Medical Semeiotics Past Paper PDF 29/10/2020

LN°21 - 29/10/2020 MEDICAL SEMEIOTICS – PROF. PERLINI BAGNATO – COSTA What can we observe in this pa1ent? (figure on the right) Enlarged and round abdomen (we may also hypothesise the presence of fat in the abdomen) Tense skin Protruding navel. It means that something inside i...

LN°21 - 29/10/2020 MEDICAL SEMEIOTICS – PROF. PERLINI BAGNATO – COSTA What can we observe in this pa1ent? (figure on the right) Enlarged and round abdomen (we may also hypothesise the presence of fat in the abdomen) Tense skin Protruding navel. It means that something inside is pushing it, so it is a clue for increase in intra-abdominal pressure. If you have a situaTon like this, in which skin is very tense and it is becoming translucent and at the same Tme you see that the umbilicus is either plain or protruding, this may mean either that there is an hernia, so, a problem in the abdominal wall, or that there is an increase in the pressure inside. Possible causes of an increase in pressure inside the abdomen: o fluid accumulaTon o enlarged viscera o a growing mass (a tumor) o pregnancy o excessive air content of the GI tract o hernia Mismatch between the abdomen dimension and the body. The dimension of the belly, in fact, is not proporTonal to the body size of this person. I would expect this belly in a very big man with fat and muscles but here we have a thin paTent with also some extent of muscle was:ng. So, the mass of the muscles is not proporTonal to what I see in the belly. This may help us in interpreTng these observaTons. I have to ask the paTent when did this belly grow. Has it been years or weeks? Usually they say that the belly has been ge\ng bigger and bigger and at the same Tme the breathing pa]ern has changed because of the pressure from the abdomen. PERITONEAL CAVITY It is a potenTal space between the parietal peritoneum and visceral peritoneum, the two membranes separate the organs in the abdominal cavity from the abdominal wall potenTal means that there is a very li]le space that is filled with Tny amount of fluid that helps the two peritoneum membranes to have fricTon movement with no problem. The fluid is produced and reabsorbed by the endothelium. The peritoneal cavity is derived from the coelomic cavity of the embryo, it is the largest serosal sac in the body and secretes approximately 50ml of fluid per day. There is Tny amount of fluid that helps the two peritoneal membranes to move without problems. ASCITES Ascites derives from a Greek world meaning bag or sac and it is defined as an exaggerated accumulaTon of freely moving fluid in the peritoneal cavity, so, in this case the cavity is not virtual anymore. The paTent of the picture may have ascites. But how can I understand whether it is ascites or something else? Look at the anatomy: we have a Tny amount of fluid allowing the viscera not to hurt one another during the movements. Ascites may be common in several causes, the main one being liver cirrhosis. Ascites is not only characterised by accumulaTon of fluid, but also by the fact that this fluid can move. In fact, you may have an accumulaTon of fluid in the abdomen, in a cavity, in an enlarged viscera as the bladder, but in those cases the fluid is not really moving. Whereas in ascites the fluid, as you can see from anatomy, may move freely around the cavity and this have several consequences in term of the possibiliTes of diagnosis and in the general evaluaTon. This is an excessive protrusion of the umbilicus and in this paTent, you can observe very well how depleted are the muscles. What also can we observe in this paTent in addiTon to protrusion and muscle wasTng? -Obvious tension of the skin -GynecomasTa, oden present in people with some forms of ascites -Tny network of veins under the umbilicus in the lower belly (caput medusae) Since I want to know whether this is ascites or something else, I need to have a hint on the possible diagnosis. EPIDEMIOLOGY Sex: Normally healthy men have li]le or no intraperitoneal fluid, but women may normally have as much as 20ml, depending on the phase of their menstrual cycle. Mortality/morbidity Ambulatory paTents with an episode of cirrhoTc ascites have a 3-year mortality rate of 50%. The development of refractory ascites carries a poor prognosis, with a 1-year survival rate of less than 50 %. So, when ascites is caused by liver cirrhosis, survival is impaired, and you have high mortality of these paTent. This has to be kept in mind in interpreTng and understanding which is the situaTon of our paTent. CAUSES OF ASCITES WITH ANASARCA Anasarca is a generalised