Short clinical consultations Flashcards

Question

Ddx of the inherited ataxias?

Answer 1

Spinocerebellar ataxia (trinucleotide repeat disorder) Friedreich's ataxia Ataxia-telangiectasia Ataxia with oculomotor apraxia type 1 Ataxia with oculomotor apraxia type 2 (all autosomal recessive)

Answer 2

Using the Curacao criteria: if 3 criteria are present then the diagnosis is definite. If 2 present, diagnosis is possible. 1. Epistaxis that is spontaneous + recurrent 2. Multiple mucocutaneous telangiectasia 3. Visceral lesions: GI / hepatic / lung / cerebral AVMs 4. FH in 1st degree relative with genetic testing to confirm diagnosis

Answer 3

Patient presenting with recurrent nosebleeds and / or anaemia. Telangiectasis on face, lips and buccal mucosa. Vascular dysplasia which causes telangiectasia. Autosomal dominant inheritance. Vascular malformations: pulmonary shunts and IC aneurysms which cause SAH. Increased risk of GI bleed, epistaxis and haemoptysis.

Answer 4

Graves' disease (most common) Thyroiditis of any cause (de Quervain's, radiation, post-partum, drug-related) Toxic multinodular goitre Toxic adenoma Ectopic secretion Excess levothyroxine replacement Hashimoto's: period of hyperthyroidism before hypo

Answer 5

Thyroid function tests: T3/4 Autoantibodies: Thyroid peroxidase (TPO) Thyroglobulin TSH-receptor antibodies

Answer 6

Overactive thyroid gland - too much thyroid hormone which causes bodily functions to speed up. If thyroid is overactive, treat with a medication (carbimazole) to reduce level of thyroid hormone. Should start to work within 2 weeks, most people take it for 1-2 years. 50% chance of cure, 50% chance of relapse. Warn about smoking cessation and agranulocytosis. Other options: - Radioactive iodine: kills thyroid cells, 90% of people respond. Can worsen eye disease, can't have kids for 6mo, can't hold children / pets after - Surgery: 90% chance of cure. Risks of nerve damage, low calcium, need thyroid replacement for life

Answer 7

Medical: - Carbimazole / PTU - Propranolol for symptoms - Radioactive iodine Surgical: - Thyroidectomy

Answer 8

Bedside: ECG (AF) Bloods: TFTs, thyroid autoantibodies, FBC, UE, CRP, pregnancy test Imaging: USS thyroid, radioactive iodine uptake scan, echo (high output CCF)

Answer 9

Autoimmune: Hashimoto's + atrophic hypothyroidism Iatrogenic: post-thyroidectomy, iodine, amiodarone, lithium, anti-thyroid drugs Iodine deficiency: dietary Genetic: Pendred's syndrome (+ deafness)

Answer 10

Bedside: ECG (rule out pericardial effusion and ischaemia) Bloods: TSH, T4, autoantibodies, short SynACTHen test to exclude Addison's Imaging: CXR (pericardial effusion and CCF)

Answer 11

Cardiac: pericardial effusion, CCF Neuro: carpal tunnel syndrome, proximal myopathy, ataxia

Answer 12

Thyroxine titrated to TSH suppression + clinical response. NB: can precipitate angina and unmask Addison's disease leading to adrenal crisis.

Answer 13

Tiredness: - what do you mean by tiredness? physical / mental / both? - timing: sudden / gradual / intermittent / progressing / stable? Thyroid questions: - weight gain, poor memory, low mood, hoarse voice, dry skin, hair loss, feeling cold, constipation, angina, muscle weakness, oedema, SOB, neck swelling Other causes of tiredness qu's: - malignancy: weight loss / night sweats, bleeding - heart failure - COPD - renal (CKD) - neuro (myasthenia) - endocrine (Addison's, Cushing's, diabetes) - infection (TB, HIV) - mental health, anxiety, depression PMH: thyroid disorders + treatment, other AI conditions FH: thyroid + AI conditions DH: amiodarone, lithium, carbimazole, interferon alpha SH: impact on life, smoking / alcohol / illicit drug use

Answer 14

This patient has a peripheral symmetrical deforming polyarthropathy. The presence / absence of nodules suggests seropositive / negative RA. Hand function was preserved / restricted by deformity and weakness. There were / was no evidence of extra-articular manifestations: no CT syndrome, no ocular, cardiovascular, pulmonary, GI or neurological involvement

Answer 15

Eyes: scleritis / episcleritis / scleromalacia / keratoconjunctivitis sicca Lungs: lung nodules, pulmonary fibrosis, MTX-related pulmonary fibrosis Heart: constrictive pericarditis, pericardial effusions Kidneys: nephrotic syndrome, membraneous GN, renal amyloidosis Neuro: peripheral neuropathies, carpal tunnel syndrome Spleen: splenomegaly + RA + neutropaenia (Felty's)

Answer 16

'SALP' Soft tissue swelling Articular erosions Loss of joint space Periarticular osteopenia

Answer 17

Anaemia of chronic disease IDA from chronic NSAID use Bone marrow suppression - DMARD use Autoimmune haemolytic anaemia Splenomegaly + RA + neutropaenia (Felty's)

Answer 18

Bedside: peak flow, obs, history Bloods: FBC (multifactorial anaemia), CRP/ESR (biomarker of inflammation) Autoantibodies: rheumatoid factor (positive in 70%), anti-CCP antibodies Imaging: hand and feet XRs, CXR if suspecting fibrosis (+/- HRCT)

Answer 19

Mainstay of medical management rests on early use of DMARD. Methotrexate - 1st line. If contraindicated: leflunomide, sulfasalazine, hydroxychloroquine. If patients fail to respond to 2 DMARDS OR if they have poor prognostic markers, then biologics to be added. - TNF alpha (adalimumab) - anti-CD20 (rituximab) - T cell blocker (abatacept) Steroids are advised as short-term bridging therapy when switching to DMARD. Surgical options: arthroplasty, arthrodesis + synovectomy.

Answer 20

Any of the seronegative spondyloarthropathies: - psoriatic arthritis - ankylosing spondylitis - reactive arthritis - enteropathic arthritis

Answer 21

RA has a strong association with HLA-DR4.

Answer 22

A patient has RA if they have 3 or more of the American College of Rheumatology Criteria: - Morning stiffness >1h - Swelling of 3 or more joints - Swelling of PIP, MCP, wrist joints - Symmetrical joint swelling - Rheumatoid nodules - Presence of IgM rheumatoid factor - Radiographic erosions / periarticular osteopenia

Answer 23

Objective tools such as DAS28 (disease activity score), based on an assessment of: - no. of tender joints - no of swollen joints - global pain score - ESR/CRP DAS28 score >5.1 = active disease score <2.6 = remission

Answer 24

Symmetrical deforming polyarthropathy, typically affecting MCPJs and PIPs Presence of rheumatoid nodules at elbows

Answer 25

Palmar subluxation + ulnar drift of MCP Swan-neck deformity: rupture of lateral slip of extensor in finger Boutonniere: rupture of central slip in finger Z-shape deformity of thumbs Swelling + subluxation of ulnar styloid Carpal tunnel scar, wasting of intrinsic muscles of the hands + pain, swelling, stiffness of affected joints

Answer 26

The '3 P's': provocation, prodrome, postural - if all 3 present then likely benign cause and can continue driving. Solitary syncope with no clear cause: 6 month ban Clear cause that has been treated: 4 week ban Recurrent seizures: must be fit-free for 1 year

Answer 27

Cardiac: brady/tachy, obstructive cardiac lesion (AS, MS, HOCM or PE) Neuro: epilepsy, vertebrobasilar insufficiency Orthostatic: postural hypotension (+ medication history) Vasovagal: stress, cough, micturition, defecation

Answer 28

Bedside: ECG, tilt-table test if orthostatic hypotension suspected, L/S BP Bloods: FBC, UE, LFT, CRP/ESR, TFTs, morning cortisol Imaging: echo (structural heart defects / valves), EEG, CT/MR brain Special: Holter monitor, loop recorder, EP study, exercise tolerance test

Answer 29

Dependant on cause. Cardiac: pacemaker, ICD, revascularisation / valve surgery Vasovagal: education on avoidance, isotonic muscle contraction Orthostatic hypotension: salt / water replacement, support stockings, medication review, fludrocortisone / midodrine, SSRIs Neuro: anti-epileptics

Answer 30

Paroxysmal: <7 days, self-terminating Persistent: >7 days, requires chemical or electrical cardioversion Permanent: >1 year / no further attempts to restore sinus rhythm

Answer 31

Confirmation of AF (12-lead ECG or 24h Holter) Echo: for structural heart disease, LVH, LA size (>4cm, recurrence is high) TFTs

Answer 32

Ideally, rate control: beta-blockers, digoxin, pacemaker, AV node ablation If rhythm control is warranted, either chemical or electrical cardioversion: - If severe / unstable heart failure, amiodarone - If hypertension / LVH / CAD / HF, sotalol - If no structural heart disease, flecainide Pulmonary vein isolation: saved for refractory, symptomatic patients Anticoagulation: with warfarin or NOAC Need to predict embolic risk using the CHADSVASc score NB: patients hgh risk for bleeding + embolic complications should be considered for left atrial appendage occlusion to isolate the commonest source of thrombus in AF

Answer 33

Used to predict systemic embolus risk in AF. Cardiac failure = 1 HTN = 1 Age >75 = 2 Diabetes = 1 Stroke / TIA / embolus = 2 Vascular disease = 1 Age 65 - 74 =1 Female = 1 0 - low stroke risk, no anticoagulation 1 - medium, pt preference 2 - high risk, oral anticoagulation recommended

Answer 34

HASBLED or ORBIT score. HASBLED: - HTN = 1 - abnormal kidney / liver function = 1 for each - stroke = 1 - bleeding = 1 - labile INR = 1 - elderly = 1 - drugs (NSAIDs / alcohol) = 1 for each 3 or above - high risk, avoid oral anticoagulation

Answer 35

Grade 1: silver wiring Grade 2: silver wiring + AV nipping Grade 3: silver wiring + AV nipping + CWS + flame haemorrhages Grade 4: silver wiring + AVN + CWS + flame haemorrhages + papilloedema

Answer 36

Evidence of end-organ damage: - fundoscopy - LVH on ECG - U+Es (renal impairment) - CXR (heart failure) - echo (heart failure) Exclude underlying cause: - pregnancy test - urinalysis / ACR (blood and protein) - U+Es - renin / aldosterone levels, plasma metanephrines

Answer 37

Essential: 94% - associated with age / obesity / salt / alcohol Renal: 4% - underlying CKD Endocrine: 1% - Conn's, Cushing's, acromegaly, phaeochromocytoma Aortic coarctation Pre-eclampsia (pregnancy)

Answer 38

Blurring of disc margins / elevation of disc / venous engorgement Causes: raised ICP, SOL, IIH, CVST, malignant hypertension, CRVO (presents with normal visual acuity but tunnel vision, bilaterally)

Answer 39

A medical emergency. Treatment: - Grade III + IV retinopathy + hypertension: bed rest, long-acting CCB, BP monitoring, gradual drop in BP - If have encephalopathy / stroke / MI / LV failure: IV vasodilators + invasive BP monitoring. Over-rapid correction can lead to watershed stroke.

