Medical and Surgical shorts Flashcards
(110 cards)
1
Q
Sign of active inflammation in rheumatoid arthritis?
A
Hot swollen painful joints
2
Q
Presentation of rheumatoid hands
A
Symmetrical polyarthritis +/- signs of active synovitis +/- signs of cause (nodules, psoriatic plaques)
3
Q
Findings on systemic examination in rheumatoid arthritis
A
Skin - steroid use BP/pulse - increased CVD risk Eyes - anaemia, scleritis Heart - pericardial rub Lungs - pulmonary fibrosis, pleural rub Abdomen - splenomegaly (Felty’s)
4
Q
X-ray features of rheumatoid arthritis
A
Loss of joint space Periarticular erosions Deformity Periarticular osteopenia
5
Q
Mx of rheumatoid arthritis
A
Conservative: PT OT - aids + splints Medical: - Analgesia - Steroids: IM, PO, periarticular - DMARDS: Methotrexate - Biologics –> treat CVD risk!! Surgical: - Carpal tunnel decompression - Joint replacement - Tendon repairs
6
Q
Extra-articular features of rheumatoid arthritis
A
Nodules Carpal tunnel Scleritis Pericarditis Pulmonary fibrosis Splenomegaly (Felty’s)
7
Q
What should be monitored in pts receiving methotrexate?
A
FBC (BM suppression) LFTs (hepatotoxicity) CXR (fibrosis)
8
Q
Name some biologics used to treat Rheumatoid arthritis? what needs to be done for patients first?
A
Require tuberculin skin test + CXR Anti-TNF + rituximab (anti-CD20)
9
Q
What is Rheumatoid factor? what is its significance
A
anti-IgG IgM Higher titres assoc. w more severe disease + extra-articular manifestations
10
Q
C-spine problem seen in RA?
A
Atlanto-axial subluxation: occurs due to weak ligaments - Can cause progressive spastic paresis due to cord compression - Pre-op: main risk is during intubation
11
Q
Facial features of scleroderma
A
Microstomia Beaked nose Telangiectasia
12
Q
Diffuse vs limited scleroderma
A
Limited: distribution in limbs + face. progresses over years. Diffuse; early visceral involvement. Progresses over months
13
Q
Ix in scleroderma
A
- Urine dip: haematuria, proteinuria - ECG: RV strain (st depression + t wave inversion) - Bloods: FBC, U+Es, !!antibodies!! - Imaging: CXR, HRCT, echo (pulm HTN) - Lung function - Barium swallow
14
Q
Mx of scleroderma
A
Raynaud’s: Gloves + hand warmers +/-nifedipine Oesophageal dysmotility: SALT review + PPI for reflux Renal: aggressive BP control pulmonary HTN: sildenafil
15
Q
Mixed CTD?
A
RA SLE Scleroderma polymyositis Sjogrens
16
Q
Mx of chronic limb iscehmia
A
Conservative: RF optimisation (= HTN/DM control, smoking cessation, diet + exercise) Medical: RF control: statin, clopidogrel Analgesia Surgical: Stenting Bypass surgery Amputation :(
17
Q
Critical limb ischemia features
A
Pain Pallor Pulseless Parasthesia Perishingly cold Paralysis
18
Q
Causes of medical 3rd nerve palsy
A
- DM - MS - Midbrain infarction: Contralateral hemiplegia - Migraine
19
Q
Ddx for surgical 3rd nerve palsy
A
***PCA aneurysm!!!! Cavernous sinus thrombosis Trauma Raised ICP: transtentorial herniation
20
Q
initial mx of hip fracture
A
ABC: resus Analgesia Assess neurovascular status of limb IMAGING - orthogonal views Prep for theatre: Anaesthetist - inform + book for theatre Bloods - FBC, clotting, G+S, Xmatch, U+E CXR DVT prophylaxis ECG
21
Q
Indications for amputation
A
Dead: PVD Sepsis Trauma Burns Frostbite
22
Q
Complications of amputation
A
Early: Bleeding, infection (cellulitis, gangrene, osteomyelitis), DVT specific: MI/stroke/angina Late: Phantom limb pain Contractures
23
Q
Definition of varicose veins
A
Dilated + tortuous superficial veins
24
Q
Causes of varicose veins
A
Prolonged standing Obesity OCP Pregnancy secondary: DVT, pelvic mass, AVM
25
Sx of varicose veins
Heaviness Tingling Cramping Pain Bleeding Oedema
26
NICE guidelines re management of varicose veins
Conservative: Compression stockings Compression bandages for ulcers Reduce time spent standing Weight loss Surgical: Laser ablation of superficial veins (refer if CEAP4a or more)
27
NICE guidelines re management of varicose veins
Conservative: Reduce time spent standing Weight loss Grade 2 Compression stockings Compression bandages for ulcers Medical: analgesia + piriton (pruritus) Surgical: 1) Laser ablation 2) sclerotherapy 3) ligation + stripping (refer if CEAP4a or more)
28
Complications of varicose veins
Chronic venous insufficiency Ulcers Thrombophlebitis --\> infected thrombophlebitis DVT
29
investigations in suspected testicular tumour
Markers: AFP, LDH, hCG Scrotal USS CT TAP
//////////////////////////////////////////
all tumours produce LDH
Seminoma produce PLAP (Placental ALP)
Teratoma produce AFP.
