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

Sep 02, 2022 •418 likes •901 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.

  1. @One2OneMedicine #O2OMClin One 2 One Medicine 2016 SAMPLE Clinical Revision Course Dr. Jake Mann One 2 One Medicine: Clinical revision course 2016

  2. Course outline 7. Confusion 1. Abdominal pain 8. Cough 2. Blackout SAMPLE 9. Dizziness 3. Bloating 10.Fall 4. Change in bowel habit 11.GI bleed 5. Chest pain 12.Headache 6. Coma 13.Itch One 2 One Medicine: Clinical revision course 2016

  3. Case presentation SAMPLE A 19-year old geography student presents to his GP with a change in bowel habit . #O2OMClin One 2 One Medicine: Clinical revision course 2016

  4. Case history SAMPLE He has been passing loose stool with occasional blood up to 7x per day for the last 2 weeks. One 2 One Medicine: Clinical revision course 2016

  5. Case history - PMHx: nil, no surgery - FHx: nil SAMPLE - Drugs: nil, NKDA - Social: independent, lives in halls, drinks alcohol ‘occasionally’ One 2 One Medicine: Clinical revision course 2016

  6. Di fg erential diagnosis of a change in bowel habit SAMPLE What examination findings would help? #O2OMClin One 2 One Medicine: Clinical revision course 2016

  7. Case examination - Alert, well, sat up SAMPLE - Thin, not cachetic - Mildly tender abdomen. No masses. - Normal bowel sounds. One 2 One Medicine: Clinical revision course 2016

  8. 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. - PMHx: nil, no surgery - FHx: nil SAMPLE - 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. Di ff erential diagnosis? One 2 One Medicine: Clinical revision course 2016

  9. Di fg erential diagnosis of colitis - Infectious - Bacterial SAMPLE - Diverticulitis Investigations? - Inflammatory - Inflammatory bowel disease - Ischaemic [Cancer?] One 2 One Medicine: Clinical revision course 2016

  10. Case investigations Result Range Hb 91 115 - 160 g/L MCV 77 80 - 96 fL WCC 17.6 4.0 - 11.0 cells x10 9 /L SAMPLE Neut 9.4 2.0 - 7.5 cells x10 9 /L 578 Platelets 150 - 400 cells x10 9 /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 41 ALT 3 - 40 IU/L ALP 130 39 - 117 IU/L 16 Bili 1 - 17 μ mol/L ESR 79 0 - 29 mm/hr One 2 One Medicine: Clinical revision course 2016

  11. Case developments SAMPLE Treated with IV hydrocortisone and antibiotics. Begins to make a recovery and undergoes colonoscopy. One 2 One Medicine: Clinical revision course 2016

  12. Case investigations SAMPLE One 2 One Medicine: Clinical revision course 2016

  13. Case investigations SAMPLE One 2 One Medicine: Clinical revision course 2016

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

  15. Crohn’s disease SAMPLE #O2OMClin One 2 One Medicine: Clinical revision course 2016

  16. Crohn’s disease SAMPLE One 2 One Medicine: Clinical revision course 2016

  17. Crohn’s disease SAMPLE One 2 One Medicine: Clinical revision course 2016

  18. Crohn’s disease - fistulae SAMPLE #O2OMClin One 2 One Medicine: Clinical revision course 2016

  19. Crohn’s disease - fistulae - Treat infection SAMPLE - Remove distal obstruction - Reduce flow - (Rehydrate) One 2 One Medicine: Clinical revision course 2016

  20. Extraintestinal manifestations SAMPLE #O2OMClin One 2 One Medicine: Clinical revision course 2016

  21. Extraintestinal manifestations SAMPLE #O2OMClin One 2 One Medicine: Clinical revision course 2016

  22. Extraintestinal manifestations SAMPLE #O2OMClin One 2 One Medicine: Clinical revision course 2016

  23. Extraintestinal manifestations SAMPLE #O2OMClin One 2 One Medicine: Clinical revision course 2016

  24. Case developments SAMPLE Long term remission achieved with azathioprine (after failure of trial of sulfasalazine). One 2 One Medicine: Clinical revision course 2016

  25. Case developments SAMPLE 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. One 2 One Medicine: Clinical revision course 2016

