4. Interactive Cases in General Internal Medicine 3

Question 1

24 yr old man
Breathlessness
Facial swelling
After having a Chinese take-away

First step in management

Answer 1

IM adrenaline

NOT IV - can cause cardiac arrest

Question 2

45 yr old man
Cough
Breathlessness
Recent travel

O/E coarse crepitations and bronchial breathing

Hyponatraemia
Deranged LFTs

Which antibiotic would you prescribe in addition to amoxicillin

Answer 2

Need to add a macrolide to cover the atypical organisms

–> Clarithromycin

Question 3

Use of Tazocin

Answer 3

Gram negatives; choice for HAP infections

Question 4

Use of Vancomycin

Answer 4

Suspected MRSA

Question 5

Atypical Organisms

Answer 5

Mycoplasma pneumoniae
Chlamydia pneumoniae
Legionella pneumophila

–> implicated in up to 40% of CAP

Question 6

Most common cause of Pneumonia?

Answer 6

Streptococcus pneumoniae

Question 7

50 yr old man
Dyspepsia
Wt loss
Hb 70
MCV 79

Which test would you request

Answer 7

OGD (gastroscopy)

Then colonoscopy if no abnormality found

Question 8

Microcytic anaemia: next step?

Answer 8

Haematinics:

• iron studies
• ferritin
• folate
• B12

Coeliac screen (TTG Ab) (diagnosis confirmed on duodenal biosy: villous atrophy)

Remember red flags
Top and tail:
Order depends on upper vs lower GI symptoms

Question 9

Ferritin also marker of…

Answer 9

infection/inflammation –> therefore if ferritin is ‘normal’, might actually be elevated in a patient with normally low ferritin

e.g. patient with iron deficiency anaemia, then gets pneumonia

Question 10

70 yr old man
Bloody diarrhoea
Stool micro and culture -ve
Stool C. diff toxin -ve

Likely diagnosis

Answer 10

Ischaemic Colitis

Question 11

Causes of Bloody diarrhoea

Answer 11

Infection: Infective colitis

Inflammation: Ulcerative/ Crohn’s colitis (younger pts)

Ischaemia: Ischaemic colitis (older pts)

Malignancy

Diverticulitis

Question 12

40 yr old man
Palpitations 4 hrs ago onset
ECG AF

How to treat?

Answer 12

DC cardioversion

less than 48 hrs

Question 13

Direction of flow in the distended veins below the umbilicus is towards the legs.

What is the name of this clinical sign?

Answer 13

Caput medusae

Question 14

Grey Turner

Answer 14

Bruising of the flanks (w/ pancreatitis)

Question 15

Troisier’s sign

Answer 15

Hard and enlarged left supraclavicular node (Virchow’s node)

Question 16

Trousseau’s sign (not of malignancy)

Answer 16

Hypocalcaemia

–> a blood pressure cuff is placed around the arm and inflated to a pressure greater than the systolic blood pressure and held in place for 3 minutes. This will occlude the brachial artery. In the absence of blood flow, the patient’s hypocalcemia and subsequent neuromuscular irritability will induce spasm of the muscles of the hand and forearm. The wrist and metacarpophalangeal joints flex, the DIP and PIP joints extend, and the fingers adduct.

Question 17

Portal Hypertension presentation

Answer 17

Encephalopathy
Ascites
Spontaneous bacterial peritonitis
Variceal Bleed

Question 18

Schistocyte

Answer 18

Red cell fragment

Question 19

Microangiopathic haemolytic anaemia

Answer 19

3 conditions:

Disseminated intravascular coagulation

Haemolytic Uraemic Syndrome

Thrombotic Thrombocytopenic Purpura

Question 20

Disseminated Intravascular Coagulation

Answer 20

Decrease in platelets and fibrinogen
Increase in PT/APTT
Increase in D-dimer/fibrin degradation products

Forming clots in small vessels; these further narrow the vessels. As red cells try to pass through they break up –> schistocytes formed; haemolysis.
Platelets and fibrinogen used up making clots, therefore are decreased.
PT/APTT increased because you are making clot and using clotting factors.
D-dimers and fibrin degredation products are formed when the clots are broken down by the body.
Paradoxically prone to bleeding, as they are using up all their clotting factors elsewhere; therefore need replacement

Question 21

Haemolytic Uraemic Syndrome

Answer 21

Haemolysis (Decreased HB, Increased bilirubin)
Uraemia
Decreased Platelets

Question 22

Thrombotic Thrombocytopenic Purpura

Answer 22

HUS + Fever + Neurological manifestations

Question 23

D-dimer

Answer 23

Fibrin degradation product; small protein fragment present in blood after a blood clot is degraded by fibrinolysis.

