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Clinical Consultations Flashcards

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1
Q

What are systemic complications of RA? (11)

A

Osteoporosis
Dry eyes and mouth - sjogrens
Infections
Carpal tunnel syndrome
Heart - peri/myocarditis, IHD, pericardial effusion
Lung- ILD, pleural effusion, pleurisy
Metabolic syndrome
Felty syndrome - neutropenia and splenomegaly
Vasculitis
Amyloidosis
Renal- amyloid, drugs, glomerulonephritis

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2
Q

What are complications associated with drug treatment of RA? (5)

A

Gastric ulcers - NSAIDs
Infections - steroids and immunosuppressants
Liver toxicity - methotrexate
Skin malignancy - TNF alpha inhibitors
Osteoporosis - steroids

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3
Q

What defines nephrotic syndrome? (3)

A

Heavy proteinuria >3.5g/day
Hypoalbuminaemia <30
Peripheral oedema

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4
Q

What are causes of primary nephrotic syndrome? (4)

A

Minimal change disease
FSGS
Membranous nephropathy
Membranoproliferative glomerulonephritis

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5
Q

What are secondary causes of nephrotic syndrome? (9)

A

Infection - bacterial, viral, parasitic
Immunological - SLE, RA, PN, HSP, vasculitis, sarcoidosis
Metabolic - diabetes, amyloidosis
Inherited - alports, sickle cell
Malignant - myeloma, melanoma, leukaemia, cancer of breast, lung, colon, stomach
Drugs - NSAIDs, lithium, pamidronate, interferon alpha
Toxins - snake bite, insect sting
Pregnancy - pre eclampsia
Transplant rejection

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6
Q

What are symptoms of nephrotic syndrome? (7)

A

Oedema - Leg swelling, Abdominal distension, SOB, weight gain
Hypovolaemia - dizziness
Infection - fever, rash
Frothy urine
Hypercoagulability - DVT, MI
Fatigue
Poor appetite

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7
Q

What are signs of nephrotic syndrome and causes? (5)

A

Oedema including facial
Tachypnoea
Dyslipidaemia
Rash, purpura, joint swelling
Muehrckes lines - hypoalbuminaemia

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8
Q

What investigations would you do for nephrotic syndrome? (5)

A

Urine dipstick, MSU
ACR
Bloods: FBC, clotting, U&Es, LFTs, Bone profile, Fasting glucose, Lipid profile, ESR/CRP, Immunoglobulins/serum electrophoresis, Hep B/C, HIV, TFTs
Renal USS
Renal biopsy

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9
Q

What are treatment options for nephrotic syndrome oedema? (5)

A

Low salt diet
Fluid restriction
Loop diuretic
Potassium sparing diuretic
Thiazide diuretic
ACEi - reduce proteinuria

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10
Q

What are treatments for nephrotic syndrome? (4)

A

Steroids
Immunosuppression - calcineurin inhibitors (ciclosporin or tacrolimus), alkylating agents (cyclophosphamide or chlorambucil), rituximab, mycophenolate
Diuretics
ACEi

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11
Q

What are complications of nephrotic syndrome? (7)

A

Infection - urinary immunoglobulin loss
VTE risk - loss of anticoagulant proteins
AKI and CKD
End stage renal failure
Osteomalacia and osteitis fibrosa cystica
Hypothyroidism
Anaemia - loss of iron/transferrin

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12
Q

What are complications of diabetes? (4)

A

Retinopathy
Neuropathy
Nephropathy
Atherosclerosis

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13
Q

What is uthoffs phenomenon?

A

Worsening of MS symptoms in heat eg hot bath

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14
Q

What are symptoms/features of MS? (9)

A

Numbness or weakness in limbs
Lhermitte’s sign - electric shock on neck forwards
Uthoffs phenomenon - worse in heat
Fatigue
Truncal ataxia
Optic neuritis
Double vision
Dysarthria
Urinary incontinence

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15
Q

How do you investigate MS? (3)

A

MRI - dissemination of lesions in time and space
LP - slightly raised protein, oligoclonal bands, raised lymphocytes
Visual evoked potentials

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16
Q

What are different types of MS? (3)

A

Relapsing remitting 85%
Secondary progressive 66% of RR patients
Primary progressive 10-15%

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17
Q

What is clinically isolated syndrome in the context of MS?

A

First MS episode associated with other asymptomatic demyelinating lesions

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18
Q

What is McDonald criteria for MS?

A

Need to show evidence of dissemination in time and space either clinically or radiologically or combination

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19
Q

What investigations help to exclude alternative causes in MS? (9)

A

FBC
Inflammatory markers
U&Es
LFTs
TFTs
Glucose
HIV serology
Calcium
B12 levels

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20
Q

What should be in MDT for MS? (12)

A

specialist nurse
neurologist
physio
OT
SLT
psychologist
dietician
social worker
continence specialist
Pharmacist
GP
Rehab medics

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21
Q

What are treatment options in MS for relapsing remitting disease? (3)

A

Treating a relapse - methyprednisolone 0.5g daily for 5 days or 1g IV if severe
DMARDs - interferon beta, glatiramer acetate, teriflunomide, dimethyl fumarate
More active disease - natalizumab or almetuzumab, fingolimod

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22
Q

What are treatment options for secondary progressive MS? (2)

A

Interferon beta 1b
Siponimod

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23
Q

What management options can be used as adjuncts in MS? (13)

A

Vestibular rehabilitation
Supervised exercise programme
Functional electrical stimulation for foot drop
Analgesia
CBT
Gabapentin for nystagmus visual impairment
SLT involvement for speech
Baclofen or gabapentin for spasticity
THC:CBD spray for spasticity
Stretching and serial plasters for contractures
Botox for spasticity and overactive bladder
Anticholinergics for overactive bladder
Linoleic acid and fish oils

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24
Q

What are differential diagnosis for headaches? (10)

A

Tension
Cluster
Migraine
SOL
Bleed - SAH or subdural
Meningitis
Sinusitis
Hypertensive encephalopathy
Benign intracranial HTN
CVST

