year 4 CDM 2 > Case 18: functional > Flashcards

Case 18: functional Flashcards

(51 cards)

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1
Q

Some of the theories for functional abdo pain

A
  • Early life events: Nociceptive somatic stimuli early in the neonatal period. Neonatal gastric suction
  • Psychological factors: abuse, separation, failure in an exam, loss of parents jobs, hospitalisation
  • Poor gastric emptying and poor antral motility, abnormality gastric accommodation
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2
Q

Different causes of IBS

A
  • Alteration of central processing of afferent stimuli due to an episode of severe or poorly controlled acute GI pain (i.e. gastroenteritis or abdo surgery)
  • Anxiety and depression
  • Post-infection IBS
  • Post inflammatory IBS
  • Bile acid malabsorption
  • Visceral hyperalgesia
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3
Q

Disrupted nociception and neuromodulation

A
  • Lowers pain threshold causing non-nociceptive signals to be interpreted as pain i.e. gut peristalsis
  • Can be triggered by an episode of severe or poorly controlled acute pain especially if current life stress or psychological distress i.e. gastroenteritis or abdo surgery. Good post op pain control is important in reducing rates of chronic pain
  • Can co-exist or be caused by GI disease
  • More common in patients with depression/anxiety or life stressors. Descending pain pathway is closely associated with limbic and emotional systems which receives input from the anterior cingulate cortex (part of the limbic system)
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4
Q

GI red flags

A
  • History: persistent RUQ or RLQ pain, persistent vomiting, GI blood loss, chronic severe diarrhoea, unintentional weight loss, unexplained fever, FH or IBD, coeliac etc
  • Examination findings: deceleration of growth in paeds, uveitis, oral lesions, skin rashes, icterus, anaemia, hepatomegaly, splenomegaly, arthritis, costovertebral angle tenderness, tenderness over the spine, perianal abnormalties
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5
Q

Management for functional abdo pain: move down the list

A
  • General: supportive environment, validation of symptoms, patient education, agree and set realistic treatment goals.
  • Support networks
  • Improving co-morbid conditions
  • Pharmacological: TCA’s, SNRI
  • Psychological: CBT, Hypnotherapy
  • Step up therapy: Gabapentin, Pregabalin
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6
Q

Functional chronic pelvic pain

A
  • Pain lasting >6 months in the lower abdomen or pelvic area
  • Not purely associated with menstruation, intercourse or pregnancy
  • Tends to be gyanecological
  • Normal investigations
  • Can be associated with abnormal uterine bleeding, urinary symptoms and constipation
  • May be a result of central sensitisation, biopsychosocial factors and contributing organic pathology
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7
Q

Differentials of chronic abdo pain other than functional

A
  • GORD (epigastric pain, worse with spicy or fatty foods)
  • chronic pancreatitis (pain after eating, foul stools, weight loss)
  • peptic ulcer disease (pain with eating)
  • chronic mesenteric ischaemia (pain after eating, bloody diarrhoea and pain)
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8
Q

Differentials of chronic pelvic pain other than functional

A
  • endometriosis: cyclical pain, dyspareunia
  • PID: pelvic pain, discharge, dyspareunia and fever
  • adhesions
  • gynaecological malignancy
  • ovarian cyst
  • recurrent UTIs
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9
Q

Red flags for pelvic pain

A
  • Post-coital bleeding
  • Post-menopausal bleeding
  • PR bleeding
  • New GI symptoms e.g. constipation, bloating, early satiety, especially age >50
  • Pelvic mass
  • Unexpected weight loss
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10
Q

Organic differential diagnoses for pelvic pain

A
  • Gynaecological: Endometriosis, adhesions, PID, gynaecological malignancy
  • GI: IBS, IBD: colon mlignancy, coeliac
  • Urological: irritable bladder, bladder malignancy, recurrent UTI’s
  • Neurological: nerve entrapment, central neurological pain i.e. MS
  • Musculoskeletal: fibromyalgia, joint/muscle tension
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11
Q

What red flag symptoms would warrant further investigations of chronic abdo pain

A
  • rectal bleeding
  • weight loss
  • over 60 and change to bowel habit
  • anaemia
  • abdominal or rectal masses
  • FH of bowel or ovarian cancer
  • raised inflammatory markers
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12
Q

Medically unexplained chest pain

A
  • not related to exertion
  • Younger age
  • Not necessarily related to FH
  • Normal CT coronary angiogram and echocardiogram
  • Personal and psychological stressors
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13
Q