oedema, found everywhere throughout the body, also in muscles and in the abdominal wall. So, ascites with anasarca is a condiTon characterised by the presence of generalised oedema together with effusion in the main caviTes. This may be caused by: CongesTve heart failure NephroTc syndrome Hypoproteinaemia with severe anaemia (nutriTonal) Pericardial effusion ConstricTve pericardiTs Myxoedema Protein losing enteropathy CAUSES OF ASCITES WITHOUT ANASARCA The paTents in the pictures we have seen, don’t show oedema in the chest and in the arms, so, this is another point I have to consider in my evaluaTon. (Slide below lists causes of ascites without anasarca)  Cirrhosis of the liver eventually may lead to anasarca because liver producTon of proteins is impaired but at the beginning, it causes ascites with any form of oedema. As a consequence, if I see a paTent in whom I suspect ascites, I also have to look if there is oedema. If it is not present it is more likely to be a localised problem and not a generalised one STAGING OF ASCITES I can give a quanTficaTon or a semi-quanTficaTon to the ascites according to the capability of seeing it. - Stage 1: it is detectable only ader careful examinaTon - Stage 2: it is easily detectable but of relaTvely small volume - Stage 3: it is obvious, but the abdomen is not tense - Stage 4: is tense ascites The possibiliTes we have to idenTfy ascites signs and symptoms heavily depend on the body morphology of each paTent: - In a very fat paTent, it is very difficult to find ascites unTl it is very severe. - In very thin paTent ascites may be obvious even with a small accumulaTon of fluid During ascites, how many litres of fluid can be accumulated? Normal quanTty of fluid we have in the peritoneum is 50mL, whereas in ascites accumulaTon can be 2 to 10 or even 15 L of fluids. So, the paTent also tells you that there is a change in body weight. All these litres cause extension of abdomen as we saw before. Causes are different and you will study in lab evaluaTon that analysis of acidic fluids will help you but here we don’t cover chemical analysis. We must understand how to clinically suspect the presence of ascites. The most common cause is chronic liver disease causing portal hypertension. Portal hypertension is an increase in pressure in the portal vein. The la]er drains blood from the GI tract and brings it to the liver. So, it is part of a venous circulaTon from the belly to the liver hence it is normally characterised by a very low pressure. If you have a situaTon that is causing portal hypertension you will have a high likelihood of extravasaTon of fluid in the intersTTum of peritoneum and so into the peritoneal cavity. So, ascites has to be seen as a consequence of portal hypertension. Liver cirrhosis is obviously the main cause of portal hypertension but some other causes exist: Let’s start with chronic liver disease caused by cirrhosis. If you have a paTent who has got ascites and you suspect the presence of liver impairment and fibroTc changes of the liver so, cirrhosis, what are the consequences that I may use in my clinical evaluaTon? So, which are the signs and symptoms that may help me in understanding this paTent has a liver problem? First of all jaundice which is a condiTon of yellow or yellowish skin, mucosae and sclera caused by high bilirubin level. Bilirubin when accumulaTng gives a yellowish colour. It easier to see jaundice in sclera and mucosae since here we don’t have the confusion factor of melanin content in the skin. The melanin content in the skin depends on many factors among which ethnicity. If I am visiTng a Caucasian paTent it will be much easier to detect jaundice from the skin with respect to when visiTng an Asian paTent, but the sclerae will be yellowish in the same way. Another consequence of jaundice is that biliary salt are very irritaTng to the skin so, the paTent will complain of pruritus and this will also cause the paTent to have some lesions on the skin due to nails. if the paTent has also a problem of fragility of the vessels and a problem of coagulaTon (very oden present in people with advanced liver cirrhosis) and I ask if they have pruritus and/or lesions this will be another hint toward the diagnosis. CirrhoTc liver In the picture on the right we can see a cirrhoTc liver. It has an enTrely changed structure with the presence of nodules (not normally present). By palpaTng the liver, I can understand it is fibroTc since it will be very firm, no tender and it will be shrinked. So, all these characterisTcs will bring to the possibility to have ascites caused by liver cirrhosis. Another important