interactive cases in general internal medicine 6 Flashcards
What differential diagnosis for microcytic anaemia
- Iron deficiency (low ferritin)
- Diet
- Blood loss (GI, UG)
- Beta thalassaemia heterozygosity
What are differential diagnosis for normocytic anaemia?
- Chronic disease
- e.g. Rheumatoid arthritis
- Normal/high ferritin
50 year old woman • Hb: 90 g/L • MCV: 75 • On NSAIDs for joint pain
The most likely cause is:
A. Iron deficiency
B. Beta thalassaemia heterozygosity
bleeding ulcer due to NSAIDS
A. Iron deficiency
• 40 year old woman • Hb: 110 g/L • MCV: 65
The most likely cause is:
A. Iron deficiency
B. Beta thalassaemia heterozygosity
B. Beta thalassaemia heterozygosity
What are differential diagnosis for macrocytic anaemia?
What are clues that would point you towards one or the other?
REMEMBER with Alcoholics May Have Liver Failure
Alcohol - Hx, high GGT
Myelodysplasia - Pancytopenia & Bone marrow
Hypothyroidism - Hx (lethargy, constipation, wt gain) &Low T4, High TSH
Liver disease- Hx/Exam
Folate/B12 deficiency - Hx (small bowel disease, ? Gastrectomy)
What are presentation signs of Polycythaemia
- Headache
- Pruritus after hot bath
- Blurred vision (hyperviscosity)
- Tinnitus
- Thrombosis (stroke, DVT)
- Gangrene
- Choreiform movements
What are the different crises you can have in sickle cell?
- Acute painful crises
- Stroke
-
Sequestration crises (RBC pooling)
- Lung (SOB, cough, fever)
- Spleen (exacerbation of anaemia)
- Gallstones, chronic cholecystitis
How do manage an acute painful crisis?
Analgesia
O2
IV fluids
Antibiotics
How would manage a stroke ina patient with sickle cell?
Exchange blood transfusion
How would you manage a patient with splenic sequestration?
Splenectomy for repeated episodes of splenic sequestration
How would manage a patient with chronic cholecystitis due to sickle cell anaemia?
• Cholecystectomy
What are the Presentations of Multiple Myeloma?
Calcium - Polyuria, polydipsia, constipation
Renal failure - Ur & Cr
Anaemia - Breathlessness, lethargy • FBC
Bone (pain, osteoporosis)- Fracture, bone pain DXA
Might also have infection and cord compression
50 year old man • Hypercalcaemia • Low PTH • Backache • Normal ALP
The most likely cause is:
A. Malignancy
B. Multiple myeloma
B. Multiple myeloma
50 year old man • Hypercalcaemia • Low PTH • Backache • High ALP •
The most likely cause is:
A. Malignancy
B. Multiple myeloma
A. Malignancy
What are differentials anaemias with a high reticulocyte count?
Haemolytic crises
(DDx: haemorrhage)
What are differentials anaemias with a low reticulocyte count?
- parvovirus B19 infection
- Aplastic crisis in patients with Sickle cell anaemia
- Blood transfusion
What is diabetes?
Fasting > 7 •
Random ≥ 11.1
• Impaired glucose tolerance (IGT)
– 75g OGTT
– 2-hour glc: 7.8-11
What are the classification
Type 1 •
Young, thin, insulin deficiency •
Wt loss •
Ketones •
Acidosis
Type 2
- Older
- Overweight, obese
- Insulin resistant
Case • A 45 yr old man • lethargy, fatigue, polyuria, polydipsia • urinalysis: – no ketones – glc +++ • Random glc: 12
How would you treat him?
A. Insulin
B. Metformin
C. Sulfonylurea
D. DPP-IV inhibitor
E. GLP-1 agonist
B. Metformin
What are complications of diabetes
Microvascular
– Retinopathy
– Nephropathy
– Neuropathy
• Macrovascular
– MI/Stroke/PVD •
Metabolic –
DKA/HHS/Hypoglycaemia
What is the insulin sliding scale
scale where there is a blood glucose
measurement and the correspondent insulin dose
used in surgery or sepsis
Wt loss • Good appetite • Irritability • Palpitations • irregular periods
O/E •
Tremor • Proptosis • Smooth goitre • Pretibial myxoedema
What will the TFTs show?
A. High free T4/T3, suppressed TSH
B. High free T4/T3, High TSH
High free T4/T3, suppressed TSH
Wt loss • Good appetite • Irritability • Palpitations • irregular periods
O/E
• Tremor • Proptosis • Smooth goitre • Pretibial myxoedema
Fee T4: 30 (10-20)
TSH < 0.05
What is the next most appropriate investigation? A. TPO antibodies
B. TSH receptor stimulating Ab
B. TSH receptor stimulating Ab
Wt loss • Good appetite • Irritability • Palpitations • irregular periods
O/E
• Tremor • Proptosis • Smooth goitre • Pretibial myxoedema
Fee T4: 30 (10-20)
TSH < 0.05
What will the NM uptake scan show?
