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DPD 2019 > Interactive cases in general internal medicine 3 part 2 > Flashcards

Interactive cases in general internal medicine 3 part 2 Flashcards

1
Q

When would you give IM vs IV adrenaline

A

IM- anaphylaxis

IV- cardiac arrest

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2
Q

Q fever is caused by what pathogen

A

Coxiella burnetii

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3
Q

What antibiotic is used in addition to amoxicillin if you suspect an atypical pneumonia

A

Macrolide e.g. clarithyromycin or erythromycin

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4
Q

What is the most common electrolyte disturbance in pneumonia

A

Hyponatraemia

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5
Q

Atypica organisms causing pneumonia.

What proportion of CAPs are they implicated in?

A
  • Mycoplasma pneumoniae
  • Chlamydia pneumoniae
  • Legionella pneumophila

Implicated in up to 40% of CAP

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6
Q

What is dyspepsia vs indigestion

A

Oxford handbook:

It is defined as one or more of:

  • Postprandial fullness
  • Early satiety
  • Epigastric or retrosternal pain or burning

Indigestion can refer to dyspepsia, bloating, nausea and vomiting.

Try to find out exactly what patient means!

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7
Q

When would symptoms of peptic ulcer disease typically occur

A

2-5hrs after a meal and on an empty stomach

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8
Q

What test for

  • 50 yr old man
  • Dyspepsia
  • Wt loss
  • Hb: 70
  • MCV: 70
A

ODG

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9
Q

What is a haematinic

A

A hematinic is a nutrient required for the formation of blood cells in the process of hematopoiesis.[1] The main hematinics are iron, B12, and folate

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10
Q

Investigations for microcytic anaemia

A

Haematinics

Coeliac screen

Remember red flags

Top and tail

Order depends on upper/lower GI symptoms

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11
Q

What does a coeliac screen comprise

A

TTG Ab

But diagnosis confirmed on duodenal biopsy with villous atrophy

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12
Q

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

Likely diagnosis?

A

Ischaemic colitis is a likely cause of bloody diarroeah

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13
Q

What is the sign if there are periumbiliac veins with blood flow TOWARDS THE LEGS

A

Caput medusae

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14
Q

What occurs in portal HTN

A
  • Encephalopathy
  • Ascites
  • Spontaneous bacterial peritonitis
  • Variceal bleed
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15
Q

Cause of microangiopathic haemolytic anaemia

A

Disseminatied intravascular coagulopathy (e.g. due to infection)

Haemolytic uraemic syndrome (e.g. due to infection)

Thrombotic thrombocytopenic purpura (an AI cause)

Physical trauma (e.g. mechanical heart valves)

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16
Q

What are the findings in DIC

A

DIC can cause MAHA

Low platelets and fibrinogen (used to make clots)

Increased PT and APTT

Increased d-dimer/FDGs

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17
Q

What are the findings in haemolytic uraemic syndrome

How is this related to thrombotic thrombocytopenic purpura

A

HUS can causes MAHA. HUS is most often caused by E. Coli O157 bacteria (GI infection) , but also shigella.

Causes:
Haemolysis (reduced Hb and increased bilirubin)

Uraemia

Reduced platelets (because it causes lots of little clots in the kidney vasculature, as well as haemolytic anaemia)

TTP is an autoimmune cause

It results in the findings of HUS + fever + neurological manifestations

18
Q

Causes of haemolytic anaemia

A

Hereditary:

Enzyme deficiency (G6PD deficiency)

Red cell membrane (hereditary spherocytosis)

Haemoglobinopathy (sickle cell, thalassaemia)

Acquired:

  • AI
  • Drugs
  • Infection
  • MAHA
19
Q

Where do you find Valvulae conniventes and haustra.

How can you tell the difference

A

Valvulae conniventes in small intestine- they are lines that go all the way across the small bowel wall

Haustra are the pockets of large bowel but they don’t go across the whole bowel wall

20
Q

Classifications of hyponatraemia

A

Hypervolaemic

  • Heart failure
  • Nephrotic syndrome
  • Liver cirrhosis

Euvolaemic

  • Hypothyroidism
  • Adrenal insufficiency
  • SIADH

Hypovolaemic

  • Diarrhoea
  • Vomiting
  • Diuretics
21
Q

What happens to the sodium in the urine if there is hypovolaemia

When can you not use the urine sodium

A

There will be low sodium in the urine because the kidneys will hang on to it because they’re good at detecting hypovolaemia

BUT you can’t measure if they’re on diuretics (which would well be the cause of their hypovolaemic hypontraemia!)

