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Clinical Consultations Flashcards

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1
Q

What symptoms are associated with yellow nail syndrome

A

Lymphoedema (80%)
Pleural effusions (36%)
Chronic sinusitis
Bronchiectasis

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2
Q

Which underlying conditions are associated with yellow nail syndrome

A

Chronic bronchiectasis, rheumatoid arthritis, hypogammaglobulinaemia, malignancy, thyroid disease

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3
Q

What are the causes of a high-arched palate

A
  • Freidrich’s ataxia
  • Marfan’s syndrome
  • Turner’s syndrome
  • Tuberous sclerosis
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4
Q

Which blood test is helpful in differentiating graves and toxic multinodular goitre

A

TSH receptor Abs (positive in Grave’s)

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5
Q

Which test is helpful in differentiating Grave’s and thyroiditis

A

Radioisotope scanning (increased uptake in grave’s, reduced in thyroiditis)

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6
Q

When can’t radioiodine treatment be used for hyperthyroidism

A

Thyroid eye disease, pregnancy

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7
Q

What causes a saddle nose appearance

A

Granulomatosis with polyangiitis

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8
Q

What exam findings may be present in ankylosing spondylitis

A
  • question mark posture
  • reduced ROM throughout spine
  • occipital-wall distance >5cm
  • Schober’s test positive
  • signs of aortic regurgitation
  • apical fine crackles
  • eye redness, Achilles tendinitis
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9
Q

What can be seen on spine XR in ankylosing spondylitis

A
  • sclerosis of sacroiliac joint
  • syndesmophytes
  • loss of lumbar lordosis
  • bamboo spine
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10
Q

What can cause breathlessness in ankylosing spondylitis

A
  • anemia (chronic disease, GI loss)
  • kyphoscoliosis
  • apical fibrosis
  • aortic regurgitation
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11
Q

What is the pharmacological management of Ankylosing spondylitis

A
  1. NSAIDs
  2. If uncontrolled with NSAIDs, DMARDS (anti TNF e.g. adalimumab, etanercept)
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12
Q

What complications are associated with ankylosing spondylitis

A
  1. Anterior uveitis
  2. Apical lung fibrosis
  3. Aortic regurgitation
  4. AV block
  5. Arthritis
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13
Q

What are the seronegative spondyloarthropathies

A
  • ankylosing spondylitis
  • psoriatic arthritis
  • IBD associated arthritis
  • reactive arthritis
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14
Q

How does anterior uveitis present

A

Painful red eye, reduced acuity, excess lacrimation, ciliary flush, abnormally shaped pupil

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15
Q

What are the causes of anterior uveitis

A
  • seronegative spondyloarthropathies
  • IBD
  • Bechet’s
  • sarcoidosis
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16
Q

What are the grades of hypertensive retinopathy

A
  • Grade 1: silver wiring
  • Grade 2: plus AV nipping
  • Grade 3: plus cotton wool spots and flame haemorrhages
  • Grade 4: plus papilloedema
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17
Q

What are most common causes of secondary hypertension

A
  1. Renal (CKD - GN, PKD, renovascular)
  2. Endocrine (Conn’s, cushing’s, acromegaly, phaeochromocytoma)
  3. Aortic coarctation
  4. Pre-eclampsia
  5. OSA
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18
Q

When should stage 1 hypertension (>140/90) be treated

A

Evidence of end-organ damage, IHD, diabetes, CKD, 10-year cardiovascular risk >20%

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19
Q

When should patients with hypertension be admitted

A

Severe hypertension (>180 or >110) and grade 3/4 retinopathy or end organ damage

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20
Q

When should a patient with IBD be admitted to hospital

A

Systemically unwell with symptoms such as bloody diarrhoea, fever, tachycardia or hypotension

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21
Q

What are the physical signs associated with acromegaly

A

Spade like hands, tight rings, coarse sweaty skin, protruding jaw, widely spaced teeth, macroglossia, prominent supra-orbital ridges

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22
Q

What are the complications of acromegaly

A
  • diabetes
  • HTN
  • heart failure
  • field defects
  • lactation
  • carpal tunnel syndrome
  • OSA
  • proximal myopathy
  • goitre
  • GI malignancy
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23
Q

What are the diagnostic tests of acromegaly

A
  • IGF-1 (raised)
  • OGTT (no suppression of GH)
  • MRI pituitary (adenoma)
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24
Q

