Clinical Consultation Flashcards

Question

Complications of pituitary resection in acromegaly

Answer 1

Pan hypopituitarism

Answer 2

Score >11 signifies presence of OSA

Answer 3

If confirmed on polysomnography can trial CPAP overnight

Answer 4

Rutherford-Morrison

Answer 5

Bicuspid aortic valve Aortic degneration Poor hearing Small stature Barrel chested Scoliosis Translucent teeth Bowing of long bones Joint hypermobility Skin hyper laxity Retinal detachment and haemorrhages

Answer 6

Usually AD Can be de novo

Answer 7

Oesophagitis/gastritis Osteonecrosis of the jaw

Answer 8

Fragile skin - ecchymoses and fish mouth scars Hyperextensible skin Joint hyper mobility Mitral valve prolapse Aortic dilatation - risk of dissection/rupture Aneurysm rupture and dissection Bowel perforation and bleeding

Answer 9

APLS MPN e.g PV, myelofibrosis and essential thrombocytosis

Answer 10

TIA/Stroke DVT PE Livido reticularis Thrombocytopenia Thrombophlebitis Foetal loss

Answer 11

APLS Extra cranial haemorrhage Vasculitis Cardiac Myxoma Subacute infective endocarditis AF Sickle cell disease Premature atheroma Substance abuse - cocaine and methamphetamine Mitochondrial problems eg MELAS

Answer 12

Chronic hypertension: - Presents prior to pregnancy or at booking <20 weeks Gestational hypertension: - New hypertension >20 week without proteinuria - Relabeled as chronic/primary hypertension if >12 weeks post partum Pre eclampsia: - New hypertension >20 weeks of pregnancy with one or both of proteinuria (PCR >30mg/mmol), OR renal/liver involvement, haematological complications, uteroplacental dysfunction

Answer 13

Labetolol Nifedipine - 1st choice in afro-Caribbean women Methylodopa Can also give aspirin 150mg ON to decrease risk of pre eclampsia

Answer 14

Aim for BP <135/85 Initiate treatment in women with BP >140/90

Answer 15

Maternal AKI Liver dysfunction - especially increase in ALT Neurological features - headache/confusion/flashing lights Haemolysis or thrombocytopenia Fetal growth restriction

Answer 16

Urine dip PCR or ACR Placental growth factors Growth scans

Answer 17

20% risk of hypertension 20% risk of pre-eclampsia Long term CV risks

Answer 18

Asthma LRTI PE Pneumothorax Peripartum cardiomyopathy DKA

Answer 19

Oxygen Diurese with furosemide Nitrates ACEi - only in postpartum Consider beta-blockers after liaising with obstetric cardiologists Liaise with obstetric team for delivery

Answer 20

No validated scoring systems >35 years BMI >30 Multiple pregnancy Para 3+ Hyperemesis Post partum after prolonger labour, operative delivery or PPH >1L

Answer 21

Continue for full duration of pregnancy, for at least 3 months in total and for at least 6 weeks post partum

Answer 22

VTE - IPC Further stroke Haemorrhagic transformation Malignant middle cerebral artery syndrome Seizures Aspiration pneumonia Spasticity Falls urinary and faecal incontinence

Answer 23

Antiplatelets if no AF - clopidogrel long term Anticoagulation if AF found Statin Weight loss Stop smoking Optimisation of blood pressure and diabetes Endarcterectomy if >70% stenosis in carotid artery on ipsilateral side to stroke

Answer 24

MCA - in posterior stroke macula will be spared due to occipital pole receiving blood supply from the MCA

Answer 25

Pituitary tumour Glaucoma Diabetic retinopathy and maculopathy Bilateral cataracts Idiopathic intracranial hypertension Leber's hereditary optic neuropathy Retinitis pigmentosa Vitamin A deficiency

Answer 26

Progressive inherited retinal degeneration chcarcterised by by loss of photo receptors No treatment, though vitamin A may slow progression

Answer 27

Refsum's syndrome - muscle weakness and ataxia Usher's syndrome - sensorineural deafness Kearn-Sayre's syndrome Abetalipoproeinaemia

Answer 28

Analgesia Treating underlying cause

Answer 29

STI - chlamydia Diarrhoeal illnesses

Answer 30

HLA B27 Associated with seronegative spondyloarthropathies - enteric arthritis, psoriatic arthritis, ankylosing spondylitis

Answer 31

Hashimoto's thyroiditis - lymphocytic destruction of thryroid follicles De quervains thyroiditis Iatrogenic hypothyroidism - post thyroidectomy or radio-iodine, amiodarone, lithium, carbimazole, propyl thiouracil Post partum thyroiditis Iodine deficiency

Answer 32

Tired and low energy levels Constipation Cold intoleranceMental slowing Weight gain Hair loss Decreased libido Oedema

Answer 33

TFTs - T3, T4 and TSH TPO and anti-thyroglobulin - positive in Hashimoto's Lipid profile FBC - microcytic anaemia U&Es - Na USS thyroid - goitre/FNA CXR - retrosternal extension of goitre Cortisol - to screen for Cushing's

Answer 34

T1DM Vitiligo Addison's disease Hypercholesterolaemia

Answer 35

Bradycardi Cool peripheries Peaches and cream complexion - anaemia and carotenaemia Peri-orbital oedema Loss of eyebrows Xanthelasma Thinning hair Goitre or thyroidectomy scar Slow relaxing ankle jerk

Answer 36

Pericardial effusion CCF Carpel tunnel syndrome Proximal myopathy Ataxia

Answer 37

May unmask Addisons - precipitate crisis May precipitate angina

Answer 38

IV beta blockers - e.g propranolol unless contraindicated e.g. severe asthma (then use CCB - diltiazem) Lugol's iodine Carbimazole/propylthiouracil Hydrocortisone Patients who fail medical therapy should be treated with plasma exchange or thyroidectomy

Answer 39

Illness/infection Recent iodine contrast Trauma Withdrawal or non-compliance of thyroid treatment Myocardial infarction or stroke DKA Overdose of levothyroxine

