OSCE Guide, University of Queensland School of Medicine

OBJECTIVE)STRUCTURED)CLINICAL)EXAMINATION)(OSCE’s)) ! There!are!5!stations:! 1.! History)Taking)) 2.! Physical)Examination) 3.! Clinical)Reasoning)) 4.! Clinical)Communication)Skills)) 5.! Procedural)Skills)) ! How$much$time$do$I$get$at$each$station?$$

What$can$they$ask$me$about?$$

! ! ! What$are$some$typical$presenting$complaints?$ Chest!pain,!SOB,!dizziness,!abdominal!pain,! nausea/vomiting,!diarrhoea,!headache,!special!senses! (hearing/vision),!joint!pain,!cough,!collapse,!tiredness,!fever!! $ $ !

STATION)1)–)HISTORY)TAKING)!

! This!station!is!designed!to!allow!you!to!demonstrate!your!skills!in!taking!focused!or!systematic!medical!histories!from!patients.!! It!will!also!test!your!ability!to!develop!rapport!with!your!patient.!!The!examiner!will!let!you!know!when!there!is!1!minute! remaining,!and!you!must!give!the!examiner!your!provisional)diagnosis!(but!you!will!not!be!asked!to!justify!this).! ! EXAMPLE! Clinical'Scenario:'Christine)Black,)45yo)lady!complaining!of!urinary!frequency!and!lethargy.!She!is!seeing!you!for!the!first!time.!' ! Candidate!Tasks! 1.! You!have!eight)(8))minutes)to)take)a)history.!You!are!to!interact!with!the!patient!as!in!a!consultation.!! 2.! The)examiner)will)observe)and)notify)you)when!there!is)one)(1))minute!remaining.!! 3.! In!the!final!minute,!you!need!to!conclude)the)consultation)and)provide)one)(1))likely)provisional)diagnosis.!You!do)not) need)to)justify!this.!! 4.! Do!not!make!any!inferences!based!on!the!appearance!of!the!simulated!patient! ! MARKING)SHEET! Score)sheet)–)How)well)were)the)components)demonstrated?) 1.!General) Introduces!self!to!patient! Speaks!clearly!and!fluently! Conveys!caring!and!empathic!manner! Clear!communication!skills!O!verbal!and!nonOverbal! Good!use!of!open!and!closed!questions! 2.!History)of)Presenting)Complaint) Presenting!complaint!clearly!identified!) NILDOCAAFIAT!specifics! Timeline!of!symptoms!clearly!elicited! 3.)History)of)Presenting)Systems)&)Systems)Review) Red!flags!noted!! Systems!review!adequately!performed!in!sufficient!depth! 4.)Important)Past)History)Items) PMHx!! PSH!! Medications/allergies! Substance!Use!! Screening/Immunization/Diet/Exercise!noted! 5.)Social)History)&)Conclusion) Social!History!! Provisional!Diagnosis! Overall)impression)and)comments!

!

Rated!from:!! Not!at!all! Poorly! Partially!! Well! Very!Well!

Overall:!! Unacceptable! Not!satisfactory! Borderline! Satisfactory!! Proficient!

STATION)2)–)PHYSICAL)EXAMINATION)!

! The!physical!examination!station!requires!you!to!demonstrate!focused!or!systematic!physical!examination!skills!on!a!simulated! patient.!!You!will!be!given!a!clinical!scenario!(eg.!presenting!complaint!or!diagnosis_!and!asked!to!perform!the!appropriate! examination!or!examination(s).!!You!may!find!your!scenario!requires!a!combined!examination!approach!(eg.!SOB!–!combine! Resp!and!CVS).!!You!will!be!required!to!explain!to!the!examiner!throughout!your!examination!what!you!are!looking!for!and!what! you!might!expect!to!find!in!the!particular!clinical!scenario.! ! It!is!not!expected!that!you!will!be!able!to!complete!a!comprehensive!examination!within!8!minutes.!!For!this!reason,!the! examiner!has!been!instructed!to!politely!interrupt!you!and!ask!you!to!move!on!so!that!you!might!demonstrate!a!wide!range!of! examination!techniques!during!the!time!frame!(eg.!you!may!be!asked!to!move!on!before!completing!your!full!peripheries! inspection!or!your!complete!lung!auscultation.!!The!examiner!may!ask!you!to!perform!only!part!of!an!examination!(eg.!examine! only!the!first!5!cranial!nerves).!!However,!it!is!up!to!the!examiner,!not!the!student,!to!decide!which!parts!other!examination!may! be!omitted.!!! ! You!must!treat!the!simulated!patient!with!the!same!respect!and!professionalism!as!a!real!patient.! ! All!required!equipment!will!be!provided!by!the!School!of!Medicine,!but!you!are!allowed!to!bring!your!own!stethoscope,!if! preferred.!! ! EXAMPLE! Clinical'Scenario:))The!patient!you!are!about!to!examine!is!Matthew)Smith,)a)68)year)old)man!who!has!presented!with!acute!left! sided!abdominal!pain!and!recent!change!in!bowel!habit.!) ! Candidate!Tasks:! 1.! You)have)eight)(8))minutes)to!perform!an!appropriate)examination.!! 2.! Explain)to)the)examiner)during)the)examination)the)reasoning)for)the)examination)that)you)do)and)the)specific)findings! that!you!may!expect!in!a!patient!with!this!presentation.!! ! MARKING)SHEET! Score)sheet)–)How)well)were)the)components)demonstrated?) 1.!Introduction)and)Consent) Candidate!introduces!self!–!name!and!role! Explains!examination/s!!&!!obtains!consent!! Washes!hands!! Interacts!with!simulated!patient!appropriately! Appropriate!exposure!! 2.)General)Observations)) Discusses!general!appearance!! Dependent!on!required!examination! 3.)Appropriate))Examination)) Dependent!on!required!examination! 4.)Appropriate))Examination)) Dependent!on!required!examination! 5.)Appropriate)Examination) Dependent!on!required!examination! Overall)impression)and)comments)

Rated!from:!! Not!at!all! Poorly! Partially!! Well! Very!Well!

Overall:!! Unacceptable! Not!satisfactory! Borderline! Satisfactory!! Proficient!

! Notes:! O! All!equipment!required!for!this!station!will!be!supplied! O! You!may!bring!your!own!stethoscope!and!watch! O! If!fundoscopy,!otoscopy!is!indicated!please!MENTION)THIS!to!the!examiner,!but!you!will!not!be!expected!to!do!it!! !

STATION)3)–)CLINICAL)REASONING)!

! The!Clinical!Reasoning!station!is!designed!to!assess!the!following!skills:! O! !Your!ability!to!formulate!differential!diagnoses!from!a!medical!history!provided!to!you! O! Your!ability!to!do!an!oral!presentation!of!your!clinical!reasoning!to!another!medical!professional! O! Your!ability!to!justify!your!choices!of!differential!diagnoses!in!a!logical!manner!and!in!response!to!questioning!! ! EXAMPLE! Clinical'scenario:''The!patient!in!the!next!room!is!Thomas)Brown,)a)42)year)old)man!who!presents!complaining!of!rectal! bleeding.!!You!have!been!given!this!patient’s!history.' ! !

