General medicine: CL Lai Session 2 Flashcards
Mx of diabetic ketoacidosis?
- Hydration
- IV bolus insulin. When BG <14mmol/L, change to D5 and decrease dose of insulin
- K
- NaHCO3 supplement
Mx of hyperK
- Calcium gluconate 10ml IV over 2-3 mins with cardiac monitoring
- Dextrose insulin infusion
- NaHCO3- (as often associated with acidosis: can be renal failure)
Commonest causes of liver abscess?
Treatment?
Cholangitis (can be PBC), DM
Tx: IV 3rd gen cephalosporin and gentamicin (enhance response of 3rd gen cephalosporin) given for 4-6 weeks.
* If patient responsive can change to oral afer 2 weeks. Monitor by body temperature, WCC, CRP and USG
* For indian, amoebic coverage may be needed
* Drainage
* Surgery (segmentectomy) if not successful
What are the drugs to treat hypertension and AE?
- ACEI: cardioprotective and renoprotective. AE: hyperK, hypoglyc, angioedema, dry cough
- ARB. AE: dry cough
- B blocker (given after managing heart failure as will improve mortality rate). SE: bradycardia, bronchospasm, hides the effect of hypoglycemia)
- CCB. AE: ankle swelling
- Thiazide diuretics for moderate hypertension. AE: hypoK, may precipitate gout
- Alpha blocker seldomly used: can be used in severe hypertension –> used in phaeochromocytoma
- Methyldopa. AE: autoimmune hepatitis, AIHA
Causes of protein losing enteropathy?
Important to do urine analysis to see if urine loss
What are the Ix for protein losing enteropathy?
- Alpha1-antitrypsin clearance: calculated from fecal and serum levels of alpha1-antitrypsin. It is a
relative high molecular weight protein which is easily measurable. Need to measure over 5 days
because of daily variability - I-125 rdiolabelled albumin injection: measure fractional loss into feces. Can indicate the approximate site of protein loss. However it needs special ordering and it is harder to do.
Mx of protein losing enteropathy
- Endoscopy (capsule, balloon enteroscopy) or MRI
- Endoscopic ultrasound aspiration of mesenteric LN (to prove lymphangiectasia)
- Can stain LN with methylene blue
- Try steroid in view of the autoimmune etiology. Budesonide is good due to its first pass effect and little systemic effect
- Need to add K due to mineralocorticoid effect
Causes of hypercalcemia
- Primary or tertiary hyperparathyroidism
- Hypercalcemia of malignancy (bone metastasis or paraneoplastic): multiple myeloma/lymphoma (any malignancy involving bone)
- Sarcoidosis
- Pagets disease
- Familial hypocalciureic hypercalcemia
Causes of increased AFP
- HCC
- Germ cell tumor (surgical)
- Exacerbation of chronic HBV (regeneration): as AFP produced by fetal hepatic cells
- Pregnancy
- Puberty
When there is increased AFP what Ix to different chronic HBV reactivation and HCC?
- LFT (if reactivation AST and ALT will be high, in HCC liver enzymes may not increase)
- USG
- Serial AFP (measure in 1-2 weeks to see if reduces as AFP half life = 3-6 days)
Causes of secondary hypertension
- Renal causes: renal parenchymal diseases, renal artery stenosis
- Arterial: coarctation of aorta, takayusas vasculitis
- Endocrine: phaeochromocytoma, conns syndrome
PE for secondary hypertension
- Cafe au lait complexion and signs of fluid retention
- Auscultate for renal artery stenosis (midpoint between xiphisternum and umbilicus: 1-2cm lateral from midline)
- Ballotable kidneys (polycystic kidney)
- Radiofemoral delay (coarctation of aorta)
- Cushingoid features
Ix for secondary hypertension?
- LFT
- RFT: hypoK (periodic paralysis due to hypoK) and metabolic acidosis (conns syndrome)
- USG kidneys (size)
- Dopper USG if suspect renal artery stenosis (caused by atherosclerosis/fibromuscular hyperplasia)
- Differential renal function test (DTPA): to compare the left and right kidney. Delay in appearance of the DTPA in affected side, delayed disappearance and increased concentration
