All quizes Flashcards
55 yr old man is taking increasing doses of sublingual GTN for established stable angina. He also has COPD with a reduced PEFR. Coronary angiography has shown diffuse disease but he has refused intervention. What is the most appropriate initial management?
A CCB e.g. Nifedipine.
First line anti-anginal therapy for stable angina is a beta blocker such as metoprolol. However, this patient has COPD and beta blockers are relatively contraindicated due to bronchospasm (even those considered to be cardioselective). 2nd line treatment is with a CCB such as nifedipine. Long acting nitrates can be used as additional therapy or in patients where beta blockers and CCBs are contraindicated.
60 yr old man with stable angina is awaiting surgery. He is on the highest tolerated dose of beta blocker and CCB but is still symptomatic. BP is 170/95 mmHg. What is the most appropriate initial management?
Long acting nitrates such as isosorbide mononitrate or transdermal GTN is indicated as the patient is still symptomatic on beta blockers and CCBs. Appropriate nitrate-free periods will be needed to avoid tolerance. Severe hypotension may occur if combined with a phosphodiesterase-5 inhibitor.
A 30 year old male alcoholic presents nausea and pain in the lower chest in a band radiating around to the back. The pain makes the patient curl up in a ball and movement worsens it. On examination there is decreased breath sounds on the left side which is stony dull to percussion at the base. What is the most useful investigation?
CT scan abdomen.
This patient has acute pancreatitis. He has vomited and is describing mid-epigastric pain radiating around to the back which is relieved in the fetal position and is worse with movement. He is an alcoholic and alcoholic pancreatitis is seen more frequently in men usually after an average of 4-8 years of alcohol intake. Binge drinking also increases the risk. This patient also has nausea and may describe vomiting too, with agitation and confusion. The examination findings described here allude to a pleural effusion which is seen in half of patients with acute pancreatitis. Complicated haemorrhagic pancreatitis may exhibit Cullen’s sign, Grey-Turner’s sign and Fox’s sign. Make sure you know what these are and you are familiar with the causes of acute pancreatitis. Those caused by hypocalcaemia may display Chvostek’s sign and Trousseau’s sign.
Key to diagnosis is serum amylase or lipase levels which are massively elevated. Prognostic criteria are outlined in Ranson’s criteria applied on admission and after 48 hours, or the modified Glasgow score which you can find in your Oxford Handbook. An abdominal CT is however the most sensitive and specific study and findings may include enlargement of the pancreas with irregular contours, necrosis, pseudocysts and peripancreatic fat obliteration.
For interest, urinary trypsinogen-2 is now considered a better screening test than amylase but is not currently clinically used.
A 49 year old man presents to A&E with a 2 week history of a ‘tight’ central chest pain radiating to the jaw experienced when he is lying down. What is the most likely diagnosis?
Decubitus angina.
Usually as a complication of heart failure. This patient has chest pain which occurs on lying down, which is decubitus angina by definition.
A 75 year old woman with long standing hypertension has had progressive swelling of her legs over the last 3 months. She has consulted her GP because she has developed an ulcer on the anterior aspect of the right shin which weeps serous fluid profusely. She wonders what caused this ulcer?
Cardiac failure.
This sounds like a venous ulcer due to right-sided heart failure. Venous ulcers are mainly caused by either venous insufficiency or heart failure. RVF will lead to peripheral oedema which may be complicated by a venous ulcer. Initial investigations should include ECG, CXR, TTE and bloods including BNP levels. First line treatment is with an ACE inhibitor which reduces morbidity and mortality. Salt and fluid restriction is also beneficial. All patients with chronic heart failure will also receive a beta blocker such as carvedilol. Other adjuncts include spironolactone, diuretics, hydralazine and a nitrate, and digoxin.
The pulse is irregularly irregular and jerky in character. There is an ejection systolic murmur lessened by squatting loudest at the lower left sternal edge. There is a double apical impulse felt. The apex beat is not displaced. What is the most likely diagnosis?