Candidate!Tasks:! 1.! You!have!a!total!of!four)(4))minutes!to!peruse!this!information!! •! two!(2)!minutes!in!the!perusal!time!and!! •! a!further!two!(2)!minutes!after!the!station!begins.!The!examiner!will!notify!you!when!you!need!to!start!talking.! 2.! You!then!have!six)(6))minutes!to!discuss!with!the!examiner!three)possible)differential)diagnoses,)starting)with)the)most) likely)diagnosis.! ) 3.! You!should!include!positive)and)negative)features)of)this)history!which!support!or!refute!your!diagnoses.! ' MARKING)SHEET! Score)sheet)–)How)well)were)the)components)demonstrated?) ' 1.)General)–)summary) ' Organised!summary!of!diagnoses! ' Logical!structure!to!presentation! ' Appropriate!diagnoses!chosen! Prioritises!diagnoses! ' ! ' Rated!from:!! Overall:!! 2.)Differential)Diagnosis)ONE) ' Not!at!all! Unacceptable! Diagnosis:! ' Appropriate!supportive!points! Poorly! Not!satisfactory! ' Appropriate!negative!points! Partially!! Borderline! Logical!presentation!of!reasoning! ' Well! Satisfactory!! 3.)Differential)Diagnosis)TWO) ' Very!Well! Proficient! Diagnosis:! ' Appropriate!supportive!points! ' Appropriate!negative!points! Logical!presentation!of!reasoning! ' 4.)Differential)Diagnosis)THREE) ' Appropriate!supportive!points! ' Appropriate!negative!points! ' Logical!presentation!of!reasoning! ' 5.)Adequate)Reasoning! Oral!presentation!O!clear!and!fluent!! ' Appropriate!medical!terminology!used! ' No!major!hesitation! ' Minimal!irrelevant!material!included! ' Overall)impression)and)comments! ' Notes:' O! !Your!reasoning!will!be!based!on!history!alone!–!including!HPC,!HPS,!systems!review!and!past!medical!history!! O! You!will!not!be!given!examination!findings!or!investigation!results!to!interpret!! !

STATION)4)–)CLINICAL)COMMUNICATION)SKILLS))! ! This!station!will!test!your!ability!to!communicate!with!patients!in!varying!and!difficult!circumstances.! ' EXAMPLE) Clinical'Scenario:!You!are!a!medical!student!on!clinical!placement!in!general!practice.!!Your!next!patient!is!Grant!Writer,!a!60yo! man.!!The!GP!is!running!late,!and!asks!you!to!interview!Graham!regarding!a!particular!health!or!behavioural!issue.! ! Candidate!Tasks:! 1.! You!have!a!total!of!eight)(8))minutes!to!! •! Assess!Grant! •! Convey!to!the!examiner!(when!asked)!your!assessment!of!Grant!! •! Utilize!strategies!learnt!in!Clinical!Communication!Skills!to!communicate!with/counsel!the!patient!appropriately!! ) MARKING)SHEET! Score)sheet)–)How)well)were)the)components)demonstrated?) 1.!General)communication) Uses!active!listening!skills!and!open!questions! Asks!for!clarification;!paraphrases;!summarises!to!check! understanding! Picks!up!cues!from!patient! Shows!empathy!&!sensitivity!to!patient’s!concerns! 2.)Consultation)structure) Logical!and!organized!structure! ! 3/4/5)Criteria)dependent)on)case) Overall)impression)and)comments!

!

Rated!from:!! Not!at!all! Poorly! Partially!! Well! Very!Well!

Overall:!! Unacceptable! Not!satisfactory! Borderline! Satisfactory!! Proficient!

STATION)5)–)PROCEDURAL)SKILLS))!

! The!Procedural!Skills!station!is!designed!to!test!your!competency!in!basic!procedural!skills!learned!in!Years!1!and!2!PSWs.!!You! ma!be!required!to!report!findings!to!the!examiner.! ! EXAMPLE)! Clinical'Scenario:''You!have!been!asked!to!perform!the!following!procedural!skill/s.!!The!equipment!required!for!the!task!is! provided!at!the!station.' ! Candidate!Tasks! 1.! You!have!seven)(7))minutes!to!do!the!following!procedural!skill/s..! 2.! After!7!minutes,!the!examiner!will!stop!you.!You!then!have!one)(1))minute)to)report)your)findings!to!the!examiner!or! answer)the)examiner’s)questions.) ! MARKING)SHEET)) Rated!from:!! Overall:!! Score)sheet)–)How)well)were)the)components)demonstrated?) Not!at!all! Unacceptable! 1.!General)communication) Poorly! Not!satisfactory! Communication!skills! Consent! Partially!! Borderline! 2/3/4/5)Criteria)dependent)on)case) Well! Satisfactory!! Criteria!are!taken!from!the!PSW!competency!sheets ! Very!Well! Proficient! ) Notes:! O! !You!will!be!asked!to!perform!a!skill!on!either!a!simulated!patient,!partOtask!trainer!or!mannequin! O! You!are!not!required!to!verbalise!your!actions!to!the!examiner!during!this!station,!however!they!can!ask!you!to!clarify! technique! O! You!will!NOT)BE)EXAMINED)ON)CANNULATION)OR)VENEPUNCTURE! ! ! !

YOU)MUST)PASS)ALL)5)STATIONS)TO)PASS)

GOODLUCK)!)! ! ! !

! ! ! ! HISTORY!TAKING! ! ! ! ! ! ! ! ! ! !

History Presenting Complaint & HPC For each symptom SOCRATES (UK) or NILDOCAAFIAT (UQ) Site Onset (sudden/gradual) Character Radiations Associations (e.g. pain with food intake) Timing (duration) Exacerbating and alleviating factors Severity (1-10)

Family History (FH) Nature Intensity Location Duration Onset Contributing factors Aggravating factors Alleviating factors Frequency Impact Attribute Treatment

Past Medical History (PMH)

• • • •

Social History (SH) • • • • •

Hospital visits, previous illness, previous operations

• •

•

Specifically: diabetes, asthma, bronchitis, TB, jaundice, high BP (don’t say hypertension), heart disease, stroke, epilepsy, peptic ulcers

•

•

Medications - tablets, injections, prescriptions, herbal remedies, the pill

•

Allergies & adverse drug reaction

•

Vaccination history

• • • •

Indications to ask – urethral/vaginal discharge, genital ulcer/rash, abdominal pain, pain on intercourse Last date of intercourse, # partners, homosexual/bisexual, prostitutes Type of sexual practice (vaginal, oral, anal, ano-oral) History of sexual abuse

All women; esp. abdominal pain, ? endocrine disease, genitourinary symptoms Date of last menstrual period, whether or not periods are regular Age at menarche, whether menopause has occurred Symptoms related to menstruation – pain etc.

Alcohol – average per day, CAGE (Cut down, Annoyed, Guilty, Eye opener) Smoking - pack years (= # of packs (20 cigarettes) smoked per day * # of years patient has smoked)

Recreational drugs

Systems Review •

General - weight loss, night sweats, lumps, fevers, fatigue / malaise / lethargy, appetite, sleeping (sleepiness, early waking, being woken by pain), itch / rash, recent trauma

•

Cardio-respiratory - chest pain, dyspnoea (exertional, PND, orthopnoea), oedema, palpitations, cough, wheeze sputum production, haemoptysis

•

Gastrointestinal – abdominal pain, difficulty / pain on swallowing, indigestion, nausea / vomiting, change in bowels (constipation / vomiting), stools (colour, consistency, blood, slime, difficulty, urgency, tenesmus)

•

Genitourinary – incontinence, dysuria, haematuria, nocturia, frequency, polyuria, hesitancy, terminal dribbling

•

Neurological – sight, hearing, smell, taste, seizures, faints, dizzy spells, headaches, paraesthesia, limb weakness, poor balance, function

•

Musculoskeletal – pain / stiffness / swelling of joints / muscles, changes throughout the day, functional impact

Menstrual History • • • •

Home life – marriage, children, living situation Vocation - job, education, hobbies, spouse’s job Mobility – need for walking aids, stairs in home Diet – average day Exercise

Substance History

•

Sexual History

Do any conditions run in the family? Parents, siblings, grandparents etc. (pedigree) Alive – health, age, any conditions, similar presenting complaint Dead – age at death, cause of death

! ! ! ! SYSTEMS!SUMMARIES! ! ! ! ! ! ! ! ! ! !

