8/12/15 Interactive Cases In General Medicine 2

Question 1

Management of anaphylactic shock

Answer 1

IM adrenaline first line. Consider raising legs, IV fluids, IV hydrocortisone, antihistamines afterwards

Question 2

50 year old man presents with cough, SOB, recent foreign travel, coarse crepitations on auscultation and bronchial breathing. His LFTs are deranged and he is hyponatraemic. What is the diagnosis and which antibiotics would you use to treat this?

Answer 2

CAP atypical pneumonia (Chlamydia, Mycoplasma, Legionella) likely to be Legionella due to hyponatraemia. Atypical are implicated in 40% of CAPs

Treat with amoxicillin (normal CAP) plus macrolide to cover atypicals: azithromycin, clarithromycin, erythromycin

Question 3

How would you treat a HAP and what are the likely organisms?

Answer 3

Tazocin for Gram -ve cover

E. coli, Klebsiella

Question 4

What does a coeliac screen involve and how is coeliac disease diagnosed?

Answer 4

TTG tissue transglutaminase antibodies. Confirm with a duodenal biopsy showing villous atrophy

Question 5

How is a microcytic anaemia investigated in an otherwise well 50 year old male?

Answer 5

Top n Tail: OGD/colonoscopy, the order depends on the symptoms
Haematinics: Fe, ferritin, TIBC
Coeliac screen

Question 6

Top differentials for bloody diarrhoea?

Answer 6

1. Infectious colitis
2. Inflammation: CD/UC in younger patients
3. Ischaemic colitis in older patients
4. Diverticulitis
5. Malignancy

Question 7

40M with palpitations that started 4 hours ago is found to have AF on ECG. What is the management plan?

Answer 7

Attempt rhythm control as

Question 8

70M found to have AF with haemodynamic compromise, what is the management plan?

Answer 8

DC cardioversion

Question 9

How is SVT treated?

Answer 9

IV adenosine

Question 10

How is haemodynamically stable VT treated?

Answer 10

Amiodarone

Question 11

How is haemodynamically compromised VT treated?

Answer 11

Defibrillation

Question 12

What are caput medusa a sign of?

Answer 12

Portal hypertension due to chronic liver disease

Question 13

What are the signs of hypocalcaemia?

Answer 13

Trousseau sign of latent tetany: inflating a blood pressure cuff >3 mins greater than systolic causes carpopedal spasm

Chvostek sign: tapping the facial nerve at the cheek causes a twitch

Hyperreflexia

Question 14

What is Grey Turner sign?

Answer 14

Haematoma in the flanks due to a retroperitoneal haemorrhage seen in acute pancreatitis

Question 15

What are the signs of portal hypertension?

Answer 15

Encephalopathy: confusion, drowsiness, coma
Ascites: reduced oncotic pressure due to low liver albumin synthesis and high hydrostatic pressure
Spontaneous bacterial peritonitis
Variceal bleed

Question 16

20M diarrhoea and malaise, blood film shows schistocytes, high urea and creatinine, what is the diagnosis?

Answer 16

Haemolytic uraemic syndrome: red cell fragments (schistocytes), high urea, high creatinine, low Hb, high BR, low platelets

This is a MAHA

Question 17

What are the three top causes of microangiopathic haemolytic anaemia?

Answer 17

DIC, HUS, TTP
Disseminated intravascular coagulation
Haemolytic uraemic syndrome
Thrombotic thrombocytopaenic purpura

Question 18

Low platelets, low fibrinogen, high fibrin degradation products, high D-dimer, long PT/APTT

Answer 18

DIC

Question 19

Low Hb, uraemia (high Cr, Ur), red cell fragments, high Br, low platelets, diarrhoea

Answer 19

HUS

Question 20

Fever, fatigue, seizures, LOC, low Hb, high Br, Cr, Ur, low plt

Answer 20

TTP

Question 21

What is the Trousseau sign of malignancy?

Answer 21

Migratory thrombophlebitis felt as a nodule under the skin, associated with pancreatic and lung cancer

Question 22

Hereditary causes of haemolytic anaemia

Answer 22

RBC membrane defect: hereditary spherocytosis
Enzyme deficiency: G6PD deficiency
Haemoglobinopathies: SCD, thalassaemia

Question 23

Acquired causes of haemolytic anaemia

Answer 23

Infection, AI, drugs, MAHA

Question 24

3 Causes of euvolaemic hyponatraemia?

Answer 24

Hypothyroidism test with TFTs
Hypoadrenalism (Addison’s) test with short synACTHen test
SIADH (inappropriate ADH secretion)

Question 25

Mechanism of hypovolaemic hyponatraemia?

Answer 25

Hypovolaemia due to diuretics is the most common cause. Also due to diarrhoea and vomiting causing loss of total body water volume, decreased blood pressure stimulates baroreceptors causing increase in secretion of ADH. This is physiological. Low urine sodium

Question 26

Mechanism of hypervolaemic hyponatraemia?

Answer 26

Heart failure, cirrhosis, nephrotic syndrome. Low urine sodium

Question 27

60M confused, cough, no postural hypotension, Na 120, K 4, TFT, SST normal. Urine Na high, urine osmolality high

Answer 27

SIADH secondary to SCLC CXR
Or to brain pathology CT/MRI head
May also be due to drugs and trauma

Question 28

Nail changes: Beau lines, nail pitting, koilinychia, leuconychia

Answer 28

Beau lines: growth and cessation (chemo/ITU)
Nail pitting: psoriasis
Koilinychia: IDA
Leuconychia: hypoalbuminaemia

Question 29

Onycholysis causes

Answer 29

Trauma, thyrotoxicosis, psoriasis, fungal infection

Question 30

20F vomiting, abdominal pain, T1DM known, CBG: 20, venous pH: 7.20. What is the next most appropriate test? How should she be managed?

Answer 30

Capillary ketones for DKA. Manage with IV fluids, insulin, potassium

Question 31

What are the 3Cs of diabetes?

Answer 31

Control (how is your sugar and HbA1c at home?)
Complications (microvascular, microvascular, metabolic)
Cardiovascular risk factors

Question 32

How are the microvascular complications assessed?

Answer 32

1. Retinopathy: yearly retinal photography and laser treatment if indicated
2. Nephropathy: albumin:creatinine ratio urine to lab
3. Neuropathy: check sensation in feet

Question 33

How is DKA/HHS treated?

Answer 33

Fluids, potassium, insulin. DKA in T1, HHS in T2 (very dry)

Question 34

24M smoker, SOB and CP, on auscultation you hear a rub or crunching sound. What will be seen on ECG?

Answer 34

This is pericarditis, can see diffuse saddle shaped ST elevation, S1Q3T3