SS and DD of GERD

Gastroesophageal Reflux Disease [GERD]

DDx
• Peptic ulcer disease, gastritis, nonulcer dyspepsia, or cholelithiasis
• Angina pectoris - chest pain
• Infectious esophagitis: Candida, herpes simplex virus, cytomegalovirus
• Pill-induced esophagitis - dysphagia, odynophagia
• Esophageal motility disorders, eg, achalasia, esophageal spasm, scleroderma
• Radiation esophagitis - dysphagia, odynophagia
• Zollinger-Ellison syndrome (gastrinoma) - heartburn, dysphagia
Typical Presentation
Heartburn - often occurs 30–60 minutes after meals and upon reclining/ relief from taking antacids or baking soda, symptom is dominant, the diagnosis is established with a high degree of reliability.
Concomitant nausea, vomiting or early satiety – Gastroparesis is suspected.
Overall, a clinical diagnosis of gastroesophageal reflux has a sensitivity of 80% but a specificity of only 70%.
Regurgitation - the spontaneous reflux of sour or bitter gastric contents into the mouth.
Dysphagia or Odynophagia - occurs in one-third of patients and may be due to erosive esophagitis, abnormal esophageal peristalsis, or the development of an esophageal stricture.
It is necessary to undergo gastroscopy if find weight loss, anemia, family history of Upper GI cancer, GI bleed or advanced age.
Atypical Presentation
• Asthma – microaspiration causes initiation of asthma, adult onset asthma KIV.
• Otitis Media – children, with effusion results hearing loss
• Chronic cough
• Chronic laryngitis
• Sore throat
• Chest pain
In the absence of heartburn or regurgitation, atypical symptoms are unlikely to be related to gastroesophageal reflux.
Physical examination and laboratory data are normal in uncomplicated disease.

Cholecystitis Role Play: History Taking

History:

PAIN: sharp, cramping, dull,
WHEN: come and go, acute
WHERE: begin at epigastric, then localized at right hyppchondrium; radiate to the back or below the right scapula
Aggregating factors: Breathing deeply , after meal (esp: large meal or high fat meal)
Associated symptoms: Chills


GIT system review:

Abdominal pain AS ABOVE
Appetite YES
Weight NO
Nausea YES
Vomiting YES
Vomiting blood (haematemesis) NO
Heartburn NO
Difficulty swallowing (dysphagia) NO
Bloating (Abdominal fullness) YES (at RUQ)
Change in bowel habit NO
Blood in stools/ bowel motion NO
Black-tar like stools (malaena) YES
Fevers YES (above 38’c)
Jaundice YES
Itch NO
Overseas travel NO


References:
http://www.nlm.nih.gov/medlineplus/ency/article/000264.htm
http://emedicine.medscape.com/article/171886-overview
http://www.mayoclinic.com/health/cholecystitis/DS01153/DSECTION=symptoms

Sign & Symptoms of Pneumonia

Symptoms of pneumonia caused by bacteria in otherwise healthy people (younger than 65) usually come on suddenly. They often start during or after an upper respiratory infection, such as influenza or a cold, and may include:

• Cough, often producing mucus (sputum) from the lungs. Mucus may be rusty or green or tinged with blood.
• Fever which may be less common in older adults.
• Shaking, "teeth-chattering" chills (one time only or many times).
• Fast, often shallow, breathing and the feeling of being short of breath.
• Chest wall pain that is often made worse by coughing or breathing in.
• Fast heartbeat.
• Feeling very tired (fatigue) or feeling very weak (malaise).
• Nausea and vomiting.
• Diarrhea

Clinical signs of pneumonia are characteristic and are referred to clinically as consolidation :

• Expansion : reduced on the affected side
• Vocal fremitus : increased on the affected side (in other chest disease this sign is of very little use!)
• Percussion : dull
• Breath sounds : bronchial breath sounds
• Additional sounds : medium, late or pan-inspiratory crackles
• Vocal resonance : increased
• Pleural rub : may be present