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25
What is the management of acute pericarditis? (6)
Anti inflammatories - ibuprofen Colchicine Steroids Treat underlying cause Pericardiocentesis if life threatening effusion Pericardectomy if constrictive pericarditis
26
What are causes of pericarditis? (10)
Virus - Coxsackieviruses, echoviruses, influenza viruses, adenoviruses, mumps virus, HIV and hepatitis Bacterial - TB, syphilis Uraemia MI Post surgery Traumatic Inflammatory diseases - SLE, RA, PN, scleroderma Radiotherapy Cancer
27
What are skin/joint presentations of SLE? (8)
Arthralgia Joint deformity - jaccouds arthropathy Raynaud’s phenomenon Photosensitive butterfly rash Discoid lupus Alopecia Vasculitis Mouth ulcers
28
What lung involvement can occur in SLE? (4)
Pleurisy Fibrosing alveolitis Obliterative bronchiolitis PE if antiphospholipid syndrome
29
What cardiovascular involvement can occur in SLE? (4)
Pericarditis HTN Libman sacks endocarditis IHD
30
What renal involvement can occur in SLE?
Lupus Nephritis - proteinuria, haematuria, HTN
31
What neurological involvement can occur in SLE? (7)
Anxiety and depression Psychosis Seizures Neuropathy Meningitis Organic brain syndrome Stroke if antiphospholipid syndrome
32
What are investigations for SLE? (9)
FBC ESR ANA Urinalysis Anti dsDNA , Anti smith Lupus anticoagulant, anti cardiolipin or anti beta2glycoprotein-1 for APS MRI if neuro Echo if cardio Renal biopsy
33
What are complications of SLE? (9)
Anti phospholipid syndrome Drug allergies Atherosclerosis HTN Dyslipidaemia Diabetes Osteoporosis Avascular necrosis Non Hodgkin lymphoma
34
What are management options for SLE? (10)
NSAIDs Steroids Hydroxychloroquine and methotrexate Cyclophosphamide for life threatening disease - lupus nephritis/vasculitis/cerebral disease Mycophenolate mofetil Azathioprine Belimumab or rituximab adjunct if disease remains active Plasma exchange whilst awaiting immunosuppressants take effect Flu vaccine - avoid live High factor sunscreen
35
What are pregnancy related complications in SLE? (5)
Recurrent miscarriage Pre-eclampsia IUGR Pre-term delivery Increased thrombosis risk
36
What are criteria for APLS? (5)
Vascular thrombosis - arterial, venous or small vessel Pregnancy morbidity - death of 1 foetus after 10 weeks, preterm birth before 34 weeks due to pre-eclampsia or placental insufficiency, 3 or more unexplained miscarriages Lupus anticoagulant on 2 occasions 12 weeks apart Anti cardiolipin on 2 occasions 12 weeks apart Anti b2glycolrotein 1 on 2 occasions 12 weeks apart
37
What proportion of people with SLE have anti phospholipid antibodies?
30%
38
What are causes of bloody diarrhoea? (6)
IBD Infection: Shigella, Salmonella, Amoebic dysentery Malignancy Diverticulosis Ischaemic colitis Radiation proctitis
39
What are extra intestinal manifestations of UC? (9)
Erythema nodosum Aphthous ulcers Episcleritis Arthropathy affecting large joints Pyoderma gangrenosum Anterior uveitis Sacroiliitis Ankylosing spondylitis Primary sclerosing cholangitis
40
What are causes of erythema nodosum? (7)
No cause in 60% Drugs: sulfonamides, amoxicillin Oral contraceptives Sarcoidosis /lofgrens Ulcerative colitis/ crohns Micro: TB, HIV, hepatitis, campylobacter, syphillis, giardia Bechets
41
What are investigations for UC? (7)
Bloods: FBC, LFTs, U&Es, CRP, iron, B12, folate Faecal calprotectin Stool culture CMV Sigmoidoscopy and biopsy or full colon AXR for ? Toxic megacolon CT
42
How is disease severity assessed in UC?
Truelove and witts criteria: Mild: fewer than 4 stools per day, minimal blood, no anaemia, pulse not above 90, no fever, normal CRP/ESR Moderate: 4-6 stools per day, more blood than mild, no anaemia, pulse not above 90, no fever, normal CRP/ESR Severe: 6 or more stools per day, visible blood, at least one of temp, pulse over 90, anaemia, ESR above 30
43
What are indications for urgent hospital referral in UC?
Severe colitis as per truelove and witts Moderate disease fail to respond to steroids in 2 weeks
44
What are management steps for UC? (6)
Topical aminosalicylates if local disease - mild to moderate Steroids to induce remission Oral mesalazine to maintain remission Azathioprine if steroids not tolerated, need multiple courses, relapse when tapering or stopped Ciclosporin for severe refractory colitis Infliximab/adadlimumab, golimumab if not responding to conventional therapy
45
What are complications of UC? (4)
Colectomy Colorectal cancer Toxic megacolon Osteoporosis
46
What are causes of jaundice? (7)
Cirrhosis: ALD, Wilson’s, haemochromatosis, NASH, PBC, PSC Obstruction: CBD stone, pancreatic cancer Hepatitis: Viral, Autoimmune Isolated bilirubinaemia: Giberts, crigler najjar, rotor, Dubin Johnson Infection: Leptospirosis Drug induced liver disease Haemolysis, hereditary spherocytosis
47
What is the inheritance pattern of hereditary haemochromatosis?
Autosomal recessive HFE gene Chromosome 6 Variable penetrance
48
What are symptoms of hereditary haemochromatosis? (9)
Fatigue Weakness Arthropathy Abdominal pain Erectile dysfunction Arrhythmias Bronze skin New diabetes Psychiatric symptoms
49
What are investigations for hereditary haemochromatosis? (7)
Iron studies Ferritin HFE gene testing if increased trans sat LFTs Blood sugars FBC NILS screen
50
What are differential diagnosis for hereditary haemochromatosis? (5)
Secondary iron overload: thalassaemia, myelodysplastic syndrome, repeated transfusions Drug toxicity Chronic haemodialysis Hepatitis, alcohol misuse, NASH Porphyria cutanea tarda
51
What are treatments for hereditary haemochromatosis? (4)
Phlebotomy - removing 500ml blood 1-2 times per week until stable iron levels achieved Once stable 3-4 times per year Aiming for ferritin less than 50 Treat diabetes if present Immunise against hep a and b Liver transplantation
52
What are different types of pituitary adenoma? (6)
Non functioning adenoma Prolactinoma GH secreting ACTH secreting TSH secreting LH/FSH secreting
53
What are symptoms of prolactinoma in women? (8)
Amenorrhoea Galacotorrhoea Infertility Hirsutism Reduced libido Headache Visual disturbance - bitemporal hemianopia Cranial nerve palsy
54
What are symptoms of prolactinoma in men? (9)
Reduced libido Erectile dysfunction Reduced facial hair Gynaecomastia Galactorrhoea Azoospermia Headache Visual disturbance - bitemporal hemianopia Cranial nerve palsy
55
What investigations should be done for prolactinoma? (7)
TFTs Pregnancy test Basal serum prolactin Visual field testing MRI pituitary Anterior Pituitary function tests: GnRH, TRH, IGF1, synacthen test Posterior pituitary test: plasma and serum osmolality, water deprivation test
56
What are causes of hyperprolactinaemia? (11)
Pregnancy and Breast feeding Pituitary tumour Head injury and brain surgery Post seizure Hypothyroidism Cushing’s syndrome Liver cirrhosis PCOS Drugs: dopamine receptor antagonists , antidepressants, oestrogens Sarcoidosis Langerhans cell histiocytosis
57
What are treatments of prolactinoma? (3)
Most don’t need treatment - only if adverse effects of tumour size or hyperprolactinaemia Dopamine agonists: cabergoline, bromocriptine Surgery
58
What are complications of prolactinoma? (5)
Osteoporosis Reduced fertility Erectile dysfunction Visual loss Pituitary apoplexy - haemorrhage or infarction
59
What are the different types of hyperparathyroidism?
Primary: excess PTH production Secondary: increased PTH in response to low calcium due to renal, liver or bowel disease Tertiary: autonomous pth secretion after glands enlarge from long-standing secondary
60
What are the functions of PTH? (4)
Increases calcium resorption from bone Increases calcium reabsorption by kidney Increases phosphate excretion Increases renal production of 25 hydroxyvitamin d3 which increases intestinal absorption of calcium
61
What are causes of hyperparathyroidism? (4)
Single parathyroid adenoma 85% Parathyroid hyperplasia 10% Double adenomas 5% Parathyroid carcinoma 1%
62
What are presenting symptoms of hyperparathyroidism? (5)
Most asymptomatic Bones: Osteopenia/osteoporosis Moans: depression, dementia Stones: Renal calculi Groans: Muscle weakness and fatigue, Nausea and vomiting, Abdo pain Constipation
63
What are causes of hypercalcaemia? (7)
Malignancy Hyperparathyroidism Thyrotoxicosis Sarcoidosis Paget’s disease of the bone Addisons disease Lithium induced
64
What are investigations for hyperparathyroidism? (7)
Bone profile PTH Vitamin D 24 hour urinary calcium excretion Renal function DEXA scan USS Renal tract
65
What are treatments for hyperparathyroidism? (6)
Replace vit d High fluid intake Avoid thiazide diuretics Parathyroid surgery Calcinet if symptomatic and surgery unsuccessful or unsuitable Bisphosphonate to reduce fracture risk
66
What are complications of parathyroid surgery? (3)
Hypocalcaemia - hungry bone syndrome Recurrent laryngeal nerve injury Haematoma formation
67