Gastrointestinal System Presenting Complaints

Examination

•

Appetite changes – anorexia, hyperphagia

•

Weight loss (malabsorption, malignancy, diabetes, thyroid, IBD, eating disorder, depression)

•

Weight gain

•

•

Dysphagia (oesophagus, nodes, goitre)

Mental state – alert, confused, coma

•

•

Indigestion / heartburn – reflux

Body habitus – weight, wasting, oedema, hydration

•

Nausea / vomiting – onset, frequency, contents (infection, inflammation, obstruction)

•

Colour – pallor, jaundice, haemochromatosis

•

Vital signs – Temp, HR, BP, RR, O2

•

Haematemesis – frank or coffee ground (ulcer, varices, Mallory Weiss tear, malignancy)

•

•

Abdominal pain – colicky (biliary, GI), severe (peritonitis)

•

Jaundice (haemolysis, liver, biliary)

Hands – leukonychia (↓albumin), koilonychia (spooning, ↓iron), clubbing (cirrhosis, IBD), pallor in palmar creases, palmar erythema (oestrogen), wasting, dupuytren’s contracture

•

Change in bowel motions – volume, frequency, consistency, colour, tenesmus, blood

Patient History •

PMH – abdominal surgery

•

Family – colorectal cancer, haemochromatosis, IBD, ulcers

•

Medications – NSAIDs (ulcers), metformin (diarrhoea), opioids (constipation), antibiotics (bowel changes), bisphosponates (oesophagitis), SSRIs (nausea)

•

Social – smoking, alcohol, IV drugs, travel, vaccinations, birth country

Patient lying supine with one pillow Inspection • General – age, gender, comfort/distress

•

Hepatic flap

•

Arms/shoulders – spider naevi (oestrogen), bruising, wasting, scratch marks (?obs jaundice)

•

Eyes – xanthelasma, icterus, conjunctival pallor, uveitis, KayserFleisher rings (Wilson’s disease)

•

Salivary glands – parotid & submandibular glands & ducts

•

Lips – hydration, agular cheilitis, ulceration, pigmentation, telangiectasia

•

Mouth – foetor, stomatitis, candidiasis/leukoplakia (L won’t scrape off, C will), gums, glossitis, central cyanosis, teeth

Red Flags •

Lymph nodes – cervical & axillary

•

Chest – spider naevi (oestrogen), loss of hair distribution, gynaecomastia (oestrogen)

•

Abdomen – scars, striae, bruising, stoma, distension (8 Fs), masses, veins, peristalsis, pulsations

Palpation • Superficial – tenderness, masses •

• • • •

Deep – masses, guarding, rigidity, rebound tenderness, McBurney’s point,Rosving’s sign Liver & gallbladder (Murphy’s sign) Spleen Kidneys Abdominal aorta

Percussion • Liver • Bladder • Shifting dullness Auscultation • Bowel sounds • Epigastric bruits • Renal bruits Other •

• • •

DRE – inspection (fissure, fistula, tags, blood, rash, ulcer, mucus); palpation (wall consistency; prostate size, surface, tenderness) Urinalysis Pregnancy test Bowel chart

• • • • • • • • • • • • •

Sudden onset of pain Increasing severity of pain Syncope / pre-syncope Vomiting Haematemesis Abdominal distension Pallor & sweating Tachycardia & atrial fibrillation Hypotension Fever Rebound tenderness, guarding, rigidity Oliguria / anuria Positive pregnancy test

Respiratory System Presenting Complaints •

Cough – nature, onset, wet (viral, LRTI, COPD, bronchiectasis), dry (viral, asthma, GI reflux, restrictive, ACEi), night (asthma LVF, post-nasal drip), morning (smoking), whooping, bovine (laryngeal nerve), croup

•

Sputum – colour, volume, type (purulent, mucoid), blood

•

Haemoptysis – acute (malignancy), chronic (bronchiectasis), pink frothy (pulmonary oedema)

•

Dyspnoea / shortness of breath – onset, nocturnal (asthma/LVF), on waking (COPD), duration, relieving factors, severity, exertional change

•

Wheeze (high pitch) – when, ∆ with coughing, exercise (asthma)

•

Stridor (inspiratory rasp) – onset (respiratory obstruction)

•

Chest pain – nature, intensity, exertional change (chest wall, pleura or mediastinal causes)

•

Sleep apnoea – snoring or waking up dyspnoeic (airway obstruction)

•

Voice change - dysphonia, aphonia

Patient History

Examination Patient sitting upright, general inspection then entire back exam → entire front exam Inspection • General – age, gender, body habitus, oxygen equipment, posture (?dyspnoeic), respiratory distress, cough, sputum •

Hands – clubbing (pus in lungs), peripheral cyanosis, wasting (brachial plexus), pallor in creases

•

Asterixis (CO2 retention)

•

Radial pulse, respiratory rate, breathing (Cheyne-Stokes = alternating, Kussmaul = shallow)

•

Eyes – conjunctival pallor, Horner syndrome (miosis, partial ptosis, lower lid elevation, enopthalmos, anhydrosis)

•

Nose (straight in) – polyps, enlarged turbinates, displaced septum

•

Mouth – central cyanosis, erythema, tonsils, exudates, candidiasis

•

Voice

•

Sinuses – frontal, ethmoidal, maxillary

•

Lymph nodes – cervical & axillary

•

PMH – hay fever, eczema, HIV

•

Trachea – cartilage, tug, deviation

•

Family – atopy, CF, α1-antitrypsin, TB asbestos, same symptoms

•

•

Occupation – asbestos, chemicals

•

Meds – ACEi, β-blockers, NSAIDs

Chest – shape, symmetry, scars, tattoos, scoliosis, pigeon chest, funnel chest, barrel chest, breathing

•

Social – smoking, travel, pets

Red Flags Palpation • Back – chest expansion, tenderness, spring chest (front, back, sides), tactile fremitus • Front – tenderness, tactile fremitus, apex beat (lying) Percussion • Lungs (remember dullness over liver & heart) Auscultation • Breath sounds - vesicular (normal), bronchial (hollow, consolidation) •

Added sounds – stridor (inspiratory, upper airway obstruction) wheezing (narrowed airways), crackles (fine=fibrosis, medium=pulmonary oedema, coarse=pneumonia/COPD), pleural rub (pneumonia, infarction)

•

Vocal resonance

Other • • •

Temperature Pulse oximetry Spirometry – FVC, FEV1, PEFR

•

Haemoptysis – URTI, LRTI, bronchiectasis, bronchial carcinoma

•

Sudden onset dyspnoea – ? PE or pneumothorax

•

Sudden onset stridor – anaphylaxis, inhaled foreign body, acute epiglotitis (may block airway), gas inhalation

Cardiovascular System Presenting Complaints •

•

•

•

Chest pain – crushing (MI), angina (tight, retrosternal, exertional), sharp inspiratory (pericarditis, pleuritic), interscapular (dissecting aneurysm, back pain), acid taste/burping (GI reflux), chest wall (costochondritis, rib fracture, skin) Dyspnoea – precipitating factors, exertional (CCF, angina), orthopnoea (CCF, LVF), paroxysmal nocturnal dyspnoea (LVF, silent MI) Palpitations – fast (SVT, heart cond., hyperthyroid, stress, meds), slow Peripheral oedema – where, when, pitting (CCF), generalised (kidney, liver), unilateral (DVT, lymph obstr.)

