DPD 6 - Haem, Endo Flashcards
What are the symptoms of immediate transfusion reaction?
Fever, rigor, increased HR, decreased BP, chest pain, dark urine
What is polycythaemia?
Increased Hb
Primary - polycythaemia rubra vera, sedondary - chronic hypoxia e.g. COPD or EPO drugs used by athletes
What is thrombocytopenia?
Decreased platelets Causes: Decreased production (marrow infiltration) Increased destruction (DIC) Pooled in spleen (CLD, portal HTN)
What is thrombocytosis?
Increased platelet
What are the causes of microcytic anaemia?
Iron deficiency (low ferritin) - diet or blood loss (GI, urogenital); a complication is Plummer-Vinson syndrome = oesophageal web
Anaemia of chronic disease
Thalassaemia - beta thalassaemia heterozygosity
Siderblastic anaemia
Lead poisoning
What Ix would you do for microcytic anaemia?
FBC
Blood film - hypochromic
Hb electrophoresis - for beta thalassaemia
What causes normocytic anaemia?
Chronic disease (normal/high ferritin - ferritin is an acute phase protein): infection, inflammation e.g. RhA, malignancy
What are the causes of macrocytic anaemia?
Alcohol Myelodysplasia Hypothyroidism Liver failure Folate/B12 deficiency
What Ix would you do for macrocytic anaemia?
FBC
Blood film
Schilling test for pernicious anaemia
What is the Tx for folate/B12 deficiency?
IM hydroxycobalamin
PO cyanobalamin
A 50 y/o woman presents w/ microcytic anaemia and has been on NSAIDs for joint pain. What is the most likely cause?
- Iron deficiency
- Beta thalassaemia
Iron deficiency
NSAIDs increase risk of gastric erosions therefore gastric ulcers. Prostaglandins required for protection of gastric mucosa
A 40 y/o woman; Hb 110; MCV 65 (80-100). What is the most likely diagnosis?
- Iron deficiency
- Beta thalassaemia
Beta thalassaemia heterozygosity - MCV is out of proportion of the Hb (low MCV in relation to degree of anaemia)
What are the symptoms of polycythaemia?
Headache, pruritus after a hot bath, blurred vision (hyperviscosity), tinnitus, thrombosis (stroke, DVT), gangrene, choreiform movement (dance-like)
What Ix would you do for sickle cell anaemia?
Blood film: Howell-Jolly bodies = DNA in electrophoresis
What is the Tx for acute painful crises?
Analgesia (morphine)
Oxygen - hypoxia causes sickling
IV fluids - dehydration causes sickling
ABx (if underlying infection)
What is the Tx for a stroke crisis from sickle cell anaemia?
Exchange blood transfusion (remove sickle cells)
What is the Tx for a sequestrian crisis (Sickle cell anaemia)?
Sequestrian crises are caused by RBC pooling and can occur in the lungs causing SOB, fever, cough or in the spleen causing exacerbation of anaemia. A splenectomy will be the most appropriate step for recurrent splenic sequestrian
What is the Tx for gallstones, chronic cholecystitis caused by sickle cell anaemia?
Cholecystectomy
Chronic haemolysis causes pigment stones thus causing gallstones
What are the symptoms of multiple myeloma?
Think CRAB
Calcium - polyuria, polydipsia, constipation; hypercalcaemia causes increased ADH resistance which causes nephrogenic diabetes insipidus
Renal failure - Ix: urea + creatinine
Anaemia - Breathlessness, lethargy; Ix: FBC
Bone - fracture, bone pain, osteoporosis; Ix: DKA scan (assess bone mineral density). Osteoporosis T score <2.5
Infection
Cord compression - spastic paraperesis (weakness in legs)
A 50 y/o man presents w/ hypercalcaemia, low PTH + backache. ALP normal. What is the most likely cause?
- Malignancy
- Multiple myeloma
Multiple myeloma
ALP is normal - this is a big hint as ALP is made by osteopblasts. In MM, plasma cells suppress osteoblasts so in myeloma, ALP is normal whereas in malignancy it is raised.
A 50 y/o man presents w/ hypercalcaemia, low PTH + backache. ALP high. What is the most likely cause?
- Malignancy
- Multiple myeloma
Malignancy
What are reticulocytes?
Precursors to RBCs
What are the causes of anaemia with increased reticulocyte count?
