Clinical Clues

Abdominal Pain
Location Causes
RIF Appendicitis; renal colic; perforated caecal tumour
Suprapubic Cystitis
LIF Diverticulitis; sigmoid colon
Central Meckel’s diverticulum, small bowel obstruction
abdominal
RUQ Biliary colic; cholecystitis

Epigastric Pancreatitis, DU;

LUQ Pancreatitis, DU
Causes of rectal bleeding

Bright red blood Anorectal cause or significant distal or proximal

bleeding
Dark red blood Distal colonic bleeding
Altered/occult Proximal bleeding
Younger pts Haemorrhoids; colitis
Older patients Diverticular disease, Cancer; Angiodysplasia
Colorectal cancer
Site Percentage Symptoms
Right – Caecal 15% Iron deficiency anaemia (occult bleeding)
Weight loss
RIF mass; rarely small bowel obstruction

Left sided 10% Altered bowel habits

Altered blood
Large bowel obstruction

Rectal 50% Altered bowel habit

Fresh blood
Mucus per rectum
Tenesmus
Mass per rectum

Types Polyp, Ulcer, Mass, Stricture

Dukes stages A confined to wall; B Through bowel wall; C Involved lymph nodes; D distant
metastases
Non surgical causes of abdominal pain
• Gynaecological causes • Medical causes
• Ectopic pregnancy
• Salpingitis
• Uterine fibroids
• Ovarian cyst
Injuries – Upper limb nerve injuries
Myotome Shoulder Elbow Wrist Fingers Reflex

C5 Abduction and Flexion Biceps

external rotation
C6 Flexion Flexion/extension Supinator
pronation/supination
C7 Adduction and Extension Flexion/extension Flexion / Triceps
external rotation extension
C8 Extension Finger
T1 Abduction /
adduction
History History of trauma, sensory and motor disturbance and functional limitation
hints
Froment’s To distinguish between median and ulnar nerve lesion test opponent muscle (median)
test and 1st dorsal interosseous muscle (ulnar)
 Individual Nerve lesions
Nerve Causes
Radial Fracture shaft of humerus
Pressure in axilla
Median Carpal tunnel Syndrome
Supracondylar fracture of
humerus in children
Dislocation of lunate bone
Ulnar Fracture at medial epicondyle
Compression at the elbow
Penetrating injuries
Marked cubitus valgus
Lacerations of the wrist
Long Injury to nerve during axillary
thoracic dissection for breast cancer
surgery
Motor loss Sensory loss
Loss of triceps (only with high injuries) Dorsal radial 3 ½ digits
Wrist drop Autonomous area (1st
Loss of finger extension dorsal website)
Thumb and
Thenar muscle wasting 2nd 3rd and medial side of 4th
(extensor pollicis, fingers
opponence, flexor pollicis brevis and
1st +2nd lumbricals (partial claw hand)
Hypothenar muscles Little finger and lateral ½ of
Abductor digitiminimi 4th finger
Flexor digiti minimi
3rd and 4th lumbricals (partial claw hand)
Serratus anterior (C5 –C7)
Ask pt to push against wall while standing
and note winging of the scalupa (due to
unopposed action of the pectoralis minor.)
Pneumonia
• History • Examination
• SOB • Expansion – decreased
• Productive cough
• Percussion – Dull
• Fever
• Malaise • Breath sounds – Bronchial
• Confusion • Vocal resonance – increased
• Myalgia • Added sounds – Crackles
• Recent travel
• Other signs – rapid respirations,
sputum pot, hypotension, fever,
tachycardia
 Pneumonia
Classification Causes of Community Investigations Management for all types
acquired P (CAP)
Community acquired P Strep pneumoniae Hb, WCC, ESR, Blood urea and Oxygen and IV fluids
(CAP) electrolytes
Hospital acquired P Moraxella catarrhalis Chest x ray Antibiotics
Aspiration Haemophilus influenzae ABG Physiotherapy

Pneumonia in Psudomonas (Cystic Sputum

immunocompromised pt. fibrosis/ bronchiectasis)

