Carcinoma of unknown primary
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Carcinoma of unknown primary Definition and clinical features Carcinoma which metastasises before primary site large enough to identify. 3% of cancer cases. 50% present with multiple sites of involvement, and 50% a single site, commonly liver, bones, lung, or lymph nodes.
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Depression
Background
Pathophysiology
• The monoamine theory of depression is that it results from a central deficit in the monoamine neurotransmitters serotonin (5-HT) and norepinephrine.
• Other reported physiological features include ↑cortisol and a blunted TSH response.
• However, there is no widely accepted and definitively proven biological model of depression.
Epidemiology
• Time course: for most it is an episodic illness, but for other it follows a more chronic course.
• Incidence: 5% annual risk, 20% lifetime risk.
Presentation
DSM and NICE criteria
These are based on DSM-4, though DSM-5 does not significantly differ.
Major depressive disorder is ≥2 weeks of low mood and/or anhedonia, and at least 4 symptoms out of:
• ↓Energy or fatigue.
• ↓Concentration
• ↓Weight/appetite.
• Disturbed sleep, which commonly includes early waking. Diurnal pattern to symptoms also seen, with symptoms often worse in the morning.
• Slowing of thought and movements (psychomotor slowing) or agitation.
• Ideas of worthlessness or guilt.
• Recurrent thoughts of death or suicide.
• All but the last 2 are considered 'biological' symptoms.
Psychiatric history
Psychiatric history
Basic structure
Standard history – presenting complaint, drug history, past medical history etc. – plus PSYCH extras:
Pre-morbid personality: "how would friends and family describe you before you were unwell?". Ask about previous hobbies and habits.
Substance use, including alcohol. Ask about frequency, volume, location and situation, and if relevant, administration route and needle sharing.
Youth: personal history.
Crime: forensic history.
Harm risk i.e. risk assessment. SO CRAP: Risk to Self, Risk to Others, Chronic physical health problems, Relapse risk, Medication Adherence, Protective factors.
Standard history components
Presenting complaint:
"What's been happening with you lately?". Put their own words in quotations as the presenting complaint.
If anxious, reassure: "we don't have to talk about anything you don't want to discuss".
Think about 4 key components of the episode, in a causal sequence: (1) triggers and life circumstances → (2) thoughts and emotions → (3) behavioural and physical symptoms, including functional impairments → (4) impacts on family, work, and physical health.
Make sure to cover the onset, duration, and pattern of symptoms, and factors that perpetuate, exacerbate, or relieve them.
Get their ideas, concerns, and expectations: what do they think is going on?
Ask about specific psych symptoms – e.g. delusions – as part of the mental state exam.
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More from medicostest
Depression
Depression
Background
Pathophysiology
• The monoamine theory of depression is that it results from a central deficit in the monoamine neurotransmitters serotonin (5-HT) and norepinephrine.
• Other reported physiological features include ↑cortisol and a blunted TSH response.
• However, there is no widely accepted and definitively proven biological model of depression.
Epidemiology
• Time course: for most it is an episodic illness, but for other it follows a more chronic course.
• Incidence: 5% annual risk, 20% lifetime risk.
Presentation
DSM and NICE criteria
These are based on DSM-4, though DSM-5 does not significantly differ.
Major depressive disorder is ≥2 weeks of low mood and/or anhedonia, and at least 4 symptoms out of:
• ↓Energy or fatigue.
• ↓Concentration
• ↓Weight/appetite.
• Disturbed sleep, which commonly includes early waking. Diurnal pattern to symptoms also seen, with symptoms often worse in the morning.
• Slowing of thought and movements (psychomotor slowing) or agitation.
• Ideas of worthlessness or guilt.
• Recurrent thoughts of death or suicide.
• All but the last 2 are considered 'biological' symptoms.
Psychiatric history
Psychiatric history
Basic structure
Standard history – presenting complaint, drug history, past medical history etc. – plus PSYCH extras:
Pre-morbid personality: "how would friends and family describe you before you were unwell?". Ask about previous hobbies and habits.
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Crime: forensic history.
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Standard history components
Presenting complaint:
"What's been happening with you lately?". Put their own words in quotations as the presenting complaint.
If anxious, reassure: "we don't have to talk about anything you don't want to discuss".
Think about 4 key components of the episode, in a causal sequence: (1) triggers and life circumstances → (2) thoughts and emotions → (3) behavioural and physical symptoms, including functional impairments → (4) impacts on family, work, and physical health.
