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station 5 Flashcards

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1
Q

Causes of pyoderma gangrenosum

A

IBD (UC)
Sarcoidosis
Idiopathic
TB
Haematological malignancies, myeloproliferative disorders
Rheum - RA, ank spond, seronegative arthritis, SLE
Liver - PBC

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2
Q

Ix for non-healing ulcer

A

Bloods to look for underlying condition - autoimmune screen
Biopsy of the ulcer (pyoderma, Marjolin’s)
Imaging - colonoscopy, CT

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3
Q

Psoriasis
Types / classification
Triggers / exacerbating factors
Key management points

Measuring effect on QOL

Complications

A 
Types:
Plaque
Pustular (palmar/plantar or generalised)
Guttate (post-infection)
Flexural 
Brittle (can be post steroids)
Erythrodermic
Psoriatic arthropathy (10-30%)

Triggers / exacerbating factors:
NSAIDs, Li, beta blockers
Trauma
Infection

Mx:
Topical - emollient and calcipotriol (vit-D derivative) +/- topical steroid (hydrocortisone)
Can also add dithranol, tar, topical retinoids and salicylic acid (keratinolytic)

Systemic:
Phototherapy 
DMARDs - methotrexate, ciclosporin as first line agents 
Retinoids
Biologics

Disease severity score:
DLQI - max 20 (very bad)
PASI - needed prior to biologics

Complications:
Psychosocial effects
Psoriatic arthropathy
Increased independent cardiovascular risk

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4
Q

Indications for bisphosphonate / bone protection

A

Those who have been taking steroids for over 3mths, or are likely to, AND

Age over 65
Under 65 but with fragility fracture (NOF)
Under 65 without fragility fracture but T-score <1.5

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5
Q

Drugs that can worsen Raynauds

A

Beta blockers
Cocaine
Sumatriptan

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6
Q

Key things to ask about if suspect CREST (Hx)
Key things o/e
Other things to examine

A

Raynauds sx
Oesophageal dysmotility and red flags
Fibrosis - ILD, renovascular disease causing htn
Other autoimmune conditions

O/e:
Calcinosis and Raynauds of fingers
Sclerodactyly
Face - tight shiny skin, telangiectasia 
Hand function

Other:
Lung for ILD
BP - CREST is RF for malignant htn
Cardiovascular system - pul htn

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7
Q

Difference between Raynaud’s disease and Raynauds syndrome

A

Disease - colour change seen in fingers occurs in isolation without any associated condition

Syndrome (secondary) - Raynaud’s phenomenon occurs as a result of an associated condition (SLE, CREST)

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8
Q

Crohns disease

Indications for biologics

A

Fistulating disease
Disease refractory to steroids
Pts not suitable for surgery - eg short bowel, diffuse disease

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9
Q

Crohns disease

Indications for surgery

A

Emergency - perforation, intractable haemorrhage, failure of medical management of acute flare (obstruction or dilatation)

Elective - abscess, fistula, carcinoma; failure of medical mx, perianal disease (likely complex)

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10
Q

Crohns disease

Acute management of flare

A

ABCDE assessment, IVF, NBM
Induce remission - oral/IV steroids depending on severity of flare
5-ASA second line, with azathioprine/mercaptopurine or methotrexate if no response to 5-ASA
Inflixiamb third line acutely

Ix:
Obs, bloods, imaging

Mx:
Abx, steroids, analgesia, muscle relaxant

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11
Q

Indications for colonoscopy in context of UC and frequency

A

5yrly
No active inflammation
L sided colitis only
Crohns colitis in <50% of bowel

3yrly
Mild active inflammation
Polyps
Fhx colorectal malignancy occurring >50yrs

Yrly
Mod to severe inflammation
Stricture
Prev dysplasia 
PSC or gallbladder involvement 
Fhx colorectal malignancy <50yrs
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12
Q 
RA hx
Features of examination 
Ix
Scoring system 
Mx
Complications 
Poor prognostic factors
A 
Joint pain, stiffness, swelling
Function 
Progression 
Numbness / sensory change 
Weakness

Systemic sx - Fever, fatigue

O/e:
Hands, wrists, elbows
Lungs
Eyes 
Carpel tunnel 
Ix:
Bloods incl RF and CCP
Hand and foot XR; wrist XR 
CXR 
USS joints if effusion

DAS28 score - aim <3 (>5.1 = high; <2.6 = remission)
Number of tender/swollen joints
Subjective perception of disease activity
ESR

Mx:
Aim to induce and maintain remission

Cons - PT, stop smoking

Med - analgesia, start methotrexate with short bridging course of steroids (methotrexate CI if nodule positive)
Biologics if 2 DMARDs have failed consecutively
Steroids for acute flare