•

Syncope / pre-syncope –postural (postural hypotension), lightheaded, sudden collapse (arrhythmia)

•

Sputum – pink frothy (LVF)

•

Leg pain – calf (DVT), exertional (intermittent claudication)

Examination Patient sitting initially and lying at 45° (starting at neck) Inspection Sitting • General – age, gender, comfort, dysmorphism (Downs, Turner, Marfan), mental state, body habitus, oedema •

Surroundings - cigarettes, O2 devices, GTN spray, holter monitor, ECG leads

•

Colour – pallor (anaemia/ vasoconstriction), cyanosis

•

Hydration status

•

Hands – pallor of nail bed, peripheral cyanosis, capillary refill, clubbing (congenital heart disease, IE), xanthomata, signs of infective endocarditis (Janeway lesions, splinter haemorrhages, Osler nodes)

•

Patient History •

•

PMH – HTN, lipids, BMI, diabetes, CKD, AF, previous cardiac events, rheumatic fever, renal disease, Marfan / Downs / Turner syndrome Family – IHD, lipids, HTN, CKD, DM, sudden cardiac death

•

Meds – T4 (angina), β-agonists (↑HR), β-blockers (↓HR)

•

Social – smoking, IV drugs (IE), alcohol (AF, HTN), job (pilot / driver)

Arms - radial pulse (rate, rhythm), radio-radial delay (aortic coarctation, subclavian stenosis), respiratory rate, blood pressure (+pulsus paradoxus)

•

Eyes – xanthelasma, conj. pallor

•

Mouth – central cyanosis, higharched palate (Marfan), gums, dentition (poor → ?IE)

•

Neck (lying 45°) – JVP, carotid pulse (rhythm, character)

Red Flags Chest Lying 45° • Inspection – scars, deformities, pacemaker / defibrillator, visible apex beat •

Palpation - apex beat, thrill (LVF), heave (palpable murmur)

•

Diaphragm of steth (A,P,M,T,axilla) – heart rate, heart sounds (S1, S2, S3, S4), carotid, murmurs (intensity, timing, location, breathing insp→↑right, exp→↑left)

•

Bell of steth – mitral area

•

Left lateral position (MS)

•

Sitting forward holding breath after expiration (AS, AR, pericardial rub)

Abdomen • Palpate – tenderness, masses, organomegaly, AAA • Back Sitting • • • •

Auscultate – aortic, renal, iliac, femoral bruits

Inspect – scars, deformities Palpate – sacral oedema Percuss – lung bases (effusion) Auscultate – lung bases

Lower Limbs • Inspection – varicose veins, colour, trophic ∆s (thin/dry/shiny skin, hair, nails, ulcers), xanthomata, clubbing • Palpation – temp., tenderness, pulses (F, P, PT, DP), pitting oedema

•

Irregularly irregular pulse (arrhythmia e.g. AF)

•

Six Ps (acute limb ischaemia) – pallor, pulseless, pain, paraesthesia, perishing cold

•

Unilateral leg swelling (DVT)

•

Very sudden & severe tearing pain (thoracic aortic dissection)

Musculoskeletal System Presenting Complaints •

Pain – site, symmetry, radiation, mono/polyarticular, acute/chronic, bone, nociceptive/neuropathic, inflammatory/noninflammatory

•

Morning joint stiffness – brief & worse w/ movement (osteoarthritis) vs. prolonged & improved with exercise (rheumatoid arthritis)

•

Muscle stiffness (polymyalgia rheumatica)

•

Joint abnormalities - locking (loose body, meniscal tear), instability (ligamentous stretching / rupture), triggering (tendon thickening)

•

Swelling – location, shape, size, consistency, surface texture, mobility, tenderness, pulsation

•

Tenderness (inflamm., infection)

•

Skin changes – erythema, shiny skin, ulceration, rash (psoriasis, SLE)

•

Loss of function

•

Other symptoms – fever, weight loss, bowel symptoms, urethritis, uveitis, conjunctivitis, dry mouth

Red Flags • • • •

Regular night sweats Unintentional weight loss Constant (day & night) pain >50 or 6 months 2. >4 of the following symptoms persistent for >6 months: o Multi-joint pain o New headaches o ↓memory, concentration o Sore throat o Unrefreshing sleep o Tender cervical/ axillary lymph o Muscle pain nodes

Clinical Approach

Red Flag Symptoms • Sudden onset • Severe and debilitating pain • Fever • Vomiting • Disturbed consciousness • Worse on bending or coughing • Worst in the morning • Neurological symptoms / signs • Young obese female • New headache in elderly Red Flag Signs • Altered consciousness • Altered cognition • Meningism • Abnormal vital signs – BP, temp, RR • Focal neurological signs – pupils, fundi, eye movement • Tender, poorly pulsatile cranial arteries

History • Onset, duration, relation to other symptoms • Attributions – what the patient thinks is the cause, how it is affecting them • Physical features – general health, diet, appetite, systems review • Recent infection e.g. glandular fever Investigation • Medications Tired all the time (TATT) screen • Substance use – alcohol, marijuana, other illicit drugs • Full blood count • Depression/anxiety history • Erythrocyte sedimentation rate • Sleep – quality, snoring, apnoea • Urea, electrolyes, creatinine • Social history – relationships, work, stress, last holiday • Urine culture and microscopy • Sexual history + HIV, Hep C • HIV, hepatitis B and C • Occupational exposure – heavy metals, CO • Liver function tests • Iron studies – serum iron and Examination Ferritin • Lymphadenopathy • Thyroid stimulating hormone • Cardiovascular signs • Glucose • Full mental state examination

Management 1. Treat the pathological condition if one is identified 2. If all tests are normal → possible psychiatric disorder → full psych and mental exams o Usually only mild to moderate psychiatric disorder e.g. depressed mood or anxiety disorder o Consider counselling and cognitive behavioural therapy before medication 3. If still complaining of fatigue despite normal results, consider more detailed tests – cortisol, calcium, magnesium, rheumatoid factor, infection screen (EBV, CMV, lyme disease, tuberculosis), chest X-ray, echocardiogram, sleep studies

Fever • •

Lymphadenopathy Aetiology

Normal body temperature: 36.8 ±0.4°C at ~6am and is higher between 4-6pm Fever: >37.2°C (at 6am, or 37.7°C at 4pm)

Pathogenesis •

↑ hypothalamic set point → ↑body temp. until affector neurons register blood temp. at new set point

Mechanism 1. Pyrogens → release of prostaglandin E2 (PGE2) by hypothalamic endothelial cells 2. ↑PGE2 → release of cAMP by glial cells in the hypothalamus o PGE2 release in peripheral cells → muscle and joint pain 3. ↑cAMP → ↑ set point by neuronal cells in the thermoregulatory centre Muscle/joint pain

Endogenous Pyrogens IL-1, IL-6, TNF-α, IFN- α

↑PGE2 Exogenous Pyrogens Bacteria, endotoxins, hormones, medications

↑cAMP

2. Benign immune disorder o Autoimmine - rheumatoid arthritis, systemic lupus erythematosus o Serum sickness o Drug reactions (e.g. to phenytoin) o Langerhans cell histiocytosis

Vasoconstriction ↑ Set point

Hypothalamus

Shivering

1. Infection o Bacterial – all pyogenic bacteria, syphilis o Mycobacterial – tuberculosis, leprosy o Fungal – histoplasmosis o Chlamydial o Parasitic – toxoplasmosis, trypanosomiasis, filariasis o Viral – Epstein-Barr virus, cytomegalovirus, rubella, hepatitis, HIV

↑"Temperature

↑ Liver metabolism

3. Malignant immune disorder o Leukaemia – acute/chronic, myeloid/lymphoid o Lymphoma – Hodgkin’s, non-Hodgkin’s o Monoclonal gammopathy - multiple myeloma, Waldenström’s macroglobulinaemia o Malignant histiocytosis 4. Other malignancies – breast, lung, melanoma, head & neck, GIT, germ cell