What investigations should be performed to look for complications of acromegaly

A
  • blood pressure
  • ECG (ischaemia), CXR (cardiomegaly)
  • BM, HbA1c
  • pituitary function tests
  • visual field defects
  • sleep studies
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25
What is the follow up for acromegaly
Annual GH, prolactin, ECG, visual fields and CXR +/- CT head
26
What are the features of MEN1
- parathyroid hyperplasia (raised Ca) - pituitary tumours - pacreatic tumours (gastrinomas)
27
What are the causes of macroglossia
Acromegaly Amyloidosis Hypothyroidism Down’s syndrome
28
What is acanthosis nigricans associated with
- obesity - T2DM - acromegaly - cushing’s - malignancy (gastric cancer)
29
What are the causes of retinal angioid streaks
PEPSI Pseudoxanthoma elasticum Ehler-Danlos syndrome Paget’s disease of the bone Sickle cell disease Idiopathic
30
What are the causes of proximal myopathy
- inherited (myotonic dystrophy, muscular dystrophy) - endocrine (cushings, thyrotoxicosis, diabetic amyotrophy) - inflammatory (polymoyositis, RA) - LEMS - Drugs (alcohol, steroids)
31
What are the causes of optic atrophy
PALE DISCS P = pressure A = ataxia (Friedrich’s) LE = Leber’s D = diet (B12), degenerative (RP) I = ischaemia (CRAO) S = syphilis C = cyanide and other toxins S = MS
32
What are the 2 most common causes of optic atrophy
1. Increased pressure (eg glaucoma) 2. MS
33
What are the causes of tunnel vision
- retinitis pigmentosa - papilloedema - glaucoma - choroidoretinitis - migraine - histeria
34
What are the causes of a retinal artery occlusion
1. Embolic - carotid/cardiac (AF) 2. GCA
35
What does a cherry red spot and pale retina suggest on fundoscopy
Retinal artery occlusion
36
What are the causes of retinal vein occlusion
- hypertension - hyperglycaemia (diabetes) - hyperviscosity (Waldenstroms, MM) - high pressure (glaucoma)
37
What does flame haemorrhages radiating from a swollen optic disc suggest on fundoscopy
Retinal vein occlusion
38
What are the causes of sudden unilateral painless vision loss
- retinal detachment - retinal artery or vein occlusion - vitreous detachment/haemorrhage - ischaemic optic neuropathy - amaurosis fugax
39
What are the causes of painless bilateral vision loss
- medication/drugs - stroke (hemianopia) - metabolic derangement
40
What are the causes of painful unilateral vision loss
- optic neuritis - temporal arteritis (GCA) - iritis, uveitis - acute angle closure glaucoma - infection - cavernous sinus thrombosis
41
What are the causes of dactylitis
- spondyloarthropathies - sickle cell - sarcoidosis - syphilis - TB
42
What ANA pattern is associated with limited cutaneous systemic sclerosis
Anti-centromere
43
What ANA pattern is associated with diffuse cutaneous systemic sclerosis
Scl-70 / topoisomerase-1
44
What is the difference in age of onset between Friedrich’s ataxia and ataxia telangiectasia
- Friedrich’s = 10-15 years - AT = 1-5 years
45
What does ataxia telangiectasia predispose patients to
1. Recurrent infections (IgA deficiency) 2. Cancer (ATM repairs DNA breaks)
46
What are the typical ocular features seen in Kearns-Sayre syndrome
1. Complex ophthalmoplegia 2. Bilateral ptosis 3. Retinitis pigmentosa
47
What are the causes of erythema nodosum
- Inflammatory (Sarcoidosis, IBD) - Infection (Strep, TB, Histoplasmosis, Brucellosis) - Malignancy (Lymphoma) - Pregnancy - COCP - Idiopathic
48
What are the skin manifestations of sarcoidosis
- erythema nodosum - nodules and papules (red/brown around face, nose, ears and neck that demonstrate koebner’s phenomenon) - lupus pernio
49
What are the side effects of NSAIDs
- renal failure - GI bleeding - Cardiovascular disease
50
What are the side effects of steroids
- Diabetes - Osteoporosis - Hypertension - Infection - Avascular necrosis of hip - Striae and weight gain (cushing’s) - Cataracts - Increased ICP - Myopathy - Pancreatitis
51
What are the features of osteogenesis imperfecta
- multiple fractures (low impact) - blue sclera - discoloured, translucent teeth - aortic regurgitation - hearing impairment - small stature, spinal scoliosis, curvature of long bones
52
What are the causes of blue sclera
- osteogenesis imperfecta - pseudoxanthoma elasticum - Ehler Danlos syndrome
53
