Post on 06-May-2018
M5MEQs2016Session3:Lethargy18/11/16http://tinyurl.com/zevjhqu
Mdm Tanisa78yearoldfemale.Shepresentstotheemergencydepartmentwithlethargy.Shecomplainsofabdominalpaininthepara-umbicial region.Shehasbeenpassinghardstoolswithdecreasingamounts.Herdaughternotedthatshewasdrinkingmorewaterthanusualandgoingtothetoiletmoreoften.
Herpastmedicalhistoryincludeddiabetesmellitusforwhichsheisonglipizide15mgBD,metformin850mgTDS,hypertensionforwhichsheisonhydrochlorothiazide12.5mgOM.
Question1
Onexamination:T36BP170/72HR100SpO298%onRAGCS15,orientatedtotime,placeandpersonHS1S2LClearASoftnon-tenderslightlydistendedbowelsoundssluggishCulves SuppleClinicallydehydrated
Whichofthefollowingstatementsislikelyincorrect.1.Diabeticketoacidosisisadifferentialinthispatient2.ACTabdomenandpelvisshouldbeconsideredasaupfrontinvestigation3.Patient’sGCSshouldbecloselymonitored4.TheECGmayshowashortenQTinterval5.Hydrochlorothiazidemayhaveworsenedthepatientsunderlyingcondition
Question1
Whichofthefollowingstatementsislikelyincorrect.1.Diabeticketoacidosisisadifferentialinthispatient2.ACTabdomenandpelvisshouldbeconsideredasaupfrontinvestigation3.Patient’sGCSshouldbecloselymonitored4.TheECGmayshowashortenQTinterval5.Hydrochlorothiazidemayhaveworsenedthepatientsunderlyingcondition
Question1
Initialinvestigationsarethefollowing:Hb 8.2Tw2.3Plt 120U12Na127K3.6Bicarb 18Glu 11Cr180Alb 20AST30ALT40TB3Ca 2.6Mg0.9PO40.5
CXR:Noconsolidation,noairunderthediaphragmAXR:prominentbowelloops
Question2
Whatisthecorrectedcalciumforthispatient?1. 2.1mmol/L2. 2.8mmol/L3. 3.0mmol/L4. 3.2mmol/L5. 4.6mmol/L
Question2
Whatisthecorrectedcalciumforthispatient?1. 2.1mmol/L2. 2.8mmol/L3. 3.0mmol/L4. 3.2mmol/L5. 4.6mmol/L
Question2
CorrectedCalcium=Measuredcalcium+(40– Alb)*0.02
OrForeverydropof4g/lAlb =>CorrectCa by
0.1mmol/L• Approximately50%oftotalcalciumisproteinbound,andthetotalcalciumlevelwillvarywithprotein-bindingcapacity.• Standardlabtestsaremeasuringthetotalcalcium
Question2
Younotethepatienthasacorrectedcalciumof3.0g/L.Indicativeofhypercalcemia.Yourregistrarmakesthepassingstatementthatthepatientssymptomscanbeaccountedforduetothehypercalcemia andtheteamwouldneedtomonitorthepatientfortheclinicalmanifestationsandcomplicationsofhypercalcemia.
Question3
Whichoftheofthefollowingstatementsisfalse.1.OneofthecardiaceffectsisalongQTC2.Nephrogenic diabetesinsipidus resultinginpolydipsiaandpolyuriaisaconsequence3.Hypertensionmaybecausedbyrenalinsufficiency,calcium-mediatedvasoconstriction4.Chronichypercalcemic nephropathymaycontinuetoworsenaftercorrectionofhypercalcemia5.Pepticulcerdiseaseandpancreatitisarepossiblegastro-intestinalcomplication
Question3
Whichoftheofthefollowingstatementsisfalse.1.OneofthecardiaceffectsisalongQTC2.Nephrogenic diabetesinsipidus resultinginpolydipsiaandpolyuriaisaconsequence3.Hypertensionmaybecausedbyrenalinsufficiency,calcium-mediatedvasoconstriction4.Chronichypercalcemic nephropathymaycontinuetoworsenaftercorrectionofhypercalcemia5.Pepticulcerdiseaseandpancreatitisarepossiblegastro-intestinalcomplication
Question3
Question3
ClinicalSymptomsandcomplications:• Stones(Renalcolicandhypercalcaemicstones)• Bones(Increasedosteolysisandfractures)• Psychicmoans(Depression,confusion,hallucinationsandcoma)• Abdominalgroans(Anorexia,N,V,constipation,PUD,pancreatitis)• Other
• Muscleweakness,malaise,hyporeflexia• Confusion,apathy,decreasedmemory• Nephrogenicdiabetesinsipidus (Polyuriaandpolydipsia)
Question3
Thepatientisadmittedtothewardwiththediagnosisofhypercalcemia andanemiaforinvestigation.IVfluidswasstartedforthepatient.