This patient has HOCM which is the most frequent cause of sudden cardiac death in younger people. Examination findings may be normal or may reveal an ejection systolic murmur which is positionally responsive and a double carotid or apex pulsation due to the transient interruption of CO. A fourth heart sound may also be heard due to hypertrophy. There may also be MR. The arterial pulse is described as ‘jerky’ and this patient is also in AF which warrants anticoagulation and anti-arrhythmics. Echocardiography must be performed to establish a diagnosis, though ECG and CXR will also be done and may also show changes. Echo will show septal hypertrophy. This has a benign prognosis in most people though symptomatic patients are treated medically with beta blockade, CCBs or disopyramide. Chest pain on exertion is a common presentation in those who are symptomatic, as is dyspnoea on exertion, palpitations (such as due to AF) and a history of either pre-syncope or syncope (due to LV outflow obstruction). Inheritance is autosomal dominant with a variable penetrance. It is worth noting that ventricular hypertrophy causes concentric hypertrophy i.e. the wall of the ventricle gets thicker inwards. Hence the apex beat is not displaced unlike in DCM.
There is a constant ‘machinery-like’ murmur throughout systole & diastole. What is the most likely diagnosis?
Patent ductus arteriosus.
The ductus arteriosus is a fetal structure which normally closes within 2 days of birth. Persistence can result in heart failure and increased pressures in the pulmonary vasculature as blood is shunted from the aorta into the pulmonary artery. The classic murmur is known as a Gibson murmur or machinery murmur and is best heard in the left infraclavicular area, usually peaking in late systole and continuing into diastole. Maternal rubella infection in the first trimester is a predisposing risk factor for PDA. The definitive diagnostic test is an echocardiogram.
There is a harsh pan-systolic murmur loudest at the lower left sternal edge & inaudible at the apex. The apex is not displaced. What is the most likely diagnosis?
Tricuspid regurgitation.
The murmur of TR is a lower left parasternal systolic murmur (pansystolic, or less, depending on severity). The murmur commonly increases on inspiration (Carvallo’s sign). The apex is not displaced in TR whereas it may be displaced in MR. Key risk factors for TR include LVF, rheumatic heart disease, endocarditis and the presence of a permanent pacemaker. Patients typically present with SOB, periperal oedema and tiredness. There may also be abdominal distension. An enlarged and pulsatile liver is normally seen in severe TR and caused by a reversal in blood flow during systole. It is worth noting that mild to moderate TR is not necessarily abnormal and is present in many asymptomatic young adults.
Pain on breathing in & out, dyspnoea, coughing up blood as well, stony dull to percuss. What is the most likely diagnosis?
PE.
Patients with a high clinical suspicion of PE should be anticoagulated while waiting a definitive diagnosis unless contraindicated. PE can cause atelectasis which can result in a dull percussion note and a pleural effusion which is exudative in nature, causing a ‘stony dull’ percussion note. The underlying pathophysiology is based on Virchow’s triad. SOB and chest pain are common symptoms and there may also be haemoptysis. Strong risk factors include DVT, obesity, surgery in the past 2 months, prolonged bed rest, malignancy, previous VTE, pregnancy and the thrombophilias such as factor V Leiden. ECG may be normal, or may show tachycardia, new RAD, new RBBB or the classical S wave in I, Q wave with T inversion in III. Various clinical probability scores exist for PE and D-dimer can be used to exclude PE as a diagnosis.
70 yr old retired boiler maker presents with a 5 year history of exertional dyspnoea and a dry cough. The patient is non-smoker. Examination reveals fine crackles heard at the lung bases. What is the most likely diagnosis?