  26. Case investigations Result Range Hb 91 115 - 160 g/L SAMPLE MCV 77 80 - 96 fL WCC 1.5 4.0 - 11.0 cells x10 9 /L Neut 0.1 2.0 - 7.5 cells x10 9 /L 621 Platelets 150 - 400 cells x10 9 /L 278 CRP <5 mg/L One 2 One Medicine: Clinical revision course 2016

  27. SAMPLE One 2 One Medicine: Clinical revision course 2016

  28. Cardiogenic Obstructive Septic SAMPLE Shock Hypovolaemic Distributive Anaphylactic Neurogenic One 2 One Medicine: Clinical revision course 2016

  29. Septic shock 1. Blood cultures 2. Lactate & Hb SAMPLE 3. Urine output 4. Oxygen 5. Antibiotics 6. Fluid challenge One 2 One Medicine: Clinical revision course 2016

  30. Neutropenic sepsis - Gram positive or negative bacteria - Culture everything SAMPLE - Broad spectrum antibiotics - E.g. Tazobactam-piperacillin + vancomycin - ± Anti-fungals One 2 One Medicine: Clinical revision course 2016

  31. Case developments SAMPLE Makes a full recovery with appropriate treatment. Maintained on steroids, ciclosporin, & infliximab. Good disease control is achieved. One 2 One Medicine: Clinical revision course 2016

  32. Case developments SAMPLE Attends annual review feeling generally well but slightly tired. Abdomen soft. One 2 One Medicine: Clinical revision course 2016

  33. Case investigations Result Range Hb 120 115 - 160 g/L 10.1 WCC 4.0 - 11.0 cells x10 9 /L Neut 6.4 2.0 - 7.5 cells x10 9 /L SAMPLE 132 Platelets 150 - 400 cells x10 9 /L Na + 135 135 - 146 mmol/L K + 5.2 3.5 - 5.5 mmol/L 6.1 Urea 2.5 - 6.7 mmol/L ALT 82 3 - 40 IU/L 856 ALP 39 - 117 IU/L Bili 78 1 - 17 μ mol/L ESR 41 0 - 29 mm/hr One 2 One Medicine: Clinical revision course 2016

  34. Case investigations USS abdomen: Dilated intrahepatic ducts, multiple strictures in SAMPLE extrahepatic ducts. No masses seen. Coarse liver edge. Anti-mitochondrial antibody - negative One 2 One Medicine: Clinical revision course 2016

  35. SAMPLE One 2 One Medicine: Clinical revision course 2016

  36. Liver function test - ‘pictures’ - Hepatitic : very high ALT/AST , slightly high ALP/bili/GGT SAMPLE - Cholestatic : very high ALP/bili/GGT , slightly high ALT/AST - Mixed One 2 One Medicine: Clinical revision course 2016

  37. Di fg erential diagnosis of abnormal LFT Hepatitic Cholestatic Alcoholic liver disease Gallstones SAMPLE Non-alcoholic fatty liver Drugs disease Viral hepatitis Primary sclerosing cholangitis Paracetamol overdose Primary biliary cirrhosis Other Cancer One 2 One Medicine: Clinical revision course 2016

  38. Case investigations SAMPLE One 2 One Medicine: Clinical revision course 2016

  39. Case investigations SAMPLE Liver biopsy shows gross architectural disruption with regenerative nodules and bands of fibrosis. ‘Onion skin’ fibrosis around portal tracts. One 2 One Medicine: Clinical revision course 2016

  40. Case developments SAMPLE One 2 One Medicine: Clinical revision course 2016

  41. Chronic liver Cirrhosis disease Decompensation Portal Hepatic SAMPLE hypertension failure Features of chronic - Encephalopathy - Coagulopathy liver disease - Hypoglycaemia #O2OMClin One 2 One Medicine: Clinical revision course 2016

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

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

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

  45. Exam tips When you read… Think about… Tender bruises on shin Erythema nodosum SAMPLE ‘Skip lesions’ on colonscopy Crohn’s disease Transmural inflammation with granulomas One 2 One Medicine: Clinical revision course 2016

  46. Exam tips When you read… Think about… SAMPLE Positive anti-mitochondrial Primary biliary cirrhosis antibody ‘Beads on a string’ appearance on Primary sclerosing ERCP cholangitis One 2 One Medicine: Clinical revision course 2016

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