30
Mx of testicular cancer
inguinal orchidectomy histology of biopsy chemo/radiotherapy - Bleomycin, etoposide, cisplatin
31
staging of testicular tumours
1) confined to testes 2) LNs below the diaphragm 3) LNs above and below the diaphragm 4) extra-lymphatic spread (lungs, liver)
32
Common skin rash in Coeliac disease - what does it look like? Fx? name?
Dermatitis herpetiformis Blistering + itchy on EXTENSOR surfaces
33
Commonest cause of erythema multiforme
HSV
34
Causes of erythema multiforme
HSV Mycoplasma SLE Drugs: allopurinol, penicillin, NSAIDs Sarcoid Malignancy
35
causes of acanthosis nigricans
Endo--\> increased weight: DM, Cushings PCOS acromegaly OCP GI cancer
36
Pemphigus vs pemphigoid
Blisters are superficial in pemphigus(flaccid), deep in pemphigoid (tense)
37
Features of hypocalcemia
SPASMODIC Spasms: Trousseau's sign (BP cuff) Paraesthesia Anxious Seizures Muscle tone increased = Hypertonia Orientation impaired = Confusion Dermatitis (atopic) Impetigo Chovstek's sign (tapping CN7), Cardiomyopathy
38
CAUSES of hypocalcemia
Commonest = CKD!! Raised PO4: CKD, hypoPTH Low PO4: active pancreatitis, osteomalacia
39
Mx of mild hypocalcemia
oral Ca QDS PO
40
Fx of hypercalcemia
Bones, Stones, Moans, Groans Bone pain + pathological #s Renal stones + nephrogenic DI Depression Abdominal pain + constipation
41
Causes of hypercalcemia
HyperPTH (or PTHrP in paraneoplastic) Normal PTH: Myeloma(normal ALP), bone mets (high ALP) or sarcoid
42
Ix in hypercalcemia
PTH phosphate FBC, CXR, protein electrophoresis, bone scan
43
Mx of hypercalcemia
FLUIDS 0.9% saline
44
Special mx of hypercalcemia of malignancy
Bisophosphonates
45
Psoriasis - describe the skin leasions
well defined salmon-pink plaques On extensor surfaces + behind ears + scalp + sites of trauma (Koebner phenomenon)
46
Nail changes in psoriasis
Pitting Onycholysis Sublingual hyperkeratosis
47
Why might some psoriatic plaques be brown
Application of coal tar treatment
48
Causes of onycholysis
Psoriasis Fungal infection Trauma HypERthyroidism
49
Causes of nail pitting
Psoriasis Fungal infection Lichen planus
50
Psoriasis - Sx? triggers?
Itch + arthritis Triggers: stress, SMOKING, EtOH, b-blockers, injury
51
Subtypes of psoriasis
Guttate = drop-like lesions on trunk, commoner in children after strep infection Pustular Psoriatic arthritis: asymmetric olygoarthritis (mimics RA)
52
Mx of psoriasis
MDT: GP, dermatologist Conservative: avoid triggers (EtOH, stress, smoking) Topical: Emollients (epaderm, diprobase) Steroid cream Coal tar Phototherapy: Narrow band UVB Systemic: Ciclosporin, retnoids, methotrexate
53
3 Skin features of dermatitis
LIchenification Excoriations Painful fissures
54
Differential for dermatitis
Atopic eczema Contact dermatitis - just hands Discoid Seborrhoea dermatitis
55
Diff btw seborrheic dermatitis and psoriasis
Scales!! Psoriasis = thick and silvery seborrheic dermatitis = thin + white
56
proper name for dandruff
seborrheic dermatitis Dandruff is a milder form, without associated inflammation (red skin)
57
Mx of dermatitis
MDT + avoid triggers Topical steroids + emollients + soap subs + antihistamines + Abx for secondary infection Phototherapy If severe --\> systemic steroids or cyclosporin
58
Cutaneous manifestations of DM - on hands? on abdomen? on shins? on feet?