What are the different types of MEN?
MEN1: parathyroid adenoma, gastrinoma, insulinoma, carcinoid tumours, prolactinoma MEN2A: medullary thyroid cancer, pheochromocytoma, hyperparathyroidism MEN2B: medullary thyroid cancer, pheochromocytoma, mucosal neuroma, marfanoid habitus, hyperparathyroidism
68
What are differentials for generalised lymphadenopathy? (7)
Viral: EBV, CMV, rubella, varicella, measles, HIV, hep A/B, dengue Bacterial: typhoid, TB, syphilis, plague, Lyme disease, brucellosis Protozoal: toxoplasmosis, leishmaniasis, Chagas’ disease Autoimmune: juvenile idiopathic arthritis, SLE Storage diseases: gauchers, Niemann pick disease Neoplastic: leukaemia, lymphoma, neuroblastoma, histiocytosis Sarcoidosis
69
What are investigations for generalised lymphadenopathy? (14)
FBC Blood film ESR/CRP LFTs Infection swabs Viral titres: EBV, hep, HIV TB: mantoux, IGRA, sputum for AFB Syphilis serology Blood cultures Autoantibody screen CXR CT staging FNA biopsy or excisional PET
70
How is Hodgkin’s lymphoma staged?
Stage 1: one lymph node region or structure Stage 2: two or more on same side of diaphragm Stage 3: nodes on both sides of diaphragm Stage 4: involvement of extra nodal sites A: no symptoms B: fever, night sweats, weight loss over 10% in 6 months X: bulky disease E: single or proximal extranodal site
71
How is Hodgkin’s lymphoma classified? (2)
Classic: nodular sclerosis, mixed cellularity, lymphocyte rich, lymphocyte depleted Nodular lymphocyte predominant
72
What are risk factors for Hodgkin’s lymphoma? (4)
EBV HIV Immunosuppression Cigarette smoking
73
How does Hodgkin’s Lymphoma present? (5)
Enlarged lymph node in neck Mediastinal mass on CXR Chest pain/cough/dyspnoea B symptoms: Night sweats, fever, weight loss Alcohol induced pain in nodes
74
What are differentials of Hodgkins lymphoma? (10)
EBV HIV Non Hodgkin’s Lymphoma TB Leukaemia Sarcoidosis Myeloma Toxoplasmosis CMV Tularaemia
75
What are difference between Hodgkin’s and non Hodgkin’s lymphoma? (5)
Presence of reed sternberg cells in Hodgkin’s Non Hodgkin’s more common Younger patients Hodgkin’s Neck nodes predominant in Hodgkin’s Hodgkin’s more predictable and easier to treat
76
What are management steps for Hodgkin’s lymphoma? (6)
Cardiac and pulmonary function tests pre treatment Reproductive counselling pre treatment Chemo +/- radiotherapy Autologous stem cell transplant if relapse Vaccinations Antibiotic prophylaxis and gCSF if neutropenia
77
What are complications of Hodgkin’s lymphoma? (10)
Leukaemia post chemo/radiotherapy Second solid tumours - colon, lung, bone, breast, thyroid post radiotherapy Melanoma Non Hodgkin’s lymphoma Soft tissue sarcoma Salivary gland cancers Pancreatic cancer Hypothyroidism Cardiovascular disease Infertility
78
What are poor prognostic features in Hodgkin’s lymphoma? (9)
Increasing tumour burden Increasing age Male Presence of B symptoms Anaemia, lymphopenia, monocytosis Low albumin Increasing ESR Elevated beta2 microglobulin EBV presence
79
What are differentials of lymphadenopathy? (9)
Lymphoma HIV Glandular fever TB Sarcoidosis Connective tissue disease Adenocarcinoma Melanoma Drugs
80
What investigations are done for Hodgkin’s lymphoma? (9)
FBC ESR (above 70 unfavourable) EBV serology LFTs (albumin) LDH HIV test Lymph node biopsy CT TAP staging /PET CT Bone marrow biopsy for staging
81
What are some provoking causes of seizures? (9)
Fever. Head injury. Excessive alcohol intake; withdrawal from alcohol or drugs. Hypoglycaemia; electrolyte disturbance. Brain infection: meningitis, encephalitis. Ischaemic stroke, intracranial haemorrhage / SOL Eclampsia. Potentially proconvulsive drugs - eg, tramadol, theophylline, baclofen.
82
What are differentials for seizures? (7)
Syncope Transient ischaemic attack Metabolic encephalopathy Sleep-walking / Night terrors Complex migraines. Cardiac arrhythmias. Psychogenic non-epileptic seizures
83
What tests should be used to investigate seizures? (5)
Video of episodes if available Bloods: fbc, u&e, lfts, blood sugars CT acute or MRI head EEG ECG/ 24 hour tape if cardiac cause suspected
84
What are driving rules for first seizures?
Group 1: 1 off seizure with low risk for further (no changes on MRI) then 6 months. If high risk or more than 1 - 12 months Group 2: 1 off - 5 years seizure free and not on meds. 10 years if more than 1 seizure
85
What are some causes of erratic INR? (5)
Poor compliance Alcohol Poor diet - lacking vitamin k Drug interactions - erythromycin/ciprofloxacin, St John’s wort etc Anti phospholipid syndrome
86
What are treatment durations for anticoagulation in PE?
Provoked: 3-6 months Unprovoked: lifelong
87
What screening should be done for prothrombotic states? (7)
Antithrombin III Protein C Protein S APS: Lupus Anticoagulant and anti-cardiolipin antibodies Factor V Leiden Prothrombin Gene Mutation anti-β-2-Glycoprotein-1 antibodies
88
Who should have thrombophilia screening? (5)
VTE or arterial thrombus under 40 Recurrent VTE Unusual site thrombosis Strong family history of thrombophilia /clots Recurrent miscarriage
89
How long does warfarin need to be held prior to liver biopsy?
5 days
90
How long does DOAC need to be stopped prior to surgery?
1-2 days depending on bleeding risk
91
What are guidelines for emergency reversal of warfarin in bleeding?
life threatening bleeding: Vitamin K 5 mg IV, Prothrombin complex concentrate IV Significant bleeding: Vitamin K 2 mg IV Minor bleeding: vitamin K 2mg PO
92
What are guidelines for warfarin reversal if not bleeding?
INR > 8: vitamin k 1-2mg PO INR 5-7.9: omit dose or 1-2mg vit k if high risk bleeding INR <5: omit dose
93
What risk scoring systems can be used for MI? (3)
HEART score Grace score TIMI score
94
What is emergency treatment of ACS? (9)
DAPT Tirofiban if high Grace or TIMI score PPCI if stemi, angio if NSTEMI GTN IV morphine Beta blocker ACEi Statin ? CABG if multi vessel disease
95
What further investigations should be done if cardiac sounding chest pain but trop and ECG negative? (4)
exercise stress test myocardial perfusion scan (nuclear medicine) Dobutamine stress echo cardiac MRI
96
What anti anginals can be used for ongoing angina symptoms in a stable patient? (5)
GTN Beta blocker or calcium channel blocker first line (nifedipine/amlodipine) Then switch to other or both BB/CCB Then add long acting nitrate or ivabradine or nicorandil or ranolazine Only add 3rd if awaiting recasc or not a candidate
97
What are localising neuro signs? (3)
Upper limb pronator drift Extensor plantar reflex Cranial nerve palsy
98
How would you investigate someone with a headache with concern for meningitis? (3)
Blood cultures and bloods for inflammation markers CT head exclude raised ICP LP: MC&S, glucose, protein, virology, xanthochromia to exclude SAH
99
How would you treat suspected meningitis? (2)
High dose penicillin IV Notifiable disease - contact tracing
100
What are risk factors for DVT? (9)
Cancer Heart failure Immobility Recent flight Surgery (esp orthopedic) Stroke Previous DVT or PE FH VTE OCP use
101
What clinical finding fit with DVT? (3)
Calf swelling >3cm difference, 10cm below tibial tuberosity Superficial venous engorgement Pitting oedema
102
What else might you examine in someone with a DVT? (4)
Abdo and pelvis for masses Signs of Thrombophlebitis Signs of PE: pleural rub or RV failure Peripheral pulses for ?compression stockings
103
What are investigations for DVT? (6)
D dimer (sensitive but not specific) Doppler Consider thrombophilia screen if recurrent or strong FH CT AP if over 50 Mammogram for females PR and PSA in men
104
What are management steps for DVT? (2)
Anticoagulation; 3 months if provoked, 6 months if unprovoked, lifelong if recurrent or high risk Compression stockings to reduce post phlebitic syndrome
105
What are symptoms of DKA? (6)
Polyuria and polydipsia Preceding illness/fever Recent high sugar readings or increased insulin requirement Nausea and vomiting sweating Breathlessness
106
What are risk factors for DKA? (2)
Poor compliance with insulin: Young Change in social circumstances
107
What are differentials for DKA in someone who has been found drowsy and confused? (3)
Alcohol intoxication Drug abuse Hypoglycaemia
108
What examination findings help to look for DKA? (5)
GCS Ketotic breath - pear drops Hyperventilation/kussmauls breathing Medic alert bracelet Finger prick marks
109
What are 4 precipitating factors for DKA? (4)
Missed insulin Infection Infarction Injury
110
What are complications of DKA? (3)
Retina: diabetic changes, papilloedema Pulse and BP: haemodynamic compromise Aspiration pneumonia (gastroparesis due to autonomic neuropathy)
111
How do you investigate DKA? (6)
Bedside sugar and ketones ABG: metabolic acidosis with resp compensation FBC, U&E, CRP, LFT ECG (silent MI) Blood and urine cultures CXR
112
What is the treatment for DKA? (7)