Answer 40

May require ITU Ventilation if needed - rest failure from airway obstruction or macroglossia Hydrocortisone IV/PO thyroid IV fluids

Answer 41

Guillain Barre Miller Fischer syndrome Lambert Eaton syndrome

Answer 42

Anti-acetylcholinesterase (positive in 20%) and Anti-MuSK (positive in 15%) TFTs - graves present in 5% CXR CT chest - ?thymoma (present in 10%) MRI head if bulbar involvement present CT/MRI orbits if thyroid opthalmoplegia suspected Nerve conduction studies -decrement of compound muscle action amplitude with repetitive stimulation Tension test - less commonly less

Answer 43

Pyridostigmine Steroids Steroid sparing treatments - azathioprine (check TPMT levels prior) or MMF IVIG or plasma exchange Note have steroid dip - symptoms may worsen when starting Thymectomy in some groups

Answer 44

Other autoimmune disease - diabetes mellitus, RA, thyrotoxicosis, SLE, thymomas

Answer 45

Paraneoplastic - VGCC abs present, association with SCLC EMG - increment on repetitive stimulation Diminished reflexes that become brisker after exercise

Answer 46

Neuropathic bladder Constipation Leg spasticity Hydrocephalus - sometimes requiring VP shunts Arnold-Chiari malformations Recurrent meningitis Syrinxes

Answer 47

Deficiency of folate during 1st trimester Family history of NTDs Anti-epileptics - sodium valproate Methotrexate Poorly controlled diabetes

Answer 48

Expiration increases venous return and therefore increases the amount of blood going through the VSD

Answer 49

If evidence of left ventricular failure or reversal of shunt (right to left) - will need to consider closure of VSD either through patch or VSD closure device

Answer 50

Endovascular stenting - balloon angioplasty and stent placement Surgical open repair - resection and end-end anastomosis

Answer 51

Oslers nodes Janeway lesions Splinter haemorrhages Roth spots in eyes Septic emboli distally Poor dentition Intravenous drug use Haematuria on urine dipstick

Answer 52

PDA VSD Berry aneurysms Turner syndrome

Answer 53

Heart failure in Children Hypertension Heart failure in adults Leg claudication Headaches Epistaxis

Answer 54

Radio-radial delay Weak femoral pulses Radio-femoral delay Systolic ejection click (bicuspid vale) Pansystolic murmur - VSD Adjacent bruits - arterial collaterals e.g scapula, anterior axillary area, Mid systolic murmur in infraclavicular area or posteriorly over left scapula ECG - LV hypertrophy CXR - posterior rib notching, figure 3 sign

Answer 55

Stroke Heart failure Aortic rupture

Answer 56

Anaemia Bone marrow suppression Pulmonary fibrosis Liver dysfunction

Answer 57

Eyes/face: Sicca symptoms - dry eyes, throat Scleritis (pain and redness) or episcleritis (redness) - scleromalacia (blue grey discolouration of eye) Kerotconjunctivits sicca Steroid induced cataracts Fatigue Lungs: Pulmonary fibrosis Fibrosing alveoli's Obliterative bronchiolitis Lung nodules Pleural effusion Heart: Pericarditis (constrictive) Pericardial effusion Renal: Nephrotic syndrome - membranous glomerulonephritis Renal amyloidosis Neuro: Carpal tunnel syndrome Peripheral neuropathies Felty's Syndrome - splenomegaly and neutropenia

Answer 58

Anaemia of chronic disease Secondary to renal disease Iron deficiency anaemia - due to gastric ulceration with medications (NSAIDs) B12 deficiency - pernicious anaemia Bone marrow suppression with DMARDs Autoimmune haemolytic anaemia Felty's syndrome (splenomegaly)

Answer 59

Soft tissue swelling Loss of joint space with subluxation Periarticular osteopenia Joint erosions

Answer 60

Volar subluxation and ulnar deviation at the MCPJs Swan neck - Hyperextension of of PIPJ and flexion of the DIPJ Boutonieres deformities - Flexion of the PIPJ and hyperextension of the PIPJ Z shaped deformity of thumbs Swelling and subluxation of the ulnar styloid Carpal tunnel scar Wasting of the dorsal interosseous muscles Pain, swelling and restriction of joints in RA

Answer 61

DAS28 - Involves number of swollen and tender joints, ESR/CRP and objective assessment of the patients global health DAS >5.1 - Active disease DAS <2.8 - remission

Answer 62

Seropositive disease - rheumatoid factor or anti-ccp Articular erosions at onset Severe disease activity at onset

Answer 63

Anti-TNF alphas - adalimumab, etanercept, inflixamab Anti-CD20 - rituximab T cell co-receptor blocker - Abatercept Anti IL-6 - Rocilizumab

Answer 64

Methotrexate Leflunamide Sulphasalazine Hydroxychloroquire

Answer 65

Autosomal dominant in ATM gene

Answer 66

Ataxia Dysarthria and dysphasia Nystagmus Dysdiadokinesia Susceptibility to infections Increased risk of cancer esp leukaemia and lymphoma Telangiectasia

Answer 67

Before age of 5 years

Answer 68

Autosomal recessive

Answer 69

Frataxin - anticipation

Answer 70

Wheelchair user Pes cavus Bilateral cerebellar signs Combined UMN and LMN signs - Leg wasting with absent reflexes and bilateral upping planters Posterior column signs - loss of vibration and joint position senses Kyphoscoliosis optic atrophy - 30% High arched palate Sensorineural deafness Murmur associated with HOCM Diabetes testing - 10% develop diabetes

Answer 71

Familial Cardiac disease: - Infective endocarditis - Congenital heart disease Respiratory disease: - Lung cancer - ILD - Bronchiectasis - Cystic fibrosis - Asbestosis - EAA - Lung abscess - HHT with pulmonary AVMs Coeliac disease Cirrhosis of the liver Ulcerative colitis Hyperactive thyroid

Answer 72

Autosomal dominant

Answer 73

Vascular dysplasia causing telangiectasia and AVMs Epistaxis Telangiectasia and AVMs in the GI tract causing acute haemorrhage or chronic slow bleeding with resulting iron-deficiency anaemia. Pulmonary AVMs occur may present as dyspnoea, cyanosis, bruits, high-output heart failure, clubbing and paradoxical cerebral emboli that may cause stroke and cerebral abscess. They can also lead to haemoptysis and haemothorax. Pulmonary hypertension can occur. AVMs in the liver can cause high-output cardiac failure or cirrhosis. Some patients have cerebral involvement resulting in headache, seizures or epilepsy, intracranial haemorrhage and stroke.