Surgical - joint replacement, tendon reconstruction

Complications:
Disease related - Progression of disease, deformity, loss of function, extra-articular manifestations, megaloblastic anaemia, haemolytic anaemia
Treatment-related - steroids, immunosuppression, GI bleed from NSAIDs, BM suppression from DMARDs

Poor prognostic factors:
Seropositive disease (RF, anti-CCP)
Poor functional status at presentation 
Early erosions on XR 
Extra-articular disease
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13
Q

Extra-articular manifestations of RA

A 
Lung - pleural effusion, ILD
Heart - pericarditis 
Carpel tunnel syndrome
Splenomegaly 
Anaemia of chronic disease 
Amyloidosis and renal impairment 
Eyes - scleritis / episcleritis
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14
Q

CXR changes in sarcoidosis

A 
Stage 0 - normal CXR
Stage 1 - BHL alone
Stage 2 - BHL with pulmonary infiltrates / reticulonodular changes 
Stage 3 - Pulmonary infiltrates alone
Stage 4 - fibrosis
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15
Q

Which skin feature is pahthognomic of sarcoidosis

A

Lupus pernio - malar rash

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16
Q

Lupus pernio is pathognomic of which condition

A

Sarcoidosis

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17
Q

Triggers worsening gout

A

Diet - purine rich
Alcohol
Drugs - thiazides, loop diuretics, aspirin
Renal impairment

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18
Q

Features on examination of Marfans

A 
Increased arm span (arm:height >1.05)
Lens dislocation - upward 
Aortic regurgitation and mitral regurg
AAA
High arched palate
Skin stretch marks 
Thumb across palm with fingers over
Bend thumb to wrist 
Bend little finger backwards 
Thumb and little finger around wrist
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19
Q

Tx for Raynauds

A

Tx underlying cause if present

Cons - stop smoking, gloves
Medical - CCB (nifedipine), PDEi (sildenafil), topical GTN

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20
Q

Features to ask about in presence of Raynauds

A 
Digital ulceration 
Mouth ulcers 
Dysphagia, reflux, malabsorption
Serositis - pericarditis, pleurisy
Eyes
Rash
Joint pain
Alopecia 
Dyspnoea - ILD, Pul htn
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21
Q

Complications of acromegaly

A

Compression - bitemporal hemianopia
Diabetes
CV - cardiomyopathy
Increased risk of GI malignancy

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22
Q

Features of acromegaly

A

G - hypogonadism
T - hypothyroidism
A - hypoadrenalism

Hyperprolactinaemia - galactorrhea 
DM - polyuria, polydipsia
Proximal muscle weakness
Carpel tunnel 
Htn - headache
Hypercalcaemia - stones
Hx of bowel polyps / malignancy
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23
Q

Focussed examination of acromegaly

A 
Insp - coarse features
Bitemporal hemianopia
Evidence of carpel tunnel syndrome 
Hearing aids 
Fundoscopy to assess papilloedema 
Proximal weakness
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24
Q

Acromegaly
Ix
Tx

A

Dx - IGF, OGTT with no suppression of GH

Ix - BP, ECG, MRI head, pituitary function testing, visual field testing, echo (for hypertrophy)

Tx:
1st line - surgery

2nd - medical:
Somatostatin analogues - octreotide
Dopamine agonists - cabergoline, bromocritpine
GH antagonists - pegvisomant

