CBL - 13 Flashcards

1
Q

A 69-year-old man attends his GP with his wife complaining of a three month history of abdominal pain, constipation and feeling generally very low in mood.

Q1. What areas of the history would you ask about? [+]

A

History; ask about:
- Skeletal symptoms: bone pain; osteoporosis; skeletal
- Neuropsychiatric symptoms drowsiness; impaired concentration ability; confusion; depression; irritability; psychosis; ataxia; hypotonia; insomnia
- Neuromuscular symptoms: fatigue, muscle weakness;
- GI symptoms: N & V; anorexia; WL; consipation; abdominal pain
- Renal symptoms: renal colic; thirst (polyuria, polydipsia, nocturia, and dehydration)
- CV symptoms: hypertension; shortened QT interval;

Medications that can cause hypercalcemia include:
- Thiazide like diuretics
- Too much vit. D supplement
- Lithium

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2
Q

What questions should you ask regarding constipation? [+]

A

Establish timeline about constipation:
- Timeline
- Fibre intake?
- When did you last open your bowels?
- How often do you move your bowels?
- Have you noticed any change in the bulk of your stools?
- Do you feel that you have emptied your bowels entirely after you go to the toilet?
- What medication might take?
- Weight loss?
- Associated fever, nausea, vomiting, loss of appetite and/or weight?

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3
Q

What are red flag questions for stool questions? [+]

A
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4
Q

A 69-year-old man attends his GP with his wife complaining of a three month history of abdominal pain, constipation and feeling generally very low in mood.

Q1. What areas of the clinical examination would you ask about [+]

A
  • Hydration status
  • LNs and breast mass (if suspect someone with hypercalcemia secondary to malignany)
  • High BP (hypercalcemia and renal failure)
  • Assess for cognitive impairment
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5
Q
A
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6
Q

What investigations would you consider? [+]

A

FBC:
- diagnose or exclude anaemia of chronic disease or haematologic malignancy

HbA1C
- DMT2 gastroparesis

U&Es

ESR or CRP:
- may be increased in malignancy or other inflammatory or granulomatous conditions.

eGFR:
- assess hydration status
- AKI ?
- CKD?

Serum and urine protein electrophoresis:
- urine Bence-Jones protein — to exclude myeloma

LFTs:
- liver metastases or chronic liver failure
- alkaline phosphatase may be increased in primary hyperparathyroidism
- myeloma

Thyroid function tests
- to exclude thyrotoxicosis

Vitamin D & Ca2+ levels

PTH:
- raised in primary (and tertiary) hyperparathyroidism
- suppressed or undetectable in malignancy-related hypercalcaemia or other non PTH-dependent causes.

Serum cortisol
- if Addisons disease suspected

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7
Q

His GP organises some routine blood tests, prescribes him some medication for his constipation, and decides to refer him for a two week wait cancer investigation for possible bowel cancer.

A few days later, however, the patient starts developing severe right loin pain, radiating to the groin. The pain is so bad that his wife calls an ambulance who take him to the Emergency Department.
In the Emergency Department he is noted to have severe pain and tenderness in the right loin. He is unable to stay still on the examination couch.

Urinalysis shows blood ++, but nil else.

Q2. What is the likely cause of his acute pain? [2] What treatment should be given and what investigation should be done?

A

AKI picture:
* Kidney stone
* Pyelonephritis

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8
Q

Q2. What is the likely cause of his acute pain?

What investigation should be done?

