Consultation Flashcards

Question

Back pain differentials

Answer 1

-Osteoporosis with compression fracture -Cauda equina -Malignancy e.g. primary, MM, metastases -Inflammatory e.g. ankylosing spondylitis **-Infection e.g. discitis or OM** -Intervertebral disc herniation -Spinal stenosis -Intra-abdominal pathology

Answer 2

PC: Loose skin, hyper-extensible joints, VA reduced, HTN, premature CAD, CVA, MV prolapse, gastric bleed FH: 80% autosomal recessive, due to degenerative elastic fibres in skin, blood vessels and eyes OE: 'Loose skin folds at neck and axillae with yellow pseudo-xanthomatous plaques' Associated blue sclera and retinal angioid streaks DDx: EDS (no CAD, FH more apparent as is AD) (defect in collagen causing increased skin elasticity)

Answer 3

Referral to specialist within 24 hours DAPT for 21 days (load first) Followed by clopidogrel monotherapy

Answer 4

PC: Meningism, N+V, fever, rash, neurology, immunosuppressed, close contacts, foreign travel, check chance of pregnancy PMH: HTN, smoking, bleeding disorders FH: PCKD DDx: -Migrainous -Tension -Cluster -Trigeminal -Medication-overuse -Meningitis -SAH -CVST -GCA -SOL -Malignant hypertension **-Pre-eclampsia** Ix: Blood culture, CT head, LP (MC+S, glucose, protein) Mx: -Meningitis: antibiotics and treat close contacts -SAH: neurosurgical review, nimodipine to reduce vasospasm -Migraine: aspirin, NSAIDs, anti-emetics, triptans, lifestyle and preventative therapy (e.g. propranolol) -Cluster: oxygen and triptans, prevention with verapamil

Answer 5

PC: Speech, vision, Lhermitte's, mood, bladder, bowel, Uthoff's Ask about: Stroke RF, early morning headaches or nausea, vertigo, previous head or neck injury, alcohol or drug history (phenytoin), diet (B12), FH (FA, Wilson's) ## Footnote N.B. In vestibular ataxia, fast phase is AWAY from affected ear

Answer 6

PC: Ask about meat, seafood and beer, diuretics, CNIs, CKD, metabolic syndrome OE: Look for gouty tophi, HTN, history of urate stones (e.g. nephrectomy), chronic renal failure (fisulae), solid organ transplant Ix: -Uric acid levels (unreliable) -Synovial fluid needle-shaped negatively bifringent (NoNo) -Radiographic features punched out periarticular changes (PeePee) Tx: -Treat cause e.g. stop diuretic -Increase fluids -NSAIDs or colchicine or steroids Prevention: -Allopurinol or febuxostat (XOI) to get urate <300 -Losartan has a urate-lowering effect

Answer 7

OE: -Asymmetrical DIPJ deformity with Heberden's nodes (and Bouchard's at PIPs) -Diffuse atrophy of hand muscles -Crepitations, reduced movement and function -Replacement scars Ix: -XR (not needed) would show COLP (cysts, osteophytes, loss of joint space, peri-articular sclerosis) -CT/MRI may be helpful when planning surgery Tx: Weight reduction, exercise, PT/OT Oral or topical NSAIDs, intra-articular steroids Joint replacement

Answer 8

PC: Fatigue, weak, low mood, anorexia and weight loss, thirst, dark skin (raised ACTH and melanocyte stimulating hormone), fainting, cramps, bitemporal hemianopia (if pituitary adenoma) PMH: -Known Addison's -Other autoimmune disease -TB or metastases DDx: Secondary adrenal insufficiency due to pituitary adenoma or tertiary adrenal insufficiency (hypothalamic suppression of ACTH release due to sudden discontinuation of exogenous steroid therapy) Causes: -Autoimmune process (80%) -Adrenal metastases -Adrenal TB or other infection -Infiltration e.g. amyloidosis -Adrenalectomy -WF syndrome (adrenal infarction secondary to meningococcal sepsis) Ix: -8am cortisol -Short Synacthen Test (cortisol fails to rise) -ACTH level (if raised suggests primary adrenal insufficiency) -Aldosterone and renin (to look for mineralocorticoid deficiency, low aldosterone and compensatory rise in renin) and low adrenal androgens -Adrenal imaging +/- pituitary imaging with CT or MRI Other Ix: -Bloods including U+Es, glucose, adrenal autoantibodies, TFTs -CXR if concerns for malignancy or TB -L/S BP Tx: -IV saline and glucose -HC -Education on compliance, sick-day rules, steroid card, medic alert bracelet -Titrate maintenance HC and fludrocortisone to response ## Footnote N.B. Treatment may unmask DI N.B. Anti-TB treatment increases clearance of steroid so larger doses required

