Internal Medicine Online

Imaging in Medicine module

Eleri Williams — Mon, 14 May 2012 12:20:25 +0000

This week sees the start of our Imaging in Medicine module, which will be the final taught module of this academic year.

We are delighted to welcome all of our specialist tutors, including Professor Edwin van Beek, SINAPSE Chair of Clinical Radiology, and Dr Michael Jackson, Consultant Radiologist, who will be leading the teaching for this module. Over the next six weeks our students will be considering the important safety issues in radiology, looking at the science underpinning modern medical imaging and how these apply in a clinical setting.

A GP referral

Eleri Williams — Sun, 13 May 2012 21:43:47 +0000

A 69 year old man is referred to the local hospital by his general practitioner. Our students can see the referral letter in the classroom. Please add your thoughts about differential diagnosis and initial management to the discussion board. There will be more information available tomorrow.

Many thanks to Dr Sergio Diez Alvarez for this case.

Revision and assessment week

Eleri Williams — Sun, 06 May 2012 21:53:04 +0000

Our students will be using this week to revise and complete the online assessment for the Principles of Laboratory Medicine module. We will be back with a new clinical case next week.

A 69 year old man with breathlessness and oedema

Eleri Williams — Sun, 29 Apr 2012 20:56:33 +0000

A general practitioner has requested hospital admission for a 69 year old retired truck driver with a 12 month history of worsening fatigue, breathlessness and peripheral oedema. The GP is concerned that despite increasing doses of loop diuretic for the last 3 months he had become progressively more oedematous and is now struggling to walk any distance. There is no previous history of cardiac disease. There is a past history of gout, renal calculi, mild asthma and testicular cancer at age 23. He is a non-smoker and takes a moderate amount of alcohol.

On examination, pulse is 105/minute and irregular, blood pressure 98/60mmHg, severe oedema from toes to mid abdomen, JVP elevated, heart sounds soft, no murmur audible. Chest is clear with slightly reduced air entry at the lung bases. Blood tests are as follows:

Na 130 mmol/L

K 4.6 mmol/L

Urea 15.1 mmol/L

Creatinine 140 micromol/L

Bilirubin 23 micromol/L

ALT 60 U/L

AST 30 U/L

Alkaline Phosphatase 120 U/L

Albumin 28 g/L

Urinalysis negative

What aspect of the patients past history is of key importance and requires further exploration?
What bedside clinical examination test could provide the diagnosis here?

Many thanks to Dr Martin Denvir for this case. Students, add your thoughts as usual to the discussion board.

A man with diarrhoea and a swollen neck

Neil Turner — Sun, 22 Apr 2012 19:15:24 +0000

A 70 year old man is referred with a six month history of intractable, watery diarrhoea occurring about every two hours, including through the night.
He has a history of type 2 diabetes, ischaemic heart disease, and hypertension, for which he is taking Metformin, Gliclazide, Simvastatin, Candesartan, Doxazosin, Bisoprolol, and Lisidopine. He was taking all of these before the symptoms began, and has tried a short period without metformin without any improvement. Stool cultures and colonoscopy have returned normal results. He has had minimal improvement in symptoms with loperamide 12mg daily.

On examination he is overweight. There is some swelling in his neck – he reports that he has been aware of this for many years during which time he thinks it has slowly enlarged. It causes mild discomfort but no obstructive symptoms. He has no feature of thyrotoxicosis and has normal thyroid function tests. Investigations revealed normal RBC, WCC and platelets, normal urea and electrolytes but creatinine 122, suggestive of mild CKD (eGFR 54 ml/min/1.73m2). Calcium and phosphate were normal. His chest radiograph and some CT cuts are shown.

What is the differential diagnosis of his neck swelling?
What is the most likely diagnosis?
Apart from a biopsy, what would be the most useful diagnostic test?

Thanks to Dr Mark Strachan for this case. Dr Rachel Williamson will be leading the discussion on this case in the classroom.

Hypomagnesaemia in a young man

Eleri Williams — Sun, 15 Apr 2012 20:50:57 +0000

A 24 year old nursing student is admitted to hospital. He complains of muscle cramps that have been getting progressively worse since they started six weeks ago. He also complains of increasing weakness over the last few days. He is normally fit and well, and takes no regular medication, prescribed or otherwise. He is a non-smoker and drinks around 10 units of alcohol a week. He denies any illicit drug use.

