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DPD Amir Sam GK > 5. Interactive Cases in General Internal Medicine 4 > Flashcards

5. Interactive Cases in General Internal Medicine 4 Flashcards

1
Q

Signs of immediate transfusion reaction.

A 
Fever
Rigor
Increased HR
Decreased BP
Chest pain
Dark urine

(Haemolysis)

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2
Q

Polycythaemia DDx

A

Primary Polycythaemia:
Polycythaemia rubra vera

Secondary Polycythaemia:
Appropriate increase in erythropoietin:
-Chronic hypoxia e.g COPD

Inappropriate increase in erythropoietin:

  • Renal (carcinoma, cysts, hydronephrosis)
  • Hepatocellular carcinoma
  • Fibroids
  • Cerebellar haemangioblastoma
  • Erythropoietin abuse amongst athletes

Relative polycythaemia:

  • Dehydration
  • Gaisbock’s syndrome (in obese, HTN causes hypovolaemia)
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3
Q

Subclassifications of Anaemia

A 
Macrocytic
Microcytic
Normocytic
Haemolytic (hereditary and acquired)
Aplastic
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4
Q

Macrocytic anaemia DDx

A

Alcoholics May Have Liver Failure:

Alcohol

  • Hx
  • Raised GGT

Myelodysplasia

  • Pancytopenia (low platelets/Hb/WCC)
  • Bone marrow problems

Hypothyroidism

  • Hx (lethargy, weight gain, constipation)
  • Low T4
  • High TSH

Liver disease
-Hx and Examination

Folate/B12 deficiency
-Hx (small bowel disease, ? Gastrectomy - lack of intrinsic factor produced by stomach required for B12 absorption)

[Alcohol
Folate/B12 deficiency
Haemolytic anaemia
Hypothyroidism
Liver disease
Myelodysplasia
Drugs: methotrexate, hydroxyurea, azathioprine, zidovudine]
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5
Q

Microcytic anaemia DDx

A

Iron Deficiency (low ferritin)

  • Diet
  • Blood loss (GI/UG)

Beta thalassaemia heterozygosity

[Iron deficiency: blood loss (GI - peptic ulcer, malignancy, etc; Urogenital - menorrhagia, haematuria; Hookworm; Decreased absorption - gastrectomy, small bowel disease; Increased demands - growth, pregnancy; Decreased intake - vegans)
Thalassaemia
Sideroblastic anaemia: congenital (X-linked), alcohol, drugs (isoniazid, chloramphenicol), lead, myelodysplasia
Lead poisoning
Anaemia of chronic disease (often normocytic but may be microcytic)]

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6
Q

Normocytic anaemia DDx

A

Chronic disease

  • Infection, inflammation, malignancy. eg. RA
  • Normal or high ferritin.

[Anaemia of chronic disease (chronic infection, inflammatory/connective tissue diseases, malignancy)
Haemolytic anaemia (may also cause macrocytic anaemia)
Hypothyoidism (may also cause macrocytic anaemia)
Pregnancy
Renal failure
Bone marrow failure]

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7
Q

Haemolytic anaemia DDx

A

Hereditary:
Haemoglobinopathies: sickle cell anaemia, thalassaemia
Membrane defects: spherocytosis, elliptocytosis
Metabolic defects: pyruvate kinase deficiency, glucose-6-phosphate dehydrogenase deficiency.

Acquired:
Autoimmune: Warm antibodies (idiopathic, SLE, lymphoma, drugs e.g. methyldopa), Cold antibodies (idiopathic, infections e.g. Mycoplasma, EBV, lymphoma)
Alloimmune: Transfusion reaction, haemolytic disease of newborn
Drugs: penicillin, quinidine
Microangiopathic haemolytic anaemia: TTP, HUS, DIC, malignant hypertension, malignancy (widespread adenocarcinoma), pregnancy complications (preeclampsia, HELLP syndrome: haemolysis, incrased liver enzymes, decreased platelets)
Artificial heart valves
March haemoglobinuria
Infection: malaria, clostridia
Paroxysmal nocturnal haemoglobinuria
Secondary to liver and renal failure

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8
Q

Aplastic anaemia DDx

A

Idiopathic

Inherited: Fanconi anaemia, dykeratosis congenita

Acquired: Drugs (cytotoxics, chloramphenicol, gold, methotrexate) chemicals, radiation, viral infection, paroxysmal nocturnal haemoglobinuria, sepsis

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9
Q

Thrombocytopenia DDx

A

Not making them - marrow infiltration by lymphomas, leukaemias, drugs, cancer., radiotherapy.

Breaking them down - DIC

Pooling in spleen - alcoholic chronic liver disease with portal hypertension.

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10
Q

WCC raised when?

A

Infection or malignancy

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11
Q

Ferritin

A

Acute phase reactant, up in inflammation etc.

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12
Q

50 yr old woman
Hb 90g/L
MCV 75 (decreased)
On NSAIDs for joint pain

Most likely cause?