Answer 9

DDx: -Ischaemia, dissection, AS or pericarditis -PE, PTX or pneumonia (if pleuritic) -MSK -Oesophageal reflux or spasm (N.B. GTN can help in oesophageal spasm) -Sickle cell crisis Investigations: ECG CXR Troponin, FBC, U+Es, lipids, glucose Tx: Treatment of ACS and further investigations (Know how to manage coronary vasospasm) Mention: Risk scores DVLA

Answer 10

A to E Aspirin 300mg If STEMI: -PPCI -P2Y12 inhibitor and statin If NSTEMI: -Fondaparinux -P2Y12 inhibitor and statin -Consider Tirofiban -If any high risk features, urgent PCI -Otherwise, refer to cardiology for evaluation and risk stratification Secondary prevention

Answer 11

Causes: Viral/HIV/TB, uraemic, AI, Ca, Dressler's Ix: -Bloods -Viral screen (most common is coxsackie) -ECG: global saddle STE, PR depression, low voltage if effusion, electrical alternans (heart swinging in large effusion) -CXR: globular heart -Echo: bright pericardium, effusion, RV diastolic collapse, RWMA (if myopericarditis) -Cardiac MR: epicardium LGE suggests myopericarditis -Diagnostic pericardiocentesis Tx: -Usually self limited -NSAIDs, colchicine -Steroids in recurrent -Tamponade is a medical emergency (Beck's triad hypotension, JVP and muffled heart sounds) -Constrictive pericarditis may need surgical pericardiectomy

Answer 12

PC: OE: CV examination Thyroid status Neurological examination Ix: -12 lead, 24hr Holter, event recorder -Echo LA >4cm high recurrence -Hb, TSH, INR Paroxysmal: <7 days usually self-terminating within 4 hours Persistent: >7 days may require chemical or electrical CV Permanent: >1 year or when no further attempts to restore sinus rhythm Tx: See cardiology section

Answer 13

PC: Headache, CP, weakness, abdominal pain, polyuria and muscle cramps (Conn's), visual, paroxysmal symptoms for phaeochromocytoma (headache, sweating , palpitations, anxiety) PMH: Renal, CV and PVD CV risk factors Thyroid FH: MEN OE: -Acromegaly? Cushingoid? -RR delay (coarctation) -BP different (coarctation, dissection, PVD) -Systolic murmur in L infraclavicular (coarctation) -Renal bruits (RAS) or ballotable kidney (PCKD) -Visual fields and acuity -Fundoscopy 1) silver wiring 2) AV nipping 3) cotton wool/flame haemorrhages 4) papilloedema DDx in order of incidence: -Essential -Renal (CKD, ADPKD, RAS, nephrotic syndrome) -Endocrine (Conn's, Cushing's, acromegaly, phaeochromocytoma) -Coarctation -Pre-eclampsia -Also remember scleroderma crisis Ix: -End organ damage: fundoscopy, ECG and CXR and echo, urinalysis and PCR, U+Es Then look at underlying cause: -PT -ARR, plasma or urinary metanephrines, dexamethasone suppression test -Consider CT adrenals and US kidneys -TSH, Ca (MEN) -OSA tests Tx: -Lifestyle -Anti-hypertensives (first choice depends on if >55 or Afro-Carribean) -Other CV risk factors Tx of HTN emergency: -If encephalopathy, stroke, MI, LV failure etc.: -Venodilators (give alpha and beta blockers in phaeo) -Avoid rapid over-correction, aim for 25% in first hour SBP and the to 160/100 for next 48 hours, then slowly reduce thereafter (ACC) ## Footnote N.B. Hypertensive emergencies (LV failure, HE, or dissection) Urgencies include malignant or acclerated hypertension and pre-eclampsia