Aetiology 1. Infections – viral bacterial, malaria, syphilis etc. 2. Malignancy – lymphoma, carcinoma 3. Rheumatological disorder – SLE, sarcoid, rheumatoid arthritis 4. Drug fever – reaction with medicine (usually accompanied by rash) 5. Pulmonary embolism (mild fever) 6. Osteomyelitis

5. Lipid storage diseases – Gaucher’s disease, Niemann-Pick disease 6. Endocrinopathies o Thyroid disease - hyperthyroidism; thyroiditis o Andrenal insufficiency 7. Miscellaneous o Sarcoidosis o Amyloidosis o Dermatopathic lymphadenitis

History •

Age, sex, occupation o Children – usually benign e.g. viral, bacterial, toxoplasmosis o > age 50 – incidence of malignant disorders increases significantly

•

Localised symptoms – suggests infection or malignancy

•

Exposure – cats, undercooked meat, travel, unsafe sexual or drug activity

•

Indicators of systemic involvement -suggest tuberculosis, lymphoma or other malignancy o Fever o Night sweats o Unexpected weight loss of >10%

•

Medications – e.g. phenytoin

•

Generalised pruritis

•

Pain – from inflammation

Bleeding

Examination 1. Location – localised or generalised 2. Size o o o

• 2.25$cm$→$38%$malignant

3. Consistency o Hard – malignant leading to fibrosis o Firm/rubbery – lymphoma or chronic lymphocytic lymphoma 4. Fixation - chronic infection or malignancy 5. Tenderness – due to inflammation o Infection → rapid growth within capsule → tenderness o Malignancy → gradual expansion of entire encapsulated node → no tenderness 6. Signs of inflammation over the node 7. Splenomegaly – systemic illness e.g. infectious mononucleosis, lymphoma, leukaemia, SLE, sarcoidosis

Investigations 1. Observe for 3-4 weeks if there are no clues about aetiology 2. Full blood count 3. Serology – EBV, CMV, toxoplasmosis, HIV, Bartonella henselae, syphilis, TB 4. Chest X-ray 5. Biopsy Types of Biopsy 1. Excision biopsy – for when malignancy is suspected and the patient has no history of malignancy 2. Core biopsy – for when lymphoma is suspected and lymph nodes are not easily obtainable 3. Fine needle aspirate (FNA) – to confirm recurrence of malignancy, but not for diagnosis

Who to Biopsy • Patients >40 years • > 2cm in size • Abnormal chest X-ray • Supraclavicular LN involvement • Hard consistency • Generalised pruritis • No symptoms of local/systemic infection

Purpura: bleeding into the skin or mucous membranes o Petechiae: smaller purpuric lesions ≤2mm o Ecchymoses: purpuric lesions >2mm

Aetiology Vessel Wall Abnormalities Platelet count, bleeding time, PT and aPTT are usually normal 1. Infections: meningococcaemia, septicaemia, infective endocarditis, rickets o Microbial damage to microvasculature, or DIC 2. Drug Reactions: usually vascular injury is mediated by deposition of drug-induced immune complexes 3. Scurvy & Ehlers-Danlos Syndrome: microvascular bleeding resulting from defects in collagen Platelet Deficiency Thrombocytopenia: reduced platelet number - 15-20 minutes, typically heavy & crushing, with pallor, sweating or vomiting

Causes Sudden (seconds to minutes) • Pneumothorax • Pulmonary embolism • Pulmonary oedema • Aspiration • Anaphylaxis • Anxiety • Chest Trauma

Aortic Dissection • Usually sudden, severe and midline • Tearing sensation retrosternally and between scapulae • Inequality of carotid, radial and femoral pulses

Most Probable • Asthma • Left heart failure • COPD • Obesity • Lack of fitness

Pulmonary Embolism • Usually retrosternal chest pain • May be associated, with syncope and breathlessness • Massive embolus – hypotension, right heart failure or cardiac arrest Pneumothorax • Acute onset of pleuritic pain and dyspnoea • Often in a patient with a history of asthma or emphysema (due to rupture or a subpleural cyst) Gastrointestinal

Character Site Precipitation Relief

Orthopnoea – breathlessness when lying down lfat Paroxysmal nocturnal dyspnoea – breathlessness causing waking from sleep Tachypnoea – fast breathing Hyperpnoea – increased level of ventilation (e.g. during exertion) Hyperventilation – overbreathing

Acid reflux

Oesophageal spasm

Peptic Ulcer

Gallbladder disease

Burning

Constricting

Gnawing

Deep ache

Epigastric

Retrosternal

Retrosternal

Right hypochondrium

Heavy meals

Food and drink

Eating

Fatty food

Standing Antacids

Antispasmodics GTN

Antacids

Psychogenic • Can occur anywhere in the chest, but often in the left submammary region, usually without radiation • Continuous and sharp / stabbing • May mimic angina but tends to last for hours or days • Usually aggravated by tiredness or emotional tension • May be associated with shortness of breath, fatigue and palpitations

Acute (hours to days) • Asthma • Respiratory infection • Lung tumour • Pleural effusion • Metabolic acidosis

Chronic (months to years) • COPD • Cardiac failure • Anaemia • Arrhythmia • Valvular heart disease • Chest wall deformities • Cystic fibrosis • Pulmonary hypertension

Most Serious • Cardio – AMI, arrhythmia, pulmonary embolism, DA, cardiomyopathy, anaphylaxis • Neoplasia – bronchial carcinoma • Infection – SARS, avian flu, pneumonia • Respiratory – foreign body, obstruction, pneumothorax, pleural effusion, tuberculosis

Assessment History • Identify what the patient means by breathlessness • Onset; provoking factors • Associated symptoms - wheeze (asthma, COPD), cough (pulmonary causes) Examination • Inspection – cyanosis, clubbing, alertness, dyspnoea at rest, use of accessory muscles, rib retraction • Tremor of outstretched hands → CO poisoning • Tracheal displacement - bronchial collapse (toward affected side), pleural effusion, pneumothorax (away) • Chest expansion • Percussion • Breath sounds - vesicular / bronchial • Vocal fremitus • Crackles – LVF, alveolitis, pneumonia, bronchiectasis, chronic bronchitis, asbestosis, pulmonary fibrosis • Wheeze – partial obstruction, asthma, bronchitis, bronchiolitis Investigations • Pulmonary function tests – PEF, FEV1, FVC • Blood count • Arterial blood gases • Pulse oximetry

• • • •

Cardio tests – ECG, echo, cardiac markers Imaging – MRI, CT, V/Q scan Bronchoscopy Lung biopsy

Hoarseness

Abdominal Pain

Aetiology

Aetiology

•

Laryngitis o Assorted viruses – parainfluenza, coronavirus, influenza, rhinovirus, adenovirus o Excessive abuse of voice o Bacteria – Moraxella catarrhalis, haemophilis influenzae o Irritants – cigarette smoke, alcohol, caustic chemicals (e.g. HCl in GORD)

•

Benign laryngeal growths – papillomas, cysts, polyps, chondromas, lipomas, nodules

•

Laryngeal cancer

•

Compression of larynx – e.g. oesophageal cancer

•

Thyroid disease – thyroiditis, goitre

•

Vocal cord pathology o Trauma – blunt, penetrating, iatrogenic (intubation / surgery) o Stenosis / calcification

•

Nerve pathology o Left recurrent laryngeal nerve palsy o Left recurrent laryngeal nerve compression – apical lung cancer, oesophageal cancer o Motor neurone disease

•

Foreign body

History • • • •

• • • •

Nature and duration of hoarseness History of excessive voice straining Respiratory symptoms Symptoms of hypothyroidism - depressed, slow, tired, thin hair, croaky voice, heavy periods, constipation, dry skin, prefers warm weather Medications – corticosteroid inhalations Recent surgery Smoking Exposure to environmental pollutants

