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DPD Amir Sam GK > 2. Interactive Cases in General Internal Medicine 1 > Flashcards

2. Interactive Cases in General Internal Medicine 1 Flashcards

1
Q

Complication of COPD

A

Pulmonary Hypertension (Hypoxia -> vasoconstriction)

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2
Q

Breathlessness DDx

A

By onset…

Acute:
Pneumothorax
PE
Foreign Body
Anxiety
Anaphylaxis 
Sub-acute:
Airways (inflammation/obstruction)
Chest infection (pus)
Acute heart failure (fluid)
Pulmonary Hemorrhage (blood)
Chronic:
All of above (chronic/unresolving)
Interstitial Lung Disease
Malignancy
Large Pleural Effusion
Neuromuscular
Anaemia/Thyrotoxicosis
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3
Q 
60 yr old man
SOB
Sudden onset
PMH COPD
DH Symbicort and Tiotropium
HR 110
Raised JVP
Decreased breath sounds, scattered wheeze and creps (R)
Peripheral oedema
Sats 80% air
FBC: 
HB 85
WCC 12
plt 300

Most likely diagnosis?
Treatment?

A

Pneumothorax

Chest Drain

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4
Q

CPAP

A

Continuous Positive Airway Pressure

CPAP improves oxygenation

Used in Type 1 Resp Failure

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5
Q

Management of Pneumothorax

A

Primary:

  • <2cm: Discharge, repeat CXR 1 wk
  • > 2cm or SOB: Pleural aspiration, if unsuccessful: chest drain

Secondary:

  • <2cm: Pleural aspiration
  • > 2cm: Chest drain

ALSO don’t forget regular, adequate analgesia!

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6
Q

What to tell patient with Chest Drain in

A

Underwater seal must always be below the waistline

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7
Q

Pneumothorax
Improved after Chest Drain insertion.
Recurrent SOB after 2hrs
Potential cause of recurrent SOB?

A

Re-expansion pulmonary oedema (one lung!)

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8
Q 
47 yr old woman
Acute SOB
Pleuritic Chest Pain
PMH DVT
O2 Sat 78% air
PR 110
BP 120/80
Raised JVP
Vesicular Breath Sounds

Cause and management

A

PE

LMWH

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9
Q

RBBB and Right axis deviation signs of…

A

Right sided heart strain

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10
Q

S1, Q3, T3

A

ECG PE finding
S wave in I
Q wave and T wave inversion in III

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11
Q

Suspected PE (120/80 BP) Management

A
  1. LMWH
  2. CTPA
  3. If PE confirmed, start Warfarin and continue LMWH
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12
Q

Indication for BiPAP

A

Respiratory Acidosis/High CO2

e.g. COPD

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13
Q

Suspected PE; why do we need to continue BOTH LMWH and Warfarin together for a few days?

A

Warfarin has a paradoxical PROCOAGULANT effect initially. LMWH covers them during this period - when INR comes back up, stop LMWH

–> (inhibition of Protein C and Protein S causes their levels to drop faster than procoagulation proteins such as Factor II/VII/IX/X)

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14
Q

Suspected PE (60/30 BP) Management

A

Thrombolysis

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15
Q

Primary Pneumothorax,Greater than 2cm

Management

A

Pleural Aspiration

If unsuccessful: Chest Drain

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16
Q

Primary Pneumothorax, SOB

Management

A

Pleural Aspiration

If unsuccessful: Chest Drain

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17
Q

Primary Pneumothorax, Less than 2cm

Management

A

Discharge, repeat CXR

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18
Q

Secondary Pneumothorax, Less than 2cm

Management

A

Pleural Aspiration

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19
Q

Secondary Pneumothorax, Greater than 2cm

Management

A

Chest Drain

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20
Q

FEV1/FVC ratio > 70%

A

Restrictive Lung disease

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21
Q

FEV1/FVC ratio < 70%

A

Obstructive Lung Disease

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22
Q 
50 yr old female
Progressive SOB
Dry Cough
Clubbing
FEV1/FVC ratio > 70%

DDx?