Answer 14

PC: Worsening dyspnoea, oedema, syncope, palpitations, haemoptysis, family planning Ask about hyperviscosity, paradoxical embolism OE: Loud P2, right parasternal heave, clubbing, cyanosis, scars, absent shunt murmur but TR common, signs of R heart failure DDx: ASD, VSD, AVSD, PDA Ix: FBC, BNP, ECG, CXR Lung function tests, CT-PA, echo and R heart catheter Tx: -Pulmonary vasodilator -Diuretic and oxygen -Contraception -Exercise training -Avoid extreme heat or dehydration and isometric exercise -Immunisations and prophylacic antibiotics -Heart lung transplant Correction of shunt is CI

Answer 15

-Malignancy **-Gastrointestinal conditions e.g. coeliac** -Psychiatric causes -Cachexia syndromes associated with organ failure (e.g., heart failure, chronic obstructive pulmonary disease, stage 5 chronic kidney disease) -Endocrinopathies (e.g., hyperthyroidism, diabetes mellitus, adrenal insufficiency) -Serious infections (e.g., tuberculosis, HIV) **-Medication adverse effects (GLP-1)** **-Substance misuse** -Social factors that prevent adequate access to food

Answer 16

PC: -Fatigue, SOB, CP -GI: melena or steatorrhoea, weight loss, GORD/dysphasia/NSAIDs, pain/bloating -Mensturation -FH: malignancy or anaemia -Travel history -Diet -Previous transfusions OE: -Koilonychia, glossitis, angular stomatitis, LNs, abdominal masses, tenderness and megaly -Offer to perform rectal and vaginal examinations -Look for signs HHT (telangiectasia) (AD disease with increased risk of GI bleed, epistaxis and haemoptysis, pulmonary shunts and inracranial aneurysms) DDx: MICRO -IDA e.g. chronic GI bleed, malignancy, coeliac -Anaemia of chronic disease -Inherited haemoglobinopathy e.g. thalassaemia NORMO -Acute blood loss -Haemolytic anaemia -CKD -Hypothyroidism -Bone marrow failure MACRO -Megaloblastic (i.e. B12 or folate deficiency) -Non-megaloblastic (e.g. alcohol or liver disease) Ix: -FBC, U+Es, LFTs, TFTs, iron studies, ferritin, folate, B12 -Consider Hb electrophoresis (thalassaemia and HbE) or haemolysis screen with blood film -FOB test and endoscopy or CT abdomen Tx: -Treat cause -Iron supplementation -Blood transfusion (usually if <70)

Answer 17

PC: Wheeze, SOB, cough, triggers (allergy versus URTI), previous admissions, PEFR (best, normal, current), vaccination status, compliance and technique, urticaria, calf swelling, fever DDx: PE, pneumothorax, anaemia, RTI Ix: ABG, CXR, PT-PA Tx: Bronchodilators, steroids, astha specialist nurse Life-threatening if: -PEFR <33% -Silent chest, cyanosis, altered consciousness, exhaustion, arrhythmia, hypotension, poor effort -Saturations <92% -PaO2 <8kPa -Normal CO2 Criteria for safe discharge: -PEFR >75% -Asthma mx plan and inhaler technique -Follow-up with GP/asthma nurse 2 days -Hospital follow-up

Answer 18

'Multiple, well-demarcated salmon pink scaly plaques on extensor surfaces' with 'nail pitting and onycholysis' with 'associated psoriatic arthropathy' Pathophysiology: Epidermal hyperproliferation and accumulation of inflammatory cells Types: Plaque, guttate, pustular Triggers: Trauma (Koebner phenomenon) Infection Medications (e.g. beta-blockers, lithium) Tx: -Emollients, calcipotriol (vitamin D analogue), topical steroids, coal tar, topical tacrolimus -Phototherapy -Cytotoxics e.g. MTX, anti-TNF, retinoids Complications: Erythroderma and SEs of immunosuppression

Answer 19

'Erythematous and **lichenified** patches of skin predominantly affecting the flexor aspects of joints' with 'fissures, excoriations and some evidence of secondary bacterial infection' Ix: Patch testing for allergens Tx: -Avoid precipitants -Emollients, topical steroids and **topical tacrolimus** -Anti-histamines -Consider antibioitcs -Phototherapy -Systemic immunosuppression (steroids, MTX, ciclosporin, MMF) ## Footnote N.B. Also examine respiratory system for wheeze Comment on if any signs of eczema herpeticum or bacterial infection