point is history taking: I should ask to the paTent whether he has one of the major causes of cirrhosis so if they are an alcohol abuser or if have had previous infecTon of viral hepaTTs B or C. If the paTent knows that he had a viral hepaTTs or admits of being an alcohol abuser, this will increase the likelihood that your diagnosis is ascites in cirrhoTc paTent. Otherwise maybe you have to check if there are signs of previous viral hepaTTs that the paTent may not remember. So, all these condiTons (have big belly, liver that is deranged, jaundice) are several elements that are poinTng to the diagnosis of portal hypertension caused by liver cirrhosis. The physiopathology will be that cirrhosis causes portal hypertension. The la]er in turn induces several changes in circulaTon, locally and systemically, several changes in many of the pepTdes and vasoconstrictors, a change in sodium and water balance trying to keep some water to improve circulaTon and this will eventually cause hyponatremia and ascites (accumulaTon of fluid). If to this, you also add that in cirrhosis you have a lower producTon of albumin, you have an oncoTc factor contribuTng to the development of ascites It’s important to keep in mind also anatomy: the portal system is represented in the picture. Portal vein drains blood from umbilicus, from the superior mesenteric vein, from the inferior mesenteric and from the splenic vein. So, you have several organs that drain blood toward the liver through this system. If the pressure in the portal vein is increased, this increase will be transmi]ed throughout the whole system. For example, spleen that is like a sponge will lead to splenomegaly. Keep in mind that the venous system from the stomach to the anus is normally draining through the portal vein to the liver but, at the level of the esophagus and at the level of the hemorrhoidal plexus, you will have the possibility of draining either in the portal circulaTon or in the caval circulaTon: Superior vena cava for the esophagus Inferior vena cava for the hemorrhoidal plexus. If you have increased pressure in the portal vein this will mean that you will have the possibility through the oesophageal plexus or the hemorrhoidal plexus to have half of the blood going to the inferior vena cava or superior vena cava, thus bypassing the liver filter. Two consequences to this: 1. You can have varices either at the esophagus or in the hemorrhoidal plexus. So, we ask the paTent whether he has haemorrhoids (red blood in feces), whether he has black stools (due to digested blood) caused by blood losses in GI tract, or whether he has hematemesis, that is vomiTng blood from rupture of varices in esophagus. 2. If you have blood drained from the GI tract bypassing the liver, this blood will cause collateral circulaTon that I can see on the surface of the belly. Moreover it may cause the passage of some of the metabolites that are drained by the GI tract without the liver filter. For example all the amino acids that are normally processed by the liver, with this bypass will go into the systemic circulaTon without any liver processing. Another important problem: Amino acids from the absorpTon of our GI tract are normally detoxified by the liver if you drain somewhere else you may have the accumulaTon of ammonium in the systemic circulaTon that is normally present at a very low level. Consequences of this: change in urine ph (not clinically important) change in blood ph Main property of ammonium is that it can cross the BBB so you can have hyper-ammonemia which is toxic to the neural transmission. So, the paTent will have neurological problem that usually manifests through a flapping tremor (unintenTonal) in moving the hand up and down. Moreover, ammonium is volaTle, so you smell it in the air near the paTent: this tells you that the level of ammonium that has crossed the BBB and has arrived to the lungs to be expelled has increased. In addiTon to the flapping tremor the paTent may also be confused, somnolent, drowsy or may fall to coma. This is the reason why in a paTent with liver cirrhosis and ascites I also have to check his level of consciousness, because if there is a toxic level of ammonium that has reached the brain, not only the movement, but also the consciousness may be changed. So, ascites has got many causes and it has got several physio pathological mechanisms (slide on the led). Let’s look at the clinical foundaTon perspecTve. The main point is observaTon.  