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Gen med/station 5 Flashcards

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1
Q

What are some causes of palmar erythema?

A

Cirrhosis
Hyperthyroidism
Pregnancy
Rheumatoid arthritis
Polycythaemia

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2
Q

What are some causes of gynaecomastia?

A

Physiological, with puberty and old age
Klinefelter’s
Cirrhosis
Drugs eg spironolactone and digoxin
Testicular tumour
Thyroid disease
Addisons

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3
Q

What does pulsatile hepatomegaly indicate?

A

tricuspid regurgitation and ccf

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4
Q

What are the red flag/differential questions you should cover in a history of someone presenting with chest pain?

A

Type of pain - ?crushing/sharp
Any pain at rest
Associated symptoms eg breathlessness, nausea
Any recent infection
Radiation of pain -?arm/back
Haemoptysis
Recent immobilisation
History of trauma
Rashes - chest wall herpes zoster

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5
Q

What are important differentials to consider in someone presenting with chest pain?

A

ACS
PE
MSK pain
Pericarditis
Aortic dissection
GI cause
Pneumonia

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6
Q

What are the red flag/differentiating questions you should cover in a history of someone presenting with palpitations?

A

Any chest pain
Any LOC/dizziness/lightheadedness
Any SOB#
Exercise tolerance
Cardiac risk factors and family history
Thyroid symptoms
Pheo questions = sweating/headache/blood pressure

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7
Q

What are important differentials to consider in someone presenting with palpitations?

A

Ectopics/physiological
Cardiac arrhythmia
Structural heart disease
Phaeochromocytoma
Psychosomatic
Medications and recreational drugs
Systemic causes eg hyperthyroid, hypoglycaemia

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8
Q

What are the red flag/differentiating questions you should cover in a history of someone presenting with joint pain?

A

Which joints involved/always the same?
History of trauma
Timing of pain
Impact on function
Fever/night sweats/weight loss/fatigue
Rashes
Nail changes
Cold fingers
Visual disturbance
Dry eyes/dry mouth
Ulcers
Hair loss
Miscarriages
CVS symptoms
resp symptoms
GI/GU symptoms

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9
Q

What are some important differentials to consider in a patient presenting with joint pain?

A

Arthritis - osteo/inflammatory
Autoimmune eg SLE
Systemic sclerosis
Crystal arthropathy
Enteropathic arthritis
Infection
Reactive arthritis

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10
Q

What are some important questions to ask in a history of fever in a returning traveller?

A

Places visited and accommodation used
Dates of departure/arrival and dates of symptom onset
Animal contact
Activities while away
Food and drink
Sexual contact
Systems reviews inc. bleeding
Vaccines/malaria prophylaxis

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11
Q

What are some differentiating/red flag questions to ask in a history of a patient presenting with jaundice?

A

Abdo pain
Urine and faeces colour
Weight loss
Prodromal viral symptoms
Travel history
Abdo swelling
Confusion
Bleeding
Vaccination status
Sexual history
Alcohol and recreational drug use
Symptoms of diabetes
Weight/diet

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12
Q

What are some important differentials to consider in a patient presenting with jaundice?

A

Hepatic - cirrhosis/alcoholic liver disease/viral/drug induced liver injury
Malignancy
Hepatobiliary
Wilson’s
BBV/infection
Haemolysis

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13
Q

What are some important differentials to consider in a patient presenting with a history of diarrhoea?

A

Infective diarrhoea
IBD
Malabsorption and Coeliac disease
Hyperthyroidism
Medications
Overflow
Malignancy
Bacterial overgrowth
Result of surgery

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14
Q

What are some important differentials to consider in a patient presenting with weight loss?

A

Malignancy
Non malignant GI disease eg IBD, coeliac, infection, achalasia
Psychiatric disorders eg anxiety/ depression
Endocrine causes eg diabetes, addison’s, hyperthyroidism
Infections
Neurological causes eg MND, parkinson’s
Drug induced
Chronic vigorous exercise

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15
Q

What are some important questions to ask of a patient presenting with a history of haemoptysis?

A

Confirm is haemoptysis and not haematemesis
?melaena
Quantify and clarify
Any other bleeding inc from gums, nose
CVS and resp symptoms inc SOB/chest pain/wheezeleg swelling
Fever/night sweats/swelling
Weight loss/anorexia/malaise
Rashes and joint pain
Family history
Recreational drug use
Occupational history

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16
Q

What are some important differentials to consider in someone presenting with haemoptysis?

