Medical Complexity

Question 1

1. 46 yr old Sarah attends the GP with tiredness. On review of systems she complains of palpitations, shortness of breath and menorrhagia. Her blood test results are as follows

Na 136 (135-145)

K 3.8 (3.5-5)

Urea 5.6 (2.5-8)

Creatinine 88 (70-150)

Free T4 18 (12-22)

TSH 3.6 (0.2-4.2)

WBC 6.2 (3.6-11)

Hb 88 (115-165)

MCV 68 (80-100)

Based on the results above which one of the following tests would you request next to establish the cause of her abnormal blood results?

Answer 1

Ferritin

Question 2

82 yr old Tom is visited at home after his carers reported that he was acting strangely. On examination his vital signs were:

Heart rate 86 bpm regular,BP 135/88mmHg, Temp 37.4, Sats 98%ra, Cap blood sugar 3.2mmol.

Which of the following medications is the likeliest cause for his hypoglycaemia?

Metformin

Simvastatin

Gliclazide

Ramipril

Warfarin

Answer 2

Gliclazide

Question 3

35yr old Jane attends the GP complaining of lightheadedness. She notices her legs feel weak on standing and she feels that her peripheral vision becomes blurred. Jane denies any palpitations.

She has T1DM and has checked her blood sugar during an episode and ruled out hypoglycaemia.

On examination she is noted to have a postural drop in her blood pressure and pigmentation in a recent surgical scar.

The GP suspects Addison’s disease. Which of the following investigations should the GP request to confirm his diagnosis?

Answer 3

Serum cortisol

Question 4

Symptoms of Addison’s disease

Answer 4

Symptoms of Addisons Disease:

• insidious
• weakness
• weight loss
• lethargy
• anorexia
• abdominal pain
• nausea / vomiting
• hyperpigmentation (ACTH cross reacts with melanin receptors)

Question 5

Biochemistry of Addison’s disease

Answer 5

• Low cortisol
• low glucose
• low sodium
• high potassium

Question 6

What’s synachten test?

Answer 6

Synacthen Test

test blood plasma cortisol before and 30 minutes after synthetic ACTH

Inadequate rise in cortisol = adrenal failure → Addison’s disease

Question 7

45yr old Michelle is told to see her GP after she is found to have a blood pressure of 178/98mmHg at a work’s medical. The GP checks her blood pressure and it is normal at 128/78mmHg. Michelle thinks that it is her anxiety. She has had some palpitations with associated sweating which she had attributed to panic attacks. Michelle has also had some headaches. On reviewing her notes Michelle has documented intermittent hypertension for the past 3 years. Which of the diagnoses could explain Michelle’s symptoms?

Answer 7

Phaeochromocytoma

Question 8

Diagnosis of phaeochromocytoma

Answer 8

• excess catecholamines in urine / blood – plasma and urine metanephrines
• CT scan demonstrating tumour

Question 9

Symptoms of phaeochromocytoma

Answer 9

• headaches
• sweating
• palpitations
• hypertension

Question 10

67yr old Joan presents to her GP with tiredness, weight loss and pain in her limbs. She has noticed difficulty in pegging her washing up on the line and getting up out of the chair. On examination, she has Heberden’s nodes, no synovitis. She has tenderness on palpation of the proximal muscles of the arms and legs. Which of the investigations should the GP request to confirm the diagnosis?

Answer 10

ESR

(suspected polymyalgia rheumatica)

Question 11

56yr old Mary presents to her GP for help to lose weight. Her BMI is 40 and she has tried various diets without success. Mary reports that she gained the weight quickly 5 years ago. She has a past medical history of hypertension for which she is on 4 agents, T2DM and osteoporosis. On examination her BP is 156/98, she has vivid purple stretch marks to her abdomen, thighs and arms. The GP also notices central obesity and hirsutism.

Which of the following investigations should the GP request to confirm the diagnosis?