Answer 20

Hydrocortisone Eumovate Betnovate Clobetasol (Dermovate)

Answer 21

'Tender, red, smooth, shiny nodules on the skins' Granulomatous inflammation of subcutaneous fat (panniculitis) Screen for cause: Nodes (lymphoma) OCP Dunno (idiopathic) Other drugs (streptomycin or sulphonamides) Sarcoidosis or Streptococcal throat infection UC or Crohn's Mycobacterial (TB) or maternity Also look for lupus pernio if suspecting sarcoidosis (diffuse bluish plaque with central small papules commonly affecting the tip of the nose)

Answer 22

'Purpuric rash usually on extensor surfaces of buttocks and legs' Small-vessel vasculitis due to IgA and C3 deposition Associated arthralgia and abdominal pain Precipitants: infections (streptococci, HSV, parvovirus) or antibiotics Complications: HTN, IgA nephropathy Ix: Plts normal or raised (unlike other forms purpura) Mx: Most spontaneously recover, though steroids may help recovery Can recur

Answer 23

PC: Location, growth, recent changes, bleeding PMH: Sun exposure, occupation, FH, immunosuppression, bone pain, neurological or abdominal problems BCC: Pearly nodule with rolled edge, superficical telangiectasia, slowly growing, rarely metastasise Tx: curettage/cryotherapy if superficial or surgical excision +/- radiotherapy SCC: Keratotic nodule, polypoid mass, cutaneous ulcer, metastases Tx: surgery +/- radiotherapy MM: Asymmetrical Border irregularity Colour Diameter >6mm Enlarging Metastases Tx: excision, staged based on Breslow thickness, consider immunotherapy

Answer 24

-Pancreatitis -Renal colic, UTI -Peptic ulceration, ischaemic bowel, perforation, gastroenteritis, BO, IBD, IBS, coeliac -Hepatitis, gallstone disease -Malignancy -Pregnancy complications, PID, testicular torsion, endometriosis -AAA -DKA or Addison's or gastroparesis -Porphyria, PNH or FMF

Answer 25

'This patient has some features of Trisomy 21' Up-slanting palpebral fissures Epicanthic folds Low set ears Low nasal bridge **Brushfield spots in the iris** Single palmar crease Wide gap between 1st and 2nd toes AVSD most common

Answer 26

Sudden headache if apoplexy Visual field defects TSH: hypothyroidism GH: - ACTH: features of adrenal insufficiency Gonadothrophins: low libido, amenorrhea Prolactin: may have galactorrhoea if prolactinoma DDx: -Neoplastic (pituitary adenoma) -Vascular (apoplexy or Sheehan's) -Infiltration (sarcoid) -Infection (TB, abscess) -Iatrogenic (RTX or surgery) -Trauma Ix: -U+Es -TFTs -IGF-1 -9am cortisol and ACTH -FSH and LH **-PLT** -Paired osmolarities Imagining of pituitary Mx: Replace hormones IV hydrocortisone in apoplexy

Answer 27

PC: Frothy urine, DM, SLE, RA, medications, VTE Ix: -Urinalysis and PCR -U+Es, lipids -Autoimmune serology (PLA2R), infections (HIV, HBV, HCV) -CXR and underlying malignancy investigations -Renal tract US -Renal biopsy Mx: -Loop diuretics, fluid and Na restriction -Anticoagulation if serum albumin <20 -Treat primary cause -ACEi to reduce proteinuria -SGLT2 inhibitors in selected cases e.g. IgA nephropathy Nephrotic syndrome = hypoalbuminaemia + oedema + proteinuria (>3g/day or PCR >350) Also associated with hypercholesterolaemia, increased thrombotic risk, increased susceptibility to encapsulated bacterial infections Common causes: Primary e.g. membranous, FSGS, minimal change, IgA Secondary e.g. diabetic nephropathy, amyloidosis, SLE, RA, drugs e.g. NSAIDs, infections e.g. HIV, HCV, malignancy e.g. solid organ tumours, haematological malignancy

