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DPD > interactive cases 5 > Flashcards

interactive cases 5 Flashcards

1
Q

24 yr old man
Breathlessness
Facial swelling
After having a Chinese take-away

initial management?

A

o IM adrenaline in anaphylaxis – first
o IV hydrocortisone e
o Fluids

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2
Q

when give IV adrenaline

A

cardiac arrest

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3
Q

why not IV adrenaline in anaphylaxis

A

dangerous in anaphylaxis because precipitate arrhythmia in someone who is conscious = tachyarrhythmia and cardiac arrest

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4
Q

45 yr old man
Cough
Breathlessness
Recent travel

O/E: coarse crepitations & bronchial breathing

Hyponatraemia
Deranged LFTs

A

clarithromycin - macrolide
o Amoxicillin cover strep pneumonia gram +ve
o Macrolide AB - clarithromycin – to cover atypicals- Na and LFT derangement might increase likelihood of atypical pneumonia eg legionella, mycoplasma, chlamidyia in community acquired pneumonia – implicated in 40% CA pneumona
5-7days of AB, sputum culture might not be that beneficial

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5
Q

fine crepitations

A

fibrosis

HF = pul oedema

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6
Q

coarse crepitations

A

pneumonia and consolidation

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7
Q

when do you suspect atypical pneumonia

A

o Low na – can be in any pneumonia
o Travel
o Deranged LFT

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8
Q

organisms in atypical pneumonia

A

Mycoplasma pneumoniae
Chlamydia pneumoniae
Legionella pneumophila

Implicated in up to 40% of CAP

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9
Q 
50 yr old man
Dyspepsia
Wt loss
Hb: 70
MCV: 70
what test do you get?
A

OGD (gastroscopy)
o Dyspepsia – pain in digestion, upper abdo
o Microcytic anaemia
o Micrrocytic do top and tail
o Upper abdo discomfort – prompt OGD look at stomach fro pep ulcer, erosion, malignancy

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10
Q

what do you order when you see microcytic anaemia

A

haematinics - ferritin, b12 folate
o Coeliac screen – transglutaminase Ab (in pathogeneissis – autoAg tissue transglutaminase in coeliac) when suspecting coeliac - Diagnosis confirmed with duodenal biopsy – look for villus atrophy
o Top and tail
o Order colonoscopy/OGD depending on whether upper or lower GI symptoms

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11
Q

microcytic anaemia red flags

A

weight loss
change bowel habit
dyspepsia

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12
Q

70 year old man
Bloody diarrhoea
Stool micro & culture: -ve
Stool C. diff toxin: -ve

most likely dx

A

ischemic colitis
o Infection ruled out
o Malig – change of bowel habit and blood in stool so also in ddx
o Bloody diarrhoea in old person- ischemic colitis (know not infection)

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13
Q

investigations for bloody diarrhoea

A

stool for culture and C diff toxin screen

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14
Q

causes of bloody diarrhoea

A

Infection: infective colitis
Inflammation: ulcerative/Crohn’s colitis (younger pts)
Ischaemia: ischaemic colitis (older pts)

Malignancy
Diverticulitis

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15
Q

colonoscopy findings of bloody diarrhoea

A

see characteristic feature of ischemic colitis – loss of epi integrity – infection, inflammation or ischemia
o Ischemic get damage and death of cells
o Bloody diarrhoa because of loss if epithelial integrity

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16
Q

40 yr old man
Palpitations
Started 4 hours ago
ECG: AF

how treat

A

DC cardioversion

o treatment of AF if <48hr DC cardioversion in young person – want to resolve problem so not just rate control
o in >48hr anticoag reduce risk of thromboembolism for weeks until eligible for DC cardioversion and control the rate until you can cardiovert

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17
Q

what is amiodarone used for

A

VT

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18
Q

rate control drugs

A

digoxin and metoprolol

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19
Q

what does adenosine treat

A

SVT

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20
Q

when choose metoprolol over digoxin

A

if AF is precipitated by pneumonia - digoxin augments the PNS so isnt v effective when SNS high - so use metoprolol

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21
Q

Direction of flow in the veins below the umbilicus is towards the legs.

what is the sign

A

caput medusae

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22
Q

complications of portal hypertension

A 
splenomegaly 
Encephalopathy
Ascites
Spontaneous bacterial peritonitis
Variceal bleed
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23
Q

causes of splenomegaly

A

haematological malignancy
portal HTN
infection
inflammation

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24
Q 
20 year old boy
Recent diarrhoea
Malaise
Hb: 70
Cr: 300

schistocyte (red cell fragments)
dx

A

o Recent diarrhoea and then anaemia, fragments and high creatine
o Red cell haemolysis- haemolytic uraemic syndrome
o Anaemia because of red cell fragmentation – haemolysis

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25
Q

cause of microangiopathic haemolytic anaemia

A

 Small vessels – if small clots in small vessels as red cells try and pass through may get haemolysis