ABCDE approach Early ITU input if required Fluid resuscitation + K replacement later Fixed rate insulin IV Consider NG to prevent aspiration VTE prophylaxis Antibiotics if infection suspected
113
What are differentials for causes of IDA? (4)
Chronic GI blood loss Dietary Coeliac Inherited haemoglobinopathy
114
What symptoms do you need to ask about in history of anaemia? (12)
lethargy/tiredness/ breathlessness Angina Change in bowel habit/ Foul smelling hard to flush stools/ Melena Weight loss GORD/ Dysphagia/ NSAID use Abdo pain/bloating/wheat intolerance Previous abdo surgery or ulcers History of IBD/polyps Heavy periods or PV bleeding FH GI malignancy or anaemia Risk factors for hookworm or tropical sprue Previous blood transfusions
115
What would you examine in an anaemia case? (9)
Look for pallor and pale conjunctivae Koilonychia in nails (IDA) Glossitis (IDA) and angular stomatitis (B12 def) Sentinel cervical lymph node Abdominal mass and hepatomegaly Epigastric tenderness Abdo scars (resections) Offer rectal +/- PV exam Pulse and BP: haemodynamic stability
116
What are investigations for IDA? (8)
FBC: microcytic hypochromic anaemia, target cells on film Low iron and ferritin, increased TIBC Check B12 and folate Hb electrophoresis if suspected Hbopathy Faecal occult blood Endoscopy CT AP Barium studies
117
What is hereditary haemorrhagic telangiectasia and what are features? (4)
Autosomal dominant condition Multiple telangiectasia on face, lips and buccal mucosa Increased risk GI bleed, epistaxis and haemoptysis Vascular malformations: pulmonary shunts, intracranial aneurysms
118
What are differentials for haemoptysis? (4)
Bronchial carcinoma PE Pneumonia Pulmonary oedema
119
What are symptoms in a history of haemoptysis that you need to ask, particularly if malignant cause suspected? (11)
Cough: chronicity, mucous colour, blood Breathlessness Pleuritic chest pain Weight loss Bone pain (mets) Tiredness (anaemia) Paraneoplastic phenomena Abdo pain (liver mets or hypercalcaemia) Headache (brain mets) Smoking history Occupational exposure
120
What would you examine in suspected bronchial carcinoma? (11)
Cachexia Nail clubbing Tar stained fingers Radiotherapy tattoo Cervical lymphadenopathy Tracheal deviation: lobar collapse Dull percussion note: consolidation and effusion Reduced air entry/bronchial breathing Craggy hepatomegaly Spinal tenderness Focal neurology
121
What are investigations for bronchial carcinoma? (3)
CXR CT chest / staging CT Bronchoscopy / CT guided biopsy/ lymph node biopsy for tissue diagnosis
122
What are treatment options for bronchial carcinoma? (5)
Surgical resection: lobectomy or pneumonectomy chemo - cisplatin/gemcitabine Radiotherapy Immunotherapy Palliative care
123
What are important questions in a history of elderly patient with worsening mobility? (7)
Carer role and frequency Mobility aids Falls Housing History of Parkinson’s/stroke Precipitant: infection, drug changes, pain Legal aspects: advanced directives, LPA, DNACPR
124
What are important examination steps for an elderly patient with reduced mobility? (5)
Get them to walk Rising from chair Rombergs Lying /standing BP Neuro exam
125
What investigations would you do for an elderly patient with declining mobility? (2)
Sepsis screen: MSU, CXR, blood cultures Consider CT head if falls/confused
126
What are management steps for an elderly patient with declining mobility? (7)
Antibiotics if suspect infection Avoid poly pharmacy MDT: nurse, social worker, OT, PT Best interests meeting if lack capacity Walking aids Equipment / care at home Discuss resus
127
What are differentials for persistent fever and malaise? (6)
Lymphoma Endocarditis TB/ Malaria Inflammatory disease (joint or skin) HIV Drug induced (anti psychotics)
128
What would you examine for in someone with persistent fever and malaise? (9)
Needle tracks Splinter haemorrhages Roth spots on fundoscopy Lymphadenopathy Murmur Craggy liver or mass Splenomegaly Urine dip: haematuria Joints and skin
129
How would you investigate someone with persistent fever and malaise? (7)
Septic screen Blood films inc thick and thin films HIV test Autoantibodies /immunoglobulins/complement levels CK (malignant hyperthermia) TOE Consider bone marrow if haematological cause suspected
130
What are important symptom questions in an asthma history? (5)
Wheeze, SOB, cough Triggers: allergy, excercise, cold, dust URTI symptoms Previous ITU admissions Compliance with preventer therapy
131
What would you examine for in an asthma patient? (4)
Severity: conscious level, resp rate, breath count, pulse and BP, silent chest Expansion and percussion note: exclude pneumothorax Wheeze Stridor, angioedema, tongue swelling Urticaria
132
How would you investigate an asthma patient acutely? (4)
ABG Peak flow Septic screen CXR
133
What are important history questions in a patient with syncope? (10)
Provocation: micturition, cough, stress Prodrome: light headed, dizzy, tunnel vision, no warning Posture: sitting/lying, standing, sudden head turning Associated symptoms: palpitations, chest pain, headache, tongue biting, incontinence Duration Recovery Injury Eyewitness account PMH of syncope, cardiac disease or neurological condition Medications
134
How would you examine someone with syncope? (3)
Pulse and BP Brief CV exam: murmur, PPM, scars Brief neuro exam: fundoscopy, pronator drift, reflexes, Parkinson’s features with orthostatic hypotension (MSA)
135
What are differentials for syncope? (4)
Cardiac: Brady or tachyarrhythmia, obstructive lesion (AS, MS, HOCM, PE) Neuro: epilepsy, vertebrobasilar insufficiency Orthostatic hypotension Vasovagal: stress, cough, micturition, defecation
136
How would you investigate syncope? (6)
12 lead ECG, holter monitor, loop recorder depending on frequency of symptoms EP study ETT Echo Tilt table test if orthostatic EEG and MRI head if epilepsy suspected
137
What is management of syncope? (4)
Cardiac: PPM/ICD, revascularisation, valve surgery Vasovagal: education on avoidance, isotonic muscle contraction Orthostatic: salt and water replacement, support stockings, meds review, fludro or midodrine Neuro: anti seizure drugs
138
What are DVLA rules on syncope? (4)
If provocation, prodrome and postural features all present then likely benign and can continue to drive If solitary with no clear cause: 6 month ban Clear cause that is treated: 4 weeks Recurrent syncope due to seizures: must be fit free for 1 year
139
What are symptoms to ask in the history of atrial fibrillation? (6)
Onset and offset, frequency and duration Breathless, chest pain, palpitations, syncope Precipitants: alcohol, caffeine, exercise Associated conditions; valvular heart disease, HTN, hyperthyroidism, stroke or TIA, lung disease including PE Risk factors for bleeding with anticoag Suitability for medical vs EP treatment
140
What are important things to look for when examining a patient with AF? (5)
Pulse and BP Murmurs: particularly mitral CCF signs Thyroid: tremor, goitre, eye disease If stroke/TIA features then brief neuro
141
What are investigations for AF? (3)
12 lead ECG or 24 hour holter Echo: structural disease, LVH, LA size >4cm recurrence high TFTs
142
What are different types of AF? (3)
Paroxysmal: <7 days, self terminating Persistent: >7 days, requires cardioversion Permanent: >1 year or when no further attempts to restore sinus
143
What is management of AF? (4)
Rhythm control: chemical or electrical cardioversion Rate control: beta blocker, digoxin, PPM, AV node ablation Pulmonary vein isolation; refractory symptomatic patients Anticoagulation depending on CHADsVASc score
144
What is chadsvasc score?
Congestive cardiac failure Hypertension Age >75 = 2 Diabetes Stroke or TIA = 2 Vascular disease Age 65-74 = 1 Sex female = 1 Score 0: low risk, no anti coag Score 1: medium risk, patient preference Score 2: high risk, anti coag recommended
145
What are important history questions for possible IBD? (11)
Duration of symptoms Precipitants: travel, antibiotics, infectious contacts, food, sexual history Stool frequency and consistency Blood: fresh PR, mixed with stools Mucous Urgency, incontinence, tennis Abdo pain, bloating, association with eating Systemic symptoms; fever, anorexia, weight loss Rash and arthralgia Mouth ulcers FH
146
What are important examination features in IBD? (12)
Pallor/ anaemia Nutritional status Pulse and BP Oral ulceration Surgical scars/stoma sites Tenderness Palpable masses Examine for perianal disease Steroid side effects Ciclosporin; gum hypertrophy and HTN Hickman lines/scars Pyoderma gangrenosum
147
What are investigations for IBD? (6)
Stool microscopy and culture FBC and inflam markers AXR: exclude toxic megacolon/obstruction Flexi sig/colonoscopy with biopsy Small bowel MRI in crohns CT scan if unwell
148
What are differentials for IBD? (6)
Infectious: campylobacter, TB, yersinia Ischaemia Drugs Radiation Malignancy Diverticulitis
149
What are treatments for crohns? (6)