Answer 28

RA: RF, CCP SLE: ds-DNA, **Sm** Drug SLE: histone Sjogren's: Ro, La Myositis: Jo Mixed: RNP Limited SS: centromere Diffuse: topoisomerase Scleroderma renal: RNA polymerase III

Answer 29

PC: Constitutional symptoms (fever, WL, fatigue) Photosensitive rash (malar or discoid), oral ulceration, alopecia, Raynaud's (always ask RASHES, **HAIR AND RAYNAUD'S**), nail fold infarcts Sjogren's (sicca) Clots, miscarriage/VTE Anaemia, thyroid symptoms Mood, focal neurology Arthralgia, Jaccoud's Pleural effusion, pericarditis, Libman-Sacks, **hypertension Frothy** urine DH: Drug-induced e.g. hydralazine, procainamide, isoniazid FH Ix: -Urinalysis and BP -FBC, U+E, CRP/ESR, APTT -Autoimmune screen including ANA, ds-DNA, anti-Sm (type of ENAs), complement, aPL screen -Anti-histone if considering drug induced lupus -Consider TFTs, CK -CXR and PTFs -ECG and echo -Joint XRs -Skin or renal biopsy Diagnosis by ACR criteria DDx: -Scleroderma -Sjogren's -MCTD -RA (lupus don't get much joint swelling, RA no rashes) -Fibromyalgia -Lymphoma Tx: -Sun cream and smoking cessation -Occasionally watch and wait in mild disease -Most patients started on hydroxychloroquine -Topical steroids if severe skin disease -MTX and steroids if inflammatory arthritis -MMF or cyclophosphamide in severe renal disease -Rituximab in multi-system -Pregnancy counselling (anti-Ro heart block and IS) -If aPL consider aspirin (prophylaxis) or anticoagulation (after venous thrombosis) ## Footnote Side effects of cyclophosphamide: -Haemorrhagic cystitis or haematological -Infertility -Teratogenic N.B. aPL screen: anti-cardiolipin, lupus anticoagulant, beta2-glycoprotein

Answer 30

DDx: APLS PAN SLE Cholesterol embolisation

Answer 31

1) AI, older, basement membrane, better prognosis, tense blisters 2) AI, mucus membranes, intraepidermal, Desmoglein, Nikolsky's +ve, flaccid blisters Both treated with oral and topical steroids

Answer 32

PC: Raynaud’s phenomenon, ischaemic digital ulcers, hypertensive crisis, pulmonary arterial hypertension, ILD, oesophageal dysmotility, SIBO Also: beaked nose, microstomia, peri-oral furrowing, fibrosis, pulmonary hypertension Limited SSc: limited to face, below elbows, below knees; slow progression; CREST Diffuse SSc: widespread cutaneous and early visceral involvement; rapid progression Ix: -ANA, anti-centromere (limited), anti-topoisomerase (diffuse) and anti-RNA (renal) -FBC, B12/folate, U+Es, CK +/- myositis screen To investigate complications: -HR-CT, PFTs (aspiration, fibrosis) -Consider OGD or oesophageal manometry and hydrogen breath test -ECG, echo, right heart catheter -NCS/EMG -Urinalysis and consider renal biopsy -Hand radiographs (calcinosis) -Nailfold capillaroscopy (microvascular disease) Tx: -MDT (rheumatologists working closely with respiratory, renal, GI, psychologists, palliative at end-stage) -Gloves and CCB (ERA, PDEi, prostacyclins) for Raynaud's -ACEi for renal and AVOID HIGH DOSE STEROIDS -PPI for reflux and treatment of SIBO with antibiotics -Trials suggest anti-fibrotics and immunomodulators beneficial for ILD in context SSc -Manage pulmonary artery hypertension (ERA, PDEi, prostacyclins, LTOT)

Answer 33

Multi-system, autoimmune disease, characterised by functional and structural abnormalities of small blood vessels and fibrosis of skin and internal organs

Answer 34

DDx: Histaminergic or mast cell mediated: -Allergic angio-oedema e.g. in context of anaphylaxis (serum tryptase) Bradykinin: -Drug-induced angioedema (ACEi, non-allergic, no urticaria) -Hereditary angioedema (non-allergic) **-Acquired angioedema (no FH, non-allergic, history of SLE or lymphoma)**