Answer 40

The autoimmune polyglandular syndromes (type 2) Autoimmune thyroid disease T1DM

Answer 41

Primary and secondary. Primary: - problem with adrenal glands causing decreased cortisol production - 80% Addison's disease - CAH, HIV, TB, adrenal adenomas Secondary: - due to impairment of pituitary gland to produce ACTH - most common reason is exogenous steroid use - could also be due to pituitary adenoma, hypothalamic tumour

Answer 42

Lack of feedback inhibition by cortisol, leading to increased ACTH and increase melanocyte-stimulating hormone (and therefore increased pigmentation). In 80% of cases, due to an autoimmune process. Other causes = adrenal mass, adrenal TB, amyloidosis, adrenalectomy and Waterhouse-Freidrichsen syndrome (meningococcal sepsis + adrenal infarction).

Answer 43

8am cortisol: no morning elevation suggests Addison's (unreliable) Short SynACTHen test: excludes Addison's if cortisol rises to adequate levels Long SynACTHen test: diagnose Addison's if cortisol does not rise to adequate levels Adrenal imaging (in primary AD) and / or pituitary imaging (in secondary AD) with MR/CT Bloods: decreased sodium, raised potassium, increased urea (dehydration), hypoglycaemia, adrenal autoantibodies, TFTs and eosinophilia CXR: malignancy or TB

Answer 44

Acute (adrenal crisis) - 0.9% saline rehydration IV + glucose - Hydrocortisone IV 100mg 6 hourly - Treatment may unmask diabetes insipidus - Anti-TB treatment increases clearance of steroid, so higher doses needed Chronic: - Patient education: increase steroid dose if unwell, steroid card, medic alert bracelet - Titrate maintenance hydrocortisone + fludrocortisone dose to levels / response

Answer 45

Fernandez et al, 2018 Supportive until cause is found - avoid early abx until identification of cause and avoid steroid trials. Consider stopping all drugs + reinstituting them one by one. Ensure patient is aware of the strong possibility of no diagnosis being made. Do not perform serological testing if there is no history of exposure to the pathogen you are testing for.

Answer 46

Bedside: obs / other exams Bloods: culture (+ extended cultures for HACEK organisms), thick and thin films (parasites), HIV test, CRP / ESR, autoantibodies, immunoglobulins, complement levels, CK (malignant hyperthermia) Other: bone marrow aspirate, CSF, TOE, (looking for vegetations, aortic root abscess, myxoma as cause), PET-CT

Answer 47

Stable angina vs ACS Pericarditis Costochondritis Aortic dissection Respiratory cause / pleurisy Gastro cause Miscellanous: HSV, anaemia, sickle cell, thyroiditis, sarcoid, substance abuse, anxiety

Answer 48

DAPT (aspirin / clopidogrel), glycoprotein IIb / IIIa inhibitor (tirofiban) if high risk (TIMI score >4) + fondaparinux Anti-anginal: GTN + beta-blocker Risk modification: statin + ACEi If positive trop - proceed to coronary angiography (angioplasty + stent vs CABG) If negative trop - functional tests to confirm ischaemia: - exercise stress test - MIBI scan - stress echo - cardiac MRI

Answer 49

Estimates mortality for patients with unstable angina or NSTEMI. Age >65: 1 point >3 risk factors: 1 Known CAD: 1 Taking aspirin on admission: 1 Severe angina: 1 Trop rise: 1 ST depression: 1 >3 points = high mortality risk

Answer 50

Diabetes mellitus Tabes dorsalis Syringomyelia

Answer 51

Doppler USS ABPI (0.8 - 1.2 is normal, <0.8 implies arterial insufficiency) Arteriography

Answer 52

Specialist nurse / TVN: wound care Venous: - 4 layer compression bandaging (if no PVD) - varicose vein surgery Arterial: - angioplasty or vascular reconstruction - amputation

Answer 53

Type 1: neurofibromas Type 2: bilateral acoustic neuromas Schwannomatosis: painful schwannomas develop on spinal and peripheral nerves

Answer 54

Neurofibromatosis Leprosy Amyloidosis Acromegaly Refsum's disease

Answer 55

LEOPARD syndrome Legius syndrome Proteus syndrome Macrodystrophia lipomatosa

Answer 56

Neurofibromatosis type I is the most common of the three types - is caused by genetic changes in the NF1 gene located on chromosome 17 (17q11.2). This gene encodes for neurofibromin, which acts as a tumour suppressor gene. NF1 - neurofibromas NF2 - schwannomas are more common NF2's most characteristic symptom is hearing loss, due to pressures of tumours on the acoustic nerve. May also have headaches / dizziness / nausea.

Answer 57

Bedside: EEG Bloods: genetic testing Imaging: XR, MR/CT brain, slit-lamp exam Other: histology from biopsy of neurofibromas

Answer 58

2 or more cutaneous neurofibromas Cafe au lait patches: 6 or more, >15mm diameter Axillary freckling Lisch nodules: melanocytic hamartomas of the iris Visual acuity - optic glioma / compression BP: hypertension (associated with RAS and phaeochromocytomas) Resp: fine crackles (honeycombing of lung - ILD) Neuropathy with enlarged, palpable nerves

Answer 59

Phaeochromocytoma (2%) Renal artery stenosis (2%)

Answer 60

Epilepsy Sarcomatous change Scoliosis Cognitive delay

Answer 61

Eye problems: painful red eye / visual disturbance Skin: bruised / tender shins (erythema nodosum) Joint pain Resp: SOB, cough, haemoptysis, wheeze, Lofgren's syndrome (triad of fever, erythema nodosum and hilar lymphadenopathy) CVS: chest pain, palps, syncope Abdo: pain, renal stones, polyuria, thirst Neuro: headache, face droop, swollen face glands (parotids - Heerfordt-Waldenström syndrome), weakness / numbness Systemic: weight loss / night sweats TB history: contacts, travel, place of birth, vaccinations, occupation HIV risk assessment PMH / FH / DH Occupational: birds / farmers / metal / stone / pottery / pets

Answer 62

Strep - sore throat? Meds - COCP, abx, sulphonamides, phenytoin IBD questions Behcet's: mouth / genital ulcers Pregnancy Travel history

Answer 63

Hands: joint swelling, pulse Face: rash (lupus pernio), eyes (+ fundoscopy), parotids, facial nerve assessment, look in mouth at throat / tonsils Neck: lymph nodes (including parotids) Chest: listen to heart sounds, chest, look for rash and check for axillary LNs Abdo: feel for hepatosplenomegaly and inguinal LNs Legs: look for erythema nodosum Neuro: power, peripheral neuropathy

Answer 64

A multisystem, granulomatous disorder Tends to affect northern europeans, females, 20-40y, black more often than white individuals CXR is abnormal in 90% of patients Serum ACE is used to monitor disease activity and response to treatment, but not for diagnosis On bloods often see hypercalcaemia, high IgG, anaemia and thrombocytopaenia

Answer 65

Bedside: obs, urine dip, 24h urine for calcium (if blood calcium high), slit lamp exam, visual acuity, fundoscopy, o2 sats + ambulatory oximetry, spirometry, ECG Bloods: CRP / ESR, FBC (thrombocytopaenia), LFTs, ACE, calcium (raised as non-caseating granulomas secrete vit D), immunoglobulins, UEs, vitamin D, TFTs Imaging: CXR (hilar lymphadenopathy), BAL / bronchoscopy (+ biopsy), HR-CT, echo, 24h Holter, USS abdomen, CT/MRI brain

Answer 66

HRCT: ground glass changes + beading Spirometry: restrictive pattern BAL: increased lymphocytes Biopsy from bronchoscopy: non-caseating granulomas + wide alveolar septae

Answer 67

Sarcoidosis Infection: TB, mycoplasma, HIV Malignancy: lymphoma, lung cancer, metastasis Pneumoconiosis: silicosis, berylliosis

Answer 68

'NODOSUM' No - no cause / idiopathic D - drugs: COCP, abx, sulphonamides, phenytoin O - OCP S - sarcoidosis / streptococcus U - ulcerative colitis / Crohn's disease M - mycobacterium / maternity (pregnancy)

Answer 69

A type of acute sarcoidosis. Inflammatory disorder characterised by a triad of: - Hilar lymphadenopathy - Erythema nodosum - Arthritis (+ fever) Is often HLA-DRB1*03 associated

Answer 70

ASO titre (antistreptolysin titre - strep A) TB tests (early morning urine / sputum for AFB) Mycoplasma serology Pregnancy test Blood film / LDH

Answer 71

NSAIDs for arthralgia and skin Refer to respiratory and ophthalmology Steroids are indicated if: - bilateral hilar lymphadenopathy - infiltrates - lung fibrosis - eye problems - hypercalcaemia - neurological / cardiac involvement (Give 40mg prednisolone for 4-6 weeks, then weaning doses) Monitor with serum ESR and ACE Steroid-sparing agents: MTX, hydroxychloroquine, ciclosporin, cyclophosphamide, infliximab Surgery: - lung transplant - pacemaker

Answer 72

Skin + joints: hyperextensible skin, fragile skin, bruises, scarring, scars on knees Joint hypermobility + dislocation Cardiac: mitral valve prolapse Abdominal: scars - aneurysm rupture / dissection - bowel perforation / bleeding

Answer 73

Autosomal dominant inheritance Defect in collagen, causing increased skin elasticity No premature coronary artery disease (unlike PXE) 6 types (joint hypermobility most common) Largely a clinical diagnosis Pregnancy can be dangerous - PROM + PPH Genetic testing and counselling

Answer 74

MDT approach PT to strengthen muscles Splints / orthoses to prevent joint dislocations Analgesia Activity modification (no contact sports)

Answer 75

Joint hypermobility syndrome Ehlers-Danlos Syndrome Osteogenesis imperfecta Marfan's syndrome Pseudoxanthoma elasticum (PXE) Nail-patella syndrome (NPS)

Answer 76

Skin problems: 'looks like smoker's skin', hereditary and chronic Other issues: - hyperextensible joints - reduced visual acuity - hypertension - MI or CVA (strong hx of coronary artery disease) - gastric bleed Family history of PXE symptoms (skin issues and CAD)

Answer 77

Skin: 'plucked chicken skin' appearance, loose folds at neck and axillae, with yellow pseudoxanthomatous plaques, skin laxity Eyes: blue sclerae and macular degeneration Cardiovascular: hypertension and mitral valve prolapse

Answer 78

A genetic disease that causes mineralisation of elastic fibres in some tissues. Affects skin, eyes and blood vessels. Inheritance: 80% autosomal recessive (ABCC6 gene, chromosome 16) Premature coronary artery disease

Answer 79

Triad: 'PAA' Purpuric rash (buttocks and legs) Arthralgia Abdominal pain Precipitants: infections (strep, HSV, parvovirus B19), drugs (abx) Complications: renal involvement (IgA nephropathy), hypertension

Answer 80

Small-vessel vasculitis: IgA + C3 deposition Normal or raised platelet count (distinguishes from other causes of purpura) Children > adults, Male > female

Answer 81

Other skin manifestations: - Nodules + papules: face / ears / nose / neck / Koebner's phenomenon - Lupus pernio: diffuse bluish / brown plaque with central small papules commonly affecting the nose

Answer 82

Hypothyroidism Nephrotic syndrome Alcohol Cholestasis

Answer 83

Topical steroid and support bandaging. Tight diabetic control does not help.

