Interactive cases 4

Question 1

Causes of thrombocytopaenia

Answer 1

Fever, rigor, increased PR interval, reduced BP, chest pain, dark urine

1. Reduced production (bone marrow disorders)
2. Increased use (DIC)
3. Pooling of spleen (this occurs in liver disease as the spleen enlarges due to portal hypertension, and then platelets can pol there!)

Question 2

DDx for micro and normocytic anaemia

Answer 2

Microcytic: Fe deficiency anaemia, beta thalassaemia heterozygosity

Normocytic: Anaemia of chronic disease. Normal/high ferritin

Question 3

Why might ferritin be high in anaemia of chronic disease

Answer 3

Because it’s an acute phase reactant

Question 4

High ferritin and desaturation on exercise, SoB

Answer 4

PCP (pneumocystic pneumoniae)

Question 5

Ddx macrocytic anaemia

Answer 5

Alcohol excess

Myelodysplasia

Hypothyroidism

Liver failure

Folate/b12 deficiency

Alcoholics May Have Liver Failure

Question 6

Clues that macrocytic is a result of each of the following

Alcohol excess

Myelodysplasia

Hypothyroidism

Liver failure

Folate/b12 deficiency

Answer 6

EtOH: Hx, raised GGT

Myelodysplasia: pancytopaenia, bone marrow

Hypothyroidism: Hx (lethargy, constipation, weight gain), low T4, high TSH

Liver failure : Hx/exam

Folate/b12 deficiency: Hx, small bowel disease, gastrectomy

Question 7

Presentation of polycythaemia

Answer 7

Headache,

pruritis after hot bath,

blurred vision (hyperviscosity)

tinnitus

Thrombosis (stroke, dvt)

gangrene

choreiform movements

Question 8

Sickle cell anaemia: list possible crises

Answer 8

Acute painful

Stroke

Sequestration crises (RBC pooling)

Gall stones/chronic cholecystitis

Question 9

List the 2 types of sequestration crises in SCA and the symptoms of each

Answer 9

– Lung (SOB, cough, fever)

– Spleen (exacerbation of anaemia)

Question 10

Management of each of the following sickle cell crises:

Acute painful
Stroke (IMPORTANT)
Sequestration (lung?spleen?)
Gallstones/chronic cholecystitis

Answer 10

Acute painful:

• Analgesia
• o2
• IV fluids Abx

Stroke:
-Exchange blood transfusion

Sequestration:
Splenectomy

Gallstones/chronic cholecystits: cholecystectomy

Question 11

Multiple myeloma features

CRABIC

Answer 11

Calcium (high). Leads to nephrogenic diabetes insipidus: polyuria, polydipsia. Constipation too.

Renal failure: Urea and creatinine

Anaemia: breathlessness, lethargy, FBC

Bone (pain, osteoporosis):
fracture, bone pain, DXA

Infection

Cord compression

Question 12

What might you detect in the urine in multiple myeloma

Answer 12

Bence Jones proteins

Question 13

Which bone cells make ALP

Answer 13

Osteoblasts

Question 14

Hypercalcaemia, low PTH, backache, normal ALP

Answer 14

Multiple myeloma (it’s the exception because it suppresses osteoblasts, which usually produce ALP!)

Question 15

If there’s high calcium, low PTH, backache and normal ALP what’s the diagnosis

Answer 15

It’s multiple myeloma

Question 16

If there’s high calcium, low PTH, backache and high ALP what’s the diagnosis

Answer 16

In this case it’s likely to be malignancy (not MM)

Question 17

Anaemia associated with high reticulocyte count

Answer 17

Haemolysis

Acute blood loss

Question 18

Anaemia with low reticulocyte?

Answer 18

Parvovirus b19 infection

Aplastic crisis in patients with sickle cell anaemia

Blood transfsuion

Question 19

What conditions are associated with parvovirus 19 infection in:

children
adults
those with sickle cell

Answer 19

children: slap cheek ( Fifth disease or erythema infectiosum)
adults: arthraligas

sickle cell: aplastic crisis (the virus causes a reduced production of RBCs in everyone. This is fine for people if their RBCs have a normal lifespan, but in people with SCD, and also hereditary spherocytosis, the RBCs have reduced life span so they can go into an aplastic crisis)

Question 20

How is diabetes diagnosed

Outline OGTT

Answer 20

> 7 on fasting

> 11.1 on random.

Impaired glucose tolerance. 75g OGTT. 2hr glucose: 7.8-11

Question 21

-gliclazide?

Answer 21

Sulphonyureas

Question 22

-gliptin?

