3. Interactive Cases in General Internal Medicine 2 Flashcards
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?
Salbutamol nebuliser
Ipratropium
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?
Radiotherapy
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?
Percutaneous Coronary Intervention
When prescribing GTN ensure what?
BP over 100 systolic
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?
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%
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
CT head
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?
Capillary Ketone
To make the diagnosis of DKA
need confirmation of K
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?
Colonoscopy +/- biopsy
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?
Tamsulosin
alpha blocker
relaxes smooth muscle of urethra
improves lower urinary tract obstructive symptoms
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?
Knee Aspiration
To exclude septic/infective arthritis
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?
Intravenous heparin
Refer to vascular surgeons
59 yr old man
HTN
Exertional chest pain
Normal ECG
Most likely Diagnosis?
Coronary Artery Stenosis
Neurological Diagnoses
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
UMN signs
Tone increased (spasticity)
Power decreased
Reflexes Increased
-> plantar upwards
LMN signs
Tone decreased (flaccid)
Power decreased
Reflexes decreased
Diplopia (bilateral 6th) Bilateral ptosis Slurred speech Dysphagia Sluggish pupillary response to light Descending symmetrical muscle weakness Multiple skin abscesses on arms and legs
Neuromuscular Junction problem - e.g. Myasthenia Gravis
Cerebellar signs
Dysdiadochokinesia Ataxia Nystagmus Intention tremor Slurred speech Hypotonia/Heel-shin test
Abnormal sensation patterns:
Cerebral cortex
Hemisensory loss
Abnormal sensation patterns:
Spinal Cord
Level (e.g. umbilicus)
Abnormal sensation patterns:
Nerve roots (radiculopathy)
Dermatome(s)
Mononeuropathy
Specific area
Polyneuropathy
Glove and Stockings
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
He has peripheral neuropathy:
Duloxetine
Toxic/Metabolic causes of peripheral neuropathy
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)
Non Toxic/Metabolic causes of peripheral neuropathy
Infection - HIV
Inflammation/Autoimmune
- Vasculitis
- CTD
- Inflammatory demyelinating neuropathy
Tumour/Malignancy
- Paraneoplastic
- Paraproteinaemia
Hereditary
-Hereditary sensory motor neuropathy
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
Optic neuritis (papillitis)
- blurred optic disc margins
- blurred vision
- pain on eye movement
Spinal cord pathology causes
Spastic paraparesis:
- Vascular
- ->anterior spinal artery thrombosis
- Infection
- ->TB of spine (“Potts”)
- Inflammation (demyelination)
- -> Transverse myelitis
- Toxic/Metabolic
- Tumour/Malignancy
Multiple sclerosis
Two lesions
Separated in time/space
60 yr old man
Pain and paraethesia on anterolateral thigh
PMH T2DM
Metformin
HbA1C 60
BMI 30
Decreased pinprick sensation on anterolateral thigh
Meralgia paraesthestica
Compression of lateral femoral cutaneous nerve
Reassure, avoid tight garments, lose weight.
If persistent, carbamazepine or gabapentin
Radiculopathy
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
60 yr old man Recurrent falls Tremor at rest Rigidity More forgetful Dysphagia Micrographia Limited upgaze
Progressive supranuclear palsy
Patients with Parkinsonian Features
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.
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
Carbon monoxide poisoning
–> Exclude VIIT –> only toxic/metabolic left
ECG shows widespread cardiac ischaemia!
Causes of confusion
excluding VIITTs
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
DDx of Confusion/Decreased consciousness
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)
Clinical assessments of confusion/consciousness?
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
Headache in A and E DDx
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
Management of Stroke
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
Management of TIA
Aspirin Don't treat BP acutely unless greater than 220/120 or other indication ECG Echocardiogram Carotid Doppler Risk factor modification
40 yr old Backache LMN weakness Admitted to HDU Regular Forced Vital Capacity Cardiac Monitor IVIG
Guillain-Barre
Guillain–Barré syndrome
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
Papilloedema
Raised ICP
not painful
no blurred vision
