interactive cases 5

Question 1

24 yr old man
Breathlessness
Facial swelling
After having a Chinese take-away

initial management?

Answer 1

o IM adrenaline in anaphylaxis – first
o IV hydrocortisone e
o Fluids

Question 2

when give IV adrenaline

Answer 2

cardiac arrest

Question 3

why not IV adrenaline in anaphylaxis

Answer 3

dangerous in anaphylaxis because precipitate arrhythmia in someone who is conscious = tachyarrhythmia and cardiac arrest

Question 4

45 yr old man
Cough
Breathlessness
Recent travel

O/E: coarse crepitations & bronchial breathing

Hyponatraemia
Deranged LFTs

Answer 4

clarithromycin - macrolide
o Amoxicillin cover strep pneumonia gram +ve
o Macrolide AB - clarithromycin – to cover atypicals- Na and LFT derangement might increase likelihood of atypical pneumonia eg legionella, mycoplasma, chlamidyia in community acquired pneumonia – implicated in 40% CA pneumona
5-7days of AB, sputum culture might not be that beneficial

Question 5

fine crepitations

Answer 5

fibrosis

HF = pul oedema

Question 6

coarse crepitations

Answer 6

pneumonia and consolidation

Question 7

when do you suspect atypical pneumonia

Answer 7

o Low na – can be in any pneumonia
o Travel
o Deranged LFT

Question 8

organisms in atypical pneumonia

Answer 8

Mycoplasma pneumoniae
Chlamydia pneumoniae
Legionella pneumophila

Implicated in up to 40% of CAP

Question 9

50 yr old man
Dyspepsia
Wt loss
Hb: 70
MCV: 70
what test do you get?

Answer 9

OGD (gastroscopy)
o Dyspepsia – pain in digestion, upper abdo
o Microcytic anaemia
o Micrrocytic do top and tail
o Upper abdo discomfort – prompt OGD look at stomach fro pep ulcer, erosion, malignancy

Question 10

what do you order when you see microcytic anaemia

Answer 10

haematinics - ferritin, b12 folate
o Coeliac screen – transglutaminase Ab (in pathogeneissis – autoAg tissue transglutaminase in coeliac) when suspecting coeliac - Diagnosis confirmed with duodenal biopsy – look for villus atrophy
o Top and tail
o Order colonoscopy/OGD depending on whether upper or lower GI symptoms

Question 11

microcytic anaemia red flags

Answer 11

weight loss
change bowel habit
dyspepsia

Question 12

70 year old man
Bloody diarrhoea
Stool micro & culture: -ve
Stool C. diff toxin: -ve

most likely dx

Answer 12

ischemic colitis
o Infection ruled out
o Malig – change of bowel habit and blood in stool so also in ddx
o Bloody diarrhoea in old person- ischemic colitis (know not infection)

Question 13

investigations for bloody diarrhoea

Answer 13

stool for culture and C diff toxin screen

Question 14

causes of bloody diarrhoea

Answer 14

Infection: infective colitis
Inflammation: ulcerative/Crohn’s colitis (younger pts)
Ischaemia: ischaemic colitis (older pts)

Malignancy
Diverticulitis

Question 15

colonoscopy findings of bloody diarrhoea

Answer 15

see characteristic feature of ischemic colitis – loss of epi integrity – infection, inflammation or ischemia
o Ischemic get damage and death of cells
o Bloody diarrhoa because of loss if epithelial integrity

Question 16

40 yr old man
Palpitations
Started 4 hours ago
ECG: AF

how treat

Answer 16

DC cardioversion

o treatment of AF if <48hr DC cardioversion in young person – want to resolve problem so not just rate control
o in >48hr anticoag reduce risk of thromboembolism for weeks until eligible for DC cardioversion and control the rate until you can cardiovert

Question 17

what is amiodarone used for

Answer 17

VT

Question 18

rate control drugs

Answer 18

digoxin and metoprolol

Question 19

what does adenosine treat

Answer 19

SVT

Question 20

when choose metoprolol over digoxin

Answer 20

if AF is precipitated by pneumonia - digoxin augments the PNS so isnt v effective when SNS high - so use metoprolol

Question 21

Direction of flow in the veins below the umbilicus is towards the legs.

what is the sign

Answer 21

caput medusae

Question 22

complications of portal hypertension

Answer 22

splenomegaly 
Encephalopathy
Ascites
Spontaneous bacterial peritonitis
Variceal bleed

Question 23

causes of splenomegaly

Answer 23

haematological malignancy
portal HTN
infection
inflammation

Question 24

20 year old boy
Recent diarrhoea
Malaise
Hb: 70
Cr: 300

schistocyte (red cell fragments)
dx

Answer 24

o Recent diarrhoea and then anaemia, fragments and high creatine
o Red cell haemolysis- haemolytic uraemic syndrome
o Anaemia because of red cell fragmentation – haemolysis

Question 25

cause of microangiopathic haemolytic anaemia

Answer 25

 Small vessels – if small clots in small vessels as red cells try and pass through may get haemolysis

