
Aspiration pneumonia
Usually in the right middle lobe cos the right bronchus is straighter
Especially in unconcscious, drunk, epileptic, stroke patients; may follow after gen anaesthesia, partial
drowning
Gastric contents: can cause asphyxia if massive; can cause pulm edema + infection
Necrotising pneumonia, pursues a fulminant clinical course
Complications: lung abscess, death
Nosocomial pneumonia
Common in patients with underlying disease, immsuppression, prolonged antibiotic therapy, invasive
devices/foreign bodies, mechanical ventilation
Commonest causative organisms: Pseudomonas, S aureus and enterobacteriaceae
Clinical features
History
Symptoms: Fever, rigors, cough, purulent sputum, malaise, dyspnea, pleuritic chest pain
Diarrhea (legionella)
Confusion in elderly
Preceding viral illness
Hospitalisation/insitutionalisation
Smoking/alcohol
Co-morbidities
Contact/travel/sexual history
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Physical examination
Fever, confusion (in the elderly), tachypnea, tachycardia
Consolidation: diminished chest expansion, dull percussion note, increased vocal fremitus/resonance,
bronchial breathing
Pleural rub
Sputum mug
Differentials (non-infectious)
Chemical pneumonitis / inflammation due to radiotherapy
Allergic mechanisms, asthma
Lung cancer
COPD
Investigations
FBC: leukocytosis with left shift, CRP
Bld c/s
Viral serology if suspected
CXR: lobar/patchy consolidation (opacity with air bronchograms)
multicentric, likely hematogenous route IVDA (Staph aureus)
cavitating: TB, anaerobic, kleb, meliodosis, staph aureus
+/- parapneumonic effusions
- CXR changes lag behind clinical course, hence initial CXR may not show typical changes
- CXR may show consolidation after resolution of symptoms, but should clear by 6 wks
Sputum for microscopy and c/s, AFB smear and culture, TB PCR
- should have < 10 epithelial cells
- > 25 WBCs are abnormal
- lancet shaped diplococci = S pneumoniae
Urine antigen for legionella, pneumococcus
Bronchoscopy for immunocompromised patients
Pleural fluid for analysis (thoracocentesis) if effusion present
Severity
Two scoring systems to decide outpatient vs inpatient treatment; also of prognostic value
CURB 65 score
- Confusion (abbreviated mental test score < 8)
- Urea > 7 mmol/L
- Respiratory rate > 30/min
- BP systolic < 90 mmHg
0-1: treat as outpatient
2: inpatient treatment
3 or more: admit to ICU
PSI (see attached)
- PORT study (Patient Outcomes Research Team)
- Risk class I: no co-morbidities, normal phy exam and age < 50
- Risk class II – V: points are assigned for different comorbidities and abnormal lab findings
Direct ICU admission if patient is in septic shock requiring vasopressors or intubation
Management
Outpatient antibiotic treatment: amoxicillin
Hospitalised patients are generally begun on intravenous antibiotics (ceftriaxone + azithro OR
levofloxacin). Patients who are improving clinically, hemodynamically stable, and able to take oral
medications can be switched to oral therapy.