Answer 74

Sarcoidosis Thymoma Lymphoma TB Pneumoconiosis e.g silicosis, berylliosis

Answer 75

NSAIDs for arthralgia Referral to respiratory and ophthalmology Steroids indicated if: - Stage 2-4 on CXR e.g BHL + infiltrates, infiltrates or fibrosis - Eye involvement - Hypercalcaemia - Neurological involvement - Cardiac involvement 40mg prednisolone with GI and bone protection Monitor with ESR and ACE Steroid sparing agents = methotrexate, hydroxychloroquine, ciclosporin, cyclophosphamide, infliximab Surgery- lung transplant, pacemaker

Answer 76

FBC, U&E, LFTs, Clotting ESR, CRP ANA, RF, anti-CCP, ANCA (+PR3/MPO), Immunoglobulins, complement (+/- cryoglobulins) Antiphospholipid Abs (anticardiolipin, antiB2GPI), lupus anticoagulant screen Anti-dsDNA, antiscl70, anticentromere Ab, AntiRo, AntiRNP, antism, Antijo1, AntiLa, Antism/RNP, antichromatin, antihistone Miscellaneous: ACE (sarcoid), ferritin (stills),anti-GBM (goodpastures) Nailfold capillaroscopy Pregnancy test Renal: BP, urine dipstick for blood and protein, urine PCR, renal USS, renal biopsy Joints/Spine: Xrays/USS, aspiration, MRI CVS: ECG, troponin, ECHO, BNP, cMRI Resp: Sats, ABG, CXR, pulmonary function tests, HRCT, Right heart catheterisation, BAL, broncoscopy

Answer 77

ANA (95% sensitive, low specificity). Positive in 98% of SLE patients. Antiribosomal P (specific, can be positive in ANA negative patients). AntidsDNA (70% of SLE, 95% specific) Antism (pathognomic for SLE) Positive in 10-30% Antiphospholipid Abs positive in 30-50% Anti Ro and La (neonatal lupus, heart block) Anti-RNP (mixed connective tissue disease) RF (positive in 40%) Antihistone antibodies for drug induced lupus

Answer 78

ACR criteria - 4 out of 11 of SOAP BRAIN MD Serositis - pericarditis/pleuritis Oral mucosa Arthritis Photosensitivity Blood - lymphopenia - Haemolytic anaemia - Leucopenia Renal ANA Immunological Neurological - seizures and psychosis Malar rash Discoid rash

Answer 79

Conservative: Sunscreen, pregnancy advice Medical: Manage CVS risk factors. ACEI for proteinuria. Mild-moderate lupus (MSK and mucocutaneous features): low dose oral prednisolone and bone and GI protection, hydroxychloroquine, azathioprine, methotrexate. NSAIDs for joint pain (watch U+E) Severe (major organ involvement): iv methylprednisolone, cyclophosphamide, mycophenolate mofetil, rituximab/belimumab Surgical: renal transplant

Answer 80

Streptococcus OCP Rickettsia Eponymous - Behcets Sarcoidosis Hansen's disease - leprosy IBD - usually UC Infections - TB (cutaneous) Idiopathic NHL Sulfonamides Pregnancy

Answer 81

Diagnosis is made using the Curacao Criteria. If 3 criteria are present the diagnosis is definite. If 2 criteria are present, the diagnosis is suspected or possible. If only 1 criterion is present the diagnosis is unlikely. 1 Epistaxis that is spontaneous and recurrent 2 Multiple mucocutaneous telangiectasia at characteristic sites such as the lips, nose, tongue and mucous membranes, fingers, conjunctiva 3 Visceral lesions- GI telangiectasia, Pulmonary, Hepatic, Cerebral AVMs 4 Family History in a first degree relative. Genetic testing can be performed to confirm the diagnosis if necessary.

Answer 82

Trauma Low platelets Drugs - antiplatelets etc Malignancy Cocaine Wegener’s granulomatosis (now called Granulomatosis with Polyangiitis) HHT

Answer 83

Managing epistaxis - Nasal humidification - Ointments - Saline spray - Tamoxifen - TXA - Laser therapy or cauterisation Blood transfusion if needed Embolisation or ablation of GI AVMs Treatment of iron deficiency

Answer 84

Autosomal dominant MEN gene defects Pituitary adenoma Parathyroid hyperplasia Pancreatic tumours and gastronomes

Answer 85

Autosomal dominant RET gene defects Parathyroid hyperplasia Medullary thyroid carcinoma Phaechromocytoma

Answer 86

Autosomal dominant RET gene defects Marfanoid body habitus Mucosal neuromas Medullary thyroid carcinoma Phaechromocytoma

Answer 87

Bihilar lymphadenopathy, erythema nodosum, fever, weight loss, arthralgia, uveitis

Answer 88

Obs and urine dip Bloods- ESR, CRP, FBC, LFTs, ACE, Calcium, Immunoglobulins, U+E, vitamin D, TFTs 24 hour urine for calcium if raised serum calcium Respiratory tests: sats and ambulatory oximetry, CXR, spirometry, BAL, bronchoscopy and biopsy (send biopsy for mycobacterial and fungal testing and histology), HRCT Cardio tests: ECG, echo, 24 hour Holter, cardiac MRI Abdo tests: urine dipstick, USS, CT Eye tests: slit lamp examination, visual acuity, fundoscopic examination Neuro tests: CT/MRI, LP LN biopsy/skin biopsy/peripheral nerve biopsy

