Interactive cases 4 Flashcards
Causes of thrombocytopaenia
Fever, rigor, increased PR interval, reduced BP, chest pain, dark urine
- Reduced production (bone marrow disorders)
- Increased use (DIC)
- Pooling of spleen (this occurs in liver disease as the spleen enlarges due to portal hypertension, and then platelets can pol there!)
DDx for micro and normocytic anaemia
Microcytic: Fe deficiency anaemia, beta thalassaemia heterozygosity
Normocytic: Anaemia of chronic disease. Normal/high ferritin
Why might ferritin be high in anaemia of chronic disease
Because it’s an acute phase reactant
High ferritin and desaturation on exercise, SoB
PCP (pneumocystic pneumoniae)
Ddx macrocytic anaemia
Alcohol excess
Myelodysplasia
Hypothyroidism
Liver failure
Folate/b12 deficiency
Alcoholics May Have Liver Failure
Clues that macrocytic is a result of each of the following
Alcohol excess
Myelodysplasia
Hypothyroidism
Liver failure
Folate/b12 deficiency
EtOH: Hx, raised GGT
Myelodysplasia: pancytopaenia, bone marrow
Hypothyroidism: Hx (lethargy, constipation, weight gain), low T4, high TSH
Liver failure : Hx/exam
Folate/b12 deficiency: Hx, small bowel disease, gastrectomy
Presentation of polycythaemia
Headache,
pruritis after hot bath,
blurred vision (hyperviscosity)
tinnitus
Thrombosis (stroke, dvt)
gangrene
choreiform movements
Sickle cell anaemia: list possible crises
Acute painful
Stroke
Sequestration crises (RBC pooling)
Gall stones/chronic cholecystitis
List the 2 types of sequestration crises in SCA and the symptoms of each
– Lung (SOB, cough, fever)
– Spleen (exacerbation of anaemia)
Management of each of the following sickle cell crises:
Acute painful
Stroke (IMPORTANT)
Sequestration (lung?spleen?)
Gallstones/chronic cholecystitis
Acute painful:
- Analgesia
- o2
- IV fluids Abx
Stroke:
-Exchange blood transfusion
Sequestration:
Splenectomy
Gallstones/chronic cholecystits: cholecystectomy
Multiple myeloma features
CRABIC
Calcium (high). Leads to nephrogenic diabetes insipidus: polyuria, polydipsia. Constipation too.
Renal failure: Urea and creatinine
Anaemia: breathlessness, lethargy, FBC
Bone (pain, osteoporosis):
fracture, bone pain, DXA
Infection
Cord compression
What might you detect in the urine in multiple myeloma
Bence Jones proteins
Which bone cells make ALP
Osteoblasts
Hypercalcaemia, low PTH, backache, normal ALP
Multiple myeloma (it’s the exception because it suppresses osteoblasts, which usually produce ALP!)
If there’s high calcium, low PTH, backache and normal ALP what’s the diagnosis
It’s multiple myeloma
If there’s high calcium, low PTH, backache and high ALP what’s the diagnosis
In this case it’s likely to be malignancy (not MM)
Anaemia associated with high reticulocyte count
Haemolysis
Acute blood loss
Anaemia with low reticulocyte?
Parvovirus b19 infection
Aplastic crisis in patients with sickle cell anaemia
Blood transfsuion
What conditions are associated with parvovirus 19 infection in:
children
adults
those with sickle cell
children: slap cheek ( Fifth disease or erythema infectiosum)
adults: arthraligas
sickle cell: aplastic crisis (the virus causes a reduced production of RBCs in everyone. This is fine for people if their RBCs have a normal lifespan, but in people with SCD, and also hereditary spherocytosis, the RBCs have reduced life span so they can go into an aplastic crisis)
How is diabetes diagnosed
Outline OGTT
> 7 on fasting
> 11.1 on random.
Impaired glucose tolerance. 75g OGTT. 2hr glucose: 7.8-11
-gliclazide?
Sulphonyureas
-gliptin?