Mild to moderate: oral steroids Severe: IV steroid, biologics Maintenance: azathioprine, methotrexate, inflixmab, adalimumab, ustekinumab High fibre, Low residue diet Abx if perianal infection/fistula or SBO Surgical
150
What are treatments for UC? (4)
Mild to modetate: oral or topical steroids, mesalazine Severe: IV steroid, IV ciclosporin, infliximab Maintenance: steroid, 5ASA, azathioprine, biologic Surgery
151
What are complications of crohns? (5)
Malabsorption Anaemia Abscess Fistula Obstruction from strictures
152
What are complications of UC? (4)
Anaemia Toxic dilatation Perforation Colonic carcinoma
153
What surveillance is done for patients with UC?
3 yearly colonoscopy if over 10 years duration 2 yearly if 20-30 years duration Annually if over 30 years duration Colectomy if dysplasia detected
154
What are extra intestinal manifestations of IBD? (10)
Mouth ulcers Erythema nodosum Pyoderma gangrenosum Clubbing Large joint seronegative arthritis Uveitis Episcleritis Iritis PSC Systemic amyloidosis
155
What are important questions in a history of headache and raised BP? (9)
Duration of symptoms Nature of headache BP readings Medical history: renal, CV disease, diabetes Smoking Drug history and alcohol Visual disturbance Paroxysmal symptoms (phaeo) Pregnancy
156
What are important examination findings in a patient with headache and HTN? (6)
Body habitus: obese, cushingoid, acromegalic Radial pulse: AF, radio-radial/femoral delay Check BP in both arms manually CCF features Renal: bruit, PKD, RRT, urine dip Fundoscopy: hypertensive retinopathy
157
What are findings of hypertensive retinopathy on fundoscopy? (4)
Grade 1: silver wiring Grade 2: plus AV nipping Grade 3: plus cotton wool spots and flame haemorrhages Grade 4: plus papilloedema
158
What are causes of HTN? (5)
Essential: age, obesity, salt, alcohol Renal: CKD, ADPKD, renovascular disease Endocrine: conns, cushings, acromegaly, phaeochromocytoma Aortic coarctation Pre eclampsia in pregnancy
159
What are investigations for HTN looking for end organ damage? (5)
Fundoscopy ECG: LVH U&Es Echo CXR (pulmonary oedema)
160
What are investigations for HTN looking to exclude underlying causes? (4)
Urinalysis and ACR U&Es Consider renin/aldosterone levels, plasma or urinary metanephrins Pregnancy test
161
What are the guidelines for diagnosing HTN? (7)
Clinic BP 140/90 then use 24h ABPM to confirm Stage 1: >135/85 on ABPM Stage 2: clinic BP 160/100, 150/95 ABPM Severe: clinic 180/110 Treat if stage 1 and end organ damage, diabetes, or q risk >20% Treat all stage 2 and above Same day admission if severe and grade 3 or 4 retinopathy or renal impairment
162
What are treatments for HTN? (7)
Lifestyle modification: smoking cessation, lose weight, increase exercise ACEi or ARB if <55 CCB or thiazide like diuretic if >55 or Afro Caribbean Then add in the other one then all 3 Consider adding spiro, beta blocker, alpha blocker and specialist opinion CV risk modification: aspirin, statin
163
What is treatment for malignant hypertension? (2)
Grade 3/4 retinopathy and HTN: bed rest, oral anti hypertensives, aim for gradual reduction Encephalopathy/stroke/MI/LV failure: parental venodilators and invasive BP monitoring, rapid BP decrease can cause watershed cerebral and retinal infarction
164
What are causes of papilloedema? (3)
Raised ICP: SOL, BIH, cavernous sinus thrombosis Accelerated HTN Central retinal vein occlusion
165
What is papillitis and what are features? (5)
Inflammation of head of optic nerve eg in MS Usually unilateral Reduced visual acuity Central scotoma Pain
166
What are important questions in history of rash? (6)
Location, appearance, itchiness Psychosocial impact, affect on work, relationships Exacerbating factors: stress, alcohol, cigarettes, drugs Atopy Sun exposure Irritants
167
What are treatments for psoriasis? (6)
Emollients Calcipotriol Coal tar Topical steroids PUVA /UVB Immunosuppression: ciclosporin/methotrexate, adalimbumab, retinoids
168
What are examination features of psoriasis? (6)
Multiple, well demarcated, salmon pink, scaly plaques on extensor surfaces Check behind ears, scalp and umbilicus Koebner phenomenon Skin staining from treatment Nails; pitting, onycholysis, hyperkeratosis Joints: psoriatic Arthropathy
169
What are 5 forms of psoriatic Arthropathy?
DIPJ involvement (like OA) Large joint mono/oligoarthritis Seronegative (like RA) Sacroiliitis (like ank spond) Arthritis mutilans
170
What is psoriasis?
Epidermal hyperproliferation and accumulation of inflammatory cells
171
What is a life threatening complication of psoriasis?
Erythroderma
172
What are causes of nail pitting? (4)
Psoriasis Lichen planus Alopecia areata Fungal infections
173
Which conditions cause koebner phenomenon? (5)
Psoriasis Lichen planus Viral warts Vitiligo Sarcoidosis
174
What are examination findings in eczema? (6)
Erythematous and lichenified patches of skin on flexor surfaces Painful fissures Excoriations Secondary bacterial infections Atopy: wheeze Systemic treatment effects: steroids
175
What are investigations for eczema?
Patch testing for allergies
176
What are treatments for eczema? (8)
Avoid Precipitants Emollients Topical Steroids Topical Tacrolimus Anti histamines Antibiotics if secondary infection UV light therapy Systemic therapy if severe
177
Which conditions are associated with leg ulcers? (8)
Venous: DVT, chronic venous insufficiency, varicose veins, CCF Arterial: PVD Neuropathic: sensory neuropathy, diabetes Vasculitic: RA Neoplastic: SCC Infectious: syphilis Haematological: sickle cell Tropical: cutaneous leishmaniasis
178
What are stigmata of venous hypertension on examination? (6)
Varicose veins Scars from vein stripping Oedema Lipodermatosclerosis Varicose eczema Atrophie Blanche
179
What are examination changes in PVD? (4)
Arterial ulcers in distal extremities and at pressure points Hairless, paper thin, shiny skin Cold with poor cap refill Absent distal pulses
180
What are examination findings with neuropathic ulcers? (3)
Pressure areas eg under metatarsal heads Peripheral neuropathy Charcot joints
181
What are complications of chronic leg ulcers? (2)
Infection: temperature, pus, cellulitis Malignant change; Marjolins ulcer, squamous cell carcinoma
182
What are investigations for leg ulcers? (3)
Doppler USS APBI <0.8 arterial insufficiency Ateriorography
183
What are treatments for leg ulcers? (3)
Venous: compression bandaging, varicose vein surgery Arterial: angioplasty, amputation Abx if infection
184
What are causes of neuropathic ulcers? (3)
Diabetes Tabes dorsalis Syringomyelia
185
What does necrobiosis lipoidica diabeticorum look like? (3)
Well demarcated plaques with waxy yellow centre and red-brown edges May resemble a bruise in early stages Prominent blood vessels
186
What skin changes can be associated with diabetes? (8)
Necrobiosis lipoidica diabeticorum Leg ulcers Eruptive xanthomata (hyperlipidaemia) Granuloma annulare Lipoatrophy Fat hypertrophy Candidiasis in skin folds Vitiligo (autoimmune association)
187
What is treatment for necrobiosis lipoidica diabeticorum? (2)
Topical steroid Support bandaging
188
What are skin and eye signs of hypercholesterolaemia? (3)
Tendon xanthomata Xanthelasma Corneal arcus
189
What are skin changes and eye changes of hypertriglyceridaemia? (2)
Eruptive xanthomata Lipaemia retinalis
190
What are causes of secondary hyperlipidaemia? (5)
Diabetes Hypothyroidism Nephrotic syndrome Alcohol Cholestasis
191
What are causes of erythema nodosum? (9)
Sarcoidosis Strep throat Streptomycin, sulfonamides OCP Pregnancy TB IBD Lymphoma Idiopathic
192
What are examination findings of erythema nodosum? (2)
Tender, red, smooth, shiny nodules on shins Older lesions leave a bruise
193
What is the pathophysiology of erythema nodosum?
Inflammation of subcutaneous fat - paniculitis
194
What are skin manifestations of sarcoidosis? (3)
Erythema nodosum Nodules and papules Lupus Pernio
195
What is the triad of symptoms of HSP? (3)
Purpuric rash usually on buttocks and legs Arthritis Abdominal pain
196
What are Precipitants of HSP? (2)
Infections: strep, HSV, parvovirus b19 Drugs: abx
197
What are complications of HSP? (2)
Renal involvement: IgA nephropathy, haematuria, proteinuria HTN
198
What are examination/bedside test findings of HSP? (4)
Purpuric rash on buttocks and legs Arthritis Raised BP Proteinuria on urine dip
199
What is HSP? (3)
Small vessel vasculitis IgA and C3 deposition Normal or raised platelet count Most spontaneously recover although some need steroids
200
What are questions in a history for someone with a skin lump, possible malignancy? (7)
Location and rapidity of growth Recent changes Bleeding Sun exposure Occupation FH or personal history skin cancer Immunosuppression: solid organ transplant
201
What are typical features of basal cell carcinoma? (4)
Sun exposed areas Pearly nodule with rolled edge Superficial telangiectasia Ulceration in advanced lesions
