Internal assessment

Oct 21,2021

https://medicinedepartment.blogspot.com/2021/10/mbbs-2017-batch-oct-2021-internal.html?m=1

1)Q. Define bone density,how is it measured? What are the causes, clinical features, diagnosis and management of osteoporosis?

Review ;

Bone density 

Bone density, or bone mineral density, is the amount of bone mineral in bone tissue. The concept is of mass of mineral per volume of bone.

It is measured by densitometry or Dexa - scan

Causes of osteoporosis; 

Nutrition and Gi disorders; malnutrition, malabsorption syndromes,severe liver disesase

Endocrine; cushings syndrome, thyrotoxicosis,hyperparathyroidism, acromegaly, hypogonadism.

Rheumatological disorders; rheumatoi arthritis,ankylosong spondylosis

Inherited disorders;

Osteogenesis imperfecta,

Marfan syndrome, hemochtomatoais

Porphyria

Drugs; corticosteroid,chronic heparin therapy

Miscellaneous;immobilizaton,post menopausal,pregnancy, lactation,senile osteoporosis

Clinical features;

Fracture produces sudden pain

Common site fracture- spine ,hip,wristjoints

Vertebral fractures can occur with out pain

Lab investigations;

Serum calcium, alkaline phosphatase, urinary calcium and other relevant investigations for suspected underlying cause

* Urinary level os cross linked N- telopeptides indicate rate of bone break down or turnover

Radiograph of spine and pelvis;

Reduced cortical thickness of bones

Increased radiolucency of bones

Vertebrate  shows " cod fish" appearance

Collapse of vertebral body with kyphosis

Measurement of bone density;

Quantitative CT scan

Quantitative ultrasound

Dual energy x-ray absorptiometry(DEXA) scan for bone mineral density

Treatment;

Diet should include atleast 1g of calcium and 800-1000IU of vitamin D daily.additional supplementation may be done to maintain bone and muscle strength

* Ensure adequate weight bearing exercises

*Smoking and alcohol should be stopped

Bisphosphonates;

Combined with vitD and calcium

Bisphosphonates suppress osteoclast mediated bone resorption.they accelerate osteoclast apoptosis

Risedronate :5mg orall

Alendronate10mg orall

Ibandronaye; 150mg once a month

Pamidronaye90mg iv month

A/e: git upset

Hormone replacement therapy

Recombinant human parathyroid hormone

Selective oestrogen receptor modulators; raloxifene for post menopausal osteoporosis

Salmon calcitonin

Strontium ranelage; prevention of both vertebral and non vertebral fractures

Denosumab;

Inhibits osteoclast formation ,thus decreasing bone resorption

2) Q. What is myxedema coma? Describe it's clinical features, diagnosis and treatment of myxoedema coma.

Review

It is a rare complication of hypothyroidism seen usually in elderly pts

More than 90% of cases occur during winter months

Causes; infections,drugs ( amiodarone, b blockers,diuretics, barbiturates,) cardiac failure, hyponatremia, hypoxia,hypercapnia

Clinical features,; depressed level of consciousness,low body temperature, bradycardia

*Neuropsychiatric manifestations.

*They develop psychosis with delusions and hallucinations (myxoedema madness) proegressed to depressed level of consciousness, convulsions,coma ( myxoedema coma).

Diagnosis; 

Metabolic abnormalities; hyponatremia, hypoglycemia

Arterial blood gas ; respiratory acidosis,hypoxi,hypercapnia

Csf pressure ; low and protein content elevated

Treatment;

Supportive care;

Gentle warming with blankets,Broad spectrum antibiotics,high flow oxygen,and if required assisted ventilation

Correction of hyponatremia and hypoglycemia

Hydrocortisone (100mg ivsly,8hrly)is required due to increased metabolic stress

Thyroid hormone replacement;

T4- initially 100-150Micro gm and then 75-100 MCG iv is recommended

T4- - orally ina dose of 300mcg start followed by 100-300mcg daily

Treat precipitating causes

3)Q. What is the diagnostic approach  of young onset hypertension and it's treatment.

Treatment:

Beta-adrenergic antagonists:atenolol,Timolol

Maelate,betaxolol,labetalol.

Atenolol-Initial dose of 50mg po daily.

ACE Inhibitors:captopril,enalapril(20mg daily), Lisinopril.

Angiotensin receptor blockers:Losaratan(50-100mg daily),candesartan,valsartan.