What are the causes of secondary raynauds
1. Systemic sclerosis 2. SLE 3. Dermatomyositis 4. Sjogren syndrome 5. GPA
54
What is the inheritance pattern of HHT
Autosomal dominant
55
What are the complications of HHT
- bleeding -> IDA - stroke (paradoxical emboli) - subarachnoid haemorrhage - pulmonary hypertension
56
What is the main difference between complications in PXE and EDS
PXE increases risk of coronary artery disease and MI
57
List 9 autosomal recessive conditions
Ataxia telangiectasia Cystic fibrosis Friedrich’s ataxia Haemochromatosis Homoscystinuria Pseudoxanthoma Elasticum Sickle cell disease Thalassaemia Wilson’s
58
What percentage of discoid lupus progresses to SLE
5%
59
What are the causes of carpal tunnel syndrome
- hypothyroidism - pregnancy - obesity - wrist trauma - diabetes - rheumatoid arthritis - acromegaly
60
What are the causes of a bulbar palsy (CN IX, X and XII)
- MND - Syringobulbia - Guillian-Barre - Poliomyelitis - Neurosyphilis - Brainstem CVA
61
What are the causes of a pseudobulbar palsy (CN IX, X and XII)
- MS - MND - High brainstem tumours
62
What is Jaccoud’s arthropathy
Seen in SLE - mimics RA but due to tendon contractures
63
What are the systemic effects of SLE
1. Resp - pleural effusion, rub, fibrosis 2. Neuro - chorea, ataxia, focal neurology 3. Renal - CKD, nephrotic syndrome, HTN
64
What can be used to measure disease activity in SLE
- raised ESR (But normal CRP) - raised immunoglobulins - reduced C4 - UEs, urine microscopy
65
What are the 11 criteria that 4 of which are required to diagnose SLE
SOAP BRAIN MD - serositis (pleuritis, pericarditis) - oral ulcers - arthritis - photosensitivity - blood disorders (eg AIHA) - renal involvement (eg proteinuria) - ANA+ - immunology (anti-DsDNA) - neurological disorders (eg seizures) - malar rash - discoid rash
66
What is the management of mild SLE with cutaneous/joint involvement only
- topical corticosteroids - hydroxychloroquine
67
What is the management of moderate SLE with cutaneous/joint involvement + other organ involvement
- prednisolone - azathioprine
68
What is the management of severe SLE with severe inflammation of vital organs
- methylprednisolone - MMF - cyclophosphamide - azathioprine
69
What are the side effects of cyclophosphamide
Haemorrhagic cystitis Infertility Teratogenicity
70
What are the classical facial appearances in systemic sclerosis
- tight skin - beaked nose - microstomia - peri-oral furrowing - telangiectasia - alopecia
71
What is the appearance of a discoid lupus rash
- persistent scaly plaques - scalp, face and ears most affected - progress to scarring - hypo or hyperpigmentation - scarring alopecia
72
What is the difference in progression between limited and diffuse systemic sclerosis
Limited - slow (years) Diffuse - rapid (months)
73
What investigations are important in systemic sclerosis
1. Diagnosis - ANA, anti-centromere, Scl-70 2. Hands - XRays (calcinosis) 3. Lungs - CXR, HRCT, PFTs 4. GI - contrast swallow, FBC, B12 5. Renal - UE, urinalysis, ACR, biopsy 6. Cardiac - ECG, echo
74
What is the treatment of Systemic sclerosis
Symptomatic treatment only! - Reynauds - gloves, CCBs, prostacyclin infusion if severe - Renal - ACEi - GI - PPI
75
What are most deaths due to in systemic sclerosis
Respiratory failure
76
What are the 4 S’s to be asked in a rheumatological history
Sun sensitivity Scalp involvement Scarring Systems involvement
77
What is the management of thyroid eye disease
1. Stop smoking, selenium 2. Block and replace or titrate (carbimazole, PTU)
78
What causes memory loss, ataxia and urinary incontinence
Normal pressure hydrocephalus
79
What are the organic causes of memory loss
- Alcohol inc korsakoff’s - hypothyroidism - B12 deficiency - infection e.g. HIV, Neurosyphilis - head injury
80
What might be found on examination in Addison’s disease
- medic alert bracelet - hyperpigmentation (skin folds, lips) - postural hypotension - bitemporal hemianopia (pituitary adenoma)
81
What are the causes of Addison’s disease
- 80% autoimmune - adrenal mets - adrenal tuberculosis - amyloidosis - adrenalectomy - Waterhouse-Friederichsen syndrome
82
What is the treatment of an adrenal crisis
- fluid resuscitation - IV hydrocortisone
83
