Clinical cases - other

Question 1

Rheumatoid arthritis sx

Answer 1

Joints - small joint symmetrical poly arthritis. MCP. Swan neck and boutonnieres. Z thumb. Ulnar deviation MCPs.

Lung - pleural effusions, fibrosing alveoli’s, obliterative bronchiolitis
Eyes - Sjogrens, scleritis
Neuro - peripheral neuropathy, atlanto-axial subluxation
Cardiac - pericarditis, CAD
Renal - nephtrotic sundrome
Felty’s syndrome - RA + splenomegaly + neutropenia

Question 2

Rheumatoid arthritis ix

Answer 2

Bloods - anti-CCP, ESR, RF, ANA
Neuts (felty)
XR hands and feet - soft tissue swelling, loss of joint space, articular erosions
CXR +/- HRCT / PFTs

Question 3

Rheumatoid arthritis

Answer 3

Conservative - physio, OT, occupational
Medical - steroids, methotrexate / sulfasalazine (orange liquids) / hydroxycholorquine
Progressing to anti-TNF, B cell depletion therapy or anti IL-6
Surgical - joint replacement
Regular rheum f/u

Question 4

Hyperthyroidism examination for gold stars

Answer 4

Eyes - lid retraction + lag -> proptosis -> opthalmoplegia -> Colour vision + acuity loss
Goitre +/- bruit
Hands - palmar erythema, tremor,
Proximal myopathy and brisk reflexes
Pretibial myxoedema

Question 5

Hyperthyroidism mx

Answer 5

Carbimazole or propylthiouracil - either block and replace or titrate. Stop at 18m + monitor

1/3rd reoccur -> try again / radioiodine / subtotal thyroidectomy

If severe ocular signs - may need steroids / orbital irradiation

Question 6

Hypothyroidism complications

Answer 6

Pericardial effusion
CCF
Carpal tunnel
Proximal myopathy
Ataxia

Question 7

Hypothyroidism causes

Answer 7

AI - hashimotos
Iatrogenic - amiodarone, lithium, post surgery
Iodine deficiency
Genetic

Question 8

Erythema nodosum causes

Answer 8

Autoimmune - Sarcoid. IBD.
Infectious - streptococcal infection. TB.
Malignancy - lymphoma. 
Pregnancy.
Drugs - OCP, streptomycin, sulphonamides.

Question 9

Cushing

Question 10

Goitre

Question 11

Pyoderma gangrenosum

Question 12

Acromegaly signs + symptoms

Answer 12

Bitemporal hemianopia. Headache.

Big hands. Right rings. Sweaty.
Big supraorbital ridges. Macroglossia.

Question 13

Acromegaly ix

Answer 13

IGF-1 (raised.
OGTT - non suppression of GH.
MRI pituitary fossa.
Assess for complications - TSH. ACTH. PRL. Testosterone. HbA1c. ECG. CXR.

Question 14

Tophaceous gout causes

Answer 14

Xanthine rich foods - meat, beer, seafood
Drugs - diuretics, calcineurin inhibitors
CKD
Metabolic syndrome

Question 15

Acromegaly mx

Answer 15

Somatostatin analogues or dopamine agonists

Transphenoidal surgery -> SE meningitis, diabetes insipidus, panhypopituitarism

XRT - for non surgical candidates

Question 16

Systemic sclerosis ix

Answer 16

ANA.
Anti-centromere, Scl-70.

Hand XR
Lung - HRCT + PFTs
GI - endoscopy, oesophageal manometry
Renal - dip, consider renal biopsy
Cardiac - ECG, echo, ? R heart catheter

Question 17

Systemic sclerosis mx

Answer 17

Symptomatic.
Raynaud’s - CCB, ACEi. Prostacyclin infusion.
Renal - ACEi.
GI - PPI.

Question 18

Osler-Weber-Rendu / Hereditary Haemorrhagic Telangectasia

Signs. Genetics. Risk.

Answer 18

Multiple telangectasia - face, lips, buccal.

Autosomal dominant.
Increased risk UGIC, epistaxis, haemoptysis.
Vascular malformations -> pulmonary shunts. SAH.

Question 19

Ankylosing spondylitis features

Answer 19

Back pain - worse at rest
Anterior uveitis
Psoriasis and psoriatic arthropathy
IBD
Kyphosis. Lung fibrosis - apical.
Complete heart block. Aortic regurg.

