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You are in Home >> Exams >> Mitchell Anaesthetic Notes


Miscellaneous medicine

Created: 1/6/2006
Updated: 8/1/2007
 

Short case history

  • General history
    • Presenting symptoms
    • History of the presenting illness
      • Symptoms: duration, site and radiation, character, severity, onset, aggravating and relieving factors, associated symptoms, treatment
    • Past history
    • Social history
    • Family history
    • Systems review
      • Cardiovascular, respiratory, gastrointestinal, hepatobiliary, haematological, genitourinary, musculoskeletal, neurological, endocrine
  • Cardiovascular history
    • Symptoms
      • Chest pain (nature, stable or unstable), dyspnoea (exertional, postural, nocturnal), ankle swelling, palpitations, syncope, claudication, fatigue
    • Risk factors
      • Family history, smoking, hypertension, hypercholesterolaemia, diabetes, obesity, sex and age
    • Past history
      • Angina, AMI, rheumatic fever, chorea, preeclampsia, investigations
    • Treatment
      • Drugs, revascularization
    • Social history
      • Work, exercise tolerance, smoking
    • Family history
  • Respiratory history
    • Symptoms
      • Cough, sputum, haemoptysis, dyspnoea, wheeze, chest pain, sinusitis, hoarseness, night sweats
    • Past history
      • Pneumonia, tuberculosis, bronchitis, allergies
    • Treatment
      • Steroids, bronchodilators, antibiotics
    • Social history
      • Occupation, hobbies (exposures), smoking, alcohol
    • Family history
      • Tuberculosis, asthma, emphysema (e.g. cystic fibrosis)
  • Gastrointestinal history
    • Symptoms
      • Pain, nausea, vomiting, bleeding, reflux, dysphagia, appetite and weight change, diarrhoea, constipation, mouth ulcers, fever
    • Past history
      • Peptic ulcer, colitis, carcinoma
    • Treatment
      • Steroids, NSAIDs, antibiotics, diet
    • Social history
      • Alcohol, smoking, travel, occupation
    • Family history
      • Bowel cancer, IBD, coeliac disease, polyposis coli
  • Hepatobiliary history
    • Symptoms
      • Jaundice, dark urine, pale stools, fever, pruritus
    • Past history
      • Jaundice, surgery, hepatitis, transfusion, blood-borne virus risks
    • Treatment
      • Drugs, especially sex steroids and other hepatotoxic drugs
    • Social history
      • Alcohol, viral exposure (travel, contacts, sex, occupation, drug use)
    • Family history
      • Genetic disease (Wilson’s disease, haemochromatosis…), family contacts
  • Haematological history
    • Symptoms
      • Blood loss, bruising, infection, gland enlargement, bone pain, symptoms of anaemia, paraesthesia, rash
    • Past history
      • Gastric surgery, colitis, malabsorption, rheumatoid arthritis, uraemia, transfusion
    • Treatment
      • Anticoagulants, immunosuppressants, anticonvulsants
    • Social history
      • Diet, alcohol
    • Family history
      • Genetic disease (haemophilia, thalassaemia, sickle cell, pernicious anaemia, haemolytic anaemia)
  • Genitourinary history
    • Symptoms
      • Infection
        • Dysuria, frequency, urgency, fever, loin pain, urethral discharge
      • Renal failure
        • Anuria, nocturia, polyuria, anorexia, vomiting, fatigue, hiccough, itch, bruising, oedema
      • Obstruction
        • Reduced stream, hesitancy, dribbling
    • Menses
      • Onset, regularity, last period, dysmenorrhoea, menorrhagia, parity, discharge
    • Past history
      • Infections, stones, surgery, proteinuria, nephritis, diabetes, gout, hypertension, preeclampsia
    • Social history
      • Analgesic use
    • Family history
      • Polycystic kidneys
  • Musculoskeletal history
    • Symptoms
      • Pain, stiffness, swelling, loss of function, nodules, dry eyes or mouth, red eyes, rash, fever, fatigue, weight loss, mucosal ulcers, Raynaud’s
    • Past history
      • Trauma, infection, IBD
    • Treatment
      • Physiotherapy, analgesics, NSAIDs, steroids, DMDs, surgery
    • Social history
      • Home arrangements, work, carer, STDs
    • Family history
      • Arthritis, gout, psoriasis, IBD
  • Neurological history
    • Symptoms
      • Headache, pain, paraesthesia, anaesthesia, weakness, disturbance of sphincter control, special senses, loss of consciousness, dizziness, ataxia, tremor, speech disturbance
    • Risk factors for stroke
      • Hypertension, family history, smoking
    • Past history
      • Meningitis, head or spinal injury, convulsions, operations, STDs
    • Treatment
      • Anticonvulsants, anti-Parkinsonian agents, steroids, antihypertensives
    • Social history
      • Alcohol, drugs, work, travel
    • Family history
      • Neurological disease, consanguinity
  • Endocrine history
    • Symptoms
      • Hyperthyroid
        • Goitre, heat intolerance, weight loss, increased appetite, palpitations, sweating, anxiety, diarrhoea
      • Hypothyroid
        • Goitre, cold intolerance, lethargy, eyelid swelling, hoarse voice, constipation, coarse skin
      • Diabetes
        • Polyuria, polydipsia, thirst, blurred vision, weakness, infections
    • Past history
      • Thyroid surgery, irradiation, diabetic complications, hypertension
    • Treatment
      • Iodine, antithyroid drugs, hormone replacement (thyroxine, steroids, insulin…)
    • Social history
      • Impotence
    • Family history
      • Thyroid disease, diabetes, endocrine adenomatosis

