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Clinical Exam Flashcards

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1
Q

What does double apex beat correspond with?

A

Hypertrophic cardiomyopathy

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2
Q

What is Schamroth’s sign?

A

Fingernail ‘diamond’ test for clubbing

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3
Q

JVP: cause of dominant a-wave (3)

A

Tricuspid stenosis
Pulmonary stenosis
Pulmonary HTN

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4
Q

JVP: cause of dominant v-wave

A

Tricuspid regurgitation

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5
Q

Causes of canon a-waves (3)

A

3rd degree heart block
SVT
VT

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6
Q

What does left parasternal heave suggest? (2)

A

RV hypertrophy

LA enlargement

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7
Q

On heart palpation, what does ‘tapping’ apex beat indicate?

A

Mitral stenosis

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8
Q

What does fixed splitting of S2 suggest?

A

ASD

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9
Q

Kussmaul sign

  • What is it?
  • Causes (4)
A

Paradoxical RISE in JVP with inspiration (would usually fall) - inability of the heart to accept the increase in RV volume without an increase in filling pressure.

Restrictive cardiomyopathy, constrictive pericarditis, severe R) heart failure, tamponade

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10
Q

What is Ebstein’s anomaly?

A

Apical displacement of tricuspid valve –> Tricuspid regurgitation

Associated with WPW and R) conduction defects

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11
Q

True / false: you can hear diastolic murmurs in HOCM

A

False

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12
Q

Causes of pitting oedema (8)

A 
Medications (CCBs)
Heart failure
Nephrotic syndrome
Liver failure
Malabsorption / starvation (beri beri, B1)
Protein-losing enteropathy
Myxoedema
Cyclical oedema
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13
Q

Causes of non-pitting oedema (2)

A

Lymphoedema (malignancy, congenital, filariasis)

Myxoedema

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14
Q

Define pulsus paradoxus

A

Fall of systolic blood pressure of >10 mmHg during the inspiratory phase.

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15
Q

True / false: clubbing occurs with sarcoidosis

A

False

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16
Q

True / false: clubbing occurs with COPD

A

False

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17
Q

Light’s criteria for exudate (3)

A

Pleural:serum protein >0.5
Pleural:serum LDH >0.6
Pleural LDH >2/3 ULN

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18
Q

Arthritides involving DIPs (3)

A

OA
Gout
Psoriatic

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19
Q

Nerve root for biceps reflex

A

C5/6

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20
Q

How to test for ulnar nerve lesion

A

Fromet’s sign

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21
Q

How to test for median nerve lesion

A

pen touching test (thumb abduction)

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22
Q

Components of dominant parietal lobe assessment (4)

Gerstmann syndrome

A 
'AALF'
A - acalculia
A - agraphia
L - left-right disorientation
F - finger agnosia (name fingers)

(Often dysphasia as well)

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23
Q

Signs of chronic liver disease:

  • General (4)
  • Hands (4)
  • Face (4)
  • Chest / abdomen (5)
A

Cachexia, jaundice (or grey if haemochromatosis), excoriation, bruising

Clubbing, palmar erythema, contractures, leukonychia

Fetor hepaticus, icterus, dentition, parotid swelling

Spider naevi, caput medusae, gynaecomastia, reduced hair, testicular atrophy

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24
Q

Signs (definitions) of liver decompensation (7)