Sarcoidosis is a chronic multisystem disease with an unknown aetiology. The mauve lesions are erythema nodosum and are tender erythematous nodules. Lupus pernio is another typical skin manifestation of sarcoidosis presenting with indurated plaques with discoloration on the face. CXR will typically show bilateral hilar lymphadenopathy and CXR findings are used in the staging of disease. Additionally, serum calcium and ACE levels may be raised. A transbronchial biopsy is essential for diagnosis in most cases and shows the presence of non-caseating granulomas. Black people have a higher lifetime risk of sarcoidosis, as do those of Scandinavian origin. The mainstay of treatment for severe disease involves systemic corticosteroids.
A 19 year old presents with headache and malaise for 1 week. His chest was clear on auscultation. He subsequently developed a cough and was given erythomycin for 1 week. What is the most likely diagnosis?
Mycoplasma pneumonia.
The atypical presentation (a week of headache and malaise before the cough) and the prescription of erythromycin, a macrolide antibiotic, point to infection with an atypical pneumonia. However, depending on local prescribing policies, first line therapy for a CAP like pneumococcus may also be with a macrolide. Young people who ‘live together’ are commonly affected. The cough often does not resolve and is dry in nature. Symptoms tend to be prolonged and a low-grade fever is a common finding. Mycoplasma is the only atypical pneumonia on the list although there is no reason why this cannot be Legionella or Chlamydia. All can be treated with macrolides although in EMQs Chlamydia tends to be treated with doxycyline. All 3 atypicals are to some extent sensitive to fluoroquinolones and tetracylines too although these cannot be used in pregnancy. Whether they are first or second line therapy depends on the organism.
A 42 year old man has a 3 year history of progressive SOB and joint pains. His bloods show positive rheumatoid factor. What is the most likely diagnosis?
Wegeners Granulomatosis is a systemic vasculitis affecting the small and medium vessels and presents with the classic triad of upper respiratory tract involvement, lower respiratory tract involvement and GN. It is a multisystem disease which can manifest with symptoms ranging from cutaneous, musculoskeletal, ocular and neurological features. Joint swelling and tenderness may all be present. It is associated with a positive cANCA and rhematoid factor is positive in around half.
A 50 year old male patient on the ward awakes with dyspnoea & frothy sputum. He had suffered an MI a week earlier. On examination, he is cyanosed & tachypnoeic. Auscultation of the lung reveals crepitations. What is the most likely diagnosis?
This patient has acute pulmonary oedema (the classic finding of pink frothy sputum). This is likely to be caused by LVF secondary to his MI a week earlier. This accounts for the basal crepitations heard on ascultation. Patients need to be sat upright to improve the SOB and IV access needs to be established. Oxygen, morphone, diuretics (frusemide or another loop diuretic) and nitrates will be given. Once stable, medical treatment of heart failure should be started which involves in the first instance, an ACE inhibitor followed by beta blockade. Ongoing diuretics are necessary if the patient has persistent symptoms of fluid overload.
A 35 year old previously healthy man returned from a conference in the USA 5 days ago. He travels frequently and gives a 30 pack year history. He presents with mild confusion, a productive cough, diarrhoea and is pyrexic. His chest examination is normal. CXR shows infiltrates in the RUL. What is the most likely causative organism?
Legionella pneumophila is a gram negative rod. Legionella infecting the lungs is legionnaires’ disease or Legionella pneumonia whereas non-lung infection is known as Pontiac fever. This bacteria is found in aqueous environments such as lakes and almost all cases are from contaminated water systems, which relates to the risk factors of getting Legionella (recent water exposure like a hot tub). Smoking is also a risk factor. It can cause confusion as well as hyponatraemia, abdominal pain, diarrhoea and bradycardia. Legionella does not grow on routine culture media and diagnosis relies on urine antigen detection, serology or culture on special media.
A 20 year old previously healthy woman presents with general malaise, severe cough & breathlessness which has not improved with a 7 day course of amoxicillin. There is nothing significant to find on examination. The x-ray shows patchy shadowing throughout the lung fields. The blood film shows clumping of red cells with suggestion of cold agglutinins. What is the most likely causative organism?
