Common Clinical Questions

[Dr.Mohamed]

hi, everyone, i just wonder if you guys give me the answers of these question, i am waiting for your reply as soon as possible and here we go:-

1.WHAT ARE THE CAUSES OF CYANOSIS IN CASE OF LIVER CELL FAILURE?
2.WHAT IS THE MECHANISM OF HEPATORENAL SYNDROME?
3.WHAT ARE THE CAUSES OF ABDOMINAL DISTENTION?
4.WHAT ARE THE TYPES OF ASCITES?

  I hope all of you with good luck  and thanks,salam.

 

[Admin]

1.WHAT ARE THE CAUSES OF CYANOSIS IN CASE OF LIVER CELL FAILURE?
In cirrhosis pulmonary arteriovenous shunts develops, leading to hypoxia and eventually central cyanosis, this is called HEPATOPULMONARY SYNDROME.

2.WHAT IS THE MECHANISM OF HEPATORENAL SYNDROME?
This results from a cirrhotic liver due to decrese in blood flow as a result of low peripheral resistance due to secretion of nitric oxide, the reduced blood flow leads to increased secretion of vasoconstriction such as noradrenaline, angiotensin, aldosterone and vasopressin, that cause vasoconstriction of renal vasculature resulting in reduced GFR that leads to extremely low sodium excretion (<5 mmol/l), salt water retention & renal failure
There may be decreased production of renal vasodilators such as prostaglandin E2.

3.WHAT ARE THE CAUSES OF ABDOMINAL DISTENTION?
There are a lot of causes but most of them are categorized under “6 Fs”: Fat, feces, fetus, fibroids, flatulence, and fluid.

4.WHAT ARE THE TYPES OF ASCITES?
There can be 2 ypes of Ascites according to the level of the serum-ascites albumin gradient (High or Low gradient)
Hope I answered your questions
Dr.Mahdi

[Dr.Mohamed]

salam all of you and many thanks Dr.mahdi , in future i am going to post here any question that faced to me and here they are:-
1.WHAT ARE THE CAUSES OF PALPABLE GALLBLADDER?
2.WHAT ARE THE CAUSES OF SHIFTING,EVERTION,PIGMENTATION,DISCHARGE OF THE UMBLICUS?
3.HOW TO DIFFERENTIATE BETWEEN RENAL AND SPLENIC ENLARGEMEN?
4.WHAT ARE THE CAUSES AND MECHANISM OF ASCITES IN CASE OF LIVER CELL FAILURE?
5.WHAT ARE THE SIGN OF LIVER CELL FAILURE?.
 
  i wish you good luck with your studies and exam,salam

[Admin]

1.WHAT ARE THE CAUSES OF PALPABLE GALLBLADDER?

• Obstruction of the cystic duct

        +Stone in Hartmann's pouch
        +Cholangiocarcinoma

• Obstruction of the common bile duct

        +Stone in common bile duct
        +Carcinoma of the head of the pancreas

2.WHAT ARE THE CAUSES OF SHIFTING,EVERTION,PIGMENTATION,DISCHARGE OF THE UMBLICUS?

• causes of umbilical shifting:

        +Mass
        +Fluid
        +Fat
        +Pregnant

• causes of umbilical eversion:

        +Congenital
        +Ascites
        +Hernia

• causes of umbilical pigmentation:

There may be diseases that can present with pigmentation around the umbilicus like pancreatitis but I didn't come across pigmentation in the umbilicus it self unless skin pigmentations for other dermatological problems.

• causes of umbilical discharge:

        +Infections like Omphalitis
        +Any acute umbilical inflammation
        +Embryonic anomalies
        +Other rare cuases

3.HOW TO DIFFERENTIATE BETWEEN RENAL AND SPLENIC ENLARGEMEN?

• Signs of splenomegaly

        +Mass descending below the left 10th rib and enlarging in a line towards the umbilicus
        +Often has a palpable notch on the medial border
        +Moves with respiration and can not get above it
        +Dullness to percussion
        +Can be brought forward by lifting the lower ribs
        +Can not be felt bimanually or balloted

• Signs of a renal mass

        +Mass lies in paracolic gutter
        +Moves with respiration but usually only lower border is palpable
        +Can be felt bimanually or balloted
        +Not dull to percussion

4.WHAT ARE THE CAUSES AND MECHANISM OF ASCITES IN CASE OF LIVER CELL FAILURE?
The most common cause of ascites is portal hypertension secondary to chronic liver disease, which accounts for over 80% of patients with ascites.
The most common causes of nonportal hypertensive ascites include infections (tuberculous peritonitis), intra-abdominal malignancy, inflammatory disorders of the peritoneum, and ductal disruptions (chylous, pancreatic, biliary).

Mechanisms are complex and incompletely understood. Factors include altered Starling's forces in the portal vessels (low oncotic pressure due to hypoalbuminemia plus increased portal venous pressure), avid renal Na retention (urinary Na concentration is typically < 5 mEq/L), and possibly increased hepatic lymph formation.

