Lecture 4 - Mixed Flashcards
What are the typical symptoms a patient wold present with when suffering from an immediate transfusion reaction and why?
Due to Haemolysis
Fever
Rigor
Tachycardia
Hypotension
Chest Pain
Dark Urine
Give a couple of examples of causes of polycythaemia.
Physiological (Response to chronic hypoxia casused by COPD)
Pathological (excess EPO)
What are the main causes of thrombocytopenia?
Decreased production
Increased breakdown/usage
Pooling in the spleen
Give a couple of causes of a thrombocytosis.
Primary - Myeloproliferative Disorder, CML
Response to haemorrhage
What causes microcytic anaemia?
Iron Deficiency - Diet, blood loss (GI, UG)
Beta Thalassaemia heterozygosity
What causes a normocytic anaemia?
Chronic Disease - eg. Rheumatoid Arthritis
How do ferritin levels present in a patient with a normocytic anaemia and why?
Normal/High
Ferritin production is an acute phase reaction, seen in chronic disease (similar to CRP)
In which condition are ferritin levels extremely high?
Haemochromatosis
What are the main causes of a macrocytic anaemia?
Alcoholics May Have Liver Failure
Alcohol
Myelodysplasia
Hypothyroidism
Liver Disease
Folate/B12 Deficiency
How does polycythaemia present?
Headache
Pruritus after a hot bath
Blurred vision (hyperviscosity)
Tinnitus
Thrombosis (Stroke, DVT)
Gangrene
Choreiform Movements
What are the main types of Sickle Cell Crises?
Acute Painful
Stroke
Sequestration
Gallstones/Chronic Cholecystitis
How would you manage an acute painful Sickle Cell crisis?
Analgesia
O2
IV Fluids
Antibiotics
How would you manage a stroke secondary to Sickle Cell disease?
Exchange Blood Transfusion
What is a Sequestration crisis and how does it present?
RBC Pooling
Affects the Lungs (SOB, Cough, Fever)
Affects the Spleen (Exacerbation of anaemia)
How would you manage a Sickle Cell sequestration crisis?
Usually symptomatic.
Chronic splenic episodes requires a Splenectomy.
Why does Hypercalcaemia cause Polyuria and Polydipsia?
Impairs ADH function, leading to the development of Nephrogenic Diabetes Insipidus.
How might a patient with Multiple Myeloma present?
CRAB
Hypercalcaemia (Stones, bones etc.)
Renal Failure (Ur/Cr)
Anaemia (SOB, Lethargy)
Bone Pain/Osteoporosis (Fractures, Pain, Check DXA)
Infection
Cord Compression
What do you test the urine for when investigating a suspected case of Multiple Myeloma?
Bence-Jones Proteins.
IG Light chains, excreted in the urine due to excess IG production by neoplastic Plasma Cells.
What may cause an Anaemia with an increased reticulocyte count?
Haemolytic Crisis
Haemorrhage
What may cause an anaemia with a decreased reticulocyte count?
Parvovirus B19 Infection
Aplastic Crisis in Sickle Cell patients
Blood Transfusion
What is the diagnostic criteria that defines Diabetes?
Fasting Glucose >7
Random Glucose >11.1
Describe a typical T1DM patient.
Young, thin, insulin deficient.
Present with:
Weight Loss
High Ketones (may present with DKA initially)
Acidotic (^)
Describe a typical T2DM patient.
Older, Overweight, Insulin resistent
How would you treat a newly diagnosed case of Type 2 Diabetes?
Lifestyle Advice
Metformin
What do Sulfonylureas do and what are the common side-effects?
Stimulate Insulin release by Pancreatic ß-Cells
Weight Gain
Hypoglycaemia
(Add onto Metformin after a few months - progressive disease must be proven)
Give an example of a DPP-IV Inhibitor.
Linagliptan
Sitagliptan
How do DPP-IV Inhibitors work?
DPP-IV breaks down GLP-1 (Glucagon-like Peptide). Inhibition has a similar effect to GLP-1 Agonists.
What are the main classes of Diabetes complications, and how do you investigate them?
Microvascular
- Retinopathy
- Nephropathy
- Neuropathy
Macrovascular
-MI/Stroke/PVD
Metabolic
- DKA
- HHS (Hyperosmolar Hyperglycaemic State)
- Hypoglycaemia
How would you monitor Nephropathic progression in Diabetes patients, and how would you treat it?
Monitor ACR (Albumin-Creatinine ratio) every time you see the patient. Microalbuminurea occurs with Diabetic Nephropathy.
If Nephropathy is detected, start the patient on an ACE Inhibitor.
How would you manage a case of Hypoglycaemia in a Diabetic patient?
If Conscious:
- Drink glucose & milk
- Long-acting carbohydrates
If Confused:
-Buccal Glucose Gel
If Unconscious:
- IV Glucose
- Glucagon
How does Graves Disease present?
Weight Loss w/ Good Appetite
Irritability
Palpitations
Oligomenorrhoea
O/E:
Tremor
Proptosis
Smooth Goitre
Pretibial Myxoedema
What will a Graves’ Patient’s TFTs show?
High T3/4
Low TSH
What is the difference between ‘Pretibial Myxoedema’ and ‘Myxoedema’?
Pretibial Myxoedema is a waxy, discoloured rash on the shins of a patient with Graves’ Disease.