Hands: - Cheiroarthropathy (prayer sign) - Granuloma Annulare Abdomen: - Lipodystrophy (injection site) Shins: - Necrobiosis lipoidica Feet: - Charcot joint - Ulcers
59
What are charcot joints? what does it look like?
Neuropathic osteoarthropathy Progressive damage to weight bearing joint + bone due to lack of sensation Loss of medial arch + Rocker bottom deformity
60
Skin - SqCC Appearance? Pre-malignant forms?
Ulcerated + everted edge Sun-exposed sites Actinic keratoses: crusty lesion Bowens: red/brown scaly plaque
61
Evolution of SqCC
Actinic keratoses --\> bowens --\> SqCC
62
Warty stuck-on appearance
Seborrheic keratoses
63
RFs for SqCC
Sun exposure immunosuppression
64
RFs for malignant melanoma
Sun exposure Low Fitzpatrick skin type High # of common moles FH Age Immunosuppression
65
Staging of malignant melanoma
Breslow thickness
66
Neurofibromatosis - features on examination
Skin: -Neurofibromas - gelatinous nodules - Cafe au last spots \>=6 - Axillary freckling Neuro: - Lisch nodules = posts on iris - Peripheral neuropathy
67
Neurofibromatosis - complications? Types?
NF1 and NF2. Both are autosomal dominant. NF1 is more common. Complications: Epilepsy Learning difficulty Scoliosis Sarcomatous change of neurofibromas
68
Differential for cafe au lait spots
NF TS McCune Albright syndrome - precocious puberty
69
Cutaneous features of Tuberous Sclerosis
Ash leaf macule Shagreen patch = leathery skin over sacrum Facial adenoma sebaceum = pink/yellow papules on face (oil producing glands)
70
Tuberous sclerosis - noncutaneous problems
Neuro: epilepsy, LD Cystic kidneys --\> Renal transplant Dense white patches on retina
71
Hereditary Haemorrhagic telangiectasia - what is it?
Autosomal dominant condition Multiple telangiectasia due to AVMs - in lungs, liver, brain, skin
72
HHT - on examination? Differentials?
O/E: telangiectasia on face, lips, buccal mucosa --\> cyanosis from pulmonary AVMs Ddx: CREST, CLD
73
Complications of HHT
HAEMORRHAGE - epistaxis, GI bleed, haemoptysis, SAH High output cardiac failure
74
Peutz Jeghers - features?
Hyper pigmented macules on face/oral mucosa/palms + soles!! GI hamartamous polyps
75
Complications of Peutz Jeghers
- CRC - Bleeding from polyps - Pancreatic endocrine tumours
76
Ddx for erythema multiforme
Tinea Discoid eczema Erythema marginatum Erythema migrans (Lyme, trunk distribution)
77
Causes of erythema multiforme (give 4 drugs)
HSV Mycoplasma Drugs: trimethoprim, NSAIDs, penicillin, phenytoin
78
Severe erythema multiform? Mx?
Steven Johnsons syndrome Mx: dexamethasone, IVIG
79
Causes of erythema nodosum - give 7
Systemic disease: IBD, Sarcoid, Behcets Infection: TB STREP Drugs: OCP trimethoprim
80
Skin manifestations of sarcoid
Erythema nodosum Lupus pernio = brown plaques, esp on nose Red/brown nodules and papule
81
Key points to present in ?rheumatoid hands
Symmetrical deforming polyarthropathy - signs of active synovitis (hot, swollen painful joints) - signs of a cause: rheumatoid nodules, psoriatic plaques
82
Systemic features of RA
Rheumatoid nodules Carpal tunnel Episcleritis/scleritis pericarditis (rub) Pulmonary fibrosis Splenomegaly
83
Mx of RA
Conservative: PT, OT, splints Medical: DMARDs - methotrexate Analgesia Steroids Gastric protection + bone protection Surgical: Carpal tunnel decompression Tendon repair and transfers Ulna sylectmy Arthroplasty
84
4 Diff DMARDs used to treat RA + their side effects
Methotrexate - BM suppression + pulmonary fibrosis + hepatotoxic Sulfasalazine - BM suppression + skin rashes + hepatotoxic + SPERM count Hydroxychloroquine - RETINOPATHY Penicillamine - LUPUS, nephrotic syndrome
85
Significance of seronegative RA?
Less severe disease Less likely to have extra-articular features
86
If DMARDs fail in treating RA, what is used next? And what are the cautions taken when treating in this way?