Answer 89

Uveitis Granulomas which may causes visual impairment or retinal detachment Conjunctivitis Keratoconjunctivitis sick Neurosarcoidosis - papilloedema, nystagmus, visual field defects

Answer 90

Drug-induced lupus RA Stills disease Undifferentiated or mixed connective tissue disease Primary sjogrens Antiphospholipid syndrome Fibromyalgia Lymphoma Infection Pulmonary-renal syndrome (goodpastures, ANCA-associated vasculitis) Systemic sclerosis Dermatomyositis

Answer 91

Low lymphocytes Low complement Normal/low CRP Raised ESR Anaemia, thrombocytopenia Raised antidsDNA

Answer 92

Suspect if: Arterial thrombosis <50 years old Unprovoked venous thrombosis < 50 years old Recurrent thrombosis Both arterial and venous events Unusual sites eg. renal, liver, cerebral sinuses, mesenteric, vena cava, retinal Obstetrical: fetal loss (miscarriage after 10 weeks/3 unexplained miscarriages <10 weeks), recurrent miscarriages, early/severe preeclampsia, unexplained intrauterine growth restriction Lab criteria on 2 occasions 12 weeks apart: anticardiolipin Abs, Anti-B2GPI, lupus anticoagulant, raised APTT.

Answer 93

Avoid oestrogen contraceptives, prophylactic aspirin Heparin for thrombosis then warfarin

Answer 94

Infections, Atherosclerosis Osteoporosis Malignancy especially lymphoma, lung cancer, cervical.

Answer 95

Hydralazine procainamide Isoniazid Phenytoin Interferon Associated with anti-histone Abs

Answer 96

Weight loss Anxiety Palpitations Tachycardia Diarrhoea Heat intolerance Tremor Sweating Irritable mood Breathlessness Weakness going up stairs Eye symptoms - grittiness, loss of vision, loss of colour, eye pain, blurred or double vision

Answer 97

50% chance of cure / 50% chance of relapse - can have further treatment with carbimazole or trial of radioactive iodine

Answer 98

May exacerbate active thyroid eye disease

Answer 99

Aim to treat medically - usually takes 1.5-2 years If relapses can trial medical treatment again or radioactive iodine or surgery Medical Management: beta-blocker for symptomatic relief (e.g. propranolol), carbimazole or propylthiouracil (during 1st trimester). Indications for surgery: relapse after stopping antithyroid drugs, poor compliance with meds, intolerance of meds, cosmesis, compression, symptomatic and planning pregnancy, uncontrolled on meds, suspicious nodules Complications of surgery: hypoparathyroidism, damage to recurrent laryngeal nerve, hypothyroidism, recurrence of hyperthyroidism

Answer 100

Abs to TSHr

Answer 101

Optic neuropathy - visual acuity and colour vision Exposure keratopathy Double vision

Answer 102

If mild - selenium, and topical lubricants If by NOSPECS criteria >3 (ie more than or equal to proptosis consider IV methylpred weekly for 6 weeks Cyclosporin may be given as a steroid sparing agent Can try orbital decompression or radiotherapy if still no benefit

Answer 103

Thyroid eye disease Orbital tumour/met/granuloma Caroticocavernous fistula Orbital cellulitis AVM Cavernous sinus thrombosis

Answer 104

Graves disease Toxic multi nodular goitre Solitary toxic nodule Excess levothyroxine replacement Ectopic: - Pituitary adenoma - Hypothalamic mass - Ovarian teratoma, choriocarcinoma Thyroiditis: - Subacute (de Quervains) - Post radiation - Post partum - Drug induced e.g amiodarone

Answer 105

Cysts in other areas particularly the liver leading to polycystic liver disease Berry aneurysms Mitral valve prolapse

Answer 106

Painless deformity and destruction a joint with new bone formation following repeated minor trauma secondary to loss of sensation

Answer 107

Tabes dorsalis - hip and knee Diabetes - foot and ankle Syringomelia - elbow and shoulder

Answer 108

Immobilisation Referral to orthopaedics for surgical intervention Bisphosphonates can help

Answer 109

Renal: - CKD secondary to glomerulonephritis - ADPCKD - Renovascular disease e.g renal artery dysplasia Endocrine: - Cushings - Conns - Bilateral adrenal hypertrophy - Liddle's (low potassium and metabolic alkolosis, acts on ENaC transporter, treated with amiloride) - Acromegaly - Phaechromocytoma - Carcinoid Aortic coarctation Pre-eclampsia

Answer 110

Symptoms for hypertensive emergency: - Headache - Visual disturbance - Chest pain Previous blood pressure reading PMHx: renal disease, CVD or PVD, smoking, diabetes, thyroid disease, cardiac disease in childhood Associated symptoms: - Abdominal/flank pain - Polyuria - Muscle cramps (Conn's) - Frothy urine? - Change in hand size - Flushing or dumping sx - Anxiety or palpitations or sweating Illicit drug use ?Pregnancy

Answer 111

HTN if in clinic BP >140/90 on two measurements - use ABPM to confirm diagnosis (135/85 on ABPM) Graded by British hypertension society guidelines: Stage 1. Clinic BP >140/90 or ABPM >135/85 Stage 2. Clinic BP >160/100 or ABPM >150/95 Stage 3. Clinic SBP >180 or DBP >120 Treat if stage 1 hypertension and evidence of end organ damage, IHD, diabetes, CKD or 10 year CVS risk >10% Treat all stage 2 hypertension Arrange same day admission if severe hypertension and grade 3 or 4 retinopathy (or other concerns e.g. new renal impairment)

Answer 112

Grade 1. Silver wiring Grade 2. Plus arteriovenous nipping Grade 3. Plus cotton wool spots and flame haemorrhages Grade 4 Plus papilloedema

Answer 113

x2 BP readings, and alternate BP readings on arms Urine dip with PCR ECG - LVH Bloods: - FBC - U&Es - renal impairment low bicarb (conns) - LFTs - Aldosterone and renin ratio CXR ECHO USS kidney Special tests: - Plasma meatnephrines - Dexamethasone suppression tests - IGF1 - MRA renal arteries - PET - adrenal tumours - MIBG - for phaechromocytomas