He is seen on the medical assessment unit. Examination reveals global weakness. Pulse is 68 bpm, with a blood pressure of 115/70 mmHg.

Initial investigations reveal the following:

Na 138 mmol/L

K 2.3 mmol/L

Bicarbonate 34 mmol/L

Creatinine 80 micromol/L (0.9mg/dL)

Calcium 2.4mmol/L (9.6 mg/dL)

Phosphate 0.8 mmol/L (2.48 mg/dL)

He is treated with potassium and you see him on the ward round the following day. You suggest checking his magnesium level which is low at 0.4 mmol/L (0.9 mg/dL).

What is the differential diagnosis of hypomagnesaemia?
How will you proceed with your investigations in this man?

More information later in the week for our students.

Easter break

Eleri Williams — Wed, 04 Apr 2012 21:22:21 +0000

Our students will have a two week break over Easter. Teaching will resume on Monday, April 16th. We’ll continue our Principles of Laboratory Medicine module with a week dedicated to haematology.

Our next Case of the Week will be posted on Sunday, April 15th.

Thanks to Ioan Williams for this photo of Edinburgh in springtime.

Virtual open day for prospective students

Eleri Williams — Mon, 26 Mar 2012 11:57:46 +0000

We will be holding our first virtual open day for prospective students on Saturday April 21st, starting at 2pm. You’ll get a chance to meet some of the academic team and ask any questions you may have about the course. You’ll get first hand experience of some of the technology that we employ in our course, and find out if online learning is right for you.

If you would like to join in click here. Before coming along to the live session, check that your computer is correctly configured by clicking here.

If you have any queries about this, or any other question related to the course, please email us at internal.medicine@ed.ac.uk.

A fall

Eleri Williams — Sun, 25 Mar 2012 23:00:43 +0000

A 72 year old woman is seen in the emergency department following a fall. She has lived alone since her husband died six months ago, and she is normally fit and well. She had been tending to her garden when she slipped. She sustained a pre-tibial laceration, requiring treatment with adhesive strips. She is about to be sent home with her daughter, when the results of some routine blood tests are noted. These reveal a Na of 125 mmol/L, K 4.9 mmol/L, urea 4.5 mmol/L and creatinine of 65 micromol/L. Full blood count is normal. Liver biochemistry is normal. She is referred to the medical admissions unit, where you see her.

How will you approach the investigation of this woman’s hyponatraemia?

Further clinical information in a couple of days for our students.

Pulmonary renal syndrome in a young man

Neil Turner — Mon, 19 Mar 2012 00:01:27 +0000

A 28 year old man is admitted with two days of vomiting. His illness began with a sore throat but he has become progressively more unwell, developing abdominal pains which became severe, and vomiting. He saw his general practitioner who diagnosed a viral infection and prescribed throat linctus and simple analgesics. However he deteriorated and the following day his wife brought him to the local hospital.
He had been previously healthy and is not taking any drugs. He is a smoker who drinks quite heavily at weekends and sometimes during the week. His work at a local factory does not involve exposure to chemicals. He is a keen fisherman.

On assessment he is thought to be mildly dehydrated. Pulse is 100 and blood pressure 139/85, JVP just visible lying flat.
He appears to be breathless and pulse oximetry shows him to be hypoxic (saturation 90%). His chest X-ray is shown. Today he has developed a dry cough.

Tests show acute renal failure with urea 24 mmol/l, creatinine 230 micromol/l (2.6 mg/dl). Na 138, K 5.4. He is catheterised and his bladder contains 240 mls of quite dark urine which on dipstick testing shows blood + protein +. FBC shows Hb 11.8 g/dl, wbc 11.2, plats 170, film normal. Liver function tests are normal. One of the doctors having read Dr Dorward’s case from October shortness of breath in a 60 year old man, an urgent anti-GBM and ANCA test is sent.

A central venous catheter is inserted and shows CVP of 8cm from the mid-axillary line. Infusion of 1.5 litres of crystalloids raises his CVP to 12 and blood pressure to 145/90 but does not increase his urine output.

Over the next 48 hours his renal function deteriorates further: 410 the next day, 680 the third. His oxygenation also deteriorates and he now requires 80% oxygenation to maintain saturation. His anti-GBM result is reported to be weakly positive. He is transferred to a tertiary centre for dialysis and ventilation.

Have the admitting team done OK so far?

Thanks to Professor Andy Rees for this case.