If no improvement within 72 hours, consider an organism that is not covered by the initial antibiotic
regimen, including unusual pathogens or drug-resistant organisms
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Oxygen: nasal cannula/venture mask/ventilation depending on severity
IV fluids
Analgesia
Vaccines
Chest physiotherapy
Follow up CXR in 6 weeks
Antibiotic selection
Community acquired
- Mild Oral amoxicillin and/or erythromycin, or ciprofloxacin
- Severe IV augmentin or cefuroxime AND erythromycin
- Atypical Clarithromycin (Legionella), tetracycline (Chlamydia), bactrim (PCP)
Nosocomial
- Gm negs, Pseudomonas, IV aminoglycoside + 3rd gen cephalosporin
IV ciprofloxacin for pseudomonas
Anaerobes IV metronidazole
** if TB cannot be ruled out then do not give quinolones as it may mask the AFB smear
Complications
Complete resolution is rare in bronchopneumonia focal fibrosis or bronchiectasis
Pleural effusion
Empyema
Lung abscess
Respiratory failure
ARDS
Sepiticemia
Brain abscess
Pericarditis
Cholestatic jaundice
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Pneumonia Severity Index
420
Aetiology
Medicine (Respi) = Asthma Extrinsic (allergic) asthma
Principles of Diagnosis - Definite external cause
Recognise acute asthma clinically and define status asthmaticus. - Type 1 hypersensitivity reaction
Describe the severe sequelae arising from inadequate acute management. - Elevated serum IgE and eosinophils
Describe the clinical assessment of severity of asthmatic effect. - Mediated by Th2 cells release IL 4, IL5 IgE synthesis
Principles of Management sensitization of mast cells
Describe the immediate steps in management: drugs, dosage and mode of - Triggered by allergen exposure in a sensitised individual mast cell
administration. degranulation
List the clinical parameters which should be monitored after initiation of - Early phase (within 1 hr): release of leukotriene D4, PGE2, histamine
treatment. - Accompanied by reflex bronchoconstriction due to stimulation of
Describe the indications for intubation. vagal receptors
Explain the pathophysiology of acute asthma and the action of the drugs used - Late phase: recruitment of leukocytes: leukotriene B4, platelet
in acute management. activating factor, TNF
Describe the follow-up medical management after the acute attack. - Leukocytes damage the epithelium, reducing production of NO, thus
Prevention causing smooth muscle contraction
Describe the measures to minimize occurrence of severe asthmatic attacks. - Eosinophils perpetuate the inflammation
- Eg. Atopic asthma, occupational asthma, allergic bronchopulmonary
aspergillosis
Characteristics
- Often has family history of allergy/atopy
3 characteristics:
- Develops in childhood
i) Airflow limitation of changing severity, episodic, reversible
spontaneously or with treatment
Intrinsic (non-allergic) asthma
ii) Airway hyperresponsiveness to a wide range of stimuli
- Non immune mechanism, asthmatic “diathesis”
iii) Inflammation – eosinophils, T lymphocytes, mast cells, smooth muscle
- IgE antibodies are normal
hypertrophy, edema, mucosal damage
- Triggered by respiratory infection, aspirin, stress, exercise, cold
3 factors contribute to airway narrowing: i) bronchospasm, ii)
(these factors may also trigger asthma in a person with extrinsic
inflammation and swelling,
asthma cos of his bronchial hypersensitivity)
iii) increased mucus production
- No family history of allergy/atopy
o Intervals between attacks are characteristically free from respiratory
- Develops later in life, “late onset”
difficulty, but subtle deficits can be detected by spirometry
Epidemiology
o Prevalence is increasing
o More common in developed countries
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Pathogenesis
Atopy Physical examination
- individuals who readily develop IgE antibodies against common Tachypnea
materials in the environment Wheeze, cough
- runs in the family Hyperinflated chest, hyperresonance, diminished air entry
- childhood exposure to allergens has an influence on IgE production: Polyphonic wheeze
growing up in a clean environment predisposes towards IgE response Clinical severity: able to complete sentences? Silent chest, bradycardia,
to allergens PEF < 33%, cyanosis, feeble respiratory effort, confused
Airway hyperresponsiveness
→Small airway obstruction due to bronchospasm and thick tenacious Investigations
mucous plugs, progressive hyperinflation with air trapping FBC: eosinophils
Remodelling Sputum culture and cytology: eosinophils
- deposition of matrix proteins beneath the epithelium Serial peak expiratory flow measurements
- epithelial metaplasia and increase in goblet cells - Diurnal variation >20% on 3 days a week for 2 weeks: marked
- thickened basement membrane morning dipping of peak flow
- smooth muscle hyperplasia Lung function tests
- Decreased FEV1/FVC ratio and increased residual volume
Precipitating factors - Before bronchodilator, after bronchodilator variable airflow
Environmental allergens: pollen, house dust mite, pets limitation, >15% improvement in PEFR after bronchodilator
Occupational: isocyanates (varnish), flour, animals CXR: hyperinflation, exclude pneumothorax or allergic
Atmospheric: cigarette smoke, pollutants bronchopulmonary aspergillosis
Cold air, exercise (at the end of exercise), emotion Skin prick test: helps to identify allergens
Viral infections: rhinovirus, parainfluenza Histamine or methacholine challenge: to test airway
Drugs: Aspirin (imbalance in metabolism of arachidonic acid), beta hyperresponsiveness
blockers
Clinical features
History
Dyspnea (esp expiration), nocturnal cough, wheezing, chest tightness
Severity, frequency
Precipitants: Exercise, cold, stress, infection, drugs eg. aspirin
Allergens, occupational exposure, better when on holiday
Diurnal variation: worse in the morning
Other atopic disease: eczema, allergic rhinitis
Family history
Social history: occupation, impact on lifestyle
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Management
Allergen avoidance eg dust mite, smoking, drugs
Classification of asthma Pharmacologic therapy – depending on severity/frequency of asthma
New GINA guidelines symptoms
- use step-up or step-down approach
Education of patient and family:
- Check inhaler technique (avoid excess deposition in mouth)
- Use of spacer to increase lung deposition, decrease the need for
coordination
- Compliance with steroid inhalers
Asthma action plan
- grades patient’s severity of asthma into the green, yellow and red
zones, according to their symptoms + peak flow rates
- describes the dose, frequency and duration of the appropriate
treatment
- main aim of the asthma action plan is to abort exacerbations by rapid
step up of both reliever and preventor
- also prompts the patient to seek urgent hospital treatment in case of
severe exacerbations and/or failure of self medication.