A 
Ascites / SBP
Encephalopathy / Asterixis
Variceal bleed
Jaundice
Hydrothorax
HCC
Hepatorenal syndrome
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25
Causes of hepatomegaly ('CCC' + 'III')
Cirrhosis - alcohol Cancer (secondaries) Congestion Infection (HBV, HCV, EBV, CMV) Infiltrate / deposit (amyloid, myeloproliferative, haemochromatosis, Wilson's) Immune (PSC, PBC, AIH)
26
Complications of cirrhosis (3)
Variceal haemorrhage SBP Encephalopathy
27
Complications of haemochromatosis (5)
``` Diabetes Arthropathy Cardiomyopathy Hypogonadism Cirrhosis + HCC ```
28
Findings of splenomegaly (4)
``` Mass moves with inspiration Dull to percuss Palpable notch Can not get above Not ballotable ```
29
Causes of massive splenomegaly (>8cm) (2)
``` Myeloproliferative disease (CML, myelofibrosis) Tropical infections (malaria, leishmaniasis) ```
30
Causes of moderate splenomegaly (4-8cm) (2)
``` Myelo / lymphoproliferative disorders Infiltrative disease (amyloid, Gaucher's) ```
31
Causes of mild splenomegaly (<4cm) (4)
Myelo / lymphoproliferative disorders Portal HTN Infection Haemolytic anaemia
32
Splenectomy management (3)
Vaccination (ideally 2/52 prior to removal) for encapsulated organisms (Pneumococcus, meningococcus, haemophilus) Prophylactic penicillin Medical alert bracelet / education
33
Findings of palpable kidney (3)
Ballotable Can get 'above' Moves with respiration
34
Causes of kidney enlargement: - Unilateral (4) - Bilateral (4)
PCKD, RCC, hydronephrosis, simple cyst PCKD, bilateral hydronephrosis, tuberouscelrosis (AML), amyloidosis
35
Other organs involved in PCKD (3)
Liver cysts / hepatomegaly Berry aneurysms Mitral valve prolapse
36
Scars in renal patient (3)
Iliac fossa - new transplant Flank - nephrectomy (PCKD, RCC) Peri-umbilical - previous PD catheters
37
HRCT findings in UIP (4)
Sub-pleural reticulation Basal-predominant Traction bronchiectasis Honeycombing (IPF has UIP pattern only)
38
HRCT findings in NSIP (4)
Sup-pleural sparing Ground glass Traction bronchiectasis Basal predominance
39
Expected spirometry / LFTs in restrictive disease
FEV1/FVC >0.8 Small TLC Low DLCO and KCO
40
Bronchiectasis DDx / Causes (6)
``` Kartagener's Cystic fibrosis Hypogammaglobulinaemia / CVID Aspergillosis / ABPA Rheumatoid lung Chronic aspiration (alcohol, GORD) ```
41
Causes of apical fibrosis (CHARTS)
``` Coal worker's lung Hypersensitivity pneumonitis (AKA extrinsic allergic alveolitis) + Histiocytosis X Ankylosing spondylitis TB Radiation Sarcoidosis ```
42
Lung transplant: - Common reasons for single lung transplant (2) - Common reasons for double lung transplant 3)
'Dry lung' - COPD, pulmonary fibrosis 'Wet lung' - bronchiectasis, CF, pulmonary HTN
43
Indications for home O2
pO2 <7.3kPa (55mmHg) or if cor pulmonale: pO2 <8kPa (60mmHg)
44
Surgical options for COPD (4)
Bullectomy Lung reduction surgery Endobronchial valve placement Single lung transplant
45
Aortic stenosis vs aortic sclerosis
In aortic sclerosis, there is a normal pulse character and no radiation of the murmur
46
Aortic stenosis DDx (5)
``` Other systolic murmur e.g. MR, TR HOCM VSD Aortic sclerosis High output clinical state (pregnancy, anaemia, sepsis) ```
47
Causes of aortic stenosis (4)
Congenital bicuspid valve Age-related / calcification Chronic rheumatic heart disease Infective endocarditis
48
Order of worsening symptoms for aortic stenosis
Angina - 5 years Syncope - 3 years SOB - 2 years
49
Clinical features of aortic stenosis (5)
``` Slow rising pulse Narrow PP Right sternal thrill Pressure loaded apex Ejection systolic murmur / crescendo-decrescendo ```
50
Clinical features of aortic regurgitation (5)
``` Collapsing / waterhammer pulse Wide pulse pressure Corrigan's pulse Hyperkinetic (volume-loaded) apex beat Early diastolic murmur +/- Austin-Flint - Loudest leaning forward, left, lower sternal edge ``` (And many other eponymous signs)
51
Causes of aortic regurgitation: - Acute (3) - Chronic (6)
'DIT CHARMA' Dissection Infective endocarditis Trauma ``` Congenital bicuspid valve Hypertension Ankylosing spondylitis Rheumatic fever Marfan's / Ehlers-Danlos Aortitis (Syphilis, Takayasu's) ```
52
When to do surgery for aortic regurgitation: - Acute (2) - Chronic (4)
Aortic dissection Aortic root abscess NYHA > II heart failure PP >100mmHg ECG changes on ETT LV >5.5cm or EF <50%
53
Clinical signs of mitral stenosis (5)
``` Irregular pulse (likely to have AF) Malar flush Tapping apex Auscultation: opening 'snap' of stiff leaflets + diastolic murmur Often features of pulmonary HTN ```
54
Features of pulmonary HTN (5)
``` Elevated JVP Loud P2 RV heave Tricuspid regurgitation Overload / oedema ```
55
Causes of mitral stenosis (4)
Rheumatic heart disease Congenital mitral stenosis Mitral annular calcification Endocarditis
56
Differentials for diastolic murmur (4)
Aortic regurgitation Mitral stenosis Austin flint murmur Atrial myxoma
57
Management options in mitral stenosis (3)
Medical - manage AF and failure Balloon valvuloplasty Surgical valvotomy / replacement
58
Clinical signs of mitral regurgitation (6)
Atrial fibrillation Scars e.g. valvuloplasty Displaced and volume-loaded apex +/- thrill Pan-systolic murmur (radiating to axilla) +/- S3 Widely split S2 (because LV empties sooner)
59
Features that suggest severity of MR (2)
``` LV failure Atrial fibrillation (a late sign) ``` NOT murmur intensity (which just reflects flow)
60
Causes of mitral regurgitation - Acute (3) - Chronic (5)
Endocarditis Trauma Ischaemia ``` Mitral annular calcification Valve prolapse - Marfan's, amyloid Rheumatic heart disease Papillary muscle dysfunction Connective tissue disease ``` (Can also be due to 'secondary' causes - I.e. LV dilatation causing valve incompetence)
61
ECG findings in mitral valve disease (3)
P-mitrale (bifid + broad p-waves) Atrial fibrillation +/- Q-waves
62
Clinical findings of tricuspid regurgitation (5)
``` Prominent V-waves Thrill on palpation Pan systolic murmur Pulsatile liver (tender) Peripheral oedema / ascites ```
63
Causes of tricuspid regurgitation (5)
``` Ebstein's anomaly Endocarditis Functional (commonest) Rheumatic heart disease Carcinoid syndrome (secreted mediators cause right heart valve fibrosis) ```
64
Clinical signs of pulmonary stenosis (4)
Prominent a-wave on JVP Left parasternal heave + thrill Ejection systolic murmur Signs of right-heart failure
65
Causes of pulmonary stenosis (5)
``` Carcinoid Noonan's syndrome William's syndrome Rubella Tetralogy of Fallot ```
66
Late complications of prosthetic valves (6)
``` Valve failure - can sometimes do valve-in-valve for bioprosthetic Endocarditis Haemolysis Heart failure AF (esp. if mitral valve) Warfarin-related complications ```
67
Indications for ICD insertion (2, 3)
Primary prevention - >4 weeks post MI with associated high risk features - FHx cardiac conduction syndrome with high risk features Secondary - Cardiac arrest due to VT / VF - Previous haemodynamically unstable VT - Any VT with EF <35%
68
How to differentiate constrictive pericarditis vs restrictive cardiomyopathy
Ventricular interdependence (seen on ECHO) supports Dx of constrictive process.
69
Cyanotic heart disease - Due to - Causes (5)