A

Idiopathic fibrosing alveolitis
Connective tissue disease, RA
Drugs (e.g. methotrexate)
Asbestosis

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23
Q

Asbestosis

A

Pulmonary Fibrosis due to Asbestos exposure.

If you have some plaques, not enough for diagnosis of Asbestosis.

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24
Q

CXR Interpretation

A

This is a PA/AP CXR of…

  • Name and DOB
  • Taken on (Date)
  • At (Time)

Quality of film: RIP
Rotation
Inspiration
Penetration (under/over)

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25
Q

Opacities on CXR

A 
Interstitial/Alveolar shadowing ('Fluffy') - fluid or pus
Reticulo-nodular shadowing (fibrosis)
Homogeneous shadowing (e.g. pleural effusion)
Masses/Cavitations
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26
Q

Lung lobe affected if Interstitial/Alveolar shadowing obscuring Right border of heart

A

Right middle lobe

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27
Q

If unable to follow left hemi-diaphragm behind heart?

A

Collapsed lung

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28
Q

Tracheal deviation Collapsed lung vs Pleural effusion

A

Collapse pulls trachea towards it, Effusion pushes away.

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29
Q

Summary of CXR analysis

A

Compare L vs R upper/mid/lower zones:

  • alveolar/interstitial shadowing
  • reticulonodular shadowing
  • homogeneous shadowing

Follow the periphery:

  • pneumothorax
  • pleural thickness
  • costophrenic angles
  • diaphragm
  • heart
  • mediastinum
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30
Q

Type 1 Resp Failure

A

Low level of oxygen in the blood without an increased level of carbon dioxide in the blood.
Typically caused by Ventilation/Perfusion mismatch, e.g. high altitude/PE/pneumonia)

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31
Q

Type 2 Resp Failure

A

Low level of oxygen in the blood with increased level of carbon dioxide in the blood.
Caused by inadequate alveolar ventilation; both oxygen and carbon dioxide are affected.
E.g. COPD/asthma/reduced breathing effort/chronic bronchitis/neuromuscular problems

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32
Q

Abdominal General Inspection Findings

A 
Feeding Tube/Stoma Bag/Drain
Agitated/In Pain/Confused
Obese/Low BMI/ Cachectic
Scars:
Midline (laparotomy)
RIF (appendectomy)
R Subcostal (Cholecystectomy)
Jaundice (cirrhosis/hepatitis)
Anaemia (obvious pallor suggests significant anaemia (e.g. GI Bleeding)
Abdo. Distension (ascites/bowel distension/masses)
Masses (malignancy/organomegaly)
Dressings
Needle track marks (HIV/Hepatitis)
Excoriations - pruritus (cholestasis)
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33
Q

Abdominal Hand and Arms Inspection Findings

A 
Asterixis (liver flap)
Bruising
Clubbing
Dupuytren's contracture
Erythema (palmar)
Leuconychia (hypoalbuminaemia due to liver failure)
ABCDEL

+ AV fistulae

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34
Q

Abdominal Head and Neck Findings

A 
Anaemia
Jaundice
Excoriation marks
Spider Naevi
Oral exam:
Pigmentation
Gum hypertrophy (ciclosporine after renal transplant)
35
Q

Abdominal Chest Findings

A

Gynaecomastia
Hair loss
Spider naevi
Excoriation marks

36
Q

Close Abdominal Inspection Findings

A

Distension
Caput Medusae (distended superficial abdominal veins, direction of flow in the veins below the umbilicus is towards the legs)
Scars

37
Q

Causes of Hepatomegaly

A 
Cancer (primary or secondary deposits)
Cirrhosis (early, usually alcoholic)
Cardiac:
-congestive cardiac failure
-constrictie pericarditis

Infiltration
-fatty infiltration, haemochromatosis, amyloidosis, sarcoidosis, lymphoproliferative diseases