Answer 84

Shins: - necrobiosis lipoidica diabeticorum: well-demarcated plaques with waxy-yellow centre and red / brown edges. - diabetic dermopathy: red/brown, atrophic lesions Feet + legs: - ulcers: arterial / neuropathic - eruptive xanthomas: yellow papules on buttocks / knees - granuloma annulare: flesh-coloured papules in annular configurations on dorsum of feet + fingers Injection sites: - lipoatrophy - fat hypertrophy Cutaneous infections Signs of other AI diseases: - vitiligo - Addison's disease - PVD

Answer 85

'ABCDE' - appearance of lesion Asymmetrical Border irregularity Colour - black, irregular pigmentation Diameter >6mm Enlarging Metastases (draining LNs, hepatomegaly, bone tenderness)

Answer 86

- Excision - Staged on Breslow thickness (maximal depth of tumour invasion into dermis) - Glass eye + ascites - think ocular melanoma!

Answer 87

Sun exposed areas (+ lips / mouth) Actinic keratoses: pre-malignant red scaly patches Varied appearance: keratotic nodule, polypoid mass, cutaneous ulcer Other lesions / previous scars Metastases SCC in situ = Bowen's disease Biopsy suspicious lesions

Answer 88

Usually on face / trunk (sun-exposed areas) Pearly nodule with rolled edge Superficial telangiectasia Ulceration in advanced lesions Other lesions

Answer 89

Natural history: grows slowly over months, rarely metastasizes Treatment: - surgical excision +/- radiotherapy - curettage / cryotherapy if superficial

Answer 90

A condition involving cellular remodelling and deformity of >1 bones. The structural changes cause the bones to weaken, causing deformity, pain, fracture or arthritis of joints. A frequent component of multisystem proteinopathy. SQSTMI + RANK genes are associated with Paget's.

Answer 91

Paget's Osteomalacia Syphilis

Answer 92

Osteogenic sarcoma Basilar invagination (cord compression) Kidney stones

Answer 93

Paget's PXE Ehlers-Danlos Syndrome

Answer 94

Grossly elevated alk phosphatase, normal calcium and phosphate. Radiology: - 'moth eaten' on plain films (osteoporosis circumscripta) - increased uptake on bone scan

Answer 95

Bisphosphonates Calcitonin Surgery (for fractures, degenerative arthritis, bone deformity)

Answer 96

Background: 'HBM' - hard exudates - blot haemorrhages - microaneurysms Pre-proliferative: backround features PLUS - cotton wool spots - flame haemorrhages Prolierative: pre-proliferative features PLUS - neovascularisation - panretinal photocoagulation scars (treatment)

Answer 97

Annual screening for all patients with diabetes Refer to ophthalmology if pre-proliferative retinopathy or changes near macula Background retinopathy usually occurs 10-20y after diagnosis of diabetes Young people w/ T1DM usually get proliferative retinopathy Older patients with T2DM usually get exudative maculopathy

Answer 98

Maculopathy Proliferative and pre-proliferative diabetic retinopathy

Answer 99

Vitreous haemorrhage Traction retinal detachment Neovascular glaucoma

Answer 100

Loss of red reflex Cloudy lens May have RAPD with normal fundi Associations: myotonic dystrophy (with bilateral ptosis)

Answer 101

Congenital: Turner's, rubella Acquired: age (usually bilateral), diabetes, steroids, radiation, trauma, storage disorders

Answer 102

Surgery (as an outpatient): - Phacoemulsification with prosthetic lens implantation - YAG laser capsulotomy

Answer 103

Pre-morbid social history: - independence / dependence (carer role + frequency) - mobility issues - PD, stroke? walks unaided or with stick or frame - falls recently? how many? - where do they live (impt for discharge planning) Precipitant: - infection: urinary sx, pneumonia sx - drug changes: benzos, diuretics, BP meds, antipsychotics, steroids, PD drug changes - systemic enquiry - sites of pain Legal: - advanced directives / living will

Answer 104

Ask to stand / walk unaided Proximal LL strength: rise from chair Gait: wide-based, ataxic, hemiplegic, shuffling Romberg's: sensory ataxia Assess LLs: inspection, tone, power, reflexes, sensation, coordination Postural hypotension: assess lying and standing BP (20mmHg drop in systolic BP after 2 mins is significant)

Answer 105

'PINCHME' Pain Infection Nutrition Constipation Hydration Medication Environment

Answer 106

4AT: alertness, AMT4, attention, acute change / fluctuating course CAM: confusion assessment method - assess the presence, severity and fluctuation of 9 delirium features

Answer 107

Treat reversible causes: abx, avoid polypharmacy MDT: nurse, social worker, OT/PT - mobility aids - home modifications / residential care - resus decision / ceiling of care

Answer 108

Indicates a patient's risk of falling and guides further management for worsening mobility / falls. 1. Falls in the last year 2. 4+ meds per day 3. Dx stroke / PD 4. Balance issues 5. Can they get up from a chair without using arms <3 points = lower risk >3 points = higher risk

Answer 109

FRAX predicts the 10-year probability of a patient having a major osteoporotic fracture.

Answer 110

Bedside: obs, collateral history, urine MCS / CSU, delirium screen 4AT or CAM Bloods: septic screen, blood cultures, bone profile and UEs (elecs), FBC, CRP (infection) Imaging: CXR (infection), if fall and confusion / reduced consciousness, consider CT head non contrast. High risk of subdural in atrophic brain

Answer 111

Antihypertensives (low BP) Sedatives Diuretics (elec abnormalities and low BP) Antidepressants (hyponatraemia)

Answer 112

'PC SOAP' Promethazine Cetirizine Solifenacin Oxybutynin Amitriptyline Prochlorperazine

Answer 113

Once structural causes have been ruled out with brain imaging, mgmt focuses on secondary prevention of further episodes. Aspirin 300mg OD for 2 weeks, then clopidogrel 75mg OD lifelong. Optimise BP, diabetes, cholesterol, diet, exercise, smoking cessation, reduce alcohol. Surgical: carotid endarterectomy within 2 weeks if symptomatic carotid stenosis (70-99%) (ESCT criteria). Anticoagulate if AF present. DVLA: no driving for 1 month.

Answer 114

Hemiplegic migraine Hypoglycaemia Seizure Syncope GCA Electrolyte disturbances

Answer 115

Antiphospholipid syndrome Extracranial dissection Vasculitis Substance abuse: cocaine / methamphetamines Metabolic / mitochondrial disease Sickle cell disease

Answer 116

Consider APLS if young with TIA + recurrent miscarriages. Requires anticoagulation: current evidence favours warfarin > DOAC. Consider bubble echo looking for PFO in young patient. Complications: TIA / stroke, DVT / PE, livedo reticularis, thrombocytopaenia, thrombophlebitis, recurrent miscarriages.

Answer 117

Visual acuity Visual fields Pupillary responses Fundoscopy H-test for eye movements Palpate temporal arteries Cardiovascular exam Neuro: pronator drift, power, sensation, finger-nose testing, reflexes, speech, gait

Answer 118

Timing: when, sudden / gradual, how long, complete recovery now? previous episodes Vision: painful / painless, blurred, distorted, bits missing, double vision Neuro: weakness, speech, swallow, headache GCA: headache / scalp / jaw pain Migraine: aura, headache, sensitive to light / noise, N+V Seizure: LOC, drowsy after, incontinence, tongue biting Hypoglycaemia: sweating, palps, hunger before PMH stroke / TIA / recurrent miscarriages. CV risk factors: HTN, diabetes, high cholesterol, smoking, MI, stroke DH / FH SH: alcohol, drugs, smoking, CV risk factors

Answer 119

Rash: - erythematous + lichenified patches of skin - mainly flexor aspects of joints - fissures (hands, feet. painful) - excoriations - secondary bacterial infection Associated atopy: - respiratory exam: polyphonic wheeze of asthma Investigations: - patch testing for allergies

Answer 120

Avoid precipitants Topical: emollients, steroids, tacrolimus Antihistamines for itch Abx for secondary infection UV light therapy PO prednisolone in severe cases

Answer 121

Psoriasis Lichen planus Alopecia areata Fungal infections

Answer 122

Skin: - chronic plaque type: multiple well-demarcated, pink scaly plaques on extensor surfaces - check behind ears, scalp + umbilicus - Koebner phenomenon: plaques at sites of trauma - skin staining from coal tar treatment Nails: - pitting, onycholysis, hyperkeratosis, discolouration Joints: - psoriatic arthropathy

Answer 123

Epidermal hyperproliferation and accumulation of inflammatory cells

Answer 124

Topical: - emollients - calcipotriol - coal tar (stains) - dithranol - hydrocortisone Phototherapy: - UVB - psoralen + UVA (PUVA) Systemic: - cytotoxics (MTX / ciclosporin) - anti-TNF (adalimumab) - retinoids (acitretin)

Answer 125

A multisystem, inflammatory autoimmune disorder. Broad spectrum of clinical presentations, affects all organs and tissues. Demographics: Female > male, African + Latin americans, Afro-caribbeans, South Asians and Hispanic, 16-55y. Takes a chronic, waxing and waning course.