Answer 35

PC: Where, food, swimming, sex, drugs, animals, insects, sick people, prophylaxis DDx: VIRAL: -Viral gastroenteritis or respiratory viruses -Arbovirus e.g. dengue -Viral haemorrhagic fevers -HIV and hepatitis BACTERIAL: -Gastroenteritis or meningitis -Leptospirosis -Enteric fever, Coxiella, brucella, rickettsia OTHER: -Malaria -Schistosomiasis and leishmaniasis Discussion with ID

Answer 36

PC: Duration, severity, bloody, watery, travel history, contacts, DH, water raw food, employment history (UKHSA if food handler) Cause: Bloody: -Campylobacter, E. coli -Entamoeba histolytica Non-bloody: -E. coli, Salmonella, Shigella, Yersinia -Norovirus, Rotavirus -Giardia, Cryptosporidium -C. difficile, Staph Aureus Ix: FBC, CRP, U+Es, blood culture Stool testing with O+P Tx: -Usually self-limiting -IV hydration, electrolytes, loperamide -Antibiotics not indicated in mild disease but can be considered based on ID advice and local guidelines -Notify UKHSA

Answer 37

-Infective -IBD -IBS -Coeliac -Thyroid disease -Malignancy -SIBO -Pancreatic insufficiency -Ischaemic colitis

Answer 38

PC: -Meningitis symptoms, focal weakness (think septic embolism), OM symptoms, tooth pain, LUTS, respiratory symptoms, GI symptoms, lymphoma symptoms, inflammatory symptoms (SLE, RA) -Fever at night think malaria, over months think IE -Contacts, vaccinations, travel, sexual history, pets, drugs -BG ACHD -FH FMF -DH malignant hyperpyrexia syndrome with antipsychotics OE: IE, hepatosplenomegaly, joints Ix: -Culture -Urine and CSF -Viral serology -PCT **-CRP, ESR, autoantibodies, Ig, complement** **-LN biopsy** -CK -TTE +/- TOE -CT-AP Further investigations guided by ID, microbiology, rheumatology or haematology teams Mx: -Investigate a treat the underlying cause -IE: 6/52 antibiotics +/- surgery -Supportive with anti-pyretics

Answer 39

-Infective sources: IE, OM or discitis, deep-seated abdominal source, TB -Malignancy -Inflammatory: SLE, RA, Still's disease -Hereditary: FMF -Drug-induced e.g. anti-psychotics

Answer 40

-Dementia/delirium/depression/**drugs** -ETOH withdrawal/ears/eyes -Low oxygen -Infection including meningoencephalitis -Retention (urine or faeces) -Ictal/in pain -Under hydration -Metabolic (hypoglycaemia, electrolytes, thyroid, uraemia) -Stroke (ischaemic or haemorrhage)/SOL

Answer 41

4AT (alert, AMT4, attention, acute change)

Answer 42

PC: Sore throat, fever, malaise, cervical lymphadenopathy, travel, sexual, employment history, social contacts Red flags: headaches, ascending weakness, jaundice (meningoencephalitis, GBS, hepatitis) Red flags for lymphoma: weight loss, painless lymphadenopathy (alcohol-induced pain), night sweats DDx: EBV, CMV, HIV, viral hepatitis, toxoplasmosis, Hodgkin's Ix: FBC and blood film, test for heterophile antibodies Consider: EBV specific antibodies/PCR, CMV PCR, HIV screen, hepatitis serology Consider: lymphoma work-up Tx: Symptomatic, avoid contact sports, avoid amoxicillin

Answer 43

PC: -Vaso-occlusive crisis: sudden-onset bone pain or pleuritc chest pain lasting days-weeks -Acute chest syndrome: pneumonia-like ilness -Anaemia may worsen after infection -Infection due to hyposplenism -Acute PE and pulmonary HTN and stoke or TIA -Also leg ulcers, gallstones and priapism -Triggers: virus, cold weather, dehydration, ETOH, smoking, stress, exercise, hypoxia, pregnancy -Family planning: **hydroxycarbamide** is teratogenic, increased risk of crisis and miscarriage, genetic counselling Ix: -Anaemia, raised inflammatory markers, renal impairment, blood film sickling -CXR linear atelectasis in chest crisis, cardiomegaly if long-standing anaemia -Urinalysis haematuria if renal involvement -ABG -ECG and echo -CT-PA To treat crisis: -Oxygen +/- CPAP, fluids, analgesia, antibiotics if infection -Consider transfusion or exchange transfusion Prevention advice: -Fluids -Warm clothes, avoid sudden temperature changes -NSAIDs or paracetamol -Hydroxycarbamide and folic acid -Consider **exchange transfusion programme** -Penicillin prophylaxis and vaccinations in functional hyposplenism -Safety-netting