Mechanisms that appear to contribute to renal Na retention include activation of the renin-angiotensin-aldosterone system; increased sympathetic tone; intrarenal shunting of blood away from the cortex; increased formation of nitric oxide; and altered formation or metabolism of ADH, kinins, prostaglandins, and atrial natriuretic factor. Vasodilation in the splanchnic arterial circulation may be a trigger, but the specific roles and interrelationships of these abnormalities remain uncertain.

5.WHAT ARE THE SIGN OF LIVER CELL FAILURE?.

Signs of acute liver failure:
+Jaundice
+Drowsiness
+Restlessness
+Confusion
+Coma

Signs of Chronic liver failure:
The typical patient is:

+Icteric (jaundiced)
+Pigmented
+Cyanosed (due to pulmonary venous shunting in the hepatopulmonary syndrome)

He has:

+Clubbing
+Leuconychia
+Palmar erythema
+Dupuytren's contracture
+Positive liver flap (also called asterixis, suggests hepatic encephalopathy)
+Spider naevi
+Scratch marks
+Pupura
+Gynaecomastia
+Scanty body hair
+Testicular atrophy
+Hepatomegaly
+Splenomegaly
+Ascites
+Distended abdominal veins in which flow is away from the umbilicus (caput medusae)
+Ankle oedema
Dr.Mahdi

[Dr.Mohamed]

1.what are the causes of muscle tenderness and thick nerve?
2.what is the difference between  anterograde and retrograde amnesia?
3.what  are the  causes of the persistent headache?

[Admin]

1.What are the causes of muscle tenderness and thick nerve?
Thick Nerve Elaborate on this question more!

2.What is the difference between  anterograde and retrograde amnesia?
In Anterograde amnesia, new events contained in the immediate memory are not transferred to the permanent as long-term memory. The sufferer will not be able to remember anything that occurs after the onset of this type of amnesia for more than a brief period following the event.
Retrograde amnesia is the inability to recall some memory or memories of the past, beyond ordinary forgetfulness.
The terms are used to categorize patterns of symptoms, rather than to indicate a particular cause or etiology. Both categories of amnesia can occur together in the same patient, and commonly result from drug effects or damage to the brain regions most closely associated with episodic/declarative memory: the medial temporal lobes and especially the hippocampus.
An example of mixed retrograde and anterograde amnesia may be a motorcyclist unable to recall driving his motorbike prior to his head injury (retrograde amnesia), nor can he recall the hospital ward where he is told he had conversations with family over the next two days (anterograde amnesia).

3.What  are the  causes of the persistent headache?
1-Extradural hematoma
2-Preeclampsia
3-Subdural hematoma
4-Concussion
5-Brain abscess
6-Temporal arteritis
7-Infectious Mononucleosis
Advice: IF you are having persistent headache, check your blood pressure
Dr.Mahdi

[Diagnostic]

Other common clinical questions during rotations
What is the normal urine output for an adult?
1/2 cc/kg/hr
children:
1 cc/kg/hr
What are the 5 Ws of post-operative fever?
Wind, Water, Wound, Walking, Wonder drugs
What are the 4 Fs seen in a typical cholecystitis patient?
Fat, female, forty, fertile
What are the reasons a fistula may not close?
Malnutrition, malignancy, high output, epithelialization of the tract
What's the blood supply to the stomach?
Gastric aa (L+R), Gastroepiploic aa (L+R), Short gastrics
What's the Parkland formula?
% burned x 4 x weight in kg = fluids for first 24 hours (use rule of 9s to get % burned)
What are 5 indications (AEIOU) for dialysis?
Acidosis, electrolytes, ingestions, overload, uremia
What are causes of anion gap/non-anion gap metabolic acidosis?
MUDPILES - methanol, uremia, DKA, paraldehyde, INH, lactic acidosis, ethanol, salicylates (all for anion gap acidosis, i forgot the ones for non-gap)
What's the treatment of hyperkalemia?
Sodium kayexalate, albuterol, insulin + D5, calcium gluconate
What are the rule of 10's for pheochromocytoma?
10% bilateral
10% malignant
10% extra-adrenal
Most common causes of aseptic meningitis?
Enteroviruses, HSV, HIV, Crypto, Blasto, Toxo
Triad of mediastinitis?
Fever, SOB, chest pain
What are the signs of placental separation?
Cord lengthening
Gush of Blood
Uterus takes on a globular shape and becomes palpable anteriorly
Diagnostic

[Dr.Mohamed]

1.WHAT ARE THE CAUSES OF SYSTOLIC AND DIASTOLIC MURMURS  OVER THE APEX?
2.WHAT ARE THE CAUSES OF CHEST PAIN, HAEMOPTYSIS,JAUNDICE IN CARDIAC CASE?
3.HOW CAN YOU DIFFERENTIATE CLINICALLY BETWEEN THE RHEUMATIC FEVER AND INFECTIVE ENDOCARDITIS
4.WHAT IS THE DEFINITION OF DYSPNEA,ORTHOPNEA AND PAROXYSMAL NOCTURNAL DYSPNEA?
5.WHAT ARE THE CAUSES OF LOW CARDIAC OUTPUT?

