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Consultations Flashcards

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1
Q

Clinical findings of ankylosing spondylitis

A

Reduced mobility across spinal axis
Increased wall to tragus distance
+ve Schober’s test

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2
Q

What is a postive schober’s test?

A

Mark L5 and 2nd mark 10cm above
Ask to fully flex forwards
Increase <5cm is positive finding

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3
Q

Lung findings in ankylosing spondylitis

A

Apical, pulmonary fibrosis

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4
Q

Cardiac finding associated with ankylosing spondylitis

A

Aortic regurgitation

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5
Q

Investigations in ankylosing spondylitis

A

Bloods - FBC, Renal, Liver, ESR + CRP, HLA-B27

Radiographs of spine and pelvis - looking for sacral ileitis and fusion

If radiographs are normal, consider spine and pelvis MRI

If lung findings, CXR and lung function tests and consider HRCT

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6
Q

Lung function test findings in pulmonary fibrosis associated with ankylosing spondylitis

A

Restrictive pattern with reduced FEV1 and reduced FVC, but maintained ratio

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7
Q

How to associate between mechanical and lung restriction, and pulmonary fibrosis, secondary to ankylosing spondylitis

A

Look at transfer factor

Transfer factor will be preserved with mechanical restriction, but reduced in fibrosis due to underlying lung damage

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8
Q

Treatment of ankylosing spondylitis

A

And take a MDT approach

The medical perspective gives regular non-steroidal anti-inflammatory medications to control pain plus or minus PPI. In severe disease may want to consider immuno modulator therapies, such as TNF alpha inhibitors - infliximab. Refractory disease may need anti-Il17 therapy of JAK inhibtors

Regular physiotherapy to maintain mobility

Occupational therapy assessment to optimise home and work environments

Refer to smoking cessation as smoking increases disease activity

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9
Q

Considerations before starting anti-TNF therapy

A

Ensure patients are up-to-date with regular vaccinations

Screen for TB including chest x-ray

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9
Q

Character of back, pain in ankylosing spondylitis

A

Worse in the morning

Gets better throughout the day

Better with exercise
Response to non-steroidal anti-inflammatory medication

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9
Q

Differentials of backpain and associated questions

A

Degenerative
Traumatic
Neoplastic, ask about weight loss and loss of appetite
Infective ask about fever at night sweats
Systemic inflammatory conditions, such as psoriatic arthropathy ask about rash and inflammatory bowel disease ask about GI symptoms

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9
Q

What needs to be ruled out with back pain

A

Cauda equina syndrome

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9
Q

Examination in suspected ankylosing spondylitis

A

Check full range of spinal movements
Modified Schober’s test
Check Wall to tragus distance

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9
Q

Management of acute flare of IBD

A

Admit patient
Full set of observations
Send three stool cultures & faecal calprotectin
Bloods - FBC, CRP, Renal and liver, U&Es
Abdominal XR ?bowel loop dilatation

Treat with analgesia and IV steroids (hydocort 100mg QDS)
IV fluids +/- electrolyte replacement
Consider IV antibiotics if evidence of infection

Start VTEp as at high risk due to prothrombotic state

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9
Q

Activity monitoring score in ankylosing spondylitis

A

Bath, ankylosing, spondylitis, disease, activity, index

Out of 10, score > 4 = active disease

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9
Q

Complications requiring surgery in Crohn’s

A

Colon dilatation
Fistualting disease
Refeactory to full medical management

Surgery, more likely in current disease due to transmural disease activity

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10
Q

Management of IBD patient after discharge

A

Tapering course of steroids
Vitamin D and Ca supplementation
Ensure has Gastro plan re Disease-modifying agents (?does she need infliximab)

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11
Q

Malignancy associated with IBD

A

Particularly in patients with colitis

Patients may need surveillance colonoscopy after 10 years +/- biopsies

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12
Q

Skin rashes associated with IBD

A

Pyoderma gangrenosum
Erythema nodosum

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13
Q

Association between smoking and Crohn’s disease

A

Smokers are twice as likely to develop Crohn’s disease

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14
Q

Curative treatment of ulcerative colitis

A

Total colectomy as disease is only limited to the large colon

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15
Q

Causes of myelopathy

A

Acute:
Trauma
Vascular

Subacute:
Subacute combined degeneration of cord (most commonly B12 deficiency)

