Station 5 Flashcards
(285 cards)
1
Q
Signs of optic atrophy
A
- RAPD (constricts when shine light to normal pupil, dilates when shine light on abnormal pupil)
Signs of causes
- Cupping of disc: glaucoma
- Retinitis pigmentosa
- Central retinal artery occlusion: cherry red macula + milky fundus
- Foster-Kennedy syndrome (frontal tumour): optic atrophy in one eye = tumour compression; papilloedema in other eye = raised ICP)
2
Q
Causes of absent red reflex
A
Red reflex = reflection of light from back of eye
Absent = opacity in ocular media (cornea, lens, aqueous and vitreous humour)
- Cataract
- Vitreous haemorrhage
3
Q
Acronym for which lobe corresponds to which quadrantopia
A
PITS
- Parietal inferior
- Temporal superior
4
Q
An important cause of absent pupillary response
A
- Glass eye!
5
Q
Causes of sudden vision loss
A
Will always be vascular or trauma
- Vitreous haemorrhage
- Retinal artery occlusion
- Retinal vein occlusion
- Haemorrhagic (‘wet’) age-related macular degeneration
- Stroke
6
Q
Causes of altitudinal visual field defect (upper/lower visual field loss)
A
- Branch retinal artery occlusion
- Anterior ischaemic optic neuropathy
7
Q
Causes of vitreous haemorrhage
A
Bleeding into vitreous (clear jelly between retina and lens)
- Diabetic retinopathy = most common
- Trauma
- Retinal detachment
8
Q
Features of vitreous haemorrhage
A
- Sudden vision loss
- Cobwebs in vision
- Absent red reflex
- Photopsia (bright lights in peripheral vision)
9
Q
Pathogenesis of diabetic retinopathy
A
- Vascular occlusion –> VEGF release –> new vessels
10
Q
Diabetic retinopathy and pregnancy
A
- Progresses rapidly in pregnancy
- Diabetic pregnant ladies need to be reviewed once a trimester for retinopathy
11
Q
Stages of diabetic retinopathy
A
Mild/moderate non-proliferative = background retinopathy:
- Microaneurysms (dots)
- Blot haemorrhages
Severe/very severe non-proliferative = pre-proliferative
- Cotton wool spots (infarcts)
- Venous dilation/beading
- Intraretinal microvascular abnormalities (IRMA) = branching/dilation of existing vessels in retina
Proliferative retinopathy
- New vessels
12
Q
Treatment for diabetic retinopathy
A
- Mild/moderate: annual Diabetic Retinopathy Screening Service
- Pre-proliferative/maculopathy: Ophthalm referral within 3months
- Proliferate: Ophthalm referral within 2weeks
- Pan-retinal photocoagulation (lasers applied to 4 quadrants of retina)
- Do as many sessions until new vessels start to regress
- Side effects: reduced night vision/visual field loss
13
Q
Pathogenesis of diabetic maculopathy
A
- Oedema from leaking capillaries
- And/or ischaemia due to capillary loss
14
Q
Features of diabetic maculopathy
A
- Central vision loss (due to macular oedema)
15
Q
Indications for laser treatment in diabetic maculopathy
A
- Retinal thickening within 500μm of fovea (centre of macula)
- Exudates within 500 μm of the fovea, if associated with adjacent retina thickening
- Retinal thickening >1 disc area, any part of which is within 1 disc diameter of the fovea
(won’t be expected to detect retinal thickening in exam!)
16
Q
Features and inheritance mode of retinitis pigmentosa
A
- Age 10-30, symptoms progress over years–> registered blind by 40s
- Night vision loss
- Peripheral vision loss
- Severe: central vision and colour vision loss
Can be many different modes of inheritance so ask for family history (usually autosomal recessive)
17
Q
Loss of peripheral vision vs loss of central vision
A
Peripheral vision loss
- Retinitis pigmentosa (constricted fields)
- Glaucoma (constricted)
- Laser photocoagulation (constricted)
- Ischaemic optic neuropathy (unilateral)
- Stroke (homonymous)
Central vision loss
- Diabetic maculopathy
- Age-related macular degeneration
- Optic neuropathy (demyelinating/nutritional)
- Cataract
18
Q
Syndromes associated with retinitis pigmentosa
A
- Usher syndrome: sensorineural deafness = most common
- Alport Syndrome: abnormal glomerular basement membrane–> nephrotic syndrome (defect in collagen)
- Kearns–Sayre syndrome (mitochondrial disease): progressive ophthalmoplegia, cardiac conduction defect (PACEMAKER)
- Refsum disease (excess phytanic acid): scaly skin, cerebellar ataxia, peripheral neuropathy, cardiomyopathy
19
Q
Investigations for retinitis pigmentosa
A
- Automated perimetry (visual fields)
- Electroretinogram: reduced amplitude
- Optical coherence tomography: retinal atrophy
- Genetic analysis: especially X-linked recessive
20
Q
Management of retinitis pigmentosa
A
- Mainly supportive: register as blind to get benefits/reduced TFL costs
- Luxturna = gene therapy for biallelic RPE65 mutations
- Vitamin A may slow progression
21
Q
Mitochondrial inheritance comes from which parent
A
- Mother as all mitochondrial in embryo come from the egg
22
Q
Features of optic atrophy
A
- PAINLESS loss of central vision
- RAPD
- 3rd nerve palsy (inflammatory/compressive affects CNIII)
- INO if MS
- Speed of progression depends on cause
23
Q
Causes of optic atrophy
A
Sudden = ischaemic
- Embolic
- Giant Cell Arteritis!!
Subacute = demyelination
- MS
- Neuromyelitis optica
Gradual
- Compressive tumour: optic nerve glioma, frontal meningioma (at anterior cranial fossa), pituitary macroadenoma (compresses optic chiasm)
- Nutritional: B12, alcohol
24
Q
Investigations for optic atrophy
A
- Visual-evoked potentials: assess optic nerve function and differentiate from retinal disease (evoked potentials will be delayed and reduced amplitude)
- Automated perimetry
- CT brain + orbits with contrast
25
Management of optic neuropathy
- Steroids in ARTERTIC anterior ischaemic optic neuropathy i.e. GCA (prevents further vascular occlusions)
- Steroids speed up recovery in optic neuritis but not overall prognosis
26
Risk factors for thyroid eye disease
Autoimmune inflammation of the extra-ocular muscles and
retro-orbital fat
- Autoimmune thyroid disease
- Female middle-aged
- Smoking
27
Features of thyroid eye diseases
- Lid lag when looking down
- Proptosis (examine from above)
- Unilateral progressive vision loss = optic nerve compression
- Diplopia
- Signs of thyroid: goitre, thyroid acropatchy, pretibial myxoedema
RED FLAGS
- Optic atrophy due to compression (RAPD, pale disc)
- Corneal exposure during blinking
28
Investigations for thyroid eye disease
- CT orbits: bone resolution (plan decompression); MRI orbits: soft tissue
- Thyroid investigations including antibodies
29
Thyroid disease antibodies
- Anti-TSH receptor = Graves
- Anti-thyroid peroxidase = Hashimoto's (and Graves)
- Anti-thyroglobulin = Hashimoto's (and Graves)
30
Management of thyroid eye disease
Stable signs
- Artificial tears (methylcellulose eye drops)
- Stop smoking
- Optimise thyroid status
- "Burns out" in 1-5yrs, when can have surgery for cosmetic reasons
Optic nerve compression or corneal exposure = emergency
- Steroids +/- orbital radiotherapy
- Surgical decompression of orbital apex if steroids fail
31
Causes of bitemporal hemianopia
Optic chiasm compression
- Pituitary adenoma = starts from above as compresses inferior chiasmal fibres first
- Craniopharyngioma = starts from below as compresses superior chiasmal fibres first
- Meningioma
Non-chiasmal compression
- Tilted optical discs (nerve enters eye obliquely)
- Nasal retinitis pigmentosa
32
Symptoms associated with bitemporal hemianopia
Pressure effects
- Headache
- Diplopia (pressure on CN III, IV, VI)
Hypopituitarism
GH-secreting tumour
Prolactinoma
33
Symptoms of hypopituitarism
- Hypothyroid
- Reduced FSH/LH: reduced libido, erectile dysfunction, reduced menses.
