Gen Med #4 Flashcards
Most common presenting feature for spinal cord compression?
Back pain.
What are the terms we should now use for sepsis, and what do they mean?
Sepsis and Septic shock
Sepsis: life-threatening organ dysfunction caused by a dysregulated host response to infection
Septic shock: a more severe form sepsis, technically defined as ‘in which circulatory, cellular, and metabolic abnormalities are associated with a greater risk of mortality than with sepsis alone’*
Metastatic bone pain management options?
Analgesia, Bisphosphonates or Radiotherapy
How can you tell shigella apart from giardia?
Giardia is non bloody diarrhoea, shigella is bloody
What causes of gastroenteritis are bloody?
Shigella
Campylobacter (not always)
Amoebiasis
Which antibiotic classes can/can’t be used in pregnancy?
Penicillins and cephalosporins are suitable for use during pregnancy, but sulfonamides (such as sulfasalazine) and quinolones (such as ciprofloxacin) should be avoided in pregnancy.
Common presentation for encephalitis? what would differentiate a viral and bacterial cause?
Sudden change in behaviour and a fever, is highly suggestive of encephalitis. could have seizures.
What are the bugs in Group A and Group B beta haemolytic strep called?
Group A
- Strep Pyogenes
Group B
- Strep alginate
What are the main infective causes of genital ulcers and how do you differentiate?
Painful is either chancroid or Herpes. Herpes is more common than chancroid.
Painless is either syphilis or LGV, syphilis is more common.
LGV and Chancroid can cause painful inguinal lymphadenopathy
India ink and Ziehl niesen used to identify what organisms?
India ink - cryptococcus
Ziehl niesen - mycoplasma
What is acute intermittent porphyria?
Autosomal dominant condition caused by a defect in porphobilinogen deaminase.
Presents with abdominal and neuropsychiatric symptoms in 20-40 year olds, more common in females.
Abdominal: abdominal pain, vomiting
Neurological: motor neuropathy
Psychiatric: e.g. depression
Hypertension and tachycardia common
What is the more common form of acute leukaemia in adults?
Acute myeloid leukaemia?
What are the symptoms of AML?
Features are largely related to bone marrow failure:
- Anaemia: pallor, lethargy, weakness
- Neutropenia: whilst white cell counts may be very high, functioning neutrophil levels may be low leading to frequent infections etc.
- Thrombocytopenia: bleeding
- Splenomegaly
- Bone pain
Poor prognostic features in AML?
> 60 years
> 20% blasts after first course of chemo
cytogenetics: deletions of chromosome 5 or 7
What is aplastic anaemia? Causes?
Chronic pancytoaenia, due to hypoplastic bone marrow.
Can either be congenital or acquired
Congenital (fanconi) is autosomal recessive
Acquired has an identifiable cause, viral infection, radiation or drug exposure.
Treatment for aplastic anaemia?
Immunosuppression
Androgens
Stem cell transplantation
Blood product support
How may bone marrow failure present?
Anaemia
Infections
Easy bruising
What is autoimmune haemolytic anaemia? What are the types?
Either warm or cold. Normally idiopathic but can be due to lymphoproliferative disorder.
What are the causes of warm haemolytic anaemia?
Autoimmune disease: e.g. systemic lupus erythematosus*
Neoplasia: e.g. lymphoma, CLL
Drugs: e.g. methyldopa
What are the causes of cold haemolytic anaemia?
Neoplasia: e.g. lymphoma
Infections: e.g. mycoplasma, EBV
What are the features of beta thalassaemia? Pathogenesis?
Features:
- Presents in first year of life with failure to thrive and hepatosplenomegaly
- Microcytic anaemia
- HbA2 & HbF raised
- HbA absent
Caused by absent beta chains
Typical blood film picture post splenectomy?
Target cells Howell-Jolly bodies Pappenheimer bodies Siderotic granules Acanthocytes
Iron deficiency anaemia blood film picture?
Target cells
‘pencil’ poikilocytes
If combined with B12/folate deficiency a ‘dimorphic’ film occurs with mixed microcytic and macrocytic cells
Myelofibrosis typical blood film picture?
‘tear-drop’ poikilocytes
Intravascular haemolysis blood film?
Schistocytes
Megaloblastic anaemia blood film?
hypersegmented neutrophils
What are the main blood product (not blood) transfusion reactions?
Acute haemolytic transfusion reaction
- ABO mismatch
- Fever, abdo pain, chest pain, agitation, hypotension
Non-haemolytic febrile reaction
- HLA antibodies
Anaphylaxis
- Range of reactions
- Simple urticaria okay
- Any more serious reaction A-E resus
Infective
- vCJD
What is burkitts lymphoma?
High-grade B-cell neoplasm
Two forms
- Endemic (African) form: typically involves maxilla or mandible. EBV highly related.