Short case examination

  • General
    • Position
      • Patient supine in bed, examined from right side
      • Fully exposed (with consideration to modesty)
    • Overview
      • Facies, skin colour, hair, body habitus, hydration
      • HR, BP, temperature
  • Cardiovascular
    • Position
      • Supine at 45° on pillows
    • General appearance
      • Pallor, dyspnoea, fatigue, cachexia
      • Characteristic appearance (Marfan’s, Down’s…)
    • Hands
      • Clubbing, nailbeds, finger pulps
    • Pulse
      • Rate, rhythm, character and volume, radiofemoral delay
    • Blood pressure, postural effects
    • Face
      • Sclerae (pallor, jaundice), mitral facies, mouth (arched palate)
    • Neck
      • Carotid pulse, JVP (level, waveform, Kussmaul’s sign, hepatojugular reflex)
    • Praecordium
      • Inspection: scars, pacemaker, apex beat (5 ICS, 1 cm medial to MCL)
      • Palpation: apex beat size and character, left sternal heave, palpable P2, thrill
      • Auscultation
        • Bell at apex: mitral stenosis or S3
        • Diaphragm at apex: Mitral regurgitation or S4
        • 5L ICS (tricuspid)
        • 2L ICS (pulmonary)
        • 2R ICS (aortic)
        • Carotids or axilla as indicated
        • Sit forward
        • Inspiration: right-sided murmurs louder
        • Expiration: left-sided murmurs louder (esp. AI)
        • Valsalva: HOCM louder or MVP earlier (decreased LV volume)
        • Squatting: murmurs except HOCM, MVP louder (increased LV volume, CO)
    • Back
      • Lung bases, sacral oedema
    • Abdomen
      • Hepatomegaly, splenomegaly, ascites
    • Legs
      • Femoral pulses and auscultation
      • Distal pulses and oedema
      • Buerger’s test: pallor on elevation (poor perfusion), cyanosis on dependence
      • DVT, PVD signs
      • Varicose veins
    • Other
      • Urinalysis, fundoscopy
  • Respiratory
    • Position
      • Sitting
    • General
      • Sputum mug, cough, rate and depth of respiration, accessory muscle use
    • Hands
      • Colour (cyanosis, tar), clubbing, wasting, tenderness (HPO), pulse, tremor
    • Chest
      • Inspect
        • Shape (kyphosis), scars
      • Palpate
        • Expansion, nodes, fremitus, breasts
      • Percuss, auscultate (breath sounds, resonance, adventitious sounds)
      • Pemberton’s sign
      • Cardiac examination if indicated
        • JVP, pulmonary hypertension…
    • Face
      • Horner’s syndrome, jaundice, pallor, cyanosis
      • Hoarseness
      • Tracheal deviation
    • Other
      • Tests: FET, PEFR, counting tests
      • Signs of malignancy elsewhere
      • Temperature