Mycoplasma pneumoniae.
The cold agglutinins is what gives this question away. Mycoplasma is associated with with cold type agglutinins and a cold AIHA. Humans are thought to be the only host for Mycoplasma. The most commonly affected are young adults living in close proximity to each other. PCR can be used in diagnosis.
A 63 year old tramp presents to the A&E department with a 4 day history of haemoptysis. He has felt unwell for about 2 months with a cough, loss of weight & generalised weakness. He attributes his diplopia, which started a fortnight ago, to excessive alcohol consumption. On examination he has bilateral ptosis & proximal weakness in the limbs which improves on repeated testing. What is the most likely diagnosis?
Small cell carcinoma.
First line treatment aims at surgical resection if possible. Small cell lung cancer is treated with chemotherapy and is also associated with SIADH and ectopic ACTH. Non-small cell lung cancer is more often associated with clubbing. Squamous cell carcinoma is associated with PTHrp release and is treated with radiotherapy. Adenocarcinomas are usually located peripherally in the lung and are more common in non-smokers although most cases are still associated with smoking. The paraneoplastic syndromes may include Lambert-Eaton myasthenic syndrome which this patient has (though weakness of the eye muscles is uncommon in Lambert-Eaton and is more prominent in myasthenia gravis). This classically presents with weakness which improves on repeated testing (in contrast to myaesthenia gravis) and is more commonly associated with small cell lung cancer than other lung cancers. It is for this reason that the most likely diagnosis is small cell and not squamous cell lung cancer.
A 20 year old man with cystic fibrosis presents to the chest clinic with haemoptysis. He has felt unwell for a fortnight with increased sputum production, fever & rigors. Gram stain of the sputum shows Gram-positive cocci in clusters. What is the most likely diagnosis?
Pulmonary abscess.
A lung abscess is diagnosed on CXR with a cavitation with an air-fluid level in it. Preceding pneumonia which a patient with CF is at risk of is a risk factor. Of gram positive cocci, staphylococcus occurs in grape-like clusters (this patient) whereas streptococcus occurs in chains. It is worth learning your gram stains for the main organisms. It is worth noting that Staphylococcus aureus is coagulase positive (also Yersinia pestis which causes plague) and Streptoccus pneumoniae is optochin sensitive. Fever and a productive cough are common symptoms and treatment involves antibacterials and drainage/resection if unresponsive. Lung abscesses are commonly caused by aspiration of gastric contents.
A 48 year old woman with ovarian carcinoma presents to the A&E department with a 12 hour history of haemoptysis associated with dyspnoea & pleuritic pains. On examination she is apyrexial & has a right sided pleural rub. The chest x-ray shows a wedge shaped infarct peripherally on the right but is otherwise normal. What is the most likely diagnosis?
Pulmonary embolism.
This CXR finding is Hampton’s hump seen in about a third of PE. Additional CXR signs include Westermark’s sign and Fleischner’s sign. CXR is however not diagnostic and may well be normal. Patients with a high clinical suspicion of PE should be anticoagulated while waiting a definitive diagnosis unless contraindicated. The underlying pathophysiology is based on Virchow’s triad. SOB and chest pain are common symptoms and there may also be haemoptysis. Strong risk factors include DVT, obesity, surgery in the past 2 months, prolonged bed rest, malignancy (which this patient has), previous VTE, pregnancy and the thrombophilias such as factor V Leiden. ECG may be normal, or may show tachycardia, new RAD, new RBBB or the classical S wave in I, Q wave with T inversion in III. Various clinical probability scores exist for PE and D-dimer can be used to exclude PE as a diagnosis. The study of choice is a CTPA with direct visualisation of the thrombus. If there is a contraindication to a CT scan such as contrast allergy or pregnancy, then a V/Q scan is indicated. If a V/Q scan is not possible, alternatives such as MRA can be requested. It is worth noting that in patients with cardiopulmonary disease, these tests may not be accurate. A TTE can also be used to detect RV strain seen with PE.
