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4MB Clinical Problem-Solving

4MB Clinical Problem-Solving. Dr. Gerard Flaherty Dept. of Medicine. Lecture Programme. Week 1: Change in bowel habit Week 2: Pyrexia of unknown origin Week 3: Weight loss Week 4: Headache Week 5: Syncope Week 6: Chest pain Week 7: Shortness of breath.

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4MB Clinical Problem-Solving

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  1. 4MB Clinical Problem-Solving Dr. Gerard Flaherty Dept. of Medicine

  2. Lecture Programme • Week 1: Change in bowel habit • Week 2: Pyrexia of unknown origin • Week 3: Weight loss • Week 4: Headache • Week 5: Syncope • Week 6: Chest pain • Week 7: Shortness of breath

  3. 64-yr-old ♂Presenting Complaint: Constipation

  4. History

  5. What does the patient mean by “constipation”? How long has constipation been present? Is it intermittent or constant? Is there diarrhoea? Is there abdominal pain? Is tenesmus present? Any PR bleeding? Has the patient lost weight? Has the patient vomited? Is there pain on defecation? Does the patient have haemorrhoids? Any difficulty with micturition? Any features of biological depression? Is there enough fibre in the diet? Any symptoms of hypothyroidism? Any polyuria/polydipsia? Any new medications? History of the Presenting Complaint

  6. Examination

  7. Physical Examination • ? Signs of dehydration • ? Distended abdomen • ? Abdominal mass • ? Bowel sounds • Rectal examination • ? Faecal occult blood • ? Stigmata of hypothyroidism • ? Features of scleroderma • ? Evidence of Parkinson’s disease • ? Evidence of multiple sclerosis • Anal reflex

  8. Differential Diagnosis

  9. Medications • Anticholinergics • Iron • Diuretics • Opiates • Purgative abuse • Antidepressants • Aluminium salts • Calcium salts • Calcium channel blockers

  10. Mechanical • Colorectal tumours • Hernias • Volvulus • Bowel obstruction

  11. Anorectal • Anal fissure • Rectal prolapse • Haemorrhoids • Proctitis

  12. Neuromuscular • Advanced age • Irritable bowel syndrome • Diverticular disease • Scleroderma • Hirschsprung’s disease • Paralytic ileus

  13. Endocrine/Metabolic • Hypothyroidism • Hypercalcaemia • Diabetes mellitus • Pregnancy • Dehydration • Hypokalaemia • Porphyria • Lead poisoning

  14. Neuropsychiatric • Depression • Spinal cord injury • Cauda equina syndrome • Multiple sclerosis • Parkinson’s disease • Stroke • Anorexia nervosa

  15. Investigations

  16. FBC SMAC Fasting glucose ESR TFTs Tumour markers PFA Barium enema Flexible sigmoidoscopy Colonoscopy +/- Biopsy +/- MRI Spinal cord Anorectal manometry Investigations

  17. Management

  18. Management • Discontinue offending drugs • Rehydrate • High fibre diet • Laxatives • +/- Manual evacuation • Treat underlying condition

  19. 52-yr-old ♀Presenting Complaint:Diarrhoea

  20. History

  21. What does the patient mean by “diarrhoea”? Acute or chronic? ? Nocturnal Any new medications? Any affected contacts? Any suspicious food ingested? Any nausea or vomiting? ? Abdominal pain Any constipation? Any passage of mucus PR? ? Arthralgia ? Uveitis Any blood in stools? Any evidence of steatorrhoea? Any weight loss? Any symptoms of hyperthyroidism? Foreign travel? Any suggestion of immunocompromised state? History of the Presenting Complaint

  22. Examination

  23. Physical Examination • ? Dehydration • ? Signs of thyrotoxicosis • Inspect stool • ? Abdominal tenderness • ? Abdominal mass • PR exam ?overflow • Dermatitis ?Pellagra • Signs of malabsorption • ? Flushing/wheeze • ? Erythema nodosum/pyoderma gangrenosum

  24. Differential Diagnosis

  25. Acute Diarrhoea • Medications • Dietary indiscretion • Alcohol • Gastroenteritis • Psychogenic

  26. Medications (e.g. Antibiotics) Cancer chemotherapy Laxative abuse Infectious Irritable bowel syndrome Inflammatory bowel disease Colorectal tumour Villous adenoma Malabsorption Chronic pancreatitis Cystic fibrosis Autonomic neuropathy Radiation enteritis Collagenous colitis Overflow (constipation) Blind loop syndrome Thyrotoxicosis Pellagra Lactose intolerance IgA deficiency VIPoma Carcinoid syndrome Systemic Mastocytosis Medullary carcinoma of Thyroid MEN syndrome Chronic Diarrhoea

  27. Viral Rotavirus Echovirus Norwalk virus Adenovirus Protozoal Giardia lamblia Amoeba Cryptosporidium Tapeworm Bacterial Salmonella Campylobacter Clostridium difficile Shigella Staphylococcus aureus E. coli Bacillus cereus Vibrio cholerae Yersinia enterocolitica Infectious causes

  28. Investigations

  29. +/- 48hr fast FBC SMAC TFTs Anti-endomysial Abs Tumour markers Urinary 5-HIAA Gut hormone profile PFA (calcification, ?chronic pancreatitis) Stool for ova + parasites Colonoscopy +/- Biopsy Hydrogen breath test +/- Faecal fat estimation Investigations

  30. Management

  31. Management • Discontinue offending drugs • Rehydration therapy • Isolation precautions • +/- Antidiarhoeal agents • +/- Antibiotics • Treat underlying cause

  32. References • Lembo A, and Camilleri M. Chronic Constipation. N Engl J Med 2003;349:1360-8. • Donowitz M, Kokke FT, and Saidi R. Evaluation of patients with chronic diarrhea. N Engl J Med 1995;332(11):725-9.

  33. Next week…. Pyrexia of Unknown Origin

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