8/12/15 Interactive Cases In General Medicine 2 Flashcards
Management of anaphylactic shock
IM adrenaline first line. Consider raising legs, IV fluids, IV hydrocortisone, antihistamines afterwards
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?
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
How would you treat a HAP and what are the likely organisms?
Tazocin for Gram -ve cover
E. coli, Klebsiella
What does a coeliac screen involve and how is coeliac disease diagnosed?
TTG tissue transglutaminase antibodies. Confirm with a duodenal biopsy showing villous atrophy
How is a microcytic anaemia investigated in an otherwise well 50 year old male?
Top n Tail: OGD/colonoscopy, the order depends on the symptoms
Haematinics: Fe, ferritin, TIBC
Coeliac screen
Top differentials for bloody diarrhoea?
- Infectious colitis
- Inflammation: CD/UC in younger patients
- Ischaemic colitis in older patients
- Diverticulitis
- Malignancy
40M with palpitations that started 4 hours ago is found to have AF on ECG. What is the management plan?
Attempt rhythm control as
70M found to have AF with haemodynamic compromise, what is the management plan?
DC cardioversion
How is SVT treated?
IV adenosine
How is haemodynamically stable VT treated?
Amiodarone
How is haemodynamically compromised VT treated?
Defibrillation
What are caput medusa a sign of?
Portal hypertension due to chronic liver disease
What are the signs of hypocalcaemia?
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
What is Grey Turner sign?
Haematoma in the flanks due to a retroperitoneal haemorrhage seen in acute pancreatitis
What are the signs of portal hypertension?
Encephalopathy: confusion, drowsiness, coma
Ascites: reduced oncotic pressure due to low liver albumin synthesis and high hydrostatic pressure
Spontaneous bacterial peritonitis
Variceal bleed
20M diarrhoea and malaise, blood film shows schistocytes, high urea and creatinine, what is the diagnosis?
Haemolytic uraemic syndrome: red cell fragments (schistocytes), high urea, high creatinine, low Hb, high BR, low platelets
This is a MAHA
What are the three top causes of microangiopathic haemolytic anaemia?
DIC, HUS, TTP
Disseminated intravascular coagulation
Haemolytic uraemic syndrome
Thrombotic thrombocytopaenic purpura
Low platelets, low fibrinogen, high fibrin degradation products, high D-dimer, long PT/APTT
DIC
Low Hb, uraemia (high Cr, Ur), red cell fragments, high Br, low platelets, diarrhoea
HUS
Fever, fatigue, seizures, LOC, low Hb, high Br, Cr, Ur, low plt
TTP
What is the Trousseau sign of malignancy?
Migratory thrombophlebitis felt as a nodule under the skin, associated with pancreatic and lung cancer
Hereditary causes of haemolytic anaemia
RBC membrane defect: hereditary spherocytosis
Enzyme deficiency: G6PD deficiency
Haemoglobinopathies: SCD, thalassaemia
Acquired causes of haemolytic anaemia
Infection, AI, drugs, MAHA
3 Causes of euvolaemic hyponatraemia?
Hypothyroidism test with TFTs
Hypoadrenalism (Addison’s) test with short synACTHen test
SIADH (inappropriate ADH secretion)
Mechanism of hypovolaemic hyponatraemia?
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
Mechanism of hypervolaemic hyponatraemia?
Heart failure, cirrhosis, nephrotic syndrome. Low urine sodium
60M confused, cough, no postural hypotension, Na 120, K 4, TFT, SST normal. Urine Na high, urine osmolality high
SIADH secondary to SCLC CXR
Or to brain pathology CT/MRI head
May also be due to drugs and trauma
Nail changes: Beau lines, nail pitting, koilinychia, leuconychia
Beau lines: growth and cessation (chemo/ITU)
Nail pitting: psoriasis
Koilinychia: IDA
Leuconychia: hypoalbuminaemia
Onycholysis causes
Trauma, thyrotoxicosis, psoriasis, fungal infection
20F vomiting, abdominal pain, T1DM known, CBG: 20, venous pH: 7.20. What is the next most appropriate test? How should she be managed?
Capillary ketones for DKA. Manage with IV fluids, insulin, potassium
What are the 3Cs of diabetes?
Control (how is your sugar and HbA1c at home?)
Complications (microvascular, microvascular, metabolic)
Cardiovascular risk factors
How are the microvascular complications assessed?
- Retinopathy: yearly retinal photography and laser treatment if indicated
- Nephropathy: albumin:creatinine ratio urine to lab
- Neuropathy: check sensation in feet
How is DKA/HHS treated?
Fluids, potassium, insulin. DKA in T1, HHS in T2 (very dry)
24M smoker, SOB and CP, on auscultation you hear a rub or crunching sound. What will be seen on ECG?
This is pericarditis, can see diffuse saddle shaped ST elevation, S1Q3T3
