Med 2017 3 Flashcards
87M - PCx: fatigued & pale
FBC shows Hb 78, MCV 108, platelets 168
Assess and manage.
Diagnosis = Iron deficiency anaemia (IDA) due to colorectal cancer (CRC)
87M - PCx: fatigued & pale
FBC shows Hb 78, MCV 108, platelets 168
Assess and manage.
1) Diagnosis = Iron deficiency anaemia (IDA) due to colorectal cancer (CRC)
Definition of anaemia: < 130 (< 140 for men, and < 120 for women)
Causes of microcytic anaemia:
- Iron deficiency anaemia
- Anaemia of chronic disease
- Thalassaemia
An elderly patient with iron deficiency anaemia has colorectal cancer until proven otherwise.
2) History:
- Symptoms of anaemia:
+ general: lethargy
+ organ-specific: dyspnoea, chest pain, dizziness - Red flag symptoms:
+ bleeding from the GI tract: haematemesis, malaena, haematochezia
+ bleeding from the reproductive tract (vagina): spotting (from endometrial cancer)
+ bleeding from the urinary tract: haematuria - Risk factors for IDA:
+ inadequate intake of iron: eat not enough red meat, legumes or green vegetables
+ too much iron loss e.g. from bleeding: malignancy, haemorrhoids, peptic ulcer disease, history of gastric/small bowel surgery, Coeliac disease
+ anaemia of chronic disease: chronic medical conditions e.g. auto-immune disease, CT disease e.g. RA, SLE, scleroderma
3) Examination:
- Features of chronic iron deficiency: koilonychia, glossitis, thinning of hair
- Gastro exam: to look for features of malignancy
+ abdo mass
+ bleeding on DRE
4) Investigations:
- Bedside: U/A (for RBCs in haemolytic anaemia)
- Lab:
+ FBC - Iron studies
+ Coeliac screen: tissue transglutaminase IgA - Imaging:
- Upper GI endoscopy + Colonoscopy to evaluate for bleeding lesions:
+ malignancy
+ diverticula
+ IBD
+ hereditary hemorrhagic telangiectasias
if c/o PV bleeding, trans-vaginal US
5) Management:
a) Treat anaemia:
- Transfusion of packed red cells. Indications:
+ Hb < or = 70, or 100 if patient has IHD
+ Iron supplementation: PO or IV
- Oral: 2-3mg/kg Iron per day for 3-6 months
- > vit C as well as it helps with iron absorption
- > SEs of iron: bloating, nausea, constipation, diarrhoea, black stools
- IV i.e. parenteral iron polymaltose infusion
- > may be more appropriate in this setting given the acute nature of his presentation
- Dietary: encourage intake of red meat, legumes and green leafy vegetables.
b) Treat underlying cause:
- If cancer, reverse the bleeding. Treat the primary lesion with MDT (multi-disciplinary team) setting.
33F - PCx: 3-month history of pain in her hands, wrists and feet
Pain is worse in morning, a/w stiffness in joints lasting for 1 hour
O/E: swelling of wrist and MCP joints with limited movement in the joints
Assess and manage.
Diagnosis: Rheumatoid arthritis
52F - PCx: acute abdomen
BG: ESRF due to chronic glomerulonephritis
being treated for peritoneal dialysis
Assess and manage.
Diagnosis = Spontaneous bacterial peritonitis (SBP)
68M - PCx: admitted for staging investigations
BG: lung cancer
Assess and manage risk of VTE during admission.
History: assess patient’s risk of DVT using Well’s criteria
Wells criteria DVT mnemonic: C3PO+R2D2: - Cancer (active) Calf diameter increase >3 cm Collateral superficial veins visible Pitting oedema Previous DVT documented Oedema of the whole leg, tenderness of the calf Recent surgery Recent immobilisation Different diagnosis more likely (subtract 2 points).
68M - PCx: admitted for staging investigations
BG: lung cancer
Assess and manage risk of VTE during admission.
History: assess patient’s risk of DVT using Well’s criteria
Wells criteria DVT mnemonic: C3PO+R2D2: Cancer (active) Calf diameter increase >3 cm Collateral superficial veins visible Pitting oedema Previous DVT documented Oedema of the whole leg, tenderness of the calf Recent surgery Recent immobilisation Different diagnosis more likely (subtract 2 points).
Management:
- Non-pharm:
+ Compression stockings
- Pharm:
+ Heparin
+ Warfarin
55F - PCx: in hospital for 2 days with acute gastroenteritis
BG: polymyalgia rheumatica - treated with Prednisone PO for several years
BP fell to 90/70
Manage.
Diagnosis = Addisonian crisis
aka acute adrenal insufficiency, due to abrupt withdrawal of steroids from a woman who had been previously treated with steroids for a chronic rheumatological condition (polymyalgia rheumatica)
Resuscitation and Management:
- Addisonian crisis must be managed promptly to avoid circulatory collapse (aka hypovolemic shock).
- Inform a senior colleague and resuscitate following ABCDE, with particular focus on circulation:
+ Assess circulation (BP, hydration status, etc.). Insert 2x IV cannulae.
-> Give IV fluids: 5% Dextrose in Normal Saline.
+ Attach ECG. Catheterise to monitor urine output.
+ Give meds i.e. stat dose steroids until there is improvement:
-> Dexamethasone 4mg IV bolus
(or = hydrocortisone 100mg = prednisone 25mg)
later on, this dose of steroids can be tapered. once gastroenteritis settles, steroids can be given orally.