A 34 year old man presents to the A&E department with a short history of haemoptysis. He has had a cough for a fortnight & noticed his ankles beginning to swell 5 days ago. Initial blood tests show a creatinine of 400mol/l. An autoantibody screen is positive for p-ANCA & anti-glomerular basement membrane antibodies. What is the most likely diagnosis?
Goodpasture’s disease is associated with anti-GBM antibodies, and of those who are positive, some will have a positive ANCA too, although this is more suggestive of diagnoses such as Churg-Strauss and microscopic polyarteritis. Definitive diagnosis is by renal biopsy showing crescentic GN and linear IgG staining on immunofluorescence. It is one of the few causes of pulmonary renal syndrome. Aggressive treatment is often needed and plasma exchange can also be performed to remove preformed antibodies.
A 60 year old male presents with acute breathlessness & a cough productive of frothy, pink sputum. He cannot lie flat. On examination, he has crackles to both midzones & a few scattered wheezes. What is the most important step in acute management>
Intravenous furosemide.
This patient has pulmonary oedema. CXR may show pulmonary vascular redistribution to the upper zones, Kerley B lines, an increased CTR (cardiomegaly) and pleural effusion.
A 36 year old popstar presents with fever, a cough & an itchy vesicular rash. Chest x-ray shows mottling through both lung fields. What is the most likely causative organism?
Varicella zoster.
The pruritic vesicular rash (the classic description of a ‘dewdrop on a rose petal’) makes you think of VZV. The rash typically occurs on the patient’s torso and face and pneumonia is a complication occuring more commonly in those with immunosuppression. The lesions are often crusted over by 7-10 days. The diagnosis is based on clinical findings.
A holiday worker had a severe chest infection abroad & was diagnosed to have influenza A infection. He was improving but suddenly deteriorated with the last 24 hours becoming breathless, febrile & septic. X-ray chest showed circular opacities some with a fluid level. Gram stain of sputum showed Gram positive cocci in clusters. What is the most likely causative organism?
Think Staphylococcus aureus for post-influenza pneumonia. It causes a cavitating pneumonia which explains the CXR findings (some abscesses are also seen) and Gram stain of culture yields grape like clusters of Gram positive cocci which is consistent with staphylococcus. Treatment of staphyloccocal infection is with flucoxacillin or vancomycin if MRSA.
A 50 year old Asian diabetic woman is admitted with increasing shortness of breath and ankle swelling. ECG shows inverted T waves in levels I, AVL and V4-6. Upper lobe blood diversion and bilateral pleural effusions are found on chest X-ray. What is the most likely diagnosis?
Pulmonary oedema.
CXR findings here are consistent with pulmonary oedema. Pulmonary vascular redistribution to the upper zones, Kerley B lines, an increased CTR (cardiomegaly) and pleural effusion may be seen. The patient is also in CCF with evidence of LV dysfunction (SOB) and RV dysfunction (ankle swelling).
A 26 year old Italian nightclub DJ presents with abdominal pain. On enquiry he has been unwell with a productive cough, fever and breathlessness. On examination his heart rate is 110bpm and his blood pressure is 110/75. His abdomen is soft, non tender. What is the most likely diagnosis?
This is basal pneumonia which can present with upper abdominal pain. The symptoms this patient gives are consistent with pneumonia. Treatment is guided by the CURB-65 score. A CXR is the most specific and sensitive test available and antibiotics are indicated. CXR may show airspace shadowing with air bronchograms. Make sure you can spot consolidation on a CXR.
A 19 year old man who has been intubated due to a recent RTA is recovering well & is extubated. He complains of coughing up a small amount of blood streaked phlegm. What is the most appropriate investigation to confirm the diagnosis?
History only.
This is a result of intubation which has caused some iatrogenic trauma to this patient’s upper airway.