Right-to-left shunt ``` Truncus arteriosus Transposition of the great arteries Tricuspid atresia Tetralogy of Fallot Total anomalous pulmonary venous return ```
70
Acyanotic heart disease - Due to - Complication - Causes (4)
Left-to-right shunt Eisenmenger's syndrome VSD ASD AVSD PDA
71
Complications of septal defects (3)
Eisenmengers / pulmonary HTN Atrial arrhythmia Emboli
72
Auscultation of septal defects (2)
Usually systolic murmur | Note: as Eisenmenger's develops, and the gradient reduces, the murmur may actually SOFTEN
73
Causes of absent radial pulse - Acute (3) - Chronic (4)
Embolisation Trauma (e.g. catheterisation) Dissection Surgery e.g. procedure for Tetralogy of Fallot Takayasu's disease Atherosclerosis Coarctation
74
Findings in coarctation (4)
HTN right arm +/- left Reduced / absent left radial pulse Reduced femoral pulses Continuous murmur +/- radiates to back (from collateral vessels) Note: CXR shows '3 sign' and rib notching (due to pulsatile intercostal arteries)
75
Systolic murmur Ddx (4, 2)
AS MR TR PS HOCM L-to-R shunts
76
Findings of HOCM (6)
``` Prominent a-wave on JVP Double apex impulse +/- thrill ESM (due to LVOTO) PSM (due to mitral prolapse / SAM) S4 ('A Stiff Heart') Dynamic maneuvers ```
77
HOCM dynamic maneuvers (2, 2)
Increased by: Valsalva (reduced LV filling), or low afterload (vasodilators) Decreased by: squatting (increased preload), handgrip (increased afterload)
78
HOCM management / prognostic factors (6 + 2)
``` Avoid triggers (exercise, vasodilators, dehydration) Beta-blocker (reduces O2 use and gradient) Septum - alcohol ablation or myomectomy - Esp. if >3cm thick ICD - Esp. if FHx SCD, syncope or young age Cardiac transplant Genetic counselling ```
79
Cerebellar exam signs
DANISH: ``` Dysdiadochokinesia Ataxia Nystagmus - Cerebellar lesion: nystagmus towards lesion - VIII lesion: nystagmus away from lesion Intention tremor Staccato speech (scanning dysarthria) Hypotonia / hyporeflexia ``` (Also rebound phenomenon - Holmes' sign)
80
Causes for cerebellar disease
PASTRIES: ``` Paraneoplastic Alcohol Sclerosis (MS) Tumour Rare (Friedriech's, trinucleotide repeat disorders, congenital, mitochondrial) Iatrogenic (drugs, e.g. phenytoin) Endocrine (hypothyroidism, low b12/folate, low vit E) Stroke (posterior circ) ```
81
DDx for proximal myopathy (8, 3)
``` Acquired - 'PACEPODS' Polymyositis Alcohol Carcinoma Endocrinopathies Periodic paralysis Osteomalacia Drugs: steroids Sarcoidosis ``` Other: Hereditary muscular dystrophies e.g. FSH, Duchenne's Congenital myopathies e.g. myotonic dystrophy Degenerative myopathies e.g. IBM
82
MS diagnostic Ix (5)
``` MRI - time and space CSF oligoclonal bands VEPs OCT Antibodies for DDx ```
83
Multiple sclerosis DDx (8)
``` Cord compression Transverse myelitis MND Multiple strokes (embolic) B12 deficiency Hereditary spastic paraparesis Cerebral palsy Cerebral vasculitis SLE Paraneoplastic Neurosyphilis ADEM ```
84
DDx for spastic legs (10)
``` Stroke Spinal cord infarct MS Spinal cord compression Trauma / surgery Motor neuron disease (no sensory signs) Cerebral palsy Hereditary spastic paresis Subacute combined degeneration of the cord Friedreich's ataxia ``` Hint: look for sensory level (suggests spinal lesion)
85
Motor neuron disease DDx (7)
Consider if mixed LMN and UMN findings ``` Multifocal motor neuropathy Spinomuscular atrophy CIDP Cervical myelopathy Brain stem lesion (if bulbar-predominant disease) Polio Syringomyelia ```
86
Features suggesting neuropathy (7)
``` Distal weakness +/- foot drop +/- associated sensory signs in glove/stocking pattern Absent reflexes May have fasciculations No contractures Can see autonomic dysfunction Wasting of intrinsic muscles of hands ```
87
Features suggesting myopathy (6)
``` Proximal weakness Usually no sensory loss Preserved reflexes No fasciculations Tender muscles Look for cardiac complications ```
88
Causes for pes cavus of foot (2)
Charcot-Marie-Tooth Disease (AKA hereditary sensorimotor neuropathy) Friedreich's ataxia
89
DDx for sensory neuropathy (4)
Diabetes Alcohol B12 deficiency Drugs e.g. chemo, isoniazid
90
DDx for motor neuropathy (6)
``` GBS or botulism (acute) Lead toxicity Porphyria HSMN Polio MMN ```
91
Causes for mononeuritis multiplex (5)
``` Diabetes Vasculitis (PAN, EGPA) Connective tissue disease Infection (HIV) Malignancy ```
92
Nerves of cerebellar-pontine angle (4)
V, VI, VII, VIII | and cerebellar signs
93
Unilateral 7th CN palsy DDx (5)
``` Bell's palsy Mononeuritis (diabetes, sarcoid, Lyme) Tumour/trauma MS Stroke ```
94
Bilateral 7th CN palsy DDx (5)
``` Myasthenia gravis Sarcoidosis Lyme GBS Bilateral Bell's palsy ```
95
'Extras' in myasthenia exam (3)
Myasthenic snarl (when attempting to smile) Thymectomy scar Ask for FVC
96
Tuberous sclerosis skin findings (4)
Angiofibromas (butterfly distribution) Shagreen's patch Ash-leaf macules Periungal fibroma
97
Tuberous sclerosis systemic complications (5)
``` Epilepsy Intellectual impairment Cystic lung disease Angiomyolipomas / renal failure Retinal phakoma ```
98
Clinical features of neurofibromatosis (4)
Cutaneous neurofibromas Cafe au lait patches Axillary freckling Lisch nodules
99
Complications of neurofibromatosis (7)
'HELPLES' ``` Hypertension (renal a. stenosis) Epilepsy Lung fibrosis/cysts Phaeochromocytoma Leukaemia risk Enlarged palpable nerves Schwannomas and neurofibromas ```
100
Holmes-Adie pupil vs Argyll-Robertson pupil
Adies: poor reaction to light AND slow accommodation (and diminished leg reflexes) Argyll: accommodates but doesn't react (and sensory ataxia - tabes dorsalis)
101
Medical causes of third nerve palsy (4)
4x M's - consider when 'down and out pupil' but not dilated pupil. MS Midbrain infarct Mononeuritis multiplex (DM) Migraine
102
Wrist/hand findings in RA (7)
``` Ulnar deviation Wrist subluxation Swan neck deformity (bent DIP) Boutonniere's deformity (bent PIP) Z-thumb Disuse atrophy Surgical scars (carpal tunnel) ```
103
X-ray findings in RA (4)
'SLAP' Soft tissue swelling Loss of joint space Articular erosions Periarticular osteopaenia
104
Complications of ank spond (5)
5x A's: ``` Apical fibrosis Aortic regurgitation Arthritis Anterior uveitis AV node block ```
105
X-ray features of osteoarthritis (4)
'LOSS' Loss of joint space Osteophytes Subchondral sclerosis Subchondral cysts
106
'Golden' long case questions (4)
What are your main concerns? What are your goals for the future? What do you think the future will look like? (where would you want to be when 'the time comes'?) If we could fix on thing, what would it be?
107
DDx for causes underlying a lung surgery scar (7)
Cancer (look for adenopathy and evidence of smoking) COPD (bullectomy, cyst deroofing) Bronchiectasis TB Congenital lung malformations Haemoptysis Transplant - consider if 'normal exam' otherwise
108
Features of liver on exam (6)
``` RUQ Can't get above Moves with respiration Crosses midline Dull to percussion Positive 'scratch test' (if abuts against abdominal wall) ```
109
Features of spleen on exam (7)
``` LUQ Can't get above Extends infero-medially Palpable notch Moves with respiration Dull to percussion Positive 'scratch test' ```
110