Answer 11

24 hrs urinary cortisol

(Cushing Syndrome suspected)

Question 12

Metanephrines are measured in suspicion of what?

Answer 12

Phaeochromocytoma

Question 13

Urinary 5 HIAA is measured in suspicion on what?

Answer 13

detection and monitoring of carcinoid tumour

Question 14

53 yr old Anne presents to her GP with a five month history of double vision, which is worse in the evening and when she is tired. Her voice has weakened and is quieter. She has lost 6kgs as she is finding it difficult to chew and swallow. On examination she has bilateral ptosis. Her power, sensation, reflexes and coordination is normal in all four limbs. Examination of the heart and lungs is normal.

Whatis the most likely diagnosis for her symptoms?

Answer 14

Myasthenia Gravis

Question 15

What syndrome can present with Pancoast tumour?

Answer 15

Pancoast Tumour can present with Horners syndrome (ptosis, miosis, hemianhidrosis, enophthlamos)

Question 16

Pathophysiology of Myasthenia Gravis

Answer 16

• muscle weakness increases during periods of activity and improves after rest
• Antibodies block receptors for acetylcholine at neuromuscular junction preventing muscle contraction

Question 17

45yr old John presents to his GP with a four month history of anorexia and weight loss of 8kgs. He has dyspepsia controlled by Lansoprazole 30mg od. He denies any dysphagia, or any change in bowel habit. He admits to drinking 24 units a week. On examination he has pitting oedema bilaterally to both knees. His JVP is not raised. His abdomen is distended with a fluid thrill. Examination of the heart and lungs are normal.

Hb 137 (135-170)

Albumin 26 (35-50)

BNP normal

MCV 103 (80-100)

Bilirubin 25 (3-17)

Plts 161 (150-400)

ALT 276 (5-35)

Na 135 (135-145)

GGT 873 (4-50)

K 4.2 (3.5-5)

Alk Phos 357 (30-150)

Urea 2.2 (2.5-6.7)

Creat 101(70-120)

Urine dip- no blood or protein

What is the most likely diagnosis in John’s case?

Answer 17

Liver failure

Question 18

Causes of low urea

Answer 18

• pregnancy
• malnutrition
• severe liver disease

Question 19

64yr old David is seen in Haematology clinic regarding an Hb of 132 (135-180).MCV, MCHC are all normal.Due to patient anxiety the GP has already arranged an OGD and a colonoscopy, which were all normal.Urine dip is also normal.David has requested the referral to Haematology.He has been requesting blood tests every month from his GP to monitor his Hb; which has remained stable.

What is the most likely diagnosis in David’s case?

Answer 19

Hypochondriasis

Question 20

What’s conversion disorder?

Answer 20

Conversion disorder: psychological stress produces physical symptoms e.g. blindness, paralysis

Question 21

What’s hypochondriasis?

Answer 21

Hypochondriasis: Health anxiety, worry about serious illness

Question 22

What’s somatization?

Answer 22

Somatization: psychosomatic – expression of mental anguish as physical symptoms e.g. pain, neurological or GI symptoms

Question 23

Peter Arnold is a 67yr old man who presents with a history of diarrhoea for 8 weeks. He describes loose stool three times a day which is unusual for him. He denies any bleeding or weight loss. His appetite is good. 6 weeks ago he was assessed by another doctor who felt his symptoms could be due to his Metformin. His Metformin was therefore stopped. Despite this his diarrhoea continues. He denies any other symptoms and feels otherwise well.GI examination is normal.

What needs to be done for the patient and what to do in regards to his metformin?

Answer 23

• He can restart his Metformin as this is unlikely to be causing his diarrhoea
• He needs an urgent referral to the colorectal clinic

Question 24

52 yr old Diane attends her GP surgery complaining of an 8-month history of dizziness. She has been reviewed five times by five different doctors. She has tried Betahistine and had the Epley manoeuvre carried out all with no benefit.