Examination • • •

Neck palpation – enlargement of thyroid or cervical nodes Oropharyngeal examination – epiglottis Signs of hypothyroidism – coarse dry hair and skin, slow pulse, mental slowing

Investigations • • • •

Thyroid function tests Chest x-ray (if lung carcinoma is suspected) Indirect/direct laryngoscopy CT if suspected neoplasia/laryngeal tumour

Management • • • • •

Diagnose and treat the cause Vocal rest and minimal usage Avoid irritants e.g. dust, cigarettes, alcohol Cough – consider cough suppressants Consider referral to an ENT specialist if o Acute - unexplained, fail to respond (3-4 weeks) or recur o Chronic (all cases) o Presenting with strider or non-tender lymphadenopathy o Sever vocal abuse (voice therapy is needed)

Inflammation • Inflammatory bowel disease • Appendicitis • Cholecystitis • Pancreatitis • Salpingitis • Diverticulitis Perforation • Duodenal ulcer • Gastric ulcer • Faecal peritonitis • Biliary peritonitis • Appendicitis Obstruction • Biliary colic • Acute small / large bowel obstruction • Ureteric colic • Acute urinary retention • Intestinal infarction

Most Probable - Acute • Gastroenteritis • Appendicitis • Dysmenorrhoea • Irritable bowel syndrome Most Serious - Acute • Cardio – MI, AAA rupture, aortic aneurysm, mesenteric artery occlusion • Neoplasia (bowel obstruction) • Infection – salpingitis, peritonitis, cholangitis, abscess • Ectopic pregnancy • Obstruction • Sigmoid volvulus • Perforation – duodenal ulcer, colonic / Meckel’s diverticulum, colonic cancer

Haemorrhage • Ruptured ectopic pregnancy • Ruptured spleen / liver • Ruptured ovarian cyst • Ruptured AAA Torsion (Ischaemia) • Sigmoid volvulus • Torsion ovarian cyst • Torsion of testes

Most Probable - Chronic • Irritable bowel syndrome • Dysmenorrhoea • Peptic ulcer / gastritis Most Serious - Chronic • Cardio – mesenteric artery ischaemia, AAA • Neoplasia – bowel, stomach, pancreas, ovaries • Infection – hepatitis, PID

Common Causes in Children •

Infantile colic (2 weeks – 16 weeks) – regular, unexplained, inconsolable crying, usually in the afternoon

•

Intussusception (3 months – 2 years) – severe colicky abdominal pain; very serious condition

•

Acute appendicitis (school age / adolescence) – usually occurs with vomiting (80%) or diarrhoea (20%)

•

Mesenteric adenitis – similar Hx to appendicitis, except with high fever and preceding URTI / tonsillitis

•

Child abuse

•

Testicular Torsion

•

Recurrent abdominal pain – three distinct episodes of abdominal pain over 3+ months – occurs in 10% of school-aged children; only 5-10% have an organic cause

Assessment History • SOCRATES o Constant / coming and going o Severity (1-10) o Contributing / relieving factors o Response to milk, food, antacids • Previous attacks with similar pain • Associated symptoms – sweats, chills, burning urination • Bowel motions – constipation, diarrhoea, blood • Urine • Medications – aspirin • Smoking, alcohol, drugs • Recent travel • Menstrual history • Past medical history – e.g. appendectomy

Pain Patterns Examination • General appearance • Oral cavity • Vital signs • Heart & lungs • Abdomen – inspection, palpation, percussion, auscultation • Inguinal region – hernias • DRE • Vaginal examination – for suspected problem with fallopian tubes, uterus, ovaries • Thoracolumnar spine – referred spinal pain • Urine analysis – WBC, RBC, glucose, ketones, porphyrins

Investigations • Haemoglobin - ↓ → anaemia due to chronic blood loss (peptic ulcer, carcinoma, oesophagitis • Blood film – e.g. sickle cell anaemia • WCC – leukocytosis → appendicitis, pancreatitis, mesenteric adenitis, cholecystitis, pyelonephritis • ESR - ↑ → carcinoma, Crohn’s, abscess • CRP - ↑ →$infection, inflammation • LFTs – hepatobiliary disease • Serum • Abdominal X-ray – see features → • ECG • Upper GIT endoscopy • Sigmoidoscopy / colonoscopy

Acute Pain

Chronic Pain

Red Flag Features Symptoms • Collapsing at toilet → intra-abdominal bleeding • Lightheadedness • Progressive intractable vomiting • Progressive abdominal distension • Progressive intensity of pain • Prostration (appearance of praying)

Timing • Colicky pain: rhythmic pain with regular spasms of recurring pain building to climax then fading • Usually indicative of intestinal obstruction

Signs • • • • • •

Pallor & sweating Hypotension Atrial fibrillation / tachycardia Fever Rebound tenderness & guarding Decreased urine output

Constipation

Diarrhoea

Aetiology • • • •

Dietary/exercise causes Dehydration Faecal impaction Intestinal obstruction

• • • •

Volvulus Irritable bowel syndrome Depression Anorexia nervosa

History • • • •

Ask patient what they mean by ‘constipation’ Diet Medications Lumps in the perianal area

• • • •

Acute appendicitis Spinal cord compression Hypokalaemia Hypercalcaemia

Examination • •

Digital rectal examiniation – always Abdominal examination

•

A relative increase in stool volume, frequency and/or fluidity (compared to normal) Technically – stool weight >200g / day (difficult to assess)

•

Consider: frequency, volume, consistency, content, colour, smell

•

Consequences– dehydration, electrolyte loss, cardiovascular collapse, chronic malnutrition

Classification By Time Course •

Acute ( 4 weeks) o Many causes (chronic infection, hormones, enzyme dysfunction, osmosis) o Usually watery, fatty or inflammatory o Generally causes damage to gut mucosa

Investigations

Bowel Motions • What are they normally like? • Frequency • Consistency - bulky, hard, soft • Pain on opening bowels • Blood • Soiling in underwear (?incontinence)

• • • •

Endoscopy Stool – occult blood biochemistry, culture Radiological studies – e.g. barium enema Physiological tests o Anal manometry – testing anal tone o Rectal sensation and compliance

Management Advice • Adequate exercise • Plenty of fluids – water, prune juice • Optimal bulk diet – fruits, vegetables, cereals • Defecate as soon as possible when the need strikes • Avoid laxatives and codeine compounds Medication 1. First line – bulking agent e.g. psyllium 2. Second line – osmotic laxative or fibre-based stimulant preparation (e.g. sorbitol) 3. Third line – magnesium sulphate

By Location •

Small Intestinal – large volume; usually malabsorptive or secretory

•

Colonic – smaller volume but frequent; usually exudative, loss of electrolytes, osmotic, nervous.