Features of kidney on exam (6)
``` Able to get above Full flanks on inspection Never cross midline Usually resonant on percussion Move with respiration Ballotable ``` (Will often see fistula or old PD catheter scar) (Consider concurrent cystic liver)
111
Hand x-ray clues: - New bone formation - Bone erosion - Calcinosis - Marked deformity but N x-ray
OA or psoriatic RA or gout Scleroderma SLE (Jaccoud's arthropathy)
112
Describing / summarising rheum exam findings (5)
1. Deforming vs non-deforming 2. Symmetrical vs asymmetrical 3. Poly / oligo / monoarticular 4. Predominantly affecting the ... joints 5. Active vs inactive Then go on to DDx and why.
113
Diseases affecting basal ganglia (3)
Parkinson's Wilson's disease Huntington's
114
'National Asthma Plan' Steps (6)
1. Assess severity 2. Optimise lung function 3. Maintain lung function - avoid triggers 4. Maintain lung function - medications 5. Develop an action plan 6. Education / regular review
115
Complications to ask about in HIV (6)
``` Medication side-effects Cardiovascular Renal Osteoporosis HIV-associated neuro and dementia Sexual health ```
116
Steps to help patient quit smoking (3)
1. Assess dependency E.g. smoke on waking, smoke when sick, how many per day, smoke in forbidden areas? 2. Assess willingness to quit E.g. not ready to quit, ready to quit in 6/12, ready to quit in 1/12 3. Treat with behavioural, psychological and medical interventions E.g. set quit date, social support, ID high risk situations, NRT, regular follow-up
117
Managing obesity template: - Initial considerations (6) - Approaches (5)
Address underlying causes e.g. steroid, thyroid Assess for comorbidity e.g. diabetes, OSA Assess underlying / associated risk factors / drivers e.g. smoking, FHx Manage complications e.g. OA, gout, ca risk Assess risk e.g. calculators, waist circumference Assess psychological readiness / address barriers 5-stage approach: - Diet - Exercise - Behavioural therapy - Pharmacological - Bariatric surgery
118
Weight loss goals (1, 2)
Aim to lose 10% of weight over 6 months. | Low likelihood of response if <2kg lost in first month (If immobile, patient will gain 6-12kg/year)
119
General 'managing a medical condition' framework (5)
``` Treat reversible causes / triggers Treat underlying disease Prevent further deterioration Manage complications of disease/treatment Disease-specific therapy ```
120
Depression mnemonic | I.e. the neurovegetative symptoms
'DSIGECAPS' ``` Depression Sleep impairment Interest (loss) Guilt Energy (low) Concentration (reduced) Appetite (low) Psychomotor agitation Suicidality ```
121
Assessing alcohol dependence (or other substances) (4)
'CAGE' Have you ever felt the need to CUT down? ANNOYED at someone telling you to quit? Feel GUILT about your use? EYE opener?
122
Managing substance dependence framework (6)
``` Set goals Brief intervention ('FRAMES' approach) Counselling (or appropriate services) Pharmacotherapy Detox referral Manage complications ```
123
Annual stroke risk if CHADS-VASc = 2
2.2% per year | Goes up roughly one percent for each extra point
124
Implication of high HAS-BLED score
Caution and regular review of benefit / risk (but no an indication to stopping!)
125
DDx for massive hepatomegaly (5)
'HAMMR' ``` HCC Alcoholic liver with fatty infiltrate Metastases Myeloproliferative disease (PRV, ET, myelofibrosis) Right heart failure ```
126
DDx for non-massive hepatomegaly (6)
'HI CHAF' ``` Haematological cancer (CML, lymphoma) Infection e.g. malaria, hydatid, HIV Cirrhosis Haemochromatosis Amyloid Fatty liver disease ```
127
DDx for pulsatile liver (2)
TR | HCC
128
DDx for firm + irregular liver (4)
Cirrhosis Hydatid disease Metastic disease Infiltrative disease
129
DDx for large kidney (5)
``` Polycystic kidney Renal cancer Renal vein thrombosis Hydronephrosis Infiltrative disease e.g. amyloid, lymphoma ```
130
DDx for massive splenomegaly (3)
'CML' CML Myelofibrosis Lymphoma (primary)
131
DDx for non-massive splenomegaly (8)
'SO PITCHI' ``` Storage disease e.g. Gaucher's Other haematological malignancy Portal HTN Infiltrative disease e.g. sarcoid, amyloid Thalassaemia Connective tissue disease Haemolytic anaemia Infection e.g. EBV, malaria (Idiopathic is the most common cause) ```
132
Why does valsalva make HOCM louder?
By decreasing left ventricular filling, the left ventricular outflow tract obstruction worsens, making the murmur louder.
133
Mitral stenosis indications for surgery (4, 1)
Worsening dyspnoea Falling valve area <1cm2 Pulmonary HTN Recurrent thromboembolism (Do surgery before pulmonary oedema or haemoptysis arises)
134
Mitral regurgitation indications for surgery (2)
Usually mitral valve REPAIR (rather than replacement) NYHA III or IV symptoms or worsening LV dysfunction (try to do before LV has become too damaged, i.e. before EF <30%)
135
Aortic regurgitation indications for surgery (3)
Worsening dyspnoea Worsening LV function LV dilatation >5.5cm
136
Most common type of ASD in adults
Ostium secundum
137
DDx for digital clubbing (9)
``` Non-small cell lung cancer Suppurative lung disease: bronchiectasis, CF, PCD ILD Cyanotic heart disease Lymphoma Endocarditis IBD Cirrhosis Thyrotoxicosis (achropachy) ```
138
Cushingoid patient with thoracotomy scar; consider:
Lung transplant
139
Complications of portal HTN (5)
``` Ascites +/- SBP Varices +/- bleed Encephalopathy Hydrothorax Hepatorenal syndrome ```
140
DDx for hepatosplenomegaly (6)
'IPMAIL' ``` Infection Portal HTN Myeloproliferative disease Acromegaly Infiltrative Lupus ```
141
Complications of Autologous SCT (6)
``` Mucositis Infection Marrow suppression Sinusoidal obstruction syndrome (liver Sx) Secondary cancer Fertility issues ```
142
Post-SCT-transplant management (3)
Transfusion support Infective prophylaxis e.g. cotrimoxazole, valaciclovir, fluconazole Vaccinations
143
Things to ask about in allogenic SCT (5)
``` When/why Donor source: syngeneic, matched sibling, MUD, haploidentical, cord blood Donor: HLA match, CMV status Recipient: CMV status Conditioning regimen ```
144
Complications of allogeneic SCT | - Infectious (4)
Fungal Viral: herpes, varicella, CMV/EBV, BK, JC Bacterial: mycobacterium, pneumococcus Protozoal: pneumocystis, toxoplasmosis
145
Allogeneic SCT: post-transplant management (5)
Long-term immunosuppression (cf. autologous SCT) Transfusion support GvHD prophylaxis (MTX, cyclosporin) Infection prophylaxis: cotrimoxazole, valaciclovir, fluconazole Vaccinations
146
Complications of allogeneic SCT - Acute (6) - Chronic (5)
``` Mucositis Marrow suppression GvHD - acute/chronic Infection Sinusoidal obstructive syndrome Rejection ``` ``` PTLD Disease relapse Infertility Secondary malignancy Long-term increase in cardiovascular risk ```
147
CKD; complications + management
'AABCDEFGHI + UM' ``` Acidosis - bicarb Anaemia - iron + EPO Bones - phosphate binders Calcium - vit D sups, parathyroidectomy Diabetes - screen +/- manage Electrolytes - monitor (K+ and Mg2+) Fluid - restriction +/- frusemide Gout - monitor +/- treat Hypertension / CARDIOVASCULAR - address/treat risk factors (statin, aspirin) Immunisations Uraemia - encephalopathy, pericarditis Malnutrition - high protein ```