Question 20

Ankylosing spondylitis ix

Answer 20

HLA B27
Spinal XR
MRI sacroiliac joints

Question 21

Lupus pernio

Question 22

Tophaceous gout

Question 23

Tuberous sclerosis signs

Answer 23

Skin - facial adenoma sebaceous, periungual fibromas, shagreen patches, ash leaf males
Resp - cystic lung disease
Abdominal - polycystic kidneys, renal angiolipomata
Eyes - retinal phakomas
CNS - epilepsy

Question 24

Tuberous sclerosis genetics

Answer 24

Autosomal dominant with variable penetrance

Question 25

Sickle cell crisis sx

Answer 25

Sudden onset bone pain or pleuritic chest pain Viral, cold, dehydration, ETOH + smoking, psychological stress, exercise, hypoxia, altitude Infection (functional hyposplenism), PE + pulm HTN, stroke/TIA, leg ulcers, priapism

Question 26

Sickle cell treatment

Answer 26

O2 and CPAP. IVF. Analgesia. Bood transfusion / exchange if severe Long term hydroxycarbamide (teratogenic) or exchange transfusions. Folic acid. penicillin prophylaxis + vaccinations.

Question 27

Marfans syndrome - manifestations

Answer 27

Pectus carinatum, scoliosis Eye - upward lens dislocation (+ iris movement with eye movement) Kyphoscoliosis, arachnodactyly (little finger round wrist), hyper extendable joints High arched palate Aortic root dilatation, aortic valve incompetence, mitral valve prolapse

Question 28

Marfans genetics

Answer 28

Autosomal dominant Chromosome 15 Fibrillin gene

Question 29

Marfans mx

Answer 29

Surveillance echo BB or ARB - slow progression of root dilatation Pre-emptive aortic root surgery Genetic screening family + echo

Question 30

EBV red flags and advice

Answer 30

Complications - meningoencephalitis sx, GBS, jaundice Lymphoma dx - painless lymphadenopathy, weight loss, ETOH induced pain Monospot -ve -> HIV / hepatitis work up, Avoid contact sport 4/12. Avoid amoxicillin.

Question 31

Familial hypercholesterolaemia - examination

Answer 31

Tendon xanthomata - knuckles, achilles, less commonly Other xanthomata - eyelids, corneal arcus Hepatomegaly Carotid bruit Heart sounds

Question 32

Secondary causes lymphoedema

Answer 32

Chronic venous insufficiency Surgery Pelvic mass - large fibroids XRT Lymphatic filariasis

Question 33

Secondary causes HTN

Answer 33

Renal - ADPKD, glomerulonephritis Endocrine - hyperthyroidism, pheochromocytoma, cushing's, conn's CV - coarctation, renal artery stenosis Genetic - Liddle's Steroids Cocaine OSA

Question 34

Haemochromatosis genetics and presentation

Answer 34

Autosomal recessive. HFE gene. Screening. Asymptomatic raised ferritin. Arthralgia. Libido issues. -> DM. Cardiomyopathy. Cirrhosis.

Question 35

Cushing’s causes

Answer 35

- ACTH dependent - Pituitary adenoma. Ectopic ACTH. - ACTH independent - Exogenous steroids. Adrenocortical adenomas.

Question 36

High cortisol ix

Answer 36

- ACTH level - MRI pituitary fossa +/- adrenal CT +/- whole body CT - Bilateral inferior petrosal sinus vein sampling - pituitary vs ectopic origin - High dose dexamethasone suppression test (cortisol falls if ACTH dependent Cushing’s).

Question 37

Secondary ammenhorrea causes

Answer 37

Pregnancy, Postpartum and breastfeeding, Pills, Premature menopause, PCOS, Pituitary adenoma

Question 38

Nephrotic syndrome ix

Answer 38

Urinalysis and uPCR or uACR Renal function FBC, UE, CRP Cause - ANA, complement, HIV + Hepatitis, HbA1c CXR 
Renal USS +/- biopsy

Question 39

Nephrotic syndrome causes

Answer 39

- Primary glomerulonephritis - membranous, FSGS, minimal change, IgA - Secondary - DM, amyloid, SLE, RA, HIV + hepatitis, malignancy (solid + haematological)