Most typical signs are the ones we have already seen (big belly, round abdomen, tense skin and you may have protrusion of umbilicus). Moreover, in men you may have gynecomas:a. The liver is processing sexual hormones and this might be a cause a change towards the estrogenic pathway, so the paTent will complain of gynecomasTa. The la]er can also worsen with some drugs used for ascites that have got gynecomasTa as side effect, so this must be kept in mind during our evaluaTon. The colour of the skin is yellowish (jaundice), pruritus Collateral circula:on in the abdomen. Portal hypertension to such an extent that part of the blood is going, either through the oesophageal varices or through the hemorrhoidal plexus, to the systemic circulaTon via skin. If you look at these collateral veins and you press you finger on them you may also check whether there is movement from the inferior vena cava to the superior or the other way round: just pushing the vein and looking whether the filling is coming from the inferior or the superior. This just gives us an idea whether the collateral circulaTon is more from the portal vein to the IVC or to the SVC. Collateral veins are usually located at the borders of the abdomen or at the level of the umbilicus. When at the level of the umbilicus, it is called caput medusae because it is reopening the physiological circulaTon in the umbilicus that is present in the fetal life. Another very important point: as we said before the accumulated fluid in the peritoneal cavity during ascites can also freely move. There’s a manoeuvre that we use as a clinical hint. You have the paTent laying in the bed, obviously the fluid is in the lower part of the abdomen and you will have the viscera that are above the level of the fluid (the viscera are filled with air so they will be in the surface and they will be floaTng in this abdominal fluid). So, if I use percussion I try to see whether with my percussion I have a dull sound or a resonance sound, and in this way I can see where the boundary between water and the abdominal organs is. This technique is called radiated percussion. You start from the top and you go towards the lower lateral parts of the abdomen where you will have the dull sound. The dull sound confirms the presence of fluid. How can I understand if it is ascites or not? If the fluid is present because it is accumulaTng in a sac, it cannot move but if the fluid is present because of ascites it is free to move as we said at the beginning. So, I will ask the paTent to turn on the led side or on the right side and I will see whether at this point the line of boundaries between resonance and dullness is changing. In ascites it will be shiding with the paTents movements. With this I understand the fluid is freely moving and we are In a condiTon of ascites. So, shi?ing dullness gives you the possibility of saying the fluid is freely moving and this is another hint to your clinical evaluaTon.  Obviously the flanks of the abdomen will be bulging and someTmes we called this a frog belly We can also observe an umbilical hernia that will be worsened if the paTent has had a previous hernia. Other signs that are very important and that we must recognise: (in addiTon to tense skin, jaundice, signs of stretches) Liver producTon of coagulaTon factors is depressed for the situaTon and so the likelihood of having hematoma is much higher. PaTents with severe cirrhosis and ascites have frequent hematoma in all the points in which blood is drained I can also have another sign that is spider nevi, typical of ascites. They are like an artery with a spider distribuTon in the skin and if you press with the point of your pen on the centre of the spider you will see that it is arterial. It is very typical of cirrhoTc ascites. Another sign is palmar erythema -> very red palms. Very oden present in paTent with cirrhosis To sum up: - InspecTon: I look at all these possible signs and symptoms - History taking: I check whether the paTent has got a cause of liver disease - PalpaTon: the abdomen is very tense - Percussion (radiated percussion): very useful to check whether there is fluid and whether it is freely moving - AuscultaTon doesn’t say much in this situaTon but just confirms that the problem is not an occlusion of viscera because there is peristalsis. - In palpaTon you don’t have a recordable fremitus in this case. Obviously the paTent will have superficial respiraTon because of the big belly. N.B. If you see a women at the end of pregnancy you will see big belly, someTmes umbilical hernia, tense abdomen and the breathing pa]ern is more superficial because of compression of the diaphragm, but in this case of course it is not a disease. Also, in this case you have increased pressure within the