148
Causes for bronchiectasis (6)
'PIC CAT' ``` Primary ciliary dyskinesia / Kartagener's Immune deficiency / infection Cystic fibrosis Connective tissue disease ABPA TB ```
149
Bronchiectasis key HRCT findings (4)
Bronchial wall thickening Bronchial dilatation (bigger than adjacent vessel) Signet rings 'Tree in bud'
150
X-ray findings in psoriatic arthritis (5)
``` Narrowed joint space NO periarticular osteopaenia (cf RA) Pencil in cup Joint tuft erosion Arthritis mutilans ```
151
Key x-ray finding in gout
'Punched out' erosions
152
Causes /groups for interstitial lung disease (7)
``` Idiopathic Connective tissue disease Drug related Hypersensitivity pneumonitis Occupational exposure Smoking-related Sarcoidosis ```
153
If finding ILD on exam, where to proceed to (2)
Look for pulmonary HTN | Look for connective tissue disease (RA, scleroderma, nodules etc.)
154
Normal liver span
8-12cm (midclavicular line) Depends on age, size etc.
155
DDx for generalised adenopathy (7)
``` Lymphoma Leukaemia Metastatic disease Infection Connective tissue disease Sarcoidosis Phenytoin (pseudolymphoma) ```
156
Eye signs only found in Grave's disease (but not other thyroid diseases) (5)
``` Exophthalmos Ophthalmoplegia (affects inferior rectus → difficulty with upward gaze) Chemosis Change in visual acuity, Optic atrophy ```
157
Causes for goitre (6, 2)
``` Grave's Iodine deficiency Thyroiditis Idiopathic Peri-partum Pendred syndrome (inborn error of T4 synthesis, a/w SNHL) ``` If irregular: - Multinodular goitre - Malignancy
158
DDx for frontal bossing (5)
``` Acromegaly Paget's disease Thalassaemia Achondroplasia Hydrocephalus ```
159
How to assess disease activity in acromegaly (7)
Skin tag number Hypertension Worsening visual fields / new CN palsies (cavernous sinus) Excessive sweating Glycosuria Headache Increasing ring size, shoe size or dentures
160
Exam 'types' to consider if given hand stem (4)
Rheum Acromegaly Peripheral neuropathy / isolated nerve lesion Myopathy
161
DDx for deforming polarthropathy (5)
``` RA Seronegative arthropathies e.g. PsA, Reiter's, enteropathic Gout OA Haemochromatosis ```
162
Geriatric giants (5)
Think about this when doing a geriatric style long case: - Immobility / instability (falls) - Incontinence - Confusion / memory / dementia - Iatrogenic (polypharmacy) - Impaired self-care
163
Considerations re: illness that started in childhood (4)
Impact on missed school Playing sports Making / playing with friends Final education level
164
'Niche' questions in renal long case (5)
Dry weight Still passing urine? (residual renal function) Current Hb / EPO / iron use Salt / fluid restriction Post-dialysis Sx e.g. nausea, hypotension, cramps
165
Long-term complication of analgesic nephropathy (other than ESRF)
Transitional cell carcinoma
166
Most common causes of ESRF in NZ (4)
Diabetes - 50% GN - 25% HTN - 9% Idiopathic
167
eGFR considerations (5)
Start dialysis at eGFR ~10-15 Plan vascular access for HD at eGFR ~20 Pre-emptive renal transplant performed at eGFR ~15 eGFR starts to fall from ~35 years of age Many confounders e.g. amputees, AKI, weight loss
168
IgA nephropathy associations (4)
HIV IBD Chronic liver disease Coeliac disease
169
Cons of peritoneal dialysis (5)
``` Infection risk (peritonitis, tunnel site) Diabetes worsening Peritoneal fibrosis Protein loss Hernias ```
170
DDx for livedo reticularis (3)
Cholesterol emboli Anti-phospholipid syndrome Vasculitis
171
Antibodies associated with GPA (2)
cANCA | anti-pr3
172
Systemic vasculitides associated with pANCA (2) Other conditions with positive pANCA but negative MPO (3)
EGPA MPA Also have positive MPO antibodies - IBD - Autoimmune hepatitis - PSC
173
Key toxicities of cyclophosphamide (5)
``` Cytopaenia Haemorrhagic cystitis (manage with mesna) / bladder cancer Infertility / premature menopause Opportunistic infection Increased malignancy (haem/skin) ``` Mechanism: DNA cross-linking
174
Classifying tremor (3)
Parkinsonian Action / Postural (drug, thyroid, alcohol/toxin, essential) Cerebellar - intention vs outflow tract
175
Seronegative spondyloarthropathies (5)
``` Psoriatic arthritis Ankylosing spondylitis Reactive arthritis Enteropathic Arthritis Juvenile spondyloarthritis ```
176
When to use DMARDs in ankylosing spondylitis?
If there is also peripheral joint involvement. (Can use anti-TNF-alpha for axial and peripheral disease as second line).
177
Ankylosing Spondylitis: non-medical management (7)
Regular exercise and daily stretch (or hydrotherapy) Self-help groups Stop smoking Education re: iritis - needs urgent review Education re: maintaining good posture Firm mattress - offers symptomatic benefit Monitor cardiovascular risk (main cause of early mortality)
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Indications for ASD / PFO closure (4)
Asymptomatic but haemodynamically-significant shunt e.g. RV enlargement Some pulmonary hypertension (prior to right-to-left shunt developing) Paradoxical embolic stroke in patient <60 Platypnoea-orthodeoxia syndrome
179
Cut-off in FEV1 of how much is clinically important in lung transplant?
>10%
180
Why is diltiazem still used in patients after they have had a heart transplant?
Slows metabolism of cyclosporin - can use lower doses, and is cheaper.
181
Angiography after heart transplant (2)
Performed 1-2x / year For coronary artery intimal proliferation (AKA coronary artery vasculopathy)
182
Scars to look for in heart transplant (2)
Sternotomy Small neck scars (from endomyocardial biopsy forceps)
183
Components of MELD score (3)
INR Bilirubin Creatinine +/- extra points for haemodialysis or liver cancer
184
Components of Child-Pugh score (5)
``` Ascites Encephalopathy Bilirubin Albumin INR ```
185
Things addressed at cardiac rehab class (4)
Safe exercise Weight reduction strategies Changes to diet Smoking reduction
186
Possible examination finding if only LIMA graft CABG performed (2)
Sternotomy | Numbness to left side of sternum
187
Patients who would benefit from CABG > angio (3)
LMS disease 3x vessel disease Diabetics
188
Indications for surgery in infective endocarditis (5)
``` Valve / root abscess or conduction disturbance Persistent bacteraemia despite Rx Heart failure secondary to valve failure Resistant organisms (e.g. fungi) Recurrent major embolic phenomena ``` I.e. not just an isolated vegetation
189
NYHA classification
I - no limitation on physical activity II - Sx on moderate activity III - Sx on mild activity IV - Sx at rest
190
DDx for wheeze (7)
``` Asthma COPD Bronchiectasis L) heart failure Polyarteritis nodosa EGPA External compression e.g. tumour ```
191
Complications of bronchiectasis (5)
``` Recurrent infections Sinusitis Haemoptysis Brain abscess Amyloidosis ```
192
Components of Kartagener's syndrome (3)
Bronchiectasis Sintus inversus Chronic sinusitis
193
Which systems have irreversible damage from haemochromatosis? (2)
Joints | Endocrine
194
Extrahepatic complications of hepatitis C (6)
``` GN (membranoproliferative) Cryoglobulinaemia Porphyria cutanea tarda Vasculitis Polyarthralgias B cell lymphomas ```
195
Key features of nephrotic syndrome (4)
Proteinuria >3.5g / day Hypoalbuminaemia Oedema Hyperlipidaemia