She denies any vertigo and struggles to explain her symptoms. She mentions feeling ‘empty’. Her sleep is disturbed and she wakes up in the early hours of the morning. Even when she has had a good night’s sleep she feels ‘slowed down’ and even minor everyday tasks are too much effort. She has stopped going to the bingo with her friends, blaming being ‘too tired after working all day’. Diane feels guilty that she can’t spend enough time with her family as she has to look after her frail parents, and work to pay the mortgage.

List 3 features Diane’s history that would suggest depression. (3)

Answer 24

• Poor sleep with early morning wakening
• feeling guilty
• stopping socialising/ minor tasks too much effort – lack of interest/ motivation/ enjoyment
• Feeling physically ‘slowed down’

Question 25

Differentials for vertigo

Answer 25

• Labyrinthitis
• Meniere’s disease
• BBPV
• Acoustic neuroma
• TIA/ stroke
• migraine

Question 26

Non-pharmacological management of depression

Answer 26

Exercise, psychology referral: talking therapy/ CBT, self-help –on line mood gym etc.

Question 27

A 78 yr Bill presents to his GP with his wife and son. They are concerned about his memory loss. His wife describes a nine-month history of stepwise deterioration in his memory. His past medical history includes hypertension, hypercholesterolemia and TIAs. He is an ex-smoker of 40 a day.

Given the history above what is the specific diagnosis in Bill’s case?

Answer 27

Multi infarct/vascular dementia

Question 28

What investigations to request in order to exclude reversible causes of dementia/memory loss?

Answer 28

• TFTs
• folate
• B12
• MRI – space occupying lesions, normal pressure hydrocephalus

Question 29

What Mental State Examination score out of 30 would indicate memory impairment?

Answer 29

Less than 24

Question 30

Complications of advanced dementia

Answer 30

• pressure sores
• increased rates of infection
• difficulties with communication
• behavioural changes
• loss of mobility
• incontinence
• weight loss
• aspiration pneumonia

Question 31

What does it mean ‘medically unexplained symptom’?

Answer 31

• A physical symptom for which no organic cause can be demonstrated
• Consider in any patient who has physical symptoms, present for 3 months or more that are affecting functioning but that cannot be readily explained
• May also be described as having ‘functional’ or ‘somatoform’ disorders

Question 32

(3) main types of medically unexplained symptoms

Answer 32

• Pain in specific location e.g. back pain, headache
• Functional disturbance in a particular organ e.g. IBS, palpitations
• Disorders related to fatigue and exhaustion e.g. chronic fatigue

Question 33

Common medically unexplained symptoms

Answer 33

• Pains in the muscles or joints
• Back pain
• Headaches
• Tiredness
• Feeling faint
• Chest pain
• Palpitations
• Abdominal symptoms - pain, feeling bloated, diarrhoea and constipation.
• Others include collapsing, fits, breathlessness, weakness, paralysis, numbness and tingling

Question 34

What to ask in Hx of a patient with the suspected medically unexplained symptom?

Answer 34

• History of current complaint, how is it affecting them
• Explore their ideas, concerns and expectations
• Has there been any recent life events?
• Does the patient have any mood/anxiety symptoms?
• Examine the patient are there any signs of disease?

Question 35

What’s the abnormality?

Answer 35

Rheumatoid nodules

Question 36

Answer 36

Cushing’s, striae

Buffalo hump, moon shaped face, central obesity, proximal myopathy, Hirsutism, baldness/ thin hair

Question 37

Answer 37

• Ulnar nerve lesion
• lack of innervation to the small muscles of the hand

Question 38

Answer 38

Fibromyalgia trigger points

Question 39

What’s the abnormality?

What else would you examine?

Answer 39

• Nail pitting → secondary to psorasis
• Examine extensor surfaces

Question 40

Answer 40

Claw toes, loss of hair, dry skin, callus formation, loss of sensation, ulcer formation

Causes: Alcohol, b12 def, diabetes, leprosy, HIV, trauma to the nerve, chemo, myeloma, rheumatoid, heavy metal poisoning