3. Interactive Cases in General Internal Medicine 2 Flashcards

1
Q
75 yr old man
3 days of worsening breathlessness
Productive cough
Reduced exercise tolerance
50 pack yr smoking history
Wheeze
Temp: 38.5 
110 bpm
140/87 BP
RR 28 b/m
87% O2 sats on air

Treated with oxygen aiming for sats of 88-92%.

Next step in management?

A

Salbutamol nebuliser

Ipratropium

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

66 yr old man
Metastatic prostate cancer
Ongoing bony pain; taking max doses of paracetamol, codeine and morphine.
Currently pain not well controlled.

Next step in pain control?

A

Radiotherapy

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q
64 yr old woman
Sudden onset central crushing chest pain
Radiates to left arm
Sweating
Breathless
History of hypercholesterolaemia
ECG ST elevation in II, III, AVF
O2 sats 98% air
Treated with morphine, nitrates, aspirin, clopidogrel

Next priority in her management?

A

Percutaneous Coronary Intervention

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

When prescribing GTN ensure what?

A

BP over 100 systolic

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q
66 yr old woman
Increasing drowsiness and vomiting for 2 days
Hypertension and osteoarthritis; takes perindapril and ibuprofen
Temp 37.5
96  bpm
BP 110/67
RR 24 bpm
O2 95% on air
Investigations: 
Sodium 144 (135-146)
Potassium 8.2 (3.5-5.3)
Creatinine 400 (60-120)
Urea 20 (2.5-7.8)

Next stage in management?

A

Calcium Gluconate for high potassium

If patient has K+ over 6.5 or characteristic ECG changes, must give calcium gluconate to stabilise the myocardium

–> Hyperkalaemia = 10mls of 10% calcium gluconate

Then insulin (drives both potassium and glucose into cells) and dextrose (to counter insulin’s effects)

Dextrose: 20% or 50%, NOT 5%

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q
72 yr old man
Sudden onset left sided weakness
Duration of 2 hrs
Hyperlipidaemia
Hypertension
T2DM
40 pack yr smoking history
36.5 Temp
93 bpm
BP 144/89
RR 18 bpm
O2 96% on air

Next step management

A

CT head

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q
16 yr old girl
T1DM
Severe abdo pain
N and V
36.9 Temp
110 bpm
BP 114/74
RR 28 bpm
O2 99% on air

Investigations:

Venous blood gas on 28% o2

pH 7.2 (7.35-7.45)
PO2 5.3kPa (10-13.5)
PCO2 3.4kPa (4.5-6.0)
Bicarbonate 10 (18-22)
Glucose 24 (4-7)

Next step in management?

A

Capillary Ketone

To make the diagnosis of DKA
need confirmation of K

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q
74 yr old man
2 month history of wt loss, change in bowel habit and intermittent rectal bleeding
Blood is fresh and mixed with stool.
temp 36.4
74 bpm
BP 132/87
RR 21 bpm
O2 97% on air

Investigations:

Haemoglobin 110 (130-180)
MCV 72 (76-96)
Platelets 400 x 10^9 (150-400)
White cells total 5.6 x 10^9 (4-11)

Next step in management?

A

Colonoscopy +/- biopsy

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q
78 yr old man
3 month worsening hesitancy, nocturia, terminal dribbling
Smooth firm prostate
Temp 36.9
84 bpm
BP 132/88
RR 18 bpm
O2 98% on air

Urinalysis: Glucose negative, ketones negative, blood negative, protein negative, nitrites negative, leucocytes negative.

Next step in management?

A

Tamsulosin

alpha blocker
relaxes smooth muscle of urethra
improves lower urinary tract obstructive symptoms

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q
52 yr old woman
Right knee swelling
Severe pain
No history of trauma
Temp 38.9
84 bpm
Bp 124/68
RR 20 bpm
O2 100% air

Next step management?

A

Knee Aspiration

To exclude septic/infective arthritis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q
75 yr old man
Sudden onset painful right leg
Cold, pale
Dorsalis pedis pulse not palpable
History of hypercholesterolaemia
Hypertension
ECG shows irregular rhythm with no clear p waves

Next step in management?