What is the classic presentation of diabetic lumbosacral radiculopathy (previously diabetic amyotrophy)
Sudden onset unilateral aching/burning pain in thigh and hip which becomes bilateral over weeks/months, can affect walking, leads to proximal weakness and wasting
84
What complication can occur after transphenoidal surgery that leads to persistent runny nose
CSF leak
85
What is the main risk associated with CSF leak
Infection - meningitis, encephalitis
86
What are the differentials of a symmetrical deforming polyarthropathy
- rheumatoid arthritis - psoriatic arthritis - osteoarthritis - JIA (diagnosis <16 years) - SLE - gout
87
What can cause SOB in lupus
- acute pneumonitis - ILD - pulmonary hypertension - anaemia - PE (secondary APLS)
88
What nail changes are seen in lupus
None - patients may be prone to fungal nail infections though if on immunosuppression
89
What increases the risk of hallux valgus (bunions)
- arthritic conditions - neuromuscular diseases - ehler-danlos, Marfan’s
90
What is the difference between erythema and purpura
erythema blanches, purpura does not blanch
91
What are the causes of cranial diabetes insipidus
- trauma (head injury) - tumours (eg craniopharyngioma) - infiltrative (eg sarcoid, Histiocytosis) - vascular (sickle cell, Sheehan’s) - iatrogenic (transphenoidal surgery)
92
What are the causes of nephrogenic diabetes insipidus
- inherited (x-linked recessive) - metabolic (hypercalcaemia, hypokalaemia) - drugs (demeclocycline, lithium) - chronic renal disease
93
What are the 5 types of psoriatic arthritis
1. Distal IP predominant 2. Asymmetrical oligoarticular 3. Symmetric polyarthritis 4. Spondylitis 5. Arthritis mutilans
94
What are the causes of livedo reticularis
- Antiphospholipid syndrome - SLE - PAN - cryoglobulinaemia - EDS - homocystinuria - idiopathic
95
What are the common causes of secondary amenorrhoea
- hypopituitarism - hyperprolactinaemia - PCOS - premature ovarian insufficiency - functional hypothalamic (eg weight loss, excessive exercise) - hypothyroidism - pregnancy - drugs/meds
96
What are the causes of scarring alopecia
- *discoid lupus* - Trauma/burns - radiotherapy - lichen planus - tinea capitis
97
What are the causes of non-scarring alopecia
- alopecia areata - cytotoxic drugs - nutritional e.g. iron deficiency - male pattern baldness
98
Which autoimmune conditions classically improve during pregnancy
Rheumatoid arthritis, multiple sclerosis
99
What are the potential causes of breathlessness in rheumatoid arthritis
- ILD - drug related (MTX) - pleural effusion - Bronchiolitis obliterans - anaemia of chronic disease - anaemia from GIB (steroids/NSAIDS) - pericardial effusion
100
Why is it important to ask about constitutional symptoms in a patient with rheumatoid arthritis
- increased risk of infection with active RA - may be immunocompromised (e.g. MTX) - Felty’s syndrome - increased risk of lymphoma with RA
101
Which joints are most commonly affected in rheumatoid arthritis
MCP and PIP
102
Which infections are linked to reactive arthritis
- GI: campylobacter, shigella, salmonella - GU: chlamydia
103
How long after infection does reactive arthritis take to develop
1-4 weeks
104
What pattern of joint involvement is typically seen in reactive arthritis
Asymmetrical oligoarthritis of the lower limbs
105
What is the first line management of reactive arthritis
Oral NSAIDs
106
What are the causes of small vessel vasculitis
- anti-GBM disease - IgA vasculitis - cryoglobulinaemic vasculitis - Microscopic polyangiitis - GPA - EGPA
107
What symptoms do all vasculitides have in common
Constitutional symptoms: - Fever - Malaise - Arthralgia - Myalgia - Weight loss
108
What are the symptoms of small vessel vasculitis
- Palpable purpura - Haematuria - Nasal symptoms - Sinus pain - Wheeze - Haemoptysis - Ear pain
109
What are the symptoms of medium vessel vasculitis
- foot/wrist drop (MNM) - cutaneous ulcers - livedo reticularis - digital gangrene - abdominal pain
110
What are the symptoms of large vessel vasculitis
- headache, scalp tenderness (GCA) - visual changes - limb claudication - asymmetrical brachial pulses - bruits
111
What are the first investigations to order for suspected vasculitis
- ESR, CRP - ANCA - UEs, urine dip, urine ACR - Biopsy of affected tissue
112
What are the causes of a purpuric rash