Pathogenesis (DOMES)

Mechanism

Examples

Deranged Motility

Dysfunction of neuromuscular control Decreased transit time (↓ absorption)

Hyperthyroidism, IBS, diabetic neuropathy

Osmotic

Osmotic pressure generated by non-absorbed molecules draws water into lumen

Lactose intolerance, laxatives

Correlates with ingestion of food (slows with fasting)

Malabsorptive

Impaired absorption Often ↓ fat absorption (steatorrhoea) Slows with fasting

Physical blanketing (Giardia), reduced surface are (coeliac disease), mal-digestion (pancreatic insufficiency)

Exudative

Inflammation & destruction of mucosa Small volume, high frequency Blood/pus/mucus in stools Persists with fasting

Inflammatory bowel disease, Infection (shigella/ entamoeba)

Secretory

Secretion > absorption Large volume stools, no blood/pus/mucus Persists with fasting

Enterotoxin-mediated (cholera), hormonal, villous adenoma

Aetiology •

Infection – bacterial, viral, parasitic

•

Bowel inflammation – inflammatory bowel disease, appendicitis, diverticulitis, ischaemic colitis

•

Colorectal cancer

•

Drugs – alcohol, antibiotics, antihypertensives, cytotoxic agents, heavy metals, H2 receptor antagonists, iron-containing compounds, laxatives, metformin, NSAIDs, quinidine, salicylates, statins, theophylline

•

Malabsorption – coeliac disease, lactase deficiency, tropical sprue, pancreatic insufficiency

Jaundice • • • •

Yellowish colouration of the body due to build-up of bilirubin (hyperbilirubinaemia), also known as icterus A symptom, not a disease Clinically noticeable (in the skin/sclera of the eyes) at plasma [bilirubin] > 50μmol/L Increased bilirubin can be from disturbance in heme catabolism or in conjugation/excretion of bilirubin

Aetiology heme oxygenase

Macrophages

reductase

Hemoglobin

•

Endocrine – hyperthyroidism, diabetic neuropathy

•

Psychogenic – irritable bowel syndrome

Diagnosis

Frequency

•

Associated symptoms – abdominal pain, fever, nausea, vomiting

•

Food intake in the past 72 hours – chicken (Salmonella, Campylobacter), seafood (Vibrio)

•

Recent travel abroad

•

Medications – antibiotics

•

Normal diet (if chronic) – milk, alcohol, vitamin C supplementation, wheat

Examination •

GIT examination – especially for masses, hepatomegaly, splenomegaly, tenderness, skin changes, iritis

•

Stool examination - blood, mucus, steatorrhoea

Investigations •

Stool microscopy, culture and sensitivity

•

Blood tests – FBC, iron studies, folate, B12, calcium, electrolytes, thyroid function tests, HIV tests

•

Antibodies – e.g. transglutenaminade for coeliac disease

•

Malabsorption studies

•

Endoscopy – proctosigmoidoscopy, flexible sigmoidoscopy + biopsy, small bowel biopsy (coeliac)

•

Radiology – barium enema

Unconjugated Bilirubin

pre-hepatic Jaundice

Globin (protein) Plasma

disturbance causes unconjugated hyperbilirubinaemia

Unconjugated Bilirubin (bound to albumin)

Liver 1. Uptake

History • Nature o Amount – small volume (inflammation, cancer), large volume (laxative abuse, malabsorption) o Consistency – liquid (gastroenteritis), bulky/pale (malabsorption) etc. o Blood – present (more likely to be bacterial), profuse (diverticulitis, cancer) o Mucus – inflammatory bowel disease •

Biliverdin biliverdin

Heme

Unconjugated Bilirubin + 2 glucuronic acid UDP-glucuronyl

hepatic Jaundice

transferase

2. Conjugation

Conjugated Bilirubin 3. Excretion

Bile.

post-hepatic Jaundice

Conjugated Bilirubin

Duodenum Unconjugated Bilirubin

disturbance causes conjugated hyperbilirubinaemia

Conjugated Bilirubin

Urobilinogen through plasma

Colon

(80-90%) Urobilinogen

Stercobilinogen Stercobilin (colours stools)

Kidney Urobilinogen (10-20%) Urobilin (colours urine)

If there is blockage of the flow of bile (conjugated bilirubin) then these result: •

Pale stools - ↓bile in the duodenum → ↓stercobilin (stool pigment) excretion

•

Dark Urine - ↑ conjugated bilirubin backflows into liver and is taken up by the kidney$→↑urobilin (urine pigment)

Upper Gastrointestinal Bleeding

Pre-Hepatic Jaundice • Excessive bilirubin production from Haemolysis, glomerular nephritis etc. • ↑ unconjugated bilirubin in blood • ↑ urobilinogen in urine & stools • Normal urine and stool colour

• • •

Hepatic Jaundice • Impaired liver function or hepatocellular damage from hepatitis, toxins, cirrhosis • Three processes that can be affected

Aetiology • • • • •

1. ↓Uptake + ↑ unconjugated bilirubin in blood + Normal urine colour, pale stools 2. ↓Conjugation + ↑ unconjugated bilirubin in blood + Normal urine colour, pale stools

• • • •

3. ↓Excretion (hepatic cholestasis) + ↑$conjugated bilirubin in blood + Dark urine & pale stools Post-Hepatic Jaundice • Blockage of outflow from liver from gallstones, head of pancreas cancer • ↑ unconjugated bilirubin in blood • Dark urine & pale stools

Hepatic

Bilirubin in Plasma

Urine

Stool

AST/ALT

ALP

Urine Bilirubin

Urine Urobilinogen

Unconjugated

Normal

Normal

Normal

Normal

Absent

↑$

↓Uptake

Unconjugated

Normal

Pale

↓Conjugation

Unconjugated

Normal

Pale

Conjugated

Dark

Pale

Conjugated

dark

pale

↓Excretion Post-Hepatic

! ! !

Gastritis Ulcer – gastric, duodenal, stomal (can be caused by NSAIDs, alcohol) GORD Oesophageal varices – due to portal hypertension (usually due to cirrhosis) Mallory-Weiss syndrome o Tears at lower end of oesophageal mucosa due to an episode of severe vomiting / coughing o Blood in vomitus after a bout of heavy vomiting / dry retching o Usually seen in alcoholic patients Carcinoma - gastric / oesophageal Anticoagulant therapy Vascular malformations Hereditary haemorrhagic telangiectasia

Assessment

Differential Diagnosis

Pre-Hepatic

Haematemesis: vomiting of blood (fresh blood or ‘coffee ground’) Melaena: black tarry stools with distinctive odour Severe upper GI haemorrhage is life-threatening (melaena is less life-threatening than haematemesis)

↑$

Normal

↑$

↓$

Normal

↑$

↑$

Absent

History • Amount and appearance of vomit - black dots like coffee grounds? • Indigestion, heartburn, stomach pain • Appearance of stools • Medications – especially aspirin and NSAIDs; also prednisolone, warfain, clopidogrel, SSRIs • Alcohol history • Previous operations on stomach – especially for peptic ulcer • History of normal vomiting before blood in vomit Examination • General state – haemodynamic status (heart rate, blood pressure, postural change) • Abdominal examination including DRE – looking for a mass, hepatomegaly or splenomegaly Investigations • Upper GIT endoscopy – detects cause in >80% of cases • Haemoglobin - 2,000 RBCs / mL urine using light microscopy o Glomerular (from kidney parenchyma) or non-glomerular (urinary tract) o Athletes can develop transient microscopic haematuria following vigorous exercise

•

Often a sign of a serious underlying disorder

Aetiology •

Infection – cystitis, urethritis, vaginitis, prostatitis, urethral syndrome (males), gonorrhea, genital herpes

•

Neoplasia – bladder, prostate, urethra

•

Calculi – e.g. in the bladder

•

Foreign body in lower urinary tract

•

Acidic urine

•

Vaginal prolapse

•

Obstruction – BPH, urethral stricture, phimosis, meatal stenosis

Most Likely • Cystitis (females) • Urethritis • Vaginitis Most Serious • Neoplasia • Severe infection • Reiter’s Syndrome • Calculi

Aetiology • • • • • • • • •

Assessment History • Description of discomfort o Timing i. Pain at onset of micturition  urethritis ii. Pain at end of micturition  cystitis o Location - suprapubic  cystitis • Colour of urine • Discharge – could it be sexually acquired • Painful intercourse (women) • Systemic features – fever, sweats, chills Examination • Vitals – HR, temp, BP • Abdominal palpitation – loins & suprapubic area • Vaginal, rectal, genital examination – may be appropriate Investigations • Urine dipstick • Urine microscopy & culture (midstream)

