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DPD Amir Sam GK > 4. Interactive Cases in General Internal Medicine 3 > Flashcards

4. Interactive Cases in General Internal Medicine 3 Flashcards

1
Q

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

First step in management

A

IM adrenaline

NOT IV - can cause cardiac arrest

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2
Q

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

A

Need to add a macrolide to cover the atypical organisms

–> Clarithromycin

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3
Q

Use of Tazocin

A

Gram negatives; choice for HAP infections

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4
Q

Use of Vancomycin

A

Suspected MRSA

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5
Q

Atypical Organisms

A

Mycoplasma pneumoniae
Chlamydia pneumoniae
Legionella pneumophila

–> implicated in up to 40% of CAP

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6
Q

Most common cause of Pneumonia?

A

Streptococcus pneumoniae

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7
Q 
50 yr old man
Dyspepsia
Wt loss
Hb 70
MCV 79

Which test would you request

A

OGD (gastroscopy)

Then colonoscopy if no abnormality found

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8
Q

Microcytic anaemia: next step?

A

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

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9
Q

Ferritin also marker of…

A

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

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10
Q

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

Likely diagnosis

A

Ischaemic Colitis

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11
Q

Causes of Bloody diarrhoea

A

Infection: Infective colitis

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

Ischaemia: Ischaemic colitis (older pts)

Malignancy

Diverticulitis

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12
Q

40 yr old man
Palpitations 4 hrs ago onset
ECG AF

How to treat?

A

DC cardioversion

less than 48 hrs

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13
Q

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

What is the name of this clinical sign?

A

Caput medusae

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14
Q

Grey Turner

A

Bruising of the flanks (w/ pancreatitis)

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15
Q

Troisier’s sign

A

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

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16
Q

Trousseau’s sign (not of malignancy)

A

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.

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17
Q

Portal Hypertension presentation

A

Encephalopathy
Ascites
Spontaneous bacterial peritonitis
Variceal Bleed

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18
Q

Schistocyte

A

Red cell fragment

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19
Q

Microangiopathic haemolytic anaemia

A

3 conditions:

Disseminated intravascular coagulation

Haemolytic Uraemic Syndrome

Thrombotic Thrombocytopenic Purpura

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20
Q

Disseminated Intravascular Coagulation

A

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

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21
Q

Haemolytic Uraemic Syndrome

A

Haemolysis (Decreased HB, Increased bilirubin)
Uraemia
Decreased Platelets

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22
Q

Thrombotic Thrombocytopenic Purpura

A

HUS + Fever + Neurological manifestations

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23
Q

D-dimer

A

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

24
Q

Haemolytic anaemia framework

A

Hereditary or Acquired

Hereditary:

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

Acquired:

  • Autoimmune
  • Drugs
  • Infection
  • MAHA
25
Q

Haustra

know what they look like

A

Small pouches characteristic of large bowel

26
Q

Valvulae conniventes

know what they look like

A

Large valvular flaps projecting into the lumen of the small intestine

27
Q

Management of small bowel obstruction

A

NBM
Fluids
NG tube

(Drip and suck)

Cause and complications

28
Q

Hyponatraemia…

A 
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

29
Q

Hyponatraemia algorithm

A

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
30
Q

Causes of SIADH

A
  • CNS pathology (e.g. stroke, tumour)
  • Lung pathology (pneumonia, PE, lung cancer)
  • Drugs (SSRI, TCA, Opiates, PPIs, carbamazepine)
  • Tumours

–> Brain, Lungs, Drugs, Cancer

31
Q 
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?

A

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

32
Q

Onycholysis

A

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
33
Q

Leukonychia

A

Also known as white nails or milk spots; white discoloration appearing on nails.

e.g. hypoalbuminaemia liver disease

34
Q

Koilonychia

A

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

35
Q

Beau’s lines

A

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

36
Q

Nail pitting

A

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

37
Q

What to bear in mind when treating hyponatraemia…

A

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.

38
Q 
20 yr old woman
Abdo pain
Vomiting
T1DM
CBG 20
Venous pH 7.2

Next most appropriate test

A

Capillary Ketone

To check if it is Diabetic Ketoacidosis

39
Q

Diabetes Complications

A

Microvascular
-Retinopathy
(background, pre-proliferative, proliferative)
-Nephropathy (raised urine albumin-creatinine ratio)
-Neuropathy (foot ulcers)

Macrovascular
-MI/Stroke/PVD

Metabolic
-DKA/HHS/Hypoglycaemia

40
Q 
26 yr old man
Chest pain
Smokes 5/day
Auscultation 'scratching sounds'
Widespread ST elevation on ECG

What diagnosis is supported by his ECG

A

Pericarditis

41
Q 
60 yr old woman
Collapse
BP 120/70
No postural drop
HS S1+S2+ESM
ECG shows LAD
A

Left ventricular hypertrophy

likely due to aortic stenosis

42
Q

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

Next investigation?

A

CT KUB
(kidney ureter bladder)

…renal colic
–> causes dilated renal pelvis

43
Q

Next thing you want to know after seeing hypercalcaemia?

A

PTH

44
Q

Alkaline phosphatase:

  • Sources
  • Raised when?
A

Liver and bone

Raised in obstructive liver disease (stone/head of pancreas cancer) and bone disease

e.g. Malignancy, fracture, Paget’s disease

45
Q

Myeloma and ALP

A

Normally ALP high in cancer. Bone: osteoblasts make ALP

Plasma cell suppress osteoblasts, therefore ALP is normal in myeloma.

46
Q

Multiple myeloma

A

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

47
Q

Multiple myeloma signs/symptoms

A

CRAB

Calcium (high)
Renal impairment
Anaemia
Bone pain

48
Q

23 yr old woman
Breast lump
1cm
Smooth mobile

Diagnosis?

A

Fibroadenoma

49
Q

Cavitating lung lesions

A

Infection

  • TB
  • Staph
  • Klebsiella (e.g. alcoholics)

Inflammation (Granulomatosis with polyangiitis, RA)

Infarction (PE)

Malignancy

50
Q

35 yr old woman
Ankle oedema
Recent echocardiogram: NAD

U&Es normal
ALT, AST & ALP normal
Albumin 15

Next test?

A

Urinalysis

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

51
Q

Nephrotic syndrome

A

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.

52
Q

Hereditary Haemorrhagic Telangiecstasia

A 
Autosomal dominant
Abnormal blood vessels in
-skin
-mucous membranes
-lungs
-liver
-brain
53
Q

Causes of hyperprolactinaemia

A 
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
54
Q

Normal OGTT result

A

Suppression of GH - failure to suppress GH = acromegaly

55
Q

Low oestradiol
High FSH
High LH
PRL normal

A

Premature ovarian insufficiency

56
Q

Why is prolactin mildly elevated in primary hypothyroidism?

A

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

DPD Amir Sam GK (5 decks)

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