Acute on Chronic:
Relapsing-remitting - e.g. demyelination

Chronic:
Degenerative

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16
Q

How to localise a level of myelopathy

A

Check for a sensory level - expect upper motor neuron features below the level and potentially lower motor features at the level of lesion

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17
Q

Investigations in a patient with a myelopathy

A

Bloods - FBC, haematinics, ESR, consider AI screen, renal, liver, U&Es, copper studies

Urgent MRI spine

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18
Management of degenerative, cervical myelopathy
Refer to neurosurgeons for consideration of surgical intervention - urgent intervention warranted with cord compression or impingement Consider physiotherapy input timing dependent on surgical intervention Occupational therapy review to optimise home and work setting Referral to the neuro rehabilitation MDT meeting
19
Pyramidal signs in one limb with hyperaethesia to sharp touch on contralateral signs
Partial brown-sequard syndrome
20
What always needs to be done with a suspected myeloapthy
Check for sensory level
21
Timing of MRI spine in myelopathy
Urgency should be reflected characterised by timing of onset of symptoms. In patients with acute onset symptoms same day, MRI should be performed.
22
Management of metastatic cord compression
Consider radiotherapy
23
What is Kernig's sign
Neck pain on extension of the knees due to meningeal inflammation
24
Types of meningitis
Bacterial viral, fungal, protozoal, lyme Also, can consider paraneoplastic or malignant
25
Management of suspected meningitis
Admit patient Bloods, inc. FBC, CRP, Renal, U&Es, Liver, Clotting, glucose and lactate CT Head Perfrom fundoscopy & otoscopy Lumbar Puncture - cell count, culture, protein, paired glucose + lactate, viral studies Start broad-spectrum IV antibiotics and antiviral Give IV fluids and complete sepsis 6 bundle
26
LP findings in bacterial versus viral meningitis
Bacterial - raised WBC - neutrophilia - Raised protein - Low glucose - +ve gram stain Viral - Raised WBC - lymphocytes - Serum:CSF glucose ratio should be normal
27
Complications of meningitis
Death Neuro: Deafness and blindness Cognitive impairment Vascular: Amputations 2o sepsis syndrome
28
Headache DDx
Infective: R/o meningitis Could be associated with viral illness Abscess Neoplastic: SOL Vascular: Subarachnoid haemorrhage Venous sinus thrombosis Tension type headache Migraine
29
Management of migraine
Prophylaxis - lifestyle adjustments, healthy diet and exercise - Consider prophylactic agents if recurrent - e.g. propranolol - consider patients individually Acute treatment - Simple analgesia - paracetamol / NSAIDs - If early, consider triptans
30
High risk features in history of patient presenting with headache
Check for immunosuppression previous HIV infection Exposure to others with meningitis Positive travel history
31
Migrainous, headaches, unilateral or bilateral
Unilateral
32
Typical migrainous, headaches features
Preceded by aura Unilateral Throbbing nature Disabling for patient Associated with nausea and photophobia 30% may have associated focal neurological deficit
33
Preciptants associated with migrainous headaches
Stress Fatigue and sleep deprivation Chocolate and red wine
34
Red flag features for headache
Age, more than 50 years Limb weakness, or abnormal neurological features Confusion Woken from sleep Worse with exertion, position, coughing or sneezing (raised ICP)
35
Issue with performing LP with raised ICP
Risk of brainstem herniation through foramen magnum
36
Screening test acromegaly
Insulin like growth factor one Following this do glucose tolerance test and there should be failure to suppress growth hormone
37
Screening test for obstructive sleep apnoea
Consider overnight sleep studies and overnight pulse oxymetry
38
Imaging test in acromegaly
MRI head, looking for pituitary involvement
39
Organs affected in acromegaly
Multisystem disease Cardiomyopathy & IHD HTN & T2DM Visual impairment
40
Visual disturbance in acromegaly
Typically, bitemporal hemianopia secondary to compression of the optic chiasm, due to pituitary adenoma