38
Q

Summary of liver disease

A 
Alcohol
Autoimmune
Drugs
Viral
Biliary Disease
39
Q

Causes of splenomegaly

A

H’s - Portal Hypertension, Haematological (e.g. lymphoma/haemolytical anaemia/leukaemia)

I’s - Infection, Inflammation

40
Q

Symptoms of chronic liver disease

A 
Asterixis (decompensated)
Bruising (decompensated)
Clubbing
Dupuytren's contracture
Erythema
Fetor Hepaticus
Gynaecomastia
Hair Loss
Icterus/Jaundice (decompensated)
Also:
Leukonychia
Parotid enlargement
Spider Naevi
Scratch marks
Ascites
Hepatomegaly
Testicular atrophy
Caput medusae
Splenomegaly
Encephalopathy (decompensated)
41
Q

Infections that can cause splenomegaly

A 
Malaria
Schistosomiasis
Leishmaniasis
TB
Infective Endocarditis
Infectious Mononucleiosis
42
Q

Presenting Complaint of Following Conditions?

Peptic Ulcer
Pancreatitis
Pancreatic Cancer
Cholecystitis
Hepatitis
Chronic Liver Disease
Appendicitis
Diverticulitis
Ruptured Aortic Aneurysm
IBD
Coeliac
A

Peptic Ulcer:
Dyspepsia/Bleeding

Pancreatitis:
Abdominal Pain if acute

Pancreatic Cancer:
Painless Jaundice

Cholecystitis:
Pain RUQ

Hepatitis:
Jaundice

Chronic Liver Disease:
A-J

Appendicitis:
Abdominal Pain (mid->RLQ)

Diverticulitis:
LLQ pain

Ruptured Aortic Aneurysm:
Patient in Shock

IBD: Pain/Diarrhoea/Bleeding

Coeliac:
Diarrhoea/Pain/Bloating/Anaemia

43
Q 
75 yr old man
Epigastric Pain
Back Pain
PR 130bpm
BP 80/50

Dx?

A

Ruptured Aortic Aneurysm

44
Q

Epigastric Pain DDx

A 
Stomach:
Peptic Ulcer (?NSAIDs)
GORD (better w antacids)
Gastritis (retrosternal, ETOH)
Malignancy
Pancreas:
Acute Pancreatitis (?Gallstones, high amylase)

Above (heart):
MI

Below (aorta):
Ruptured Aortic Aneurysm

Right (liver/gall bladder):
Cholecystitis
Hepatitis

45
Q

Pancreatitis: Acute vs Chronic

A

Acute:
Pain
High Amylase

Chronic:
Pain
Weight Loss
Loss of endocrine function (can’t produce insulin ->diabetic?)
Loss of exocrine function (can’t digest food -> lose weight, steatorrhoea)
Normal amylase
-> Low faecal elastase! is diagnostic test, NOT AMYLASE

46
Q

RUQ Pain DDx

A

Gall Bladder:
Cholecystitis
Cholangitis
Gallstones

Liver:
Hepatitis
Abscess

Above (lungs):
Basal Pneumonia

Below (appendix):
Appendicitis

Left (stomach/pancreas):
Peptic Ulcer
Pancreatitis

Right (kidney):
Pyelonephritis

47
Q

Charcot’s Cholangitis Triad

A

RUQ colicky pain
Jaundice
Fever

48
Q

Cholecystitis Signs and Symptoms

A 
Raised WCC
Raised CRP
Tender
Abdominal Pain RUQ
Fever
Murphy's Sign
49
Q

Murphy’s Sign

A

A sign of gallbladder disease consisting of pain on taking a deep breath when the examiner’s fingers are on the approximate location of the gallbladder