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26
Q

3 types of haemolytic anaemia

A

DIC (Disseminated Intravascular Coagulation)
HUS (Haemolytic Uraemic Syndrome)
TTP (Thrombotic Thrombocytopenic Purpura)

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27
Q

summarise DIC

A

o Platelet and fib low – making clots so low
o PT/APTT up because using the clotting factors
o D dimer – fibrin degradation products tell you there have been clots and now theyre being degraded – break clots
o Get very sick with sepsis

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28
Q

summarise HUS

A

hereditary or acquired
haemolysis -> low Hb and high BR
uraemia - haemolysis in renal vessels
low platelets

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29
Q

summarise TTP

A

HUS + fever + neurological manifestations

30
Q

causes of hereditary haemolytic anaemia

A

Red cell membrane (hereditary spherocytosis)
Enzyme deficiency (G6PD deficiency)
Haemoglobinopathy (Sickle cell disease, Thalassaemias)

31
Q

causes of acquired haemolytic anaemia

A

Autoimmune
Drugs
Infection
MAHA

32
Q

Valvulae conniventes

A

– circular folds valvulae conniventes go all the way across = SBO

33
Q

haustra

A

large bowel – don’t go all the way across – sign of LBO

34
Q

onycholysis

A 
separation of nail from bed
causes:
trauma
Thyrotoxicosis – if losing weight and sweating likely this 
Fungal infection 
Psoriasis
35
Q 
20 year old woman
Abdominal pain
Vomiting
Type 1 diabetes
CBG: 20
Venous pH: 7.20

what is the most appropriate next step

A

capillary ketone
o Acidotic
o Capillary ketone – pt likely has DKA – med cause of abdo pain
o Can use urinary ketone but capillary is better and more specific

36
Q

treatment of hypoglycaemia

A

give sugary glucose if conscious and can comply, if cant comply ie confused- gel, if not conscious/drowsy and cant swallow – IV glucose or IM glucagon

37
Q

diabetes complications

A

Microvascular
Retinopathy
Nephropathy
Neuropathy (foot ulcers)

Macrovascular
MI/Stroke/PVD

Metabolic
DKA/HHS (hyperosmolar hyperglycaemic state)/Hypoglycaemia

38
Q

treatment of t2dm v high glucose and v dehydrated

A

.9% NaCL - and bit of insulin

39
Q

DKA treatment

A

fluid, insulin, K+

40
Q

HONKC

A

high osmolarity, high Na and glucose – could be 1st presentation of dm

41
Q

26 year old man
Chest pain
Smokes 5/day

Auscultation: ‘scratching sound’

widespread ST elevatio

A

o Pericardial rub is the scratching side – pericarditis, pain better on leaning forward
o Not STEMI – because if STEMI in every lead = dead

42
Q 
60 yr old woman
Collapse
BP: 120/70 mmHg
No postural drop
HS: S1+S2+ ESM (ejection systolic murmur)

deep S in V1 and tall R in V6

A

LV hypertrophy
narrow aortic valve is cause
HTN is another cause

43
Q 
40 year old man
Loin pain
CRP: normal
Urinalysis: blood ++
What investigation would you request?
A

CT KUB
o Pyelonephritis and stones
o In acute setting – CT KUB very sensitive
o Abdo US can be used – but not acute, use if think hyperparathyroidism eg hypercalcaemia see if renal calculi
o Non contrast – calculus in dilated renal pelvus and PUJ = obstruction

44
Q

non contrast KUB

A

shows Pelvi-ureteric junctionobstruction

Calculus within the dilated renal pelvis

45
Q 
50 year old man
Hypercalcaemia
Low PTH
Backache
Normal ALP

dx

A

multiple myeloma

o High ca – need to know if PTH up or down
o PH down = malignancy
o If PTH high – it is driving the Ca
o Here know it is malignancy – either met or myeloma
o No hyperca in osteoporosis
o Secondary pth – high PTH because low ca or vit D
o Normal alkphos
• Bone osteoblast make alkphos
• Alkphos high in obstructive liver disease and malignancy
• ALhphos normal so likely option is multiple myeloma
• Malignancy makes PTH related peptide
• If met to bone sometimes excess ca from that

46
Q

summarise ALP

A

from liver and bone
high in obstructive liver disease & bone disease (malignancy, fracture, Paget’s disease)

Bone: osteoblasts make ALP
Plasma cell suppress osteoblasts therefore ALP is normal in myeloma

47
Q

symptoms of multiple myeloma

A

Calcium
Renal impairment
Anaemia
Bone

48
Q

23 yr old woman
Breast lump
1cm
Smooth mobile

likely dx

A

fibroadenoma

49
Q

galactocele

A

retention cyst by occlusion of lactiferous duct – post preg

50
Q

fat necrosis in breast - cause

A

trauma

51
Q

lesion on CXR with air fluid level, necrosis

A

cavitating lesion

52
Q

causes of cavitating lesion

A

Infection: TB, Staph, Klebsiella (e.g. alcoholics)
Inflammation (RA)
Infarction (PE)
Malignancy

53
Q

35 yr old woman
Ankle oedema
Recent Echocardiogram: NAD

U&Es: normal
ALT, AST & ALP: normal
Albumin: 15

What test would you order next?