202
What are treatments for basal cell carcinoma? (2)
Curettage/cryotherpy if superficial Surgical excision +/- radiotherapy
203
What are clinical features of squamous cell carcinoma? (3)
Sun exposed areas Actinic keratosis around Keratotic nodule, polypoid mass, cutaneous ulcer
204
What is treatment for SCC of skin?
Surgery +/- radiotherapy 5% metastasise
205
What are risk factors for malignant melanoma? (5)
Fair skin with freckles Light hair Blue eyes Sun exposure FH
206
What are concerning features for malignant melanoma? (5)
Asymmetrical Border irregularities Colour: black, irregular pigmentation Diameter >6mm Enlarging
207
How is malignant melanoma staged?
Breslow thickness <1.5mm = 90% 5 year survival >3.5mm = 40% 5 year survival
208
What might be the diagnosis if a patient has a glass eye and Ascites?
Ocular melanoma
209
What is pseudoxanthoma elasticum?
Hereditary: 80% autosomal recessive Degenerative elastic fibres in skin, blood vessels and eyes Loose skin folds neck and axillae with yellow pseudoxanthomatous plaques
210
What issues are associated with pseudoxanthoma elasticum? (7)
Plucked chicken skin appearance Hyperextensible joints Reduced visual acuity HTN MI or CVA GI bleed Mitral valve prolapse
211
What eye changes can be seen in pseudoxathoma elasticum? (2)
Blue sclerae Retinal angioid streaks
212
What is inheritance pattern of ehlers Danlos and what is it?
Autosomal dominant Defect in collagen causing increased skin elasticity
213
What findings might be present in ehlers danlos? (5)
Fragile skin: multiple ecchymoses, scarring Hyperextensible skin: able to tent skin when pulled Joint hypermobility and dislocation (scar from repair or replacement) Mitral valve prolapse murmur Abdominal scar: aneurysm rupture and dissection, bowel perforation
214
What are examination findings of RA in the hands? (10)
Symmetrical and deforming polyarthropathy Volar subluxation and ulnar deviation at MCPJs Subluxation at wrist Swan neck deformity Boutonnières deformity Z thumbs Muscle wasting: disuse atrophy Carpal tunnel release scar Joint replacement scar Rheumatoid nodules (elbows)
215
What are systemic manifestations of RA? (6)
Pulmonary: effusion, fibrosing alveolitis, obliterative bronchiolitis, caplans nodules Eyes: secondary sjogrens, scleritis Neuro: carpal tunnel, atlanto-axial subluxation - quadriplegia, peripheral neuropathy Haem: feltys (RA, splenomegaly, neutropenia), Anaemia Cardiac: pericarditis Renal: nephrotic syndrome (amyloid or membranous glomerulonephritis)
216
What are radiological changes of RA? (4)
Soft tissue swelling Loss of joint space Articular errosions Periarticular osteoporosis
217
What features are required for diagnosis of RA? (7)
4/7 of: Morning stiffness Arthritis in 3+ joint areas Arthritis of hands Symmetrical arthritis Rheumatoid nodules Positive RhF Erosions on imaging
218
What are treatments for RA? (5)
NSAIDs Steroid injections and tablets DMARDs Anti TNF therapy B cell depletion therapy Supportive: education, exercise and physio, OT and social support Surgery: joint replacement, tendon transfer
219
What are important symptoms to ask about in a history of someone with suspected lupus? (8)
Face rash, photosensitivity Raynauds Dry eyes and mouth Psychosocial impact Family planning Protein or haematuria (renal involvement) HTN (renal) Immunosuppression: infections, skin changes
220
What might be found on examination of someone with lupus? (9)
Malar rash Discoid rash and scarring Oral ulceration Scarring Alopecia Nail fold infarcts (vasculitic lesions) Jaccouds Arthropathy (tendon contractures) Resp: pleural effusion, pleural rub, fibrosing alveolitis Neuro: chorea, focal neurology, ataxia Renal: HTN
221
What are investigations for lupus? (6)
Autoantibodies: ANA and anti dsDNA Raised ESR, normal CRP Immunoglobulins raised Reduced C4 complement U&Es Urine microscopy
222
What is required for diagnosis of lupus? (11)
4/11 of: Malar rash Discoid rash Photosensitivity Oral ulcers Arthritis Serositis: pleuritis or pericarditis Renal: proteinuria or casts Neurology: seizures or psychosis Haem: autoimmune haemolytic anaemia or pancytopenia Positive auto antibodies dsDNA or Sm Elevated ANA
223
What are treatment options for lupus? (3)
Mild (cutaneous/joints): topical steroid, hydroxychloroquine Moderate (other organs): prednisolone, azathioprine Severe: methylpred, mycophenolate, cyclophosphamide, azathioprine
224
What are side effects of cyclophosphamide? (8)
Thrombocytopenia Anaemia Haemorrhagic cystitis Infertility Tetatogenicity Infection Hair loss Deranged LFTs
225
What are important symptoms to ask in a history for systemic sclerosis? (6)
Raynaud’s phenomenon: white, blue, red Function: ADLs, work HTN Heart problems Lung problems Dysphagia /GORD
226
What are features on examination if hands and face of a patient with systemic sclerosis? (11)
Sclerodactyly Calcinosis Digital ulcers Nail fold capillary abnormalities Tight skin on face Beaked nose Microstomia Peri oral furrowing Telangiectasia Alopecia En coup de sabre: scar down central forehead
227
What systemic features can be found on examination of a patient with systemic sclerosis? (3)
HTN Resp: interstitial fibrosis Cardiac; pulmonary HTN (RV heave, loud p2 and TR), CCF, pericardial rib
228
What are differences between limited and diffuse systemic sclerosis?
Limited: distal limbs only, below elbows, knees and face. Slow progression over years Diffuse: widespread, early visceral involvement. Rapid progression over months
229
What is CREST?
Calcinosis Raynaud’s phenomenon Esophageal dysmotility Sclerodactyly Telangiectasia
230
What are investigations for systemic sclerosis? (11)
Auto antibodies: ANA in 90%, anti centromere in limited, Scl 70 in diffuse Hand xray: Calcinosis CXR: lower lobe fibrosis, aspiration pneumonia HRCT Pulmonary function tests Barium swallow B12/ folate: malabsorption U&Es, urinalysis, microscopy Consider renal biopsy ECG Echo
231
What are investigations for systemic sclerosis? (11)
Auto antibodies: ANA in 90%, anti centromere in limited, Scl 70 in diffuse Hand xray: Calcinosis CXR: lower lobe fibrosis, aspiration pneumonia HRCT Pulmonary function tests Barium swallow B12/ folate: malabsorption U&Es, urinalysis, microscopy Consider renal biopsy ECG Echo
232
What are investigations for systemic sclerosis? (11)
Auto antibodies: ANA in 90%, anti centromere in limited, Scl 70 in diffuse Hand xray: Calcinosis CXR: lower lobe fibrosis, aspiration pneumonia HRCT Pulmonary function tests Barium swallow B12/ folate: malabsorption U&Es, urinalysis, microscopy Consider renal biopsy ECG Echo
233
What is scleroderma renal crisis? (6)
life-threatening complication abrupt onset severe HTN rapidly progressive renal failure hypertensive encephalopathy congestive heart failure microangiopathic hemolytic anemia
234
What are treatment options for systemic sclerosis? (11)
Expert patient programmes Scleroderma Society Physio Camouflage creams Gloves/hand warmers for Raynaud’s Nifedipine or losartan Prosacyclin infusion if severe ACEi prevent HTN crisis and reduce mortality from renal failure PPI for reflux methotrexate, mycophenolate mofetil or cyclophosphamide if <3 years Autologous stem cell transplant may be appropriate in some cases
235
What symptoms are important to ask about in a patient with potential ank spond? (5)
Psychosocial impact: work, driving, ADLs Explore back pain Eye problems: uveitis Pneumonia Syncope: CHB
236
What are findings on examination of a patient with ank spond? (5)
? Posture: fixed kyphoscoliosis Protuberant abdomen: diaphragmatic breathing, reduced chest expansion Increased occiput - wall distance >5cm Reduced ROM in entire spine Schobers test: two points marked 15cm apart on dorsal spine expand by less than 5cm on maximal forward flexion
237
What are complications of ank spond? (5)
Anterior uveitis Apical lung fibrosis Aortic regurgitation Atrio ventricular nodal heart block Arthritis
238
Which gene is linked with ank spond?
HLA B27
239
What are treatment options for ank spond? (7)
Patient education Support groups Physio Analgesia: NSAIDs Steroid injections for Sacroiliitis Refer rheumatology Anti TNF: adalimumab, infliximab, etanercept
240
What are important history questions for a patient with potential marfans? (5)
Need for glasses/ eye surgery Heart surgery /screening Stretch marks Back/joint problems History of pneumothorax
241
What are examination findings of marfans? (12)
Tall with long extremities (arm span > height) Arachnodactyly Hyperextensible joints High arched palate with crowded teeth Iridodonesis (trembling lens) with upward lens dislocation Pectus carinatum or excavatum Scoliosis Scars from cardiac surgery or chest drains Aortic regurgitation with collapsing pulse Mitral valve prolapse Coarctation Inguinal herniae
242
What is marfans?
Autosomal dominant Chromosome 15 Defect in fibrillin protein in connective tissue