Answer 126

Initially the American College of Rheumatology criteria (out of 11), and now the SLICC (2012) classification criteria (out of 17) - 4/17 including 1 clinical and 1 immunological - biopsy-proven lupus nephritis and ANA / anti-dsDNA

Answer 127

Mild disease (cutaneous / joint only): - topical corticosteroids - hydroxychloroquine Moderate disease (+ other organ involvement): - prednisolone PO - azathioprine Severe disease (+ severe involvement of vital organs) - methylprednisolone - MMF (for lupus nephritis) - cyclophosphamide - azathioprine

Answer 128

ANA anti-dsDNA elevated immunoglobulins

Answer 129

Bedside: obs, sats, ECG, skin/renal biopsy, nailfold capillaroscopy, pregnancy test Bloods: - FBC, UE, LFT, clotting, ESR / CRP - ANA, RF, anti-CCP, ANCA, immunoglobulins, anti-dsDNA - anti-Scl70, anticentromere, anti Ro/La, anti-Jo1, antihistone - HIV / Hep B + C / CMV / EBV screen - serum electrophoresis + urine BJ proteins - ACE (sarcoid), ferritin (Still's), anti-GBM (Goodpastures) Other: - If suspecting specific organ involvement, relevant tests for that organ

Answer 130

Hydralazine Procainamide Isoniazid Phenytoin Interferon

Answer 131

SLE: ANA, dsDNA, anti-Smith Antiphospholipid syndrome: anti-cardiolipin, lupus anticoagulant, beta2-glycoprotein Sjogren's syndrome: anti-Ro (SSA), anti-La (SSB) MCTD: anti-U1 RNP RA: rheumatoid factor, CCP Myositis: anti-Jo1 Scleroderma: anti-centromere, Scl-70, RNA polymerase III ANCA vasculitis: c-ANCA (GPA), p-ANCA (EGPA)

Answer 132

Severity of COPD is categorised on MRC dyspnoea scale, instead of previously-used FEV1. 0-1 exacerbations (not leading to hospital admission): - mMRC 0-1, CAT <10 = single bronchodilator - mMRC =>2, CAT =>10 = LABA + LAMA =>2 mdoerate exacerbations or =>1 leading to hospitalisaton: = LABA + LAMA (consider LABA + LAMA + ICS if blood eosinophil count >300) Key: mMRC: modified Medical Research Council dyspnoea questionnaire CAT: COPD Assessent Test

Answer 133

Systemic: weight loss, night sweats, fatigue, fever Rashes: sensitive to sun? hair loss? mouth / nose ulcers? swollen / tight skin? Eyes: Dry eyes / mouth, visual changes, painful eyes CVS / resp: CP, SOB, orthopnoea, palps, ankle swelling, LOC, wheeze, cough, haemoptysis, exercise tolerance Raynaud's: fingers go cold + change colour (white, blue then red) GI / GU: bladder and bowels, dysphagia, heartburn, abdo pain Renal: high BP, blood / protein in urine Neuro: headaches, double vision, LOC, dizziness, weakness, numbness Muscle weakness / pain Pregnancy: baby have heart block or rash? PMH/DH: drug-induced lupus FH of rheumatological or AI disease SH: pregnant, breastfeeding? plans to do so?

Answer 134

Head / face / scalp: malar rash, discoid rash, oral ulceration, scarring alopecia (edges of bald patches look more ragged than alopecia areata) Hands / nails: nailfold vasculitis, synovitis, Raynaud's, fistula on arm, Jaccoud's arthropathy (mimics RA but due to tendon contractures and not joint destruction) CVS exam Resp exam: effusion, rub, fibrosing alveolitis Abdo: organomegaly, renal transplant Legs: oedema, DVT Skin: discoid lupus, vasculitic rash, photosensitivity rash, livedo reticularis Cushingoid appearance: steroid use

Answer 135

Autoantibodies (bloods): - ANA +ve in 90% - anti-centromere in limited SS - anti-Scl70 in diffuse SS Hand XRs: for calcinosis. Pulmonary: CXR, HR-CT, PFTs. Expect lower lobe fibrosis and aspiration pneumonia. GI: Contrast scans, FBC, B12 and folate. Gut dysmotility and malabsorption. Renal: UE, urinalysis, urine microscopy (casts), consider renal biopsy. Cardiac: ECG and echo. Myocardial fibrosis and arrhythmias.

Answer 136

CREST is a type of limited systemic sclerosis. It consists of: - Calcinosis - Raynaud's phenomenon - Esophageal dysmotility - Sclerodactyly - Telangiectasia

Answer 137

SS is a connective tissue disease characterised by autoimmunity, vasculopathy and fibrosis. Most commonly affects females aged 35-65y. Prognosis for diffuse SS is around 50% 5-year survival, most deaths are due to respiratory failure.

Answer 138

Limited SS: - distribution below elbows, below knees and face - slow progression (years) Diffuse SS: - widespread cutaneous and early visceral involvement - rapid progression (months)

Answer 139

Symptomatic treatments: - camouflage creams - Raynaud's treatments: hand warmers, CCBs, ACEi's, prostacyclin infusions Renal: ACE's GI: PPI for reflux Treat pulmonary hypertension: CCBs, diuretics, iloprost, bosentan, sildenafil, o2 Immunosuppression: MMF, MTX, cyclophosphamide, azathioprine, ciclosporin, prednisolone, rituximab

Answer 140

Hands: - sclerodactyly 'prayer sign' - calcinosis (may ulcerate) - assess function: hold pen Face: - tight skin - microstomia - beaked nose - peri-oral furrowing, telangiectasia, alopecia Other skin lesions: - morphoea: focal / generalised patches of sclerotic skin - en coup de sabre (scar down central forehead) BP: hypertension Resp: fibrosis (fine, bibasal crackles) Cardiac: pulmonary hypertension (RV heave, loud P2, TR), evidence of CCF, pericarditis (rub)

Answer 141

MDT approach! - PT and hydrotherapy - Analgesia: NSAIDs, paracetamol, weak opioids - Corticosteroid injections: for sacroiliitis and enthesitis - Biological agents: anti-TNF (adalimumab) - Treat complications such as iritis - Treat osteoporosis with bisphosphonates (prevent spinal fractures) - Smoking cessation (close association with disease activity)

Answer 142

Immunisations Screen for active and latent TB with CXR and blood test

Answer 143

Mainly from clinical history and examination with supporting radiological evidence. Young patients (<40) with +ve FH Plain spine XR: erosions / sclerosis of SI joints, and squaring of vetebrae ('bamboo spine') Bloods: raised ESR / CRP, anaemia of chronic disease Genetic testing: HLA-B27 CXR / HRCT if suspecting lung fibrosis, consider PFTs

Answer 144

The 5 A's: Anterior uveitis (commonest, 30%) Apical lung fibrosis Aortic regurgitation (midline sternotomy) AV node block (pacemaker) Arthritis (may be psoriatic arthropathy)

Answer 145

Seronegative spondyloarthropathy HLA-B27 positive in >90% of individuals TNF and interleukin-1 also implicated in disease activity

Answer 146

Look at the TLCO (transfer factor). Mechanical restriction - normal TLCO ILD - reduced TLCO due to underlying damaged lung

Answer 147

Apical lung fibrosis Anaemia: NSAIDs / anaemia of chronic disease Mechanical restriction due to fusion of the spine causing restrictive defect Cardiac causes: AR

Answer 148

Using the BASDAI: Bath Ankylosing Spondylitis Disease Activity Index. - 10-point scale - anything >4 indicates active disease

Answer 149

Spine: - ask pt to stand up (back and chest exposed) - kyphotic spine, hyperextension of the neck (question-mark posture) - increased occiput to wall distance - reduced spinal movements - increased AP diameter of chest wall - Schober's test: 2 points marked 15cm apart, expand by <5cm on maximum forward flexion is a positive test Cardiac: - listen to aortic area and left sternal edge (AR) Chest: - apical fibrosis, apical fine creps Eyes: iritis, visual acuity check Gait: likely antalgic, will make spinal deformity more obvious

Answer 150

Cushing's disease: glucocorticoid excess due to an ACTH-secreting pituitary adenoma Cushing's syndrome: the physical signs of glucocorticoid excess

Answer 151

1. Confirm high cortisol - 24h urinary collection - low dose dex suppression test (won't suppress cortisol if +ve) 2. If elevated cortisol, identify cause - ACTH level: if high, ACTH-secreting tumour / pituitary adenoma. If low, adrenal adenoma / carcinoma. 3. Other tests - MRI pituitary fossa +/- adrenal CT +/- whole body CT to identify lesion - Inferior petrosal sinus vein sampling (pituitary vs ectopic origin)

Answer 152

Surgical: - transsphenoidal approach to remove pituitary tumour - adrenalectomy for adrenal tumours Nelson's syndrome: bilateral adrenalectomy causes Cushing's disease, as causes increased ACTH production and leads to pituitary overgrowth due to lack of feedback inhibition Pituitary irradiation Medical: metyrapone

Answer 153

Inherited: muscular / myotonic dystrophy Endocrine: Cushing's, hyperparathyroidism, thyrotoxicosis Inflamm: polymyositis, RA Metabolic: osteomalacia Malignancy: paraneoplastic / LEMS Drugs: alcohol, steroids

Answer 154

Spot diagnosis: - Face: round, hirsuite, acne - Skin: bruised, thin, purple striae - Back: intrascapular fat pad - Abdomen: central adiposity - Legs: wasting and oedema Complications: - HTN (check BP) - Diabetes (CBG) - Osteoporosis (kyphosis) - Cellulitis - Proximal myopathy (stand from sitting) Cause: - Exogenous: signs of chronic condition (RA, COPD) requiring steroids - Endogenous: bitemporal hemianopia + hyperpigmentation (if increased ACTH)

Answer 155

Acromegaly causes soft tissue swelling in the face / around the throat. This can lead to respiratory compromise - especially when lying down at night.

Answer 156

1st line: surgery - transsphenoidal resection (curative) 2nd line: somatostatin analogues (ocretotide), bromocriptine if not tolerated 3rd line: radiotherapy to pituitary gland is an option if other treatments fail NB a potential complication of surgery is panhypopituitarism - need to warn patients about this before surgery.

Answer 157

Classically, a bitemporal hemianopia occurs. This is due to compression by the adenoma on the optic chiasm.

Answer 158

General appearance: prognathism, prominent supraorbital ridges, coarse facial features, macroglossia, incrased teeth separation, spade-like hands, sweating, large feet May have goitre Bitemporal hemianopia on VF testing Carpal tunnel syndrome Axillae for acanthosis nigricans Chest: gynaecomastia, galactorrhoea Cardiovascular: increased JVP, displaced apex beat, bibasal crackles, pedal oedema (CCF) Joints: arthropathy (Heberden's nodes) Offer to examine: BP, urine dip (glucose), DRE (polyps), testicular exam (hypogonadism)

Answer 159

Screening: test IGF-1 levels (will be high) Confirm diagnosis with OGTT (shows failure to suppress GH) Look for underlying cause: MRI brain, looking for pituitary adenoma Investigating complications: - fasting glucose + HbA1c - anterior pituitary hormone screen - ECG: look for LVH and cardiac conduction defects - TTE: assess ejection fraction - sleep study: assess for OSA - colonoscopy for polyps - NCS for carpal tunnel syndrome

Answer 160

OSA: CPAP CCF: diuretics, ACEi's, beta blockers Diabetes: hypoglycaemic agents Anterior pituitary deficiency: hormone replacement

Answer 161

A problem with poorly formed type 1 collagen. In >90% of cases, OI occurs due to mutations in COLIA1 or COLIA2 genes.