- Reduced ACTH: tiredness, depression, abdominal pain
- Reduced GH: dry wrinkly skin, reduced well-being.
34
Symptoms of prolactinoma
- Men: galactorrhoea, reduced libido, erectile dysfunction
- Women: galactorrhoea, reduced libido/menses
35
Investigations for bitemporal hemianopia
- MRI pituitary fossa
- Endocrine: IGF-1 (high in acromegaly), LS/FSH, ACTH, TFTs
36
Management of optic chiasm tumour
- Transphenoidal surgery (transfrontal if suprasellar extension)
- Radiotherapy if residual tumour
37
Cause of macula sparing homonymous hemianopia (central vision intact)
- Occipital lobe lesion (because macula supplied by PCA and MCA so PCA lesion still means MCA working!)
38
Features of retinal artery occlusion
- Optic atrophy--> sudden blind
- Branch retinal artery occlusion = visual field defect opposite to affected quadrant
39
Causes of retinal artery occlusion
Embolic
- Carotid plaque
- Mural thrombus
Arteritis = GCA
- Tender scalp and pulseless temporal arteries
40
Causes of retinal vein occlusion
4 H's
- HTN
- Hyperglycaemia (diabetes)
- High intraocular pressure (glaucoma)
- Hyperviscosity (myeloma)
41
Management of retinal vein occlusion
- Usually observe and manage risk factors
- Macular oedema: intravitreal VEGF inhibitor
- Neovascularisation: retinal photocoagulation
42
Pre-pregnancy counselling in diabetic women
- HbA1c <7.0% for 3 months pre-conception
- Folic acid 5mg (continue until 12 weeks pregnant)
- Stop ACEi and statins
43
Management of diabetic foot
MDT approach!!!
- "Offloading" pressure: non-removable cast walkers (uninfected/non-ischaemic)
- Debridement of slough/necrotic/callus (TVN)
- non-adherent dressings covered with a layer of gauze (maintain moist environment)
- Fluclox + metronidazole (covers anaerobes)
44
Different types of neuropathy in diabetes
- Progressive sensory
- Mononeuritis e.g. cranial nerves
- Pressure palsies e.g. carpal tunnel syndrome
- Amyotrophic
- Autonomic.
45
Causes of hyperthyroidism
2 most common:
- Graves: eye disease and hx of autoimmune
- Toxic multinodular goitre
Also
- Viral thyroiditis: neck pain/recent child-birth
- Drugs: iodine, amiodarone, lithium, contrast
- Gestational
46
Management of hyperthyroidism
Drugs
- Titration: carbimazole 30mg tapered over 8 weeks to 5-10mg
- Block and replace: carbimazole 40mg until T4 low (after 6-8weeks), then add levothyroxine 100mcg
- Each lasts 18months
- 50% relapse rate in Graves
- Also: non-selective beta-blockers (propranolol- avoid in asthma/COPD)
Radio-iodide
- More than 1 dose likely needed
- Complications: long-term hypothyroidism and worsens thyroid eye disease (/can cause thyroid eye disease)
- Can use in mild eye disease with steroid cover afterwards
Surgical = thyroidectomy
- Complications: hypothyroidism, hoarse voice (laryngeal nerve) and parathyroid damage
47
Important complications of carbimazole
- Rash (10%)
- Agranulocytosis (0.5%)-- stop immediately if mouth ulcers and check neutrophils
48
Thyroid uptake scan results
High uptake = more uptake than surrounding thyroid tissue
- Graves: diffuse
- Toxic multinodular goitre: focal
- Toxic adenoma: focal
Low uptake
- Non-functioning nodules = 10% are malignant (hot nodules never are)
- Thyroiditis
- Drug-induced
49
Management of toxic multinodular goitre
- Radio-iodide (may cause enlargement briefly first!)
- Surgery if compressive symptoms (dysphagia/stridor)
(- Meds don't work! If not candidate for above, can give low-dose levothyroxine to suppress TSH but not really effective!)
50
Causes of hypothyroidism
- Autoimmune (Hashimoto's) = most common in UK
- Thyroiditis (post-hyperthyroid stage)
- Iatrogenic: post-ablation/thyroidectomy
- Drugs: amiodarone/litium/carbimazole!
51
Implications of pregnancy on hypothyroidism
- Levothyroxine doses increase by 25-50%
- Check TSH every trimester (aim 0.5–2.0mU/L.)
52
Features of myxoedema coma
Hypothyroid emergency (long-term undiagnosed hypothyroidism or insult e.g. MI)
- Bradycardia
- Hypothermia
- Reduced GCS
- Cardiogenic shock
53
Important differential diagnosis for hypothyrodism
- Addison's (can co-exist!
--> giving levothyroxine in undiagnosed Addison's may cause Addisonian crisis (enhances cortisol clearance)
54
Signs of active disease in acromegaly
- Sweating
- HTN
- Peripheral oedema
- Skin tags = skin growth
55
Important co-existing condition in acromegaly
Hypopituitarism
- T4
- LH, FSH and testosterone/oestradiol
- Short Synacthen, cortisol, ACTH
56
Investigations in acromegaly
- OGTT: growth hormone does not suppress <2nmol/L
- IGF-1: disease progression
- MRI pituitary
- Automated perimetry (visual fields)
57
Management of acromegaly
- Trans-sphenoidal surgery = 1st line
- Radiotherapy
- Drugs
--- somatostatin analogue (octreotide) reduces GH secretion
--- Dopamine agonists (bromocriptine)
--- GH receptor antagonists (Pegvisomant)
58
Features of each Multiple Endocrine Neoplasia
- MEN1 = 3P = pit, para, panc
- MEN2a = 2P 1M = PTH, phaeo, medullary cancer
- MEN2b = 1P 2M = phaeo, marfan's, medullary cancer
59
Complications of pituitary surgery
- Diabetes insipidus (may be transient)
- SIADH (may be transient)
- Hypopituitarism
- CSF leak
60
Investigations for Addison's Disease
Short Synacthen test
- 250mcg tetracotaside
- Check cortisol before, 30mins, 60mins
- Normal: basal cortisol in the reference range, a cortisol rise
of >170nmol above the basal result and/or a peak cortisol > 530nmol/L
ACTH: raised in primary hypoalderstonism
CT adrenals
61
Management of Addison's Disease
- Hydrocortisone 20mg AM, 10mg night
- Fludrocortisone 100mcg (for postural hypotension)
- DHEA for post-menopausal women with low libido
- Double dose when unwell
- Medic alert bracelet
62
Management of Addisonian Crisis
- IV hydrocortisone: 100mg STAT --> 50mg QDS
- IV fluids
63
Types of Polyglandular Autoimmune Syndromes
Type 1 (AIRE mutation)
- Addison's
- Hypoparathyroid
- Mild immune deficiency (candida)
Type 2
- Addison's
- T1DM
- Thyroid disease
64
Nelson's Syndrome
- Bilateral adrenalectomy --> lots of ACTH (negative feedback) --> rapid enlargement pituitary microadenoma --> compress optic chiasm
65
Investigations for Cushing's Syndrome
- Pregnancy test!!!