SMART approach to asthma (Symbicort Maintenence and Reliever
Treatment)
o 2 puffs BD for maintenence
o 4 puffs BD in exacerbation for rapid relief
o 2 puffs BD when symptoms resolve
o Symbicort = budesonide + formoterol
- Better compliance when using a combined inhaler than two separate
inhalers
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Asthma drugs
Beta-2 agonists
- selective for bronchial smooth muscle relaxation and
bronchodilation
- for symptomatic relief (2 puffs prn)
- effective up to 6 hrs Status asthmaticus
- excessive use (>2 canisters per month) is associated with increased Poor response to drug therapy after 24 hours
mortality Signs of respiratory failure: ABG: PaCO2>6kPa, PaO2<8kPa, pH low and
Anticholinergic (ipratropium bromide) falling
- muscarinic receptor antagonists
Long acting beta-2 agonists Risk factors for death from asthma
- effective up to 12 hours Past history of sudden severe exacerbation
- for patients who cannot be controlled on 800mcg/day of ICS Prior intubation for asthma
Sodium cromoglycate and nedocromil Two or more hospitalisations for asthma in the past year
- blocks chloride channel prevent mast cell activation Three or more emergency care visits for asthma in the past year
Inhaled corticosteroids (ICS) Hospitalisation or an emergency care visit for asthma within the past
- any form of persistent asthma (needing relief meds at least once a month
week) requires steroid inhaler treatment Use of >2 canisters per month of inhaled short-acting B2-agonist
- beclometasone, budesonide, fluticasone, triamcinolone Current use of systemic corticosteroids or recent withdrawal from
- most of the dose is swallowed or exhaled systemic corticosteroids
- adding a long acting beta-2 agonist is more effective than doubling the Known difficulty perceiving airflow obstruction or its severity
dose of ICS Comorbidity, as from cardiovascular diseases or chronic obstructive
- side-effects: oral candidiasis, hoarseness, subcapsular cataract, pulmonary disease
avascular necrosis of the femoral head, osteoporosis, growth Serious psychiatric disease or psychosocial problems
retardation Low socioeconomic status
- step down treatment after the condition is under control Illicit drug use
Oral corticosteroids ABG: PaCO2>6kPa, PaO2<8kPa, pH low and falling
- keep the dose as low as possible
- for those who cannot be controlled on ICS
Leukotriene-receptor antagonists
- add on therapy
- good for aspirin-intolerant asthma
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Severity of Asthma Attack
Feeble
Silent
chest
<30%
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Management of an acute attack
Supportive measures:
- oxygen
Monitoring:
- O2 saturation
- ABG
- PEFR
- Level of consciousness
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Medicine (Respi) = Pulmonary embolism
Principles of Diagnosis
Identify risk factors and acquired conditions predisposing to DVT and PE
Enumerate differential diagnoses of DVT (leg swelling) and PE (collapse, chest pain, dyspnea or hemoptysis).
Clinically differentiate between the clinical syndromes of PE, i.e. pulmonary infarction, submassive PE,
massive PE and chronic PE.
Outline the diagnostic work-up of patients with suspected PE, including non-imaging and imaging methods,
and their limitations.
Principles of Management
Describe the management of PE including –
a) 1° strategies such as anticoagulants, thrombolysis and surgery.
