General medicine: CL Lai Session 6

Question 1

Causes of hypercalcemia?

Answer 1

Primary and tertiary hyperparathyroidism, malignancy (paraneoplastic and bony metastasis), Sarcoidosis, Pagets disease

Question 2

HyperCa Mx

Answer 2

IV fluids
Bisphosphonates

Question 3

Pancreatitis causes

Answer 3

• Biliary tract disease (gallstones, cholangitis)
• Alcohol
• Idiopathic: hypertriglyceridemia, hypercalcemia, pregnancy, infection (viral: mumps, CMV, hepatitis virus). parasites: clonorchis sinensis)
• Iatrogenic: pos ERCP
• Drugs: steroids, azathioprine, OC pills

Question 4

Ix for pancreatitis

Answer 4

Amylase
USG: for dilated bile duct if there is biiary obstruction (lower CBD could be obscured by bowel gas)
ERCP
Not CT in the first 24 hours (normal), only CT later for complication screening

Question 5

Falsely normal amylase level

Answer 5

• Serum amylase normally peaks at day 1 and normalize after 2-3 days so late presentation gives falsely normal amylase
  1. Then could check urine amylase (raised for 48 hours to 1 week)
  2. Paired with amylase to creatinine ratio (amylase clearance rises in pancreatitis, not in other causes)
  3. Lipase (peak @ day 2, raised for 2-3 weeks)

Question 6

Causes of raised amylase?

Answer 6

• Pancreatitis (>3-5 times normal, probably 5)
• Abdominal emergencies (could be along whole bowel as whole bowel secretes amylase): intestinal obstruction, ischemic bowel
• Gynaecological emergencies (never miss ectopic pregnancy) (genitourinary tract also secretes amylase)
• Paraproteinemia (amylase gets stuck to paraprotein and can’t be excreted)
• CA lung paraneoplastic syndrome
• DKA (ileus, pain, abdominal distention (amylase raised))
• Salivary gland problems (e.g. mumps, which also cause pancreatitis)
• Renal failure: amylase not excreted

Question 7

How to confirm genuine pancreatitis after raised amylase?

Answer 7

Serum lipase: peaks at 2-3 days
Down at 2 weeks (not good as may have a 2nd attack and can’t tell)

Can further check urine amylase paired with amylase to creatinine ratio (amylase clearance rises in pancreatitis)

Question 8

Why is CT done in pancreatitis?

Answer 8

Pancreatic pseudocyst from the lesser sac of stomach

Question 9

What prognostic tests done for pancreatitis

Answer 9

• sO2, pO2
• Ca2+
• LDH

Question 10

Causes of pancytopenia

Answer 10

• Bone marrow failure (aplastic anemia (parvovirus B19))
• MDS
• bone marrow infiltration (stage 4 lymphoma, bone metastases)
• Hypersplenism
• Autoimmune diseases (causing secondary aplastic anemia)
• Megaloblastic anemia (MCV>110): hypersegmented neutrophils (more than 10%)

Question 11

Ix to do in pancytopenia

Answer 11

• CBC: anemia, MCV
• PBS: leukoerythroblastic picture (nucleated RBC, tear drop RBC, immature myeloid cell)
• Bone marrow aspirate and trephine biopsy (need to decalcify the bone which takes 2-3 days before slicing)

Question 12

What are the causes of motor neuron disease?

Answer 12

• UMN disorders: primary lateral sclerosis, pseudobulbar palsy
• LMN disorders: progressive musclular artrophy, spinal muscular atrophy, progressive bulbar palsy
• UMN and LMN disorders: amyotrophic (anterior horn cells) lateral sclerosis (UMN)

Question 13

Leukoerythroblastic picture?

Answer 13

• Nucleated RBCs
• Tear drop RBCs
• Immature myeloid cells

Question 14

Indications for liver biopsy?

Answer 14

• Autoimmune hepatitis (anti smooth muscle, anti LKM1)
• Wilsons disease
• Non alcoholic steototic hepatitis (NASH)
• Drug induced hepatitis
• Post BMT: infection by CMV, HSV. GVHD: skin biopsy (rash) and rectal biopsy (diarrhea), venoocclusive disorder (sinusoidal osbtruction syndrome): thrombosis of small veins, presented with hepatomegaly and ascites. reactivation of HBV.
• Primary biliary cirrhosis (If AMA M2+/clinically matched than no need biopsy)
• Research purpose

Question 15

Complications of liver biopsy?

Answer 15

• Pain
• Bleeding
• Perforation of biliary tract
• Pneumothorax