- Low-dose dexamethasone suppression test (1mg at midnight --> 0900 cortisol >50nmol/L is Cushing's): normal in pseudo-Cushing's
- Midnight salivary cortisol
- 24hr urine cortisol (ideally 3x)
If positive:
- ACTH: inappropriately normal/elevated in pituitary and ectopic Cushing's
- High-dose dexamethasone suppression test (2mg QDS for 2 days -- measure cortisol at 0hrs and 48hrs)- suppressed is pituitary Cushing's, not suppressed is ectopic ACTH
- Adrenal CT: may find incidentaloma
- MRI pituitary
- Bilateral inferior petrosal sinus sampling (if nothing seen on MRI pituitary)
66
Management of Cushing's Syndrome
- Metyrapone while await definitive treatment (blocks 11b-hydroxylase = involved in steroid metabolism)
Pituitary Cushing's
- Transphenoidal resection +/- radiotherapy
Adrenal Cushing's
- Adrenalectomy
- Ketoconazole/metyrapone
67
Differentiate pseudo-Cushing's from Cushing's
Low-dose dexamethasone suppression test then CRH test
- Cortisol not increased in pseudo-Cushing's but is increased in Cushing's (as dexamethasone suppresses ACTH greater in pseudo-Cushing's vs Cushing's)
68
Causes of Cushing's
Pituitary adenoma
Adrenal
- Adenoma
- Hyperplasia
- Carcinoma
Ectopic
- Small cell lung cancer
Exogenous
- Steroids
69
Cause of Klinefelter's Syndrome
- 47 XXY (could also be XXXY or XYY)
70
Features of Klinefelter's Syndrome
- Infertility (leading cause in men!)
- Gynaecomastia + breast tenderness
- Hypogonadism: erectile dysfunction, low body hair, small testes, fatigue
71
Causes of male infertility
- Klinefelter's
- Kallman's: can't smell
- Haemachromatosis: joint pain, tanning, diabetes
- Fragile X: low IQ
72
Investigations for Klinefelter's
- High FH/LSH, low testosterone
- Karyotype (XXY)
- Bone mineral density
73
Management of Klinefelter's
- IM testosterone every 3 months (does not help with fertility!)
- Fertility assistance
- Cosmetic surgery for gynaecomastia
74
Diagnostic criteria in PCOS
Rotterdam criteria = 2 of:
- Amenorrhoea (no period in 3months if usually regular, or 6months if usually irregular)
- Hyperandrogenism (acne, hirsutism, male-pattern baldness)
- Polycystic ovaries seen on USS
75
Differential diagnosis for PCOS
- Congenital adrenal hyperplasia (high 17-hydroxyprogesterone)
- Androgen-secreting tumour (very high testosterone)
76
Cause of Turner Syndrome
- 45X (missing X chromosome in girl)
77
Complications of Turner Syndrome
Cardio
- Bicuspid aortic valve
- Aortic dissection
- HTN
Renal
- Horseshoe kidney
Gastro
- Coeliac
- Angiodysplasia
78
Management of Turner Syndrome
- Growth: recombinant growth hormone until growth <2cm/year
- Pubertal delay: low-dose oestrogen + cyclical progesterone
- Once cyclical periods induced: ovarian HRT (oestrogen + progestogen)
79
Features of Noonan Syndrome
Like Turner Syndrome but autosomal dominant so can occur in men
- NOT infertile
- Webbed neck
- Short
- Pectus excavatum
- Hypertelorism (long distance between eyes)
- Congenital heart defects: pulmonary stenosis, HOCM, tetralogy of Fallot
80
Investigations for arterial ulcer
- Ankle-brachial pressure index (0.9-1.2 is normal, <0.5 is severe arterial disease)
- Doppler ultrasound
81
Management of venous ulcer
- 4-layer compression bandaging (if no PVD)
82
Management of arterial ulcer
- Angioplasty
- Amputation
83
Complications of diabetic retinopathy
- Vitreous haemorrhage
- Traction retinal detachment
- Neovascular glaucoma (due to rubeosis iridis = new vessels on iris)
84
Causes of cataract
Congenital
- Turner syndrome
- Myotonic dystrophy
- Rubella
Acquired
- Old
- Steroids
- Diabetes
85
Signs specific to Graves eye disease
- Proptosis
- Exposure keratitis
- Chemosis (redness)
- Ophthalmoplegia
86
Progression of eye signs in Graves Disease
NO SPECS
- No signs
- Only lid lag/retraction
- Soft tissue involvement (periorbital oedema)
- Proptosis
- Extraocular muscle involvement
- Chemosis
- Sight loss (optic nerve compression/atrophy)
87
Condition to be careful when prescribing levothyroxine
- IHD (levothyroxine may worsen angina)
88
Complications of hypothyrodism
Cardiac
- Pericardial effusion (rub)
- CCF (oedema)
Neurological
- Proximal myopathy
- Carpal tunnel
- Ataxia
89
Why get pigmentation in Addison's
- Cleavage of POMC gives ACTH and MSH (melanocyte-stimulating hormone)
90
Uses of Wood's light (UV)
- Depigmentated = bright white
- Fungi (dermatophytes) = green
- Corynebacterium (erythrasma) = coral pink
- Porphyria = urine turns red
91
Papule vs nodule
- Papule: raised dome-shaped <0.5cm (lichen planus)
- Nodule: dome-shaped >0.5cm (acne vulgaris)
92
Vesicle vs bulla
- Vesicle: circumscribed cavity containing fluid <0.5cm (HSV)
- Bulla: >0.5cm (bullous pemphigoid)
93
Erosion vs ulcer
- Erosion: lose part of epidermis (pemphigus vulgaris)
- Ulcer: extends into dermis and below (venous ulcer)
94
Management of cutaneous lupus
- Strong suncream
- Stop smoking
- Discoid lupus: topical steroids (clobetasol)
- Oral steroids and steroid-sparing agents
95
Differential for malar rash
- Lupus
- Seborrheic dermatitis: scaly
- Rosacea: telangiectasia, papules/pustules--> worsened by heat, spicy food, alcohol
96
Differential for photosensitive rash
- Lupus
- Drug-induced: tetracyclines/quinolones, NSAIDs, diuretics
- Polymorphous light eruption: very itchy- starts 2days after sun and fades within a week
- Actinic dermatitis: sun-exacerbated eczema
97
Differential for discoid patches
- Discoid lupus
- Discoid eczema: not photosensitive, no scarring
- Psoriasis
- Tinea corporis: scaling/erythema at margins, central clearing
98
Differential for scarring alopecia
- Discoid lupus
- Lichen planus: itchy, violaceous, on wrists, not photosensitive
- Tinea capitis: children, scaling
99
Management of psoriasis
1st line = Topical
- Frequent emollients
- Vitamin D (calcipotriol)
- Topical steroids in flares
- Coal tar (stains skin brown)
2nd line = UVA phototherapy + psoralen (makes skin sensitive to UVA)
- 6 weeks at a time
- Side effects: blistering, erythema, CANCER
3rd = Systemic
- Retinoids (acitretin = teratogenic, dry lips)
- Methotrexate
- Biologics: adalimumab (anti-TNFa)
100
Triggers for psoriasis
- Trauma (Koebner phenomenon)
- Infections: beta-haemolytic strep
- Drugs: beta-blockers, NSAIDs, antimalarials
- Cold weather
- Smoking/alcohol
101
How to quantify skin condition's effect on patient's life
- Dermatology Life Quality Index
102
Most common areas for vitiligo
Hyperpigmented areas
- Face
- Dorsum
- Nipples
- Axilla
- Anus/genitals
103
Management of vitiligo
Conservative
- Psychological support
- Skin camouflage (make-up)
Medical
- Topical steroids
- Phototherapy if more widespread
- Depigmentation (bleaching): monobenzone cream
104
Pathogenesis of vitiligo
- No melanocytes--> no melanin (unclear why exactly)
105
Conditions associated with pyoderma gangrenosum
- IBD (UC)
- Rheumatoid arthritis
- Haem: acute and chronic myeloid leukaemia
106
Management of pyoderma gangrenosum
MDT approach!