Biologics - anti-TNF (Infliximab, etanercept) and B-cell depleters (rituximab) Risk of opportunistic TB infection (do tuberculin skin test) Risk of viral reactivation (HepB, PML)
87
Apart from RA, other diseases where RhF is common
Sjogrens = 100% SLE
88
American College of RHeu Criteria for RA
4/7 of: - Morning stiffness \>1h - 3+ joints involved - Hand involvement - Rheumatoid nodules - +ve RhF - SYMETRICAL - XR changes
89
Abs in SLE
ANA (100%) Anti-dsDNA anticardiolipin and lupus anticoagulatn
90
Mx of SLE
MILD disease: topical steroids + sun cream + hydroxycloroquine MODERATE disease(organ involvement) - Pred + AZT Severe (AIHA/CNS/pericarditis) - Cyclophosphamide - High dose methylpred
91
Specific examination test for ANk SPon
Schooner's test \<5 cm
92
Ank spon - findings on back examination
Inspection: - Thoracic kyphosis - Neck hyperextension Mvmt: Reduced ROM throughout spine Test: Schober's test \<5cm (from PSIS to 10cm above)
93
Tests for sacroilitis
Pain on palpation Pain on adduction of the hip, with the knee and hip flexed
94
Extra-articular features of Ankylosing Spondylitis
Anterior Uveitis (small pupil --\> irregular) Apical pulmonary fibrosis Aortic regurgitation Achilles tendonitis Psoriatic plaques
95
Sx of Ank Spon? Ix?
Morning stiffness Back pain relieved by movement Eye pain SOB Ix: ECG - AV block is common! Bloods: FBC, ESR, CRP, HLAB27 Imaging: spine XR - sacroileitis, bamboo spine CXR - fibrosis DEXA scan
96
Mx of Ank Spon
Conservative: Physio, exercise Medical: NSAIDs Steroid injection Anti-TNF if severe Surgery: ?hip replacement
97
Findings O/E of Marfan's
Tall + long arm span Hands: long fingers, hyper extensible PULSE: radioradial delay (coarctation), collapsing pulse (AR) Face: High arched palate, Lens dislocation Chest: Deformity, AR
98
Cause of Marfans syndrome
Autosomal dominant inheritance Fibrillin protein
99
Goitre + hypothyroidism
Hashimoto's thyroiditis
100
Hands in Acromegaly
Spade like Tight rings Increased skin fold thickness ?thenar wasting if carpal tunnel
101
Features of acromegaly
Hands: spade like, rings are tight Face: prognathism, prominent supraorbital ridges, large ears + nose, widely spaced teeth HTN Bitemporal hemianopia + headaches Acanthosis Nigerians Organomegaly Carpal Tunnel syndrome OSA
102
Ix in ?Acromegaly
OGTT Urine dip: glucose BP: raised ECG: LVH CXR: cardiomegaly AbdoUSS: organomegaly Bloods: raised IGF, other pit hormones (bitemp hemianopia) - prolactin, TFTs, glucose
103
Mx of acromegaly 1st line? 2nd line?
1st line: SURGICAL - transphenoidal excision of pituitary 2nd line: Medical: OCTREOTIDE - ss analogue
104
F/U in acromegaly
Bloods: GH Visual fields ECG MRI head
105
Side effects of steroids
Hands: thin skin, bruising Arms: Proximal myopathy, HTN Face: cataracts, glaucoma, psychosis Trunk: DM, central adiposity, osteoporosis, DM Infections Suppression of ACTH --\> need steroids for surgery and infection
106
Considerations in patients taking steroids
- Do not suddenly stop or reduce steroid dose - Use lowest possible dose - Increase dose if infection/surgery - Consider bone and gastro protection - Carry alert bracelet
107
MOA of CBZ and PTU? of radio iodine?
CBZ + PTU - block T4 synthesis Radioiodine - blocks T4 --\> T3
108
Technetium scan of thyroid : low uptake? high uptake?
Low uptake = hashimoto's high uptake = graves multiple hot and cold nodule = TMN
109
Sarcoidosis: features
Erythema nodosum + arthralgia = acute sarcoidosis - Lupus pernio (raised, hard purpley skin on face) - LNopathy - Hepatosplenomegaly - Enlarged parotids - Cardiomyopathy - Hypercalcemia - BHL + pulmonary fibrosis
110
Causes of glomerulonephritis?
- Clue: "VALID MD"
- Vasculitis (Eg Wegener's granulomatosis)
- Amyloidosis
- Lupus
- Infection (Hep B, strep, malaria)
- Diabetes
- Malignancy
- Drug toxicity