A

Malignancy
Infective inc bronchitis, pneumonia, TB
Cardiac inc heart failure
PE
Pulmonary AVM
Inflammatory/rheumatic cause inc anti-GBM, GPA, SLE
Coagulopathy

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17
Q

What are some important differentials to consider in a patient presenting with collapse?

A

Syncope - neurally mediated/cardiac/orthostatic
Seizure
Metabolic disorders inc addisons, hypoglycaemia
Intracranial haemorrhage
Intoxication
Haemorrhage inc ectopic pregnancy

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18
Q

What are the features of Kartagener’s syndrome?

A

Ciliary dyskinesia
Situs inversus
Sinusitis
Infertility

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19
Q

What are some differential diagnoses for leg ulcers?

A

Venous
Arterial
Neuropathic
Vasculitic
Diabetic
Infection
Neoplasia
Traumatic
Pyoderma gangrenosum
Calciphylaxis

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20
Q

What examinations should be considered for a station 5 patient presenting with a leg ulcer?

A

General inspection of patient and leg
Count toes and look for scars
Look at ulcer shape/colour/depth/size and location
Feel for temperature and cap refill and peripheral pulses
Neurological check for sensation
quick CVS exam
Consider depending on history:
Abdo/lymph nodes/rest of skin/joints

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21
Q

What conditions are associated with pyoderma gangrenosum?

A

IBD
Rheumatoid arthritis
Seronegative arthritis
Myeloproliferative disorders
Hep C
Autoimmune hepatitis
up to 50% are idiopathic

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22
Q

What are some important differentiating questions to ask of a person presenting with deterioration in vision?

A

Worse at any particular time of day
Painful or painless
One or both eyes
Intermittent or constant
Is colour vision affected

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23
Q

Which drugs can be toxic to the optic nerve?

A

Ethambutol
Amiodarone
Alcohol
Methotrexate
Ciclosporin

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24
Q

What are some common causes of a pale optic disc?

A

Demyelination and optic neuritis
Ischaemic optic neuropathy
Compression eg due to tumour/glaucoma/pagets
Chronic glaucoma
Retinal disease