Calcium channel blockers:Nifedipine(10-20mg TlD (or)QID,Verapamil.

Diuretics:

Thiazides:Hydrochlorothiazide,chlorthalidone.

Loop diuretics: Furosemide,bumetanide.

Potassium sparing diuretics:Amiloride,Triamterene.

Direct renin inhibitor:Aliskiren

Alpha adrenergic antagonists: Doxazosin,prazosin,terazocin.

Centrally acting adrenergic agonists:

Clonidine,methyldopa.

Direct acting vasodilators: Hydralazine, Minoxidil.

4)Q How do you clinically localize the anatomical level of lesion in spinal cord diseases.

4)ans ; localization of spinal cord lesions

Plegia ;severe or complete weakness

Paresis : mild or moderate weakness

Monoplegia ; weakness of one limb

Paraplegia ; weakness of both lower limbs

Quadriplegia ; weakness of all 4 limbs

Diplegia ; quadriplegia in which lower limbs are affected more than upper limbs

Cord lesion above D12 segment

Acute state retention

Reflex bladder

Reflex emptying,vague sensation,small bladder

Conus lesion(

 S3-CO1)

Autonomic bladder;

No bladder sensation ,dribbling, more residual urine

Cauda equina lesion (L2-co1)

Bladder sensation normal

Results of spinal cord lesion ;

At the level;

Motor; segmental LMN findings

Sensory ; segmental sensory root findings

Below the level

Motor :UMN findings

Sensory : tract involvement findings

Autonomic ; bowel.bladder

Others

Localization of C5 segment lesion

1)atC-5

a) motor LMN weakness of C5 myotome-deltoid and biceps

b) reflex; absent

c)sensory; radicular symptoms atC5

2) below C5

a) UMN findings

b) posterior column and spinothalamic tract involvement

Localization at D10 segment

Weaknesses of lower abdominal muscles

Absent lower abdominal reflex

Sensory dermatomal signs at D10

2) Below D10

a) UMN findings

b) posterior column and spinothalamic tract involvement

5)Q. Causes and diagnosis and treatment of atrial fibrillation

review ;

Causes; Rheumatic heart disease, ischemic heart disease, hypertension, thyrotoxicosis, congenital heart disesase, cardiomyopathy, pericardial diseases,rare causes; alcohol, pulmonary embolism

Symptoms; palpitations,fatigue,syncope, 

Signs; irregularly irregular pulse

Absence of waves on jvp, hypotension,disappearance of psa of mid diastolic murmur of mitral stenosis

Disappearance of fourth heart sound

Diagnosis;

ECG; irregularly irregular rhythm of qrs complexes

Absent p waves

Small irregular waves at state of 350-600/minute 

Complications ; syncope,angina, thromboembolism

Hypotension.

Management;

Goals; 

Hemodynamic stabilization

Control of ventricular rate

Restoration of sinus rhythm

Treatment of underlying cause

1) if pt s clinical status is severely compromised synchronised dc cardioversion is treatment of choice

2) if pts cardioversion is not severely compromised treatment is in 2steps

*Slowing ventricular rate with  diltiazem,verapamil,digoxin

Amiodarone; 150mg over 10 minutes followed by 1mg / minute over 6hrs and0.5mg/minute for another 18hrs

A/E; hepatic toxicity, pulmonary toxicity, thyroid dysfunction

2(converting rhythm to normal sinus rhythm

Pharmacological cardioversion to sinus rhythm with quinidine,flecanide

*Antithrombotic therapy

*Aspirin

*Refractory cases are managed with catheter ablation therapy

6)Q. Describe about megaloblatic anemia

review;

* Abnormal erythroblasts seen in bone marrow of pts with deficiency of vitamin B12,folate orboth

Megaloblasts abnormally large in size and nucleated,well hemoglobinized

* Macrocytes are erythrocytes with increased mcv

Causes: vitaminb12 or folate deficiency, liver disease,alcohol,aplastic anemia, Hypothyroidism, sideroblastic anemia,nitrous oxide abuse

Peripheral smear; 

Macroovalocytes and hypersegmented neutrophils ,poikilocytosis,fragmented rbcs

Investigations; HB-reduced

MCV; raised>120fl

RBC count; reduced

Reticulocyte count: reduced

TLC; reduced

Platelet count : reduced

Indirect bilirubin mildly elevated

Serum iron elevated

Tibc reduced

Serum ferritin increased

Plasma LDH markedely increased

Bone marrow; 

Hypercellular, megaloblatic erythroid cells, giant megakaryocytes,dysplastic megakaryocytes, marrow iron stores increased

Specific tests; reduced serumb12or folate

Management;

Supportive therapy;

* Blood transfusion s

* Treatment of infections

* Treatment of cardiac failure

Specific therapy

* Treatment of underlying cause vit B12 or folate deficiency

*VitaminB12 therapy

*Folate therapy

7)Q. What are the causes , pathogenesis and differential diagnosis of ascites. 