196
Extra-colonic complications of UC (8)
``` Pyoderma gangrenosum Erythema nodosum Oral ulcers Eye: uveitis Liver: PSC, cirrhosis Anaemia Amyloidosis Arthropathy ```
197
Bowel-related complications of UC and CD (4, 2)
``` Both: Pain / bleeding Strictures / obstruction Perforation Malignancy ``` Crohn's: Malnutrition Peri-anal disease
198
Evaluating stricture in Crohn's (3, 1)
CT enterography MR enterography Push endoscopy Pill cam has high risk of worsening obstruction
199
Why is budesonide useful in IBD?
Acts locally in bowel, but is 90% metabolised by liver thereby reducing systemic effects.
200
Major AZA side-effects (4)
Cytopaenia Pancreatitis Rashes Lymphoma
201
Key CIDP exam findings (3,1)
Proximal > distal weakness Stocking/glove sensory loss (all modalities) Absent reflexes +/- sensory ataxia
202
CIDP DDx (4)
Guillain-Barre HMSN (Charcot's) MMN Neuropathy due to MGUS, diabetes, vasculitis, drugs etc.
203
Mitral stenosis: signs of severity (5)
``` Small pulse pressure 'Opening snap' Signs of pulmonary HTN Diastolic thrill Short distance between S1 and S2 ```
204
Mitral regurgitation: signs of severity (4)
LV displacement LV failure Pulmonary HTN Early diastolic murmur
205
Aortic regurgitation: signs of severity (6)
``` Wide pulse pressure Collapsing pulse Quinke's nails Corrigan's pulse Austin flint murmur LV failure ```
206
Aortic stenosis: signs of severity (6)
``` Narrow pulse pressure Aortic thrill Loss of heart sounds S4 presence Radiates to carotids CP / SOB / syncope (LV failure) ```
207
Cancer screening in NZ (4)
Prostate - not routine if asymptomatic Bowel - 60-74 years (kit +/- scope) Breast - 45 - 69 years (mammogram) Cervical - 25 - 69 (smear)
208
Key side-effect of protease inhibitors
E.g. saquinavir Increased CVD risk - e.g. via diabetes, increased lipids Use pravastatin - has less interaction with antivirals
209
DDx for chorea (6)
``` Sydenham's chorea Huntington's Wilson's disease SLE Basal ganglia infarcts Chorea gravidarum ```
210
ABCs approach for substance misuse
A - ask about current patterns of use. Can quantify risk using 'AUDIT C' score B - brief interventions / advice C - counselling (this may involved community / allied health services)
211
Alcoholism - potential drugs (3)
Disulfiram - aldehyde dehydrogenase inhibitor (no change in cravings) Topiramate - reduced cravings and withdrawal Sx Naltrexone - opioid receptor antagonist (reduces urge to drink)
212
Mechanical valve INR targets (3, 1, 1)
Newest AVRs ('On-X') - 1.5 - 2.0 AVR with no other risk - 2 - 3 AVR with other thromboembolic risks, or old valves 2.5 - 3.5 Mitral or tricuspid valves - 2.5 - 3.5 UpToDate recommends concurrent aspirin in all patients with a mechanical prosthetic valve
213
'Extras' in renal transplant exam (7)
``` Prednisone complications - skin, myopathy, Cushings Gouty tophi Mouth - gum hypertrophy, candida Diabetes screening exam Skin cancers Parathyroidectomy scar Fistula function ```
214
General principles for pre-op assessment (4)
Consider the operation: what is planned, is there something safer Assess comorbidity / severity + optimise Manage medications: blood thinners, insulin, BP meds, stress dosing etc. Planned post-op care e.g. incentive spirometry, warfarin bridging, stress dosing, temporary dialysis
215
Components of CHADS-VASc with 2 points
Age >75 Prior stroke / TIA (all others are 1 point)
216
Oestrogen-related breast cancer risks (4)
Nulliparity First pregnancy >30 years Early menarche / late menopause Obesity
217
Tamoxifen key side effects (3, 1)
Thromboembolism Hot flushes Endometrial hyperplasia (Via CYP2D6 inhibition from SSRIs, the conversion of tamoxifen to its active metabolite is slowed)
218
Multiple myeloma prognostic factors
Beta-2-microglobulin conc. Albumin level Patient age Cytogenetics
219
Key side effect of myeloma chemotherapy (lenalidomide / bortezomib)
Peripheral neuropathy
220
Criteria for bariatric surgery (2)
BMI >40 or BMI >35 and complications present (e.g. OSA, diabetes) Both need to have tried and failed optimal medical therapy and be smoke-free
221
Trachea deviates away from (2)
Tension PTX | Large pleural effusion
222
Trachea deviates towards ... (2)
Lobectomy / pneumonectomy | Lobar collapse
223
``` Tactile fremitus: Increased by (1) Decreased by (3) ```
Consolidation Effusion, pneumothorax, emphysema
224
Normal spleen size
10-12cm
225
Metabolic syndrome criteria (5)
3 of 5 of: - Increased waist circumference (102cm M, 88cm F) - Increased triglycerides - Decreased HDL - Increased BP (>130/85) - Increased BSLs (Or on treatment for any of the above factors)
226
Heart failure pharmacotherapy (6, 2)
``` ACEi - key agent Beta blockers Mineralocorticoid receptor antagonists ARNIs Ivabridine ``` (These all have hospitalisation and mortality benefit) Emerging evidence for SGLT-2 inhibitors Frusemide is symptomatic only
227
Heart failure lifestyle management (3,1)
Fluid restriction Salt restriction Daily weights (Think of 'rule of 2's ') Iron store optimisation
228
Heart failure devices (4)
CRT ICD (primary vs secondary) Ventricular assist device Intra-aortic balloon pump
229
Indications for heart transplant (3, 1)
Severe AND symptomatic HF (despite optimal Tx) Frequent discharges from ICD Intractable angina NOT just for low ejection fraction
230
Causes for late mortality after heart transplant (4)
Graft failure Infection Malignancy Coronary artery vasculopathy (neointimal proliferation)
231
How to monitor myeloma progression (2)
'CRAB' criteria | Or increase in M-protein band
232
Medication that causes false-positive Coomb's test
Daratumumab | anti-CD38, used in myeloma, which causes cross linking of RBCs
233
Engraftment - What is it? - How long to occur? - How to measure?
Establishment of transplanted haematopoietic stem cells 2-3 weeks usually Chimerism studies (seeing what proportion of peripheral cells are derived from donor vs recipient haematopoiesis)
234
How to assess for hyposplenism (3)
Howell-Jolly bodies on blood film Pitted erythrocytes Technecium-99 imaging
235
How to distinguish HOCM from hypertensive heart disease (3)
Predictors of hypertensive disease include: Elevated indexed left ventricular mass Absence of SAM Absence of midwall LGE
236
Indications for ICD in HOCM (6)
``` Arrest from VF or sustained VT FHx of sudden cardiac death Septal wall thickness >30mm Unexplained syncope Young patient age High LV outflow tract gradient ```
237
HOCM screening (2, 1)
Autosomal dominant disease, with hypertrophy developing in second decade. As such: - Screen 1st degree relatives aged 12-18 annually (Hx, Ex, ECG, ECHO) - Screen 1st degree relatives >18 every 5 years (Usually only then do diagnostic / genetic testing if positive screening. I.e. don't screen via genetic testing)
238
What is the Fontan procedure (4)
Done for 'univentricular' congenital heart diseases, e.g. hypoplastic left heart syndrome. SVC and IVC get directed straight to pulmonary arteries and into lungs, i.e. bypassing the heart. The RV (via and ASD/VSD) then acts as the only pump around the body for blood returning from the lungs Palliative procedure only - 10-20 years. Will eventually need heart/lung transplant.