Detailed knowledge of anticoagulants including contraindications, the types of drugs, route of administration,
indications and maintenance doses, lab monitoring, potential interactive actions to take in case of
overanticoagulation
b) Resuscitative and supportive means for shock, RVF, chest pain
Prevention
Describe the recommended antithrombotic or anticoagulation regimes and mechanical measures for
prophylaxis of DVT.
Know the anticoagulation regimes for secondary prevention of PE.
Describe briefly the role of catheter-based strategies, including inferior vena caval interruption for secondary
prevention of massive PE.
Pathophysiology
Describe the pathophysiology of pulmonary embolism, including the concept of ventricular interdependence.
Predisposing factors
Prolonged bed rest, immobilisation
Surgery, trauma, fractures
Previous stroke or thromboembolism
Congestive cardiac failure
Disseminated cancer
Pregnant women
Antiphospholipid syndrome
Drugs: OCP
Smoking
Genetic: Factor V Leiden mutation, thrombophilias
Pathogenesis
- Thrombi from deep veins of the leg (95% are from the popliteal vein or the veins above it)
- Clots break off and embolise to the lungs
- Large embolus obstructing the main pulmonary artery increased pulmonary artery pressure due to
blockage of flow + vasospasm due to release of mediators/neurogenic mechanism leads to
hypoxemia, acute cor pulmonale (when more than 60% of vasculature is obstructed) and death
- Small thrombi may be clinically silent cos they are rapidly removed by fibrinolytic activity, and the
bronchial circulation maintains the viability of the affected parenchyma till this is achieved
- Smaller thrombi continue traveling distally and are more likely to produce pleuritic chest pain, by
initiating an inflammatory response adjacent to the parietal pleura
- Pulmonary infarction may occur rarely (less likely due to dual blood supply)
- Multiple small emboli may lead to pulmonary hypertension decreased cardiac output
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Clinical syndromes of PE
Massive pulmonary embolism
- PE associated with a systolic blood pressure <90 mmHg or a drop in systolic blood pressure of ≥ 40
mmHg from baseline for a period >15 minutes, which is not otherwise explained by hypovolemia,
sepsis, or a new arrhythmia
- a catastrophic entity that often results in acute right ventricular failure and death
Pulmonary infarction
- Infarction only occurs if bronchial circulation is impaired
- The more peripheral the embolic occlusion, the more likely is infarction
Clinical features
History
Acute breathlessness, pleuritic chest pain, hemoptysis, dizziness, syncope
Risk factors
Physical examination
Tachypnea, pyrexia, tachycardia, hypotension
Cyanosis
Raised JVP, loud P2, 4th heart sound
Pleural rub or effusion
Signs of DVT
Recent surgical scar
Clinical scoring
Wells score
Previous DVT/PE 1.5
Immobilization or surgery in previous 1 month 1.5 0-2 Low probability
Malignancy 1 3-6 Mod probability
Clinical symptoms of DVT 3
Hemoptysis 1
> 6 High probability
Heart rate >100 1.5
Other diagnosis less likely than PE 3
Geneva score
Age > 65 1
Previous DVT or PE 3 0-3 Low probability
Surgery (under GA) or lower limb fracture within 1 month 2
Active malignant condition or cured in < 1 yr 2 4-10 Mod probability
Unilateral lower limb pain 3 > 10 High probability
Pain on lower limb deep venous palpation and unilateral edema 4
Hemoptysis 2
Heart rate 75-94 bpm 3
Heart rate ≥ 95 bpm 5
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Investigations
Nonspecific lab findings
ESR raised
BNP raised
Trop T raised
Specific investigations
CXR
- Normal
- Atelectasis
- Oligemia of affected segment
- Dilated pulmonary artery
- Small effusion
- Wedge shaped opacities
ECG
- S1Q3T3 pattern, right ventricular strain, new incomplete RBBB (classical but rare)
- Atrial arrhythmias
- T wave inversion, ST changes
D dimer: degradation product of cross-linked fibrin
- Sensitivity 95%
V/Q perfusion scan: look for perfusion defects without corresponding ventilation defects
CT pulmonary angiography (gold standard)/ “spiral CT”
Lower limb Doppler ultrasound
Differential diagnoses
PE
Acute coronary syndrome
COPD
Myocarditis
DVT
Cellulitis
Superficial thrombophlebitis
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Algorithm for diagnosis of PE
Suspicion of PE
Perform Wells/Geneva
score
Start tx
D Dimer assay