- Sporadic form: abdominal (e.g. ileo-caecal) tumours are the most common form. More common in patients with HIV
Main difference in chronic and acute leukaemia?
In chronic they are partially matured, in acute they are not matured at all.
Philadelphia chromosome is associated with what?
CML
Difference in signs in CLL and CML?
CML associated with splenomegaly (and hepatomegaly)
CLL associated with Lymphadenopathy
features of CLL?
- Often none
- Constitutional: anorexia, weight loss
bleeding, infections - Lymphadenopathy more marked than CML
CLL complications?
- Anaemia
- Hypogammaglobulinaemia leading to recurrent infections
- Warm autoimmune haemolytic anaemia in 10-15% of patients
- Transformation to high-grade lymphoma (Richter’s transformation)
Normal age at presentation in CML?
60-70
First line treatment for CML?
Imatinib
What is the management for an unprovoked DVT or PE?
All patients:
- Physical examination
- CXR
- Blood tests
> 40 years old
- CT Abdo pelvis
- Mammography
What is factor V leiden?
Common inherited thrombophilia.
What is fanconi anaemia, what are the features?
Autosomal recessive
Features:
Aplastic anaemia
Increased risk of acute myeloid leukaemia
Neurological
Skeletal abnormalities: short stature
Cafe au lait spots
Features of G6PD deficiency?
X linked recessive
Neonatal jaundice is often seen
Intravascular haemolysis
Gallstones are common
Splenomegaly may be present
Heinz bodies on blood films
Key differences in G6PD deficiency and Hereditary spherocytosis?
G6PD is X linked so males
Spherocytosis is Autosomal dominant
Hereditary spherocytosis is northern european, G6PD is African and Mediterranean
On blood film there is spherocytes in HS, and Heinz bodies in G6PD
Most common Thrombophilia?
Factor V leiden
How would Haemophilia present? (features and bloods)
Features
- Haemoarthroses, haematomas
- Prolonged bleeding after surgery or trauma
Bloods
- Prolonged APTT
- Bleeding time, thrombin time, prothrombin time normal
How would hereditary spherocytosis present?
Failure to thrive Jaundice, gallstones Splenomegaly Aplastic crisis precipitated by parvovirus infection Degree of haemolysis variable MCHC elevated
Reed sternberg cells characteristic of?
Hodgkins lymphoma
Features of hodgkins lymphoma?
Lymphadenopathy (75%) - painless, non-tender, asymmetrical
Systemic (25%): weight loss, pruritus, night sweats, fever (Pel-Ebstein)
Alcohol pain in HL
Normocytic anaemia, eosinophilia
LDH raised
How do you stage in Hodkins lymphoma?
CT abdo pelvis
Different forms of hodgkins lymphoma?
- Nodular sclerosing Hodgkin lymphoma (NSHL)
- Mixed-cellularity Hodgkin lymphoma (MCHL)
- Lymphocyte-depleted Hodgkin lymphoma (LDHL)
- Lymphocyte-rich classical Hodgkin lymphoma (LRHL)
In ITP what are antibodies directed against?
Antibodies are directed against the glycoprotein IIb/IIIa or Ib-V-IX complex.
Feautures of Iron deficiency anaemia?
koilonychia
atrophic glossitis
post-cricoid webs
angular stomatitis
Features of lead poisoning?
Consider when Neurological and abdo pain
abdominal pain peripheral neuropathy (mainly motor) fatigue constipation blue lines on gum margin (only 20% of adult patients, very rare in children)
What is MGUS? how do you tell it apart from myeloma?
Monoclonal gammopathy, resembles myeloma, but:
normal immune function normal beta-2 microglobulin levels lower level of paraproteinaemia than myeloma (e.g. < 30g/l IgG, or < 20g/l IgA) stable level of paraproteinaemia no clinical features of myeloma
What is myelodyspasia?
acquired neoplastic disorder of hematopoietic stem cells
pre-leukaemia, may progress to AML
What is Myelofibrosis?
a myeloproliferative disorder (bone marrow proliferation)
thought to be caused by hyperplasia of abnormal megakaryocytes
the resultant release of platelet derived growth factor is thought to stimulate fibroblasts
haematopoiesis develops in the liver and spleen
Presents with:
- elderly person with symptoms of anaemia e.g. fatigue (the most common presenting symptom)
- massive splenomegaly
- hypermetabolic symptoms: weight loss, night sweats etc
CRAB for myeloma?
Calcium high
Renal failure
Anaemia
Bone lesions (rain drop skull), bone pain.
Major and minor criteria for multiple myeloma?
Major criteria
Plasmacytoma (as demonstrated on evaluation of biopsy specimen)
30% plasma cells in a bone marrow sample
Elevated levels of M protein in the blood or urine
Minor criteria
10% to 30% plasma cells in a bone marrow sample.
Minor elevations in the level of M protein in the blood or urine.
Osteolytic lesions (as demonstrated on imaging studies).