Other causes of non-cardiac chest pain

A
  • Gastrointestinal:GORD, oesophageal spasm, swallow pathology. May be related to eating/swallow + acid/water brash.
  • Respiratory:pleurisy, pneumonia, PE and rarely, cancer. Pain may be pleuritic, related to deep breathing + associated with cough.
  • Musculoskeletal:chostochondritis, trauma, bony metastasis. May be tender to palpation and worsened by movement.
  • Psychiatric:Generalised anxiety, panic disorder. Episodes of stress-response adrenaline leading to racing heart, palpitations, chest pain.
  • Functional:No organic explanation. May felt felt constantly or intermittently with varied symptoms.
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14
Q

Palpitations: causes and concerning features

A
  • Cardiac causes: Afib or flutter, SVT, other arrhythmias, ectopics, sinus tachy, structural heart disease
  • Other causes: anxiety, panic disorder, hyperthyroidism, pheochromocytoma, anaemia, menopause, caffeine, recreational drugs, drug withdrawal. beta 2 agonists i.e. salbutamol
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15
Q

Concerning features of palpitations

A
  • Accompanying chest pain, lightheadedness or syncope
  • Family history of sudden cardiac death
  • ECG changes (e.g. prolonged QTc, Brugada pattern, delta waves)
  • Cardiac co-morbidities e.g. severe LVSD, known ischaemic heart disease, structural heart disease
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16
Q

Investigations for palpitations

A
  • Cardiac exam and relevant blood tests
  • Refer to cardiology if cardiac disease suspected
  • Echo if suspect heart failure
  • ECG, ECG Holter monitors or loop recorders (combined with symptom diary)
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17
Q

Benign palpitations

A
  • Ectopic beats: atrial or ventricular. Feel like a ‘missed beat’ then a ‘heavy squeeze.’
  • Atrial ectopics are common and do not affect prognosis.
  • Ventricular ectopics can be associated with increased caffeine intake or stress (reducing caffeine and stress). More common with increased age. Lots of ventricular ectopics (e.g. bigeminy) can indicate electrolyte disturbances, underlying cardiac ischaemia or structural abnormalities and warrant further investigation.
  • Sinus tachycardia- racing heart beat but the rhythm is regular Can be a physiological response to underlying pathology such as sepsis or PE. Sinus tachycardia is also associated with anxiety as the increase in catecholamine levels lead to increased heart rates.
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18
Q

How to treat benign palpitations

A
  • Reassurance, lifestyle advice and managing cardiac risk factors i.e. hypertension and hypercholesterolaemia
  • Relaxation, mindfulness and coping strategies can be helpful in reducing palpitation frequency and severity.
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19
Q

What associated features may suggest palpitations are concerning

A
  • accompanying chest pain, lightheadedness or syncope
  • FH of sudden cardiac death
  • ECG changes
  • cardiac co-morbidities
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20
Q

What should be carried out to clarify the cause of death after someone is confirmed dead

A
  • death certificate issued by doctor stating cause of death
  • medico-legal investigation to establish cause of death
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21
Q

Definition of cause and mechanism of death

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A
  • Cause: the medical explanation for death in terms of pathological processes as expressed on a death certificate i.e. lung cancer, atherosclerosis. Can have up to 3 causes. 1a should be due to 1b and 1b should be due to 1c etc. As explanatory as possible
  • Mechanism: the physiological derangement leading to death. Can be multiple, leads to interpretation. Examples: haemorrhage, cardiac arythmias, cerebral hypoxia, sepsis, Hypoglycaemia, organ failure. homicide. Not the same as the cause of death
22
Q

Common causes of death

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A
  • In order: Circulatory system, Cancer, Respiratory, Accidents, Suicide, Infection, Maternal
  • Cardiac failure is a mechanism and not cause of death - need to be more specific
23
Q

Death certificate

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A
  • Written by the doctor who attends the patient in their last illness stating their cause of death.
  • You issue a death certificate in 2/3 of deaths: Natural disease, No suspicious/unusual circumstances, know the cause of death, seen recently by doctor <14 days
24
Q