7ans contd

Review ;

causes of ascites

Hepatic cirrhosis,

*Malignant; hepatic, peritoneal

*Infection; tuberculosis,bacterial peritonitis

*Hypoproteinemia; Nephrotic syndrome, malnutrition

*Cardiac failure, constrictive pericarditis

*Hepatic venous obstruction; budd-chiari syndrome,veno occlusive disease

*Pancreatitis

*Lymphatic obstruction-chylous ascites

In common; meigs syndrome, vasculitis, Hypothyroidism,

Pathogenesis;

Ascites occurs due to imbalance between formation and resorption of peritoneal fluid.in cirrhosis of liver ascites is due to

* Portal hypertension

*Renal changes; increased sodium and water resorption.thre is stimulation of RAAS,increased ADH release and decreased release of natriuretic hormone or third factor

*Imbalance between formation and removal of hepatic and gut lymph

*Hypoalbunemia

*Elevated Padma vasopressin and epinephrine levels in response to volume depleted state accenuates renal and vascular factors

Differential diagnosis;

Acute liver failure,cirrhosis, budd-chiari syndrome,dilated cardiomyopathy, alcoholic hepatitis, biliary disease

8)Q APPROACH to Acute pancreatitis

8ans contd

Review;

approach to Acute pancreatitis

* Inflammation of pancreas.

Etiology; alcoholic ingestion,biliary calculus

Post ercpa,trauma to abdomen

*Metabolic : renal failure,hypercalcaemia,hypertryglyceridemia

*Penetrating peptic ulcer

* Connective tissue disorders; systemic lupus erythematosus,polyarteritisnodosa

* Infections; viral hepatitis,mumps

* Drugs: sulphonides, tetracycline s,

Hereditary

Pathology; 

Oedematous pancreatitis; diffuse enlargement of pancreas with lack of pancreatic parenchymal necrosis

Necrotsing pancreatitis

*Hemorrhagic pancreatitis

Clinical features;

Symptoms;

* Cardinal symptom of acute pancreatitis is;

Pain- mild to severe intensity,dull and boring and steady,sudden pain in onset and gradually increase es in severity

Located in epigastric region,though may be percieved more on left or right side depending on which portion of pancreas is involved

Radiates directly through abdomen to back

Partial relief if sits up and leans forward s

Lasts more than 1 day

*Nausea and vomiting

*Anorexia

Signs;

*Fever low grade

Tachycardia

Tachypnoea

Hypotension,jaundice, abdominal tenderness,muscle guarding,and distension,bowel sounds - hypoactive

Lungs; cyanosis,basal crepitation s, pleural effusion

Skin; 

Cullen sign; bluish discoloration around umbilicus

Grey Turner sign; bluish discoloration in flanks due to hemoperitoneum

Others : hematmesis,melena

Investigations;

Serum amylase; initial increase in 24hours and then decline to normal in2-3 days

Serum lipase; preferable for diagnosis

Takes longer time to clear from blood

*Marked elevation in pleural or peritoneal fluid(>5000IU/dl)suggests pancreatitis

Other; blood glucose,total leucocyte count, platelet count,blood urea,serum creatinine,and other electrolytes, triglycerides,

Blood gas

Plain x-ray abdomen and chest

Ultrasound of abdomen

Ct scan of abdomen; show solid mass of swollen pancreas (phlegmon),pseudocyst or pancreatic abscess

Mri abdomen; 

Endoscopic ultrasound

Treatment;

Nil oral initially with gradual return to oral intake as abdominal pain recedes and hunger return s.enteral feeding should be restarted in severe cases .this can be done by oral intake or useof nasogastric tube

* Iv fluids to maintain intravascular volume in first few days

* Analgesics for pain relief

*Nasogastric aspiration if pain continues

*Monitor pulse,bp, abdomen girth, urine output,blood glucose, calcium, blood gases

*Prophylactic antibiotics; ,carbepenams(imepenam,meropenam),ceftazidimein severe cases

*Other drugs; ppis, glucagon,octreotide and aprotinin

* Surgery ;

Infected pancreatic necrosis

Complications

ERCP with in first 36-48hours in pts with gallstones pancreatitis

Complications; 

Local; 

Necrosis

Pseudocyst,pancreatic abscess, pancreatic ascites, obstructive jaundice

Systemic;

Hypovolemic shock,ARDS,renal failure,fat necrosis,pleural effusion,DIC,muliple organ failure.