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25
What is the chromosomal abnormality seen in klinefelters?
Extra x chromosome - 47XXY
26
What are the clinical features seen in Kleinfelter's syndrome?
Gynaecomastia Absent body hair Testicular atrophy Infertility May be mild intellectual disability Tall stature
27
How is klinefelter's managed?
MDT approach included psychologist, geneticist, endocrinologist Testosterone injections to help prevent side effects of low testosterone
28
What are some causes of hair loss?
Localised, non-scarring: Alopecia areata Tinea capitis Trichotillomania Traction Diffuse, non-scarring: Androgenetic Drugs Chemo Thyroid dysfunction Malnutrition Secondary syphillis Scarring: Discoid lupus Lichen planus Tinea capitis
29
What are some features of retinitis pigmentosa?
Impaired night vision and adaptation to dark/light Associated with heart/hearing//balance/kidney/liver problems
30
How is retinitis pigmentosa investigated?
Visual acuity assessment Visual fields testing Retinal photography Colour vision testing Genetic testing OCT ECG and hearing test
31
What causes acromegaly?
Growth hormone overproduction, usually pituitay. Can get ectopic excess GHRH from non-pituitary malignancies. Familial cases familial isolated pituitary adenoma, AIP gene. Growth hormone stimulates IGF-1.
32
SYMPTOMS of acromegaly
Headaches Visual field loss Large tongue Dental changes Facial changes Sweating Skin tags Arthralgia Carpal tunnel
33
Associations of acromegaly
Carpal tunnel Colonic polyps OSA T2DM Hypertension Cardiomyopathy Prolactinoma Hypopituitarism Nodular goitre, thyroid cancer
34
Examination for acromegaly
Hands-enlargement, carpal tunnel release scars/thenar wasting, Tinels/Phalens, finger pricks (T2DM) Pulse, BP Facial features, ask for old pics, hirsutism, tongue, dental spacing Visual fields Neck-JVP, thyroid Axillae - acanthosis nigricans Skin tags
35
Investigation of acromegaly
IFG-1 level to screen in suspected cases, then OGTT to see if GH level supresses. Other pituitary hormones-prolactin, ACTH, FSH, LH, TSH. Blood glucose, HbA1C Bone profile MRI pituitary fossa. ECG, ECHO
36
Management of acromegaly
Trans-sphenoidal surgery Somatostatin analogues eg ocreotide, lanreotide. Dopamine agonsits eg bromocriptine, cabergoline Pegvisomant (genetically modified analogue of GH, antagonises GH receptor)
37
What should be examined if gout is suspected?
"All joints"- for station 5 do all affected joints and hands and feet. Redness, tenderness, swelling. Can get chronic stiffness due to erosion in recurrent disease. Comment on tophi-usually extensor surfaces elbow, knee, achilles tendon as well as helix of ear and dorsum of hands and feet.
38
What are the diagnostic criteria for gout?
Monosodium urate crystals in joint aspirate or from tophus, or 6 of: -More than 1 attack of acute arthritis -Inflammation peaks within 1 day -Monoarthritis with redness -1st MTP joint -Tophi -High urate -Asymmetrical swelling on xray -Subcortical cysts without erosions on x ray -Culture negative during attack
39
What are the investigations for gout?
Serum urate - >360 micromol/L (may be normal in acute attack so repeat 2-4 weeks after resolution). Joint aspiration- needle shaped negatively birefringent crystals X-ray (Also U and E for renal function, CRP, FBC etc)
40
What would be common differentials for gout?
Bursitis Haemochromatosis Pseudogout (other crystal athropathies) OA RA Psoriatic arthritis Septic arthritis Trauma
41
Management of acute gout
NSAID at maximum dose (PPI) Colchicine 3-5 days of oral steroid with PPI (off license) Can use paracetamol as an adjunct.
42
Management of chronic gout
Long term urate lowering therapy - allopurinol/febuxostat. 2-4 weeks after flare has settled. Monthly urate levels to adjust dose. Do not cease during subsequent flares. Diet and alcohol advice Cardiovascualr risk screening Refer to rheumatology if diagnosis uncertain, treatment ineffective or not tolerated, CDK 3b+
43
What are some common causes of reactive arthritis?
Chlamydia thrachomatis, chlamydia pneumoniae, shigella, Neisseria gonnorrhoeae
44
What is the typical presentation of reactive arthritis?
2-4 weeks post GI or GU infection. Asymmetrical oligoarthritis. Often lower back pain Triad of urethritis, conjunctivitis and arthritis.
45
What are the typical investigation findings in a reactive arthritis?
Raised ESR, raised CRP High white cells and platelets HLA-B27 positivity High white cells in joint aspirate Screen for causitive organisms - STI, urine culture, BBV screen X-ray usually normal in the acute phase
46
What is the management of reactive arthritis?
Rest affected joints NSAIDs Steroid injections Steroids if unresponsive to NSAIDs Physio Rheumatology referral for consideration of DMARDS
47
In which conditions may ANA be raised?
SLE RA Polymyositis/dermatomyositis Systemic sclerosis
48
Which antibodies are screened in an ENA panel?
Anti-Ro Anti-La Anti-Sm Anti-RNP anti-Jo anti-scl70 Anti-centromere
