SBA 5

SBA 5

Multiple Choice

A 47 year old man is complaining of nausea and vomiting, swollen legs and left sided back pain over the last few days. The patient describes a history of sometimes seeing red or dark urine over the past 6 months with gradually smaller amounts being passed in the last few days. He has not passed any urine in the last 24 hours. Ultrasound finding shows a gross hydronephrosis and dilatation in the left kidney. What is the most appropriate initial management?

• IV furosemide to increase urine output

• CT scan of the abdomen and pelvis so definitive surgical correction can be undertaken and any tumour removed

• Placement of a left nephrostomy tube to relieve obstruction of the left kidney

• An intravenous urogram to allow the level of obstruction to be assessed

• Intravenous fluid 500ml bolus to restore the fluids in the body

Explanation

Answer is C. He placement of a left nephrosotomy is the first step in managing this patients obstruction. Hopefully this will improve the patients renal function and thus dialysis will be avoided. In addition the sooner the obstruction is relieved the better the long-term function of the kidney will be.

Intravenous urogram and CT abdomen, pelvis can be done after the initial management to look for underlying causes.

Acute Kidney Injury

• Rise in creatinine >26micromol/L within 48hrs

• Rise in creatinine >1.5x baseline within 7 days

• Urine output <0.5ml/kg/hr for >6hrs

Multiple Choice

A 68-year-old gentleman presents with a day history of dyspnoea and productive green sputum. His past-medical history is significant for hypertension, type 2 diabetes, hypercholesterolemia and osteoarthritis. He takes ramipril, simvastatin and paracetamol as and when he needs for his osteoarthritis. He is diagnosed with community-acquired pneumonia and discharged with a penicillin-based antibiotic. He returns shortly after complaining of lower back pain, reduced urine output with dysuria. Urine dip is positive for blood and proteins. What is the most appropriate initial management?

• Take blood sample for serum creatinine

• IV fluid bolus

• Stop ramipril, simvastatin and penicillin-based antibiotics

• Renal biopsy

• Ultrasound KUB (kidney ureter bladder)

Explanation

Answer is C. Patient is having AKI, initial step is stopping all nephrotoxic drugs and treat sepsis if there is any. Investigate the underlying cause when the patient is stable.

Pre renal causes of AKI

• Hypovolaemia

• Renal artery stenosis

• Sepsis

• Shock

• Burns

Intrinsic causes of AKI

• Glomerulonephritis

• Acute tubular necrosis

• Acute interstitial nephritis

• Rhabdomyolysis

• Tumour lysis syndrome

Post renal causes of AKI

• Kidney stone in ureter or bladder

• BPH

Risk Factor of AKI

• CKD

• Other chronic diseases

• Nephrotoxic drugs (NSAIDs, aminoglycosides, ACEi, diuretics)

• Age >65

Multiple Choice

A 22-year-old man with a background of end stage renal disease uses continuous ambulatory peritoneal dialysis (CAPD) at home.

He presents to the renal unit feeling lethargic, feverish and vomiting.

What is the most likely pathogen causing this man to be unwell?

• Candida

• Escherichia coli

• Pseudomonas aeruginosa

• Mycoplasma genitalium

• Staphylococcus epidermis

Explanation

Answer is E. Coagulase-negative staphylococcal species such as Staphlyococcus epidermis are the most common pathogens causing peritonitis as they colonise the skin and hands and the patient or the carer will then contaminate the dialysis equipment inadvertently by touch.

Peritoneal Dialysis

• Continuous ambulatory peritoneal dialysis (CAPD)- 3-5 exchanges during the day and 1 with longer dwell during sleep

• Continuous cycling peritoneal dialysis (CCPD)- uses machine that performs multiple exchanges during sleep, must retain for 10-12hrs at night

Peritoneal Dialysis

Open Ended

How many types of diabetes mellitus? Please list down as much as u can.

Types of Diabetes Mellitus

• Type 1

• Type 2

• Latent autoimmune diabetes in adulthood (LADA)

• Maturity Onset Diabetes of the Young (MODY)

• Gestational

Impaired Fasting Glucose

Fasting blood glucose of 6.1mmol/L to 7.0mmol/L.