Answer 22

DPP4-inhibitor

Question 23

-itide

Answer 23

GLP-1 agonist

Question 24

-flozins

Answer 24

SGLT2 inhibitors

Question 25

How do you measure nephropathy and what do you do if they have it

Answer 25

ACR.... check at the lab! You can put them o`n ACEi

Question 26

How to manage hypoglycaemia

Answer 26

Conscious: get them glucose to drink, and then a long acting carb for after Confused- gel Unconscious: IV glucagon or IV glucose 20%

Question 27

What is sliding scale insulin

Answer 27

When patient is not eating or unwell (surgery, sepsis) Variable rate IV insulin infusion

Question 28

What is pretibial myxoedema, what is myoedema

Answer 28

pretibial myxoedema is the rash seen almost always in Grave's (also rarely in hashimotos) myxoedema means underactive thryoid

Question 29

What type of thyroid cancer particularly metastases to the lungs

Answer 29

Follicular

Question 30

What is the most appropriate treatment of prolactinoma

Answer 30

Cabergoline Don't operate with trans-sphenoidal surgery unless it's really really refractory

Question 31

What is the initial test if you think they have acromegaly, what is diagnositc

Answer 31

INITIAL TEST is IGF1 Then you go on to do a OGTT

Question 32

Weight gain, depressed, central obesity, fatigue. Are they likely to have cushings

Answer 32

No.... this describes a lot of the population! Don't start investigating for cushing's if the pre-test probability is low because you get a lot of false positives and the patient may be labelled as having cushings when they actually don't

Question 33

What are the discriminatory features of cushings

Answer 33

Purple stretch marks Bruising Myopathy DM, HTN osteoporosis AT A YOUNG AGE

Question 34

Causes of amenorrhoea

Answer 34

``` Pregnancy Hypothalamus Pituitary Thyroid (hyper/hypo) Ovaries (PCOS/ovarian failure) ```

Question 35

``` What would the investigations for the following: Pregnancy Hypothalamus Pituitary Thyroid (hyper/hypo) Ovaries (PCOS/ovarian failure) ```

Answer 35

``` Pregnancy- urine bHCG Hypothalamus- ?Excessive thirst, low BMI Pituitary- excess prolactin/low FSH/LH Thyroid (hyper/hypo)- TFTs Ovaries (PCOS/ovarian failure) - excess androgens (or hirsutism), high FSH ```

Question 36

How can hypothalamus cause amennorrhoea

Answer 36

Too much exercise and low BMI causes amenorrhoea

Question 37

Causes of pituitary amenorrhoea

Answer 37

Prolactinoma or pituitary adenoma that is reducing LH/FSH secretion

Question 38

Presentation of hypokalaemia

Answer 38

Polyuria (it causes nephrogenic diabetes insipidus, like hypercalcaemia does!) Weakness Arrhythmia

Question 39

DDx for hypokalamaemia

Answer 39

Primary hyperaldosteronism (Conn's--> look at aldosterone:renin ratio) GI: vomiting Diuretics

Question 40

Causes of hypernatraemia when urine osmolality is high

Answer 40

High plasma osmolarity- 572 Due to dehydration or HHS (urine high osmolarity glycosuria)

Question 41

Causes of hypernatraemia when the urine osmolality is low

Answer 41

Diabetes indipidus (DIlute urine osmolarity <300)

Question 42

Low calcium, high phosphate, high PTH Low calcium, low phosphate, high PTH

Answer 42

PTH is phosphate trashing hormone! So if phosphate is low then it means PTH is effectively excreting it. The calcium is low due to vit D deficiency. So the second one is vit D deficiency. In the first one, the phosphate is high. So why is the phosphate high, even though PTH is meant to excrete phosphate. It's because the kidneys fail to excrete phosphate. But calcium is low because there is low levels of ACTIVATED vit D (due to reduced hydroxylation in the poorly functioning kidney) leading to low calcium. PTH will go up due to a reduced -ve feedback response. BUT phsopahte is not excreted because of the kidney failure

Question 43

Someone recently put on ACEi, and had a deterioration of renal function. Finding of asymmetrical kidneys on ultrasound.

Answer 43

BILATERAL renal artery stenosis

Question 44

Gold standard investigation for RAS

Answer 44

Magnetic resonance angiography

Question 45

Should CO2 and bicarbonate be going in the same direction?

Answer 45

Yes. If CO2 is going up, then you would expect bicarb to go up If CO2 is going down you would expect bicarb to go down.

Question 46

What if co2 is going up but bicarb is going down

Answer 46

If the co2 and bicarb are going in different directions, we know there is MIXED PICTURE. I.e. there must be an element of respiratory and metabolic disturbance

Question 47

Investigations for thyroid cancer

Answer 47

1. USS 2. FNAC 3. Uptake scan Discuss at MDT