49
What are anti-Ro and anti-La associated with?
SLE, Sjogren's
50
What is anti-Sm associated with?
SLE
51
What is anti-RNP associated with?
SLE, systemic sclerosis, mixed connective tissue disease
52
What is anti-Jo associated with?
Polymyositis, dermatomyositis
53
What is anti-Scl70 associated with?
Systemic sclerosis
54
What is anti-centromere associated with?
CREST syndrome (systemic sclerosis)
55
What are some causes of primary hypothyroidism?
Autoimmune, eg primary atrophic ( common) and hasimotos thyroiditis (causes goitre. Often after initial period of hyperthyroidism. High titres of autoantibodies Iodine deficiency Post-thyroidectomy Drug-induced
56
What autoimmune conditions are often associated with hypothyroidism?
Vitiligo Addison's Type 1 diabetes Pernicous anaemia
57
What are some common extra-articular features of rheumatiod arthritis?
Eyes - Sjogren's, scleritis, episcleritis Felty syndrome (RA, neutropenia, splenomegaly) Nodules Atlanto-axial subluxation Polyneuropathy, mononeuritis multiplex Lung - nodules, ILD, obliterative bronchiolitis CVS - cardiovascular disease, pericardial, valvulitis Renal - amyloid
58
What conditions are associated with hypothyroidism?
Down syndrome Turner's syndrome Cystic fibrosis Primary biliary cirrhosis Vitiligo Addison's T1DM Pernicious anaemia
59
What are the specific rheumatological tests for RA?
Rheumatiod factor (60-70%) Anti-CCP
60
What are some signs found on physical examination that indicate Grave's disease is the cause of hyperthyroidism?
Graves eye disease and exophthalmos Pretibial myxoedema Clubbing and thyroid acropachy
61
What are the causes of hyperthyroidism?
Graves disease - autoimmune (assoc with T1DM, vitiligo, addisons) Toxic multinodular goitre - usually needs radioiodine +/- surgery due to size of goitre Toxic adenoma Malignancy with ectopic thyroid tissue Subacute thyroiditis, usually post viral with painful goitre Drugs eg amiodarone
62
How should you examine a patient for signs of sarcoidosis?
Thoroughly examine skin looking for rashes, plaques or nodules. Check old scars or tattoos for granulomatous infiltration. Check shins for erythema nodosum Check eyes for redness Examine painful joints if present Neck for lymphadenopathy Abdomen for hepato/splenomegaly Focal neurological exam if symptoms, esp cranial nerve palsies Chest - signs of heart failure Lungs for ?crackles indicating fibrosis
63
How should a person with suspected sarcoidosis be investigated?
Biopsy showing non-caseating granulomas diagnostic CXR Bloods inc FBC, U+Es, LFTs, bone profile (high calcium) ACE levels Lung function tests ECG
64
How is the severity of pulmonary sarcoidosis staged?
According to CXR findings 0 = normal 1= bilateral hilar lymphadenopathy 2 = bilateral hilar lymphadenopathy and peripheral pulmonary infiltrates 3 = peripheral pulmonary infiltrates alone 4 = pulmonary fibrosis/bullae formation/pleural involvement
65
How is sarcoidosis managed?
If bilateral hilar lymphadenopathy alone, usually don't need treatment and will resolve spontaneously but 50% will need systemic therapy Mainstay is oral steroids Steroid sparing agents eg MTX, azathioprine Anti TNF MABs eg infliximab if other options not suitable
66
What is the difference between raynaud's disease and raynaud's phenomenon?
The disease is idiopathic. Phenomenon is when there is an underlying cause
67
In which conditions may Raynaud's phenomenon be seen?
Connective tissue disease eg SLE, systemic sclerosis, rheumatoid arthritis, dermatomyositis, polymyositis Occupational use of vibrating tools Hypothyroidism Atheroma Thoracic outlet obstruction Thrombocytosis Polycythaemia rubra vera Use of beta blockers
68
What is the inheritance pattern of osler-weber-rendu/hereditary telangiectasia?
Autosomal dominant
69
What are the main features of hereditary telangiectasia?
Skin and mucous membrane telangiectasia, leading to epistaxis and GI bleeds. Associated with pulmonary, hepatic and cerebral AVMs
70
What is the classical triad seen in wernicke's encephalopathy?
Ophthalmoplegia, ataxia and confusion
71
How do you examine for hypermobility?
Beighton Score: little finger hyperextension (1 point per side) thumb to wrist (1 point per side) passive hyperextension of the elbow beyond 10 degrees (1 point per side) passive hyperextension od the knee beyond 10 degrees (1 point per side) Hands touch the floor when forward folded.
72
What is the typical pattern of pain and stiffness seen in ankylosing spondylitis?
Gradual onset lower back pain, with stiffness worse in morning, relieved by exercise Pain radiates from sacroiliac joints to spine/buttocks and usually gets better towards the end of the day
73
Causes of joint hypermobility
Hypermobility Spectrum Disorder (previously known as joint hypermobility syndrome) Ehlers–Danlos syndrome Marfan syndrome Osteogenesis Imperfecta Stickler syndrome
74
What are some extra-skeletal features of ankylosing spondylitis?
