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DPD 2019 > Cases in general internal medicine 2 > Flashcards

Cases in general internal medicine 2 Flashcards

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1
Q

At what level of Hb would you probably see SoB at

Why might you have a raised JVP in COPD

A

Below 80

Because of right heart failure secondary to pulmonary hypertension secondary to COPD

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2
Q

Onset of breathlessness; seconds

A
  • Pneumothorax
  • PE
  • FB (foreign body! Don’t forget this one)
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3
Q

Onset of breathlessness; mins/hrs

A
  • Airways (inflammation/obstruction)
  • Chest infection (pus)
  • Acute heart failure (fluid)
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4
Q

Onset of breathlessness; days/weeks

A

These(chronic/not resolving):

  • Airways (inflammation/obstruction)
  • Chest infection (pus)
  • Acute heart failure (fluid)

AND:

  • Interstitial lung disease
  • Malignancy/ Large pleural effusion
  • Neuromuscular
  • Anaemia/ Thyrotoxicosis
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5
Q

What is a primary pneumothorax

A

A primary spontaneous pneumothorax is one that occurs without an apparent cause and in the absence of significant lung disease

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6
Q

What is the management of primary pneumothorax

A

< 2 cm:
– Discharge, repeat CXR

> 2 cm OR THEY HAVE SOB:
– Aspiration
– If unsuccessful: chest drain

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7
Q

What is management of secondary pneumothorax

A

< 2 cm:
– Aspiration

> 2 cm:
– Chest drain

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8
Q

What could cause breathlessness after a chest drain insertion

A

Re-expansion pulmonary oedema

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9
Q

What is are lung bullae

A

A bulla is a permanent, air-filled space within the lung parenchyma that is at least 1 cm in size and has a thin or poorly defined wall;

NOT to be confused with pneumothorax!

You wouldn’t put a chest drain in for bullae.

Aka vanishing lung disease

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10
Q

When can it be called asbestosis

A

You can only call it asbestosis when there is pulmonary fibrosis

Asbestos lung disease gives you plaques, but this is not asbestosis

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11
Q

What are the types of opacity on xray and what are their respective DDx

A
  • Interstitial/alveolar shadowing (=fluid, pus, blood)
  • Reticulo‐nodular shadowing (fibrosis)
  • Homogeneous shadowing (pleural effusion)
  • Masses/cavitations
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12
Q

If a patient has a PE what drug do you think about in the first instance

A

LMWH (e.g. dalteparin)

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13
Q

If the x ray is very white, what can you say about penetration

A

Too white= underpenetrated

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14
Q

Should you be able to see the left hemidiaphragm behind the heart?

A

Yes you should! If you can’t, there’s something going on (e..g tumour or consolidation)

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15
Q

Air fluid level on X-ray/CT and reduced BS, hyper-resonant percussion notes

A

Bullous disease. Do not put drain in

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16
Q

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A

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17
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A

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18
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19
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20
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21
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22
Q

ABDO…..

A

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23
Q

Causes of hepatomegaly

A 
• Cancer (primary or secondary deposits)
• Cirrhosis (early, usually alcoholic)
• Cardiac:
– Congestive cardiac failure
– Constrictive pericarditis