Answer 114

Lifestyle advice firstling - increase exercise, salt restriction, lose weight, reduce alcohol, stop smoking ACEi or ARB if <55yrs first line CCB if afro-Caribbean or >55yrs A+B second line A+B+D (thiazide-like diuretic 3rd line e.g. indapamide) Then consider spironolactone, beta blocker or alpha blocker Aim <140/90, except - >80yrs - aim <150/90 - If ACR >70 - aim <130/80 Consider cardiovascular risk and consider statin and aspirin

Answer 115

Aortic dissection PRES - posterior reversible encephalopathy syndrome Aortic aneurysm MI Stroke Left ventricular failure If above conditions present invasive blood pressure monitoring and IV anti-hypertensive agents e.g GTN, labetalol and alpha blocker if considering phaechromocytoma

Answer 116

MEN1 (MEN oncogene): - Pituitary - Parathyroid hyperplasia - Pancreas MEN2A (RET oncogene): - Parathyroid hyperplasia - Phaechromocytoma - Medullary carcinoma MEN2B (RET oncogene) - Phaechromocytoma - Medullary hyperplasia - Mucosal neuromas - Marfanoid habitus

Answer 117

1. Background retinopathy +/- maculopathy - Hard exudates - Flame and dot haemorrhages - Microaneurysms - Annual retinal screening 2. Pre-proliferative retinopathy +/- maculopathy - Multiple cotton wool spots Multiple dot haemorrhages - Venous beading - Intraretinal microvascular abnormalities - Routine referral to ophthalmology 3. Proliferative retinopathy +/- maculopathy - Neovascularisation of the disease - New vessels elsewhere - pan retinal photocoagulation from previous treatment - Urgent referral to ophthalmology Diabetic maculopathy - macular oedema or hard exudates with one disc space of the fovea - routine referral to ophthalmology unless reduced vision (then urgent)

Answer 118

Tight glycemic control Treat other factors - hypertension, hypercholesterolaemia, smoking cessation VEGF inhibitors Photocoagulation

Answer 119

Vitreous haemorrhage Traction retinal detachment Neovascular glaucoma due to rubeosis irisis

Answer 120

Back and joint pain/stiffnes - >1hr in the morning Enthesitis - tenderness at the tendon insertion points e.g. Achilles heel, planter fasciitis Fever Fatigue

Answer 121

Schober's test - mark a spot and then measure 5cm inferiorly and 10cm superiorly on the dorsal spine - if expands <5cm on forward flexion positive test

Answer 122

Anterior uveitis Aortic regurgitation Apical fibrosis AV block Arthropathy e.g psoriatic and psoriasis

Answer 123

GRACE score - 6 month mortality TIMI score - 14 day risk of mortality, new or recurrent MI, or severe recurrent ischaemia necessitating cardiac revasculairsation

Answer 124

Infection: - Viral - HIV Autoimmune: - SLE - Rheumatoid Post MI - Dresslers Uraemia Cancer

Answer 125

Beck's Triad Hypotension Raised JVP Muffled heart sounds Tachycardia will also be an early sign

Answer 126

Large often congenital heart defects e.g. VSD, PDA, ToF, AVSD Permenant vascular changes, PAH and elevated pulmonary vascular resistance Reversal of the shunt direction to RTL causing cyanosis

Answer 127

Poor prognosis - 50% mortality at one year Medical: - Pulmonary vasodilator therapy e.g. endothelia receptor antagonist, PDE5 inhibitor, epoprostenol - Anticoagulation - Symptomatic - iron supplementation, diuretic, anti-arrhythmic, oxygen (if hypoxaemia responsive) - Supportive - contraception (pregnancy contraindicated), avoidance of extreme heat or dehydration Surgical: - Correction of shunt generally contraindicated - Heart lung transplant

Answer 128

Migraine: - Associated with aura, photo- and photophobia, last <72 hours, unliateral - Triptans, aspirin and NSAIDs in acute - Topiramate, propranolol, amitriptyline in chronic Tension: - Bilateral, throbbing Cluster headache: - Very intense, lasting 15 mins, supraorbital, associated with lacrimation and rhinorrhea - Verapamil for prophylaxis, oxygen and triptans in acute Medication overuse - Episodic headache in patients using analgesia >10 days/month for >3 months Trigeminal neuralgia: - Stabbing pain in trigeminal nerve distribution

Answer 129

FRAX - calculates the ten year probability of fracture

Answer 130

Bloods: - FBC - U&Es, LFTs - TFTs - CRP and ESR - Calcium and phosphate (Pagets) - Vitamin D - Immunoglobulins and protein electrophoresis X rays of affected area DEXA scan - if for primary prevention refer if >10% risk of fracture in ten years in scoring tools

Answer 131

IF T score <-2.5: - Oral bisphophonates - If not tolerated can suggest zolendronic acid, raloxifene and denosumab

Answer 132

Psoriasis area and severity Index (PASI)

Answer 133

Topical treatment first line: - topical corticosteroids OD - can be increased to BD if satisfactory control not gained - Vitamin D analogue OD - may be increased to BD if not satisfactory control - Coal tar preparation, shampoos can be used in scalp psoriasis - Dithranol Phototherapy - UVB - UVA with psoralen (PO or topical)for palmoplantar pustulosis or plaque psoriasis - increased risk of cancer (especially SCC) - Avoid PUVA in those at risk of SCCs in future ie younger patients, light skin types (Fitzpatrick 1 and 2), likely to require long term cyclosporin, or previous skin cancer Systemic treatments - Offered if psoriasis cannot be controlled with topical therapy, it has significant impact on psychological or social well-being and one of: - - Psoriasis is extensive >10% of BSA or PASI score >10 - - Associated with significant functional impairment or high levels of distress - - Phototherapy cannot be used or associated with rapid relapse - Can use methotrexate, ciclosporin or acreitin (vitamin A analogue), apremilast (PDE4 inhibitor) Can then use biologics - TNFa, IL-17 and IL-23