Impaired fasting glycemia (IFG) means that the body cannot regulate glucose as efficiently as it should be able to.

It has 5-15 times higher risk to develop T2DM than people with normal blood glucose.

Impaired Glucose Tolerance

Blood glucose of 7.8 mmol/L or more but less than 11.1mmol/L after a 2-hour oral glucose tolerance test (OGTT).

Impaired glucose tolerance (IGT) means that blood glucose is raised beyond normal levels, but not high enough to warrant a diabetes diagnosis.

1-3 out of every 4 people with impaired glucose tolerance will develop diabetes within a decade.

Gestational Diabetes Mellitus (GDM)

Every pregnant lady had their blood glucose checked during their first booking visit. If she is high risk or having borderline blood glucose level, OGTT is carried out during 24-28 weeks of gestation to confirm the diagnosis of GDM.

Fasting glucose : >5.6mmol/L

2-hrs post OGTT : >7.8mmol/L

Multiple Choice

A 54-year-old female has come to the GP diabetic clinic to review her medications and blood results. Up until now her HbA1c has been well controlled on metformin 1g twice-a-day. She has a past medical history of type 2 diabetes and heart failure. Today her HbA1c result is 59mmol/mol.

What is the most appropriate next step in this patient's management?

• No further management

• Increase metformin dosage

• Prescribe DPP4-inhibitor

• Start insulin

Explanation

Answer is C. You can titrate up metformin (maximum 2g/day) and encourage lifestyle changes to aim for a HbA1c of 48 mmol/mol (6.5%), but should only add a second drug if the HbA1c rises to 58 mmol/mol (7.5%).

Indication of insulin

• Acute illness or surgery

• Pregnancy

• Contraindications or failure of oral hypoglycemic agents

• Flexible therapy

Multiple Choice

A 10-year-old boy is brought in by ambulance after being found drowsy and confused by his parents this morning. He is usually fit and well with no past medical history. His glucose reading is unreadable and GCS scores 12/15. What is the most likely diagnosis?

• Meningitis

• Diabetic ketoacidosis

• Hypoglycemia

• Influenza

• T1DM

Explanation

Answer is B. DKA can present with an 'unrecordable' blood sugar measurement with confusion and abdominal pain. Its important to remember that 'unrecordable' blood glucose always means that the blood sugar is high rather than low. Therefore hypoglycaemia can be ruled out here.

Influenza and meningitis are also possible, but less likely than DKA given the abdominal pain and absence of a temperature.

-A patient with neck swelling-

Open Ended

When you see a patient coming in with neck swelling, what would be the differential diagnosis in your mind?

Causes of neck swelling

• Acute - CMV infection, EBV infection, viral URTI

• Subacute - carcinoma

• Chronic - thyroid pathology, brachial cleft cyst, lipoma

Multiple Choice

The most common thyroid disorder is

• Hypothyroidism

• Hyperthyroidism

Explanation

• The prevalence of hypothyroidism in the UK is 2%

• Thyrotoxicosis is much less common, with a prevalence of 0.4%.

Hashimoto's thyroiditis

• Destruction of thyroid cells by various cell- and antibody-mediated immune processes

• This condition causes an enlarged thyroid (goitre). The enlargement is due to infiltration of the thyroid with lymphocytes, and resultant fibrosis.

• !!! Goitre is often associated with hyperthyroidism, but in these circumstances, this is not the case.

Causes of goitre

• Diffuse - physiological, Graves' disease, Hashimoto's thyroiditis, Subacute thyroiditis

• Nodular - multinodular goitre, adenoma, carcinoma

Multiple Choice

Hypothyroidism caused by Hashimoto's thyroiditis is much more common in women than in men.

• True

• False

Explanation

• It is 10 times more common in women

• Other risk factors include having a family history of thyroid disease, being age 50 or older; or using certain medicines. You are also more at risk if you have an autoimmune disease or had radiation treatment to your neck.

Open Ended

The symptoms of hypothyroidism are

Sign and symptoms of hypothyroidism

Investigation for primary hypothyroidism

• TSH, T4

• Thyroid peroxidase antibodies

Multiple Choice

A 62-year-old woman attends her GP complaining of weight gain, lethargy and hair loss. She denies any intercurrent illness. Thyroid function tests are performed and the results show low TSH and T4.