Myxoedema is a term given to the consistency of the skin in a patient with Hypothyrodism
Which Antibody is responsible for Graves’ Disease?
TSH Receptor Stimulating Antibody
What will the Nuclear Medicine Technetium uptake scan show in a case of Graves’ Disease?
Diffuse, increased uptake
What would you look for in the History and Examination of a patient when suspecting Thyroid Cancer?
Lump
Typical Hyperthyroid Symptoms (eg. Thyroid Acropachy)
Risk Factors (Radiation, FHx, Rapid Enlargement/Compression, Lymphadenopathy)
Metastases (Lung, follicular thyroid carcinoma)
How would you investigate a possible case of Thyroid Cancer?
1) Ultrasound
2) Fine Needle Aspiration (Uptake Scan may show cold nodules)
How might you treat a case of Thyroid Cancer?
Surgery:
- Papillary
- Follicular
- Medullary
- Anaplastic (Poor Prognosis)
Thyroxine
Radioiodine
How would a Prolactinoma case typically present?
Irregular Periods
Galactorrhoea
Bitemporal Hemianopia
Sexual Dysfunction
What is the most appropriate treatment for a Prolactinoma?
Cabergoline (Dopamine Agonist)
How could a Pituitary Tumour present?
Headache & Hemianopia
Hyposecretion (of most other hormones)
Hypersecretion (of a particular hormone)
Local compression of other structures
How would someone with Acromegaly typically present?
Headache, sweating
Poor sleep (Snoring is common), Obstructive Sleep Apnoea
Tingling in fingers (Carpal Tunnel, compression of Median Nerve)
What are the initial investigations for a suspected case of Acromegaly?
1) IGF-1
2) Oral Glucose Tolerance Test (OGTT)
When should you test for Cushing’s?
Only when you have a high pre-test probability of a positive result.
What are the discriminatory signs of Cushing’s Syndrome?
Bruising
Thick Skin
Myopathy
Purple Striae >1cm wide
Diabetes
Hypertension
Osteoporosis at a young age
What would be your Ddx for a patient presenting with Amenorrhoea/Oligomenorrhoea?
Pregnancy
Hypothalamus
Pituitary
Thyroid (Hyper/Hypo)
Ovaries (PCOS, Failure)
How would you investigate a patient presenting with Amenorrhoea/Oligomenorrhoea?
1) Urine BHCG
Hypothalamus - ?excess exercise, low BMI?
Pituitary (Prolactinoma) - ?excess prolactin, Low LH/FSH
Thyroid -TFTs
PCOS - Androgen levels
Ovarian Failure - High FSH
How does Hypoklaemia present?
Weakness
Arrhythmia
Polyuria
What are the main causes of Hypokalaemia?
Vomiting
Diuretics
Primary Hyperalodesetornism - Either Bilateral hyperplasia or Conn’s
Why does Hypokalaemia cause Polyuria?
Hypokalaemia is a cause of Nephrogenic Diabetes Insipidus.
How would you calculate Plasma Osmolality?
2 x (Na + K) + Ur + Glucose
What cause low urine osmolality (dilute urine)?
Diabetes Insipidus - Decreased response to ADH
What would the likely diagnosis be in a patient presenting with
Low Ca
Low Phosphate
High PTH
?
Vitamin D Deficiency
Low Ca/Phosphate absorption
Less negative feedback means PTH increases
What would the likely diagnosis be in a patient presenting with
High Ca
Low Phosphate
High PTH
?
Hyperparathyroidism
High Ca
High PTH
Low Phosphate is a response to high PTH
What would the likely diagnosis be in a patient presenting with
High Ca
Normal Phosphate
Low PTH
?
Malignancy
High Ca
Low PTH therefore..
Normal Phosphate
What would the likely diagnosis be in a patient presenting with
Low Ca
High Phosphate
Low PTH
?
Hypoparathyroidism
Low PTH
Leads to..
Low Ca &
High Phosphate
What would the likely diagnosis be in a patient presenting with
Low Ca
High Phosphate
High PTH
?
Renal Failure
Vitamin D needs to be hydroxylated in the kidneys.
Different from Vit D Deficiency because of the High Phosphate. In Renal failure, Phosphate cannot be effectively excreted.
How would you classify AKI?
Pre-Renal:
- Hypovolaemia
- Sepsis
Renal:
- Drugs
- Glomerulonephritis
Post-Renal:
-Obstruction
How would you investigate an Acute AKI suspected to be due to Glomerulonephritis?
?Active Urine Sediment
Haematurea
Proteinurea
How would you investgate an Acute AKI suspected to be due to obstruction?
Ultrasound
Check for malignancy/prostate hyperplasia
How would you investigate Renal Artery Stenosis?
Asymmetrical Kidneys (USS)
Magnetic Resonance Angiography is Gold Standard
In Bilateral RAS, ACE Inhibitors worsen renal function.
How do you determine the cause of an Alkalosis?
Check CO2
Low = Respiratory
High = Metabolic
Which ABG abnormality indicates a complex mixed picture?
CO2 and Bicarbonate going in opposite directions (Increasing/Decreasing)
What are the main ways in which a Seronegative Arthropathy (eg. Psoriatic Arthritis) can present?
Symmetric Polyarthropathy, identical to RA - must check the skin
Distal Oligoarthritis
Sacroilitis
What is the most likely diagnosis if a patient presents with a pearl-like lesion with telangiecstasias, as seen below?
Basal Cell Carcinoma