- Bed rest/compression bandages
- Topical steroids, or prednisolone if large ulcers
- Steroid-sparing agents (ciclosporin, infliximab)
107
Skin changes in diabetes
- Infection
- Ulcers: neuropathic/arterial
- Necrobiosis lipoidica: on shins
- Diabetic dermopathy: brown scaly patches on shins
- Granuloma annulare
108
Diagnostic criteria for Haemorrhagic Hereditary Telangiectasia
- Epistaxis
- Telangiectasia at multiple sites
- Organ AVMs (brain, lungs, liver)
- 1st-degree relative with HHT
3 criteria = definite; 2 = suspected
109
Mode of inheritance for Haemorrhagic Hereditary Telangiectasia
- Autosomal dominant due to mutations in endoglin ( ENG) on chromosome 9 and activin receptor-like kinase 1 ( ACVRL1) on chromosome 12
110
Cause of porphyria cutanea tarda
- Lack enzyme uroporphyrinogen decarboxylase (UROD)--> accumulation of porphyrins in the skin
- Usually sporadic but can be autosomal dominant
111
Triggers for porphyria cutanea tarda
- Alcohol: reduced UROD activity
- Oestrogens (COCP)
- Liver disease: increased iron in liver reduces UROD activity
112
Differential for porphyria cutanea tarda
- Epidermolysis bullosa: mechanically induced bullae
- Epidermolysis bullosa acquisita: autoimmune, blisters on skin and mucous membranes (unlike porphyria)
- Pseudoporphyria: CKD and drugs (NSAIDs, doxycycline, diuretics)
113
Investigations for porphyria cutanea tarda
- Urine fluoresces red under Wood's light
- 24hr urine: uroporphyrins
- Liver screen + AFP if diagnosis made
114
Management of porphyria cutanea tarda
- Phlebotomy to reduce hepatic iron
- Low-dose hydroxychloroquine if phlebotomy does not work
- Remove triggers (alcohol)
115
Causes of Koebner phenomenon
- Psoriasis
- Vitiligo
- Lichen planus
116
Triad of features in Henoch-Schonlein Purpura
- Purpuric rash (legs/buttocks)
- Abdo pain
- Arthritis
117
Triggers for Henoch-Schonlein Purpura
- Infection: parvovirus B19, streptococcus, HSV
- Drugs: penicillin, minocycline, phenytoin
118
Cause of Henoch-Schonlein Purpura
- IgA vasculitis with C3 deposition
119
Complication of Henoch-Schonlein Purpura
- IgA nephropathy: proteinuria and haematuria
- HTN
120
Management of Henoch-Schonlein Purpura
- 90% resolve by themselves
- Steroids may help arthritis
121
Glass eye and ascites
- Ocular melanoma!
122
Different types of malignant melanoma
- Superficial spreading = 80%
- Lentigo maligna = face/scalp in elderly
- Acral lentiginous = palms/soles + subgungal
- Nodular = invade early
- Amelanotic
123
Prognostic marker in malignant melanoma
- Breslow thickness = how far tumour invades into dermis
- >4mm = 50% 5-year survival
124
Signs of severe asthma exacerbation which requires admission if persists after initial treatment
- PEFR 33–50 %best of predicted
- Respiratory rate > 25/min
- Heart rate > 110/min
- Inability to complete sentences in 1 breath
125
Management of migraine
Acute
1. Aspirin 900mg (max 4g per day) - paracetamol if pregnant
2. Oral triptan (not if IHD)
Chronic
- Propranolol/topiramate (not if pregnant)
126
Treatment of cluster headache
- Subcut/nasal triptans
- 100% O2
- Prophylaxis: verapamil 80mg TDS (ECG at baseline and 10 days --> can increase to 960mg OD)
127
NICE thresholds for HTN management
Clinic BP
- 140/90 to 179/119: do ambulatory monitoring
- >180/120: treat immediately if end-organ damage
Ambulatory BP
- 135/85 to 149/95: treat if 60-80 with end organ damage/co-morbidities/QRISK >10 (if <60, treat regardless)
128
NICE guidelines for HTN management
- Diabetes/<55yrs: ACEi then CCB then thiazide-like
- >55yrs or black: CCB then ACEi then thiazide-like
129
Variceal bleed- acute management
Initial
- Terlipressin (vasopressin agonist)
- Ceftriaxone
- OGD: band ligation = oesophageal, cyanoacrylate injection = gastic
Continued bleeding after OGD
- Balloon tamponade ±transjugular intrahepatic porto-systemic shunt (TIPS)
130
Non-variceal bleeding- acute management
Initial
- IV PPI
- OGD: adrenaline injection + cauterization
Continued bleeding after OGD
- Selective arterial embolization
- Surgery
131
Variceal bleeding- chronic management
- Non-selective beta-blocker (propranolol)
132
Scoring systems for upper GI bleed
- Rockall = mortality
- Blatchford = who need intervention
133
Features of upper GI bleed who can be discharged from A&E
- Age <60
- SBP > 100mmHg
- Pulse <100/min
- No significant comorbidity (especially heart/liver disease)
- No witnessed blood loss
134
Definition of sepsis
- Life-threatening organ dysfunction caused by a dysregulated host response to infection (SOFA score ≥2)
(SOFA score based on GCS, CVD, resp, coagulation, liver, renal function)
135
Definition of septic shock
- Need vasopressors to keep MAP 65 and lactate >2 despite IV fluids (40% mortality)
136
Differential diagnosis for peripheral vascular disease in legs
- Sciatica/cauda equina
- Anterior tibial compartment syndrome
- Osteoarthritis
137
What is Leriche's syndrome
Blockage of AAA as it goes into common iliac
- Bilateral leg pain
- Absent pulses
- Aorto-iliac bruit
- Impotence
138
Investigations for unprovoked DVT
- Cancer if signs/symptoms of cancer
- Antiphospholipid (must be off anticoagulant)
- Thrombophilia if also has 1st-degree relative with VTE (must be off anticoagulant): antithrombin, Protein C/S, Factor V Leiden
139
Duration of treatment for DVT
- Usually 3 months but may be longer if unprovoked
140
Contraindications for DOAC
- Moderate/severe chronic liver Disease (Child-Pugh class B or C)
- Creatinine clearance <15
- GI ulcer or varices
- Brain tumour with bleeding risk
- Arteriovenous malformations
- Weight <50kg or >120kg (warfarin to check if therapeutic)