Answer 162

Predominantly inherited in an autosomal dominant pattern. There are 8 different variations of OI, can develop spontaneously - this is the more severe form of the condition.

Answer 163

Blue discolouration of eyes Recurrent fractures since birth Palpitations + abdominal discomfort Short stature, barrel chest Deformity of the legs Abnormal gait / joint hypermobility / skin laxity Discoloured, translucent teeth (dentogenesis imperfecta) Hearing impairment (middle ear bones affected)

Answer 164

Bloods: bone profile, vitamin D, genetic screening (predominantly an inherited condition) Imaging: x-rays and DEXA to look at bone density. Echocardiogram. NB: echo is requested as there is an association with bicuspid aortic valve in patients with OI, and they can also develop AR.

Answer 165

Depends on the results of relevant investigations for OI. Replace low calcium / phosphate / vit D levels. If DEXA shows decreased bone density, consider bisphosphonates. Orthotics review. PT review.

Answer 166

Diminished reflexes that become brisker after exercise. LL girdle weakness. Associated with malignancy (SCLC). Antibodies to pre-synaptic calcium channels. EMG shows 'second wind' phenomenon on repetitive stimulation.

Answer 167

Myasthenia gravis Graves' disease Mitochondrial cytopathies (CPEO) Miller-Fisher variant of GBS Cavernous sinus pathology

Answer 168

Acute: IV immunoglobulin or plasmapharesis Chronic: - ACh esterase inhibitor (pyridostigmine) - Immunosuppression: steroids / azathioprine - Thymectomy is beneficial, even if patient does not have a thymoma

Answer 169

Anti-nicotinic ACh receptor antibodies affect neurotransmission.

Answer 170

Diagnostic tests: - Anti-ACh receptor antibodies (+ve in 90%) - Anti-MuSK antibodies - EMG: decremented response to impulses - Tensilon / edrephonium test: not done anymore as causes heart block - CT / MRI chest (thymoma in 10%) - TFTs (Graves' in 5%)

Answer 171

Guillain-Barre Syndrome Sarcoidosis Lyme disease Myasthenia gravis Bilateral Bell's palsy

Answer 172

Bell's palsy is the commonest cause of facial nerve palsy. Rapid onset over a few days, HSV1 has been implicated. Induced swelling and compression of the nerve within the facial canal. Management: - Prednisolone started within 72h (+ aciclovir if severe) - Eye protection (artificial tears, tape shut at night) - Prognosis: 70-80% make a full recovery - Pregnancy: Bell's palsy is more common, outcome may be worse

Answer 173

Bell's palsy Ramsay-Hunt syndrome Mononeuropathy (diabetes, sarcoid) Tumour / trauma MS / stroke

Answer 174

The eyeball rolls up on attempted eye closure (seen in Bell's palsy)

Answer 175

Pons: + VI palsy and long tract signs (MS+stroke) Cerebello-pontine angle: + V, VI, VIII + cerebellar signs (tumour) Auditory / facial canal: +VIII (cholesteatoma or abscess) Neck / face: + scars or parotid mass (tumour or trauma)

Answer 176

Pale, milky fundus with thread-like arterioles +/- cherry red spot on macula (choroidal blood supply) Cause: AF or carotid stenosis with bruit

Answer 177

Embolic: carotid plaque rupture / cardiac mural thrombus GCA: tender scalp + pulseless temporal arteries

Answer 178

Signs: - wet (neovascular, exudative) or dry (non-neovascular, atrophic, non-exudative) - Macular changes: drusen, geographic atrophy, fibrosis, neovascularisation (if wet) Symptoms: - loss of CENTRAL vision - issues reading / driving / recognising faces Management: - ophthalmology referral - wet ARMD: intravitreal anti-VEGF injections

Answer 179

Clinical signs: - flame haemorrhages ++ radiating out from swollen disc - engorged, tortuous veins - cotton wool spots Effect: rubeosis iridis causes secondary glaucoma in CRVO - visual loss or visual field defect

Answer 180

HTN Hyperglycaemia / diabetes Hyperviscosity syndromes: Waldenstrom's macroglobulinaemia or myeloma Increased intraocular pressure (glaucoma)

Answer 181

'PALE DISCS' Pressure: tumour, glaucoma (most common cause) Ataxia: Freidreich's LEber's optic neuropathy Dietary: B12, Degenerative: RP Ischaemia: CRAO Syphilis and other infections: CMV + toxoplasmosis Cyanide + other toxins: alcohol, lead, tobacco Sclerosis: MS (most common cause)

Answer 182

Oxygen +/- CPAP IV fluids, analgesia Abx if evidence of infection Blood transfusion / exchange transfusion depending on severity of crisis Hydroxycarbamide / exchange transfusion programme if frequent crises / poor prognosis Long-term folic acid + penicillin (due to hyposplenism)

Answer 183

Vaso-occlusive sickle crisis Acute sickle chest crisis Sicke cell crisis + pulmonary hypertension Vaso-occlusive crisis with PE

Answer 184

Vaso-occlusive crisis (sickling in small vessels of any organ). Often precipitated by viral illness, exercise or hypoxia. Leg ulcers due to ischaemia. Chest crises (high mortality associated with these in adulthood). Priapism. Pulmonary hypertension.

Answer 185

Infectious: - viral: norovirus, rotavirus - bacterial: e.coli, salmonella, shigella, campylobacter, v.cholerae, c.difficile - parasites: giardia, amoebic dysentry IBD: UC or Crohn's - blood, weight loss, abdominal pain, mucus Colorectal Ca: blood, weight loss, enlarged LNs, abdominal masses Coeliac disease: symptoms triggered by certain foods (bread, pasta) Medication-related: abx, cytotoxics, laxatives, PPIs, digoxin, NSAIDs, beta-blockers Thyrotoxicosis: sweating, hot, bulging eyes, neck lump, anxious Bacterial overgrowth: post-gastroenteritis, burping / passing excess wind Pancreatic insufficiency: steatorrhoea Short bowel syndrome: previous bowel surgeries? Ischaemic colitis: history of stroke / AF / cardiovascular disease?

Answer 186

Bedside: stool sample, fluid resus. Send stool sample for: - MC+S - C.diff toxin - Ova, cysts and parasites - Faecal calprotectin Bloods: cultures, FBC, WCC, CRP, UE, VBG (lactate), LFTs, TFTs, autoimmune screen, TTG (coeliac). Hep A/B/C and HIV. Imaging: AXR (toxic megacolon / perforation) Consider: - Antibiotics + IV steroids (if suspect an IBD flare) - Flexi-sig / colonoscopy / OGD + biopsies - Abdo USS - CT AP - Faecal elastase (pancreatitis)

Answer 187

Low-set ears Epicanthic folds Protruding tongue Collapsed nasal bridge Single palmar crease Wide gap between 1st and 2nd toes Cardiac murmurs Reduced IQ

Answer 188

Face: prominent supraorbital ridges, large lips and nose, prognathism, spaced teeth Macroglossia, large sweaty hands Complications: carpal tunnel, diabetes, hypertension, gynaecomastia, arthropathy, cardiomegaly, acanthosis nigricans Bitemporal hemianopia and optic atrophy Rare causes: MEN type 1, Mc-Cune Albright syndrome and Carney complex

Answer 189

Sudden-onset headache behind eyes / around temples (90% of cases) Associated nausea and vomiting Sometimes meningism and reduced GCS Bitemporal hemianopia visual field defect May have 3rd nerve palsy Usually have adrenal insufficiency (secondary) and other pituitary hormone deficiencies

Answer 190

Gonadotrophin: no / irregular periods, reduced libido, hot flushes GH: weight gain TSH: weight gain, feeling cold, dry skin, hair loss, fatigue, constipation, puffy face ACTH: dizzy on standing, tired, weak, nausea / vomiting, weight loss, abdo pain PMH: previous pituitary surgery, radiation, cancer, head injury NB you do not get salt wasting and hyperpigmentation in secondary adrenal insufficiency as you do in primary adrenal insufficiency

Answer 191

Pituitary tumour: often non-functioning macroadenoma Iatrogenic: pituitary surgery / radiation Compression / infiltration: meningioma, mets, sarcoid, abscess, craniopharyngioma Pituitary apoplexy: acute infarction of a pituitary adenoma Head injury / stroke / meningitis Sheehan syndrome (infarction during blood loss in childbirth) Empty sella syndrome

Answer 192

Bedside: obs, history, CBG Bloods: FBC, UE, 9am cortisol (low), TFTs (low), LH / FSH (low), morning testosterone / oestradiol (low), IGF-1 (low), prolactin (low or raised) Imaging: CT or MRI head and pituitary (MRI has >90% sensitivity for detecting pituitary apoplexy)

Answer 193

Medical: hormone replacement Surgical: transsphenoidal surgery if mass effect

Answer 194

Rinne's first: to assess conduction - If normal, air > bone - If sensorineural deafness, air > bone - If conductive deafness, bone > air If Rinne's +ve, progress to Weber's - to assess lateralisation - If sensorineural, will localise to good ear. - If conductive, will localise to affected ear.

Answer 195

Rheumatoid arthritis Other seronegative spondyloarthropathies: ank spond, reactive arthritis, enteropathic arthritis Osteoarthritis Crystal arthropathy (gout, pseudogout)

Answer 196

CASPAR criteria - to diagnose PsA, need =>3 points: - psoriasis (current, past, FH) - psoriatic nail dystrophy - negative RF - dactylitis (current or past) - XR: juxta-articular new bone formation

Answer 197

Asymmetrical oligoarthritis: DIPJ + PIPJ, MCPJs + MTPJs, knee + hip, dactylitis Predominantly DIPJ with nail changes Athritis mutilans: telescoping of fingers RA-like: wrist involvement Axial only: asymmetrical sacroiliitis

Answer 198

Nail involvement in 80% - pitting, ridging, hyperkeratosis, onycholysis Ocular involvement - conjunctivitis, iritis

Answer 199

Bedside: obs, history, urine dip, sexual hx (reactive arthritis differential) Bloods: RF and anti-CCP, ANA, ESR / CRP, FBC, UE, LFT, HLA-B27 testing if sacroiliitis Imaging: XR hands / feet: asymmetrical changes, no periarticular osteopenia, DIPJ involvement, erosion of terminal tufts, 'pencil in cup' deformity, sacroiliitis, juxta-articular new bone formation

Answer 200

Lifestyle advice: weight loss, exercise, smoking cessation NSAIDs Steroid injections (but be aware this can cause skin to flare) DMARD when NSAIDs fail, 3+ joints involved, PASI score =>10 (MTX, sulfasalazine, leflunomide) Biologic: Anti-TNF / Ustekinumab / Apremilast Surgical: joint replacement Dermatology opinion on skin disease

Answer 201

Non-caseating granulomas and Langhans giant cells.