Staphylococcus aureus Blood culture

(post viral)
Atypical ( Mycoplasma, Urine for legionella or
legionella) pneumococcal antigen
Viral – influenza
Protozoal – Pneumocystis
carinii
 Severity score for Community Acquired Pneumonia (CURB65)

Score 1 for each of

Confusion (mental score < 8 or new disorientation)
Urea >7mmols
Respiratory rate > 30/min
BP (SBP < 90 or DBP < 60)
Age > 65

0 or 1 2 3 or more
GASTRO - OESOPHAGEAL REFLUX – GORD (GERD)
• Normal main anti reflux mechanisms • Factors associated with oesophageal reflux
• Peristalsis oesophagus • Pregnancy
• Lower oesophageal sphincter • Obesity
• Intra abdominal oesophagus • Large meals
• Mucosal valve • Cigarette smoking
• Unimpeded gastric emptying
• Drugs – antimuscarinic drugs, Ca channel
• Alarm signals (red alerts) blockers, nitrates
• Dysphagia • Systemic sclerosis
• Weight loss • After treatment for achalasia (surgical or
bougie)
• Vomiting
• Hiatus hernia
• Anorexia
• Haematemesis or malaena
Features and differences of Reflux and Cardiac pain

• Oesophageal reflux pain • Cardiac ischaemic pain

• Burning
• Worse on bending, stooping or
lying down
• Rarely radiates to the arms
• Worse with hot drinks or alcohol
• Relieved by antacids and proton
pump inhibitors
• Gripping or crushing central
chest pain
• Radiates to neck and L arm
• Worse with exercise
• Relieved by rest
• Accompanied by dyspnea
HIATUS HERNIA
• Sliding Hiatus hernia
• Mechanism -The oesophageal
junction and part of the stomach
slide through the hiatus and lie
above the diaphragm
• Present in 30% of pts over the
age of 50
• Produces no symptoms by itself
• Symptoms due to reflux
• Rolling or Paraoeasophageal HH.
• Mechanism – part of the fundus of the
stomach prolapses through the hiatus
alongside the oesophagus.
• The lower oesophageal spinchter
remains below the diaphragm and is
competent.
• Occasionally produces severe pain due
to volvulus or strangulation of the
herniated part.
Osteoarthritis of the Hip
• History
• Painful limp in elderly
• Pain on exercise
• Relieved very quickly by rest
• Difficulty getting out of chair
• Gradual onset, slowly worsening
XX ray changes in OS
Peri articular bone cysts
Loss of joint space
Sclerosis around joint
Osteophytes at joint edges
• Examination
• Limp/walking aid
• Apparent shortening of leg
• Fixed flexion deformity
• Thomas’s test for demonstrating fixed
flexion deformity by full hip flexion of
other leg.
• Limitation of hip flexion
• Limitation of internal rotation
• Limitation of abduction
Bronchial Asthma
• Features of a severe asthma attack • Features of life threatening attack
• PEF < 33% predicted or best
• PEF 33-50% of predicted or best • Cyanosis
• Inability to complete a full sentence in • Silent chest
1 breath • Poor respiratory effort
• RR > 25/min • SpO2 <92%
• Pulse > 100/min • Hypotension
• Bradycardia and arrythmias
• Exhaustion
• Confusion
• Coma
• Normal or reduced PaCO2
Management of acute severe asthma
• Oxygen driven nebulised high dose salbutamol
• Steroids orally or IV
• Antibiotics ( if infection suspected)
• Close monitoring of O2 sats and ABGs
• Early referral to ITU on deterioration
• CXR– to exclude pneumothorax
• High flow O2
• Nebulised Ipratropium
• Consider IV magnesium
• Mechanical ventilation
Clinical features to distinguish between asthma and COPD

CLINICAL FEATURES COPD ASTHMA

Smoker or ex smoker Nearly all Possibly
Symptoms under age of 25 Rare Often
Chronic productive cough Common Uncommon
Breathlessness Persistent and Variable
progressive
Night time waking with breathlessness and/or Uncommon until Common
wheeze late in disease
Significant diurnal or day to day variability of Uncommon Common
symptoms and PFR readings