41
Treatment of acromegaly
First line is curative transphenoidal surgery Medical therapy with somatostatin analogues, such as ocreotide. Second line agents include bromocriptine If failure of above can consider radiotherapy of pituitary
42
Main complication of transphenoidal surgery in acromegaly
Panhypopituitarism
43
Why is acromegaly associated with obstructive sleep apnoea?
Secondary to soft tissue swelling in the face and neck, resulting in mechanical respiratory obstruction when lying flat
44
Sleepiness score in OSA
Epworth sleepiness scale Out of 24, a score of more than 11 may indicate OSA
45
Why does OSA lead to daytime somnolence?
Respiratory obstruction results in desaturation and compensatory tachycardia this results in the patient waking up frequently throughout the night, leading to restless sleep and subsequent daytime somnolence
46
Main treatment of OSA
CPAP
47
Main features to examine in acromegaly
Assessment of visual system, including cranial nerves 3, 4 and six Examine hands, including Phalen's test for carpal tunnel syndrome Assess for Proximal myopathy Assess for prominent browline, lips, jaw and tongue
48
Kidney transplant scar name
Rutherford Morrison
49
Bony complication associated with steroid use
Avascular necrosis typically of the hip
50
Investigation to assess for failing, renal transplant graft
Urinalysis looking for haematuria and proteinuria Blood is particularly looking at renal function and urea and electrolytes Tacrolimus level US duplex looking at vascular flow If really concerned about acute rejection, could consider a renal biopsy
51
Weight loss in context of immunosuppression
Think malignancy - post-transplant lymphoma or skin malignancy Also rule out chronic infection
52
53
Blue discolouration of eye and recurrent fractures
Osteogenesis imperfecta
54
Investigation’s osteogenesis imperfecta
Bloods - Bone, Vit D, PTH Genetic testing Radiographs of bones DEXA Echo
55
Tx osteogenesis imperfecta
Replace electrolytes as required Consider bisphosphinates dependent on DEXA OT/PT review ?walking aids ?orthotics
56
Cardiac complication associated with osteogenesis imperfecta
Bicuspid aortic valve Can lead to AR over time due to a lack of valve collagen
57
Inheritance osteogenesis imperfecta
Auto dominant 8 variants
58
Bony complications of bisphosphonates
A vascular necrosis of jaw
59
Non bony complications of osteogenesis imperfecta
Translucent teeth Hearing impairment Bicuspid AV
60
Complications of Ehlers Danlos syndrome
Joint deformity secondary to hypermobility CVS - MV prolapse or regurgitation, AR Vascular aneurysm Ophthalmology- risk of glaucoma and retinal issues
61
Treatment for Ehlers Danlos
Largely supportive Ot pt Analgesia for joint issues Address complications as they arise
62
Genetics of Ehlers Danlos
Mixed Can be autosomal dominant or recessive Can also be caused by de novo mutations Resulting in defective collagen synthesis
63
Initial is for suspected haem malignancy with neck mass and splenomegaly
Bloods - Fbc, blood film, u & electrolytes, monospot ? Infectious mononucleosis Ando USS to characterise splenomegaly Ct CAP ?primary ?lymphadenopathy LN biopsy PET scan
64
Young patient with neck lump and splenomegaly ddx
Infection ?infectious mononucleosis Haematological- lymphoma, leukaemia
65
Difference between FNA and biopsy
Biopsy gives histology and cytology FNA cytology only
66
Granuloma on biopsy
Ddx are TB (caseating) vs Sarcoidosis
67
Ix suspected Sarcoidosis After histology shows granuloma
CXR ?bilateral hilar lymphadenopathy Check Ca and serum ACE Lung function tests
68
Stroke like symptoms in young female patient, what should you always ask?
Any pregnancy Hx? Any miscarriage? Risk of anti-phospholipid syndrome Are they on OCP?
69
Ix suspected TIA
Bloods - FBC, Renal, Liver, Clotting, AI screen - ANA, dsDNA, complement, anti-cardiolipin & antiphospholipud Abs ECG & request 24hr ECG ?pAF Echo, can consider bubble ?PFO Carotid Doppler MRI Brain - same day
70
Management post TIA
Secondary prevention Start regular clopidogrel Manage BP, blood glucose, cholesterol (aim to reduce non-HDL cholesterol by >40%) Healthy lifestyle - exercise, diet, stop smoking, reduce EtOH Advise unable to drive for at least 1 month