This is a compensation to loss of RBC so causes include haemolytic crises and haemorrhage (blood loss)
What are the causes of anaemia with decreased reticulocyte count?
This is when the marrow is affected so causes include:
Parvovirus B19 infection
Aplastic crisis in patients w/ sickle cell anaemia
Blood transfusion
What are the diagnostic values of fasting and random blood glucose for diabetes?
Fasting glucose >7 - rate of retinopathy significantly increases after fasting glucose > 7
Random glucose of 11.1 or more
Impaired glucose tolerance (IGT), 75g OGTT, 2 hour glucose. Impaired glucose tolerance = 7.8-11.0
What are the 3 types of diabetes?
Type 1: young, thin, insulin deficiency, weight loss, ketones + acidosis
Type 2: older, overweight + obese, insulin resistance
Type 3: Pancreatectomy - total lack of pancreatic hormones + enzymes
What is the management of diabetes?
- Conservative: diet and exercise
- Medical: Metformin - reduces insulin resistance
- Check HbA1c - if not in range, add sulfonylurea (insulin secretagogue) or GLP-1 agonist (incretin effect). If still not in range: DPP4 inhibitor (decreases breakdown of GLP-1). Eventually, consider Insulin
What are the stages of diabetic retinopathy?
Background - hard exudates (leaked lipid content from blood vessels), microaneurysms + blot haemorrhages
Pre-proliferative - soft exudates/cotton wool spots (regions of retinal ischaemia)
Proliferative - Angiogenesis
What are the complications of diabetes?
Retinopathy
Nephropathy - raised urine ACR (Albumin:creatinine ratio), decreased renal function. Not urinalysis (can’t get the ratio)
Neuropathy - must examine feet
A 45 y/o man presents w/ lethargy, fatigue, polyuria, polydipsia. Urinalysis: glucose +++, no ketones. Random glucose 18. How would you treat him?
- Metformin
- Insulin
- Sulfonylurea
- DPP4 inhibitor
- GLP1 agonist
Metformin
What is the sliding scale?
Variable rate IV insulin infusion dependent by blood glucose. Indications: patient not eating, unwell e.g. surgery, sepsis. Disadvantages: constantly need to change dose, assoc. w/ decreased mortality
What are the symptoms and signs of Graves’ disease?
Weight loss + good appetite Irritability Palpitations Irregular periods Tremor Proptosis Smooth goitre Pretibial myxoedema - specific to Graves'
What are the Ix for suspected Graves’ disease?
TFT: Increased free T4/T3 but decreased TSH
TSHr stimulating antibody: +ve
Uptake scan: diffuse uptake - uptake requires TSH or TSH receptor stimulating Ab
What would the uptake scan be like in viral thyroiditis?
No uptake due to decreased TSH
What is the presentation of thyroid cancer?
Lumps
Rx: radiation, FHx, rapid enlargement/compression, lymphadenopathy
Mets (lung, follicular thyroid cancer)
What Ix would you do for thyroid cancer?
USS
FNAC: uptake scan: cold nodules
What is the Tx for thyroid cancer?
MDT
Surgery
After surgery: thyroxine, radioiodine (if high risk)
A 30 y/o female presents w/ amenorrhoea, galactorrhoea + bitemporal hemianopia, irregular periods and sexual dysfunction. What is the most appropriate Tx?
The symptoms all point towards prolactinoma, the bitemporal hemianopia suggests macroprolactinoma. The 1st line Tx is cabergoline which is a DA agonist - the prolactinoma shrinks then the prolactin normalises.
Trans-sphenoidal surgery only performed if not responding to DA agonists (rarely performed)
What is the Tx for prolactinoma
Cabergoline - DA agonist which shrinks the prolactinoma as DA suppresses prolactin
A 50 y/o man presents w/ headache, sweating, poor sleep + snoring. He also presents w/ tingling in fingers. What is the initial investigation?
IGF-1 - look for suspected acromegaly. The snoring indicates obstructive sleep apnoea caused by increased soft tissue in upper airways + the tingling in fingers indicate carpal tunnel syndrome.
What is the next Ix for acromegaly after IGF-1?
- Insulin tolerance test
- OGTT
- Dexamethosone suppression test
- Short synacthen test
- GHRH test
OGTT - GH is a counter regulative hormone that increases glucose level to protect against hypoglycaemia. Normal: decreased GH. Acromegaly: unsuppressed increased GH
What Ix would you do for Cushing’s disease?