Answer 134

Older age Female sex Low BMI Smoking Alcohol use Early menopause History of falls Previous fragility fracture Use of corticosteroids Secondary causes of osteoporosis

Answer 135

Malabsoprtion: - Coeliac disease - Chronic pancreatitis (malabsorption) Endocrine: - Hyperthyroidism - Hyperparathyroidism - Diabetes - Cushings - Hypogonadism Use of steroids: - COPD - Rheumatoid arthitis Loss of nutrients: - CKD - Chronic liver failure Medications: - Steroids - GNRH inhibitors

Answer 136

MDT involvement Orthopaedic team for surgical management if required Analgesia PT OT Dietician Patient education - smoking, weight, alcohol May require DEXA scan - NCE guidelines state if >75 and fragility fracture to treat accordingly Calcium and vitamin D supplements Bisphosphonates Denosumab Raloxifene Teriparatide HRT in younger women with premature menopause

Answer 137

A - Arrhythmia/altered conciseness level C - cyanosis or normal PaCO2 4.6 - 6kPA H - Hypoxia <8kPa, hypotension E - exhaustion S - silent chest T - Threatening PEFR - <33% 92 - Sats <92%

Answer 138

PEFR >75% of predicted Check inhaler technique and able to record PEFR Written asthma management plan Follow up arranged with Patients GP/asthma nurse and with hospital

Answer 139

1. SABA PRN - salbutamol 2. SABA plus ICS 3. SABA plus ICS plus LRTA (montelukast) 4. SABA plus moderate dose ICS plus LABA plus LRTA (if helpful) 4. Change ICS to high dose, can add theophylline 5. Consider biologics e.g omalizumab 6. Addition of steroids If symptoms not controlled on moderate dose - check FeNO level and eosinophils - if raised refer to secondary care team If symptoms not controlled on high dose ICS refer to secondary care team

Answer 140

Riociguat - stimulator of soluble guanlyte cyclase Continued oral anticoagulation Interventions: - Balloon pulmonary angioplasty - Pulmonary endarterectomy

Answer 141

Infection: - Infective endocarditis - Malaria - Abscess - EBV, CMV, HIV Inflammatory disease: - Vasculitis - SLE - RA Malignancy Drug-induced - Malignancy hyperpyrexia syndrome Genetic: - Familial Mediterranen fever Factitious

Answer 142

Urine Dip ECG - PR interval Bloods: - FBC - U&Es and LFTs - CRP and ESR - ANCA and autoimmune screen - Rh factor - HIV, EBV and CMV - Immunoglobulins and SPEP - Malaria thick and thin films - EBV monospot - CK - malignant hyperthermia Radiology: - CXR - CTTAP - PET CT - White cell scintigraphy

Answer 143

Anti-TTG and total IgA Duodenal biopsy

Answer 144

Bloods: - FBC - Iron studies and ferritin - B12 and folate - Hb electrophoresis - thalassaemia - Anti-TTG and total IgA Faecal occult blood Endoscopy CT abdomen

Answer 145

Acute: - Vaso-occlusive crisis - Acute chest syndrome - Stroke - PE - Infection - Gallstones - Anaemia - Aplastic crisis (parvovirus 19) - Osteomyelitis - AKI Chronic complications: - Pain - Anaemia - Pulmonary hypertension - Chronic sickle lung - Sickle retinopathy - Leg ulcers - Priapism - CKD

Answer 146

Treatment in acute crises: - Oxygen +/- CPAP - IV fluids - Analgesia - Antibiotics if evidence of infection - Blood transfusion/exchange transfusion Following acute crisis: - Drink plenty of fluids - Warm clothes - avoid sudden temp changes - NSAIDs and paracetamol - Hydroxycarbamide or exchange transfusions if frequent crises - Long term folic acid - Penicillin prophylaxis and vaccinations in patients with functional hyposplenism - Patient education

Answer 147

APLS Myeloproliferative disorders - ET, polycythaemia, myelofibrosis Paraxysmal nocturnal haemoglobinuria PFO/VSDs - venous clot into arterial system

Answer 148

Primary polycythaemia: - Polycythaemia rubra vera Secondary polycythaemia: - Respiratory disease e.g. COPD, OSA - Cyanotic heart disease e.g. congenital heart disease - Testosterone replacement/injection - EPO secreting tumours - renal cell carcinoma, medullary haemangiomas, parathyroid tumours - PCKD - secretion of EPO Apparent polycythaemia: - Dehydration - Diuretics - Smokers or alcoholics

Answer 149

FBC - raised HCT U&Es and LFTs JAK2 EPO Epworth score Polysomnography ABG CXR USS abdomen - spleen CT abdo/pelvis Red cell mass scintigraphy Bone marrow biopsy

Answer 150

Thrombosis AML Treated with aspirin Lifelong surveillance for AML

Answer 151

Urine dip UPCR Bloods: - FBC - U&Es and LFTs - Coagulation - Lipids - BBV - ANCA - Rh factor and ANA - Complement - Hba1c - Anti-phospholipase A2 receptor abs (PLA2R) - Immunoglobulin and SPEP CXR renal tract US CTPA or doppler if concur for clots Renal biopsy

Answer 152

Primary: - Membranous nephropathy - FSGS - Minimal change - IgA Nephropathy Secondary causes: - Amyloidosis - SLE - RA - HIV - Hep B and C - Drugs: penicillamine, NSAIDs, heroin and gold - Diabetes - Malignancy - solid organ tumours, leukaemia, lymphoma, myeloma

Answer 153

Progression of PSC to cirrhosis Development of new biliary stricture Cholelithiasis - 1/3 of PSC patients develop gallstones Cholangiocarcinoma HCC Gallbladder cancer Bowel cancer with liver mets

Answer 154

Mostly supportive UCDA Antihistamines Opiates Bile duct angioplasty/stent Liver transplant

Answer 155

Mild: - Oral mesalazine - Oral steroids Moderate: - Iv steroids - IV infliximab Maintenance: - Azathioprine - Methotraxate - TNFa agents