Answer 202

Eyes: dry eyes, blurred vision Lymph nodes: enlarged Lungs: dry cough, breathlessness, wheeze Heart: chest pain, arrhythmias, heart palps Hepatosplenomegaly Joints: pain, arthritis, swelling Skin: rashes, lupus pernio, erythema nodosum, skin lesions on back, subcutaneous nodules Whole body: fatigue and weight loss

Answer 203

Discoloured, dystrophic and thickened nails. A condition associated with lymphoedema, pleural effusions and bronchiectasis in 40% of cases.

Answer 204

Bridging steroids for flares Early DMARD’s MTX +/- second agent, such as leflunomide, sulfasalazine Anti-TNF (Infliximab) Anti-CD20 (Rituximab) T-cell co-receptor blocker (Abatacept)

Answer 205

DAS28 1. Number of swollen/tender joints 2. Global pain score 3. ESR/CRP

Answer 206

ACR/EULAR 1. No. LARGE joints 2. No. SMALL joints 3. ESR/CRP 4. Anti-RF/CCP 5. >6 weeks duration

Answer 207

Wrist subluxation Thickened synovium Ulnar deviation Boutoiniers (PIP flex.d) Swan neck (PIP ex.d) Z thumb (MP hyper-ext) Rheumatoid nodules (elbows) Arthroplasty scars

Answer 208

With all spondyloarthropathies: - aortitis - aortic regurgitation - iritis - apical lung fibrosis - colitis - enthesitis (specific for spondyloarthropathies) DDx from other spondyloarthropathies by more asymmetry, and more peripheral joint involvement.

Answer 209

Equal sex distribution (RA more common in women) Asymmetric Distal (with some exceptions) Enthesitis Spondylitis in 40%! Early bone deformity Majority RF / CCP negative

Answer 210

LVSD. If the mitral valve area is <1, this can mimic LV failure when the LV is functionally normal

Answer 211

Prominent a due to septal bulging Double carotid impulse Reverse split S2 MR (anterior motion of valve) Louder during Valsalva (reduced pre-load = reduced Starling = obstructed outflow)

Answer 212

Autosomal Dominant Several genes, all encoding sarcomeric proteins Associated with Friedrich’s ataxia, Fabry’s, WPW

Answer 213

LVH criteria (S1+R6 >35mm) Deep antero-lateral TWI Deep infero-lateral Q waves

Answer 214

Drugs that reduce pre-load as this accentuates the outflow gradient: nitrates, inotropes

Answer 215

Amiodarone if AF Beta-blockers Cardioverter defibrillator Dual chamber pacemaker Endocarditis prophylaxis

Answer 216

AD, AR, de novo mutations in gene encoding for collagen III Principally affects joints, blood vessels, heart, eyes

Answer 217

Joints = deformities, pain, impaired function Skin = easy bruising and fragility Heart = MVP, MR, AR, Aortic dissection, cardiac conduction abnormalities Vascular = haemorrhage GI = bleeding, diverticulae, diaphragmatic herniation, colonic rupture Eyes = glaucoma, retinal detachment

Answer 218

AD mutation usually in COL1A1/2 that codes for collagen I This leads to B: weak bones and atraumatic fractures I: Eyes - blue sclera (loss of collagen = choroidal veins visible) T: Teeth - dentinogenesis imperfecta E: Ear: otosclerosis (conductive hearing loss) Cardiac: Valvular disease - MVP, bicuspid aortic valve, AR/aortic root dilation Rx: 1. Vit D/calcium/bisphosphonates 2. OT/PT 3. Hearing aids 4. Valve replacement/repair if needed

Answer 219

EDS Marfan Osteogenesis Imperfecta Pseudoxanthoma elasticum Diamond Blackfan (Pure red cell aplasia)

Answer 220

AD/AR ABCC6 Abnormal MINERALISATION of ELASTIN Mid-dermal deposition of calcium that triggers a metabolic response Dermis: Pseudoxanthoma plaques and plucked chicken) in axilla/groin/neck Eyes: Angoid streaks (85%) Heart: AR, MR, MVP Vessels: Early plaques, CAD, PVD, HTN, Renovascular disease GI: haemorrhage due to friable vessels

Answer 221

GI: Oesophogeal dysfunction, dysphagia, malaborption, SIBO, PBC Skin: Raynaud’s, gangrene MSK: arthritis, osteopenia (malabsorption) Renal: HTN, scleroderma renal crisis Resp: ILD, pleural effusions CVD: Restrictive cardiomyopathy, pericarditis, PHTN, conduction defects

Answer 222

The nailfold is one of the few places you can visualise capillaries. There is significant capillary dropout due to microangiopathy, with regeneration of poorly constructed vessels in systemic sclerosis/Raynauds

Answer 223

ANA >1:80 and signs/symptoms/labs suggestive of lupus: Labs: Anti-dsDNA, Anti-smith, Anti-cardiopilin, lupus anti-coagulant, low C3/C4 Constitutional Neurological Mucocutaneous Photosensitivity MSK Serosal Renal Haematological

Answer 224

Discoid lupus (sun-exposed) Malar rash on face sparing naso-labial folds Painless mucosal ulcers Tender small joints

Answer 225

Auto-antibodies can cross the placenta and lead to congenital heart block (Anti-Ro)

Answer 226

6 different types of lupus nephritis, most common and most severe is diffuse proliferative lupus nephritis

Answer 227

Mainstay is hydroxychloroquine +/- other DMARDs like AZA, MMF, calcineurin inhibtors (ciclosporin/tac) Steroids for flares ACEi if proteinuria

Answer 228

Anaemia Arthritis Raynauds Dermatomyositis Discoid rash Malar rash Mouth ulcers ILD, pleural effusions, pleurisy pericarditis, Libman-Sacks endocarditis, PHTN CNS involvement Renal HTN, nephritis Haematological - lymphadenopathy, splenomegaly Eyes - Sjogren syndrome

Answer 229

Anterior uveitis Aortic regurgitation AV conduction defects Enthesitis Apical fibrosis Ank spond is a rare cause of amyloidosis

Answer 230

NSAIDs Excercise DMARD’s in severe cases Biologics such as anti-TNF (adalimumab, etanercept) and anti-IL17 Rarely, surgery (spinal surgery is usually avoided)

Answer 231

Bone fragility Proximal muscle werakness Muscle spasms (low Ca) X ray - looser zones Bloods: Low Vit D, Low calcium, raised ALP (trying to stimulate bone actiivty). Low calcium stimulates PTH which stimulates phosphate excretion. Low Vit D, Low Ca, Low Pho Raised ALP and raised PTH

Answer 232

Balance tips towards bone breakdown Leads to reduced number of osteoid units, however the cells are functionally normal and there is preserved mineralisation (in contrast to osteomalacia where there is reduced mineralisation)

Answer 233

Post-meonopausal Low calcium Alcohol Smoking Steroids Thyroxine Senile osteoporosis Reduced gravity/weight bearing excercises

Answer 234

Truelove and Witts' criteria: Mild: <4 stools a day Mod: 4-6 stools a day, no sys upset, CRP <30 Severe: >6 and any signs of systemic upset

Answer 235

Refractory to medical therapy Any evidence of dilatation on imaging Any evidence of fistulating disease

Answer 236

Yes, if there is colitis there is concern for colorectal ca and PSC ---> cholangiocarcinoma, particularly in UC After 10 years - surveillance colonoscopy to detect early pre-malignant changes; further colonoscopy depending on risk level at that stage.

Answer 237

Psoriasis area and severity index (PASI), and body surface area involved

Answer 238

Trauma Sunburn Stress Smoking Alcohol Beta haemolytic strep Drugs (Lithium, ACEi’s, beta-blockers, NSAID’s, terbinafine, anti-malarials)

Answer 239

Plaque Pustular Guttate Palmoplantar Erythrodermic Inverse psoriasis (flexor surfaces)

Answer 240

Stripping of skin in psoriasis reveals underlying hypertrophied dermal capillaries

Answer 241

NF1 on chromosome 17 NF2 on chromosome 22 Both these genes are TSG’s. Their absence leads to the fibrous tumours arising from the nerves - fibromas

Answer 242

Schwannomas (acoustic neuromas) Meningiomas Cataracts Retinal hamartomas Less frequent skin manifestations

Answer 243

Lungs - apical fibrosis Heart - restrictive cardiomyopathy Spine - scloliosis Adrenal - phaeochromocytoma Kidneys - Renal artery stenosis

Answer 244

TSC1 and TSC2. Both are inherited in an autosomal dominant manner, and their absence leads to uncontrolled mTOR activity. This leads to benign tumours throughout the body (made up of various cell types) and an increased lifetime risk of cancer

Answer 245

Brain - gliomas, epindymomas, astrocytomas Skin - angiofibromas (face), subungal fibromas, ash leaf spots, Shagreen patches Kidneys - angiomyolipolas (can bleed) Lungs - lymphangioleiomyomatosis (cysts) Eyes - reintal hamartomas.