Answer 44

See gastro

Answer 45

PC: Duration, travel, antibiotics, infectious contacts, foods, sexual history Fever, anorexa, weight loss, pruritis, fatigue, rash, arthralgia, ulcers, FH OE: Remember to feel for hepatosplenomegaly and ask to examine perianal DDx: Crohn's: UC, Yersinia, TB, lymphoma, IBS UC: Crohn's, infection, ischaemia, drugs, radiation, IBS

Answer 46

See jaundice section in abdomen station

Answer 47

PMH: Ca, HF, immobility, FH, previous VTE, pregnancy, OCP, IBD, nephrotic syndrome, ask about PE symptoms OE: 10cm below tibial tuberosity >3cm difference, deep calf tenderness, superficial venous engorgement and pitting oedema, tenderness along deep veins, examine abdomen and pelvis to exclude mass, examine peripheral pulses Ix: Well's D-dimer (sensitive but not specific) Compression US If DVT confirmed: PT, FBC, INR Think about underlying cause (CXR, thrombophilia screen, CT-AP, mammography, PR and PSA) Tx: DOAC 3 months or lifelong if recurrent Counsel regarding DOAC

Answer 48

PC: Pain (if arterial), location, infection PMH: DVT, chronic venous insufficiency, varicose veins, CCF, PVD, sensory neuropathy, diabetes Venous: Gaiter, varicose veins, oedema, lipodermatosclerosis, varicose eczema, atrophie blanche Arterial: Distal and at pressure points, trophic changes, cold with poor capillary refill, peripheral pulses absent Neuropathic: Pressure areas, peripheral neuropathy, Charcot's Other causes: Vasculitic, neoplastic, infectious, haematological, tropical Ix: Doppler ABPI (<0.8 arterial insufficiency) Arteriography Tx: Specialist nurse Venous: compression bandaging if no PVD, varicose vein surgery Arterial: angioplasty or vascular reconstruction or amputation

Answer 49

PC: Joints involved, pain (early morning stiffness?), function May have systemic involvement: -Pulmonary -Eyes: scleritis or Sjogren's -Neurological: CTS, peripheral neuropathy -Haematological: Felty's, anaemia -Cardiac: pericarditis -Renal: nephrotic syndrome (e.g. secondary AA amyloidosis, membranous) DDx: -Psoriatic (see below) -Enteropathic -Reactive (symmetrical) B27 -Ankylosing B27 (RA is DR4) -Crystal arthopathy -CTD: SLE (non-deforming), scleroderma -OA (worse with exercise) -Infective (disseminated gonococcal, Lyme, rheumatic fever) -Still's (largely diagnosis of exclusion) -Sarcoid OE: Symmetrical and deforming small joint polyarthropathy (particularly PIP MCP) with: -Ulnar deviation MCPJs -Subluxation at wrist -Swan-neck (PIP hyperextended fixed flexion DIP) -Boutonniere's deformity (fixed flexion PIP/hyperextended DIPs) -'Z' thumbs -Muscle wasting -May have surgical scars e.g. CTS -Nodules at elbows Ix: -Urinalysis -FBC, U+Es, CRP/ESR, LFTs -RF and anti-CCP (more specific) -XR (soft tissue swelling, loss of joint space, articular erosions, periarticular osteopenia SLAP!) -CT thorax and PFTs Diagnosis by ACR criteria (clinical, laboratory and radiographic features) DAS-28 to measure disease activity Tx: -PT/OT, counselling and support groups -NSAIDs -DMARDS (MTX, sulphasalazine, leflunamide, hydroxychloroquine) -Steroids in short-term -May require immunomodulation with anti-TNF, anti-CD20, anti-IL6 -Vaccines and infection counselling -Surgery