Answer 156

Mild: - PR mesalazine - Oral/topical steroids e.g. budesonide Moderate: - IV steroids - IV ciclosporin Maintenance: - Azathioprine - 5-ASA

Answer 157

Crohn's: - Anaemia - Fistula - Abscess formation - Malnutrition - Intestinal obstruction UC: - Anaemia - Colon cancer - Toxic dilatation - Perforation

Answer 158

Eyes: - Anterior uveitis - Episcleritis - Iritis Mouth: - Aphthous ulcers Joints: - Large joint arthritis - Seronegative arthritis GI: - PSC - Systemic amyloidosis Skin: - Erythema nodosum - Pyoderma gangrenous - Clubbing

Answer 159

Varicose veins Chronic venous insufficiency CCF DVT

Answer 160

Doppler ultrasound ABPI: - 0.8 - 1.2 is normal - >1.3 - calcified - <08 implies arterial insufficiency Arteriography

Answer 161

DIPJ involvement Large joint mono/oligo arthritis Seronegative Sacroilitis Arthritis mutilans

Answer 162

Trauma Smoking Stress Alcohol Beta blockers

Answer 163

Purpuric rash - Usually on extensor surfaces Abdominal pain Arthralgia

Answer 164

Infections: - Streptococci, HSV, parvovirus B19 Drugs: - Antibiotics

Answer 165

Renal involvements - IgA nephropathy - haematuria with proteinuria Hypertension

Answer 166

Small vessel vasculitis - IgA and C3 deposition Normal or raised platelet count Most spontaneous recover although steroids can help recovery and treat arthralgia

Answer 167

Asymmetrical Border irregularity Colour - black - often irregular pigmentation Diameter >6mm Enlarging

Answer 168

Excision Staged on Below thickness +/- sampling of draining lymph nodes Surveillance for low risk node negative disease High risk or node positive disease - immunotherapy

Answer 169

Mild disease (cutaneous or joint involvement only): - Topical steroids - HCQ Moderate disease (plus organ involvement): - Prednisolone - Azathioprine Severe disease (+ severe inflammatory involvement of vital organs): - Methylpred - MMF - Cyclophosphamide - Azathioprine With APS consider aspirin

Answer 170

Hands: - Raynauds - sclerodactyly - prayer sign - calcinosis - may ulcerate - assess function Face - tight skin - beaked nose - microstomia - telangiectasia - alopecia - peri oral furrowing Skin: - Morphoea - patches of sclerotic wkin - en coup de sabre Interstitial fibrosis Cardiac - pulmonary hypertension - RV heave, loud P2 and TR - heart failure - pericardial rub Urine dip - proteinuria

Answer 171

Distribution limited below elbows, below knees and face Slow progression CREST syndrome: - Calcinosis - Raynauds - Esophageal dysmotility - Sclerodactyly - Telangiectasia

Answer 172

Widespread cutaneous and early visceral involvement Rapid progression

Answer 173

ANA positive in 95% Limited disease - anti Centromere Diffuse disease - anti Scl 70 (anti-topoisomerase I) Anti-RNA polymerase III - increased cancer risk in diffuse disease, increased risk of dermatological complications, and increased risk of renal crisis

Answer 174

Obs - HTN Urine dip - proteinuria ECG - conduction blocks, r axis deviation Bloods: - FBC - U&ES - LFTS - Antibodies Joint X rays CXR HRCT PFTs ECHO Cardiac MRI Right heart catheterisation OGD Esophageal manometry Hydrogen breath tests for basterial overgrowth

Answer 175

MDT - OT, PT, SLT, dietician, palliative care, resp, GI, and cardio team Derm: - camouflage creams - CCBs if raynauds - PO PDE-5 inhibitors e.g. sildenafil - gloves, hand warmers - prostacyclin infusion if ulceration Renal: - ACEi Gastro: - PPI for gastric reflux - If signs of bacterial overgrowth syndrome - rifaxamin Immunomodulators: - MMF - Biologics - Rituximab (anti CD 20) and tociluzamab (IL-6) - trial evidence - Evidence that anti-fibrotic agents such as nintedanib are beneficial - IV cyclophosphamide Avoid steroids to prevent precipitation of renal crisis - If renal crisis use ACEi

Answer 176

Mitral valve prolapse Bicuspid aortic valve Coarctation of the aorta

Answer 177

Surveillance: - Monitoring of aortic root size with annual trans thoracic ECHO Treatment: - ACEi and Beta blockers to slow aortic root dilatation - Pre-emptive aortic root surgery if diameter >5cm or increasing rapidly (>1cm/year) Screen family members and genetic counselling of affected first degree relatives

Answer 178

Entrapment neuropathy: - Carpel tunnel - visual problems - optic atrophy - Cauda equina - Deafness Fragility fractures Osteoarthritis Arthralgia Kidney stones CCF - high output state Osteogenic sarcoma

Answer 179

Paget's disease Ehlers-Danlos Pseudoxanthoma elasticum

Answer 180

Elevated ALP, normal calcium and phosphate Radiology: - Moth eaten bones - Increased uptake on bone scans

Answer 181

Exercise, PT, OT Symptomatic: - Analgesia - Hearing aid - Carpel tunnel release - Joint replacement Medical: - Vitamin D and bisphosphonates

Answer 182

Alcohol Red meat Obesity Drugs - diuretics or CNIs CKD Lymphoproliferative disorders

Answer 183

Acute: - Increase fluid intake - High dose NSAIDS - Colchicine - Prednisolone Chronic: - Titrate allopurinol upwards aiming urate <300 - Febuxostat (xanthine oxidase inhibitor)

Answer 184

LOSS Loss of joint space Osteophytes Subchonral cysts Sclerosis

Answer 185

Primary Hyperparathyroidism Malignancy: - Lytic lesions - PTHrp release - usually lung SCC - Vitamin D release - lymphomas Sarcoid Addisons Hyperthryoidism Medications: - Vitamin D - Thiazide diuretics - Lithium Prolonged immobility