Which investigation is most likely to be diagnostic?

• Thyroid ultrasound

• Radio-iodine uptake scan

• Anti-TPO antibodies

• Fine needle aspiration of thyroid

• MRI of pituitary gland

Explanation

• Secondary hypothyroidism is very rare and results in a low TSH and low T4. In these cases, pituitary insufficiency is most likely and therefore an MRI of the gland should be performed.

Open Ended

How is primary hypothyroidism treated?

Treatment for primary hypothyroidism

• Offer levothyroxine monotherapy as first-line treatment for primary hypothyroidism.

• Dosage depends on age. Adjust every 3-4 weeks according to response.

• Measure TSH every 3 months until the level has stabilised.

Multiple Choice

A person with untreated hypothyroidism may also have:

• High cholesterol

• Low blood pressure

• Low blood sugar

• Non of the above

Explanation

• Thyroid hormone helps in regulation of lipid metabolism.

• People with untreated hypothyroidism have high total and LDL cholesterol levels

Myxoedema coma

• Severe hypothyroid state - endocrine emergencies

• >65 yo, history of thyroid surgery/radioactive iodine

• May be precipitated by MI, stroke, infection and trauma

• Look hypothyroid. Hypothermia, hyporeflexia, hypoglycemia, bradycardia, coma

Multiple Choice

A 32 year-old lady presents to her GP with 2 months history of painless fullness in her neck, tachycardia and heat intolerance. On examination, she has a fine tremor and a diffuse goitre.

Which of the following is the most likely cause of her symptoms?

• Grave' disease

• Postpartum thyroiditis

• Subacute thyroiditis

• Thyroid cancer

• Toxic multinodular goitre

Explanation - C

• Young lady with clear sign of hyperthyroidism

• Graves' disease - account for 60-80% of hyperthyroidism

• Postpartum thyroiditis - occur within 12 months after delivery (Hyper-Hypo-Eu)

• Subacute thyroiditis - painful goitre, occur following viral infection

• Thyroid cancer - no red flag symptom here (airway compromise, issue with voice and speech - recurrent laryngeal nerve)

• Toxic multinodular goitre - commonly seen in elderly

Causes of thyrotoxicosis

• Graves' disease

• Toxic multinodular goitre

• Toxic adenoma

• Drugs - amiodarone

• Levothyroxine excess

Multiple Choice

A 53-year-old woman presents to her GP with a 2 month history of weight loss, irritability and heat intolerance.

Which of the following additional features would most support a diagnosis of Graves' disease rather than other causes of hyperthyroidism?

• Antecedent viral infection

• Anti-thyroid peroxidase autoantibodies

• Exophthalmos

• Onycholysis

• Goitre

Explanation - C

• The eye signs (eyelid retraction, periorbital oedema, proptosis) only occur in Grave’s disease, and not in other causes of thyrotoxicosis

• Occur in 50% of cases of Grave’s disease

• Presence of anti-TPO autoantibodies only suggests that the cause of thyroid disease is an autoimmune disorder, which can be Hashimoto's disease or Graves' disease

Management of Graves' disease

• Drugs - Carbimazole / propylthiouracil (who experience SE to carbimazole, pregnant or trying to become pregnant within 6 months or with a history of pancreatitis)

• Radioactive iodine - risk of hypothyroid after treatment

• Surgery - total thyroidectomy (first line when there are concerns about compression or thyroid malignancy is suspected, or radioactive iodine and antithyroid drugs are unsuitable)

Multiple Choice

What is the most common type of thyroid carcinoma?

• Follicular carcinoma

• Papillary carcinoma

• Medullary carcinoma

• Anaplastic carcinoma

Explanation

• Papillary carcinoma is the most common type with ~80% of thyroid cancers being papillary. It is a slow growing tumor. More common in younger people.

• Even though papillary carcinoma is the most common cancer, it has the best prognosis among these 4 types of thyroid cancer. (98% at 10 years)

• Follicular accounts for ~10%. Medullary accounts for ~5%. Anaplastic is very rare and it has the worse prognosis.

Thank you!