- Insulin tolerance test
- OGTT
- Dexamethosone suppression test
- Short synacthen test
- GHRH test
Dexamethasone suppression test
Normal: decreased ACTH as it is suppressedd so decreased cortisol
Cushing’s: increased cortisol as failure to suppress cortisol due to increased ACTH
What Ix would you do for adrenal insufficiency?
- Insulin tolerance test
- OGTT
- Dexamethosone suppression test
- Short synacthen test
- GHRH test
Short synacthen test
Normal: increased ACTH - increased cortisol
A 40 y/o woman presents w/ weight gain, depression, fatigue, central obesity + googled her symptoms which suggested Cushing’s syndrome. Is she likely to have cushing’s syndrome?
No
Overweight, fatigue is a universal phenomenon as ageing
What is the difference between Cushing’s syndrome and Cushing’s disease?
Cushing’s syndrome are a collection of symptoms caused by an increased cortisol regardless of cause.
Cushing’s disease is excess cortisol caused by pituitary tumour
What are the discriminatory signs of Cushing’s syndrome?
Easy bruising, thin skin
Proximal myopathy
Purple striae - thinning and stretching of the skin allows you to see the capillaries
DM, HTN, osteoporosis at a young age
What are the causes of amenorrhoea/oligomenorrhoea?
Pregnancy
Hypothalamus - would ask for exercessive exercise
Pituitary - excess prolactin, low LH/FSH
Thyroid - TFTs
ovaries - excess androgens or hirsutism due to PCOS, Ovarian failure
What are the symptoms of hypokalaemia?
Weakness
Arrhythmia
Polyura - decreased K+ causes increased ADH resistance which causes nephrogenic DI
Vomiting
What are the causes of hypernatraemia?
Increased urine osmolality - dehydration; HHS in T2DM (increased urine oscmolality due to glucose in urine)
Decreased urine osmolality - diabetes insipidus (dilute urine) due to lack of ADH so decreased water reabsorption + increased water loss in urine so dilute urine
Decreased Ca, decreased phosphate and increased PTH
Vitamin D deficiency
Decreased Ca, increased phosphate, decreased PTH
Hypoparathyroidism
Decreased Ca, increased phosphate, increased PTH
Pseudohypoparathyroidism
Increased Ca, normal phosphate, decreased PTH
Malignancy or multiple myeloma
Increased Ca, decreased phosphate, increased PTH
Primary hyperparathyroidism
Decreased Ca, increased phosphate, increased PTH
Secondary hyperparathyroidism (chronic kidney disease)
Increased Ca, decreased phosphate, increased PTH
Tertiary hyperparathyroidism
What does PTH do?
Phosphate Trashing Hormone
Increased PTH causes decreased phosphate
What are the causes of acute kidney injury?
Pre-renal - decreased perfusion: hypovolaemia, sepsis (hypovolaemia)
Renal - Drugs, glomerulonephritis (+ve active urine sediment = blood + protein in urine)
Post-renal - Obstruction –> urgent nephrostomy to relieve obstruction. Ix: USS
What results in asymmetrical kidneys?
Renal artery stenosis
What Ix would you do for renal artery stenosis?
Magnetic Resonance Angiography (MRA)
Deterioration of renal function with ACE inhibitors (bilateral RAS)
A 21 y/o medical student on morning of exam presents w/ SOB, palpitations, tingling in hands. ABG: pH 7.5, pO2 13, pCO2, 3.5, Bicarb 26. What is the most likely cause?
- PE
- Pneumothorax
- MI
- SVT
- Hyperventilation syndrome
Hyperventilation syndrome
Patient presents w/ sacroiliitis and arthritis affecting DP joints. He has asymmetrical oligoarthropathy. What is the most likely Dx?
Psoriatic arthritis - fingers become sausage like
What are the 5 types of psoriatic arthritis?
Symmetrical arthritis
Asymmetrical arthritis
DIP joint predominant
Arthritis mutilans (telescoping of finger)
Spondylitis (sacroiliitis, affects axial skeleton)
What are the symptoms of psoriatic arthritis?
Swollen fingers + toes, tender, painful or swollen joints
Red scaly skin patches i.e. plaques
Reduced range of motion of joints
Morning stiffness
Pearl like lesion w/ telangiectasia. What is the Dx?
Basal cell carcinoma