239
How to diagnose heart transplant rejection
Endomyocardial biopsy (showing T-cell predominant inflammation). (Note, complication of repeated biopsies = TR)
240
In which direction: - Does the uvula deviate? - Does the tongue deviate?
Uvula - away from lesion Tongue - towards side of lesion
241
What does positive Romberg's indicate?
Dorsal column disease (i.e. sensory ataxia) (Normally, vision will compensate for the sensory loss. Cerebellar and vestibular disease is indicated if patient cannot stand with their feet together regardless if their eyes are open or closed).
242
Cerebellar gait (2)
Broad-based, lurching Proceed with cerebellar exam
243
Parkinsonian gait (3, 1)
Small, shuffling, fastination. Loss of arm swing. Slow initiation of gait. Proceed with Parkinson's exam
244
Hemiplegic / hemiparetic gait (2, 1)
Slow, spastic - affected limb is lifted and circumducted. Upper limb is flexed + adducted. Look for other UMN lesions
245
Sensory ataxia gait (3)
Wide based, feet lifted high off ground, patient has to look at floor, feet slap to ground. Look for positive Romberg's and then to LL sensory exam. Look for Argyll Robertson pupil (DDx Friedreich's ataxia, peripheral neuropathy, tabes dorsalis, subacute degeneration of the cord, MS, cord lesions)
246
High stepping gait (2)
Due to foot drop Proceed with foot drop isolation
247
Scissor gait (paraparetic) (seen in + DDx + examine for)
Spastic paraplegia - legs can cross in front of one another DDx: Hereditary spastic paraparesis, Friedreich's ataxia, cord lesions, MS, cerebral palsy, transverse myelitis Examine for LL UMN signs, sensory level, check spine, then check ULs to see if extended, then check cerebellum
248
Waddling gait
Proximal myopathies
249
Brown-Sequard syndrome key findings (3)
Below level of lesion: Ipsilateral weakness (UMN pattern) Ipsilateral dorsal column loss Contralateral spinothalamic loss At level of lesion: Ipsilateral weakness (LMN pattern) Ipsilateral sensory loss
250
Brown-Sequard DDx (5)
``` Syringomyelia Trauma - stab, bullet Spinal cord tumour Multiple myeloma Degenerative spine disease ```
251
Bulbar palsy findings (5)
``` Nasal speech Wasting / fasciculating tongue Weak soft palate Absent gag reflex Absent jaw jerk ```
252
Dividing hypoglycaemic symptoms (2)
Neurogenic (adrenergic excess, e.g. tremor, agitation, anxiety, palpitations, sweating) Neuroglycopaenic (low BSL e.g. delirium, coma, seizure)
253
Management approach for diabetic with hypoglycaemia - Information gathering (3) - Planning (7)
History initially - how frequent events, what symptoms, needing the help of someone else (i.e. severe)? Further information - BSL records, machine log, CGM Further information - intercurrent illness, exercise, diet change Establish plan: - Individualised regimen - balanced according to patient - May be reasonable to run higher / adjust injsulin - Run higher for 2-3 weeks to restore hypoglycaemic awareness - Increase monitoring frequency - Educate about symptoms, exercise, diet - Access to carbs / glucagon at home - Educate family/friends about Sx + emergency management
254
Hypoglycaemia / driving stand-downs (3)
Mild - one hour if insulin, longer if sulfonylurea used Severe - no driving for 24h Severe event WHILE driving - no driving 1 month / until specialist review
255
Vision standards for driving (2)
Class 1 - 6/12 | Other classes - 6/9
256
Key components of palliative care / optimising quality of life case to discuss (1, 5, 4)
"Each person has unique definition of quality of life" - needs wholistic approach. "What area is important to the patient?" ``` Areas: Physical Psychosocial Spiritual Cultural needs Support family/friends - with caring role and with bereavement ``` ``` During discussions, involve: Patient / selected close contacts Cultural support worker Palliative care team Hospice ```
257
Findings in nerve conduction studies: Compressive lesion Demyelinating condition Axonal condition Proximal nerve root lesion (e.g. GBS)
Conduction block (sudden slowing of velocity >50%) Slowed conduction velocity and temporal dispersion (signals arrive at different times) Reduced conduction amplitude Prolonged F-waves
258
Findings in EMG studies: Denervated muscles Neuronal muscle disease Myopathic muscle disease
Positive sharp waves and fibrillations (dead nerve --> upregulated AChRs --> start to respond to background ACh) - Note fasciculation is what is seen clinically, not fibrillation Increased motor unit amplitude, decreased recruitment Small motor unit amplitude, increased recruitment (Dive bomber sound in myotonic dystrophy)
259
Pulmonary HTN exam findings (6)
``` Parasternal heave Loud P2, with splitting +/- S3 or S4 Tricupsid regurgitation Elevated JVP Pulsatile liver Ascites / oedema ``` (Then to proceed to look for other causes, e.g. scleroderma)
260
'Rheum drugs' key side-effects: - All of them - Methotrexate (5)
All cause GI upset commonly. Mucositis, LFTs, cytopaenia, lung disease, teratogen. Need to avoid other anti-folate Rx e.g. triprim
261
'Rheum drugs' key side-effects: | Sulfasalazine (3)
Orange sweat/urine, LFTs, cytopaenia | Avoid in G6PD deficiency
262
'Rheum drugs' key side-effects: | Hydroxychloroquine (2)
Photosensitivity, retinitis | Avoid in G6PD deficiency
263
'Rheum drugs' key side-effects: | Leflunomide (4)
LFTs, neuropathy, cytopaenia, teratogen | Reverse with cholestyramine
264
DDx for demyelinating disease other than MS (4)
ADEM Devic's disease Leukodystrophies Tuberous sclerosis
265
Key features in MSA (5)
``` Cerebellar signs / ataxia Autonomic dysfunction Incontinence Hot cross bun sign on MRI Poor L-dopa response ```
266
Key features on exam for myasthenia gravis (8, 1)
``` Ptosis, worsening with sustained upgaze. Peek sign (can't keep eyes closed) Diplopia Snarling instead of smile Nasal speech Count to 50 - voice deteriorates (bulbar features) Proximal weakness, and weak neck flexion - Can compare by moving one arm for 15 seconds, then testing both sides simultaneously Thymectomy scar ``` NORMAL sensation and reflexes
267
Key features LEMS (vs myasthenia) (4)
Improves with exercise Absent reflexes Rare to have bulbar symptoms Positive anti-P/Q-calcium channel antibodies
268
MRC dyspnoea scale (5)
Breathless on: ``` 1 - strenuous exercise 2 - uphill / hurrying 3 - walking at pace on level / after 15min 4 - within 100m 5 - getting dressed / can't leave house ```
269
What virus causes Kaposi's sarcoma / multi-centric Castleman's disease
HHV-8 | Castleman's managed with rituximab and doxorubicin, +/- ART if HIV+
270
Barriers to medication adherence - 'Patient-related' (5) - Practical (3)
Psychiatric disease e.g. schiophrenia, bipolar Low mood / ambivalence about condition Low understanding / insight into condition + why on Rx Stigma about taking Rx / denial Doesn't trust doctor Finances / distance to pharmacy Regimen too complex / can't physically use (e.g. MDIs) Previous side-effects
271
Managing / improving medication adherence (1, 7)