Anaesthesia and connective tissue diseases

Ankylosing spondylitis

  • Epidemiology
    • 0.5 to 4 per 1000
    • Male:female 10:1
    • HLA-B27 related
    • Onset between 15 and 40
  • Pathology and clinical findings
    • Progressive inflammatory synovitis
      • Sacroiliac, intervertebral, costovertebral, hip, shoulder and other joints
    • Fibrosis and ossification, especially of the annulus fibrosus
      • “Bamboo spine”
      • May impinge spinal cord, nerve roots, vertebral arteries
    • Aortic root involvement may cause aortic incompetence (3%)
    • Fibrosis of the AV bundle may cause conduction defects
    • Pulmonary fibrosis, especially upper lobe, can cause massive haemoptysis
    • Uveitis in 20-30%
  • Treatment
    • Symptomatic treatment with NSAIDs
    • No disease-modifying therapy
  • Anaesthetic considerations
    • May present with:
      • Orthopaedic procedures (joint replacement, spinal wedge resection)
      • NSAID-associated gastric ulcer disease
      • Aortic incompetence, haemoptysis
    • Spine involvement limits neck mobility
      • May be difficult intubation
      • High incidence of cervical fractures with minimal trauma
      • Fixed neck flexion may preclude crycothyroidotomy or tracheostomy
    • TMJ involvement limits mouth-opening in 10%
    • Cricoarytenoid arthritis rarely causes vocal cord fixation
    • Costovertebral involvement limits chest expansion
      • Increased incidence of postoperative pulmonary complications
      • External cardiac massage is often ineffective
    • Neuraxial anaesthesia has an increased failure rate
      • Can J Anaesth 1996 case series:
        • 3 of 13 of spinals and 3 of 3 of epidurals unsuccessful
        • Case report analysis suggests epidural haematoma is more likely
  • Anaesthetic management
    • Investigations
      • Radiological and clinical assessment of cervical spine and airway
      • ECG
    • Induction
      • Likely difficult intubation
      • Cervical manipulation may be dangerous
      • Awake fibreoptic intubation or avoidance of intubation may be safest
      • Diaphragmatic splinting postoperatively is more likely to cause respiratory failure
    • Regional
      • Spinal or epidural is likely to be even more difficult than GA

Rheumatoid arthritis

  • Epidemiology
    • Approx. 1% of population
    • Female:male 3:1
    • Prevalence increases with age
    • Onset usually between 35 and 50
    • Associated with HLA-DR4 in some populations
  • Pathology and clinical findings
    • Aetiology uncertain
    • Persistent inflammatory synovitis with symmetric polyarthritis
    • Cartilage destruction and bone erosion
    • Pain and stiffness usually worst in the morning
    • Joints affected
      • Most commonly proximal interphalangeal, metacarpophalangeal, wrist, knee, elbow
      • Most other synovial joints
      • Axial involvement limited to cervical spine
        • Atlanto-axial subluxation
      • TMJ and cricoarytenoid joints may be involved
      • Articular swelling may cause nerve entrapment
        • Median, ulnar, radial interosseos br., anterior tibial
    • Extraarticular involvement
      • Rheumatoid nodules in 25%
      • Vasculitis can cause several complications
        • Polyneuropathy, skin necrosis, distal gangrene, visceral infarction, renal impairment
      • Pleuropulmonary nodules and pulmonary fibrosis
      • Pericarditis and pericardial effusion (present in 50% but subclinical)
      • Episcleritis and scleritis (1%)
      • Increased incidence of dysphagia
  • Treatment
    • Disease-modifying
      • Gold: thrombocytopenia, granulocytopenia, proteinuria
      • D-penicillamine: thrombocytopenia, granulocytopenia, proteinuria
      • Hydroxychloroquine: retinopathy
    • Symptomatic
      • Simple analgesics
      • NSAIDs
      • Corticosteroids
    • Immunosuppressants
      • Azathioprine, cyclophosphamide: marrow suppression, ?malignancy
      • Methotrexate: abnormal LFTs
    • Surgery
      • Synovectomy, joint replacement, nerve releases
  • Anaesthetic considerations
    • Cervical spine
      • Cervical spine instability in 25%, usually atlanto-axial
      • Most asymptomatic
      • Case reports of spinal cord damage in relaxed patients
      • Occipito-cervical fusion increases the incidence of lower instability
    • Larynx
      • Odontoid migration is associated with laygneal displacement
        • Usually anteriorly and to the left
    • Mouth opening
      • Limited by TMJ involvement
      • More common in juvenile arthritis
    • Cardiac function
      • Pericardial effusion and valve involvement
    • Pulmonary fibrosis
    • Drug-related complications
  • Anaesthetic management
    • Investigations
      • Clinical and X-ray assessment of cervical spine in flexion and extension
      • Investigation for drug complications (FBE, U&E)
      • RFT if pulmonary involvement
    • Induction
      • Cervical collar if unstable
      • Intubation with fibreoptic scope or laryngeal mask
      • Crycoarytenoid involvement may necessitate a smaller tube