50
Q

Cholangitis Signs and Symptoms

A

Jaundice
Fever
Rigor

51
Q

RIF Pain DDx

A 
GI:
Appendicitis
Mesenteric adenitis
Colitis (IBD)
Malignancy

Gynaecological:
Ovarian cyst rupture/twist/bleed
Ectopic Pregnancy

52
Q

Suprapubic Pain DDx

A

Cystitis

Urinary Retention/UTI

53
Q

LIF Pain DDx

A

GI:
Diverticulitis
Colitis (IBD)
Malignancy

Gynaecological:
Ovarian Cyst Rupture/Bleed/Twist
Ectopic Pregnancy

54
Q

Diffuse Abdominal Pain DDx

A

Obstruction
Infection: Peritonitis, Gastroenteritis
Inflammation: IBD
Ischaemia: Mesenteric Ischaemia

Medical Causes:
DKA
Addison's
Hypercalcaemia
Porphyria
Lead  Poisoning
55
Q

Mesenteric Arteries

A 
Celiac:
Stomach
Spleen
Liver
Gallbladder
Duodenum

Superior Mesenteric:
Small intestine
Right Colon

Inferior Mesenteric:
Left Colon

+Ileomesenteric arcade -> rectum

56
Q 
65 yr old man
AAA repair 2 days ago
Diffuse abdominal pain
PR 120 bpm
RR 30

Blood tests likely to show…?

A

High amylase (due to abdo pain)

57
Q

Spontaneous Bacterial Peritonitis

A

Ascites, neutrophils greater than or equal to 250 cells/mm^3

58
Q

Compensated -> Decompensated Liver Disease

A

Ascites, Bruising, Jaundice or Encephalopathy

59
Q

Abdominal Distension

A

Fluid or Flatus?

Ascites:
Shifting dullness
Features of Liver disease

Obstruction:
Nausea, vomiting
Not opened bowel
High pitched tinkling BS
?Previous surgery (adhesions)
?Tender irreducible femoral hernia in groin

Fat, Faeces, Fetus

60
Q

Ascites Classifications

A

Albumin gradient = serum albumin - ascitic albumin

High Albumin Gradient: >11g/L
Portal Hypertension
Constrictive Pericarditis
Cardiac Failure (acute and chronic)
Cirrhosis

(Increased hydrostatic pressure pushes fluid out of vasculature -> higher relative level of albumin in serum)

Low Albumin Gradient: <11g/L
Nephrotic Syndrome
TB
Pancreatitis (acute and chronic)
Cancer
Peritonitis
61
Q 
50 yr old man
Jaundice
RUQ pain
Dark urine
Pale stool

Cause of pale stool?

A
  • Post-hepatic (obstruction to flow of bile)
    caused by CBD obstruction -> Low stercobilinogen (conjugated BR does not reach into bowel where it can be converted into stercobilinogen)

Dark urine caused by conjugated bilirubin leakage from liver

62
Q

Jaundice Framework

A

Pre-hepatic:
Haemolysis,
Defective Conjugation (Gilbert’s syndrome)

Hepatic:
Hepatitis (Alcohol, autoimmune, viral, drugs)

Post hepatic:
CBD Obstruction (gallstones, stricture, Ca of head of pancreas)
63
Q

Bilirubin Pathway

A

Red blood cells -> Unconjugated Bilirubin in Spleen -> Conjugated bilirubin in liver by Glucuronyltransferase -> secreted in bile -> converted to urobilinogen + stercobilinogen (BROWN)

64
Q

Clinical difference between obstructive jaundice and hepatocellular jaundice?

A

Obstructive -> pale stool due to stercobilinogen not being formed (bile blockage)

65
Q

Abnormal Blood tests in Pancreatic Cancer

A

High Alkaline Phosphatase
High Gamma GT
Ca19-9 (tumour marker for panc. cancer)

66
Q

Blood Diarrhoea DDx

–> loss of epithelial integrity

A 
1. Infective Colitis (CHESS):
Campylobacter
Haemorrhagic E. Coli
Entamoeba Histolytica
Salmonella
Shigella

2.Inflammatory Colitis:
Young, Extra-GI manifestations (eyes/skin)

  1. Ischaemic Colitis:
    Elderly
  2. Diverticulitis
  3. Malignancy
67
Q

Obstructive Lung Disease

A

Respiratory Disease characterised by airway obstruction.
Can result from narrowing of the smaller bronchi and bronchioles, often because of excessive contraction of the smooth muscle itself.
Characterised by easily collapsible and inflamed airways, obstruction to airflow.

