Smear tactics
A 19-year-old woman with anemia has a peripheral blood smear demonstrating hypochromic, microcytic red blood cells. What is your next best test to confirm her diagnosis?
Ferritin
Diagnosis: iron deficiency anemia
Name 3 drug classes that can contribute to pre-renal acute kidney injury.
Bonus: Name 1 drug class that can cause AIN.
1. NSAIDs
2. ACEi/ARB
3. Diuretics
Bonus: PPIs, B-lactams
These antibodies will be found in 30% of the healthy population (and does not mean you have Lupus!)
ANA (anti-nuclear antibodies)
List 3 causes of bilateral leg edema.
1. CHF
2. Cirrhosis
3. CKD
4. Venous insufficiency
5. Hypoalbuminemia
A 20-year-old college student living on Mr. Noodles and Bubly presents feeling "off-balance" with numb hands and feet. Hgb is 88 g/L and MCV 108 fL. Peripheral blood smear reveals hypersegmented neutrophils. What nutritional deficiency is likely present?
Vitamin B12 deficiency
What is the single most concerning finding on a peripheral blood smear?
Bonus: in which context would you be less concerned by this finding?
Blasts
Indicative of an acute leukemia
Bonus: prolonged critical illness
Name 2 cytochrome P450 enzyme inducers?
1. Phenytoin
2. Rifampin
3. Phenobarbital
4. Carbamazapine
5. St. John's Wort
This antibody is highly specific for primary biliary cirrhosis.
Anti-mitochondrial antibody (AMA)
Name 3 causes of LFTs in the 1000's.
1. Ischemic hepatitis
2. Tylenol toxicity
3. Autoimmune hepatitis
4. Budd-chiari syndrome
5. Acute viral hepatitis (Hep A, CMV, HSV)
An 82-year-old woman with moderate dementia who lives alone presents with numerous ecchymoses, bleeding gums, perifollicular purpura, and coiled hairs. What is the most likely vitamin deficiency present?
Vitamin C hypovitaminosis (Scurvy)
A 39 year old woman presents to the emergency department with bruising, oral blood ulcers, sudden onset left sided weakness, and is found to have an acute kidney injury. What finding would be expected on the peripheral blood smear?
Schistocytes
Diagnosis: TTP
3 causes of drug-induced ILD?
1. Nitrofurantoin
2. Amiodarone
3. Methotrexate
Which antibody would be found in a patient with ptosis and a large mediastinal mass?
Anti-acetylcholine receptor antibody (Anti-ACh-R)
Dx: Myasthenia Gravis
Name 5 chronic diseases associated with a low systolic blood pressure?
1. Amyloidosis
2. Congestive heart failure
3. Multiple system atrophy
4. Parkinson's disease
5. Cirrhosis
6. Anorexia nervosa
7. Adrenal insufficiency
An unhoused man presents with confusion, heart failure, and peripheral neuropathy. Which nutritional deficiency is the cause of his symptoms?
Thiamine (vitamin B1)
1. Wernicke's encephalopathy
2. Wet beriberi
3. Dry beriberi
A 35-year-old woman is consulted to Internal Medicine from the ED for ?GI bleed. She presented with severe fatigue and is found to have Hgb 54 g/L, MCV 88, LDH 1022 U/L, Bilirubin 58, reticulocytes 0.36, and undetectable haptoglobin. DAT is positive. Peripheral blood smear reveals spherocytes. What is the diagnosis?
Autoimmune hemolytic anemia
-Anemia
-Hemolysis
-DAT positive
-Spherocytes
3 causes of drug-induced lupus
1. Minocycline
2. Procainamide
3. Hydralazine
4. Quinidine
5. TNF inhibitors
This antibody may confirm the underlying disease in a patient with hypoalbuminemia, hypertriglyceridemia, anasarca, and 24-hour urine protein >3.5 g/day.
Anti-PLA2R antibody
Clinical syndrome: Nephrotic
Associated diagnosis: Membranous nephropathy
Name 3 non-rheumatic diseases associated with a positive anti-nuclear antibody?
1. PBC (50-70%)
2. Autoimmune hepatitis (70%)
3. Hashimoto's Thyroiditis (50%)
4. Grave's (50%)
A 40-year-old woman presents with brittle nails, alopecia, and impaired wound healing. Exam reveals an erythematous vesiculobullous rash around the mouth and on the hands/feet. Which nutritional deficiency would explain her picture?
Zinc deficiency
"Acrodermatitis enteropathica" is classic rash from autosomal recessive zinc deficiency
A 26-year-old woman is in the ICU with a prolonged course of septic shock. Her peripheral blood smear reveals nucleated RBCs, metamyelocytes, promyelocytes, and bands. What is occurring and why?
Leukoerythroblastic reaction
Due to prolonged bone marrow stress e.g. from prolonged severe illness / inflammatory state
3 drugs that can trigger myasthenic crisis in those with MG?
1. Antibiotics (FQ's, Macrolides, AG's)
2. Beta blockers
3. Steroids
4. Neuromuscular blockers
5. Statins
6. IV magnesium
A 43 year-old woman complains of blanching fingers, facial rash, hair loss, oral ulcers, difficulty standing up from a chair, dysphagia, and is found to have pulmonary hypertension and interstitial lung disease. The presence of this antibody would firmly establish the diagnosis.
Anti-U1 RNP antibody is highly specific for Mixed Connective Tissue Disease (MCTD) which harbours features of SLE, Dermatomyositis, and SSc.
Name 3 causes of infiltrative cardiomyopathy.
Bonus: name the 3 most specific diagnostic tests for each (besides ECHO and ECG).
1. Cardiac sarcoidosis (CMRI, CXR, Biopsy)
2. Cardiac Amyloidosis (Pyrophosphate Scan, serum light chains, biopsy with congo red staining)
3. Cardiac hemochromatosis (TSAT, ferritin, H63D/C282Y genes)
A 30-year-old woman presents with fatigue, recurrent infections, and easy bruising. She is pancytopenic. Which nutritional deficiency could account for her picture?
Copper deficiency can cause pancytopenia.