243
What is management of marfans? (4)
Surveillance: monitoring of aortic root size with annual echo Beta blocker and ARB to slow aortic root dilatation Pre-emptive aortic root surgery to prevent dissection and rupture Screen family members
244
What is a differential diagnosis for the causes of lens dislocation? (4)
Marfans: upwards Homocystinuria: downwards Ehlers danlos Trauma
245
What are symptoms to ask in a history of a patient with Paget’s? (4)
Usually asymptomatic Can have bone pain and tenderness Entrapment neuropathy: carpal tunnel, visual problems, deafness CCF
246
What are examination findings of a patient with Paget’s? (6)
Bony enlargement: skull and long bones (sabre tibia) Deafness: hearing aid Pathological fractures: scars Cardiac: high output failure Neuro: carpal tunnel Fundi: optic atrophy and angioid streaks
247
What are investigations for Paget’s disease? (3)
ALP raised with normal calcium and phosphate X-rays: moth eaten, osteoporosis circumscripta Bone scan: increased uptake
248
What are treatment options for pagets? (3)
Analgesia Hearing aids Bisphosphonates
249
What are complications of Paget’s? (3)
Osteogenic sarcoma Basilar invagination (cord compression) Kidney stones
250
What are causes of a sabre tibia? (3)
Pagets Osteomalacia Syphilis
251
What are causes of angioid streaks? (3)
Pagets Pseuodoxanthoma elasticum Ehlers danlos
252
What are causes of gout? (3)
Diet and alcohol: xanthine rich food Drugs: diuretics CKD
253
What are examination findings in gout? (8)
Asymmetrical swelling of small joints of hands and feet Gouty tophi: joints, ears, tendons Reduced movement and function Obesity HTN Nephrectomy scars: urate stones/nephropathy Chronic renal failure: fistulae Lymphoproliferative disorders: lymphadenopathy
254
What are investigations for gout? (3)
Uric acid levels Synovial fluid: needle shaped, negatively birefringent crystals Xray: punched out periarticular changes
255
What are treatments for gout? (2)
Acute: treat cause, increase hydration, NSAIDs, colchicine Prevention: avoid Precipitants, allopurinol (xanthine oxidase inhibitor)
256
What are symptoms and features to ask about in a history of OA? (6)
Joint stiffness and weakness Not usually red or swollen Assess ADLs and work Mobility: walking stick, wheelchair etc Joint replacements NSAID use
257
What are examination findings in OA? (8)
Asymmetrical DIPJ deformity Heberdons nodes Bouchards nodes Disuse atrophy of hand muscles Crepitations Reduced movement and function Carpal tunnel syndrome or scars Joint replacement scars
258
What are radiographic features of OA? (3)
Loss of joint space Osteophytes Periarticular sclerosis and cysts
259
What are treatments for OA? (4)
Analgesia Weight reduction PT and OT Joint replacement
260
What are important questions in a history of diabetic retinopathy? (4)
Duration and nature of visual disturbance Underlying medical problems eg diabetes Previous eye problems or treatments Have they had retinal screening?
261
What are examination findings in diabetic retinopathy? (6)
White stick, braille Glucometer Background: hard exudates, blot haemorrhages, micro aneurysms Pre proliferative: cotton wool spots, flame haemorrhages, venous beading and loops Proliferative: neovascularisation of disc, panretinal photocoagulation scars Diabetic maculopathy: macular oedema or hard exudates in one area of fovea
262
In which conditions would red reflex be absent? (2)
Cataract Vitreous haemorrhage
263
What screening should be done for diabetic retinopathy? (2)
Annual retinal screening Refer to ophthalmology of pre proliferative or changes near macula
264
What is difference between type 1 and 2 diabetes when it comes to retinopathy?
Type 1: proliferative Type 2: exudative
265
What is treatment for diabetic retinopathy? (3)
Tight glycemic control Treat other risk factors: HTN, cholesterol, smoking cessation Photocoagulation if proliferative
266
When can accelerated deterioration of diabetic retinopathy occur? (3)
Poor glycaemic control HTN Pregnancy
267
What are indications for photocoagulation? (2)
Maculopathy Proliferative and pre proliferative diabetic retinopathy
268
By what mechanism does pan retinal photocoagulation help in diabetic retinopathy? (2)
Pan retinal: Prevents ischaemic retinal cells secreting angiogenesis factors causing neovascularisation Focal: targets problem vessels at risk of bleeding
269
What are complications of proliferative diabetic retinopathy? (3)
Vitreous haemorrhage Traction retinal detachment Neovascular glaucoma due to rubeosis iridis
270
What are signs of cataracts? (4)
Loss of red reflex Cloudy lens RAPD Associated with myotonic dystrophy (bilateral ptosis)
271
What are causes of cataracts? (2)
Congenital: rubella, turners Acquired: age, diabetes, steroids, radiation exposure, trauma, storage disorders, myotonic dystrophy
272
What are treatments for cataracts? (2)
Surgery: phacoemulsification with prosthetic lens implant or yttrium aluminium garnet laser capsulotomy
273
What are important symptoms to ask about in a history of graves? (9)
Goitre: non tender Eye problems: keratitis, loss of colour vision, central scotoma, reduced VA Sleep and energy levels Heat intolerance Sweating Agitation and stress Tremor Appetite and weight loss Palpitations
274
What are eye signs in Graves’ disease? (6)
Proptosis Chemosis Exposure keratitis Lid retraction Lid lag Ophthalmoplegia
275
What are peripheral signs in Graves’ disease? (7)
Thyroid acropachy: clubbing, soft tissue swelling, periosteal bone formation Pretibial myxoedema Sweating Tremor Palmar erythema Sinus tachy/AF Brisk reflexes
276
What are investigations for Graves’ disease? (3)
TFTs Thyroid autoantibodies: TPO, thyroglobulin, TSH Radioisotope scan: increased uptake of I131 in graves, reduced in thyroiditis
277
What are treatments for Graves’ disease? (4)
Beta blockers Carbimazole or propylthiouracil: block and replace with thyroxine or titrate dose, stop at 18 months and assess, 1/3 patients will remain euthyroid If returns: further course thionamide, radioiodine, subtotal thyroidectomy Eye disease: high dose steroids, orbital irradiation or surgical decompression
278
What is contraindicated in thyroid eye disease?
Radioiodine
279
What are symptoms and features of hypothyroidism to ask about in the history? (8)
Tiredness, low energy levels Cold intolerance Weight gain Previous amiodarone, lithium or antithyroid drugs Previous thyroid disease Autoimmune history: Addisons, vitiligo and T1DM Hypercholesterolaemia IHD
280
What might you find on examination of a patient with hypothyroidism? (14)
Bradycardia Dry skin Cool peripheries Peaches and cream complexion: anaemia and carotenaemia Peri orbital oedema Loss of lateral eyebrows Xanthelasma Thinning hair Goitre or thyroidectomy scar Slow relaxing ankle jerk Pericardial rub CCF Carpal tunnel Proximal myopathy
281
What are investigations for hypothyroidism? (8)
TSH raised in thyroid failure, low in pituitary failure, low T4 Autoantibodies U&Es: hyponatraemia Hypercholesterolaemia FBC: macrocytic anaemia Short synacthen test: exclude Addisons ECG: pericardial effusion and ischaemia CXR: pericardial effusion/oedema
282
What are causes of hypothyroidism? (5)
Autoimmune: hashimotos thyroiditis, atrophic hypothyroidism Iatrogenic: post thyroidectomy, radioiodine, amiodarone, lithium, anti thyroid drugs Iodine deficiency: Derbyshire neck Dyshormonogenesis Genetic: pendreds syndrome
283
What are causes of hypothyroidism? (5)
Autoimmune: hashimotos thyroiditis, atrophic hypothyroidism Iatrogenic: post thyroidectomy, radioiodine, amiodarone, lithium, anti thyroid drugs Iodine deficiency: Derbyshire neck Dyshormonogenesis Genetic: pendreds syndrome
284
What are features in history of acromegaly to ask about? (7)
Headache: pituitary SOL, early morning, nausea Visual problems: tunnel vision Loss of libido Lactation Change in appearance/ photographs Tight fitting jewellery /shoes Diabetes
285
What are examination findings of acromegaly? (16)
Hands: spade like, tight rings, coarse skin, sweaty Face: prominent supra orbital ridges, prognathism, widely spaced teeth, macroglossia Acanthosis nigrans Raised BP Carpal tunnel syndrome Diabetes Enlarged organs Field defect: bitemporal hemianopia Goitre Heart failure Hirsute Hypopituitary Joint Arthropathy Kyphosis Galactorrhoea Proximal myopathy
286
What are investigations for acromegaly? (9)
Non suppression of GH after oral glucose tolerance test Raised IGF1 CT/MRI pituitary: pituitary adenoma Other pituitary function bloods: t4, ACTH, PRL, testosterone CXR: cardiomegaly ECG: ischaemia Glucose: diabetes Visual perimetry: bitemporal hemianopia Sleep studies: OSA due to macroglossia
287
What are treatments for acromegaly? (3)
Surgery: trans-sphenoidal approach Medical: somatostatin analogue (octreotide), dopamine agonist (cabergoline), GH antagonist (pegvisomant) Radiotherapy if non surgical candidate
