10/12/15 Interactive Cases in General Medicine 4

Question 1

41M SOB, cough, CP, chronic. 30y smoking history, decreased breath sounds, hyper resonant bilaterally

Answer 1

Big bullae, vanishing lung syndrome. CT do NOT put a chest drain in. Lung volume reduction surgery

Question 2

50F progressive SOB, dry cough, clubbing FEV1/FVC >70%

Answer 2

Interstitial lung disease, reticulonodular shadowing on CXR

Question 3

50F no clubbing, hyper expansion on CXR, sputum, chronic SOB, obstructive FEV1/FVC

Answer 3

COPD

Question 4

CXR opacities: fluffy interstitial/alveolar shadowing

Answer 4

Fluid, pus or blood (pneumonia, HF)

Question 5

Reticulonodular shadowing

Answer 5

Pulmonary fibrosis: EAA, IPF…

Question 6

Homogenous shadowing

Answer 6

Pleural effusion, meniscus seen

Question 7

Mass/cavitating lesion

Answer 7

TB, abscess, rheumatoid nodule. Air-fluid level

Question 8

Which lobe is affected if the consolidation obscures the right heart border?

Answer 8

RML, listen in axilla for pathology

Question 9

What is seen with LLL pneumonia?

Answer 9

Loss of L hemidiaphragm, normally seen behind the heart

Question 10

What causes a globular heart?

Answer 10

Pericarditis with pericardial effusion

Question 11

What causes bilateral hilar lymphadenopathy?

Answer 11

TB, sarcoid, lymphoma

Question 12

3 signs of constrictive pericarditis

Answer 12

Raised JVP, hepatomegaly, ascites

Question 13

Causes of hepatomegaly:

Answer 13

Cancer, cirrhosis (early), CCF/constrictive pericarditis. Infiltration (amyloid, sarcoid, myeloproliferative)

Question 14

Causes of splenomegaly:

Answer 14

Portal HTN, haematological (lymphoma, HA), infection (TB, IE, IM), inflammation (sarcoid)

Question 15

What are the causes of diffuse abdominal pain?

Answer 15

Acute abdomen surgical causes: obstruction, mesenteric ischaemia, IBD colitis, peritonitis/gastroenteritis

Medical causes: DKA, Addison’s, porphyria, lead poisoning, hypercalcaemia

Question 16

50M painless jaundice, weight loss, dark urine, pale stool, Trousseau sign of malignancy, raised ALP, high Ca-19-9

Answer 16

Pancreatic cancer, head of pancreas

Question 17

Causes of bloody diarrhoea?

Answer 17

Infection: CHESS (Campylobacter, EHEC, Entamoeba histolytica, Salmonella, Shigella), inflammation (IBD with extra-GI manifestations: scleritis, arthritis, erythema nodosum), infarction ischaemic colitis, diverticulitis, malignancy

Question 18

How is ascites classified?

Answer 18

Transudate (low protein30) cirrhosis, heart failure, Budd-Chiari portal vein thrombosis

Exudate (high protein) malignancy, infection TB, inflammation

Question 19

What defines SBP spontaneous bacterial peritonitis?

Answer 19

Ascitic tap, WCC neutrophils >250

Question 20

What is the cause of isolated raise in BR?

Answer 20

Gilbert’s

Question 21

Dark urine, what is the cause?

Answer 21

Hepatic picture, hepatitis: drugs, inflammation, infection, alcohol. Raised AST/ALT

Question 22

High unconjugated BR what is the cause?

Answer 22

Pre-hepatic haemolysis causing jaundice, defective conjugation (Gilberts)

Question 23

Pale stool, dark urine, what is the cause of the jaundice?

Answer 23

Obstructive post hepatic picture, raised ALP/BR: gallstones, Ca head of pancreas CBD obstruction

Question 24

What enzyme conjugates BR?

Answer 24

Glucuronyltransferase

Question 25

What are features on AXR of inflammation?

Answer 25

Thumb printing, lead-pipe colon/featureless. 3-6-9 (small bowel, large bowel, caecum)

Question 26

What is a complication of IBD with pain?

Answer 26

Toxic megacolon, give fluids, hydrocortisone, AXR, risk perf, surgical review

Question 27

What can result from faecal loading?

Answer 27

Spurious/overflow diarrhoea, treat with laxatives

Question 28

How is an acute GI bleed managed?

Answer 28

ABC approach
IV access, fluids
G+S, X-match
OGD

Question 29

How is a variceal bleed/portal HTN managed?

Answer 29

Abx and terlipressin in addition to: ABC, IV fluids, X-match, OGD. Splanchnic vasoconstriction to prevent bleed progressing

Question 30

Management of acute abdomen?

Answer 30

Investigate: FBC, U+E, clotting, LFT, G+S/Xmatch, CRP, erect CXR for perforation/CT abdomen
Treat: ABC approach, IV fluids, NBM, NG tube, anti-emetics, analgesia, Abx (cefuroxime, metronidazole), monitor vitals/UO

Question 31

Why is abdominal USS done after fasting to visualise gallstones?

Answer 31

Fasting causes a distended gall bladder, better visualisation of gallstones

Question 32

Management of ascites?

Answer 32

Tap, send fluid for MCS, monitor weight daily, give diuretics spironolactone/frusemide. Salt and water retention, therapeutic paracentesis, give IV human albumin

Question 33

How is encephalopathy managed?

Answer 33

Lactulose and phosphate enema to decrease transit time, less likely for bacteria to ferment bowel contents and produce toxins. Avoid sedation, look for infection and GI bleed

Question 34

Post-op care

Answer 34

Wound infection, anastomotic leak, pelvic abscess

Question 35

Tender, red, swollen lump in perianal region?

Answer 35

Perianal abscess, incise and drain

Question 36

Pain on defecation, stool is coated with bright red blood?

Answer 36

Anal fissure, give GTN to cause relaxation, increase fluid and fibre in diet

Question 37

IBS questions to ask? Treatments?

Answer 37

Has there been a change in bowel habit? (C or D)
Have you experienced pain, bloating?
Does this improve with defecation?
Change in frequency or form?
No PR bleed or red flag signs, no nocturnal symptoms

Treat with anti-spasmodics, antiD/laxatives. Exclude coeliac disease

Question 38

Tumour markers for:

1. Ovarian cancer
2. Pancreatic cancer
3. Colon cancer
4. Breast cancer
5. Alpha-fetoprotein

Answer 38

1. CA125
2. CA19-9
3. CEA
4. CA 15-3
5. Hepatoma, teratoma