interactive cases 5 Flashcards
24 yr old man
Breathlessness
Facial swelling
After having a Chinese take-away
initial management?
o IM adrenaline in anaphylaxis – first
o IV hydrocortisone e
o Fluids
when give IV adrenaline
cardiac arrest
why not IV adrenaline in anaphylaxis
dangerous in anaphylaxis because precipitate arrhythmia in someone who is conscious = tachyarrhythmia and cardiac arrest
45 yr old man
Cough
Breathlessness
Recent travel
O/E: coarse crepitations & bronchial breathing
Hyponatraemia
Deranged LFTs
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
fine crepitations
fibrosis
HF = pul oedema
coarse crepitations
pneumonia and consolidation
when do you suspect atypical pneumonia
o Low na – can be in any pneumonia
o Travel
o Deranged LFT
organisms in atypical pneumonia
Mycoplasma pneumoniae
Chlamydia pneumoniae
Legionella pneumophila
Implicated in up to 40% of CAP
50 yr old man Dyspepsia Wt loss Hb: 70 MCV: 70 what test do you get?
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
what do you order when you see microcytic anaemia
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
microcytic anaemia red flags
weight loss
change bowel habit
dyspepsia
70 year old man
Bloody diarrhoea
Stool micro & culture: -ve
Stool C. diff toxin: -ve
most likely dx
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)
investigations for bloody diarrhoea
stool for culture and C diff toxin screen
causes of bloody diarrhoea
Infection: infective colitis
Inflammation: ulcerative/Crohn’s colitis (younger pts)
Ischaemia: ischaemic colitis (older pts)
Malignancy
Diverticulitis
colonoscopy findings of bloody diarrhoea
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
40 yr old man
Palpitations
Started 4 hours ago
ECG: AF
how treat
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
what is amiodarone used for
VT
rate control drugs
digoxin and metoprolol
what does adenosine treat
SVT
when choose metoprolol over digoxin
if AF is precipitated by pneumonia - digoxin augments the PNS so isnt v effective when SNS high - so use metoprolol
Direction of flow in the veins below the umbilicus is towards the legs.
what is the sign
caput medusae
complications of portal hypertension
splenomegaly Encephalopathy Ascites Spontaneous bacterial peritonitis Variceal bleed
causes of splenomegaly
haematological malignancy
portal HTN
infection
inflammation
20 year old boy Recent diarrhoea Malaise Hb: 70 Cr: 300
schistocyte (red cell fragments)
dx
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
cause of microangiopathic haemolytic anaemia
Small vessels – if small clots in small vessels as red cells try and pass through may get haemolysis
3 types of haemolytic anaemia
DIC (Disseminated Intravascular Coagulation)
HUS (Haemolytic Uraemic Syndrome)
TTP (Thrombotic Thrombocytopenic Purpura)
summarise DIC
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
summarise HUS
hereditary or acquired
haemolysis -> low Hb and high BR
uraemia - haemolysis in renal vessels
low platelets
summarise TTP
HUS + fever + neurological manifestations
causes of hereditary haemolytic anaemia
Red cell membrane (hereditary spherocytosis)
Enzyme deficiency (G6PD deficiency)
Haemoglobinopathy (Sickle cell disease, Thalassaemias)
causes of acquired haemolytic anaemia
Autoimmune
Drugs
Infection
MAHA
Valvulae conniventes
– circular folds valvulae conniventes go all the way across = SBO
haustra
large bowel – don’t go all the way across – sign of LBO
onycholysis
separation of nail from bed causes: trauma Thyrotoxicosis – if losing weight and sweating likely this Fungal infection Psoriasis
20 year old woman Abdominal pain Vomiting Type 1 diabetes CBG: 20 Venous pH: 7.20
what is the most appropriate next step
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
treatment of hypoglycaemia
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
diabetes complications
Microvascular
Retinopathy
Nephropathy
Neuropathy (foot ulcers)
Macrovascular
MI/Stroke/PVD
Metabolic
DKA/HHS (hyperosmolar hyperglycaemic state)/Hypoglycaemia
treatment of t2dm v high glucose and v dehydrated
.9% NaCL - and bit of insulin
DKA treatment
fluid, insulin, K+
HONKC
high osmolarity, high Na and glucose – could be 1st presentation of dm
26 year old man
Chest pain
Smokes 5/day
Auscultation: ‘scratching sound’
widespread ST elevatio
o Pericardial rub is the scratching side – pericarditis, pain better on leaning forward
o Not STEMI – because if STEMI in every lead = dead
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
LV hypertrophy
narrow aortic valve is cause
HTN is another cause
40 year old man Loin pain CRP: normal Urinalysis: blood ++ What investigation would you request?