- Bloods for investigations:
+ EUC (serum biochemistry): loss of aldosterone production can lead to electrolyte disturbances such as hypoNa+ and hyperK+
(tip for remembering: aldosterone -> salt (Na+) and water retention. hence lack of aldosterone -> Na+ not retained -> low Na+ in blood i.e. hypoNa+. K+ is opposite that is hyperK+ maybe cos not enough excretion)
treat electrolyte disturbances accordingly
+ BSL: hypoglycaemia (low blood sugar) is a known complication of Addisonian crisis
(why? adrenal hormones e.g. adrenaline, noradrenaline, cortisol mediate glycogenolysis i.e. helps liver convert glycogen (stored glucose) into glucose (circulating active glucose), and gluconeogenesis i.e. conversion of fats, proteins and carbohydrates into glucose.
hence adrenal insufficiency -> hypoglycaemia)
+ ACTH stimulation test (short synacthen test) = confirmatory test
i.e. synthetic ACTH is injected. then cortisol level is measured at 0, 30 and 60 minutes after injection. in a normal person, cortisol level should rise x2 of baseline (20-30 microg/L) after 60 minutes.
if cortisol level doesn’t rise = adrenal insufficiency.
- investigate and treat gastroenteritis:
+ electrolytes and fluid replacement
+ stools MCS and OCP: watch for signs such as bloody diarrhoea, overseas travel and prev. C. diff infections.
66M - PCx: cramping abdo pain, diarrhoea & fever (a day after Cipro)
BG: has been hospitalised for acute prostatitis and treated with Ceftriaxone
- initial symptoms have resolved
- treatment changed to Ciprofloxacin PO
Assess and manage.
Diagnosis = Pseudomembranous colitis
- caused by Clostridium difficile: Gram +ve spore-forming anaerobe
- feared complication = fulminant colitis + toxic megacolon and subsequent bowel perforation. hence, TREAT!
DDx:
- infectious:
+ gastroenteritis: viral and bacterial
+ sepsis of another source: non-GI e.g. urinary
- non-infectious:
+ ischemic bowel: important
+ non-infectious SE of antibiotic
1) RESUSCITATE: if patient looks extremely ill and toxic
- alert senior colleague
- ABCDE with focus on:
+ IV FLUIDS
+ IV ABx: Metronidazole IV + Vancomycin PO (cos iv vans does not penetrate the lumen of colon)
+ replace electrolytes - mobile abdo X-ray: look for toxic megacolon
2) History: once stable, focus on symptoms and risk factors
- Symptoms:
+ profuse watery diarrhoea +/- blood (occult bleeding)
+ marked abdo pain and distension
+ others: nausea, anorexia, dehydration and fever.
- Risk factors:
- antibiotics exposure: broad-spectrum penicillins, cephalosporins & quinolones
- old age
- hospitalisation, or residence in nursing home
- hx of C. diff disease: as relapse occurs in about 25% of prev treated C. diff infections
- Rule out DDx:
+ gastro: sick contacts, travel
3) Examination:
- Vitals
- Gastro exam: Key red flags are:
+ fulminant colitis + toxic megacolon:
* severe lower quadrant pain
* diarrhoea
* abdo distension
* fever
* hypovolemia
+ peritonitis: suggests perforation
+ DRE: for bleeding
4) Investigations:
- Bedside: ABG (if patient looks ill i.e. metabolic acidosis)
- Laboratory: \+ Bloods: * FBC: raised WCC * EUC: electrolytes, AKI * LFTs: septic transaminitis * CRP
+ Microbiology:
- stool MCS and OCP
- Clostridium toxin PCR/EIA
- 2x blood cultures
- Imaging:
+ Abdo X-ray: to rule out toxic megacolon i.e. colonic dilatation > 7cm + severe toxicity.
+ scope (sigmoidoscopy/colonoscopy): indicated when
- negative lab results but still high clinical suspicion
- if lab tests are delayed and we need prompt diagnosis
- failure to respond to antibiotics
- > C. diff infection shows raised yellow plaques (pseudomembranes), and shallow ulceration.
5) Management: depends on the severity of the disease
- Discontinue the implicated antibiotics (broad-spectrum one that caused pseudomembranous colitis), unless it’s absolutely vital.
- Supportive care: for all patients \+ fluids: to prevent dehydration \+ replace electrolytes \+ give analgesia * isolate the patient and put up contact precautions: because alcohol-based hand-washes are not effective against C. diff infections.
- Antibiotics: definitive therapy
+ Mild disease: Metronidazole 400mg PO (or via NG tube) 8hrly for 10 days
+ Severe disease (this patient, also mentioned in resusc): immediate IV Metronidazole + Vancomycin PO/NG - obtain a surgical consult cos toxic megacolon is a surgical emergency, for which colectomy is life-saving.
- For recurrent disease, do feacal transplant (highly specialised).
36M - PCx: haematemesis
his condition is stable and he’s awaiting endoscopy
has a further bleed and BP falls to 80/65
Manage.
Impression: patient is in shock (hypovolemic shock). Causes of upper GI haemorrhage are:
- PUD i.e. peptic ulcer disease
- oesophageal varices
- oesophagitis, gastritis
- Mallory-Weiss tears
- malignancy
1) Resuscitation:
- medical emergency. inform a senior colleague. resuscitate and do an urgent endoscopy to stop the bleeding source.
- Airway: ensure patent and protected
- Breathing: look, listen and feel; assess RR, SpO2
+ give high-flow oxygen immediately: 15L Hudson mask
- Circulation:
+ assess HR, BP, cap refill
+ insert 2x IV cannulae. give IV fluids i.e. 20mL/kg of NS
* blood transfusion: give O- blood. threshold is Hb < 70 for normal patients. Hb < 90 for high-risk patients e.g. elderly, chronic liver disease, coronary artery disease.
-> if coagulopathic, give FFP/pro-thrombinex +/- vit K +/- platelets.
-> consider activation of MTP i.e. massive transfusion protocol