A. Diffuse increased uptake
B. Hot nodule
A. Diffuse increased uptake
What are risk factors for thyroid cancer
Risk factors
– Radiation –
FHx –
Rapid enlargement/compression
– Lymphadenopathy
What are investigations you would like to do in someone that has thyroid cancer
USS •
FNAC, (Uptake scan: cold nodules)
• MDT
What are the treatments for thyroid cancer
Surgery
Thyroxine, radioiodine
30 year old female • Amenorrhoea • Galactorrhoea • Bitemporal hemianopia
What is the most appropriate treatment?
A. Trans-sphenoidal surgery
B. Cabergoline
B. Cabergoline
do not operate for prolactinoma
50 year old man
- Headache, sweating
- Poor sleep, snoring
– Obstructive sleep apnoea •
Tingling in fingers
– Carpal tunnel syndrome
Initial test: High IGF-1
Which test would you perform ?
A. ITT
B. OGTT
C. Dex suppression test
D. Short Synacthen test
E. GHRH test
B. OGTT
40 year old woman • Wt gain • Depressed • Fatigue • Central obesity
Is she likely to have Cushing’s syndrome?
A. Yes
B. No
B. No
What are discriminatory signs of cushings
Bruising, thin skin
- Myopathy
- purple striae, > 1cm wide
- DM, HTN, osteoporosis at a young age
What are causes of amenorrhea/ Oligomenorrhea
Pregnancy
- Hypothalamus
- Pituitary
- Thyroid (hyper/hypo)
- Ovaries
– PCOS
– Ovarian failure
What are investigations you would want to do in someone that presents with Amenorrhea/ Oligomenorrhea
Urine BHCG
- ? Excessive exercise, low BMI
- Excess prolactin
- Low LH/FSH
- TFTs
Excess androgens (or hirsutism)
High FSH
Weakness
- Arrhythmia
- Polyuria
What does this person have
hypokalaemia
What are causes of hypokalaemia
GI: Vomiting
- Diuretics
- Primary hyperaldosteronism (bilateral hyperplasia or Conn’s) – Aldosterone: renin ratio
What is this
BCC
What are causes of AKI
Pre-renal
Hypovolaemia
• Sepsis
• Renal
Drugs
• ? Active urine sediment: blood & protein in the urine (Glomerulonephritis)
• Post renal
USS (? Obstruction)
21 yr old medical student • Morning of the Yr 3 exam • SOB • Palpitation • Tingling in hands
ABG • pH 7.5 (normal 7.35 - 7.45) • pCO2 3.5 kPa • bicarb 20 mmol/L
What is the most likely cause?
A. Pulmonary embolus
B. Pneumothorax
C. MI
D. SVT
E. Hyperventilation syndrome
E. Hyperventilation syndrome
What is the diagnosis
psoriatic arthropathy
Sacroiliitis
Arthtitis affecting distal interphalangeal joints
Which biochem picture is suggestive of Vitamin D deficiency?
A. Low ca, low phosphate, high PTH
B. High ca, low phosphate, high PTH
C. High ca, normal phosphate, low PTH
D.Low ca, high phosphate, low PTH
E. Low ca, high phosphate, high PTH
A. Low ca, low phosphate, high PTH
B hyperparathyrodism
C. malignancy
D.hypoparathyrodism
E. renal failure
What are the 2 different categories of Hypernatraemia
High urine osmolality: 572
– Dehydration (elderly, children)
– HHS (urine high osm: glycosuria), type 2 diabetes
Low urine osmolality
– DI (dilute urine, osm < 300)
What are the 3 main causes of thrombocytopaenia?
using them: DIC
infiltration of bone marrow: metastasis
pooling in the spleen: portal hypertnesion
PAtient comes in with high ferritin and desaturates on exercise and has a cough.
had unprotected sex as a young girl
What does this patient have?
Pneumocystis-jirovecii-Pneumonie
gotten HIV
What are the light chain in the urine in multplie myloma
bence jones protein
What are the side effects of sulphanyle ureas
hypo
increase in weight
how often do you check for retinopathy and how
anual digital retinal photography
how do you check for diabetic nephropathy
ACR
albumin creatinin ratio
How do you manage hypoglycaemia?
conscious
have them drink glucose
after complex carbohydrates so they don’t have another hypo
unsciousious
glucagon
or intravenous glucose
What must you exclude first if you suspect a prolactinoma
pregnancy
