2016 SAMPLE Clinical Revision Course Dr. Jake Mann One 2 One - - PowerPoint PPT Presentation

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2016 SAMPLE Clinical Revision Course Dr. Jake Mann One 2 One - - PowerPoint PPT Presentation

Sep 02, 2022 418 likes •904 views

@One2OneMedicine #O2OMClin One 2 One Medicine 2016 SAMPLE Clinical Revision Course Dr. Jake Mann One 2 One Medicine: Clinical revision course 2016 Course outline 7. Confusion 1. Abdominal pain 8. Cough 2. Blackout SAMPLE 9. Dizziness 3.

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One 2 One Medicine: Clinical revision course 2016

One 2 One Medicine

  • Dr. Jake Mann

#O2OMClin @One2OneMedicine

Clinical Revision Course 2016 SAMPLE

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One 2 One Medicine: Clinical revision course 2016

  • 1. Abdominal pain
  • 2. Blackout
  • 3. Bloating
  • 4. Change in bowel

habit

  • 5. Chest pain
  • 6. Coma
  • 7. Confusion
  • 8. Cough
  • 9. Dizziness

10.Fall 11.GI bleed 12.Headache 13.Itch

Course outline

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One 2 One Medicine: Clinical revision course 2016

A 19-year old geography student presents to his GP with a change in bowel habit.

Case presentation

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SAMPLE

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One 2 One Medicine: Clinical revision course 2016

He has been passing loose stool with occasional blood up to 7x per day for the last 2 weeks.

Case history

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One 2 One Medicine: Clinical revision course 2016

  • PMHx: nil, no surgery
  • FHx: nil
  • Drugs: nil, NKDA
  • Social: independent, lives in halls, drinks alcohol

‘occasionally’

Case history

SAMPLE

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One 2 One Medicine: Clinical revision course 2016

What examination findings would help?

Difgerential diagnosis of a change in bowel habit

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SAMPLE

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One 2 One Medicine: Clinical revision course 2016

  • Alert, well, sat up
  • Thin, not cachetic
  • Mildly tender abdomen. No masses.
  • Normal bowel sounds.

Case examination

SAMPLE

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One 2 One Medicine: Clinical revision course 2016

  • PMHx: nil, no surgery
  • FHx: nil
  • Drugs: nil, NKDA
  • Social: independent, lives in a halls, drinks alcohol ‘occasionally’
  • Alert, well, sat up. Thin, not cachectic. Mildly tender abdomen. No
  • masses. Normal bowel sounds.

A 19-year old geography student presents to his GP with a change in bowel habit. He has been passing loose stool with occasional blood up to 7x per day for the last 3 weeks.

Differential diagnosis?

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One 2 One Medicine: Clinical revision course 2016

  • Infectious
  • Bacterial
  • Diverticulitis
  • Inflammatory
  • Inflammatory bowel disease
  • Ischaemic

Investigations?

[Cancer?]

Difgerential diagnosis of colitis

SAMPLE

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One 2 One Medicine: Clinical revision course 2016 Result

Range

Hb 91

115 - 160 g/L

MCV 77

80 - 96 fL

WCC 17.6

4.0 - 11.0 cells x109/L

Neut 9.4

2.0 - 7.5 cells x109/L

Platelets 578

150 - 400 cells x109/L

Na+ 146

135 - 146 mmol/L

K+ 5.0

3.5 - 5.5 mmol/L

Urea 9.3

2.5 - 6.7 mmol/L

ALT 41

3 - 40 IU/L

ALP 130

39 - 117 IU/L

Bili 16

1 - 17 μmol/L

ESR 79

0 - 29 mm/hr

Case investigations

SAMPLE

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One 2 One Medicine: Clinical revision course 2016

Treated with IV hydrocortisone and antibiotics. Begins to make a recovery and undergoes colonoscopy.

Case developments

SAMPLE

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One 2 One Medicine: Clinical revision course 2016

Case investigations

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One 2 One Medicine: Clinical revision course 2016

Case investigations

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One 2 One Medicine: Clinical revision course 2016 Ulcerative colitis Crohn’s disease Continuous segment ‘Skip’ lesions Mucosal inflammation Transmural inflammation Colon only Anywhere in GIT No granulomas Granulomatous No fistulae Fistulates

Ulcerative colitis vs. Crohn’s disease

SAMPLE

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One 2 One Medicine: Clinical revision course 2016

Crohn’s disease

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SAMPLE

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One 2 One Medicine: Clinical revision course 2016

Crohn’s disease

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One 2 One Medicine: Clinical revision course 2016

Crohn’s disease

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One 2 One Medicine: Clinical revision course 2016

Crohn’s disease - fistulae

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SAMPLE

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One 2 One Medicine: Clinical revision course 2016

Crohn’s disease - fistulae

  • Treat infection
  • Remove distal obstruction
  • Reduce flow
  • (Rehydrate)

SAMPLE

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One 2 One Medicine: Clinical revision course 2016

Extraintestinal manifestations

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One 2 One Medicine: Clinical revision course 2016

Extraintestinal manifestations

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One 2 One Medicine: Clinical revision course 2016

Extraintestinal manifestations

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One 2 One Medicine: Clinical revision course 2016

Extraintestinal manifestations

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SAMPLE

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One 2 One Medicine: Clinical revision course 2016

Long term remission achieved with azathioprine (after failure of trial of sulfasalazine).

Case developments

SAMPLE

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One 2 One Medicine: Clinical revision course 2016

Admitted to A&E with GCS 11/15, 38.7 degrees, crackles at right lung base, HR 142 bpm, BP 70/48, central capillary refill = 4s.