Answer 246

* Cell count and differential * Protein, glucose, lactate * Gram stain and culture * Viral PCR **Bacterial meningitis** Raised WCC, predominantly Neutrophils High protein Low glucose Positive gram strain **Viral meningitis** Raised WCC, predominantly lymphocytes Normal/High protein Normal glucose Viral PCR+

Answer 247

Severe morbidity Deafness Blindness Cognitive impairment Vascular - amputations due to sepsis

Answer 248

Skin - telangiectasia Mucus membranes - epistaxis GI - bleeding Lungs - AV malformations CNS - SAH, migraines, spinal AV = paraparesis Liver - can lead to liver failure due to AV malformations

Answer 249

Systemic Sclerosis SLE HHT Mitral stenosis Polycythaemia Carcinoid syndrome Ataxia telangiectasia

Answer 250

STOP-BANG questioniarre Epworth (>11)

Answer 251

Overnight polysomnography for apnoea hypopnea index

Answer 252

Genetic: HLADR3/DR5 Environment: Cocksackie virus, cancers

Answer 253

An underlying malignancy is found in 20-25% of cases of dermatomyositis. These are typically ovarian, lung, breast

Answer 254

**Skin:** Gottron's papules Heliotrope rash Malar rash Shawl sign Hypertrophy of cuticles Non-scarring alopecia. Palmar hyperkeratosis (mechanics hands). Photosensitive skin changes. **Muscles:** Prox weakness Atrophy Dysphagia Resp muscle weakness **Lungs:** Fibrosing alveolitis Organising pneumonia

Answer 255

FBC, UE CK ANA, Anti Jo1, Anti SRP, Anti M2 Muscle biopsy Directed screening for underlying malignancy

Answer 256

RA SS Lupus Dermatomyositis Polymyositis Myeloproliferative disorders Hep B/C Thoracic outlet syndrome Atherosclerosis Carpel tunnel Hypothyroidism Drugs (beta blockers, cyclosporin)

Answer 257

Primary (R. disease) - <40y No associated systemic features NO nailfold capillaries Never necrotic Normal ESR Normal ANA

Answer 258

Beta blockers OCP Ciclosporin Chemo

Answer 259

CCB’s Prostacyclins Nitrates

Answer 260

Commonly classified as Hodgkin’s (Reed Sternberg B-cells) and non-Hodgkins. Non-Hodgkins includes: High-grade Lymphoblastic (behaves like ALL) B-cell (Burkitt’s, DLBCL, Mantle cell, Follicular)

Answer 261

Ann-Arbour staging 1. Single node 2. More than one node, same side of diaphragm 3. Above and below diaphragm 4. Extra-nodal B symptoms at any stage

Answer 262

**R-CHOP** Rituximab Cyclophosphamide Hydroxydaunorubicin Oncovincristine Prednisolone and then maintenance Rituximab

Answer 263

**ABVD** Adriamycin Bleomycin Vincristine Doxarubicin

Answer 264

Thrombocytopenia (antibodies against platelets) Recurrent miscarriages Arterial (stroke) and/or venous clots (DVTs) Livedo reticularis

Answer 265

Autoimmune screen anti-cardiolipin Anti-beta2glycoprotein 1 anti-phospholipid Lupus anticoagulant

Answer 266

Primary thromboprophylaxis - low dose aspirin Secondary thromboprophylaxis - warfarin (INR 2-3, increased to 3-4 if clot on warfarin)

Answer 267

Extra-cranial - neck hyperextension Vasculitis Cardiac - embolic (mxyoma, endocarditis, valvular pathology, AF) Substance misuse - cocaine, methamphetamine Antiphospholipid syndrome Familial hyperlipidaemia Sickle cell disease Rare metabolic/mitochondrial causes such as MELAS

Answer 268

STREP THROAT! TB Sarcoid (Lofgren’s - classical triad of fever, hilar lymphadenopathy and EN) Myeloproliferative disorders IBD Behcet’s Drugs (OCP, penicillin, sulphonylureas)

Answer 269

HSV CMV, EBV, influenza, COVID-19 Medications - OCP, penicllin, carbamazapine Vaccinations SLE Sarcoidosis Malignancy Mycoplasma pneumonia - now considered a distinct entity

Answer 270

Antiphospholipid syndrome Polycythaemia rubra vera SLE Polyarteritis nodosa GPA/EGPA Walendenstrom’s Cholesterol embolism

Answer 271

Bullous = Basement Autoimmune type 2 hypersensitivity reaction against hemidesmosomes that anchor basal cells to basal membrane IgG targets BPAG1+2. This leads to mast cell degranulation and inflammation Genetic component and environmental triggers (furosemide, penicillamine, NSAIDs, abx) Nikolsky sign negative (no intraepidermal splitting) Rx topical and sytemic steroids

Answer 272

Autoimmune type 2 hypersensitivity reaction against intra-epidermal desmosomes that hold keratinocytes together in the stratum spinosum layer Can either affect mucosal cells only (Desmoglein 3) or skin+mucosal cells (Desmoglein 1+3) Histologically there is tombstoning (intra-epidermal disruption of keratinocytes) Nikolsy sign positive (lateral pressure causes a split between upper and lower layers of epidermis) Rx: topical and oral steroids, rituximab, oral rinses with lidocaine

Answer 273

Autosomal dominant mutation in the tumour suppressor gene STK11 that is expressed throughout the GI tract and also various other tissue including skin, breast, lung, ovaries, testicles Leads to the development of hamartomas in the GI tract that can become malignant. These can lead to bleeding and obstruction. Skin manifestations include flat mucocutaneous melanocytic macules on the mucosal surfaces and also palms and soles Risk of GI, breast, lung, ovarian, testicular cancer

Answer 274

Typically affects young female diabetic patients It is also associated with hypertension, thyroid disease and obesity It is a disorder of BLOOD VESSELS Starts as a red papule, becomes a plaque, and then slowly enlarges to a yellow patch with a red rim Can ulcerate and turn into a squamous cell cancer

Answer 275

Extremely painful Rapidly enlarging tender full-thickness ulcer with blue borders Non-infectious neutrophilic dermatosis More common in over 50’s Frequently associated with autoimmune conditions such as IBD, RA, GPA Rx: Urgent immunosupression

Answer 276

Paralysis Cancer Immobilised Prev DVT Is an alternative diagnosis as likely? Calf swelling, leg swelling, collaterals, tenderness along deep venous system, pitting oedema 1 = D-Dimer >=2 Doppler

Answer 277

DVT Cancer Immobilised Prev DVT Is PE as equally likely as other diagnosis HR Haemoptysis 1 = D-Dimer >2 = CTPA/VQ

Answer 278

Factor V Leiden Prothrombin mutation Protein C Protein S Anti-thrombin III (rare but aggressive) Drug history (OCP)

Answer 279

PESI Score predicts 30-day mortality and takes into consideration history, and clinical findings

Answer 280

Intracranial disease/bleed Ischaemic stroke (<3mo) Brain/spine surgery (<3mo) Internal bleeding Coag disorder Recent head trauma

Answer 281

Both have radiation - CTPA radiation comes from the X-rays, VQ radiation comes from the dye. CTPA = higher dose of X-ray radiation to breast tissue VQ = higher dose of dye - ionising radiation to fetus, but still very small amounts

Answer 282

AD, AR, X-linked recessive, and 30% are de novo.

Answer 283

**Kearns-Sayre:** Mitochondrial. Ophthalmoplegia + cerebellar ataxia. **Usher:** AR. Sensosineuronal deafness. **Refsum:** Ataxia + muscle wasting. **Alport:** X linked recessive. Type IV collagen. Haematuria + GS + SN deafness.

Answer 284

If disease involves fovea = anti-VEGF (benralizumab) If disease does not involve fovea = laser photocoagulation

Answer 285

Reduced visual acuity RAPD SWOLLEN disc Retinal haemorrhages (stormy sunset) Might develop acute angle closure glaucoma

Answer 286

The retinal artery is a terminal branch of the ophthalmic artery. Its occlusion can produce retinal infarction. Can be: 1. Embolic 2. Rapid raised IOP 3. GCA 4. Profound hypotension 5. Vasospasm 6. Hypercoagulable states

Answer 287

Sudden painless visual loss Pale retina Cherry red spot on fovea (choroidal arteries unaffected) RAPD

Answer 288

Occular massage IV acetazolamide/anterior segment paracentesis (reduce IOP) Treat underlying factor

Answer 289

Dry: Drusen + atrophy Wet: Neovascularisation in choroid

Answer 290

Central visual loss Distortion

Answer 291

Anti-VEGF (ranibizumab)

Answer 292

Red Painful Asymetric pupil

Answer 293

Ank Spond Behcet’s MS Infections: HSV, TB, HIV

Answer 294

Asian, short axial eyeball, older age, pupillary dilation

Answer 295

Extreme pain Blurred vision Haloes Red eye Mid-dilated or fixed dilated pupil Corneal oedema Raised IOP

Answer 296

Topical betablockers/pilocarpine IV acetazolamide Peripheral laser iridotomy (hole in iris)

Answer 297

Inflammation of the cornea Sight-threatening emergency Caused by infection (bacterial, fungal, viral) or inflammation (blepharitis induced irritation) Ix - slit lamp and fluorescein = corneal ulcer

Answer 298

Both associated with inflammatory conditions such as IBD and RA Scleritis is painful, episcleritis is not Both look pretty similar Scleritis is associated with photophobia and gradual decrease in visual acuity In episcleritis, injected vessels are mobile with gentle pressure and will blanch with phenylephrine drops Scleritis needs oral NSAID’s /steroids, most cases of episcleritis can be managed conservatively

Answer 299

Typically post a viral illness Phase 1: Lymphocytic infiltration: Hyperthyroidism, raised ESR Phase 2: euthyroid Phase 3: Hypothyroidism for weeks-months Phase 4: Back to normal Ix: Thyroid scintigraphy: globally reduced uptake of I-131 Rx: Self-limiting Pain control - NSAIDs Steroids if hypothyroid

Answer 300

Biguanide: increase liver and muscle insulin sensitivity (metformin) SGL-2 inhibitor: Inhibits re-absorption of glucose (dapaglifozin). DPP4 inhibitors: reduce breakdown of incretins (sitagliptin, linagliptin). Caution if hx pancreatitis/pancreatic cancer. Can use linagliptin in renal impairment Sulphonylureas: Increase insulin secretion (glizlazide) - risk of hypo’s Pioglitazone: PPAR-gamma activator = more glucose transports - risk of fluid retention, osteoporotic fractures, and bladder cancer

Answer 301

Urinary stasis + recurrent infections Lower limb spasticity Hydrocephalus Arnold-Chiari malformations Recurrent meningitis Syrinx

Answer 302

T2DM Obesity PCOS Acromegaly Cushing’s

Answer 303

Spotaneous microdeletion Mild intellectual impairment Characteristic facies with broad forehead Supravalvular aortic stenosis

Answer 304

Hydrocortisone (Mild) Betamethasone 0.025% Fluticasone/Betamethasone 0.1% Clobetasol

Answer 305

Allergen enters the dermis and triggers a Type I hypersensitivity reaction. On repeat exposure there is IgE mediated mast cell degranulation. Self-perpetuating cycle of skin breakdown, skin dryness, and itching.