A

Iron deficiency

Microcytic anaemia
On NSAIDs - therefore likely to be due to gastric erosion - inhibition of prostaglandins by NSAIDs leads to reduced protection of mucosa by acid.

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13
Q

40 yr old woman
Hb 110 g/L
MCV 65

Most likely diagnosis

A

Beta thalassaemia heterozygosity

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14
Q

Markers of XS alcoholic intake

A

High MCV

High gamma g t

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15
Q

Polycythaemia presentations

A 
Headache
Pruritus after hot bath
Blurred vision (hyperviscosity)
Tinnitus
Thrombosis (stroke, DVT)
Gangrene

Choreiform movements

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16
Q

Sickle Cell Anaemia Crises and their Managements

A

Acute painful crises
–>Analgesia, O2, IV fluids, Antibiotics

Stroke
–>Exchange blood transfusion (remove sickled cells)

Sequestration crises (RBC pooling)

  • Lung (SOB, cough, fever)
  • Spleen (exacerbation of anaemia)
  • ->Splenectomy for repeated episodes of splenic sequestration

Gallstones, chronic cholecystitis
–>Cholecystectomy

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17
Q

Environment in which red blood cells sickle

A

Low oxygen tension; irreversible.

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18
Q

Multiple Myeloma Framework + presentation

A

CRAB

hyperCalcium (polyuria, polydipsia, constipation)

Renal Failure (Ur & Cr)

Anaemia (Breathlessness, lethargy - FBC)

Bone (pain, osteoporosis, fracture - DXA)

Infection
Cord Compression (spastic paraparesis)
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19
Q

Complication of hypercalcaemia

A

Nephrogenic Diabetes Insipidus

…also: “Stones, Bones, Groans, Thrones, Psychiatric overtones.”

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20
Q

Osteoporosis

A

T score on a DXA scan of less than -2.5

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21
Q 
50 yr old man
Hypercalcaemia
Low PTH
Backache
Normal ALP

Most likely cause?

A

Multiple Myeloma

(normal ALP - alkaline phosphatase is made by osteoblasts in myeloma; plasma cells suppress the osteoblasts, therefore normal)

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22
Q

Reticulocytes framework (up or down)

A

Anaemia with increased reticulocyte count:

  • Haemolytic crisis
  • Haemorrhage

Anaemia with reduced reticulocyte count: problem with bone marrow…

  • Parvovirus B19 infection
  • Aplastic crisis in patients with sickle cell anaemia
  • Blood transfusion
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23
Q

Definition of Diabetes Mellitus

A

Fasting glucose of more than 7 (as after this level the rate of retinopathy is significantly increased)

Random glucose of at least 11.1

HbA1c more than 48 (or greater than 6.5% DCCT)

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24
Q

Definition of Impaired glucose tolerance

A

Pre-diabetic state of hyperglycaemia associated with insulin resistance and increased risk of cardiovascular pathology. May precede T2DM by many years.
Give 75g OGTT
2-hr glucose: 7.8-11