141
Treatment of DVT if pregnant
- LMWH
142
CP450 inhibitors = increased warfarin
ASS-ZOLES
- Antibiotics (cipro, erythromycin, isoniazid)
- SSRIs
- Sodium valproate
- ZOLES (fluconazole, omeprazole)
143
CP450 inducers = reduced warfarin
SCARS
- Smoking
- Chronic alcohol
- Anti-epileptics (phenytoin, carbamazepine)
- Rifampicin
- St John's wort
144
Diagnostic criteria for rheumatoid arthritis
ACR/EULAR criteria (RA scores 6+)
A. Joint involvement:
- 2–10 large joints (1)
- 1–3 small joints (2)
- 4–10 small joints (3)
- > 10 joints (5)
B. Serology:
- Low + ve RF or anti-CCP antibody (2)
- High + ve RF or anti-CCP antibody (3)
C. Acute phase response, i.e. abnormal CRP or ESR (1)
D. Duration >6 weeks (1)
145
Which joint is spared in rheumatoid arthritis
- DIP
146
Extra-articular complications in rheumatoid arthritis
Haematology
- Felty Syndrome (RA + splenomegaly + neutropenia)
- Anaemia (check for pallor)
Skin
- Pyoderma gangrenosum
- Nodules
Eyes
- Scleritis/episcleritis
Cardiac
- Pericarditis/myocarditis
- Valve regurgitation
- Accelerated atherosclerosis
Respiratory
- Lower zone fibrosis
- Effusions
- Nodules
- Bronchiolitis obliterans
- Caplan Syndrome
Neurology
- Peripheral neuropathy
- Compressive neuropathy
147
Types of compressive neuropathy in rheumatoid arthritis
- Cervical myelopathy (atlanto-axial subluxation): spastic paraparesis, UMN signs, ± scar from previous surgery
- Ulnar neuropathy (elbow involvement).
- Carpal tunnel syndrome (wrist involvement).
148
X-ray features of rheumatoid arthritis
- Periarticular osteopaenia
- Erosions
- Joint space narrowing
- Deformity
149
Commonest ILD radiological subtype in rheumatoid arthritis
- NSIP (RA is inflammatory condition)
150
Management of rheumatoid arthritis
Conservative
- MDT approach (OT, physio)
Medical
- 1st = methotrexate and folic acid (5mg weekly), with short-course steroids while takes effect (also sulfasalazine/leflunomide)
- 2nd = biologics (infliximab, adalimumab)
Surgical if
- Not responding to medical
- Nerve compression (Carpal tunnel)
- Imminent tendon rupture
151
Management of rheumatoid arthritis flare
- Intra-articular methylpred if localised
- 2-4 week reducing regimen pred (starting at 20mg)
- NSAIDs with PPI cover
152
Blood tests before starting DMARD in rheumatoid arthritis
- FBC
- LFTs
- Hep B and C
153
Monitoring needed while on DMARD for rheumatoid arthritis
- 6-monthly clinical reviews: check for TB/fibrosis
- Regular bloods (FBC/LFTs/U&Es)- initially every 2 weeks
154
Side effects of methotrexate
- Hepatitis
- Alveolitis
- Stomatitis
- Toxicity: bone marrow suppression --> pancytopaenia--> opportunistic infections
155
Treatment for methotrexate toxicity
- FOLINIC acid
156
X-ray differences between rheumatoid arthritis and osteoarthritis
- RA: juxta-articular osteopenia, erosions, symmetry, deformity.
- OA: sclerosis, osteophytes.
- Both: bone cysts, joint space narrowing.
157
Management of psoriatic arthritis
- Methotrexate (also leflunomide)
- Avoid prednisolone as skin can flare when withdraw
- Anti-TNFa (infliximab) for severe
158
Forms of psoriatic arthritis
- DIP involved (like OA)
- Large joint mono/oligoarthritis- with massive effusions
- Seronegative (similar to RA)
- Sacroiliitis (like ank spond)
- Arthritis mutilans (very severe)
159
Features suggestive psoriatic arthritis vs rheumatoid
- Asymmetry
- Nail changes (POSH)
- Dactylitis (inflammation of entire digit = sausage digit)
- Negative CCP
- Family history of psoriasis
160
HLA associations in psoriatic arthritis
- B38/B39 = peripheral distal arthritis.
- DR4 = rheumatoid
- B27 = sacroiliitis
161
Features in ACR diagnostic criteria for SLE
ANA >1:80 = a must
Then need score of 10 based on following domains:
- Renal
- Mucocutaneous
- Haem
- Constitutional
- Neuropsychiatry
162
Skin features in SLE
- Malar rash
- Discoid
- Alopecia
- Mouth ulcers
- Vasculitic rash (palms usually)
163
Systemic manifestations of SLE
- Cardio: Libman-Sacks endocarditis (AR/MR)
- Resp: fibrosis/effusions
- Renal: hypertension
- Neuro: cranial nerve lesion, transverse myelitis
164
Investigations for SLE
- Immune tests: ANA, dsDNA, C3/4
- CXR: fibrosis/effusion
- Echo
- Skin and renal biopsy: Ig and C3 deposition
165
Management of SLE
- 1st line = hydroxychloroquine (check vision before as causes retinal toxicity)
- Also other immunosuppressants
- Statin as high CVD risk
- Rituximab (anti CD20)
- IV immunoglobulin and plasmapheresis in severe flares not responding to steroids
166
Investigations to show if SLE is active
- Urine: red cell casts
- ESR
- C3 and C4 fall
- Anti-dsDNA rise
167
Side effects of cyclophosphamide
HITI
- Haemorrhagic cystitis (reduced as now take mesna before and after each infusion)
- Infection: reactivation of latent and bone marrow suppression (10 days after infusion)
- Teratogenic
- Infertility
168
Special test in Sjogren's Disease
- Schirmer's = 5mm filter paper placed in lower eyelid--> patient closes eye--> expect moisture to migrate 15mm in 5mins
169
Investigations in Sjogren's Disease
- Anti Ro and La
- Schirmer's test
- Salivary gland biopsy
170
Cause of Sjogren's Disease
- Usually secondary to other connective tissue disease (SLE/RA)
171
Limited vs diffuse cutaneous systemic sclerosis
- Limited (slow) = distal to knees and elbows, facial involvement, but the trunk is spared
- Diffuse (rapid) = proximal to the elbows and knees; organ involvement
- Note: CREST is subtype of limited (scleroderma should not extend beyond the MCPs)
172
Causes of secondary Raynaud's
- Systemic sclerosis (v. unlikely to be this if no Raynaud's!)