68
Q

Types of Obstructive Lung Disease

A

Chronic Bronchitis

Bronchiolitis
(inflammation of bronchioles - most often viral cause)

Bronchiectasis
(Abnormal and irreversible dilatation of the bronchi caused by destructive and inflammatory changes)

Asthma

Cystic Fibrosis

69
Q

Restrictive Lung Disease

A

Problem with lung expansion, usually stifness in lungs themselves. Can also be stiffness of chest wall/weak muscles/damaged nerves.

70
Q

Types of Restrictive Lung Disease

A

Interstitial Lung Disease e.g. idiopathic pulmonary fibrosis

Sarcoidosis

Obesity

Scoliosis

Neuromuscular disease

71
Q

Complication of (impacted) faecal loading

A

Overflow (spurious) diarrhoea

Confusion, often in elderly

72
Q

Management of Acute GI Bleed

e.g. Variceal Bleed

A 
ABC
IV access
Fluids
G+S, X-match blood
OGD

…e.g. Variceal Bleed
Antibiotics (due to bacterial translocation)
Terlipressin (causes splanchnic vasoconstriction)

73
Q

Investigations and Management of Acute Abdomen

A

Investigations:

Bloods:
FBC
U+Es
LFTs
CRP
Clotting
G+S
X-match

Erect CXR (looking for air under diaphragm)

CT

Managment:

NBM
Fluids
Analgesic
Anti-emetics
Antibiotics
Monitor Vitals + Urine Output
74
Q

Dysphagia + weight loss. Investigations?

A

OGD + Biopsy

75
Q

Management of Ascites

A

Diuretics (spironolactone +/- furosemide)
Dietary sodium restriction
Fluid restriction in patients with hyponatraemia
Monitor wt daily
Therapeutic paracentesis (with IV human albumin)

76
Q

Management of Encephalopathy

A

Lactulose
Phosphate enemas

Avoid sedation
Treat infections
Exclude a GI bleed

77
Q

Post-op Care

Wound infection
Anastomotic leak
Pelvic abscess

A

Wound Infection:
Erythematosus
Discharge

Anastomotic leak:
Diffuse abdo tenderness (peritonitis)
Guarding, rigidity
Hypotensive/tachycardic

Pelvic abscess, e.g. post appendectomy:
Pain
Fever
Sweats
Mucus diarrhoea
78
Q

Perianal Disease

Presentation?
Treatment?

A

Perianal abscess:
Tender red swelling
Incision + Drainage

Anal fissure:
Rectal pain (defaecation)
Stool coated with blood
Advice re diet (fluids, fibre)
GTN cream
79
Q

Irritable Bowel Syndrome

Presentation?

A 
Presentation:
Recurrent Abdo pain
Bloating
Improves with defecation
Change in frequency/form of stool

NO…

  • PR bleed
  • Anaemia
  • wt loss
  • nocturnal symptoms
  • exclude Coeliac
80
Q

Irritable Bowel Syndrome

Treatment?

A 
Diet and Lifestyle modification
Symptomatic treatment:
-Abdo pain: antispasmodics
-Laxatives for constipation
-Anti-diarrhoeals
81
Q

Management of Hyperkalaemia

A

Calcium Gluconate
10mls of 10%

Insulin

Dextrose

82
Q

Jaundice investigations?

A

Jaundice:
Bloods (FBC, LFTs, CRP)
Abdominal USS –> after a fast; gallstones better visualised in a distended, bile-filled gallbladder)

83
Q

PR Bleed, wt loss. Investigations?

A

Colonoscopy

DPD Amir Sam GK (5 decks)

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