Example cause of death on a death certificate

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A
  • 1a Acute Myocardial Infarction due to….
  • 1b Coronary Artery Thrombosis due to….
  • 1c Coronary Artery Atheroma
  • 2: Hypercholesterolaemia
25
The coroner
- 1/3 of death are referred to H.M Coroner (i.e. undergo medico-legal investigations) - The Coroner is a lawyer for 5 years, appointed by the local authority who investigates the cause of death - Doctors, The Registrar of births and deaths, the police and the public can refer to the coroner
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Deaths which must be reported to the coroner
1. Not attended by a doctor during final illness 2. Not seen by a doctor either after death or within 14 days prior to death 3. Cause of death unknown 4. Cause of death may be unnatural 5. Others: in custody, under the MH act, with a war pension
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What are unnatural causes of death
- Criminal: Murder, Manslaughter, aiding suicide, dangerous driving, suspicious - Suicide - Accident: RTC (road traffic colision), domestic, industrial. No matter the time interval - Industrial disease: pneumoconiosis, asbestosis - Deaths associated with Medical or Surgical treatment: during a medical or surgical procedure (operation/anaesthetic), 24hr rule (admission to hospital), where treatment has caused, contributed to or accelerated death, ‘Negligence.’ - Other: Patient dies during abortion or miscarriage, Neglect (Hypothermia, pressure sores), Acute alcohol, Drug abuse, Children (including SID’s)
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Flow chart for referring to the coroner
- Unnatural cause or certain specific circumstances? - The Coroner - Natural cause, attended during last illness? (No) - The Coroner - Natural cause, seen patient within 14 days before death (or after death)? (No) - The Coroner - Can you give a cause of death? (No) - The Coroner
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What does the coroner do
- If they don’t perform an autopsy they fill in Form A - If they perform an autopsy and its natural causes they fill in form B - If they perform an autopsy and its not from natural causes they have an inquest and certificate after - The inquest: Who? Where? When? How? (Conclusion) Not to apportion blame - The inquest purpose: to appoint blame, resolve financial compensation or liability
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Post mortem examination
- Medical examination of a dead body (autopsy, necropsy) by a pathologist (doctor) - Indications: Medico-legal (Coroner’s, Forensic) or Consented (Hospital) - Autopsies are carried out in a mortuary and done promptly, shouldn’t delay a funeral except in exceptional medico-legal circumstances
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Differences between a Medico-legal and Consented autopsy
- Medico-legal: done by law, family member cant oppose it - Consented: only done with consent of next of kin and can control how much is done. Done mainly for research, can be done on perinatal for diagnostics
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Mortuary
- Cold store (freezer): preserve deceased till funeral - Autopsy theatre for post mortem, may have axillary theatres for high risk autopsies i.e. highly infectious or forensic/suspicious autopsies - Facilities for viewing the dead body - Access for undertakers
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How is an autopsy done (1/2)
- Clinical history (from hospital and coroner notes): PMH, history of last illness, circumstances of death, Medications, Social history (alcohol, drugs, occupation) - External examination: general appearance (height + weight), Natural disease, Trauma, Evidence of medical intervention i.e. incubation, post mortem changes i.e. rigor mortis. In order to document relevant positive/negative findings and to prove you looked
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How is an autopsy done (2/2)
- Evisceration: role of mortuary technician, external incisions for example cutting open the abdomen. Looking for obvious injuries i.e. infarcted bowel without cutting into them - Organ dissection i.e. might see PE - Further tests: Histology (confirming damage), Microbiology, Virology, Biochemistry, Toxicology. Whole Organ retention (Brain, Heart) may be needed for histology but mostly just slices
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Autopsy report
- Need to report the findings to the coroner in Medico-legal examinations - In Consented autopsies the report will go to the doctor who requested the autopsy and then to next of kin - The coroner will report the findings to the clinician who was looking after the patient - Communication with clinicians during the post mortem to understand the clinical sequence of events - Includes important findings and conclusion
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The consented (hospital) autopsy
- Can only happen with informed consent from next of kin - Regulated by the Human Tissue Authority - Next of kin has to understand: what an autopsy involves, why the autopsy is being requested, the limitations of an autopsy, when to expect a result - Next of kin must decide: the extent of the autopsy, the extent of tissue retention, what will happen to any retained tissue i.e. given back for funeral or used for research
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Why do Consented (hospital) autopsy
1. Understanding of disease/treatment 2. Audit and education: can show discrepancy in diagnosis and autopsy, shows diagnostic errors 3. Provision of data 4. Genetic/grief counselling 5. Establishes the truth