A 55 year old lawyer who has had a chronic cough for 3 months complains of 1 episode of haemoptysis. She is a heavy smoker (about 40/day) & has experienced some recent weight loss. What is the most appropriate investigation to confirm the diagnosis?
Bronchoscopy.
This sounds like bronchial carcinoma from the history of smoking, respiratory complaints and weight loss. Initial investigation of bronchial carcinoma is with a CXR but definitive diagnosis relies on pathological confirmation from a tissue sample, often obtained from bronchoscopy. During bronchoscopy, endobronchial masses can be biopsied and washings/alveolar lavage can also be performed for cytological analysis. Trans-thoracic needle aspiration may be needed for peripheral lesions that cannot be reached by bronchoscopy. First line treatment aims at surgical resection if possible.
A young 23 year old allergic atopic asthmatic woman becomes acutely breathless. She has just taken an Aspirin for headache. Her neck is swollen, eyes puffy, & her breathing is noisy, with marked wheeze throughout the lung fields. What is the single most appropriate treatment?
Intramuscular adrenaline.
There is a sudden onset of respiratory (and cardiovascular) complaints with the recently given aspirin tablet. This patient is having an anaphylactic reaction and the airway needs to be promptly secured and prompt treatment started with adrenaline. IM adrenaline must not be delayed and the anterolateral thigh is the preferred location, with repeated doses as necessary every 10 minutes or so. A 1:1000 solution is used of 0.3-0.5mg adrenaline. Fluid replacement with IV saline is also indicated to correct the intravascular volume redistribution.
A 70 year old man has been newly diagnosed with stage I COPD and has been given inhaled salbutamol PRN and has agreed to stop smoking. What additional measure is needed?
Influenza immunisation.
The GOLD guidelines published in April 2010 provide a framework for a stepwise approach to treating COPD. Stages of COPD are based on predicted FEV1. For all stages of COPD, influenza vaccination is given yearly and pneumococcal vaccine is given every 5 years. Long term oxygen is only added if there is chronic respiratory failure in stage IV disease. Stage II involves the addition of long acting bronchodilators and rehabilitation. Stage III involves adding inhaled GCs if there are repeated exacerbations.
A 64 year old man has become acutely breathless over the last 4 days, with a productive cough, green sputum & chest tightness. He is a longstanding smoker. Clinically he is hypoxic, with tachycardia, tachypnoea, & central cyanosis. His ABG are as follows: pH 7.35, PaO2 6.7kPa, PaCO2 7.8kPa. He has been given nebulised bronchodilators & intravenous antibiotics & steroids. What is the single most appropriate treatment?
24% continuous oxygen.
This patient with COPD is having an acute exacerbation. He is being treated accordingly but will need supplemental oxygen as a result of his ABG results. >8kPa is an acceptable level of arterial oxygenation or SaO2 >90%. Ceftriaxone is an acceptable antibiotic. High risk individuals should get tazocin or meropenem (especially if pseudomonas is suspected). Check local antibiotic prescribing policies. Chronic oxygen therapy is indicated for patients with PaO2
A 9 year old girl attends her GP surgery as an emergency with wheezing, difficulty in breathing & cough. Her PEFR is 250l/min, expected PEFR 500. There is no sign of infection on her chest examination. She is admitted to hospital and given inhaled salbutamol although shows an incomplete response. Which treatment should be given next?
Oral prednisolone.
Acute asthma exacerbation this time. Bear in mind that treatment guidelines differ for adults and children. The PEFR is 50% predicted making this a moderate exacerbation of asthma (40-69%). A mild exacerbation is defined by a PEFR of 70% of more of predicted whereas severe is defined as 26 to 39% with life-threatening falling under 25%. Note that these values are for children. For moderate exacerbations like this, an oral corticosteroid needs to be prescribed alongside inhaled SABA. If this were life-threatening or severe, then IV may be indicated. It is worth knowing the symptoms and signs of mild, moderate and severe/life threatening asthma. The treatment guidelines that you need to familiarise yourself with tend to be for adults.