A

Kidney stone:

  • For most adults, offer low-dose non-contrast CT KUB
  • If pregnant offer US
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9
Q

What treatments should be given? [4]

A

IV fluids

Pain relief:
- IM diclofenac
- Paracetamol IV
- (opoids)

If less than < 5mm:
- Watchful waiting

If more than > 5mm
- shockwave lithotripsy
- ureteroscopy
- percutaneous nephrolithotomy

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10
Q

How do CT-KUBs get reported from radiologists? [3]

A

Bowels and other organs
Bones
Calcification and artefact

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11
Q

State the different therapeutic selections for kidney stones that are:

Stone burden of less than 2cm in aggregate [1]

Stone burden of less than 2cm in pregnant females [1]

Complex renal calculi and staghorn calculi [1]

Ureteric calculi less than 5mm [1]

A

Stone burden of less than 2cm in aggregate
- Lithotripsy

Stone burden of less than 2cm in pregnant females:
- Ureteroscopy

Complex renal calculi and staghorn calculi:
- Percutaneous nephrolithotomy

Ureteric calculi less than 5mm:
- Manage expectantly

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12
Q

Q3. What abnormalities are seen? What further investigations should be undertaken? [2]

A
  • Renal stone in right ureter
  • Constipation - bowel looks enlarged and full on R
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13
Q

Q3. What abnormalities are seen? What further investigations should be undertaken? [6]

A

Bone profile & Urate levels - ID cause of stones

FBC & CRP
- UTI?

Daily U&Es
- Check AKIs (and see if changes)

Urine MC&S

Urine pH

24hr urine collection for calcium, oxalate, urate citrate, sodium, creatinine

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14
Q

How do you acutely manage hypercalcemia in this patient [3]

A

0.9% saline

Bisphosphinates: zoledronic acid (dose depends on the eGFR of the patient)

Calcitonin - inhibits (blocks) the activity of osteoclasts, which are cells that break down bone

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15
Q

What are the reasons for hypercalcaemia? [+]

A

Primary hyperparathyroidism:
- Parathyroid adenomas

Tertiary hyperparathyroidism:
- autonomous PTH excess due to parathyroid hyperplasia in response to longstanding secondary hyperparathyroidism: CKD

Thyrotoxicosis:
- Elevated thyroid hormones can lead to thyroid hormone-mediated bone resorption. Mild hypercalcaemia can be seen in up to 20%.

FHH
- FHH is an autosomal dominant condition caused by a mutation to calcium-sensing receptors (CaSR). CaSRs play an important role in calcium regulation.

Sarcoidosis

Hypervitaminosis D

Iatrogenic:
- Chronic lithium use: enhances PTH release
- Thiazide diuretics: lowers urinary calcium excretion

Malignant hypercalcaemia:
- due to release of parathyroid related peptide (PTHrP)

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16
Q

Why would you consider an ECG in a patient with hypercalcemia? [1]

A

short qTC levels

17
Q

Further investigation showed:
Serum Parathyroid Hormone 15.4 pmol/L (1.6-6.9)

Q5. What is the diagnosis? What further investigation is required and what treatment can affect a cure?

A

Primary hyperparathyroidism:
- Parathyroid adenoma: approximately 80-85% of cases
- Parathyroid hyperplasia: around 15-20% of cases are caused by multi-gland hyperplasia.
- Parathyroid cancer: around 1% of cases. Difficult to diagnoses but may be suspected in patients with greatly elevated PTH and calcium or occasionally based on imaging findings.

18
Q

Describe what is meant by MEN1 [3

A

multiple endocrine neoplasia which is characterised by:

  • primary hyperparathyroidism
  • pituitary adenomas
  • pancreatic tumour
19
Q

Which types of cancer can cause increase PTH? [3]

A

Breast
Small cell lung
Renal cell carcinoma

20
Q

Treatment for primary hyperparathyroidism? [1]

A

Surgery

21
Q

What medication would you prescribe if you can’t give surgery for P? [1]

A

cinacalcet

22
Q

Following surgery, his calcium levels return to normal, and he feels much better. He attends his GP for a follow up visit, where he complains of back pain. Clinical examination is normal. His GP organises a lumbar spine x-ray which shows the following? [2]

A

spinal compression fracture ?
suggestive of osteoporosis/penia

23
Q

How do you treat osteoporosis? [4]

A

Bisphosphinates:
1. Alendronate
2. Risedronate or etidronate or IV zoledronate
3. Strontium raenlate and raloxifene

Vit D +/- Ca

24
Q

What dosing of alendronate do you give? [1]

A

70mg weekly (or 10mg daily if pill burden too big)