DPP4-inhibitor
-itide
GLP-1 agonist
-flozins
SGLT2 inhibitors
How do you measure nephropathy and what do you do if they have it
ACR…. check at the lab!
You can put them o`n ACEi
How to manage hypoglycaemia
Conscious: get them glucose to drink, and then a long acting carb for after
Confused- gel
Unconscious: IV glucagon or IV glucose 20%
What is sliding scale insulin
When patient is not eating or unwell (surgery, sepsis)
Variable rate IV insulin infusion
What is pretibial myxoedema, what is myoedema
pretibial myxoedema is the rash seen almost always in Grave’s (also rarely in hashimotos)
myxoedema means underactive thryoid
What type of thyroid cancer particularly metastases to the lungs
Follicular
What is the most appropriate treatment of prolactinoma
Cabergoline
Don’t operate with trans-sphenoidal surgery unless it’s really really refractory
What is the initial test if you think they have acromegaly, what is diagnositc
INITIAL TEST is IGF1
Then you go on to do a OGTT
Weight gain, depressed, central obesity, fatigue. Are they likely to have cushings
No…. this describes a lot of the population!
Don’t start investigating for cushing’s if the pre-test probability is low because you get a lot of false positives and the patient may be labelled as having cushings when they actually don’t
What are the discriminatory features of cushings
Purple stretch marks
Bruising
Myopathy
DM, HTN osteoporosis AT A YOUNG AGE
Causes of amenorrhoea
Pregnancy Hypothalamus Pituitary Thyroid (hyper/hypo) Ovaries (PCOS/ovarian failure)
What would the investigations for the following: Pregnancy Hypothalamus Pituitary Thyroid (hyper/hypo) Ovaries (PCOS/ovarian failure)
Pregnancy- urine bHCG Hypothalamus- ?Excessive thirst, low BMI Pituitary- excess prolactin/low FSH/LH Thyroid (hyper/hypo)- TFTs Ovaries (PCOS/ovarian failure) - excess androgens (or hirsutism), high FSH
How can hypothalamus cause amennorrhoea
Too much exercise and low BMI causes amenorrhoea
Causes of pituitary amenorrhoea
Prolactinoma or pituitary adenoma that is reducing LH/FSH secretion
Presentation of hypokalaemia
Polyuria (it causes nephrogenic diabetes insipidus, like hypercalcaemia does!)
Weakness
Arrhythmia
DDx for hypokalamaemia
Primary hyperaldosteronism (Conn’s–> look at aldosterone:renin ratio)
GI: vomiting
Diuretics
Causes of hypernatraemia when urine osmolality is high
High plasma osmolarity- 572
Due to dehydration or HHS (urine high osmolarity glycosuria)
Causes of hypernatraemia when the urine osmolality is low
Diabetes indipidus (DIlute urine osmolarity <300)
Low calcium, high phosphate, high PTH
Low calcium, low phosphate, high PTH
PTH is phosphate trashing hormone!
So if phosphate is low then it means PTH is effectively excreting it. The calcium is low due to vit D deficiency. So the second one is vit D deficiency.
In the first one, the phosphate is high. So why is the phosphate high, even though PTH is meant to excrete phosphate. It’s because the kidneys fail to excrete phosphate.
But calcium is low because there is low levels of ACTIVATED vit D (due to reduced hydroxylation in the poorly functioning kidney) leading to low calcium. PTH will go up due to a reduced -ve feedback response. BUT phsopahte is not excreted because of the kidney failure
Someone recently put on ACEi, and had a deterioration of renal function.
Finding of asymmetrical kidneys on ultrasound.
BILATERAL renal artery stenosis
Gold standard investigation for RAS
Magnetic resonance angiography
Should CO2 and bicarbonate be going in the same direction?
Yes.
If CO2 is going up, then you would expect bicarb to go up
If CO2 is going down you would expect bicarb to go down.
What if co2 is going up but bicarb is going down
If the co2 and bicarb are going in different directions, we know there is MIXED PICTURE. I.e. there must be an element of respiratory and metabolic disturbance
Investigations for thyroid cancer
- USS
- FNAC
- Uptake scan
Discuss at MDT
