Bisphosphonates

Sick, and immunocomprimised. Likely to need IV Abx.

Definitely not hydrocortisone, so (A)

I'd probably go C given dry cough and HIV with low T c count,
implicating PCP - co-trimoxazole is Rx of choice for PCP.

First step is Abx.

Then, if clinical signs of raised ICP are apparent
—> CT head
If high ICP is not clinically present or CThead rules it out
—>LP
Then, MCS LP and look for an Abx sensitivity

Older people have asymptomatic bacturia = no need to treat?

No need for IV gentamicin, could probably do with something P.O..

A once off dose of gentamicin could help develop resistance, maybe?
Regardless, her CCF is resolving so fluid monitoring is no longer needed…
=> A or B???
Chose E due to varicose veins causing
stasis dermatitis, and oedema
http://www.xmind.net/m/cbJm/
A = vascular occlusion
B = nerve stretch, or possibly DVT???
C = ulceration possible with varicose veins, but no veins
over MM
D = peripheral neuropathy
I'd probably go with C too but not sure.
Problems with the cerebellar…
I would say a(A)

Total vilous atrophy = coeliac
Would be E - non caseating granuloma
is pathognomonic for Crohn's disease (also
sarcoidosis). R lower abdo pain consistent with most
common site for CD - terminal ileum, also high CRP and
likely arthropathy all consistent with CD but not coeliac.

Looking for a bowel obstruction

 Angioplasty with the insertion of a stent (PCI)
otherwise thrombolysis

Yeah agree, IV salbutamol would prob be

reasonable if things weren't quite so dire.

She is hypoxic and hypercapnic.

IV salbutamol may increase her HR too much,
hydrocortisone won’t have any effect on O2 perfusion in the lungs until about 8hrs after the attack
Can’t transfer her, she is hypoxic and hypercapnic.

Leaning towards intubation

 I think B. It's
painless jaundice
which makes C not
likely. Back pain -
could be due to
panc. Ca.

D possibility though,
especially since
augmentin is a bit of
an offender in terms
of drug induced
cholestasis. Don't
know why they
would muddy the
water so much by
throwing this in…..

A&E - liver - no
signs of liver and Pale stools suggest post-hepatic jaundice (obstruc
AST/ALT normal
Not (A), not drinking enough
B is possible, if it obstructs the billary tree
C is possible
D not sure about this
ALP can also suggest bony mets
C most likely?

APTT is the intrinsic pathway, and involve factors I, II, V, VIII, IX, X, XI, XII.
The INR measures the PT time, (extrinsic pathway)
Given APTT is prolonged there must be a problem with the APTT clotting factors

I have no idea

think E.
Not A (lupus anticoag actually causes prothrombotic state in vivo).
APTT indicates VWd or haemophilia, maybe platelet disorder…..
Mucocutaneous bleeding > MSK in platelet disorders/thrombocytopenia (doesn't have the latter). So prob not B.
Bleeding time might narrow DDx list but won't confirm a diagnosis
D&E testing for VWd which is relatively common and fits clinical picture. I think E would be done first and could definitely confirm VWd Dx
Pericardial effusion caused by lung cancer metastases causing the pericardial buildup of fluid
 Red cells are large suggesting megablastic anaemia
characteristic of vit. B12 deficiency.
Given the resections, he probably has problems
absorbing enough vit B12

Not really sure with this one… Yeah, seems the sensible choice
Does seem like there are some nodules there that could potentially be cancer, but he seems young,
with not a long enough smoking history.
Too young for COPD, you need at least 20 packyears before it manifests…
Pulmonary metastases is just a guess of what the increased opacities could be.
Therefore answer either lung cancer or sarcoidosis
Largely agree with the above. Suggest its Sarcoidosis, the painful red lumps on both shins are consistent
with erythema nodosum, which can be a feature of Sarcoidosis, but probably makes me steer away from lung Ca.
And the patient is quite young even if he's been puffing away.
 Amiloride is a K+ sparing diuretic,
cease that so more K+ is lost.

Start with oral water, and if that doesn’t correct the

hyponatremia,
give IV 5% dextrose
I chose not to use oral rehydration solution because it
would have Na+
She's got hypernatraemia (not hypo). Given she is vomiting and is pretty unwell, I wouldn't give oral water. IV 5% dextrose seems like a
do this.