Radiotherapy
Tx complications - DM, htn, carpel tunnel

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25
Ddx of acutely painful knee
``` Reactive arthritis RA Psoriatic arthritis Gout / pseudogout Septic arthritis ```
26
Htn and hypo-K Ddx Ix Mx
Ddx: Hyperaldosteronism - Conns, Cushings, renal artery stenosis Liddles syndrome - pseudohyperaldosteronism - tx with amiloride for direct ENaC antagonism Ix: Screening - renin:aldosterone ratio, having stopped anti-htn drugs and diuretics Confirmation - saline suppression test - aldosterone doesn't fall with saline load Imaging - CT/MRI adrenals looking for adenoma or bilateral adrenal hyperplasia To distinguish one side from the other - adrenal vein sampling for raised aldosterone Mx: Medical - spironolactone and eplerenone If glucocorticoid suppressible - steroids (1-3%) Surgical - resection of adenoma or adrenalectomy
27
Ix for suspected Cushings Mx
Ix: 24hr urine cortisol Low dose dexamethasone suppression test - cortisol should suppress. If not -> Cushing's disease or ectopic ACTH release If no suppression, high dose dex suppression test. If cortisol suppresses -> pituitary adenoma secreting ACTH, if no suppression -> ectopic source of ACTH Imaging of pituitary Mx: MDT - PT Medical - bone protection, ketoconazole/metyrapone (inhibit cortisol synthesis) Surgical - resection of source (pituitary, lung, adrenal) Bilateral adrenalectomy if refractory disease with ectopic ACTH Can consider radiotherapy
28
Back/neck pain and stiffness Hx: Examination Ix Mx Scoring system
``` Hx: Duration and worsening Triggers Occupation and function FLAWS Sx of caudal equina Neurology Sciatic pain Associated features of any spond - heart (AR, AV node block), lung (ILD), Achilles tendonitis, amyloid (CTS), eyes (ant uveitis) Enthesitis - plantar fasciitis Red flags - night pain ``` Questions / concerns O/e: Neck/back - look, feel, move. Flexion, lateral flexion, extension and rotation at neck and back Sacroiliac pain Other features - Schobers test, wall test (wall-occiput) ``` Ix: Bloods incl HLA-B27 XR - neck/back, CXR, sacroiliac joints Echo Spirometry MRI ``` Mx: MDT - PT, OT, rheumatology (consider DMARDs) Analgesia Bone changes - squaring of the vertebrae, syndesmophytes, sacroiliitis BASDAI (Bath ank spond disease activity index) - >4/10 -> active disease
29
Prolactinoma | Classification
Micro vs macro Mx: 1st line - medical - cabergoline If compression causing bitemporal hemianopia - surgery is 1st line Replacement of pituitary hormones if necessary
30
Osteogenesis imperfecta
Problem with collagen type 1 Mainly AD inheritance, some AR Type 1 commonest - Type 2 - lethal Type 3 - progressive Type 4-8 also Hx: Fractures and surgery FHx ``` O/e: Bowing of bones Evidence of fractures Blue sclera Hearing aids ``` Ix: Genetic analysis Monitor with echo for aortic root dilatation Mx: MDT Bone protection
31
Acute back pain Hx Examination
Red flags - rule out cord compression, caudal equina and possible malignant cause
32
How to distinguish between a squint an an ocular nerve palsy
Cover the other eye A squint will correct A nerve palsy (eg CNIII) will not
33
Rules of driving and diabetes | When must the DVLA be informed
Pt must inform DVLA if: At risk of hypoglycaemia Visual impairment or have required laser treatment Neuropathy requiring eg automatic car or hand controls On insulin Pt must not drive if: Hypo requiring third party help Hypoglycaemic unawareness Found behind the wheel having a hypo For commercial or HGV licence: Good control for past 12mths, at necessary times of the day Can provide evidence of 3mths of good control with no hypos
34
Deranged LFTs Causes Ix Mx
x
35
Bowels loose Causes Ix Mx
x
36
Sjogrens ix tx
Ix: Bloods incl anti-Ro and -La Salivary gland biopsy Tx: hydroxychloroquine is first line DMARD
37
Optic atrophy Causes Hx and o/e
``` Causes: Congential RP Mitochondrial disorders - Leber's Friedrichs ataxia ``` ``` Acquired MS Drugs Neurosyphilis Glaucoma, SOL, Pagets Dietary deficiency - B12 Retinal artery occlusion Inflammatory cause - sarcoid ``` ``` Hx: Progressive visual loss, typically colour Bilateral Vascular risk factors Other neurology - MS Eye infection / trauma Headache - SOL ``` PMH - glaucoma ``` O/e: RAPD and INO - MS Acuity Pale, well demarcated disc Fields - chiasmal lesions Enlarged blind spot Colour vision - Ishihara ``` Signs of the cause - retinitis pigmentosa, cupped disc (glaucoma), central retinal artery occlusion Other signs - cerebellar signs -> MS; scoliosis and yes caves -> Friedrichs Argyll Robertson pupil (accommodates but doesn't react) -> neurosyphilis Frontal bossing of skull - Pagets
38
Usher syndrome | 2 facts
Retinitis pigmentosa and sensineural deafness | Commonest cause of deaf/blindness in the UK
39