belly and this is caused by the presence of the baby plus the fluids plus all the changes up to 10-15 litres/kgs. Now let’s analyse the possible causes, the differenTal diagnosis: -As we said the main one is cirrhosis and it is the most frequent. Then: 1. Fat obesity: you may have a situaTon of very severe obesity but in this case you don’t have shiding dullness 2. Faeces-megacolon: excessive accumulaTon of feces -> megacolon or very severe obstrucTon 3. Foetus-pregnancy (central dullness) 4. Flatus: accumulaTon of air. How can I diagnose it? Firstly, when I do my percussion, I don’t feel the dullness, but I will feel an incredible hyper-resonance telling you that there is a lot of air. 5. Fluid-ovarian cyst. Ascites is generalised situaTon, but you may also have an accumulaTon of fluid in one single spot and in that case you will have the dullness that is not freely moving. 6. Full bladder (problems in urethra) “6Fs” in your differenTal diagnosis If I perform an ultrasound, I will see something like this (picture on the right): bowel and a lot of fluid (the shiding line is in between them) SomeTmes you need to drain the fluid. Paracentesis. This is when you will analyse the fluid in order to understand what is present inside of it. In ascites the fluid is generally yellowish and serum-like, but if there is a problem related to cancer someTmes it can be black or bloody. Obviously you will analyse the content of this fluid to check what’s going on. In this picture above you can see how much ascites may displace organs, so it is important that I recognise clinically something that an imaging technique may find. SomeTmes is Tny, only around some organs, someTmes is massive. Obviously clinical evaluaTon will gives you the important informaTon. Very oden the paTent has got collateral circulaIon through the gastro oesophageal juncTon and through the hemorrhoidal plexus. Consequence: varices, shid of blood that is not passing through the filter of the liver so all the problems related to ammonium but also you may have a very fragile collateral circulaTon: very fragile at the level of varices and at the level of haemorrhoids. On the top of that coagulaTon is impaired because the liver is producing several proteins among which the coagulaTon factors. This means that this paTent has got the possibility of having a haemorrhage from one of these plexuses. If you have blood from the gastroesophageal tract due to a rupture in the varices you may have either vomiTng blood (hematemesis), and in this case you ask the paTent about previous cases of hematemesis, or the blood is going to the stomach and becomes digested, so it can cross all the GI tract and arrives to the stools. But if you have digested blood, the colour of this blood in the stools will be black. Black stools are called “melena” and the paTent complains about a very parTcular smell of stool which reminds tar. All these signs tell you that there is a digested blood that crossed the GI tract arriving to being extruded with faeces. In this cases I will ask the paTent about eventual previous haematemesis or melena. If I’m not convinced enough or if he didn’t have any of these in the past I may use rectal exploraTon to see if there are faeces in the rectum and if they are black and tar. In contrast when you have blood from the hemorrhoidal plexus the colour of the stools will be red. Look how many details from the clinical foundaTons perspecTve you may have that help you to diagnose and to give a name to the disease of the paTent. So, once you see a belly like the one of the first picture of this lecture, you ask yourself whether there are any symptoms that may help you to define the condiTon. Is it ascites or not? I do all the evaluaTons we have seen. Other 2 manoeuvres that may help us in understanding whether there is free fluid (in addiTon to the radial percussion):  - One is a manoeuvre in which you try to push on the belly with your fingers and you will feel that the viscera are going down in the water and then coming up (floaTng viscera in peritoneal fluid). - In the other you use your hands at both flanks and percuss at both side of the abdomen and you check if on the other side you have the transmi]ed wave arriving from the percussion moving the fluid inside. But since, we may feel a wave that may be given by my percussion on the skin I will ask another person to put an hand at the level of the umbilicus to stop the propagaTon at the level of the skin. At this point, if I feel a wave I’m sure it is caused by a freely moving fluid. I start with the radial percussion first and then these 2 manoeuvres.