Progressive systemic sclerosis (“scleroderma”), CREST syndrome

  • Epidemiology
    • Female > male
    • Onset 30-50 years
    • Variation in severity over time
  • Pathology and clinical findings
    • Increased production of normal collagen
      • Cutaneous, gastrointestinal, cardiac, renal, other organs
    • Possibly due to endothelial damage in small vessels causing an inflammatory response, antinuclear antibodies are usually present
    • Cutaneous
      • Taut, shiny skin tethered to underlying tissue
      • Contractures of joints and the mouth may occur (bird-like facies)
    • Peripheral vascular spasm causes Raynaud’s phenomenon
    • Gastrointestinal
      • Involvement spares the upper third of the oesophagus
      • Remainder of the small bowel affected
      • Diverticulae in large bowel
      • Dysphagia and dysmotility, malabsorption
    • Pulmonary
      • Vascular involvement may cause pulmonary hypertension
      • Interstitial fibrosis usually lower 2/3
    • Cardiac
      • Fibrosis of myocardium and conducting system (56%)
      • Fibrinous pericarditis, effusion (28%)
    • Renal
      • Cortical infarction and glomerulosclerosis in >50%
      • Temperature-sensitive vasospasm
    • Symmetric polyarthritis
    • Hypothyroidism due to fibrosis
  • Treatment
    • D-penicillamine, aspirin used without evidence
    • Vasodilators for Raynaud’s phenomenon (and avoidance of cold)
    • Symptomatic H2 antagonists
    • Antihypertensives may delay renal failure
  • Anaesthetic considerations
    • Periphery
      • Difficult venous access
      • Increased risk of fingertip ischaemia or ulceration
      • Telangiectasia may bleed
    • Airway
      • Mouth contractures
      • Increased reflux risk
    • Cardiovascular
      • Hypertension, LV failure, arrhythmias
      • Cold-induced vasospasm
    • Pulmonary
      • Constrictive chest wall, alveolitis
    • Regional
      • Case reports of prolonged sensory loss after local anaesthetic
  • Anaesthetic management
    • Investigations
      • Assessment of airway and any contractures
      • Assessment of pulmonary function
      • CXR may show prominent PA in pulmonary hypertension
    • Preoperative
      • Warming, possible need for CVC or cut-down for IV access
      • Increased risk of distal ischaemia with arterial cannulation
    • Induction
      • Protection from reflux risk

Systemic lupus erythematosis

  • Epidemiology
    • 15 to 50 per 100,000
    • Female:male 10:1
    • Onset 20-50 years
    • Racial differences in prevalence
    • Association with multiple autoantibodies and HLA types
  • Pathology and clinical findings
    • Type III immune complex disease
    • Aetiology uncertain
      • Drug-induced variant from hydrallazine or procainamide
    • Abnormal immune activation against self antigens
    • Skin
      • “Butterfly” rash, photosensitivity, vasculitis, ulceration, alopecia
    • Arthritis
      • Painful proximal interphalangeal and metacarpophalangeal joints, tenosynovitis
      • Ischaemic necrosis of bone
    • Renal
      • Immune complex deposition causes glomerulosclerosis
      • May cause renal failure requiring dialysis
    • Neurological
      • CNS involvement, ?personality changes, psychosis, fitting
      • Neuropathies, including cranial nerves
    • Vascular, haematological
      • Thrombotic tendency (lupus anticoagulant)
        • Binds phospholipids in prothrombin-activator complex
      • Persistent vasculitis predisposes to coronary and peripheral vascular disease
      • Commonly require anticoagulant prophylaxis
      • May develop anti-VIII or IX antibodies, causing bleeding
      • Thrombocytopenia is common
    • Cardiac
      • Pericarditis, myocarditis are uncommon
      • Endocarditis can involve mitral or aortic valves, causing incompetence
    • Pulmonary
      • Pleural effusions are common, infiltrates are most commonly infective
    • Gastrointestinal
      • Vasculitis may cause gut ischaemia or perforation
    • Eyes
      • Retinal vasculitis, infarcts, blindness
    • Pregnancy
      • Normal fertility, increased spontaneous abortion rate
      • SLE commonly exacerbated from first trimester
      • Neonates may display complete heart block or discoid lupus rash
  • Treatment
    • 30% mortality over 10 years from diagnosis, related to severity
    • Symptomatic treatment of inflammation with NSAIDs
    • Rash may respond to hydroxychloroquine
    • Severe disease responds to high-dose corticosteroids
    • Immunosuppressants sometimes used: azathioprine, cyclophosphamide, chlorambucil
  • Anaesthetic considerations
    • Pulmonary involvement may cause restrictive lung deficit
    • Thrombotic tendency, but abnormally prolonged APTT with lupus anticoagulant
    • Commonly thrombocytopenic
    • Commonly present during pregnancy
  • Anaesthetic management
    • Investigations
      • RFT for pulmonary disease
      • Assessment of cardiac involvement and renal function
      • Coagulation testing, platelet count
        • Test for lupus anticoagulant
    • Regional
      • Difficult risk-benefit assessment for epidural analgesia in labour

Kindly provided by Dr James Mitchell from his pharmacodynamics series


ArticleDate:20060601
SiteSection: Article
 
   
    
                                            
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