Not ischaemic colitis: that presents with abdo pain, then PR bleeding
Not appendicitis, wrong side
Not large bowel obstruction: bowel sounds are present
Not gastroenteritis, because there hasn’t been a bowel opening in 48 hours

.:. diverticulitis
 Not alcoholic hepatitis: ALT > AST,
in alcoholic hepatitis, AST:ALT > 2.5
Could be a hepatitis.
The history excludes Hep B.
Not paracetamol toxicity: hasn’t had enough
paracetamol(ALT does rise though in cases
of paracetamol OD
Cholestatic picture would show ALP rising.
.:. must be Hep A

Not sure about this one, which is more urgent, that needs correcting first,
his anaemia or electrolyte disturbances?
Probably his K+ level is most worrying…
Also, hydrochlorothiazide would raise his Ca++ and reduce his blood pressure…
but that is not addressing his high K+ or anaemia
this is also assuming his kidneys are still functional
That is L2 dermatome, corrrect?
Not sure how the sacro-iliac joint can cause anterior thigh pain…
I doubt it would be a muscular pain after 6 months
=> hip joint pain?

Thinking rheumatoid…
Rheumatoid fatcor test can be -ve in seronegative RA
ESR is usually done to exclude other causes of arthritis
ANA is used to look for other systemic causes of arthritis
such as SLE, etc
From reading wiki, parvovirus attacks rapidly dividing
According to wiki Parvovirus seems to cause GIT issues.
ANCA it seems can also be used to detect RA…???

Expressive aphasia in broca’s area.

Not sure how this would manifest w.r.t. limb weakness???
 Pretty sure this would be A: Aching hands and DIP enlargement are indicative of
arthralgia - a systemic manifestation of lupus. Need 4 systemic symptoms of lupus
before classified as SLE, so presumably in a diagnostic sense this lady just has
cutaneous lupus atm. The malar rash is classic lupus, appears to spare the
nasolabial folds, and is flared by hot days (UV exposure). UV can induce
keratinocyte apoptosis -> may increase source of autoantigenic dsDNA driving
lupus

I have no idea…

-Not conjunctivitis, i’ve had that, not too painful

-Not anterior uveitis, as there is no mention of a red
sclera
-Acute glaucoma presents with swollen disc, but why
the unilateral eye? Is that common?
-Not ant. ischaemic optic neuropathy, from wiki
it suggests
Yeah agree with B. Think acute glaucoma usually this occurs
presents unilaterally, in older
although patients
I guess
predisposition in both eyes.

- Vit B12 can cause such a neuropathy, but I am assuming her

liquid diet has all the nutrients she needs.
- She isn’t drinking enough to cause an EtOH neuropathy
- While post-polio syndrome can occur decades after the
initial polio diagnosis, it isn’t characterised by neuropathy
symptoms alone
- her meds wouldn’t cause a neuropathy
=> diabetic neuropathy?

Yeah I like your reasoning, and surely it is the first guess as diabetic
neuropathy has got to be much more common and this lady ticks all the
boxes. Would prob be good practice to check B12 status
 Microcalc. indicative of malignancy

Pearly edged ulcer is a basal cell carcinoma

Agree. 5FU I think is more second line and

mainly then for lesions on trunk or legs etc, not
face.

Microcytic, hypochromic anaemia

- low haematocrit
- iron deficient due to low transferrin saturation
- look at [Hb]? Will that show up in a week? Not sure…
- Serum ferritin is the compound that binds iron storing it and
releasing it when …
=> Look at serum ferritin levels?

Pretty sure it's E actually. That's ultimately what you want to see - an increase in reticulocyte
haematopoiesis. Toronto notes says as much - and also says expect
increase in Hb of 10g/L per week in absence of blood loss.
 Not sure about this…
Thinking cancer of the spine, due to night pain that is
preventing sleep as well as a gradual progression of pain
over months (growth of tumour)
(though it could be a disc herniation, or a compression
I agree Hx suggests malignancy,
crush fracture of the vertebral bodies due to osteoporosis)
especially given night pain and full ROM.
=> Which of these issues allow full range of movement…
I'd prob put X-Ray as initial just because
super quick and easy with less radiation than
CT, but would likely
end up doing CT after that... I guess youissues unlikely to allow full range of motion (when mine flare up I can hard
*Disc
want an X-Ray at baseline so can monitor
*I imagineat a crush fracture of the vertebral bodies would cause some problems
follow up more easily without having to get
CT scan every time?
movement, preventing full range of motion

- Use CT, look for space occupying lesion/tumour.

- MRI could identify disc issues
- Lumbar XR could identify crush fractures and possible tumours
- A BMD would probably require a lumbar XR done prior to confirm a fracture/
pathological fracture
=> I said CT because it is most likely to be a tumour in my opinion