A

Intravenous heparin

Refer to vascular surgeons

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

59 yr old man
HTN
Exertional chest pain
Normal ECG

Most likely Diagnosis?

A

Coronary Artery Stenosis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Neurological Diagnoses

A

Anatomy and Pathology

Brain
Spinal Cord
Nerve Roots
Peripheral Nerve(s)
Neuromuscular Junction
VIITT:
Vascular
Infection
Inflammation/Autoimmune
Toxic/Metabolic
Tumour/Malignancy

Hereditary/Congenital
Degenerative

Migraine/Seizures

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

UMN signs

A

Tone increased (spasticity)
Power decreased
Reflexes Increased
-> plantar upwards

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

LMN signs

A

Tone decreased (flaccid)
Power decreased
Reflexes decreased

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q
Diplopia (bilateral 6th)
Bilateral ptosis
Slurred speech
Dysphagia
Sluggish pupillary response to light
Descending symmetrical muscle weakness
Multiple skin abscesses on arms and legs
A

Neuromuscular Junction problem - e.g. Myasthenia Gravis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Cerebellar signs

A
Dysdiadochokinesia
Ataxia
Nystagmus
Intention tremor
Slurred speech
Hypotonia/Heel-shin test
18
Q

Abnormal sensation patterns:

Cerebral cortex

A

Hemisensory loss

19
Q

Abnormal sensation patterns:

Spinal Cord

A

Level (e.g. umbilicus)

20
Q

Abnormal sensation patterns:

Nerve roots (radiculopathy)

A

Dermatome(s)

21
Q

Mononeuropathy

A

Specific area

22
Q

Polyneuropathy

A

Glove and Stockings

23
Q
55 yr old man
Numbness and tingling in hands and feet
PMH T1DM
On basal/bolus insulin
HbA1C: 50 mmol/mol
B12: 500 (200-900)
eGFR: 90
Decreased sensation to pinprick, glove and stocking distribution
A

He has peripheral neuropathy:

Duloxetine

24
Q

Toxic/Metabolic causes of peripheral neuropathy

A

Drugs (Hx)

Alcohol (Hx, Raised GGT and MCV)

B12 deficiency (Anaemia, Raised MCV)

Diabetes (History, glucose/HbA1C)

Hypothyroidism (TFTs)

Uraemia (UandE’s)

Amyloidosis (History of myeloma or chronic infection/inflammation)

25
Q

Non Toxic/Metabolic causes of peripheral neuropathy

A

Infection - HIV

Inflammation/Autoimmune

  • Vasculitis
  • CTD
  • Inflammatory demyelinating neuropathy

Tumour/Malignancy

  • Paraneoplastic
  • Paraproteinaemia

Hereditary
-Hereditary sensory motor neuropathy

26
Q
34 yr old woman
Weakness in legs
Blurred vision
Legs: Increased tone, Decreased power and brisk reflexes
Decreased pinprick sensation in legs
Fundoscopy: blurred optic disc margins
A

Optic neuritis (papillitis)

  • blurred optic disc margins
  • blurred vision
  • pain on eye movement
27
Q

Spinal cord pathology causes

A

Spastic paraparesis:

  • Vascular
  • ->anterior spinal artery thrombosis
  • Infection
  • ->TB of spine (“Potts”)
  • Inflammation (demyelination)
  • -> Transverse myelitis
  • Toxic/Metabolic
  • Tumour/Malignancy
28
Q

Multiple sclerosis

A

Two lesions

Separated in time/space

29
Q

60 yr old man
Pain and paraethesia on anterolateral thigh
PMH T2DM
Metformin
HbA1C 60
BMI 30
Decreased pinprick sensation on anterolateral thigh

A

Meralgia paraesthestica

Compression of lateral femoral cutaneous nerve

Reassure, avoid tight garments, lose weight.