71
Treatment of antiphospholipid syndrome
Anticoagulation Warfarin recommended over DOAC But to be discussed with haematology & refer to local guidance
72
Cause of stroke or TIA in young patient
Anti-phospholipidsyndrome Carotid/vertebral artery dissection secondary to trauma Vasculitis Substance abuse - Cocaine / amphetamines Rarer - mitochondrial disorders - MELAS
73
Stroke in young afro-carribean patient
Think of sickle cell disease
74
Patient with lung transplant presenting with progressive breathlessness - what to think about?
Immunocomprised - ?PJP ?CMV ?fungal Chronic rejection of lung - this give an obstructive picture on LFTs, in keeping with bronchiolitis obliterans
75
Anticoagulation duration in provoked, pulmonary embolism
Three months
76
Pleuritic chest pain & haemopytisis DDx
PE Pneumothorax Infection
77
Features of the pericarditis chest pain
Worse on lying down and relieved by leaning forward
78
What risk or can we used to Stratified patients with Venous thromboembolic disease.
Wells score
79
When use V/Q scan over CTPA
Pregnant patients Renal impairement cannot tolerate contrast
80
Stroke complications
Thromboembolic disease 2o immobilisation Further stroke - haemorrhagic or ischameic Risk of raised ICP 2o swelling Seizures Dysphagia - need swallow assessment Spasticity - input from OT/PT +/- anti-spastic medications Urinary/fecal incontinence
81
2o prevention stroke
Antiplatelets - Clopi following high dose aspirin for 2 weeks High dose statin therapy Control RFs - HTN / Glycaemic control / stop smoking / improve diet and exercise
82
Retinitis pigmentosa findings
bone spicule pigmentation of retina
83
Bilateral progressive visual loss DDx
Glaucoma Cataracts Diabetic Retinopathy Vit A deficiency Macula degeneration Pipilloedema 2o IIH Retinitis Pigmentosa
84
Management of Retinitis Pigmentosa
Confirm diagnosis via Opthalmology Genetic counselling Supportive therapy - visual aids
85
Inheritance of retinitis pigmentosa
AD / AR / X-linked 30% de novo
86
Syndromes associated with retinitis pigmentosa
Multiple syndromes Inc. Ushers & Kearns-Sayers
87
Retinitis Pigmentosa & Driving
Need to inform DVLA - strict guidelines on visual acuity and visual field loss
88
Joint pain following infection
Reactive arthritis
89
Sti leading to reactive arthritis
Chlamydia
90
Arthritis caused by gonococcal infection
Typically septic arthritis
91
Treatment of reactive arthritis
Supportive Analgesia Maintain mobility possibly with PT input Treat underlying cause - eg infection / abx
92
Genetic association with reactive arthritis
Associated with HLA B27 Seronegative spondyloarthropathies Associated with psoriatic / enteric / reactive arthritis and ank spond
93
Organisms causing reactive arthritis
Chlamydia Salmonella Campylobacter
94
Bloods to send in suspected reactive arthritis
Fbc crp lft renal urate RF esr anti-ccp
95
What is hashimotos thyroiditis
Most common cause hypothyroidism Due to lymphocytic infiltration, subsequent inflammation and fibrosis of thyroid gland
96
Antibodies for Hasimotos
Anti tpo Anti thyroglobulin
97
Diseases associated with hashimotos
Autoimmune conditions Vitiligo Addisons disease
98
De quervains thyroiditis
Period of hyperthyroidism due to thyroid follicle destruction followed by hypothyroidism when thyroid regenerates. Then back to euthyroid.
99
Symptoms and signs of hypothyroidism
Lethargy Muscle weakness Cold intolerance Weight gain Low mood
100
What is myxoedema
Periorbital oedema Thick waxy skin Brittle hair
101
Hypothyroidism DDx
Hashimotos De quervains Drugs - carbimazole / propylthiouracial / Li / interferons Radiodine therapy
102
Hypothyroidism DDx
Hashimotos De quervains Drugs - carbimazole / propylthiouracial / Li / interferons Radiodine therapy
103
Screening test for Addisons disease
9am cortisol
104
Starting dose of levothyroxine
25-75ug Lower in elderly Titrate to TFTs
105
Complications associated with prolonged use of Steroids
Development of cushingoid appearance Increase risk of IHD Diabetes Thin skin & easy bruising Adrenal failure
106
Triggers of myasthenic crisis