Make sure to cover the onset, duration, and pattern of symptoms, and factors that perpetuate, exacerbate, or relieve them.
Get their ideas, concerns, and expectations: what do they think is going on?
Ask about specific psych symptoms – e.g. delusions – as part of the mental state exam.
Paediatric spots and rashes
Paediatric spots and rashes
• Common viral exanthemata (childhood rashes) are usually transmitted via airborne droplets entering the respiratory tract, or direct contact.
• Most self-resolve.
• Only rarely are specific treatments such as aciclovir needed.
• While all of these are commoner in children, they can also affect adults.
DDx: Maculopapular rash in children
• Measles
• Roseola infantum.
• Erythema infectiosum.
• Scarlet fever.
• Rubella (more of a macular rash).
• Non-specific viral rash e.g. associated with URTI.
• Drug reaction.
DDx: Vesicular rash in children
• Chickenpox
• Herpes simplex.
• Hand, foot, and mouth disease.
• Bullous impetigo.
DDx: Purpuric rash in children
Definitions:
• Flat, haemorrhagic rash.
• Divided into 3 sizes: petechiae < 3 mm < purpura < 10 mm < ecchymoses.
Causes:
• Meningococcaemia
• Henoch-Schonlein purpura.
• Thrombocytopenia: idiopathic thrombocytopenic purpura (affect buttocks then legs, follows URTI, and resolve in 6-8 weeks), leukaemia, aplastic anaemia, DIC, HUS.
• Trauma: direct trauma or barotrauma (e.g. from vomiting or coughing).
Paediatric fits, faints, funny turns
Paediatric fits, faints, funny turns
Differential diagnosis
Epilepsy:
• Defined as 2 unprovoked seizures at least 24 hours apart, or a tendency to seizures due to abnormal electrical activity.
Non-epileptic seizures:
• Febrile convulsions.
• CNS infection.
• Metabolic: ↓glucose, ↓/↑Na+, ↓Ca2+, ↓Mg2+.
• Acute trauma.
• Toxins
Other 'funny turns', some of which may include convulsions but are not epilepsy:
• Syncope
• Reflex anoxic seizures: stimulus like pain, cold food, or fright → asystole → generalized tonic clonic seizure due to low brain O2.
• Sleep myoclonus: a benign, random series of myoclonic movements during or just before/after sleep. Onset is usually in neonates and most resolve in infancy.
• Migraine
• Arrhythmia e.g. long QT.
• Tics
Psychological and emotional episodes:
• Breath-holding attacks: crying then breath-holding in a toddler. May become cyanosed or have a short seizure.
• Non-epileptic attack disorder.
• Panic attacks.
Paediatric msk problems
Paediatric MSK problems
Signs and symptoms
MSK signs and symptoms:
Limp.
Joint pain and swelling.
Remember that hip pain may be referred to the knee.
Morning stiffness.
Gelling: stiffness following period of inactivity.
Weakness and instability.
Pseudoparalysis: limb fixed in pain.
Associated systemic symptoms:
Fever
↓Feeding or growth.
Rash.
Poor sleep.
History of trauma:
Incongruous signs might suggest non-accidental injury.
Functional limitations.
Differential diagnosis
General:
First exclude trauma – which may be missed/unwitnessed (especially in young e.g. toddler's fracture) – and infection – septic arthritis, osteomyelitis, or discitis.
Consider general causes of MSK pain such as growing pains (often nocturnal), hypermobility, and complex regional pain syndrome.
Acute: irritable hip, neuroblastoma, leukaemia.
Chronic: developmental dysplasia of the hip, talipes, cerebral palsy, juvenile idiopathic arthritis (JIA).
Pediatric gi problems
Pediatric GI problems
Abdominal pain in children
DDx: Acute abdominal pain
Inflammatory:
• Abdominal infection: appendicitis, gastroenteritis, UTI, mesenteric adenitis (post URTI), mumps pancreatitis, hepatitis.
• Lower lobe pneumonia.
• Autoimmune: IBD, HSP, DKA.
Anatomical:
• GI obstruction, constipation.
• Meckel's complication e.g. obstruction, inflammation. However, Meckel's is usually asymptomatic.
• Renal and genitourinary: hydronephrosis, menstruation.
• Compressed anatomy: strangulated inguinal hernia, testis torsion.