Question 26

3 types of haemolytic anaemia

Answer 26

DIC (Disseminated Intravascular Coagulation) HUS (Haemolytic Uraemic Syndrome) TTP (Thrombotic Thrombocytopenic Purpura)

Question 27

summarise DIC

Answer 27

o Platelet and fib low – making clots so low o PT/APTT up because using the clotting factors o D dimer – fibrin degradation products tell you there have been clots and now theyre being degraded – break clots o Get very sick with sepsis

Question 28

summarise HUS

Answer 28

hereditary or acquired haemolysis -> low Hb and high BR uraemia - haemolysis in renal vessels low platelets

Question 29

summarise TTP

Answer 29

HUS + fever + neurological manifestations

Question 30

causes of hereditary haemolytic anaemia

Answer 30

Red cell membrane (hereditary spherocytosis) Enzyme deficiency (G6PD deficiency) Haemoglobinopathy (Sickle cell disease, Thalassaemias)

Question 31

causes of acquired haemolytic anaemia

Answer 31

Autoimmune Drugs Infection MAHA

Question 32

Valvulae conniventes

Answer 32

– circular folds valvulae conniventes go all the way across = SBO

Question 33

haustra

Answer 33

large bowel – don’t go all the way across – sign of LBO

Question 34

onycholysis

Answer 34

``` separation of nail from bed causes: trauma Thyrotoxicosis – if losing weight and sweating likely this Fungal infection Psoriasis ```

Question 35

``` 20 year old woman Abdominal pain Vomiting Type 1 diabetes CBG: 20 Venous pH: 7.20 ``` what is the most appropriate next step

Answer 35

capillary ketone o Acidotic o Capillary ketone – pt likely has DKA – med cause of abdo pain o Can use urinary ketone but capillary is better and more specific

Question 36

treatment of hypoglycaemia

Answer 36

give sugary glucose if conscious and can comply, if cant comply ie confused- gel, if not conscious/drowsy and cant swallow – IV glucose or IM glucagon

Question 37

diabetes complications

Answer 37

Microvascular Retinopathy Nephropathy Neuropathy (foot ulcers) Macrovascular MI/Stroke/PVD Metabolic DKA/HHS (hyperosmolar hyperglycaemic state)/Hypoglycaemia

Question 38

treatment of t2dm v high glucose and v dehydrated

Answer 38

.9% NaCL - and bit of insulin

Question 39

DKA treatment

Answer 39

fluid, insulin, K+

Question 40

HONKC

Answer 40

high osmolarity, high Na and glucose – could be 1st presentation of dm

Question 41

26 year old man Chest pain Smokes 5/day Auscultation: ‘scratching sound’ widespread ST elevatio

Answer 41

o Pericardial rub is the scratching side – pericarditis, pain better on leaning forward o Not STEMI – because if STEMI in every lead = dead

Question 42

``` 60 yr old woman Collapse BP: 120/70 mmHg No postural drop HS: S1+S2+ ESM (ejection systolic murmur) ``` deep S in V1 and tall R in V6

Answer 42

LV hypertrophy narrow aortic valve is cause HTN is another cause

Question 43

``` 40 year old man Loin pain CRP: normal Urinalysis: blood ++ What investigation would you request? ```

Answer 43

CT KUB o Pyelonephritis and stones o In acute setting – CT KUB very sensitive o Abdo US can be used – but not acute, use if think hyperparathyroidism eg hypercalcaemia see if renal calculi o Non contrast – calculus in dilated renal pelvus and PUJ = obstruction

Question 44

non contrast KUB

Answer 44

shows Pelvi-ureteric junction obstruction | Calculus within the dilated renal pelvis 

Question 45

``` 50 year old man Hypercalcaemia Low PTH Backache Normal ALP ``` dx

Answer 45

multiple myeloma o High ca – need to know if PTH up or down o PH down = malignancy o If PTH high – it is driving the Ca o Here know it is malignancy – either met or myeloma o No hyperca in osteoporosis o Secondary pth – high PTH because low ca or vit D o Normal alkphos • Bone osteoblast make alkphos • Alkphos high in obstructive liver disease and malignancy • ALhphos normal so likely option is multiple myeloma • Malignancy makes PTH related peptide • If met to bone sometimes excess ca from that

Question 46

summarise ALP

Answer 46

from liver and bone high in obstructive liver disease & bone disease (malignancy, fracture, Paget’s disease) Bone: osteoblasts make ALP Plasma cell suppress osteoblasts therefore ALP is normal in myeloma

Question 47

symptoms of multiple myeloma

Answer 47

Calcium Renal impairment Anaemia Bone

Question 48

23 yr old woman Breast lump 1cm Smooth mobile likely dx

Answer 48

fibroadenoma

Question 49

galactocele

Answer 49

retention cyst by occlusion of lactiferous duct – post preg

Question 50

fat necrosis in breast - cause

Answer 50

trauma

Question 51

lesion on CXR with air fluid level, necrosis

Answer 51

cavitating lesion

Question 52

causes of cavitating lesion

Answer 52

Infection: TB, Staph, Klebsiella (e.g. alcoholics) Inflammation (RA) Infarction (PE) Malignancy

Question 53

35 yr old woman Ankle oedema Recent Echocardiogram: NAD U&Es: normal ALT, AST & ALP: normal Albumin: 15 What test would you order next?

Answer 53

o Low albumin – lose protein in urine – hypoalbuminaemia – become oedematous o Want to urinalysis and 24hr collection oedema due to oncotic pressure

Question 54

nephrotic syndrome

Answer 54

increased permeability of GBM to protein Proteinura> 3g/day Hypoalbuminaemia Oedema

Question 55

30 year old man Recurrent GI & nose bleeds face exam = telangiectasia dx

Answer 55

Hereditary telangiecstasia

Question 56

acromegaly sign in mouth

Answer 56

glossitis

Question 57

systemic sclerosis sign on mouth

Answer 57

tight skin and small mouth - microstomia

Question 58

summarise hereditary haemorrhagic telangiectasia

Answer 58