- SLE
- Sjogren's
- Dermatomyositis
- Mixed connective tissue disease (SLE/scleroderma/polymyositis)
***so when see Raynaud's patient, don't just assume it is systemic sclerosis and need to ask questions to exclude the others!***
173
Systemic manifestations of systemic sclerosis
GI
- Oesophageal dysmotility
- Small/large bowel involved in 50% = malabsorption and bacterial overgrowth (--> 3 D's = dysphagia/dyspepsia/diarrhoea)
Respiratory = leading cause of death in systemic sclerosis
- ILD (NSIP)
- Pulmonary HTN (palpable P2, parasternal have = RVH, heart failure)
Sclerodermic renal crisis
- Sudden severe HTN --> CCF, rapid renal failure, microangiopathic haemolytic anaemia
174
Antibodies in systemic sclerosis
- ANA (90% of all patients)
- Anti-topoisomerase = diffuse
- Anti-centromere = limited
175
Management of systemic sclerosis
No treatment affects disease progression...
- Raynaud's: nifepidine and sildenafil (iloprost infusion if gangrene)- also heated gloves!
- Gut dysmotility: erythromycin (pro-kinetic)
- Renal crisis: ACEi
176
Colour changes in Raynaud's
- White (vasoconstriction) --> blue (cyanosis) --> red (blood rushes back- painful)
177
Most common arthritis in men over 40
- Gouty arthritis
178
Stages of gouty arthritis
- Asymptomatic hyperuricaemia
- Acute gouty arthritis
- Intercritical gout (interval between attacks)
- Chronic tophaceous gout.
179
Commonest places for gout
- Hallux (big toe)-- "podagra" is gout involving big toe
- Arch of foot
- Ankle
180
Triggers for gout
- Alcohol
- Shellfish/oily food/legumes (lentils/chickpeas)
- Dehydration
- Infection
- Trauma
181
Medical conditions that predispose to gout
- CKD
- Hypothyroidism
- Diabetes
- Polycythaemia rubra vera
- Myeloproliferative/lymphoproliferative
182
Drugs that increase urate levels
- Thiazides
- Low-dose aspirin
- Pyrazinamide/ethambutol
- Ciclosporin
- Levodopa
183
Features of gout on XR
- Punched out erosions ("mouse bites")
- No juxta-articular osteopaenia = differentiates from other inflammatory arthritis
- Joint space loss in late disease
184
Management of acute gout
- High-dose naproxen with PPI cover (continue 2 days after end of attack)
- Colchicine (contraindicated in blood disorder + severe renal/liver failure)
- Pred 30mg for 5 days
185
Indications for allopurinol in gout
- >3 flares a year
- CKD stage 3+
- Gouty arthritis
- Tophi
- On diuretics
186
Management of chronic gout (including urate targets)
Allopurinol (febuxostat is 2nd line)
- 2 weeks after acute gout
- Aim for urate <360micromol/L (or <300 if gouty tophi)
- Cover with colchicine initially
187
Mechanism of allopurinol
- Inhibits xanthine oxidase that catalyses the conversion of hypoxanthine to xanthine, and xanthine in turn to uric acid.
188
Important interactions in gout medications
Allopurinol
- Azathioprine (allopurinol increases effect = bone marrow suppression)
- Warfarin (allopurinol increases effect)
Colchicine
- Statins (colchicine increases effect = myopathy)
- Ciclosporin (increased nephrotoxic effect)
189
Causes of acute hot joint
- Septic
- Gout/pseudogout (wrist/knee)
- Palindromic rheumatism
- Polyarticular condition (reactive arthritis, psoriatic arthritis)
- Avascular necrosis (steroids/sickle cell)
- Bleeding (haemophilia)
190
Causes of reactive arthritis
- STD: Chlamydia
- Gastroenteritis: Campylobacter, Salmonella, Shigella, or Streptococcus
191
Contraindications to joint aspirate
- Prosthetic joint (done in Theatre)
- Overlying cellulitis
- Overlying psoriasis (increases risk of septic arthritis)
192
Gout vs pseudogout crystals
- Gout: negatively birefringent needles
- Pseudogout: positively birefringent rods
193
Features of polymyalgia rheumatica
- Proximal myalgia affecting shoulders and pelvic girdle
- Sudden onset (wake up with symptoms!)
- Stiffness worse in morning/after rest
- Can't lift hands above head = classic!
194
Age and ethnicity for Giant Cell Arteritis
- Over 50 always!
