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Cases for PACES von Hoole, Stephen (eBook)

  • Erscheinungsdatum: 13.03.2015
  • Verlag: Wiley
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Cases for PACES

Station 1
Abdominal and Respiratory
Clinical mark sheet Clinical skill Satisfactory Unsatisfactory Physical examination Correct, thorough, fluent, systematic, professional Incorrect technique, omits, unsystematic, hesitant Identifying physical signs Identifies correct signs Does not find signs that are not present Misses important signs Finds signs that are not present Differential diagnosis Constructs sensible differential diagnosis Poor differential, fails to consider the correct diagnosis Clinical judgement Sensible and appropriate management plan Inappropriate management Unfamiliar with management Maintaining patient welfare Respectful, sensitive Ensures comfort, safety and dignity Causes physical or emotional discomfort Jeopardises patient safety Chronic liver disease and hepatomegaly This man complains of weight loss and abdominal discomfort. His GP has referred him to you for a further opinion. Please examine his abdomen . Clinical signs
Signs of chronic liver disease
General: cachexia, icterus (also in acute), excoriation and bruising Hands: leuconychia, clubbing, Dupuytren's contractures and palmar erythema Face: xanthelasma, parotid swelling and fetor hepaticus Chest and abdomen: spider naevi and caput medusa, reduced body hair, gynaecomastia and testicular atrophy (in males) Signs of hepatomegaly
Palpation and percussion: Mass in the right upper quadrant that moves with respiration, that you are not able to get above and is dull to percussion Estimate size (finger breadths below the diaphragm) Smooth or craggy/nodular (malignancy/cirrhosis) Pulsatile (TR in CCF)
Auscultation Bruit over liver (hepatocellular carcinoma) Evidence of an underlying cause of hepatomegaly
Tattoos and needle marks Infectious hepatitis
Slate-grey pigmentation Haemochromatosis
Cachexia Malignancy
Mid-line sternotomy scar CCF Evidence of treatment
Ascitic drain/tap sites Surgical scars Evidence of decompensation
A scites: shifting dullness A sterixis: 'liver flap' A ltered consciousness: encephalopathy Discussion
Causes of hepatomegaly
The big three: Cirrhosis (alcoholic) Carcinoma (secondaries) Congestive cardiac failure Plus: I nfectious (HBV and HCV) I mmune (PBC, PSC and AIH) I nfiltrative (amyloid and myeloproliferative disorders) Investigations
Bloods: FBC, clotting, U&E, LFT and glucose Ultrasound scan of abdomen Tap ascites (if present) If cirrhotic
Liver screen bloods:

Produktinformationen

    Format: ePUB
    Kopierschutz: AdobeDRM
    Seitenzahl: 208
    Erscheinungsdatum: 13.03.2015
    Sprache: Englisch
    ISBN: 9781118983607
    Verlag: Wiley
    Größe: 4277 kBytes
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Cases for PACES

Station 1
Abdominal and Respiratory

Clinical mark sheet

Clinical skill Satisfactory Unsatisfactory Physical examination Correct, thorough, fluent, systematic, professional Incorrect technique, omits, unsystematic, hesitant Identifying physical signs Identifies correct signs
Does not find signs that are not present Misses important signs Finds signs that are not present Differential diagnosis Constructs sensible differential diagnosis Poor differential, fails to consider the correct diagnosis Clinical judgement Sensible and appropriate management plan Inappropriate management
Unfamiliar with management Maintaining patient welfare Respectful, sensitive Ensures comfort, safety and dignity Causes physical or emotional discomfort
Jeopardises patient safety Chronic liver disease and hepatomegaly

This man complains of weight loss and abdominal discomfort. His GP has referred him to you for a further opinion. Please examine his abdomen .
Clinical signs

Signs of chronic liver disease

General: cachexia, icterus (also in acute), excoriation and bruising
Hands: leuconychia, clubbing, Dupuytren's contractures and palmar erythema
Face: xanthelasma, parotid swelling and fetor hepaticus
Chest and abdomen: spider naevi and caput medusa, reduced body hair, gynaecomastia and testicular atrophy (in males) Signs of hepatomegaly

Palpation and percussion:

Mass in the right upper quadrant that moves with respiration, that you are not able to get above and is dull to percussion
Estimate size (finger breadths below the diaphragm)
Smooth or craggy/nodular (malignancy/cirrhosis)
Pulsatile (TR in CCF)
Auscultation

Bruit over liver (hepatocellular carcinoma) Evidence of an underlying cause of hepatomegaly

Tattoos and needle marks Infectious hepatitis

Slate-grey pigmentation Haemochromatosis

Cachexia Malignancy

Mid-line sternotomy scar CCF Evidence of treatment

Ascitic drain/tap sites
Surgical scars Evidence of decompensation

A scites: shifting dullness
A sterixis: 'liver flap'
A ltered consciousness: encephalopathy Discussion

Causes of hepatomegaly

The big three:

Cirrhosis (alcoholic)

Carcinoma (secondaries)

Congestive cardiac failure
Plus: I nfectious (HBV and HCV) I mmune (PBC, PSC and AIH) I nfiltrative (amyloid and myeloproliferative disorders) Investigations

Bloods: FBC, clotting, U&E, LFT and glucose
Ultrasound scan of abdomen
Tap ascites (if present) If cirrhotic

Liver screen bloods:

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