``` Autosomal dominant Abnormal blood vessels in: Skin Mucous membranes lungs Liver brain ```

Question 59

``` Na+: 120 K+: 5 Short Synacthen test 0 min cortisol: 100 30 min cortisol: 200 ``` dx

Answer 59

o Low Na and high K o Aldosterone Na in K out – so low aldosterone o Cortisol hasn’t gone up o So adrenal insufficiency – primary because also lost aldosterone. If secondary low cortisol – wouldn’t have fdamage to glomerulosa that makes aldosterone

Question 60

high prolactim low testosterone low LH and FSH dx

Answer 60

o High prolactin – inhibit normal gonadotrophin axin o So prolactinoma o Cabergoline treatment /bromcriptine less

Question 61

high prolactin high iGF2 OGTT - failure suppression of GH

Answer 61

o Acromegaly o High IGF1, excess GH secretion by pit tumour – high GH cause release of IGF1 from liver o Some tumours co-secrete PRL o Normal people suppress Gh when give glucose o Tumour won’t respond to oral glucose o Initial treatment – surgery

Question 62

low oestradiol | FH and LSH are high

Answer 62

reduced feedback to LH and FSH | Premature ovarian insufficiency

Question 63

• Low T4 high TSH and PRL

Answer 63

* Myxoedema -hypothyroidism autoimmune damage to thyroid – low -ve feedback * TRH high from low -ve feedback – high TRH stim prolactin * So this is primary hypothyroidism

Question 64

thyroiditis presentation

Answer 64

o In thyroiditis – hyperthyroid initially present like Graves (thryrotoxic) , later hypo

Question 65

TFT in multinodular goitre

Answer 65

normal

Question 66

``` 60 yr old man Confused Cough No postural hypotension Na+: 120 K+: 4.0 TFTs: normal SST: normal Urine Na+: 40 Urine osmolality: 400 ``` what test do you want next

Answer 66

CXR o Hyponat because of excess water – because more ADH, may be appropriate or inappropriate o If in response to physiological stim = adh – appropriate o If lung cancer secreting ADH = inappropriate o Want to know fluid state – are they hypovol because that would stim ADH = appropriate eg d/v or diuretic – then urine Na will be low – so kidneys hang onto salt and water o Euvolaemic – not hypotensive – have endocrine causes: hypothyroidism, adrenal insufficiency, SIADH – need to do TFT, short synacthen test, plasma and urine osmolarity o Hyeprvol – HF and liver failure, nephrotic syndrome - fluid overload and low urine Na o No post hypotension – not hypovolaemic o Urine Na is high – so not hypovolaemic o Euvolaemic o Lwo na = confusion o 3 causes of euvolaemic – hypothyroid, adenal insuf, SIADH – TFT normal, SSt normal so adrenal normal, so left with SIADH – so want to exclude lung cancer and path in brain so want to do CXR and brain MRI o Pt got a cough sso go for CXR because localising syumptoms and also easier to get than brain MRI o Low Na – 9am cortisol (decline during the day) and TFT

Question 67

why low urine Na in hypervolaemic hypernatraemia

Answer 67

secondary hyperaldosteronism Because of HF in hypervol – reduced renal perfusion – trick kidneys into thinking not a lot of vol = stim RAAS = retain Na and water – reduced effective circulating vol • in HF – reduced CO – reduced blood pressure detected by baroreceptors – signal to hypothal to make more ADH = excess ADH because of low pressure from low CO – more adh = more water retention = hyponatraemia

Question 68

causes of hyponatraemia

Answer 68

almost all due to high ADH rare: Excess water intake Sodium-free irrigation solutions (e.g. used in TURP)

Question 69

causes of SIADH

Answer 69

cns path lung path Drugs (SSRI, TCA, opiates, PPIs, carbamazepine) Tumours

Question 70

indications that pt hypervolaemic

Answer 70

peripheral oedeman and signs of HF – pulse, BP lying standing look at tissue turgor and mucous membranes

Question 71

why is euvolamic high Na in urine

Answer 71

• SIADH = excess water retention = expansion in heart, natrietic peptides released = Na loss in urine

Question 72

plasma osmolarity in hyponatraemia

Answer 72

low - because low na