If persistent, carbamazepine or gabapentin

30
Q

Radiculopathy

A

Disease of nerve roots
e.g. Lumbosacral

Pain in the buttock, radiating down the leg below the knee (sciatica)

Compression by disc herniation or spinal canal stenosis

31
Q
60 yr old man
Recurrent falls
Tremor at rest
Rigidity
More forgetful
Dysphagia
Micrographia
Limited upgaze
A

Progressive supranuclear palsy

32
Q

Patients with Parkinsonian Features

A

Parkinson’s disease

  • Dopaminergic neurons
  • Substantia nigra
  • ->Tremor, rigidity, bradykinesia

Progressive supranuclear palsy (Steele-Richardson syndrome)
–>Parkinsonian features, upgaze abnormality

Lew body dementia
–>Features of Alzheimer’s disease, Parkinson’s and hallucinations.

33
Q
55 yr old man
Confusion 
Chest pain
No headache or neck stiffness
Recently moved to new house
Temp 37
110 bpm
BP 120/60
Normal systems review otherwise
ECG sinus tachycardia, widespread ST depression
Urinalysis NAD
Blood glucose 7.0
WCC 7
CRP less than 5
CT head NAD
A

Carbon monoxide poisoning

–> Exclude VIIT –> only toxic/metabolic left
ECG shows widespread cardiac ischaemia!

34
Q

Causes of confusion

excluding VIITTs

A

Post ictal
-History of seizures?

Dysphasia

  • Receptive or expressive
  • Other features of stroke/TIA

Dementia

  • Vascular (multi-infarct); history of IHD/PVD
  • Alcoholic; signs of xs ETOH
  • Alzheimer’s disease
  • Inherited e.g. Huntington’s disease; other features of HD

Depressive pseudodementia

  • Elderly, withdrawn, poor eye contact
  • Precipitating factor
35
Q

DDx of Confusion/Decreased consciousness

A

Hypoglycaemia

Vascular

  • Bleed: headache/collapse
  • Subdural haematoma (fall, fluctuating consciousness)

Infection

  • ?temp
  • ?intracranial
  • ?extracranial

Inflammation

Malignancy

Metabolic/Toxic

  • drugs
  • u and e’s
  • LFTs
  • Vitamin deficiencies
  • Endocrinopathies (e.g. Cushing’s)
36
Q

Clinical assessments of confusion/consciousness?

A

GCS for consciousness

Eyes 4
Verbal response 5
Motor response 6

AMTS for confusion

DOB
Age
Time
Year
Place
Recall
Recognise doctor/nurse
Prime minister
Second WW
Count backwards 20-1
37
Q

Headache in A and E DDx

A

Meningitis
-Fever, neck stiffness, Kernig’s sign

Subarachnoid haemorrhage

  • Sudden onset
  • CT, LP (xanthochromia)

Giant cell arteritis

  • Polymyalgia rheumatica
  • Shoulder girdle pain, stiffness, constitutional upset)
  • older than 50
  • ESR, steroids, Bx

Migraine
-Throbbing, vomiting, photo/phonophobia, FXx, Aura

38
Q

Management of Stroke

A

Presentation within 4.5 hrs:

CT: no haemorrhage

  • Thrombolysis (tPA “alteplase”) if no contraindications
  • aspirin 24 hrs after tPA

Presentation after 4.5 hrs:

CT head (exclude haemorrhage)

Aspirin (300mg), swallow assessment

Maintain hydration, oxygenations, monitor glc, swallow assessment, DVT prophylaxis and early mobilisation

39
Q

Management of TIA

A
Aspirin
Don't treat BP acutely unless greater than 220/120 or other indication 
ECG
Echocardiogram
Carotid Doppler
Risk factor modification
40
Q
40 yr old
Backache
LMN weakness
Admitted to HDU
Regular Forced Vital Capacity
Cardiac Monitor
IVIG
A

Guillain-Barre

41
Q

Guillain–Barré syndrome

A

Rapid onset muscle weakness
Caused by immune system damaging peripheral nervous system; damages myelin insulations.

Can be triggered by infection; less commonly surgery or vaccination

42
Q

Papilloedema

A

Raised ICP
not painful
no blurred vision