- Northern European
195
Differentials for polymyalgia rheumatica
- Myositis: muscle weakness, Gottron’s papules/heliotrope rash/lung fibrosis
- Glenohumeral osteoarthritis: globally restricted shoulder movements +/- crepitus
- Rotator cuff tear: painful arc on abduction
- Rheumatoid arthritis: synovitis
196
Management of Giant Cell Arteritis
- Prednisolone 60mg
- Pulsed methylprednisolone if visual symptoms
- Consider alendronic acid/DEXA
197
Extra-articular manifestations of ankylosing spondylitis
4 A's
- Aortic regurgitation
- Anterior uveitis
- Achilles tendonitis
- Apical fibrosis
198
Differential for ankylosing spondylitis
- Psoriatic sacroiliitis
- IBD-associated spondyloarthropathy
- Paget's
- Hyperparathyroidism
- Mets
199
Severity grading system for ankylosing spondylitis
- BASDAI (Bath Ankylosing Spondylitis Disease Activity Index)--> 4+ is active disease
200
X-ray features of ankylosing spondylitis
- Sacroiliitis (sclerotic/erosions)
- Syndesmophytes (bony outgrowth from spinal ligament)
- Bamboo spine
201
Management of ankylosing spondylitis
1. NSAIDs and physio
2. Anti-TNFa (if not respond to 2 NSAIDs)
Intrarticular hydrocortisone for enthesitis
202
Complications of Paget's Disease
- Skeletal: fracture
- Cardiac: angina, high-output cardiac failure
- Neurology: deafness (auditory nerve entrapment), cerebral ischaemia due to steal syndrome (increased bone metabolism)
- Metabolic: hypercalcaemia (with immbolisation/fracture)
- Oncology: osteogenic sarcoma
203
X-ray features of Paget's Disease
- Osteoclastic and/or osteoblastic lesions
- Trabecular thickening of inner pelvis
204
Management of Paget's Disease
- Bisphosphonates if symptomatic: risedronate for 2months or STAT IV zolendronic acid
205
Bisphosphonate side effects
- Oesophagitis/ulcer
- Osteonecrosis of jaw
- Systemic symptoms: myalgia, flu-like
206
Risk score for unstable angina/NSTEMI
- TIMI (>3 is high risk for mortality)
207
Bacterial vs viral lumbar puncture results
- Bacterial: high protein, low glucose, high neutrophils, see microbe
- Viral: normal protein, normal glucose, mononuclear cells (lymphocytes/monocytes)
208
Diagnostic criteria for DVT
- >3cm increase in calf swelling (10cm below tibial tuberosity)
209
DVLA rules for syncope
- Unclear cause: 6 month driving ban
- Treated cause: 4 weeks
- Syncope due to seizures: seizure-free for 1 year
210
Side effect of hydroxychloroquine
- Retinopathy
211
Side effect of sulphasalazine
- Bone marrow suppression
- Rash
212
Side effect of azathioprine
- Bone narrow suppression
213
What is Jaccoud's athropathy
- Tendon contractures --> mimics rheumatoid arthritis
- Associated with SLE, rheumatic fever, Sjogren's
214
Features of reactive arthritis
- Can't see: conjunctivitis
- Can't pee: urethritis
- Can't climb a tree: asymmetrical lower limb oligoarthritis (esp knee)
Also:
- Keratoderma blennorrhagia (plaques on soles)
- Circinate balanitis (penile ulcers)
215
Features of amyloidosis
- Very high JVP (high right heart pressures)
- Ankle oedema
- Periorbital purpura
- Macroglossia
- Constitutional symptoms
216
Diagnosis of amyloidosis
- Congo red stain: apple-green birefringence
- Serum immunofixation (shows monoclonal protein)
- Immunoglobulin free light chain assay
217
Management of amyloidosis (primary)
- Mephalan (chemotherapy) --> stem cell transplant
218
Features of hypertensive retinopathy
1: Silver wiring (arteriole walls sclerosed)
2: +Arteriovenous nipping (arteriole crosses venule, compressing it)
3: +Cotton wool spots and flame haemorrhages
4: +Papilloedema
**SAF was a Cool Person**
219
Fundoscopy features of retinitis pigmentosa
- Peripheral pigmentation in retina
- Narrowing of retinal vessels
- Pale optic disc (neuronal loss)
220
Fundoscopy features of retinal artery occlusion
- Cherry red spot (macula gets blood supply from choroid)
- Pale retina
- Attenuated vessels
221
Fundoscopy features of retinal vein occlusion
- Flame haemorrhages
- Swollen optic disc
- Dilated tortuous veins
- Cotton wool spots (microinfarcts)
222
Aspects of an ulcer which need to be described
- Shape
- Edge
- Base
- Floor
- Secretions
223
Examination for rheumatoid arthritis
Look
- Place hands on white pillow
- Wrist --> MCP --> DIP --> PIP
Feel
Move
- Fist
- Stopping traffic
- Fingers pointing down
- Prayer sign
- Finger abduction
- Hold paper between fingers while examiner tries to pull the paper out
- Grip and pincer strength
- Undo a button/play the piano
- Sensation
- Write something
- Pallor/inside mouth
224
Mechanism of methotrexate in rheumatoid arthritis
- Inhibits T and B cells
- Inhibits purine synthesis (hence need folic acid)
225
Causes of anaemia in rheumatoid arthritis
- Anaemic of chronic disease
- GI bleeding (NSAIDs)
- Bone marrow suppression (DMARDs)
- Megaloblastic anaemic
- Haemolytic anaemia
226
Cause of Ehlers-Danlos
- Genetic mutation (autosomal dominant)--> reduced collagen
227
Investigations in Raynaud's
- Autoimmune screen (ANA, ENA, dsDNA, complement, ESR)
- Urine dip (protein/haematuria)
- ECG to check right heart strain/conduction abnormality-- so also listen to heart for loud P2 and feel for RV heave (pulmonary HTN due to diffuse systemic sclerosis)
- CXR (fibrosis)
228
Definition of gestational HTN
- BP >140/90 after 20 weeks gestation (before 20 weeks gestation is "pre-existing HTN")
229
Types of pre-eclampsia
- Early-onset = before 34 weeks (causes IUGR)
- Late-onset = after 34 weeks (no IUGR)
230
Definition of severe pre-eclampsia
- BP >160/110
- Symptoms
- Biochem/haem derangement
231
Symptoms/signs of pre-eclampsia
- Worst headache ever!
- Epigastric pain (bleed in liver due to coagulopathy)
- Sudden oedema affecting fingers/sacrum
- Brisk reflexes (CNS irritability)
- Ankle clonus
232
Complications of pre-eclampsia
- Eclampsia = grand mal seizures (LOC and tonic-clonic)
- Stroke
- AKI
- HELLP (Haemolysis, Elevated Liver enzymes, Low Platelets)
- IUGR/foetal death
233
Investigations for pre-eclampsia
- 2+ proteinuria
- Urine protein/creatinine ratio >30mg/mmol
- Monitor foetus
234
Management of pre-eclampsia
- Labetalol (nifedipine if asthmatic)
- Aspirin 75mg from 12 weeks gestation if high-risk for pre-eclampsia
- Deliver by 36 weeks
235
Management of eclampsia seizure
- IV magnesium
236
When to check d-dimer in DVT
- If Wells Score is 1 or less
- If Wells Score is 2+ but USS normal or cannot do USS within 4hrs
237
Important blood tests in acutely painful knee
- HLA-B27 (+ve in 50% of reactive arthritis)
- Urate
- Anti-CCP/rheumatoid factor
238
Complications of acromegaly
- Cardiac: cardiomyopathy/IHD
- Diabetes
- HTN
- OSA
239
Important complication of trans-sphenoidal surgery in acromegaly
Hypopituitarism
- T4
- LH, FSH and testosterone/oestradiol
- Short Synacthen, cortisol, ACTH
240
Drug causes of hyperthyroidism
- Iodine
- Amiodarone
- Lithium
- Contrast
241
Nail changes in psoriasis
POSH
- Pitting
- Onycholysis
- Subungal hyperkeratosis
242
Psoriasis variants
- Guttate
- Flexural: intertriginous areas
- Pustular: palms/soles
- Erythrodermic
243
Bullous pemphigoid vs pemphigus vulgaris
Bullous pemphigoid
- Deep = doesn't rupture
- Doesn't affect mucosal
Pemphigus vulgaris
- Superficial = ruptures
- Mucosal involvement
244
Features of high-risk proliferative retinopathy
- New vessels on/adjacent to disc > 1/4 of the area of the disc in size
- OR any new vessels causing vitreous haemorrhage
--> Needs pan-retinal laser coagulation within 2 weeks
245
Features of Turner Syndrome
- Webbed neck
- No secondary sexual characteristics (pubes)
- Cubitus valgus
- Widely-spaced nipples
- Shortened 4th/5th metacarpals
- Nail dysplasia
246
Counselling needed before radio-iodide
- Up to 4 weeks away from children/pregnant women (bad for teachers!)
- Away from confined spaces/same bed as someone for a few days
- No pregnancy for 4 months
- Can worsen eye disease
- May set off alarms in airports!