Signs and Symptoms: COPD

COPD – Signs and Symptoms
• An ongoing cough or a cough that produces large amounts of sputum (often called "smoker's cough")
• Shortness of breath, especially with physical activity
• Wheezing (a whistling or squeaky sound when you breathe upon exhalation)
• Chest tightness
• Hemoptysis
• You're having a hard time catching your breath or talking.
• You're not mentally alert.
• Your heartbeat is very fast.
Chronic bronchitis
Chronic bronchitis occurs mainly in smokers. It's defined as a cough that you have at least three months a year for two consecutive years. People who continue to smoke may go on to develop emphysema, but in smokers who are able to quit, the cough may clear in a few days or weeks.
Signs and symptoms of chronic bronchitis include:
• Having to clear your throat first thing in the morning, especially if you smoke
• A chronic cough that produces yellowish sputum
• Shortness of breath in the later stages
• Frequent respiratory infections
Emphysema
Signs and symptoms of emphysema include:
• Shortness of breath, especially during physical activities
• Wheezing
• Chest tightness
Signs
• Central cyanosis
• Clubbing of finger
• Your lips or fingernails turn blue or gray. (This is a sign of a low oxygen level in your blood.)
• Hyperinflated Chest (barrel chest)
• Hyper-resonance on auscultation
• Reduced expansion on inspiration
• Vesicular breathing but it may be low due to low flow rates
• Reduced cardiac and hepatic dullness (large lungs)
• Decreased vocal resonance as sound doesn’t travel easily through air.

Sign and Symptoms of Sleep Apnea

Sign and Symptoms of Sleep Apnea

Signs:

1. Abnormal heart rhythm and increase blood pressure (caused by decrease oxygen levels in blood.)

2. Prolonged sleep apnea leads to heart failure and malfunction of the lungs

Symptoms:

1. Snore: loudest when sleep on the back and lessen when sleep on the side. (Prominent in Obstructive Sleep Apnea)

2. Observed episodes of breathing cessation during sleep (choking and gasping)

3. Abrupt awakenings accompanied by shortness of breath

4. Breathing become slow and shallow

5. Excessive daytime sleepiness especially when inactive (hypersomnia).

6. Morning headache

7. Memory and learning problems and not able to concentrate

8. Feeling irritable, depressed, or having mood swings or personality changes

9. Sex drives reduced.

10. Urination at night

11. A dry throat when you wake up

12. Difficulty staying asleep (insomnia)

p/s: partners or family members will notice these before the patient.

In children

1. Hyperactivity, poor school performance, and aggressiveness

2. Unusual sleeping positions, bedwetting, and may breathe through their mouths instead of their noses during the day.

References:

http://www.mayoclinic.com/health/sleep-apnea/DS00148/METHOD=print

http://www.nhlbi.nih.gov/health/dci/Diseases/SleepApnea/SleepApnea_Signs.html

The Merick Manual of Medical Information

Classical Signs & Symptoms of Aortic Stenosis

***Quick review!!!
Symptoms: What the patient present with upon consultation.
Signs: What the doctor get from patient upon examination.

Symptoms
Symptoms and heart problems in aortic stenosis are related to the degree of narrowing of the aortic valve area. Patients with mild aortic valve narrowing may experience no symptoms. When the narrowing becomes significant (usually greater that 50% reduction in valve area), the pressure in the left ventricle increases and a pressure difference can be measured between the left ventricle and the aorta.

In 4% of the patients with aortic stenosis, the first symptom is sudden death, usually during strenuous exertion.

The major symptoms of aortic stenosis are:
• chest pain (angina)-usually 1st symptom. The pain is described as pressure below the breast bone brought on by exertion and relieved by rest. The thickened heart muscle must pump against high pressure to push blood through the narrowed aortic valve. This increases heart muscle oxygen demand in excess of the supply delivered in the blood, causing chest pain.
• fainting (syncope)- usually associated with exertion or excitement. These conditions cause relaxation of the body's blood vessels (vasodilation), lowering blood pressure. In aortic stenosis, the heart is unable to increase output to compensate for the drop in blood pressure. Therefore, blood flow to the brain is decreased, causing fainting. Fainting can also occur when cardiac output is decreased by an irregular heart beat (arrhythmia). Without effective treatment, the average life expectancy is less than three years after the onset of chest pain or syncope symptoms.
• shortness of breath (dyspnoe)- reflects the heart muscle's failure to compensate for the extreme pressure load of aortic stenosis. Shortness of breath is caused by increased pressure in the blood vessels of the lung due to the increased pressure required to fill the left ventricle. Initially, shortness of breath occurs only during activity. As the disease progresses, shortness of breath occurs at rest. Patients can find it difficult to lie flat without becoming short of breath (orthopnea). Without treatment, the average life expectancy after the onset of heart failure due to aortic stenosis is between six to 24 months.


Classical Clinical Signs
• Small and delayed pulse-absence of this finding, particularly in an elderly patient with noncompliant vasculature, does not exclude severe aortic stenosis.

• Systolic murmur-may be most easily audible in the ‘mitral area’. This may cause a mistaken diagnosis of ischaemic mitral regurgitation in a patient with severe aortic stenosis and angina. The absence of a murmur over the right clavicle can help to exclude aortic stenosis.

• Soft or absent second heart sound

• Hypotension