Answer 306

Physiological (pregnancy) Prolactinoma Exercise, stress Acromegaly (1/3 of patients) PCOS Hypothyroidism (Raised TRH stimulates prolactin release) Drugs (metoclopromide, domperidone, haloperidol, rarely SSRI’s)

Answer 307

AR HBB gene (beta globin) Low haptoglobin (intravasc haemolysis) Scleral icterus, jaundice, bilirubin gallstones Bone marrow hyperplasia - enlarged skull Hepatomegaly (extramedullary haematopoiesis) Autosplenectomy (R/O Strep, haemophilius, Neisseria, Salmonela) Chest syndrome Renal necrosis Priapism Rx: Prophylaxis, treat infections early, pain relief, hydroxyurea (increases gamma globin = ^ HbF)

Answer 308

1. A-E approach, stabilise pt. Blood cultures before treating if possible. Sepsis six, 3x sets of BCs from peripheral sites at different times. 2. IV abx: benzylpenicillin + gentamicin OR vancomycin if pen-allergic. If HACEK organism suspected, treat with ceftriaxone OR ciprofloxacin. 4-6 weeks of IV abx. 3. Surgery: indications include heart failure, cardiogenic shock, aortic root abscess, expanding vegetation, AV block, prevention of septic emboli 4. Temp cardiac pacing is recommended if the pt is in AV block secondary to aortic root abscess. 5. Refer to endocarditis MDT

Answer 309

Timing: when did it start, getting worse, sudden/gradual, anything made it better or worse? Patchy or widespread? Scarring: more likely to be autoimmune-related Red/scaly Scalp/beard/body hair/eyebrows/eyelashes affected? Does it re-grow white? Nails PMH: AI (DM, vitiligo, coeliac, thyroid), tiredness FH: hair loss? DH: allergies, chemo, COCP, heparin, warfarin SH: diet, stress, illness, trauma, surgery, pregnancy

Answer 310

Hair: patchy/widespread, inflamed, scarring, exclamation mark hairs, white hair Beard, brows, eyelashes, body hair Nails Don't miss vitiligo! Examine thyroid Check for conjunctival pallor

Answer 311

Mild: reassurance Topical potent corticosteroid / intralesional triaminoclone Dithranol or minoxidil 5% If severe: topical immunotherapy, systemic steroid, PUVA Trigger control Support groups, wigs

Answer 312

**Non-scarring** Androgenic/ageing Telogen effluvium Drug-induced Areata/totalis/universalis **Scarring** Trauma SLE Lichen planus Scleroderma morphoea

Answer 313

Bedside: fungal culture (scraping) Bloods: TFTs, FBC, iron/ferritin, glucose, ANA (lupus), syphilis serology Special: dermoscopy (exclamation-mark hairs vs cadaverised hairs), skin biopsy if diagnosis unclear

Answer 314

Haemarthrosis Trauma Septic arthritis Crystal arthritis (gout, pseudogout) Reactive arthritis Monoarticular presentation of RA / psoriatic / enteropathic arthritis Bursitis / cellulitis / OM Avascular necrosis

Answer 315

Bedside: urine dip + culture, stool culture, STI screen, ECG Bloods: FBC, UE, LFT, CRP, ESR, Ca, Mg, ferritin, TFT, urate, Hba1c, lipids, blood cultures (Consider: RF, anti-CCP, ANA, HLA-B27 if >1 joint involved) Imaging: XR joint, MR joint if OM suspected Special: aspirate joint (pre-abx) (Contraindicated in prosthetic joints, cellulitis, overlying psoriasis, high INR, low plts)

Answer 316

Common organisms: staph aureus, group A/B strep, gram neg bacilli, gonococcal Blood culture +ve in 50%, aspirate is +ve in 70-90% Cause: haematogenous spread, adjacent OM, soft tissue infection near joint, iatrogenic (arthroscopy), trauma

Answer 317

Crystal deposition disease Disorder of purine metabolism, resulting in hyperuricaemia Typically monoarthritis of 1st MTP joint, can be polyarticular Males > females Can become chronic, presence of tophi indicates severe, recurrent gout. Can get uric acid renal stones and nephropathy

Answer 318

**Lifestyle changes**: reduce red meat / purine intake, alcohol, weight loss, exercise **Acute phase:** - rest / ice joint, stop diuretics, address lifestyle factors - NSAIDs + PPI (diclofenac) for 1-2 weeks - Colchicine 2nd line - Steroids 3rd line **Prophylaxis:** - Allopurinol (not during acute attack, delays resolution) - Offer if 2 attacks in 1y / tophi / erosions / renal insufficiency / renal stones / diuretics / pre-chemo - Aim for urate <300 micromol/L - Monitor U+E and titrate according to urate - Start 2wks after attack settled - Alternative: febuxostat

Answer 319

Bed rest, ice, splints Treat infection / contact tracing NSAIDs IA steroid / oral steroid DMARDs: MTX, sulfasalazine Most recover within 1y, 20% become chronic. Complications more likely if HLA-B27 positive.

Answer 320

Bedside: ECG (QT prolongation, heart block, VF), 24h urinary calcium Bloods: calcium, magnesium, potassium, phos, pH (VBG), PTH, vit D, UE, ALP, amylase, TFTs, ACTH, adrenal abs, genetic testing Imaging: renal USS (stones), brain MR (basal ganglia calcification), XR hands (shortened metacarpals)

Answer 321

Kidney and bone resistance to PTH: low calcium, high phos, high PTH, low calcitriol, normal UEs. No urinary cAMP response to PTH. Type 1a: GNAS1 mutation. Albright Hereditary Osteodystrophy (AHO) - round face, short stature, short 4th and 5th metacarpal bones, obesity, subcutaneous calcifications and developmental delay. Type 1b: No phenotypic features of AHO, but similar biochemistry. Type 2: No phenotypic features of AHO. Normal / raised urinary cAMP response.

Answer 322

Management of hypocalcaemia and refer to endocrinology. May require screening for other endocrinopathies.

Answer 323

Hypoparathyroidism (low PTH, low calcium) PTH resistance (pseudohypoparathyroidism) CKD Vitamin D deficiency Bisphosphonates, calcitonin, phenytoin Acute pancreatitis Blood transfusion Rhabdomyolysis Tumour lysis syndrome Hyperphosphataemia

Answer 324

Macular sparing is usually seen in PCA lesions due to the supply from the MCA. If there is no macular sparing within the HH, then you can localise the lesion to the MCA. The weakness/numbness would be expected on the contralateral side to the brain lesion.

Answer 325

* Thromboembolic disease - give IPC boots * Risk of further strokes * Risk of haemorrhagic transformation of ischaemic strokes * In acute and long-term, there is a risk of seizures * Swallowing difficulties - risk of aspiration pneumonia * Higher risk of falls * Urinary and faecal incontinence

Answer 326

Dual antiplatelet therapy (aspirin + clopi) Lifestyle mods: BP, diet, statins, reduce salt intake, stop smoking, reduce alcohol intake Further risk factors such as diabetes should be addressed using current guidelines

Answer 327

Treatment includes: - Treating the underlying cause (diarrhoeal illness, gonococcal / chlamydial infection) - Supportive: analgesia, re-hydration if diarrhoeal illness, abx if sexually-transmitted infection

Answer 328

Bedside: stool culture, obs, sexual and travel hx. Bloods: UE, LFTs, CRP/ESR, FBC, cultures, RF + anti-CCP (in case it is first presentation of RA instead). Imaging: XR of the joint. Special: aspirate joint, with culture and microscopy looking for crystal arthropathy or septic arthritis.

Answer 329

Reactive arthritis is associated with the HLA-B27 gene. This gene is widely associated with the seronegative spondyloarthropathies which include enteropathic arthritis, reactive arthritis, ankylosing spondylitis and psoriatic arthritis.

Answer 330

'S1 Q3 T3' A large S wave in lead I Q wave in lead III Inverted T waves in lead III

Answer 331

Bedside: observations, ECG (looking for signs of right heart strain) Bloods: FBC, UE, coag profile, CRP (infection), LFTs Imaging: CTPA (to exclude PE), CXR (exclude pneumonia or PTX) Calculate Wells' score: - If patient <2 points - low risk, do d-dimer - 2-5 points - consider d-dimer or CTPA - >=6 points - do CTPA Alternative rule-out criteria = PERC score (8-item clinical criteria who identify which pts are low risk of PE and can be discharged from ED).

Answer 332

Initially start with treatment dose LMWH. Then switch to oral anticoagulation: warfarin or NOAC. **Treatment duration** If provoked PE: 3 months If unprovoked PE: 6 months If acutely unwell / haemodynamically unstable, consider thrombolysis with alteplase, or surgical thrombectomy.

Answer 333

Need to assess volume status first. If hypovolaemic - is urinary Na >20 mmol/l? - Yes: renal Na loss - No: loss elsewhere If euvolaemic - is urine osmolality >300mOsm/kg? - Yes: SIADH - No: water intoxication, severe hypothyroidism, Addison's disease If hypervolaemic: nephrotic syndrome, CCF, cirrhosis, renal failure

Answer 334

**Fundamentals**: treat underlying cause + restore normal volume status. **Acute severe hyponatraemia**: IV hypertonic saline bolus (100ml 3% NaCl) cautiously. **Hyponatraemia without neurological symptoms**: - correct by no more than 6mmol/L in first 6h - then no more than 10mmol/L in first 24h - management depends on cause + fluid status **Hypovolaemic:** rehydration with 0.9% normal saline **Euvolaemic**: fluid restrict 1.5L per 24h **Hypervolaemic:** fluid restrict 1.5L per 24h (All with regular monitoring of serum sodium levels - if done too fast can cause osmotic demyelination syndrome).

Answer 335

Hyperlipidaemia Hyperglycaemia Hyperproteinaemia Hyperbilirubinaemia

Answer 336

Bedside: - urine sodium (differentiates between renal vs extrarenal causes of hypoNa) - very high sodium in renal causes and SIADH - urine osmolality (to confirm SIADH - increased urine osm + low serum osm suggests SIADH) Bloods: - UEs, serum osm (decrease in serum osm to be expected. If normal, suspect pseudohyponatraemia) - LFTs (albumin), lipids (if pseudo suspected), glucose - Cortisol (exclude Addison's), TFTs (exclude hypothyroidism)

Answer 337

Streptococcal infections OCP Rickettsia Eponymous (Behcet's) Sulphonamides Hansen's disease (leprosy) IBD / Idiopathic Non-Hodgkin's lymphoma Sarcoidosis

Answer 338

Medical: - Acetazolamide - Mannitol Surgical: - Optic nerve sheath fenestration - CSF shunting (VP shunt) Other: - Weight loss

Answer 339

Essential (94% - assoc with age / obesity / salt / alcohol) Renal - CKD Endocrine - Conn's, Cushing's, Acromegaly, Phaeochromocytoma Aortic coarctation Pre-eclampsia (pregnancy)

Answer 340

* Mainly clinical history + exam, with supporting radiological evidence * Young patients (<40y) with positive FH * Plain spine XRs: erosions / sclerosis of SI joints, with squaring of vertebrae * Bloods: raised CRP / ESR, anaemia of chronic disease * Genetic screening: HLA-B27 * CXR / HRCT: if suspecting lung fibrosis, consider PFTs

Short clinical consultations Flashcards

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