Answer 50

Psoriatic: -Psoriasis -Different pattern of joint involvement e.g. DIPs -Often monoarticular or oligoarticular (<5 joints) -When multiple joints involved, it lacks the symmetry of RA -Dactylitis -Enthesitis -Nail changes -Spondyloarthritis -Mostly seronegative N.B. Can also have uveitis with psoriatic and there's a link with IBD

Answer 51

PC: Blue eyes, recurrent fractures since birth, joint laxity, short stature, hearing loss FH: AD defect in collagen gene Ix: -Bone, vitamin D, ALP, PTH -Skeletal survey and DEXA -Genetics -Audiology -Echo (valve regurgitation) Mx: -MDT -Vitamin D, Ca, bisphosphonates if indicated -Orthopoedic input for fractures

Answer 52

Epistaxis Mucocutaneus telangiectasias AV malformations Autosomal dominant

Answer 53

-Mechanical: vision, footwear or home hazards -Polypharmacy, sarcopenia and deconditioning -Neurological: gait disorders e.g. PD, stroke, peripheral neuropathy, vestibular dysfunction -Cardiology: valve, arrythmias, orthostatic -Endocrine: hypoglycaemia N.B. Timed up and go test, turn 180 degrees test can be used in clinic (NICE) FRAT is helpful Drugs increasing risk of falls: sedatives, tricyclics, antipsychotics, antidepressants, opiates, some PD drugs, alpha blockers, thiazides, beta blockers, anti-anginals

Answer 54

Usher syndrome Laurence-Moon-Biedl Kearns-Sayre (CPEO and cardiac abnormalities) Refsum's

Answer 55

See cardiology section

Answer 56

PC: Chest, arthralgia, eye, EN or lupus pernio, neurology (facial palsy), CVS, weight loss, fever FH Occupational history (berryliosis can mimic) and ask about TB Ix: -Slit lamp examination eyes -FBC, U+Es, LFTs, bone profile -ECG -PFTs and CXR -Interferon gamma -Serum ACE -Consider skin biopsy and BAL Mx: -Steroids for pulmonary disease depending on symptoms and stage (otherwise observation) -Lung transpant in end-stage -For skin or eye involvement, topical or oral steroids used -Other immunouppressive agents can be considered but would be guided by specialists Lofgren's = EN, bilateral hilar LN, arthralgia and fever

Answer 57

N.B. Look for underlying cause Ix: -CK -Antibodies (ANA and myositis-specific antibodies e.g. anti-Mi-2 and anti-Jo) -EMG -Biopsy -PFTs and HRCT (ILD) -ECG and echo (cardiac involvement) -Swallow assessment DDx: Overlap myositis Mx: -MDT with neurologists, rheumatologists, respiratory, PT, SLT **-Sun cream** -Steroids or other immunosuppressive agents

Answer 58

PC: Polyuria/dipsia, preceding illness, recent increased insulin requirement or high BMs, nausea, SOB, poor compliance, ETOH and drugs Ix: Septic screen Glucose >11, bicarbonate <15/pH <7.3 and ketones >3 Raised anion gap Mx: ITU IV fluids +/- K FRII pLMWH Consider antibiotics

Answer 59

Discuss with opthalmology if visual symptoms Otherwise refer on to rheumatology who will see urgently Prednisolone 40-60mg depending on if visual symptoms

Answer 60

Hodgkin's (Reed-Sternberg): Classical Hodgkin lymphoma Nodular lymphocyte-predominant Hodgkin lymphoma ABVD NHL: Most common B cell types are diffuse large B-cell lymphoma (DLBCL) and follicular lymphoma R-CHOP ## Footnote NHL can be split into low-grade versus high grade or B cell (most common) versus T cell

Answer 61

Rare, AD disorder characterised by hamartomatous polyposis mucocutaneous pigmentation and gastrointestinal polyposis High lifetime risk of intestinal and extra-intestinal malignancy Other increased risk GI malignancy: FAP and Lynch syndrome (HNPCC) (both AD)

Answer 62

Serositis Oral ulcers/alopecia Arthralgia Photosensitivity Blood Renal ANA Immunologic inc. APL Neurological Malar rash Discoid

Answer 63

Anaemia of CD Felty's Myelosuppression Pernicious (AI disease) NSAIDS occult GIB Renal disease

Answer 64

RF or CCP or HLA DR4 positive Women

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