CTPA
D Dimer D Dimer
negative positive
CTPA CTPA
negative positive
No tx CTPA
Stop tx Continue tx
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Management
Assess ABCs
Stabilise the patient
- supportive measures eg. supplemental O2
- cautiously administer intravenous fluids (avoid ppting right heart failure)
- vasopressor therapy
Anticoagulation
- Reduces mortality by preventing recurrent PE
- In those with high probability of PE, start anticoagulation before investigations
- Greatest efficacy if therapeutic heparin levels are initiated within 24 hours
- In hemodynamically stable patients with PE, SC LMWH is preferred
- Patients in whom anticoagulation was initiated during the resuscitative period should remain
anticoagulated during the diagnostic evaluation. Anticoagulation should be discontinued of PE
is excluded
- Long-term anticoagulation with warfarin is indicated if PE is confirmed
Inferior vena caval filter placement should be considered if anticoagulation is contraindicated (patient
has active bleeding), fails, or causes complications (eg, severe bleeding)
- results in less recurrence of PE
- but recurrent DVT was more common among patients who received an IVC filter
Thrombolysis should be considered once PE is confirmed
- Accelerates the lysis of acute pulmonary emboli
- Increased likelihood of major hemorrhage
- If thrombolysis is chosen, anticoagulation should be temporarily discontinued then resumed
- No mortality benefit, but shown to improve RV function
- Persistent hypotension due to massive PE is a widely accepted indication for thrombolysis
Embolectomy
- Removal of embolus using catheters or surgically
- When thrombolysis either fails or is contraindicated
- Catheter emboleeectomy: injecting pressurized saline through the catheter's distal tip, which
macerates the embolus. The saline and fragments of clot are then sucked back into an exhaust
lumen of the catheter for disposal
Preventive management: elastic stockings, leg exercises, ambulation, long term anticoagulation with
warfarin
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Anticoagulation regimes
DRUG THERAPY
LMWH (fraxiparin, enoxaparin)
- results in lower mortality, fewer recurrent thrombotic events, and less major bleeding than UFH
- greater bioavailability, once or twice daily administration, fixed dosing (ie, dose does not require
adjustment), no required laboratory monitoring, and decreased likelihood of thrombocytopenia
- exception: patients who are pregnant or have severe renal failure require anti-Xa assay monitoring
after administration of SC LMWH
Unfractionated heparin (continuous iv infusion)
- preferred in patients with persistent hypotension due to massive PE; severe renal failure (aPTT
monitoring is easier than anti-Xa assay)
- target 1.5-2.3 x the control aPTT
- protamine sulphate is the antidote for heparin (cannot fully reverse LMWH’s anti-Xa effects)
Fondaparinux (new)
- synthetic heparin pentasaccharides that catalyse factor Xa inactivation by antithrombin, without
inhibiting thrombin
- may be a viable alternative to unfractionated heparin
Warfarin
- risk factors for bleeding: age >75, concurrent aspirin therapy, hypertension, CVA, renal insufficiency,
heart disease, cancer
- Vit K and FFP are antidotes for warfarin
DURATION
First episode of Recurrent episode of
PE/DVT PE/DVT
Warfarin
3-6 months Warfarin Indefinite therapy
6-12 months,
consider indefinite
therapy
- Treatment duration among patients with a first episode of PE or deep vein thrombosis (DVT) is
determined by whether a risk factor can be identified and, if so, whether the risk factor is reversible.
- Reversible risk factor eg, immobilization, surgery, trauma: warfarin for 3-6 months
- No identifiable risk factors ie, idiopathic PE or DVT: at least 6 to 12 months, consider indefinite
anticoagulation
- Irreversible risk factor eg. protein C deficiency, protein S deficiency, factor V Leiden gene mutation: at
least 6 to 12 months, consider indefinite anticoagulation
- Indefinite therapy should be administered to patients with recurrent PE or DVT.
Prognosis
30% chance of developing a second embolus
Mortality rate of approximately 30 % without treatment, due mainly to recurrent embolism
Accurate diagnosis followed by effective therapy with anticoagulants decreases the mortality rate to 2
to 8 %
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