1. Vasculitides 2. Platelet disorders - ITP, TTP 3. Coagulation disorders - DIC, HIT
113
What are the causes of limb claudication
Main cause = atherosclerosis Other causes: - large vessel vasculitis - pseudoxanthoma elasticum - aortic coarctation - arterial compression (eg tumour)
114
Which eye signs are specific to Grave’s disease
- Proptosis/exophthalmos - chemosis (blistering conjunctivae) - ophthalmoplegia - exposure keratitis
115
Which red flags of thyroid eye disease require urgent referral to ophthalmology
- vision loss - ophthalmoplegia
116
What are the causes of thyrotoxicosis
1. Graves disease 2. Toxic multinodular goitre Rarer causes: - single toxic nodule - thyroiditis (post-infectious, post-partum) - medication
117
What are the differentials of a neck lump
- Graves’ disease - toxic multinodular goitre - thyroiditis (painful) - thyroid cancer - thyroid cyst - thyroid adenoma
118
What can be seen on routine bloods in hypothyroidism
- FBC: macrocytic anaemia - UE: hyponatraemia - Lipids: hypercholesterolaemia
119
What are the causes of hypothyroidism
- Autoimmune: Hashimoto’s, atrophic hypothyroidism - Iatrogenic: thyroidectomy, iodine, amiodarone, lithium - Dietary: iodine deficiency - Genetic: Pendred’s syndrome
120
What are the features of subacute thyroiditis
- usually hyperthyroidism - weeks to months after viral infection - painful tender goitre - self-limiting (carbimazole/PTU not effective)
121
What are the features of post-partum thyroiditis
- usually hypothyroidism - Anti-TPO Abs - 40% develop hypothyroidism - manage with low dose thyroxine
122
What are the causes of male infertility
- germ cell tumours - primary or secondary hypogonadism - genetic (klinefelter’s) - iatrogenic (medication) - ciliary dysfunction (kartagener’s, CF) + erectile dysfunction (spinal cord, meds, diabetes)
123
What are the differentials of Crohn’s disease
- Infection (yersinia, TB) - Coeliac - Lymphoma - Ulcerative colitis - IBS - GI malignancy
124
What are the differentials for ulcerative colitis
- Infection (shigella, campylobacter) - Ischaemia - Drugs - Crohn’s - Pseudomembranous colitis (C. Diff) - Diverticulitis - GI malignancy
125
What should be performed during examination of a headache
- Detailed CN exam, focused UL+LL - Fundoscopy - Otoscopy - Neck flexion - Kernig’s sign - Examine skin for rashes
126
What are the diagnostic criteria for rheumatoid arthritis (American college of rheumatology)
4/7 of: - morning stiffness - arthritis in 3+ joint areas - arthritis in hands - symmetrical arthritis - rheumatoid nodules - positive RF - erosions on XR
127
What is used to measure disease activity in rheumatoid arthritis
DAS28 score
128
What are the key features of Kearns-Sayre syndrome
- onset before 20 years - chronic progressive complex ophthalmoplegia - bilateral ptosis - retinitis pigmentosa - cerebellar ataxia - proximal weakness
129
What key features will be in the history of a patient with HHT
- recurrent epistaxis - GI bleeding - Haemoptysis - Symptomatic anaemia - strong FHx (AD)
130
What are the exam findings in HHT
- mucocutaneous telangiectasia (check inside mouth) - resp: clubbing, cyanosis, RV heave, loud P2 - cardio: pulmonary oedema - GI: pallor, signs of portal HTN - Neuro: pronator drift
131
What are the causes of recurrent epistaxis
- HHT - Trauma - Nasal polyps - Infection (chronic sinusitis) - Anticoagulation - ITP - GPA
132
What are the cardiac complications of Ehlers Danlos syndrome
- Mitral valve prolapse - Aortic aneurysm - Aortic dissection
133
What are the complications of pseudoxanthoma elasticum
- premature CAD - stroke - GI bleeding - vision loss (retinal angioid streaks) - mitral valve prolapse
134
What are the causes of secondary reynauds
- CTD/AI: SSc, SLE, myositis, Sjögren’s, PAN, APLS - Arterial disease: atherosclerosis, thromboangiitis obliterans - Hyperviscocity syndromes - Infection: Bacterial endocarditis
135
Which type of drug should be avoided in systemic sclerosis
Steroids - can precipitate renal crisis!
136
What are the main differences between reactive arthritis and gonococcal arthritis
Gonococcal normally presents with septic arthritis - fever, unwell, purulent urethral discharge

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