Infection Stress e.g. operation Withdrawal of steroids / immunosuppression
107
Patient with suspected MG what do we need to check
Resp function - spirometry and serial FVC
108
Pathophysiology of MG
Post-synaptic destruction of ACh receptors
109
DDx ocular myasthenia gravis
Thyroid ocular myopathy Cranial nerve / brainstem weakness Myotonic dystrophy
110
DDx generalised myasthenia
Generalised fatigued 2o anaemia MND Botulism (involves pupillary muscle) Lambert-Eaton Syndrome - a/w SCLC
111
Antibody in Lambert-Eaton
Voltage-gated Ca channel antibodies
112
MG with bulbar symptoms - Ix
MRI brain
113
What needs to be checked prior to commencing azathioprine
TPMT levels
114
Why does spina bifida predisopse to recurrent UTI
Neuropathic bladder results in structural changes that increase likelihood of infection
115
Conditions associated with spina bifida
Limb spasticity Hydrocephalus (requiring VP shunt) Arnold-Chiari malformation Bladder and bowel dysfunction
116
What is a spina bifida?
Part of the neural tube does not develop or close properly, leading to defects in the spinal cord and bones of the spine
117
RFs for spina bifida
1. Folate deficiency - folic acid supplementation during conception and pregnancy 2. FHx neural tube defects 3. Drugs - sodium valproate / methotrexate 4. Poorly controlled DM
118
Treatment of bladder dysfunction in spina bifida
Regular bladder catheterisation Anti-muscarinic drugs
119
Treatment of pyelonephrosis
Emergency - nephrostomy
120
Why are L sided murmurs louder on expiration?
Increased venous return to L side of heart
121
Peripheral signs of infective endocarditis
Splinter haemorrhages Janeway lesions Osler Nodes Roth spots - Retinal emboli Murmurs Haematuria on dip stick Evidence of peripheral septic emboli
122
What is coarctation of the aorta?
Congential narrowing - typically distal to L subclavian artery
123
Clinical signs of coarctation
Radio-radial & radio-femoral delay systolic murmur, loudest posteriorly
124
Complications of aortic coarctation
Stroke HF Aortic rupture
125
Management of coarctation
Balloon angioplasty and stenting Open resection and anastomosis - preferred
126
blue-grey discolouration of the eye ball
Scleromalacia
127
Anaemia secondary to rheumatoid arthritis
Anaemia of chronic disease Iron-deficiency anaemia (secondary to peptic ulceration due to chronic NSAID use) BM suppression secondary to DMARDs AI haemolytic anaemia
128
Management of Rheumatoid Arthritis
MDT PT - maintain mobility OT - adapt home and work environments Rheum - DMARDS - methotrexate / sulphasalazine - if fail 2 therapies consider biologics - rituximab / tociluzimab
129
Describe hand changes in RA
Symmetrical deforming poluyarthropathy
130
Genetic association with RA
HLA-DR4
131
Disease activity score in RA
DAS-28 Score >5.1 = active disease Score <2.6 = remission
132
Extra-articular features of RA
EYES Episcleritis - painless Scleritis - painful LUNGS Pulmonary fibrosis / nodules / effusion KIDNEY Nephrotic syndromes
133
Extra renal manifestation ADPKD
Liver cysts Berry aneurysms Mv prolapse
134
Loin pain APCKD
Cyst enlargement rupture or haemorrhage Renal stone Infection
135
Complications of immunosuppression
Direct - tremor, htn, diabetes Infection Malignancy
136
Med to slow progression of ADPKD
Tolvaptan
137
Types of muscular dystrophy
Duchenne / Becker - severe weakness expected in childhood Facioscapulohumeral Limb girdle Orophayngeal Myotonic
138
Ix suspected muscular dystrophy
Complete neuro exams Bloods inc CK Nerve conduction and EMG Muscle biopsy Genetic testing
139
Management of muscular dystrophy
No disease modifying therapies Supportive OT / PT SLT
140
Features of Parkinsonian gait
Stooped posture Reduced arm swing Shuffling Difficult turning Festination
141
Distraction technique to exacerbate Parkinsonism
Synkinesis
142
Causes of Parkinsonism
Idiopathic Parkinson’s disease Parkinson’s plus syndrome Vascular Parkinsonism Lewy body dementia Medication induced Meds induced - Antipsychotics - Haloperidol
143
Pathophysiology of PD
Destruction of dopaminergic neurones in the substantia nigra
144
Eye complication of Marfans
Ectopia Lentis

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