247
Other causes for goitre (apart from thyroid conditions)
- Iodine deficiency
- Pregnancy
- Puberty
248
Differences in the types of amiodarone-induced hyperthyroidism
Type 1
- Due to high iodine content of amiodarone
- In pre-existing thyroid condition (latent Graves/multinodular thyroid)
- 3 months onset
- Treatment: high-dose carbimazole
Type 2
- Destruction of thyroid--> release of T4
- In healthy people
- 30 months onset
- Treatment: steroids
249
Investigations for male infertility
- Morning testosterone
- Sex hormone binding globulin (high as binds to testosterone = less active free testosterone)
- FH/LSH (high in primary testicular failure)
- Semen analysis
- Pituitary scan if above investigations normal
250
Causes of female infertility
Hypothalamic-pituitary: hypopituitarism, Kallman (hypogonadism), anorexia (amenorrhoea)
- Low FSH/LH
Hypothalamic-pituitary-ovarian dysfunction: PCOS, hyperprolactinaemia
- Normal FSH/LH
Ovarian failure: premature ovarian insufficiency
- High FSH, low oestrogen
Others: uterine, tubal disorder, genetics (Turner's)
251
Investigations for female infertility
- Mid-luteal progesterone (cycle length - 7): should be high as ovulation creates corpus luteum which makes progesterone
- Testosterone (PCOS)
- Prolactin
- FSH/LH
- Ultrasound
252
Investigations in C1 esterase inhibitor deficiency
- Low C4, normal C3
- Low C1q
253
Important social history question in palpitations
- Caffeine intake!
254
Important question to ask in joint pain (especially if young)
- Joint hypermobility (if yes, ask about pneumothorax)
255
Two arachnodactyly signs
- Thumb and pinky can overlap around wrist
- Thumbnail folded across palm protrudes beyond ulnar
256
Investigations for Marfans and its complications
- Genetic testing (autosomal dominant mutation FBN1 gene)
- Echo (cardiomyopathy)
- Ophthalm referral (lens dislocation)
- MRI spine (dural ectasia)
- Pelvic XR: acetabular protrusion (femur head protrudes into pelvis)
257
Types of Ehlers-Danlos
- Hypermobile
- Classic
- Vascular
- Kyphoscoliosis
258
Important drug classes you need to ask about in haematemesis/PR bleeding
- NSAIDs
- Anticoagulants
259
Key investigation in acute intermittent porphyria
- Urine porphobilinogen (high)
260
Management of acute intermittent porphyria
- High carb diet with IV dextrose
- Haem arginate
- Haematology referral
261
Beta-blocker commonly used in thyrotoxicosis
- Propranolol (non-cardioselective)
262
Drugs which cause optic neuropathy
- Ethambutol
- Amiodarone
- Linezolid
- Ciprofloxacin
- Sildenafil
263
Other causes of pigmented retina (apart from retinitis pigmentosa)
- Infectious: rubella, syphilis, toxoplasmosis
- Drugs: hydroxychloroquine
- Angioid streaks in pseudoxanthoma elasticum
264
Management of Hereditary Haemorrhagic Telangiectasia
- Treat iron-deficiency anaemia!
- Nasal humidification/spray (keep it moist)
- Cauterisation and laser therapy
- Screening for AVMs
265
CASPAR diagnostic criteria for psoriatic arthritis
- Current psoriasis (2 points)
- Psoriatic nail changes
- Dactylitis
- Negative rheumatoid factor
- Juxta-articular new bone formation
Need to score ≥ 3 points
266
Examination findings in Paget's Disease
- Frontal bossing
- Bowing and warmth of arms and legs
- Hearing loss (CN 8 - otosclerosis)
- Heart failure
267
Pathogenesis of Paget's Disease, including stages
- Accelerated bone turnover and abnormal bone remodelling --> deformity and enlargement of bones (axial skeleton especially)
- Osteolytic phase --> mixed phase (osteoblastic and osteoclastic) --> burnt out quiescent osteosclerotic phase.
268
Causes of tunnel vision
Retinal
- Retinitis pigmentosa
Optic nerve
- Glaucoma
269
Mechanism behind panretinal laser photocoagulation
- Burn peripheral vessels --> directs blood towards ischaemic vessels in centre --> less VEGF
270
Differential for RAPD (apart from optic nerve issue)
- Massive retinal detachment
271
Normal optic cup:disc ratio (as a %)
- 30%
272
4 types of spondyloarthropathy
- Ank spond
- Psoriatic
- IBD
- Reactive arthritis
273
Skin signs for dermatomyositis
- Gottron's papules
- Heliotrope rash
- V-neck sign
274
Why might rheumatoid cause painful walking
- Subluxation (partial dislocation) of toe joints --> joint sticks out into sole --> keep on walking on this joint, causing painful callus
275
Importance of hyperpigmentation in Addison's
- Shows Primary (as increased ACTH), not Secondary
276
Differential for Port Wine Stain
- Sturge-Weber: seizures, low IQ, brain angiomas
- Klippel-Trénaunay syndrome: increased vessels one side, increased limb size on one side
277
Causes of skin hyperpigmentation
- Primary Addison's
- Haemochromatosis
- Drugs: amiodarone, chemotherapy
- Paraneoplastic secreting ACTH
278
Erythematous maculopapular rash with scarring alopecia
- Discoid lupus
279
Conditions which trigger pseudogout
- Haemachromatosis
- Acromegaly
- Hyperparathyroidism
- Hypothyroidism
- Wilson's
280
Criteria for referring rheumatoid arthritis to surgeons
- Not responding to medical
- Nerve compression (Carpal tunnel)
- Imminent tendon rupture
281
Features of Ehlers-Danlos
Skin/joints
- Fragile hyper-extendable skin (bruises)
- Joint dislocations
Cardiac
- Mitral valve prolapse (pansystolic with ejection click)
Abdo
- AAA rupture (may have scar!)
- Bowel perforation
282
Hearing loss differential
- Paget's (hypercalcaemia, increased hat size, easy fractures, heart failure symptoms)
- Acoustic neuromas
- Drug-induced (furosemide, aminoglycosides)
Remember to do Rinne/Weber's and otoscopy!
283
Phaeochromocytoma management
- Alpha blockade (phenoxybenzamine - can cause reflex tachy by increasing noradrenaline release)
- Then Beta blockade (metoprolol- to treat tachy)
- IV fluids
- High salt diet on 3rd day after alpha blockade ( counteract catecholamine-induced volume contraction and orthostasis, which can be associated with alpha-adrenergic blockade)
- IV phentolamine --> sodium nitroprusside infusion for hypertensive crisis
284
Phaeochromocytoma management
- Alpha blockade (phenoxybenzamine - can cause reflex tachy by increasing noradrenaline release)
- Then Beta blockade (metoprolol- to treat tachy)
- IV fluids
- High salt diet on 3rd day after alpha blockade ( counteract catecholamine-induced volume contraction and orthostasis, which can be associated with alpha-adrenergic blockade)
- IV phentolamine --> sodium nitroprusside infusion for hypertensive crisis
285
Why do alpha blockade before beta blockade in phaeochromocytoma
Because beta blockade first may lead to unopposed alpha stimulation --> vasoconstriction and hypertensive crisis