288
What are follow up arrangements for acromegaly? (6)
Annual IGF1, PRL, ECG, visual fields, CXR, CT head
289
What is MEN1?
Inherited tumours, autosomal dominant, chromosome 11 Parathyroid hyperplasia Pituitary tumours Pancreatic tumours; gastrinomas
290
What is MEN2a?
RET proto oncogene issue, autosomal dominant Parathyroid hyperplasia Medullary thyroid carcinoma Phaeochromocytoma
291
What is MEN2b?
Marfanoid body habitus Medullary thyroid carcinoma Phaeochromocytoma
292
What are causes of macroglossia? (4)
Acromegaly Amyloidosis Hypothyroidism Down’s syndrome
293
What is acanthosis nigricans?
Brown, velvet like skin change found commonly round neck or axillae
294
What is acanthosis nigricans associated with? (7)
Obesity T2DM Acromegaly Cushings Indian ethnicity Gastric carcinoma Lymphoma
295
What are symptoms to ask about in a history of cushings? (5)
Proximal myopathy Steroid history: endogenous vs exogenous Visual disturbance: bitemporal hemianopia Skin hyperpigmentation Diabetes
296
What are examination features of someone with cushings? (5)
Face: moon shaped, hirsute, acne Skin: bruised, thin, purple striae Back: buffalo hump Abdomen: centripetal obesity Legs: wasting, lemon on sticks body shape, oedema
297
What are complications of cushings? (5)
HTN Diabetes Osteoporosis Cellulitis Proximal myopathy
298
What are signs of the underlying causes of cushings? (2)
Signs of chronic condition: RA, COPD Endogenous: bitemporal hemianopia and hyperpigmentation if raised ACTH
299
What is the difference between Cushing’s syndrome and Cushing’s disease?
Disease: glucocorticoid excess due to ACTH secreting pituitary adenoma Cushing’s syndrome: physical signs of glucocorticoid excess
300
How do you investigate Cushing’s? (6)
Check High cortisol: 24 hour urinary collection, low dose or overnight dexamethasone suppression test ACTH level: high if ectopic secreting tumour or pituitary adenoma, low if adrenal adenoma or carcinoma MRI pituitary adrenal CT /whole body CT Bilateral inferior petrosal sinus vein sampling High dose dexamethasone suppression test: if >50% then Cushing’s disease
301
What is treatment for Cushing’s disease? (4)
Surgical: trans sphenoidal approach if pituitary tumour Adrenalectomy for adrenal tumour Pituitary irradiation Medical: metyrapone
302
What is Nelson’s syndrome?
Bilateral adrenalectomy to treat Cushing’s Causes massive production of ACTH and melanocyte stimulating hormone Due to lack of feedback inhibition Leading to hyperpigmentation and pituitary overgrowth
303
What is prognosis of Cushing’s?
50% mortality at 5 years due to accelerated IHD if untreated
304
What are causes of proximal myopathy? (6)
Inherited: myotonic distrophy, muscular distrophy Endocrine: Cushing’s, hyperparathyroidism, Thyrotoxicosis, diabetic amyotrophy Inflammatory: polymyositis, RA Metabolic: osteomalacia Malignancy: paraneoplastic, lambert Eaton myasthenic syndrome Drugs: alcohol, steroids
305
What are symptoms of Addisons to ask about in the history? (10)
Fatigue Muscle weakness Low mood Loss of appetite Weight loss Thirst Darkened skin Fainting Cramps Other autoimmune history
306
What are differentials for Addisons? (Secondary causes of adrenal insufficiency)
Secondary adrenal insufficiency: pituitary adenoma or sudden discontinuation of steroids
307
What might you find on examination of someone with Addisons? (4)
Medical alert bracelet Hyperpigmentation: palmar creases, scars, nipples, buccal mucosa Postural hypotension Bitemporal hemianopia: secondary
308
What is Addisons? And what are causes (3)
Primary adrenal insufficiency 80% autoimmune Other causes: adrenal mets, adrenal TB, amyloidosis, adrenalectomy, Waterhouse friederichsen syndrome (adrenal infarction due to meningococcal sepsis)
309
How does Addisons cause hyper pigmentation?
Pigmentation due to lack of feedback inhibition by coritsol on pituitary leading to raised ACTH and melanocyte stimulating hormone
310
What are investigations for Addisons? (11)
8am cortisol Short synacthen test: exclude Addisons if cortisol rises to adequate level Long synacthen test: diagnose Addisons if not enough rise Adrenal imaging (primary) Pituitary imaging (secondary) FBC: eosinophilia U&E: low Na, raised K, raised urea Glucose: low Adrenal autoantibodies (21-hydroxylase and 17 alpha hydroxylase) TFTs CXR: malignancy or TB
311
What are treatments for Addisons? (5)
Acute adrenal crisis: IV 0.9% saline glucose Hydrocortisone and fludrocortisone Treatment may unmask diabetes insipidus If on TB treatment, need higher doses of steroid as drugs increase clearance Education: compliance, sick day rules Medical alert bracelet
312
What are symptoms in history of sickle cell? (7)
Fatigue Breathlessness on exertion Bone pains Chest pains Hospital admissions Ulcers Priapism
313
What might be examination findings of sickle cell? (7)
Fever Dyspnoea Jaundice Pale conjunctiva Raised JVP, pansystolic murmur at left sternal edge: TR Reduced chest expansion due to pain with coarse crackles Small crusted ulcers on legs
314
What is vaso occlusive crisis in sickle cell?
Sickling in small vessels of any organ Precipitated by viral illness, exercise or hypoxia
315
What are investigations for sickle cell? (8)
FBC: low Hb, high WCC and CRP U&E: renal impairment Blood film; sickling CXR: linear atelectasis, cardiomegaly Urinalysis; microscopic haematuria ABG: T1RF if crisis Echo; dilated right ventricle with impaired systolic function, TR CTPA: linear atelectasis with patchy consolidation, acute PE
316
What are treatment options for acute presentation of sickle cell? (5)
Oxygen +/- CPAP IV fluids Analgesia Antibiotics Blood transfusion/ exchange transfusion
317
What are long term treatments for sickle cell? (5)
Hydroxycarbamide Exchange transfusion program Folic acid Penicillin (hyposplenism) May need right heart catheter to look for pulmonary HTN
318
What blood tests should be done for hereditary spherocytosis? (5)
FBC: high retics, raised MCHC Blood film: spherocytes Haemolysis screen: bilirubin, LDH, haptoglobin Coombs test: exclude autoimmune haemolysis EMA binding test
319
What are complications of hereditary spherocytosis? (4)
Gallstones Haemolysis triggered by infections Aplastic crisis: parvovirus B19 Megaloblastic crisis: folate deficiency
320
What is treatment of spherocytosis? (3)
Folic acid supplementation Splenectomy and cholecystectomy Vaccines for encapsulated organisms
321
What is treatment of spherocytosis? (4)
Folic acid supplementation Splenectomy and cholecystectomy Vaccines for encapsulated organisms Blood transfusions
322
What are history and investigations features to suggest pancreatic insufficiency? (6)
Weight loss Steattorrhoea Low faecal elastase Low Albumin Vit d def Low magnesium
323
What needs to be given alongside Creon?
PPI to prevent acid breakdown of enzymes
324
How do you differentiate between viral and bacterial meningitis from CSF samples?
Bacterial: raised WCC - neutrophilia, elevated protein, low glucose Viral; raised WCC - lymphocytes, elevated protein, normal glucose ratio
325
What are causes of meningitis? (5)
Bacterial Viral TB Fungal Paraneoplastic
326
What are important questions in suspected reactive arthritis? (5)
Recent illness - GI upset Sexual history - chlamydia Psoriasis/ank spond/IBD personal or family history Eye symptoms: anterior uveitis, conjunctivitis HIV risk factors
327
What are causes of hypothyroidism? (7)
Hashimotos: autoimmune, progressive lymphocytic infiltration De Quervains: initially hyper then hypo then resolve Iatrogenic: over treatment of hyper Post partum thyroiditis Iodine deficiency Drugs: amiodarone, lithium Infiltration: amyloidosis, sarcoidosis
328
What is thyroid myxoedema?
low body temperature Anaemia Heart failure Confusion Coma From severe hypothyroidism
329
What conditions can be associated with autoimmune hypothyroidism? (7)
Vitiligo Addisons T1DM RA Pernicious anaemia Psoriasis IBD
330
Which autoantibodies are associated with Hashimoto’s disease? (2)
Anti TPO Anti thyroglobulin
331
Which antibodies are found in Graves’ disease?
Anti TSH receptor antibodies
332
What are risk factors for spina bifida? (5)
Low folate during pregnancy FH neural tube defects Drugs: Sodium valproate / methotrexate during pregnancy Obesity Diabetes
333
What are symptoms/ associated problems in spina bifida? (3)
Weakness of legs Bowel and bladder issues: incontinence, neurogenic bladder and bowels, constipation, infections Hydrocephalus
334
What are symptoms/ associated problems in spina bifida? (3)
Weakness of legs Bowel and bladder issues: incontinence, neurogenic bladder and bowels, constipation, infections Hydrocephalus
335
What are causes of anaemia in RA? (5)
Anaemia of chronic disease Feltys syndrome IDA from NSAID use Autoimmune haemolytic anaemia Bone marrow suppression from medication

PACES (6 decks)

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