Case developments

SAMPLE

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One 2 One Medicine: Clinical revision course 2016 Result

Range

Hb 91

115 - 160 g/L

MCV 77

80 - 96 fL

WCC 1.5

4.0 - 11.0 cells x109/L

Neut 0.1

2.0 - 7.5 cells x109/L

Platelets 621

150 - 400 cells x109/L

CRP 278

<5 mg/L

Case investigations

SAMPLE

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One 2 One Medicine: Clinical revision course 2016

SAMPLE

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One 2 One Medicine: Clinical revision course 2016

Shock

Cardiogenic Obstructive Distributive Hypovolaemic

Neurogenic Anaphylactic Septic SAMPLE

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One 2 One Medicine: Clinical revision course 2016

  • 1. Blood cultures
  • 2. Lactate & Hb
  • 3. Urine output
  • 4. Oxygen
  • 5. Antibiotics
  • 6. Fluid challenge

Septic shock

SAMPLE

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One 2 One Medicine: Clinical revision course 2016

  • Gram positive or negative bacteria
  • Culture everything
  • Broad spectrum antibiotics
  • E.g. Tazobactam-piperacillin + vancomycin
  • ± Anti-fungals

Neutropenic sepsis

SAMPLE

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One 2 One Medicine: Clinical revision course 2016

Makes a full recovery with appropriate treatment. Maintained on steroids, ciclosporin, & infliximab. Good disease control is achieved.

Case developments

SAMPLE

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One 2 One Medicine: Clinical revision course 2016

Attends annual review feeling generally well but slightly tired. Abdomen soft.

Case developments

SAMPLE

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One 2 One Medicine: Clinical revision course 2016 Result

Range

Hb 120

115 - 160 g/L

WCC 10.1

4.0 - 11.0 cells x109/L

Neut 6.4

2.0 - 7.5 cells x109/L

Platelets 132

150 - 400 cells x109/L

Na+ 135

135 - 146 mmol/L

K+ 5.2

3.5 - 5.5 mmol/L

Urea 6.1

2.5 - 6.7 mmol/L

ALT 82

3 - 40 IU/L

ALP 856

39 - 117 IU/L

Bili 78

1 - 17 μmol/L

ESR 41

0 - 29 mm/hr

Case investigations

SAMPLE

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One 2 One Medicine: Clinical revision course 2016

Case investigations

USS abdomen: Dilated intrahepatic ducts, multiple strictures in extrahepatic ducts. No masses seen. Coarse liver edge. Anti-mitochondrial antibody - negative

SAMPLE

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One 2 One Medicine: Clinical revision course 2016

SAMPLE

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One 2 One Medicine: Clinical revision course 2016

  • Hepatitic: very high ALT/AST, slightly high ALP/bili/GGT
  • Cholestatic: very high ALP/bili/GGT, slightly high ALT/AST
  • Mixed

Liver function test - ‘pictures’

SAMPLE

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One 2 One Medicine: Clinical revision course 2016

Hepatitic Cholestatic Alcoholic liver disease Gallstones Non-alcoholic fatty liver disease Drugs Viral hepatitis Primary sclerosing cholangitis Paracetamol overdose Primary biliary cirrhosis Other Cancer

Difgerential diagnosis of abnormal LFT

SAMPLE

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One 2 One Medicine: Clinical revision course 2016

Case investigations

SAMPLE

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One 2 One Medicine: Clinical revision course 2016

Case investigations

Liver biopsy shows gross architectural disruption with regenerative nodules and bands of fibrosis. ‘Onion skin’ fibrosis around portal tracts.

SAMPLE

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One 2 One Medicine: Clinical revision course 2016

Case developments

SAMPLE

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One 2 One Medicine: Clinical revision course 2016

#O2OMClin

Cirrhosis Portal hypertension Hepatic failure Features of chronic liver disease

Decompensation

  • Encephalopathy
  • Coagulopathy
  • Hypoglycaemia

Chronic liver disease

SAMPLE

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One 2 One Medicine: Clinical revision course 2016 19-years old Increases risk of IBD 2 weeks Less likely to be infective Thin, not cachectic Less likely to be Crohn’s Mildly tender abdomen Not life-threatening colitis

Case summary - history & examination

SAMPLE

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One 2 One Medicine: Clinical revision course 2016 Microcytic anaemia Due to blood loss Raised WCC, platelets, ESR Due to inflammatory response ± infection Raised urea Dehydration from diarrhoea & bleeding

Case summary - investigations

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One 2 One Medicine: Clinical revision course 2016 HR 142, BP 70/48, CRT = 4s Septic shock due to pneumonia with neutropenia Neutrophils = 0.1 Agranulocytosis due to azathioprine ALP 856, bili 78, ALT 82 PSC associated with UC Dilated intrahepatic ducts Obstruction to bile drainage Anti-mitochondrial antibody negative Not PBC ‘Onion skin’ fibrosis Cirrhosis due to PSC

Case summary - developments

SAMPLE

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One 2 One Medicine: Clinical revision course 2016

Exam tips

When you read… Think about… Tender bruises on shin Erythema nodosum ‘Skip lesions’ on colonscopy Crohn’s disease Transmural inflammation with granulomas

SAMPLE

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One 2 One Medicine: Clinical revision course 2016

Exam tips

When you read… Think about… Positive anti-mitochondrial antibody Primary biliary cirrhosis ‘Beads on a string’ appearance on ERCP Primary sclerosing cholangitis

SAMPLE

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One 2 One Medicine: Clinical revision course 2016

Additional points

  • Acute colitis: do abdominal XR for toxic megacolon (dilated

transverse)

  • Low TPMT predisposes patients to neutropenia with

azathioprine

  • Surveillance colonscopy needed for all IBD with colitis and

PSC patients

  • Ursodeoxycholic acid used to help biliary drainage patients

with PSC and PBC

SAMPLE