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
non contrast KUB
shows Pelvi-ureteric junctionobstruction
Calculus within the dilated renal pelvis
50 year old man Hypercalcaemia Low PTH Backache Normal ALP
dx
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
summarise ALP
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
symptoms of multiple myeloma
Calcium
Renal impairment
Anaemia
Bone
23 yr old woman
Breast lump
1cm
Smooth mobile
likely dx
fibroadenoma
galactocele
retention cyst by occlusion of lactiferous duct – post preg
fat necrosis in breast - cause
trauma
lesion on CXR with air fluid level, necrosis
cavitating lesion
causes of cavitating lesion
Infection: TB, Staph, Klebsiella (e.g. alcoholics)
Inflammation (RA)
Infarction (PE)
Malignancy
35 yr old woman
Ankle oedema
Recent Echocardiogram: NAD
U&Es: normal
ALT, AST & ALP: normal
Albumin: 15
What test would you order next?
o Low albumin – lose protein in urine – hypoalbuminaemia – become oedematous
o Want to urinalysis and 24hr collection
oedema due to oncotic pressure
nephrotic syndrome
increased permeability of GBM to protein
Proteinura> 3g/day
Hypoalbuminaemia
Oedema
30 year old man
Recurrent GI & nose bleeds
face exam = telangiectasia
dx
Hereditary telangiecstasia
acromegaly sign in mouth
glossitis
systemic sclerosis sign on mouth
tight skin and small mouth - microstomia
summarise hereditary haemorrhagic telangiectasia
Autosomal dominant Abnormal blood vessels in: Skin Mucous membranes lungs Liver brain
Na+: 120 K+: 5 Short Synacthen test 0 min cortisol: 100 30 min cortisol: 200
dx
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
high prolactim
low testosterone
low LH and FSH
dx
o High prolactin – inhibit normal gonadotrophin axin
o So prolactinoma
o Cabergoline treatment /bromcriptine less
high prolactin
high iGF2
OGTT - failure suppression of GH
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
low oestradiol
FH and LSH are high
reduced feedback to LH and FSH
Premature ovarian insufficiency
• Low T4 high TSH and PRL
- Myxoedema -hypothyroidism autoimmune damage to thyroid – low -ve feedback
- TRH high from low -ve feedback – high TRH stim prolactin
- So this is primary hypothyroidism
thyroiditis presentation
o In thyroiditis – hyperthyroid initially present like Graves (thryrotoxic) , later hypo
TFT in multinodular goitre
normal
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
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
why low urine Na in hypervolaemic hypernatraemia
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
causes of hyponatraemia
almost all due to high ADH
rare:
Excess water intake
Sodium-free irrigation solutions (e.g. used in TURP)
causes of SIADH
cns path
lung path
Drugs (SSRI, TCA, opiates, PPIs, carbamazepine)
Tumours
indications that pt hypervolaemic
peripheral oedeman and signs of HF – pulse, BP lying standing
look at tissue turgor and mucous membranes
why is euvolamic high Na in urine
• SIADH = excess water retention = expansion in heart, natrietic peptides released = Na loss in urine
plasma osmolarity in hyponatraemia
low - because low na