•

Contamination of urine specimen Infection – bladder, kidneys, urethra, epididymis, testes Coagulopathy Vascular – endothelial injury Necrosis Autoimmune / inflammatory – nephritic / nephrotic syndrome Neoplasia – prostate, kidney, bladder, external genitalia Benign prostatic hyperplasia Trauma o Blunt abdominal trauma o Penetrative trauma o Iatrogenic - surgery, catheterization, self-inflicted o Kidney stones Fistula – labour complications, Crohn’s disease

Non-Blood Causes of Dark Red Urine • Dietary colour – beetroot, berocca, berries, confectionary • Drugs – rifampicin, phenolphthalein • Porphyria • Breakdown products – bilirubin, myoglobin, free haemoglobin

Most Likely • Infection – cystitis, urethritis, prostatitis • Calculi – kidney, ureter, bladder Most Serious • Cardiovascular – kidney infarction, kidney vein thrombosis, prostatic varices • Neoplasia – kidney, urothelium, prostate • Severe infection – IE, kidney tuberculosis, acute glomerulonephritis • IgA nephropathy • Kidney papillary necrosis

History •

Is it really haematuria – could be haemolysis / red food dye / breakdown products

•

Trauma to loin, pelvis, genital area

•

Timing o First part of stream  urethral / prostatic lesion o Terminal  bladder

•

Associated symptoms o Pain  infection, calculi, kidney infarction o Painless  infection, trauma, tumours, polycystic kidneys o Frequency o Bleeding elsewhere – skin, nosebleeds

•

Possibility of the condition being sexually acquired

•

History of kidney problems

•

History of diabetes

Examination

Proteinuria • •

Can originate from the glomeruli, tubules or lower urinary tract Healthy people excrete some protein in the urine, which can vary from day-day or hour-hour Microalbuminuria

Macroalbuminuria

Albumin / creatinine ratio

F: 3.6-35 mg/mmol M: 2.6-25 mg/mmol

F: >35 mg/mmol M: >25 mg/mmol

Dipstick

>3mg/dL (albumin)

>20mg/dL

Protein / creatinine ratio

-

Proteinuria 1+ or more

-

>0.3 g/24 hours

Aetiology •

Transient - benign o Contamination from vaginal secretions o Urinary tract infection o Pre-eclampsia

•

Kidney disease o Glomerulonephritis o Nephrotic syndrome o Congenital tubular disease – polycystic kidney, kidney dysplasia o Acute tubular damage o Kidney papillary necrosis o Overflow proteinuria o Systemic diseases – DM, HTN, SLE, malignancy, drugs

•

Non-kidney disease o Orthostatic proteinuria o Exercise o Fever o Post-operative o Heart failure

Investigations •

Urine dipstick

•

Urine microscopy o Formed RBCs  true haematuria o Red cell casts  glomerular bleeding o Dysmorphic RBCs  glomerular bleeding

•

Urine culture

•

Urine cytology – to detect malignancies of the bladder / lower UT (not kidney)

•

Blood tests – FBC, ESR, urea, creatinine

•

Radiology o IV urography (UVI) o Ultrasound – better for kidneys than lower UT o CT o Kidney angiography o Retrograde pyelography

•

Direct imaging – urethroscopy, cystoscopy

•

Kidney biopsy – indicated if glomerular disease is suspected

Orthostatic Proteinuria • •

Significant proteinuria after the patient has been standing but absent after sitting for several hours Occurs in 5-10% of people, especially during adolescent years

Diabetic Microalbuminuria • •

Presence of small amounts of protein in urine is a sensitive marker of diabetic nephropathy Dipstick is helpful, radioimmunoassay is better

Consequences of Proteinuria >3g / 24 hours • Oedema • Intravascular volume depletion • Venous thromboembolism • Hyperlipidaemia • Malnutrition

Urinary Incontinence • • • • • • •

Urinary incontinence: involuntary urine loss during the day / night Nocturnal enuresis (bed-wetting): involuntary urine loss during sleep Urge incontinence: urgent desire to void followed by involuntary urine loss Overactive bladder (detrusor instability): involuntary bladder contractions  sudden urge to urinate Stress incontinence: involuntary urine loss on coughing, sneezing, straining, lifting Voiding dysfunction: urinary difficulties, detrusor instability, overflow incontinence Function incontinence: loss of urine secondary to factors outside of the urinary tract

Aetiology DIAPPEERSS • Delerium •

Infection of urinary tract

•

Atrophic urethritis

•

Pharmacological – e.g. diuretics

•

Psychological – acute distress

•

Endocrine – e.g. hypercalcaemia

•

Environmental – e.g. unfamiliar sounds

•

Restricted mobility

•

Stool impaction

•

Sphincter damage / weakness

Management •

Exclude UTI & drug causes

Stress Incontinence • Weak pelvic floor – exercises • Obesity – weight reduction • Menopause – HRT / vaginal oestrogen creams • Chronic cough – physiotherapy Urge Incontinence • Neurological signs  neurologist • Abnormal voiding pattern  bladder retraining Voiding dysfunction • Neurological signs  neurologist • Gynaecological cause  gynaecologist • Bladder atony  anticholinergics

Lower Back Pain • • •

• •

The most common cause of back pain in people 45 years 60-80% of people will experience lower back pain in their lives Grading: o Acute: 12 weeks Predisposition to lower back pain is mostly inherited Work has been shown to contribute up to 25% of variance in lower back pain

Causes 1. IV discs o Degeneration o Herniation

Mechanical – Bones, discs, SC, nerves Non-mechanical – inflammatory, infective, neoplastic Non-spinal – viscerogenic, psychogenic

2. Vertebrae o Spondylolisthesis (forward displacement of a vertebral body onto another) o Scheuermann’s kyphosis (adolescents – vertebral wedging, schmorl’s nodes, disc degeneration) o Fractures (may be from osteoporosis) o Spinal stenosis o Infection o Tumours o Osteomalacia o Paget’s disease 3. Spinal Cord a. Epidural abcess b. Intradural tumours 4. Joints o Apophyseal osteoarthritis (facet joints) o Rheumatoid arthritis o Ankylosing spondylitis (chronic inflammation of spinal and sacroilial joints that leads to joint fusion) o Chondrocalcinosis (accumulation of calcium pyrophosphate dehydrate crystals in CT) 5. Misalignments – postural, differences in leg length, misaligned pelvis, abnormal foot pronation 6. Referred Pain – from pelvic or abdominal organs 7. Psychogenic/Neurogenic – stress, depression

Risk Factors • • • • • •

Family history Heavy manual work Sedentary lifestyle Obesity, tallness Low socioeconomic status Stress

Red Flags • • • • • • • •

Age >50 years History of cancer Unexplained weight loss Unexplained fever Steroid or IV drug use Severe, unremitting pain at night Significant trauma No improvement over 1 month

Clinical Features

Treatment

Nature of Pain

• Nature of Pain Aching throbbing pain Deep diffuse aching pain Superficial steady diffuse pain Boring deep pain Intense sharp or stabbing pain

Likely Cause Inflammation Referred pain Local pain Bone disease Radicular pain

Examples Sacroileitis Dysmenorrhoea Muscular strain Neoplasia, Paget’s disease Sciatica

Inflammatory vs. Mechanical Causes History

Inflammation Insidious onset

Nature

Aching, throbbing

Stiffness Effect of rest Effect of activity Radiation Intensity

Severe, prolonged morning stiffness Exacerbates Relieves More localised, bilateral or alternating Night, early morning

Major Conditions to Exclude Can cause major morbidity or mortality • Fractures (4%) • Tumours (1%) • Infections (5cms)

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