Infiltration

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24
Q

Give examples of infiltration causing hepatomegaly

A

Fatty infiltration, haemochromatosis, amyloidosis,

sarcoidosis, lymphoproliferative diseases

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25
Causes of liver disease
``` Alcohol • Autoimmune • Drugs • Viral • Biliary disease ```
26
Causes of splenomegaly
H (portal Hypertension) H (Haematological) Infection Inflammation
27
* 75 year old man * Epigastric pain * Back pain * PR: 130 bpm * BP: 80/50 mm Hg Likely diagnosis? ``` A. Peptic ulcer B. Pancreatitis C. Gastritis D. GORD E. Ruptured aortic aneurysm ```
E. Ruptured aortic aneurysm
28
Endo causes of acute abdominal pain
DKA | Addison's
29
Epigastric pain DDx
Peptic ulcer Gastritis GORD Malignancy Acute pancreatitis MI ALSO: ``` • Above (heart) – MI • Below (Aorta) – ruptured aortic aneurysm • Right: (liver/gall bladder) – Cholecystitis – Hepatitis ```
30
What things point to acute pancreatitis
* Pain | * High amylase
31
What is the test for chronic pancreatitis
``` Normal amylase Faecal elastase (so need a stool sample) ```
32
What things point toward chronic pancreatitis
Pain, wt loss • Loss of exocrine function • Loss of endocrine function
33
5 causes RUQ
Gall bladder: – Cholecystitis – Cholangitis – Gallstones Liver: • Hepatitis • Abscess ``` Above (lungs) – Basal pneumonia Below (appendix) – Appendicitis Left (Stomach, pancreas) – Peptic ulcer, Pancreatitis Right: (kidney) – pyelonephritis ```
34
When ballotting the kidney you need to put your hand right under the back and press on the right upper quadrant
.....
35
RIF pain
``` GI – Appendicitis – Mesenteric adenitis – Colitis (IBD) – Malignancy ``` Gynae – Ovarian cyst rupture, twist, bleed – Ectopic pregnancy
36
Suprapubic pain
* Cystitis | * Urinary retention
37
LIF pain
GI Diverticulitis Colitis (IBD) Malignancy Gynaecological Ovarian cyst rupture, twist, bleed Ectopic pregnancy
38
Causes of diffuse abdo pain
Obstruction Infection: Peritonitis, Gastroenteritis Inflammation: IBD Ischaemia: Mesenteric ischaemia ``` Medical causes DKA Addison’s Hypercalacemia Porphyria Lead poisoning ```
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42
Ascites with cells greater than what is consistent with SBP
>250 cells/mm3
43
3 causes of abdo distension
1. Fluid (ascites- shifting dullness + signs of chronic liver disease) 2. Flatus (obstruction) 3. Fat, faeces, fetus
44
Signs of obstruction
``` Nausea, vomiting Not opened bowel High-pitched tinkling BS ?Previous surgery (adhesions) ?Tender irreducible femoral hernia in the groin ```
45
Types of ascites
Transudate Exudate
46
Types of transudate ascites
Cirrhosis Cardiac failure Nephrotic syndrome
47
Types of exudate ascites
Remember this is calculated using SAAG Malignancy (abdominal, pelvic, peritoneal mesothelioma) Infection: e.g. TB, pyogenic EXCEPTIONS (these are due to low serum albumin rather than high ascites alubimin) Budd–Chiari syndrome (hepatic vein thrombosis), portal vein thrombosis
48
Classify jaundice with causes of each
Pre-hepatic -Haemolysis, defective conjugation Hepatic -Hepatitis Post hepatic -CBD Obstruction
49
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51
Investigation to do for bloody diarroeah?
MSC of the stools to look for the bacteria below
52
Blood diarroea causes
Infective colitis Inflammatory colitis Ischaemic colitis Diverticulitis, Malignancy
53
Bacteria causing infective colitis
``` Campylobacter Haemorrhagic E coli Entamoeba histolytica Salmonella Shigella ```
54
Who is inflammatoy colitis (IBD) common in, and who is it more common in
Young, Extra-GI manifestations
55
Who is ischaemic colitis present in
Elderly
56
Obsructed bowel what blood markers could be high
Lactate and CK
57
Management of acute GI bleeds What if you find it is a variceal bleed When do you give antibiotics
``` ABC IV access Fluids G&S, X-match blood OGD ``` Variceal bleed - Antibiotics - Terlipressin
58
Investigations for acute abdomen
FBC, U&Es, LFTs, CRP, Clotting, G&S, X-match Erect CXR CT
59
Management of acute abdomen
``` NBM Fluids Analgesic Anti-emetics Antibiotics Monitor vitals & UO ```
60
Investigation for jaundice
Bloods: FBC, LFTs, CRP Abdominal USS after a fast (gallstones better visualized in a distended, bile-filled gallbladder)
61
Investigations for dysphagia and weight loss
OGD & Biopsy
62
Investigations for PR bleed and wt loss
Colonoscopy
63
Management of ascites
Diuretics (spironolactone ± furosemide) Dietary sodium restriction Fluid restriction in patients with hyponatraemia Monitor wt daily Therapeutic paracentesis (with IV human albumin)
64
What calculation should you do for ascites and what can it tell you
The gradient Serum albumin-ascites albumin: >11g/L: Cirrhosis, Cardiac failure <11 g/L: TB, Cancer, (Nephrotic syndrome)
65
Why will the gradient between serum albumin and ascites albumin be low in nephrotic syndrome
Becuse the serum albulin is low because you leak proteins into the urine
66
How do you manage encephalopathy
Lactulose Phosphate enemas Avoid sedation Treat infections Exclude a GI bleed
67
Why would you want to exclude a GI bleed in encephalopathy
Because someone with chronic liver disease is prone to a GI bleed, and the blood will act as a substate for bacteria in the GI tract to metabolise and produce toxins from
68
Why do you give lactulose in encephalopathy
To reduce transit time so that there is less time for bacteria to make toxins
69
Post-op care complications in abdo surgery
Wound infection Anastomotic leak Pelvic abscess e.g. post-appendectomy
70
What are the featres of wound infection
Erythematosus | Discharge
71
What are the features of an anastomotic leak
Diffuse abdo tenderness Guarding, rigidity Hypotensive/tachycardic
72
What are the features of pelvic abscess (e.g. post-appendectomy)
Pain, fever, sweats, mucus diarrhoea
73
Presentation and treatment of a perianal abscess
Tender, red swelling | Incision & drainage
74
Presentation and treatment of an anal fissure
Rectal pain (defaecation) Stool coated with blood Advice re diet (fluids, fibre) GTN cream
75
Presentation of IBS
Recurrent abdo pain, bloating Improves with defecation Change in the frequency/form of stool
76
What red flags might be seen with IBS
No PR bleed, anaemia, wt loss or nocturnal symptoms, exclude Coeliac
77
A good question to ask somebody you suspect to have IBS/IBD
Is there nocturnal symptoms | IBD have them IBS don't
78
Treatment for IBS
Diet & Lifestyle modification Symptomatic treatment: - Abdo pain: antispasmodics - Laxatives for constipation - Anti-diarrhoeals
79
Respiratory assocaited symptoms to ask about?
WBC: Wheeze, breathlessness, cough (then leads you onto... ) sputum, haemoptysis, weight loss Chest pain
80
What is ciclosporine main side effect
Use as immunosuppresant following renal trasplant Cause gum hypertrophy
81
Retrosternal pain with high alcohol consumption
Gastritis

DPD 2019 (30 decks)

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