A 75 year old recently widowed male smoker with a history of angina presents with shortness of breath. He has also vomited & complains of a ringing in his ears. On examination the patient has a BP of 80/50mmHg & fine crackles at both lung bases. What is the most likely diagnosis?
Aspirin poisoning.
This patient has angina so probably has a stash of aspirin. Tinnitis is common in the early stages of acute salicylate poisoning and reflects CNS toxicity. There may also be deafness and both are reversible. GIT decontamination should be considered as an adjunct on arrival to A&E and activated charcoal can be given. The mainstay of treatment is alkaline diuresis induced by an infusion of sodium bicarbonate. In cases of severe poisoning, it is still started as a bridge to haemodialysis.
A 62 year old male heavy, long term smoker presenting with infection of a wound which refuses to heal. What would their ACTH and cortisol tests show?
High ACTH, high cortisol.
This wound is refusing to heal because of the high cortisol level, which is as a result of elevated ACTH due to a small cell lung cancer producing it ectopically as part of a paraneoplastic syndrome. Hence, ACTH and cortisol are both high here.
A 72 year old lady under long term therapy with biannual bone density assessment for rheumatoid arthritis. What would their ACTH and cortisol tests show?
Low ACTH, low cortisol.
This patient is on steroids for RA (hence the biannual bone density assessment). The anchor drug for RA is methotrexate which is the most commonly used DMARD. Other DMARDs include leflunomide, sulphasalazine and hydroxychloroquine. Corticosteroids given for RA will suppress the secretion of ACTH by the pituitary gland and as a result cause cortisol to become low.
An 18 year old woman with a bitemporal hemianopia, tiredness, hypoglycaemia and low BP and postural hypotension. What would their ACTH and cortisol tests show?
Low ACTH, low cortisol.
The bitemporal hemianopia suggests a pituitary adenoma compressing the optic chiasm. The patient presents with signs and symptoms of adrenal insufficiency indicating low cortisol. The cause is the pituitary adenoma (this is secondary adrenal insufficiency) leading to low ACTH.
A 43 year old woman who initially presented with a bilateral hemianopia & has gone on to develop Cushingoid signs. What would their ACTH and cortisol tests show?
High ACTH, high cortisol.
A pituitary adenoma here is secreting ACTH. This is Cushing’s disease responsible for most cases of Cushing’s syndrome. Hence, ACTH is high and so is cortisol.
A 55 year old man, whose abdominal CT shows an adrenal adenoma. What would their ACTH and cortisol tests show?
Low ACTH, high cortisol.
This is adrenal Cushing’s where an excess of cortisol is being produced by the adrenal gland adenoma. This excess cortisol suppresses ACTH production.
72 year old man with diabetes. He has been on insulin for 6 years. His daughter had noticed that he was increasingly vague. He was found unconscious. BP 160/90. Plasma urea, creatinine & electrolytes were normal. What is the most likely diagnosis?
Hypoglycaemia.
This patient has symptoms of hypoglycaemia, present when glucose drops
A 60 year old diabetic lady visits her GP complaining of tingling in her hands. This is worse at night. She describes numbness, and if there is feeling she describes tingling. This is in both hands only; not in her arms. What is the most likely diagnosis?
Symmetrical sensory polyneuropathy.
Diabetic neuropathy can be autonomic or peripheral. This is a case of diabetic peripheral sensory neuropathy. This is a microvascular complication of DM and is characterised by peripheral nerve dysfunction. The tingling this patient describes is a common complaint and loss of sensation typically occurs in a symmetrical ‘glove and stocking’ distribution. Patient’s may also describe a pain or unpleasant sensation which is prickling, burning or sticking. Examination should include peripheral pulses, reflexes and sensation to light touch, vibration (128Hz tuning fork), pinprick and proprioception. Any pain can be treated with medications like gabapentin.