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Diseases which are difficult to diagnose and may only be identifies on autopsy
PE, Peritonitis, Post op infection, Intestinal ischaemia, Metastatic carcinoma, Acute MI, Cancer
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The Human Tissue Act 2004
- A framework for regulating the storage an use of human organs and tissues from the living and deceased - Covers consent, storage of deceased, management of deceased, management of retained tissue but also the the living i.e. tissue biopsy - Informed consent above all - applies to anything which includes cells - Human Tissue Authority: issues codes of practise, inform the public, License activities i.e. proper storage facilities, Inspect premises
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Minimally invasive autopsies
- MRI/CT: limited usefullness - Needle biopsy of single organ - Laparoscopic - Limited to relevant part of body Proper burial of deceased: Burial, Cremation
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Examples of biomarkers which can guide therapy in cancer
- presence of steroid hormone receptors in breast cancer indicates use of hormonal therapy - presence of HER2 in breast cancer indicates use of trastuzumab - presence of EGFR mutation in NSCLC indicates use of EGFR tyrosine kinase inhibitors
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Precision medicine
- Customising healthcare for subgroups of patients rather than a one size fits all - The ability to apply modern diagnostics to inform the tailored approach
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What is considered with precision medicine
- Clinical procedures: Molecular biology, Sequencing technology, Medical technology - Information technology - helps us to understand and process the data: Big data, Processing capacity, Connectivity technology - Also this data makes precision medicine possible - P4 health care: a structured evidence based approach which is Predictive, Preventive (screening), Personalised and Participatory
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Different areas of precision medicine
- Precision medicine in chronic disease (NAFLD, T2DM, Psoriasis) - Precision medicine in rare disease (CYLD syndrome, PBC) - Precision oncology in solid tumours (Medulloblastoma, HCC) - Precision oncology in leukaemia (AML, ALL, CLL) - In order to understand precision medicine you need information on the genetics of complex disease, genomics, pharmacogenomics, informatics and precision diagnostics
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Precision diagnostics for oncology
- Immunohistochemistry for specific proteins i.e. ER+ breast cancer - In situ hybridisation for RNA detection - Gene expression - Single gene testing - Panel based gene testing: Formalin-fixed tissue (smaller panel) and fresh tissue (larger panel) - Exome/Whole Genome Sequencing (fresh tissue) of individual tumours
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Known biomarkers for cancer
- Breast - Steroid hormone receptor, HER2, Oncotype gene panel - Colon - KRAS mutation status, Microsatellite instability - Non small cell lung cancer: EGFR mutation, ERCC1 - Glioblastoma: MGMT methylation - Melanoma: BRAF V600E mutation
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Future of personalised oncology medicine
- The Cancer Genome Atlas and the International Cancer Genome Consortium has mapped thousands of malignancies which has caused the development of new drugs at targeted tumour types - Future: new drugs which are tailored to the molecular profile of the individual patients tumour (DNA and RNA sequencing) - Need to tackle rare cancers and increase how many people are treated by precision medicine - Cancer dependency map
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AI and types
- A programme that can sense, reason, act and adapt - Machine learning: Algorithms whose performance improve as they are exposed to more data over time - Deep learning: subset of machine learning in which multi-layered neural networks learn from vast amounts of data in order to gain new information
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Current uses of AI in medicine
- Cardiovascular disease: atrial fibrillation detection using smart-phone/wearable devices and assessment of cardiovascular risk from electronic record data mining (machine learning) - Endocrinology: Sugar.IQ system for prevention of hypoglycaemia using wearable devices. And assessment of diabetic eye disease through AI assessment of images - Gastroenterology: assessment of endoscopy images. Prediction of outcomes and survival in bleeding and malignant disease - Neurology: intelligent seizure detection devices and wearable devices in gait disorders - Imaging modalities in diagnostic pathology and radiology. In Immunohistochemistry computers can add stains to images which don’t affect the sample
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Challenges ahead for AI in medicine
- Need for rigorous clinical validation - Ethical implications of ongoing monitoring (wearable devices, storage of information etc) - The need to educate and prepare augmented doctors - Avoiding dehumanizing by technology – ambient clinical intelligence - Lack of human empathy and emotional intelligence
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Advantages of AI
- Efficacy, Accuracy, Precision - Decreased workload, increased patient facing time. Increased time on critical cases - Saves money, better monitoring
year 4 CDM 2
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