A

o Low albumin – lose protein in urine – hypoalbuminaemia – become oedematous
o Want to urinalysis and 24hr collection

oedema due to oncotic pressure

54
Q

nephrotic syndrome

A

increased permeability of GBM to protein
Proteinura> 3g/day
Hypoalbuminaemia
Oedema

55
Q

30 year old man
Recurrent GI & nose bleeds
face exam = telangiectasia

dx

A

Hereditary telangiecstasia

56
Q

acromegaly sign in mouth

A

glossitis

57
Q

systemic sclerosis sign on mouth

A

tight skin and small mouth - microstomia

58
Q

summarise hereditary haemorrhagic telangiectasia

A 
Autosomal dominant
Abnormal blood vessels in:
Skin
Mucous membranes
lungs
Liver
brain
59
Q 
Na+: 120
K+: 5
Short Synacthen test
0 min cortisol: 100
30 min cortisol: 200

dx

A

o Low Na and high K
o Aldosterone Na in K out – so low aldosterone
o Cortisol hasn’t gone up
o So adrenal insufficiency – primary because also lost aldosterone. If secondary low cortisol – wouldn’t have fdamage to glomerulosa that makes aldosterone

60
Q

high prolactim
low testosterone
low LH and FSH

dx

A

o High prolactin – inhibit normal gonadotrophin axin
o So prolactinoma
o Cabergoline treatment /bromcriptine less

61
Q

high prolactin
high iGF2
OGTT - failure suppression of GH

A

o Acromegaly
o High IGF1, excess GH secretion by pit tumour – high GH cause release of IGF1 from liver
o Some tumours co-secrete PRL
o Normal people suppress Gh when give glucose
o Tumour won’t respond to oral glucose
o Initial treatment – surgery

62
Q

low oestradiol

FH and LSH are high

A

reduced feedback to LH and FSH

Premature ovarian insufficiency

63
Q

• Low T4 high TSH and PRL

A
  • Myxoedema -hypothyroidism autoimmune damage to thyroid – low -ve feedback
  • TRH high from low -ve feedback – high TRH stim prolactin
  • So this is primary hypothyroidism
64
Q

thyroiditis presentation

A

o In thyroiditis – hyperthyroid initially present like Graves (thryrotoxic) , later hypo

65
Q

TFT in multinodular goitre

A

normal

66
Q 
60 yr old man
Confused
Cough
No postural hypotension
Na+: 120
K+: 4.0
TFTs: normal
SST: normal
Urine Na+: 40
Urine osmolality: 400

what test do you want next

A

CXR

o Hyponat because of excess water – because more ADH, may be appropriate or inappropriate
o If in response to physiological stim = adh – appropriate
o If lung cancer secreting ADH = inappropriate
o Want to know fluid state – are they hypovol because that would stim ADH = appropriate eg d/v or diuretic – then urine Na will be low – so kidneys hang onto salt and water
o Euvolaemic – not hypotensive – have endocrine causes: hypothyroidism, adrenal insufficiency, SIADH – need to do TFT, short synacthen test, plasma and urine osmolarity
o Hyeprvol – HF and liver failure, nephrotic syndrome - fluid overload and low urine Na
o No post hypotension – not hypovolaemic
o Urine Na is high – so not hypovolaemic
o Euvolaemic
o Lwo na = confusion
o 3 causes of euvolaemic – hypothyroid, adenal insuf, SIADH – TFT normal, SSt normal so adrenal normal, so left with SIADH – so want to exclude lung cancer and path in brain so want to do CXR and brain MRI
o Pt got a cough sso go for CXR because localising syumptoms and also easier to get than brain MRI
o Low Na – 9am cortisol (decline during the day) and TFT

67
Q

why low urine Na in hypervolaemic hypernatraemia

A

secondary hyperaldosteronism
Because of HF in hypervol – reduced renal perfusion – trick kidneys into thinking not a lot of vol = stim RAAS = retain Na and water – reduced effective circulating vol
• in HF – reduced CO – reduced blood pressure detected by baroreceptors – signal to hypothal to make more ADH = excess ADH because of low pressure from low CO – more adh = more water retention = hyponatraemia

68
Q

causes of hyponatraemia

A

almost all due to high ADH
rare:
Excess water intake
Sodium-free irrigation solutions (e.g. used in TURP)

69
Q

causes of SIADH

A

cns path
lung path
Drugs (SSRI, TCA, opiates, PPIs, carbamazepine)
Tumours

70
Q

indications that pt hypervolaemic

A

peripheral oedeman and signs of HF – pulse, BP lying standing
look at tissue turgor and mucous membranes

71
Q

why is euvolamic high Na in urine

A

• SIADH = excess water retention = expansion in heart, natrietic peptides released = Na loss in urine

72
Q

plasma osmolarity in hyponatraemia

A

low - because low na

DPD (38 decks)

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