Confirm the correct diagnosis - is the condition not improving because the right thing isn't being treated? 1. Establish partnership with patient - set a realistic and shared goal (avoid "therapeutic perfectionism") 2. Explore understanding / re-educate 3. Assess perceived and practical barriers 4. Simple / inexpensive regimen, clear written instructions 5. Set alarms / reminders, involve family 6. Strategies for managing with side-effects 7. Regular follow-up / review on how it's going
272
Key features of PSP (2)
Axial rigidity | Vertical gaze palsies
273
Mixed neuropathies (6)
'DAD RUM' ``` Diabetes - amyotrophy Alcohol Drugs (cisplatin, vincristine, phenytoin) Rheumatoid Uraemia Malignancy ```
274
Motor neuropathies DDx (5)
``` GBS Charcot-Marie Tooth Lead toxicity Porphyria Polio ```
275
Sensory neuropathy DDx (5)
``` Diabetes Alcohol B1/B12 Leprosy Renal failure ```
276
DDx / causes for pseudobulbar palsy (4)
Bilateral stroke MS MND Parkinson's
277
DDx for bulbar palsy (4)
MND GBS Myasthenia Myopathies
278
Radial nerve lesion: high vs low (i.e. injury above/below middle of humerus) (4, 1)
In high lesion: - Loss of forearm flexion and supination (brachioradialis lost) - Loss of wrist extension - Loss of MCPJ extension - Loss of thumb abduction (Whereas lower lesion only affects finger extension and thumb)
279
Corneal reflex pathway
V --> VII
280
Gag reflex pathway
IX --> X
281
Subacute Combined Degeneration of the Cord; - key findings (4) - proceed to (4)
Brisk knee jerk reflex Absent ankle reflex Upgoing plantars Posterior column sensory loss (and Romberg's positive) ``` Mucous membranes (red tongue, anaemia) Abdomen (gastrectomy scar) Pupils - tabes dorsalis in DDx Optic atrophy ```
282
Categories for proximal weakness (3)
Myopathy - see 'PACE PODS + others' NMJ disease e.g. myasthenia, Grave's Neurogenic e.g. MND, demyelinating disease
283
Wallenberg's key features (2)
Face: ipsilateral Horner's, Cerebellar signs, bulbar palsy and face/temp loss Limbs: contralateral pain/temp loss
284
Alcohol / smoking - management overview (6)
1. 'ABC' approach (ask, brief intervention, cessation support/counselling) - Categorise severity via 'CAGE' Set 'QUIT DATE' 2. Behavioural intervention e.g. AA, education, positive feedback, counselling, smoking helplines (Quitline), CAMS 3. Pharmacological interventions 4. Manage complications / side-effects 5. Screen for other harmful substances 6. Regular follow-up (GP probably)
285
Smoking cessation medications (4)
NRT - based on time of first cigarette (<1h) and amount per day (>10) Bupropion - atypical antidepressant, reduces cravings Nortriptyline - TCA Varenicline (Champix) - second line, blocks nACHrs in brain
286
HIV medication classes: integrase inhibitors
Names ending in -'gravir' e.g. dolutegravir
287
HIV medication classes: Non-nucleoside reverse transcriptase inhibitors
Names with 'vir' in the middle
288
HIV medication classes: fusion inhibitors
Enfurvitide, maraviroc
289
HIV medication classes: protease inhibutors
Names ending in -'navir'
290
HIV medication classes: nucleoside reverse transcriptase inhibitors
All other meds not covered by above 'rules'
291
Horner's syndrome - why does internal carotid artery lesion only cause ptosis/miosis (but not anhidrosis)?
Sweating fibres are carried along external carotid artery branch, so these are unaffected. Would see 'triad' if lesion is proximal to the carotid bifurcation.
292
Acronym for initial neuro inspection
'SWIFT' ``` Scars Wasting / walking aids Involuntary movements (chorea) Fasciculations Tremor ```
293
'Overview' for threatened independence (5)
Address / optimise underlying conditions Involve family / friends / community groups Optimise home e.g. OT, package of care Access to transport e.g. bus, shuttle, driving miss daisy 'Other': counselling, capacity, finances, will/EPoA, St John's alarm
294
Splenectomy: Vaccines (5)
Conjugate vaccine first (PCV13 AKA Prevenar) Then polysaccharide vaccine (PCV23 AKA Pneumovax) Meningitis vaccines - both types HiB vaccine Annual influenza
295
Secondary HTN screen (7)
``` Renal function Cortisol ECHO - coarctation Renal USS / angio Plasma metanephrines Renin-aldosterone ratio Consider sleep study ```
296
Vaccines in dialysis patients; key points (4)
Often generate lower immune / antibody response Often get double hepatitis B vaccine dose Annual flu vaccine Routine for other vaccines
297
When to perform screening for intracranial aneurysms in PCKD? (4)
FHx of PCKD + aneurysms About to have major surgery High risk occupation Being anticoagulated (Done at diagnosis, then again at 5 years once only)
298
Structures that move upward (>2cm) on neck swallow assessment (2)
Goitre Thyroglossal cyst (Due to attachment to the larynx)
299
Diabetic amyotrphy: key features (5)
An asymmetric motor polyneuropathy: ``` Proximal thigh/hip atrophy and weakness Burning nerve pain Sensory loss in thigh Absent knee jerk reflex Associated autonomic failure and weight loss ```
300
What is the significance of rheumatoid nodules if found?
Suggests seropositive / more aggressive arthritis. | Can be found on hands, sacrum, elbow, tendons, lungs and myocardium
301
Portal HTN features on USS (5)
``` Small / nodular liver Dilated portal vein Reversal of flow in portal vein Splenomegaly Recanalisation of the umbilical vein ``` (Note, on bloods, also look at platelets)
302
Causes of lipodystrophy (3)
Diabetes (inuslin injection) Anti-retroviral therapy CKD (MPGN)
303
Antibody associated with drug-induced lupus
Anti-histrone Abs
304
Expected findings on fundoscopy in diabetic eye exam (5)
``` Cataract (loss of white reflex) Blot haemorrhages Cotton wool spots Hard exudates Macular oedema ```
305
Glucose suppression test: - When to order - What to expect
In work-up for acromegaly if positive / elevated IGF-1 Oral glucose should lead to decrease in GH. This doesn't occur in acromegaly.
306
Medical management for acromegaly (4)
Somatostatin analogues (octreotide) Cabergoline Pegvisomant (GH-R antagonist) RTx
307
Order that hormones fall in hypopituitarism.
First: GH, FSH, LH Then: TSH, ACTH Last: ADH
308
If extra time in aortic regurgitation exam, proceed to look for: (4)
Arm-span High arch palate Ank spond Rheumatoid arthritis
309
HOCM vs aortic stenosis (3)
Valsalva - decreases AS, increases HOCM murmur Jerky pulse in HOCM AS radiates to carotids, HOCM to axilla
310
Long-term murmur after Tetralogy of Fallot repair
Pulmonary regurgitation
311
Causes for mixed aortic valve disease (3)
Rheumatic heart disease Bicuspid aortic valve Degenerative/age-related disease
312
Parkinson's: key prodrome symptoms (4)
Anosmia Constipation REM behaviour sleep disorder Mood / anxiety
313
Why are dopamine agonists preferred in younger Parkinson's patients? Examples Key caution
Delays use of L-dopa, thereby delaying onset of dyskinesia problems E.g. ropinirole, pramipexole Impulse control disorders, punting
314
What is the benefit of amantidine in Parkinson's treatment? (2)
Useful for mild Sx Reduces dyskinesia (Note caution in renal impairment)
315
What type of medications are used for tremor-predominant Parkinson's?
Anti-cholinergics
316
COPD-X components
``` Confirm Dx Optimise disease Prevent deterioration - e.g. smoking, imms Develop plan - action plan, MDT Manage exacerbations ```

RACP Exam (2 decks)

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