Low levels of antibodies (not produced by the cancer cells) in the blood.
Neutropenic sepsis antibiotic choice?
Tazocin
Features of Non-hodkins lymphoma?
median age = 55-60 years
painless widespread lymphadenopathy, hepatosplenomegaly
raised LDH, paraproteinaemia, AIHA
Causes of a normocytic anaemia?
Anaemia of chronic disease
Chronic kidney disease
Aplastic anaemia
Haemolytic anaemia
Threshold for platelet transfusion?
In significant bleeding <30, in severe bleeding <100
Causes of polycythaemia?
Relative causes
dehydration
stress: Gaisbock syndrome
Primary
polycythaemia rubra vera
Secondary (reactive)
- COPD
- Altitude
- Obstructive sleep apnoea
- Excessive erythropoietin
Features of polycythaemia vera?
Hyperviscosity Pruritus, typically after a hot bath Splenomegaly Haemorrhage (secondary to abnormal platelet function) Plethoric appearance Hypertension in a third of patients
Management of polycythaemia?
Aspirin
Venesection - first line treatment
Hydroxyurea -slight increased risk of secondary leukaemia
Phosphorus-32 therapy
Sickle cell inheritance?
Autosomal recessive
Types of sickle cell crises?
thrombotic, 'painful crises' sequestration acute chest syndrome aplastic haemolytic
Management of a sickle cell crisis?
Analgesia e.g. opiates
Rehydrate
Oxygen
Consider antibiotics if evidence of infection
Blood transfusion
Exchange transfusion: e.g. if neurological complications
Acquired forms of thrombophilia?
Antiphospholipid syndrome
Drugs
- the combined oral contraceptive pill
How is Tranexamic acid administered?
Tranexamic acid is given as an IV bolus followed by an infusion in cases of major haemorrhage
What are the B symptoms of hodgkins lymphoma that imply a poor prognosis?
Weight loss > 10% in last 6 months
Fever > 38ºC
Night sweats
In non-urgent patients how long would you transfuse a red cell infusion over? If they had HF? If it was a trauma /major haemorrhage?
1 and 1/2 to 2 hours
HF 3 hours
STAT in trauma
Main special blood test for multiple myeloma
Serum elecrophoresis
- Monoclonal band
Cause of an aplastic crisis in sickle cell?
Usually due to parovirus infection
Transfusion threshold for red cells?
70 without ACS, 80 with ACS
Blood transfusion reaction mnemonic?
Got a bad unit
G raft vs. Host disease
O verload
T hrombocytopaenia
A lloimmunization
B lood pressure unstable
A cute haemolytic reaction
D elayed haemolytic reaction
U rticaria
N eutrophilia
I nfection
T ransfusion associated lung injury
Management options for Von willibrands?
Tranexamic acid and desmopressin (stimulates release)
If a patient is deficient in B12 and Folic acid which do you need to treat first?
Treat the B12 first to avoid subacute combined degeneration of the cord
DVT and PE management?
LMWH initially, warfarin within 24 hours, keep on the LMWH until the INR is within the 2-3 range.
The philadelphia chromosome abnormality (CML) is denoted how?
t(9:22)
Burkitt’s lymphoma associated with what chromosomal abnormality?
c-myc t(8:14)
Before a CTPA in a suspected PE what do you need to do?
CXR
What is the mechanism for cocaine induced ACS?
Coronary artery spasm
How do you differentiate a epididymal cyst and a hydrocele?
In a cyst it lies above or behind the testes, in a hydrocele it envelops the whole thing
Underlying cardiac disease fluid recommendations?
20-25 ml/kg
Management of pituitary tumours?
Pituitary
- Dopamine agonist (bromocriptine)
Within sella turcica
- Trans-sphenoidal
- Can do radiotherapy or drugs before surgery with GH tumours.
ACTH
- Trans-sphenoidal
What is Amoebiasis?
Entamoeba histolytica (amoeba protozoa), chronic infections often liver abscesses
Presents with:
- Profuse, bloody diarrhoea
- Stool microscopy may show trophozoites
- Treatment is with metronidazole
Universal donor in FFP and Red cells?
FFP is just plasma (so no A or B or AB antigens). So you only need to worry about antibodies, The one you are giving can’t have the antibody to the patients cell type
How does an acute haemolytic transfusion reaction present?
Lack of angioedema/urticaria
Symptoms begin within minutes of starting
- Fever
- Abdominal and chest pain
- Agitation
- Hypotension
How do you manage acute haemolytic transfusion reaction?
Transfusion termination, Generous fluid resus, inform the lab
How can you test for Polycythaemia Vera?
JAK2 mutation screen
Large multinucleate cells with prominent eosinophilic nucleoli is a description for what type of cell?
Reed-sternberg - Hodgkin lymphoma
Elderly person with marked lymphocytosis likely diagnosis?
CLL