Enthesitis, esp. achilles tendonitis and plantar fasciitis Costochondritis Iritis Aortic valve incompetence Pulmonary apical fibrosis
75
How is ankylosing spondylitis managed?
Exercise, ideally with specialist physiotherapist NSAIDs TNF alpha blockers eg etanercept in severe disease if NSAIDs not effective
76
What are some syndromes associated with retinitis pigmentosa?
Ushers syndrome - RP and sensorineural deafness Alport's syndrome - RP and nephrotic syndrome Kearns sayre mitochondrial syndrome - RP, ophthalmoplegia, ataxia, dysphagia and cardiac conduction defects bardet-Biedl syndrome - RP, hypogonadism, developmental delay, obesity
77
What is the genetic basis for Marfan's syndrome?
Mutations in the gene encoding fibrillin 1 (elastin matrix glycoprotein)
78
Features of Marfan's syndrome
CVS- aortic root dilatation/rupture/aortic dissection, aortic regurgitation, mitral prolapse, AAA, arrhythmias Lung- pneumothorax Eyes - lens disolocation, cataracts MSK - arachnodactyly, hypermobility, pectus excavatum, kypohoscoliosis
79
Investigations in Marfan's syndrome
Annual echo, monitoring aortic root width CMR/CT to image whole aorta, every 5 years
80
What are some presenting features of lupus (SLE)?
Non specific - fatigue, malaise, fever, lymphadenopathy, weight loss, rash MSK - arthralgia, early morning stiffness, non-erosive arthritis, Reynaud's Neurological - headaches, neuropathy, seizures, meningitis, anxiety, depression, psychosis Chest - pleuritic chest pain, fibrosing alveolitis, bronchiolitis obliterans, PE, pericarditis, Libman-Sacks endocarditis, hypertension Renal - glomerulonephritis Skin-malar rash which is photosensitive, discoid lupus Haematological - AIHA, thrombocytopenia APL - VTE, miscarriage
81
What are the initial investigations for suspected SLE?
Bloods - FBC, ESR, PV, ANA Urinalysis - protein/blood If anaemia - coombs test, retics, LDH, haptoglobin Serology - ANA + in 95% Anti-DS-DNA, low complement and anti-Sm quite specific, anti-Ro/La and anti-RNP less specific Antiphospholipid - lupus anticoagulant, anti-cardiolipin, anti-beta-2 glycoprotein Then imaging/biopsy as required for suspected organ involvement
82
How does polymyositis present?
Inflammatory myopathy affecting proximal muscles - difficulty standing from a chair or raising arms. Pharyngeal weakness causing dysphagia. On examination, muscular atrophy, weakness and normal reflexes and sensation.
83
How is polymyositis investigated?
High CK Anti-Jo-1 in 20%, myositis specific antibody, myositis associated antibody EMG Muscle biopsy
84
How does dermatomyositis present?
Proximal muscle weakness, muscle pain and tenderness Rash - blue-purpl discolouration of upper eyelids Systemic - fever, arthralgia, malaise, weight loss Cardiac - arrhythmias, dilated cardiomyopathy ILD
85
How is dermatomyositis investigated?
CK ANA, Anti-Mi-2 EMG Muscle biopsy
86
What conditions are assocaited with polymyositis and dermatomyositis?
Autoimmune - Myasthenia gravis, hashimotos, systemic sclerosis Waldenstroms Malignancy - ovarian, lung, breast, pancreas (dermatomyositis), haematological (polymyositis)
87
How are polymyositis and dermatomyositis treated?
Early initiation of steroids, high dose then tapering, usually need at least 3 months, then azathioprine if disease not controlled
88
What tumours are common in MEN1?
Parathyroid Pancreas Pituitary
89
What is the inheritance of MEN1?
Autosomal dominant (but tumour supressor so needs second hit) Mutation of Menin (TSG)
90
What tumours are common in MEN2?
Medullary thyroid cancer Phaeochromocytoma
91
What is the genetic basis of MEN2?
RET-proto-oncogene mutation
92
What causes hyperparathyroidism?
Primary - adenoma, hyperplasia Secondary- low vit D, renal failure Tertiary - inappropriately high PTH in chronic renal disease due to parathyroid hyperplasia Paraneoplastic - SCC lung, breast, renal
93
What are the blood tests in primary hyperparathyroidism?
High PTH, high Ca, low phopshate, high ALP
94
What are the blood tests in secondary hyperparathyroidism?
High PTH, low Ca
95
What are the blood tests in tertiary hyperparathyroidism?
Inappropriately high PTH, high Ca
96
What are the indications for surgery in primary hyperparathyroidism?
High Ca, bone disease, renal calculi, deteriorating renal function
97
What is the pathology in Paget's disease?
Increased bone resorption (osteoclast activity) leading to increased bone creation (osteoblast activity), new bone is weaker and prone to pathological fracture. Some times hereditary.
98
What are the symptoms of Paget's disease?
Bone pain, fracture, deformity, compression neuropathy, deafness.
99
What are the complications of Paget's disease?
Hypercalcaemia, hydrocephalus, high output cardiac failure, paraplegia, osteosarcoma.
100
What are the investigations for Paget's?
Raised ALP, sometimes high Ca, rest of bone profile normal. X rays - osteolysis, osteosclerosis.

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