Acute abdominal pain in children often has no specific cause ('non-specific abdominal pain'), and resolves in 24h.
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Paediatric respiratory problems
This document discusses several common pediatric respiratory problems. It begins by outlining signs of respiratory distress and failure in children, including increased respiratory rate and heart rate, nasal flaring, recession of the chest wall, and decreased oxygen saturation despite supplemental oxygen. Specific conditions are then discussed such as croup, epiglottitis, bronchiolitis, pneumonia, whooping cough, inhaled foreign bodies, cystic fibrosis, and heart failure. For each condition, the causes, signs and symptoms, investigations, and management are summarized. The document provides an overview of approaches to evaluating and treating major respiratory issues seen in pediatric patients.
Behavioural and emotional problems
Behavioural and emotional problems
Investigations
A complete developmental history and examination is important: not just social/emotional, but also speech, hearing, or cognitive problems, which can also cause behavioural problems.
Learn the ABC of the problems:
• Antecedents
• Behaviour
• Consequence
Separation anxiety
• Anxiety about separation from main caregiver.
• Part of normal development from 6-8 months.
• By 2 years it usually reduces as they can extend attachment to others, and by school age they can normally tolerate hours away from parents.
• Its persistence or re-emergence beyond this time may be pathological, and known as separation anxiety disorder.
Cataracts
Cataracts
Pathophysiology
Opacification of lens, usually due to age-related pigment build-up.
Leads to ↓transparency and ↓refractive index of lens, and hence visual impairment.
Causes of premature cataracts
Steroids, including topical therapy near eyes.
Congenital: trisomy, myotonic dystrophy, infection (rubella, HSV).
Ocular disease: glaucoma, severe myopia, retinal detachment.
Diabetes
UV or infrared radiation.
Epidemiology
Extremely common: 30% prevalence over age 65, and 60% over 80.
Acute red eye
Acute red eye
Differential diagnosis
Common causes:
Conjunctivitis
Episcleritis
Subconjunctival haemorrhage: spontaneous (e.g. coughing) or traumatic. Self-resolves, but consider bleeding disorder if recurrent.
Trauma: corneal abrasion (+ve fluorescein test), foreign body.
Site-threatening causes (often painful):
Keratitis (corneal infection).
Scleritis
Anterior uveitis (iritis or iridocyclitis).
Acute angle closure glaucoma.
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Carcinoma of unknown primary
- 1. Carcinoma of unknown primary THIS SLIDE IS MADE WITH THE ASSISTANCE OF MEDICOS PDF APP: HTTPS://MEDICOSPDF.COM/
- 2. Definition and clinical features Carcinoma which metastasises before primary site large enough to identify. 3% of cancer cases. 50% present with multiple sites of involvement, and 50% a single site, commonly liver, bones, lung, or lymph nodes.
- 3. Subtypes 4 subtypes on microscopy: Well/moderate differentiated adenocarcinoma (50%). Poor/undifferentiated adenocarcinoma (30%). Squamous cell carcinoma (15%). Undifferentiated carcinoma (5%).
- 4. Final diagnosis 20% identified when alive, 10% identified on autopsy, 70% never identified. When identified: lung, pancreas, GI, breast, gynaecological.
- 5. Investigations General approach: Full examination including rectal and pelvic, and breast if female. Bloods: FBC, U+E, LFT, Ca2+ (especially if confusion), LDH, urinalysis (haematuria may point to GU cancer). Imaging: CXR, CT chest-abdo-pelvis. Biopsy and histology of affected sites.
- 6. Further investigations if specific cancer suspected: Tumour markers: AFP (hepatocellular, germ cell), β-hCG (germ cell), PSA (prostate), CA-125 (ovarian), CA 19-9 (pancreas, bile duct). Endoscopy Mammography in all women with adenocarcinoma, especially if there is axillary lymphadenopathy. MRI if results unclear. PET-CT if there is cervical lymphadenopathy. Immunohistochemistry: cytokeratin 7 and 20 (adenocarcinoma), TTF1 (non- small cell lung cancer), PLAP, estrogen receptor, PSA. Ascites cytology: can specify adenocarcinoma – thus rule out lymphoma – but not much else.
- 7. Management Key goal: identify those with treatable cancer. Complications and prognosis Median survival: 6 months. Worse prognosis if: Poorly-differentiated histology. ↑Serum markers: alk phos, LDH, CEA. Lymphadenopathy, multiple sites. Poor performance status, weight loss.
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