Answer 186

Primary causes: - Genetic - e.g. Turners Secondary: - Pregnancy - Postpartum and breastfeeding - Pills e.g, OCP, risperidone, antidepressant e.g SSRIs, danazol (used in endometriosis), chemotherapy - Premature menopause - Polycystic ovarian syndrome - Pituitary tumour - e.g. prolactinomas

Answer 187

ASD Coarctation of aorta Bicuspid aortic valve Hypertension

Answer 188

Acanthosis nigricans BP high Carpel tunnel - bilaterally Diabetes mellitus Enlarged organs Field defect - bitemporal hemianopia Goitre, GI malignancy Heart failure, hirsutism, hypopituiatrism IGF-1 high Joint arthropthy Kyphosis Lactation - galactorrhoea Myopathy

Answer 189

Diagnosis: - IGF-1 - OGTT with serial GH measurement - MRi pituiatry fossa Also assess pituitary function: - TFTs, LH and FSH, prolactin, ACTH, testosterone Complications: - CXR - cardiomegaly - ECG - ischaemia - Glucose and Hba1c - Visual field testing - Polysomnography - OSA due to macroglossia

Answer 190

Surgery: Trans-sphenoidal resection Medical: - Somatostatin analogues - ocreotide - Dopamine agonists - cabergoline - Pegvisomant - GH receptor antagonists Radiotherapy Follow ups: - Blood monitoring - GH and prolactin - MRI head - ECG - Visual fields

Answer 191

ACTH dependent: - Cushing's disease - pituitary adenoma - Ectopic secretion of ACTH e.g. SCLC ACTH independent: - Adrenal adenoma or carcinoma - Exogenous steroids

Answer 192

Confirm high cortisol: - 24 hour urine collection - Low dose dexamethasone suppression test Suppressed cortisol - pseudo-bushings - alcohol/depression/obesity Identify causes: - ACTH level - if high ACTH dependent - - High dose dexamethasone test - suppressed cortisol if pituitary cause, non-suppressed if ectopic or ACTH independent - MRI pituitary - CT abdo - Bilateral inferior petrosal sinus vein sampling - to confirm pituitary

Answer 193

Surgical: - Pituitary surgery - tran-sphenoidal - Adrenalectomy Pituitary irradiation Medical - Metyrapone

Answer 194

Inherited: - Myotonic dystrophy - Muscular dystrophy Endocrine: - Cushings - Hyperparathyroidism - Hyperthryoidism Inflammatory: - RA - Polymyositis Osteomalacia Malignancy: - Paraneoplastic - Lambert-Eaton Syndrome Drugs: - Alcohol - Steroids

Answer 195

Autoimmune TB Adrenal mets Amyloidosis Bilateral adrenalectomy Waterhouse- Friedrichsen syndrome - meningococcal septicaemia and adrenal infarction

Answer 196

Bloods: - Low Na, high K - Urea high - dehydration - Adrenal autoantibodies - TFTs Morning cortisol Short Synacthen test ACTH CT abdo - adrenal imaging Pituitary imaging - MRi Renin/aldosterone level - concurrent mineralocorticoid deficiency

Answer 197

Idiopathic Inflammatory disorders: - IBD - Sarcoidosis - SLE - Sjogrens Infections: - Streptococci - URTI - Mycoplasma - TB - Leprosy Medications: - OCP - Penicillins - Sulfonamides Pregnancy Malignancy: - NHL - AML

Answer 198

MDT approach: - OT - cognitive rehabilitation - SW - Dietician - Support groups Medical: - Antidepressants - AChEi - donepezil, galantamine or rivastigmine in mild/moderate disease - Memantine if intolerant of AChEi or in severe disease - Antipsychotics for BPSD - if not amenable to conservative measures and if patients at risk of harm to themselves or others

Answer 199

Stroke/TIA: - 1 month ban if recovers to good functioning, no need to tell DVLA unless residual loss of function ACS: - No driving for one week if successful PCI and no other interventions planned - 4 weeks if no coronary intervention - No driving if Group 2 and must notify DVLA CABG: - No driving for 4 weeks ICD: - No driving for 1 month and must inform DVLA - No driving for Group 2 Epilepsy/seizure: - First seizure - 6 months if seizure free - Seizure while awake - 1 year - If seizure due to medication change - 6 months - For bus/lorry drivers - 5 years if single seizure, 10 years if epilepsy and on treatment Diabetes: - Inform DVLA if on insulin or having disabling hypoglycaemia - If lorry driver inform if on any treatment - Not to drive if having more than one episode of severe hypoglycaemia and inform DVLA - Check BMs prior to starting journey and within two hors of starting journey Syncope: - Vasovagal -may drive - Unexplained - may not drive for 6 months Brain tumours - Should not drive and should notify the DVLA

Answer 200

Primary Raynauds Secondary causes: - Rheumatological diseases -- Systemic sclerosis -- RA -- SLE -- Polymyositis Vascular disease: -- Berger's - IgA vasculitis Medications -- Beta blockers -- ADHD medications - methylphenidate Hypothyroidism Occlusive vascular disease e.g. thoracic outlet obstruction Peripheral nueropathies: - Injury to nerves especially repetitive motions e.g. using jackhammer - Carpal tunnel (unilateral) - Chemotherapy

Answer 201

Primary: - Younger age of onset - teens, young 20s - Bilateral - No associated positive immunology - Can have family history - Should have complications e.g. digital ulceration Secondary: - Late onset - usually >30yrs - May be unilateral or bilateral - May have positive immunology - Can have pitting ulcers/scarring

Answer 202

Cutaneous neurofibromas Cafe au lait patches Lisch nodules Axillary freckling Neuropathy with palpable nerves Bibasal crackling - pulmonary fibrosis Raised blood pressure - associated with phaechromocytomas and renal artery stenosis Reduced visual acuity

Answer 203

Phaechromocytoma Renal artery stenosis Intellectual disability Epilepsy Scoliosis

Clinical Consultation Flashcards

(232 cards)