Medicine (7)

Question 1

Ottawa rules for knee

Answer 1

Who to X-ray

Question 2

Ottawa rules for ankle and foot

Answer 2

An ankle x-ray is required only if there is any pain in the malleolar zone and any one of the following findings:

• bony tenderness at the lateral malleolar zone (from the tip of the lateral malleolus to include the lower 6 cm of posterior border of the fibular)
• bony tenderness at the medial malleolar zone (from the tip of the medial malleolus to the lower 6 cm of the posterior border of the tibia)
• inability to walk four weight bearing steps immediately after the injury and in the emergency department

Question 3

What two areas to palpate for Ottawa rule for foot?

Answer 3

Question 4

What types of anaemia all of these pictures are?

Answer 4

Question 5

Causes of anaemia considering MCV levles

Answer 5

Question 6

Causes, signs/symptoms and investigations for iron deficiency anaemia

Answer 6

Common causes:

Gastrointestinal loss, Gynaecological loss, diet

Symptoms:

Fatigue, dyspnoea, palpitations

Signs:

Angular stomatitis, koilonychia, tachycardia

Check serum ferritin and iron studies

Replace if deficient

Investigate cause (GI investigations)

Question 7

What’s thalassemia ?

Answer 7

• reduced production rate of either alpha or beta chains.
• deficiency in one chain causes excess in other
• occurs as alpha-thalassemia or beta-thalaassemia

Question 8

Types of thalassemia

Answer 8

Alpha-thalassaemia

• Four genes affect alpha-chain

1-2: mild microcytosis

3: microcytic anaemia + splenomegaly
4: death

Beta-thalassaemia

• Major: Syndrome of anaemia, growth stunting and hepatosplenomegaly arises. Autosomal recessive
• Minor: asymptomatic. Autosomal recessive

Question 9

Com on causes of normocytic anaemia

Answer 9

• Anaemia of Chronic Disease
• Acute haemorrhage
• Combined Iron + Folate deficiency
• Occasionally haemolytic anaemia

Question 10

Common causes of macrocytic anaemia and investigations

Answer 10

Question 11

What findings (blood) suggest haemolytic anaemia? (3)

Answer 11

• normocytic/macrocytic anaemia
• raised bilirubin (jaundice)
• raised LDH

Question 12

How to test for autoimmune haemolytic anaemia?

Answer 12

Direct Antiglobulin Test (DAT) = Coomb’s test

DAT Positive (and ↑ reticulocytes) = autoimmune haemolytic anaemia

DAT Negative:

1. Membrane – Hereditary Spherocytosis/elliptocytosis
2. Cytoplasm – G6PD
3. Haemoglobin – Sickle Cell Anaemia, thalassaemia

Question 13

Subtypes of Autoimmune Haemolytic Anaemia (AIHA)

Answer 13

warm and cold types → according to at what temperature the antibodies best cause haemolysis

Question 14

Warm Autoimmune Haemolytic Anaemia

• what happens
• management
• causes

Answer 14

• the antibody (usually IgG) causes haemolysis best at body temperature
• haemolysis tends to occur in extravascular sites, for example the spleen

Management options: steroids, immunosuppression and splenectomy

Causes of warm AIHA

• autoimmune disease e.g. SLE
• neoplasia: e.g. lymphoma, CLL
• drugs: e.g. methyldopa

Question 15

Cold Autoimmune Haemolytic Anaemia

• what happens
• features/symptoms
• management
• causes

Answer 15

• IgM antibody
• haemolysis best at 4 deg C
• haemolysis is mediated by complement
• more commonly intravascular

Features may include symptoms of Raynaud’s and acrocynaosis (cyanosis of hand, feet, face)

Management: steroids

Causes of cold AIHA

• neoplasia: e.g. lymphoma
• infections: e.g. mycoplasma, EBV

Question 16

What conditions may be classified as myeloproliferative?

Answer 16

• Chronic myeloid leukaemia (it is also classified as myeloproliferative)
• Polycythaemia vera

• Essential thrombocythaemia

• Primary myelofibrosis

Question 17

Acute Myeloid Leukaemia

• investigations
• what’s seen on blood film
• treatment

Answer 17

Question 18

How to differentiate between ALL and AML?

Answer 18

Question 19

Chronic lymphocytic leukaemia

• features

Answer 19

Question 20

CLL complications

Answer 20

Question 21

Ix and characteristic ‘buzzword’ for CLL

Answer 21

Question 22

Cause/ pathophysiology of CML

Answer 22

CML

• type of myeloproliferative disorder
• proliferation of mature granulocytes and their precursors leading to their accumulation in the blood and bone marrow

PHILADEPHIA CHROMOSOME (9,22) translocation

(part of the ABL proto-oncogene from chromosome 9 being fused with the BCR gene from chromosome 22

The resulting BCR-ABL gene codes for a fusion protein which has tyrosine kinase activity in excess of normal

Question 23

Management of CML

Answer 23

• imatinib is now considered first-line treatment
• hydroxyurea
• interferon-alpha
• allogenic bone marrow transplant

Question 24

How to differentiate CML and CLL?

Answer 24

Question 25

buzzwords for ALL, AML, CLL and CML (shortly)

Answer 25

Question 26

Spot diagnosis

Answer 26

Polycythaemia

Question 27

Types of polycythaemia (2)

Answer 27

**Polycythaemia** **Primary** * Polycythaemia Rubra Vera **Secondary** * Hypoxia (COPD, altitude, cardiac hypoxia) * ↑EPO (Tumour – Renal, liver, cerebellar) * Renal artery stenosis * High-affinity haemoglobinopathies (keep hold of O2 so trick kidneys)

Question 28

Pathophysiology of Polycythaemia Rubra Vera

Answer 28

Question 29

Clinical features of polycythaemia rubra vera

Answer 29

Question 30

Lab findings and treatment of polycythaemia rubra vera

Answer 30