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25
Stereotypical Diabetic Presentations
Type 1: Young, thin, insulin deficiency - wt loss, ketones, acidosis Type 2: Older, overweight, obese, insulin resistant Type 3c: Patients with impaired pancreatic function e.g. pancreatectomy. V difficult to manage; also have decreased glucagon.
26
45 yr old man Lethargy, fatigue, polyuria, polydipsia Urinalysis: no ketones, glucose +++ Random glc: 18 How to treat?
Metformin 1st drug in treatment of T2 diabetes after lifestyle and diet advice. (Then sulfonylurea, then DPP-IV inhibitor, then insulin if not controlled by tablets. If patient is overweight, or want to avoid hypoglycaemia, think about GLP-1 agonist.)
27
Metformin action
Reduces insulin resistance
28
Sulfonylurea action
Stimulate insulin release
29
DPP-IV inhibitor action
Inhibits the enzyme that break down GLP-1
30
GLP-1 agonist action
Stimulates release of protein that increases insulin secretion, decreases glucagon secretion, reduce appetite, causes some wt loss.
31
Sliding scale/Variable rate IV insulin infusion
Used when patient is in worse condition, e.g. not eating, unwell, surgery/sepsis etc Blood glucose (mmol/L)/Insulin Dose (units/hr) ``` 0-3.9 / 0.5 4-7.9 / 1 8-11.9 / 2 12-15.9 / 4 16-19.9 / 6 20+ / 8-12 (Consult doctor) ```
32
Graves' Disease: Presentation, TFTs and Ix
``` Wt loss Good appetite Irritability Palpitations Irregular periods ``` ``` O/E: Tremor Proptosis Smooth goitre Pretibial myxoedema ``` High free T4/T3, suppressed TSH Next investigation: TSH receptor stimulating antibody
33
TPO antibodies
Marker of autoimmunity
34
Uptake in different thyroid conditions: Graves' Thyroiditis Toxic Nodular Goitre
Graves': diffuse increased uptake Thyroiditis: no uptake Toxic Nodular Goitre: One spot of increased uptake, absent elsewhere (autonomous nodule)
35
Thyroid Cancer Hx and Ex, RF
Lumps ``` Risk factors: Radiation FHx Rapid enlargement/compression Lymphadenopathy ``` Mets (lung, follicular thyroid ca)
36
Thyroid Ix and Rx
USS FNAC (Uptake scan: cold nodules) MDT ``` Surgery: Papillary Follicular Medullary Anaplastic (poor prognosis) ``` Thyroxine, Radioiodine
37
Bitemporal Hemianopia cause
Pituitary tumour compressing optic chiasm
38
30 yr old female Amenorrhoea Galactorrhoea Bitemporal Hemianopia Diagnosis and Treatment
Prolactinoma compressing optic chiasm. Cabergoline: dopamine agonist
39
50 yr old man Headache, sweating Poor sleep, snoring - obstructive sleep apnoea Tingling in fingers - carpal tunnel syndrome Initial test: High IGF-1 Next investigation?
OGTT | suspect acromegaly
40
Suspected Acromegaly Tests
1. IGF-1 | 2. OGTT
41
Insulin Tolerance Test
Test of Pituitary Function In normal, give insulin --> decreased blood glucose --> hypoglycaemia --> rise in cortisol and growth hormone. Dynamic pituitary function test
42
Oral Glucose Tolerance Test
Test for Acromegaly 75g Glucose In normal, this will suppress GH. If doesn't happen, consistent with acromegaly.
43
Dexamethasone Suppression Test
Test for Cushing's In normal, dexamethasone suppresses ACTH and Cortisol. If not low, abnormal --> Cushing's
44
Short Synacthen Test
Test for adrenal insufficiency Normal: ACTH --> increased cortisol.
45
Discriminatory signs of Cushing's
Bruising Myopathy Purple Striae more than 1cm wide (due to wt gain and thin skin) DM/HTN/Osteoporosis at young age.
46
Amenorrhoea/Oligomenorrhoea
Pregnancy -Urine BHCG Hypothalamus -? Excessive exercise, low BMI Pituitary - Excess prolactin - Low LH/FSH Thyroid (hyper/hypo) -TFTs Ovaries - PCOS: Excess androgens or hirsutism - Ovarian Failure: High FSH (low oestradiol --> less negative feedback --> high FSH)
47
Hypokalaemia Presentation and DDx
Presentation: Polyuria (caused by nephrogenic diabetes inspidus --> ADH resistance) Weakness Arrhythmia ``` DDx: GI: vomiting Diuretics Primary hyperaldosteronism (bilateral hyperplasia or Conn's) -aldosterone:renin ratio ``` (Aldosterone stimulates sodium absorption and potassium excretion)
48
Hypernatraemia
High plasma osmolality [= 2 X (Na + K) + Ur + glc] High urine osmolality? - Dehydration (elderly/children) - HHS (urine high osm: glycosuria), Type 2 diabetes Low urine osmolality -Diabetes insipidus (DIlute urine, osm , 300)
49
Low Ca Low phosphate High PTH
Vitamin D deficiency
50
PTH
Parathyroid hormone (Phosphate trashing hormone) Increased PTH --> Increased Ca, Decreased Phosphate
51
High Ca Low phosphate High PTH
Primary Hyperparathyroidism
52
High Ca Normal Phosphate Low PTH
Malignancy/Myeloma
53
Low Ca High Phosphate Low PTH
Hypoparathyroidism
54
Low Ca High Phosphate High PTH
Chronic Kidney Disease (PTH high because calcium is low; Phosphate high due to renal failure, therefore no hydroxylation of Vit. D in kidneys. No renal filtration of phosphate)
55
AKI framework
Pre-renal - Hypovolaemia - Sepsis Renal - Drugs - ? Active urine sediment: blood and protein in the urine (glomerulonephritis) Post-renal -USS (?Obstruction)
56
Renal artery stenosis
Asymmetrical Kidneys Magnetic Resonance Angiography Deterioration of renal function with ACE inhibitors (bilateral RAS)
57
Types of psoriatic arthritis
``` Oligoarticular Polyarticular Arthritis Mutilans Spondyloarthritis Distal interphalangeal predominant ```
58
Oligoarticular Psoriatic Arthritis
Affects 70% of patients Generally mild Does not occur in the same joints on both sides of the body Usually only involves fewer than 3 joints.
59
Polyarticular Psoriatic Arthritis
25% of cases | Five or more joints on both sides of the body simutaneously
60
Arthritis Mutilans
Less than 5% of patients Severe, deforming and destructive Can progress over months or years causing sever joint damage
61
Spondyloarthritis Psoriatic Arthritis
Characterised by stiffness in the neck or the sacroiliac joint of the spine; can also affect hands and feet
62
Distal interphalangeal predominant Psoriatic Arthritis
Characterised by inflammation and stiffness in the joints nearest to the ends of the fingers and toes; nail changes often marked.

DPD Amir Sam GK (5 decks)

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