22
Q

What investigations would you do for euvolaemic hyponatraemia

A

TFTs

Short synacthen test (if there is adrenal insufficiency, cortisol won’t rise when you give ACTH)

Plasma and urine osmolality

In hypovolaemic hyponatraemia, the urine sodium should be low (it will be being reabsorbed to increase BP), unless there’s diuretic. In euvolaemic, the urine sodium will be high (if it’s SIADH, then water not sodium is reabsorbed. If it’s adrenal insufficiency, then Na+ will end up in the urine too)

23
Q

What will the investigations show in hypervolaemic hyponatraemia

A

Fluid overloaded

Low urine sodium

24
Q

What will the urine sodium be in those with hypovolaemic, euvolaemic and hypervolaemic hyponatraemia?

A

hypovolaemic and hypervolaemic will have low urine sodium

euvolaemic will have high

25
Q

Most causes of hyponatraemia are caused by what

Rarer causes?

A

Increased ADH

Rarer causes:
XS fluid intake
Sodium free irrigation solutions e.g. used in TURP

26
Q

Why is SIADH euvolaemic?

A

With SIADH you get too much ADH secretion.

You’d think that, because this causes you to take up more water from the collecting ducts, you’d end up fluid overloaded

But this is not the case because the heart walls are stretched when ADH increases, and this leads to release of ANP, which allows you to excrete Na+ in the kidneys and you stay euvolaemia

27
Q

What would investigations show for SIADH

A

You would have a high urine osmolality

But you would have a low plasma osmolality and a low serum sodium because of dilution

28
Q

What are the causes of SIADH?

A

CNS: SAH, stroke, tumour, TBI

Pulmonary: pneumonia and bronchiectasis

Malignancy: lung (small cell)

Drug related

Idiopathic

29
Q

Which drugs can cause SIADH

A

Carbamazepine and SSRIs, opiates and PPIs

30
Q

What are the symptoms of SIADH

A

Can be asymptomatic

If Na<120mM, generalised weakness, poor mental function and nausea

If Na+<110mM confusion leading to coma and eventually death

31
Q

SIADH treatment

A

Appropriate treatment for the cause

To reduce immediate concern of hyponatraemia:
1. Immediate fluid restriction

  1. Longer term: use drugs which prevent vasopressin actions in the kidneys (demeclocyline). This induces nephrogenic DI to reduce renal water reabsorption
32
Q

Compare aqauresis vs diuresis

A

Diuresis involves exrectoion of sodium and water which is what diuretics do

Aquaresis is when you just get rid of water and not sodium. That’s what vaptans do as they are V2 receptor antagonists so block the effect of vasopression on the kidneys

33
Q

What are the causes of onycholysis

A

Nail moving away from nail bed.

Trauma
Psoriasis
Thyrotoxicosis
Fungal infection

34
Q

What are the causes of these nail signs:

Beau’s line

Nail pitting

Koilonychia

Onycholysis

Leukonychia

A

Beau’s line- chemotherapy

Nail pitting- psoriasis

Koilonychia- Fe deficiency

Onycholysis- see abvoe

Leukonychia- Albumin deficiency

35
Q

Which cells make ALP

A

Osteoblasts

36
Q

T/F ALP is normal in multiple myeloma

A

T. Plasma cells suppress osteoblasts so ALP doesn’t rise.

This can be used to distinguish multiple myeloma from boney mets as a cause of hypercalcaemia with a low PTH

37
Q

What are the causes of cavitatinng lung lesion

A
  1. Infection- Staph, klebsiella (alcoholics), TB
  2. Inflammation (RA)
  3. Malignancy (squamous cell carcinoma of the lung)
  4. Infarction e.g. due to PE
38
Q

What is the inheritence of hereditary haemorhagic telangiectasia

A

AD

39
Q

Where are the abnormal blood vessels

A

Skin, mucous membranes, lung, liver brain

40
Q

What other hormone would you expect to change in primary hypothyroidism

A

You can expect prolactin to go up slightly.

Because TRH will increas in primary hypothyroidism, and TRH also stimulates prolactin release

DPD 2019 (30 decks)

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