9Q.) Mention the differences in findings between UMN and LMN lesions

9 ans contd

Review;

UMN lesions;

*Weakness; voluntary movements are disturbed; distal predominant

Tone; hypertonia( claspknife spasticity)

*Reflex (tendon); increased,

*Reflex (superficial); absent or decreased

Plantar response; extensor

*Muscle atrophy; disuse

*Fasciculations ; absent

*Bilateral movements; spared

(Eyes,face,jaw,neck)

*Reaction of degeneration; absent

* Nerve conduction; normal

LMN lesions

Weakness;  paralysis of muscles supplied by that segment or nerve proximalpredominant

Tone; hypotonia

*Reflex (tendon); decreased or absent

*Reflex (superficial); absent or decreased

Plantar response; flexor or absent

*Muscle atrophy; marked

*Fasciculations ; often present

*Bilateral movements; affected

(Eyes,face,jaw,neck)

*Reaction of degeneration; present

* Nerve conduction; abnormal

10) Indications of hemodialysis

Review;

✓Acute renal failure

✓Toxins

✓Drugs

✓Chronic renal failure patients awaiting renal transplantation

✓patients with CRF in whom quality of life has deteriorated

11) role of sucralfate in treatment of erosive gastritis

11)ans;

*

Sucralfate is used to treat and prevent duodenal ulcers and other conditions . It works by forming a barrier or coat over the ulcer. This protects the ulcer from the acid of the stomach, allowing it to heal. Sucralfate contains an aluminum salt.

12Q). Mention the renal manifestations snake bite

12ans;

renal manifestations of snake bite

✓ Hematuria

✓Hemoglobinuria

✓Myoglobinuria

✓Loin pain

✓Renal failure

13Q). Causes of portal hypertension

13] ans; causes of portal hypertension

✓ Heart; constrictive pericarditis

✓inferior vene cava; congenital webs,tumor invasion, thrombosis

✓large hepatic veins; thrombosis,webs, tumor invasion

✓Small hepatic veins; veno occlusive disease

✓portal vein: thrombosis

✓splenic vein; thrombosis, invasion or compression by tumors

✓post sinusoidal causes; veno occlusive disease, alcoholic hyaline sclerosis

✓ sinusoidal causes ; cirrhosis,acute alcoholic hepatitis.   Cytotoxic drugs,vitamin A intoxication

✓pre sinusoidal causes; schistosomiasis,non cirrhotic portal fibrosis, sarcoidosis,toxins, idiopathic

14)Q. Clinical features of Downs syndrome

14)ans; Down's syndrome clinical features;

✓Craniofacial and musculoskeletal;

Flat nasal bridge,flat face,brachycephaly,malformed large ears,hypertelorism,slanting eyes with epicanthic folds, protruding furrowed tongue

Broad short neck,simian crease,short stature,hypotonia

Increased space b/w first and second toes(sandal gap)

✓Brain; increased frequency of sleep apnea syndrome,mental retardation,Adhd,autism

✓Heart; ASD,VSD,tetralogy of fallot

✓Git;. Oesophageal or duodenal atresia,imperforate anus

✓Reproductive;males are sterile

✓endocrine; Hypothyroidism,type-1DM

✓Bone marrow; increased incidence of acute leukemia

15) Q. Post streptococcal glomerulonephritis complications

15)ans;

Post streptococcal glomerulonephritis complications;

✓susceptibility to infections

✓ acute left ventricular failure

✓ hypertensive encephalopathy

✓fluid and electrolyte imbalance

✓Acute renal failure

✓Nephrotic syndrome

✓chronic glomerulonephritis

16)Q. Causes of cervical myelopathy.

16ans; 

Review ; 

                  

• Rheumatoid arthritis of the neck.
• Whiplash injury or other cervical spine trauma.
• Spinal infections.
• Spinal tumors and cancers
• Spondylosis
• Spinal cord compression or squeezed.