Question 24

Haemolytic anaemia framework

Answer 24

Hereditary or Acquired

Hereditary:

• Red cell membrane (hereditary spherocytosis)
• Enzyme deficiency (G6PD deficiency)
• Haemoglobinopathy (Sickle cell disease, Thalassaemias)

Acquired:

• Autoimmune
• Drugs
• Infection
• MAHA

Question 25

Haustra know what they look like

Answer 25

Small pouches characteristic of large bowel

Question 26

Valvulae conniventes know what they look like

Answer 26

Large valvular flaps projecting into the lumen of the small intestine

Question 27

Management of small bowel obstruction

Answer 27

NBM Fluids NG tube (Drip and suck) Cause and complications

Question 28

Hyponatraemia...

Answer 28

``` Is a water problem, not a salt problem... too much water... Cause of (almost) all hyponatraemia is too much ADH ``` -->rarer causes: excess water intake sodium free irrigation solutions e.g. used in TURP

Question 29

Hyponatraemia algorithm

Answer 29

Clinical Assessment... ?Hypovolaemia - Diarrhoea - Vomiting - Diuretics -->Low urine sodium (measure off diuretics): If hypovolaemic, kidneys will attempt to retain salt, therefore low sodium in urine. Unless diuretics, which make interpretation difficult. ?Euvolaemia - Hypothyroidism - Adrenal Insufficiency - SIADH - ->TFTs - -> Short synacthen test (synthetic ACTH - in normal, cortisol levels will rise. In adrenal insufficiency, will not.) - -> Plasma (low) and urine (high) osmolality ?Hypervolaemia - Cardiac Failure - Cirrhosis - Nephrotic syndrome - -> Fluid overloaded - -> Also low sodium due to high levels of aldosterone

Question 30

Causes of SIADH

Answer 30

- CNS pathology (e.g. stroke, tumour) - Lung pathology (pneumonia, PE, lung cancer) - Drugs (SSRI, TCA, Opiates, PPIs, carbamazepine) - Tumours --> Brain, Lungs, Drugs, Cancer

Question 31

``` 60 yr old man Confused Cough No postural hypotension Na 120 K 4.0 TFTs normal SST normal Urine Na 40 Urine osmolality 400 ``` Next test?

Answer 31

Chest X ray, if nothing then Brain MRI. ``` Cough - resp problem? X postural hypotension --> not hypovolaemic problem Low sodium --> hyponatraemia TFTs --> not hypothyroidism SST --> not adrenal insufficiency Urine --> High. ``` Start with CXR due to cough

Question 32

Onycholysis

Answer 32

Common nail disorder. It is the loosening or separation of a fingernail or toenail from its nail bed. It usually starts at the tip of the nail and progresses back. ``` e.g. Trauma Thyrotoxicosis Fungal infection Psoriasis ```

Question 33

Leukonychia

Answer 33

Also known as white nails or milk spots; white discoloration appearing on nails. e.g. hypoalbuminaemia liver disease

Question 34

Koilonychia

Answer 34

Also known as spoon nails, is a nail disease that can be a sign of hypochromic anemia, especially iron-deficiency anemia.

Question 35

Beau's lines

Answer 35

Deep grooved lines that run from side to side on the fingernail or the toenail. They may look like indentations or ridges in the nail plate. e.g. chemotherapy

Question 36

Nail pitting

Answer 36

Shallow or deep indentations in nail, often related to psoriasis, CTDs, autoimmune diseases, dermatitis.