[Sumaya]

I am a nurse but thought give it a try.

WHAT ARE THE CAUSES OF CHEST PAIN
-Acute MI's, acute bronchitis, pericarditis, pericardial effusion, pneumonia, TB, valvular stenosis, acid reflux

4.WHAT IS THE DEFINITION OF DYSPNEA,ORTHOPNEA AND PAROXYSMAL NOCTURNAL DYSPNEA?
Dyspnea: Breathlessness, difficulty breathing, shorness of breath--usually subjective symptom.
Orthopnea: Dyspnea brought up by lying down flat, can be relieved by using multiple pillows or sitting up.
Paroxysmal nocturnal dyspnea (pnd). Severe of form of orthopnea in which the person awakens from sleep during night and gasps for air. Pnd is usually common in left ventricular failure and is caused by pulmonary congestion d/t redistribution of body fluid while the person is lying down.

5.WHAT ARE THE CAUSES OF LOW CARDIAC OUTPUT? i'll list what i remember
-hypovolema- loss of fluid/blood.
-Cardiogenic- decreased cardiac output  with evidence of adequate intravascular volume, can result from heart failure, MI's, arrhythmias, heart valve disorders, pulmonary embolus.
- Neurogenic :  massive vasodilation caused by increased parasympathetic stimulation or decreased sympathetic stimulation leading to decreased cardiac output.
Anaphylactic shock: Low cardiac output caused my vasodilation as in neurogenic but caused by hypersensitivity reaction such as allergic reaction.

[Dr.Mohamed]

thank you so much sumaya for your answers,but still i want answers for other questions which are:-
1.what are the causes of systolic and diastolic murmurs over the apex?
2.how can you differentiate clinically between rheumatic fever  and infective endocarditis?
3.what are the causes of haemoptysis , jaundice in  cardiac case?.

[Admin]

1.WHAT ARE THE CAUSES OF SYSTOLIC AND DIASTOLIC MURMURS  OVER THE APEX?

• Diastolic murmur at the apex : Mitral Stenosis (mid diastolic), Austin flint murmur (mid diastolic)
• Systolic murmur at the apex: Mitral valve prolapse (late systolic), Mitral regurgitation (pansystolic)

2.WHAT ARE THE CAUSES OF HAEMOPTYSIS, JAUNDICE IN CARDIAC CASE?
On rare occasions the first manifestation of heart disease is jaundice, caused by passive congestion of the liver or acute ischaemic hepatitis, so if the following diseases (which are main causes of hemoptysis in heart condition) led to heart failure, the patient can present with jaundice and hemoptysis
1-Aortic aneurysm with leakage into the pulmonary parenchyma
2-Atrial myxoma
3-Fibrous mediastinitis with pulmonary vein obstruction
4-Mitral stenosis
5-Pulmonary arteriovenous malformation
6-Pulmonary embolism/infarct
7-Primary pulmonary hypertension

3.HOW CAN YOU DIFFERENTIATE CLINICALLY BETWEEN THE RHEUMATIC FEVER AND INFECTIVE ENDOCARDITIS?
Each disease has it's own criteria when diagnosing it, (Jones criteria for rheumatic fever), (Dukes' criteria for infective indocarditis) but clinically if you see the following signs in a rheumatic patient think of infective endocarditis: ( thromboembolic problems such as stroke in the parietal lobe of the brain or gangrene of fingers), Janeway lesions (painless hemorrhagic cutaneous lesions on the palms and soles), intracranial hemorrhage, conjunctival hemorrhage, splinter haemorrhages or immunologic phenomena: Glomerulonephritis, Osler's nodes (painful subcutaneous lesions in the distal fingers), Roth's spots on the retina).
Dr.Mahdi

[Mutaweli]

Question (1):
Mr. Jones drove his car into the ditch last night while trying to get home after the bar closed at 1 AM. He arrives at 8 AM in the emergency room with a massive contusion in the middle of his chest. He complains of chest pain. His total CK was 400 units/L. His MB-CK was 10 units/L. His MM-CK was 380 units/L and his BB-CK was 10 units/L. You conclude that:

A He has had a heart attack
B He has a bruised chest but has had no heart attack
C He has suffered brain damage
D You cannot conclude anything because the cardiac enzymes do not rise until 8 hours after a heart attack
Question (2):
You are working with arterial blood. The patient is acidotic with a pH = 7.1. The pKa for carbonic acid is 6.1. The partial pressure of CO2 is 37 mm Hg. The concentration of CO2 is 1.1 mM. What is the concentration of bicarbonate ion?

A.44 mM
B.22 mM
C.11 mM
D.1.1mM
E.0.11 mM

[Yaxya]

What are the causes of pelvi-abodminal masses associated with bleeding in women?

[Diagnostic]

Causes of Pelviabdominal mass with bleeding:
1. Bladder Cancer
2. Ectopic pregnancy
3. Endometrial stromal sarcoma
4. Endometriosis
5. Malignant mixed Mullerian tumor
6. Ovarian Cancer
7. Uterine fibroids
Diagnostic