Whatadditionalmanagementshouldbedone.1.Urgentchemotherapy2.Highcutoffhemodialysis3.Stophydrochlorothiazide4.Denosumab5.Bloodtransfusion
Question4
Thepatientisadmittedtothewardwiththediagnosisofhypercalcemia andanemiaforinvestigation.IVfluidswasstartedforthepatient
Whatadditionalmanagementshouldbedone.1.Urgentchemotherapy2.Highcutoffhemodialysis3.Stophydrochlorothiazide4.Denosumab5.Bloodtransfusion
Question4
Managementofhypercalcemia:Keytotreatmentisvolumeexpansion
• Promoteurinaryexcretion(ifCVSandrenalfunctionadequate)• ForcedsalineDiuresis(plusmagnesiumandpotassium)– 300-500mlNsaline/hr
• Thisreplaceslostfluidandforcesdiuresis• MustmonitororreplaceKandMgasthesewillbelostintheurinealongwiththecalcium
• NOTEdonotgiveTHIAZIDES,theywillworsencondition• TreatmentwithFRUSEMIDEiscontroversialasitpromotesCalciumbonereuptake
Question4
• Haemodialysis• TreatmentofchoiceinCVSorrenalcompromise
• Calcitonin/EDTAbisphosphonates• Reduceboneresorption andreduceGITabsorptionofCalcium• Effectin48hoursandlast15days
Question4
Furtherhistoryrevealsthatthepatienthasbeenhavingjointpainsforthelastfewmonths.Shehasalsobeenhavinglossofweightandlossofappetite.Shealsorevealsexertiondyspneaandnon-vertiginousgiddiness.Hb 8.2Tw2.3Plt 120U12Na127K3.6Bicarb 18Glu 11Cr180Alb 20AST30ALT40TB3Ca 2.6Mg0.9PO40.5
CXR:Noconsolidation,noairunderthediaphragmAXR:prominentbowelloops
Question5
Whatadditionalinvestigationswouldyouorder?- OGDandColonoscopy- SkeletalSurvey- Bonemarrowaspirate- Myelomapanelandlightchains- CTabdomenandpelvis- Waterdeprivationtest- Arterialbloodgas- Ironstudies
Question5
Whatadditionalinvestigationswouldyouorder?- OGDandColonoscopy- SkeletalSurvey- Bonemarrowaspirate- Myelomapanelandlightchains- CTabdomenandpelvis- Waterdeprivationtest- Arterialbloodgas- Ironstudies
Question5
Multiplemyeloma(MM)ischaracterizedbytheneoplasticproliferationofasinglecloneofplasmacellsproducingamonoclonalimmunoglobulin.
Diagnosis:Clonalbonemarrowplasmacells≥10%orbiopsy-provenbonyorextramedullary plasmacytoma andanyoneormoreofthefollowingCRABfeaturesandmyeloma-definingevents
Question5
• (C)Hypercalcemia:>2.75mmol/L(>11mg/dL)• ( R)Renalinsufficiency:creatinine clearance<40mL/minc perminuteorserumcreatinine >177µmol/L(>2mg/dL)• (A)Anemia:Hb <10g/dL• ( B)Bonelesions:oneormoreosteolytic lesiononskeletalradiography,CT,orPET/CT. Ifbonemarrowhas<10%clonalplasmacells,morethanonebonelesionisrequiredtodistinguishfromsolitaryplasmacytoma withminimalmarrowinvolvement
Question5
Haematologywasreferredandpatientwasofferedabonemarrowtoconfirmthediagnosisofmultiplemyeloma.Youarecalledtotaketheconsentforthispatient.
Whichofthefollowingstatementspertainingtoinformedconsentistrue?1.Theconsentshouldbetakenbythepersondoingtheprocedure2.Apersonwithahistoryofschizophreniacangiveinformedconsent3.Apersonwithahistoryofdementiacannotgiveinformedconsent4.Aconsentisvalidaslongasthepatienthassignedontheappropriateforms5.Achildbelowtheageof16cannotgiveavalidconsent.
Question6
Haematologywasreferredandpatientwasofferedabonemarrowtoconfirmthediagnosisofmultiplemyeloma.Youarecalledtotaketheconsentforthispatient.
Whichofthefollowingstatementspertainingtoinformedconsentistrue?1.Theconsentshouldbetakenbythepersondoingtheprocedure2.Apersonwithahistoryofschizophrenia cangiveinformedconsent3.Apersonwithahistoryofdementiacannotgiveinformedconsent4.Aconsentisvalidaslongasthepatienthassignedontheappropriateforms5.Achildbelowtheageof16cannotgiveavalidconsent.
Question6
Principlesofavalidconsent:- Thepersongivingconsentmustbecompetent- Consentmustbevoluntaryandnotsubjecttoduress orcoercion- Thepersonmusthavebeengivensufficientinformationtoreachadecision
- Thetreatmentmustnotbeunlawfuloragainstpublicpolicy.
Othernotes:• Childrenyoungerthan16mayconsentiftheyareGillick competent=>sufficientmaturityandunderstandingtomakethenecessarydecision.
Question6
• ClinicalpresentationofHypercalcemia• ApproachtotheworkupofHypercalcemia• Complicationsofhypercalcemia• Causesofhypercalcemia
LearningPoints