4. Interactive Cases in General Internal Medicine 3 Flashcards
24 yr old man
Breathlessness
Facial swelling
After having a Chinese take-away
First step in management
IM adrenaline
NOT IV - can cause cardiac arrest
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
Need to add a macrolide to cover the atypical organisms
–> Clarithromycin
Use of Tazocin
Gram negatives; choice for HAP infections
Use of Vancomycin
Suspected MRSA
Atypical Organisms
Mycoplasma pneumoniae
Chlamydia pneumoniae
Legionella pneumophila
–> implicated in up to 40% of CAP
Most common cause of Pneumonia?
Streptococcus pneumoniae
50 yr old man Dyspepsia Wt loss Hb 70 MCV 79
Which test would you request
OGD (gastroscopy)
Then colonoscopy if no abnormality found
Microcytic anaemia: next step?
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
Ferritin also marker of…
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
70 yr old man
Bloody diarrhoea
Stool micro and culture -ve
Stool C. diff toxin -ve
Likely diagnosis
Ischaemic Colitis
Causes of Bloody diarrhoea
Infection: Infective colitis
Inflammation: Ulcerative/ Crohn’s colitis (younger pts)
Ischaemia: Ischaemic colitis (older pts)
Malignancy
Diverticulitis
40 yr old man
Palpitations 4 hrs ago onset
ECG AF
How to treat?
DC cardioversion
less than 48 hrs
Direction of flow in the distended veins below the umbilicus is towards the legs.
What is the name of this clinical sign?
Caput medusae
Grey Turner
Bruising of the flanks (w/ pancreatitis)
Troisier’s sign
Hard and enlarged left supraclavicular node (Virchow’s node)
Trousseau’s sign (not of malignancy)
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.
Portal Hypertension presentation
Encephalopathy
Ascites
Spontaneous bacterial peritonitis
Variceal Bleed
Schistocyte
Red cell fragment
Microangiopathic haemolytic anaemia
3 conditions:
Disseminated intravascular coagulation
Haemolytic Uraemic Syndrome
Thrombotic Thrombocytopenic Purpura
Disseminated Intravascular Coagulation
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
Haemolytic Uraemic Syndrome
Haemolysis (Decreased HB, Increased bilirubin)
Uraemia
Decreased Platelets
Thrombotic Thrombocytopenic Purpura
HUS + Fever + Neurological manifestations
D-dimer
Fibrin degradation product; small protein fragment present in blood after a blood clot is degraded by fibrinolysis.
Haemolytic anaemia framework
Hereditary or Acquired
Hereditary:
- Red cell membrane (hereditary spherocytosis)
- Enzyme deficiency (G6PD deficiency)
- Haemoglobinopathy (Sickle cell disease, Thalassaemias)
Acquired:
- Autoimmune
- Drugs
- Infection
- MAHA
Haustra
know what they look like
Small pouches characteristic of large bowel
Valvulae conniventes
know what they look like
Large valvular flaps projecting into the lumen of the small intestine
Management of small bowel obstruction
NBM
Fluids
NG tube
(Drip and suck)
Cause and complications
Hyponatraemia…
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
Hyponatraemia algorithm
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
Causes of SIADH
- CNS pathology (e.g. stroke, tumour)
- Lung pathology (pneumonia, PE, lung cancer)
- Drugs (SSRI, TCA, Opiates, PPIs, carbamazepine)
- Tumours
–> Brain, Lungs, Drugs, Cancer
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?
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
Onycholysis
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
Leukonychia
Also known as white nails or milk spots; white discoloration appearing on nails.
e.g. hypoalbuminaemia liver disease
Koilonychia
Also known as spoon nails, is a nail disease that can be a sign of hypochromic anemia, especially iron-deficiency anemia.
Beau’s lines
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
Nail pitting
Shallow or deep indentations in nail, often related to psoriasis, CTDs, autoimmune diseases, dermatitis.
What to bear in mind when treating hyponatraemia…
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.
20 yr old woman Abdo pain Vomiting T1DM CBG 20 Venous pH 7.2
Next most appropriate test
Capillary Ketone
To check if it is Diabetic Ketoacidosis
Diabetes Complications
Microvascular
-Retinopathy
(background, pre-proliferative, proliferative)
-Nephropathy (raised urine albumin-creatinine ratio)
-Neuropathy (foot ulcers)
Macrovascular
-MI/Stroke/PVD
Metabolic
-DKA/HHS/Hypoglycaemia
26 yr old man Chest pain Smokes 5/day Auscultation 'scratching sounds' Widespread ST elevation on ECG
What diagnosis is supported by his ECG
Pericarditis
60 yr old woman Collapse BP 120/70 No postural drop HS S1+S2+ESM ECG shows LAD
Left ventricular hypertrophy
likely due to aortic stenosis
40 yr old man
Loin pain
CRP normal
Urinalysis: blood ++
Next investigation?
CT KUB
(kidney ureter bladder)
…renal colic
–> causes dilated renal pelvis
Next thing you want to know after seeing hypercalcaemia?
PTH
Alkaline phosphatase:
- Sources
- Raised when?
Liver and bone
Raised in obstructive liver disease (stone/head of pancreas cancer) and bone disease
e.g. Malignancy, fracture, Paget’s disease
Myeloma and ALP
Normally ALP high in cancer. Bone: osteoblasts make ALP
Plasma cell suppress osteoblasts, therefore ALP is normal in myeloma.
Multiple myeloma
Cancer of plasma cells, a type of white blood cell normally responsible for producing antibodies.
Multiple myeloma signs/symptoms
CRAB
Calcium (high)
Renal impairment
Anaemia
Bone pain
23 yr old woman
Breast lump
1cm
Smooth mobile
Diagnosis?
Fibroadenoma
Cavitating lung lesions
Infection
- TB
- Staph
- Klebsiella (e.g. alcoholics)
Inflammation (Granulomatosis with polyangiitis, RA)
Infarction (PE)
Malignancy
35 yr old woman
Ankle oedema
Recent echocardiogram: NAD
U&Es normal
ALT, AST & ALP normal
Albumin 15
Next test?
Urinalysis
ECG rules out HF
Oedema and hypoalbuminaemia (<25g/L) suggest nephrotic syndrome. Urinalysis could show proteinuria.
Nephrotic syndrome
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.
Hereditary Haemorrhagic Telangiecstasia
Autosomal dominant Abnormal blood vessels in -skin -mucous membranes -lungs -liver -brain
Causes of hyperprolactinaemia
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
Normal OGTT result
Suppression of GH - failure to suppress GH = acromegaly
Low oestradiol
High FSH
High LH
PRL normal
Premature ovarian insufficiency
Why is prolactin mildly elevated in primary hypothyroidism?
Increased TRH released in hypothalamus to stimulate TSH production also stimulates prolactin production.