Question 37

What to bear in mind when treating hyponatraemia...

Answer 37

Don't correct it too fast, otherwise cerebral oedema might occur --> cerebral pontine myelinolysis Must not correct sodium by more than 8mmol in 24 hrs.

Question 38

``` 20 yr old woman Abdo pain Vomiting T1DM CBG 20 Venous pH 7.2 ``` Next most appropriate test

Answer 38

Capillary Ketone To check if it is Diabetic Ketoacidosis

Question 39

Diabetes Complications

Answer 39

Microvascular -Retinopathy (background, pre-proliferative, proliferative) -Nephropathy (raised urine albumin-creatinine ratio) -Neuropathy (foot ulcers) Macrovascular -MI/Stroke/PVD Metabolic -DKA/HHS/Hypoglycaemia

Question 40

``` 26 yr old man Chest pain Smokes 5/day Auscultation 'scratching sounds' Widespread ST elevation on ECG ``` What diagnosis is supported by his ECG

Answer 40

Pericarditis

Question 41

``` 60 yr old woman Collapse BP 120/70 No postural drop HS S1+S2+ESM ECG shows LAD ```

Answer 41

Left ventricular hypertrophy likely due to aortic stenosis

Question 42

40 yr old man Loin pain CRP normal Urinalysis: blood ++ Next investigation?

Answer 42

CT KUB (kidney ureter bladder) ...renal colic --> causes dilated renal pelvis

Question 43

Next thing you want to know after seeing hypercalcaemia?

Answer 43

PTH

Question 44

Alkaline phosphatase: - Sources - Raised when?

Answer 44

Liver and bone Raised in obstructive liver disease (stone/head of pancreas cancer) and bone disease e.g. Malignancy, fracture, Paget's disease

Question 45

Myeloma and ALP

Answer 45

Normally ALP high in cancer. Bone: osteoblasts make ALP | Plasma cell suppress osteoblasts, therefore ALP is normal in myeloma.

Question 46

Multiple myeloma

Answer 46

Cancer of plasma cells, a type of white blood cell normally responsible for producing antibodies.

Question 47

Multiple myeloma signs/symptoms

Answer 47

CRAB Calcium (high) Renal impairment Anaemia Bone pain

Question 48

23 yr old woman Breast lump 1cm Smooth mobile Diagnosis?

Answer 48

Fibroadenoma

Question 49

Cavitating lung lesions

Answer 49

Infection - TB - Staph - Klebsiella (e.g. alcoholics) Inflammation (Granulomatosis with polyangiitis, RA) Infarction (PE) Malignancy

Question 50

35 yr old woman Ankle oedema Recent echocardiogram: NAD U&Es normal ALT, AST & ALP normal Albumin 15 Next test?

Answer 50

Urinalysis ECG rules out HF Oedema and hypoalbuminaemia (<25g/L) suggest nephrotic syndrome. Urinalysis could show proteinuria.

Question 51

Nephrotic syndrome

Answer 51

Increased permeability of glomerular basement membrane to protein Proteinuria >3.5g/24h Hypoalbuminaemia <25g/L Oedema (periorbital + peripheral) Prone to thrombotic diseases as patients lose natural anticoagulants into urine.

Question 52

Hereditary Haemorrhagic Telangiecstasia

Answer 52

``` Autosomal dominant Abnormal blood vessels in -skin -mucous membranes -lungs -liver -brain ```

Question 53

Causes of hyperprolactinaemia

Answer 53

``` Either prolactinoma, or any tumour that compresses the pituitary stalk - it disrupts the flow of dopamine from the hypothalamus, and dopamine inhibits the release of prolactin (disconnection hyperprolactinaemia) Primary hypothyroidism (due to TRH) Pregnancy ```

Question 54

Normal OGTT result

Answer 54

Suppression of GH - failure to suppress GH = acromegaly

Question 55

Low oestradiol High FSH High LH PRL normal

Answer 55

Premature ovarian insufficiency

Question 56

Why is prolactin mildly elevated in primary hypothyroidism?

Answer 56

Increased TRH released in hypothalamus to stimulate TSH production also stimulates prolactin production.