Retinitis pigmentosa Some conditions Inheritance Mx
Conditions - Usher syndrome (deafness), Bardet-Biedl syndrome (polydactyly), Refsums, Alports, Kearns Sayre (mitochondrial inheritance - ophthalmoplegia, ataxia, dysphagia and cardiac conduction defects) Inheritance AD, AR or X-linked Sporadic mutations can occur in approx 30% of cases Can be syndromic or not Mx: MDT OT and support services Referral to ophthalmologist
40
Causes of bilateral carpel tunnel syndrome
Narrowing of tunnel - RA, OA, PsA Fluid - Renal failure / dialysis, hypothyroid, pregnancy Infiltration - vasculitis, amyloidosis DM
41
Involvement of limited sclerosis
Skin below elbow CREST as part of limited sclerosis Lung involvement - pul htn
42
Involvement of diffuse sclerosis
Diffuse skin and organ involvement Cardiac - fibrosis, pericarditis Lung (not as common as limited sclerosis) GI - malabsorption Liver Renal - can have acute renal crisis - ARF and htn
43
Diabetes Hx O/e
``` Diagnosis and progression Medication Hypos Control Other vascular risk factors - smoking, htn, obesity, cholesterol Foot care - regular chiropodist input Eye screening Sx of peripheral neuropathy - burning, parasthesia Sx of claudication ``` ``` O/e: Retinopathy Neuropathy Charcots joints Feet - ulcers and callus Foot pulses Neuro exam ABPI ```
44
Thyroid problem
``` Sx of hyper and hypo-thyroidism Eye sx and visual change Recent URTI (thyroiditis) Drugs which can interact with the thyroid - amiodaraone, Li Current medications FLAWS ```
45
Phaeochromocytoma What conditions can be associated Ix Mx
MEN2A and MEN2B Von hippel Lindau NF1 10% bilateral, 10% malignant Ix: 24hr urinary Catecholamines and metanephrines Imaging MIGB scan Look for associated conditions - PTHrP from MEN2a medullary thyroid tumour, posterior fossa MRI for haemangioblastomas (VHL), neurofibromas (NF1) Mx: Alpha (phenoxybenzamine) then beta block (propranolol) after 2-3 days Surgery IV fluids post op due to sudden loss of vasoconstriction
46
Visual change Hx Examination Mx
Hx: Onset and progression. Unilateral or bilateral Pain - GCA, glaucoma, uveitis Associated sx - haloes around objects, flashing lights (glaucoma, RP, retinal detachment) Reduced night vision Reduced peripheral vision (pituitary, pan-retinal photocoagulation, glaucoma) Distortion of vision eg straight lines - macular pathology RF - drugs that are toxic - ethambutol (TB), methanol O/e: Assess associated signs of RP eg hearing aids Acuity, fields, neglect, reflexes, fundscopy, colour vision ``` Ix: Colour vision testing and perimetry Retinal photos for progress Fundal angiogram - fluorescin Genetic analysis ``` ``` Mx: No treatment for underlying cause Refer to ophthalmologist. OT Inform DVLA - need acuity 6/10 to drive Support groups ```
47
Signs of severe C. diff colitis
``` Fever >38.5 WCC >15 CRP >150 Toxic megacolon - Bowel >7cm dilated AKI / dry Raised lactate Diffue / severe abode pain ```
48
Causes of weight loss
``` Diet in Upper GI malignancy Lower GI malignancy Lung malignancy Thyroid Addisons DM Psych TB IBD Coeliac ```
49
Causes of dysphagia
Neuromuscular problem - MND, dystrophy, MS SOL Pharyngeal pouch Webbing Narrowing of oesophagus - stricture Oesophageal dysmotiltiy - Achalasia, corkscrew oesophagus, limited sclerosis Oesophagitis - candida
50
Rockall score Parameters What does it predict
Predicts mortality Pre and post endoscopy Pre - Age, grade of shock (BP > or < 100 systolic), co-morbidities
51
Blatchford score Parameters What does it predict
Predicts need for intervention 0 -> outpatient investigation Urea, Hb, systolic BP, HR, co-morbidities (liver and heart disease) and presentation (malaena, syncope)
52
Causes of thrombocytopaenia
``` ITP Infection - EBV, CMV HUS/TTP/DIC Splenic sequestration - malaria, extravascular haemolysis Drugs - HIT, Bone marrow - myelodysplastic syndrome, pancytopaenia, parvovirus, HIV, hep C, rubella B12/folate deficiency Malignancy - lymphoma SLE Plt aggregation Pregnancy - HELLP ```
53
Features of neurofibromatosis type 1 Inheritance and chr Complications Associated features
AD, chr 17 Cafe au lait spots (>5) Neurofibromas Lisch nodules (eyes) Axillary freckling Complications Pressure effects of the neurofibromas - acoustic neuroma, spinal root compression, hydrocephalus Malignant change Intracranial tumours - glioma, meningiomata, medulloblastoma ``` Associated features Pul htn and fibrosis scoliosis Phaeo / MEN2A Fibromuscualr hyperplasia causing renal artery stenosis and htn ```
54
Features of neurofibromatosis type 2
Bilateral acoustic neuromas and intracranial tumours
55
Tuberous sclerosis Features Mx
AD but 80% sporadic new mutations TSC1 (hamartin - chr 9) or TSC2 (tuberin - chr 16) Hamartomas in kidiney, skin, brain, eye and heart ``` Ash leaf macules Shagreen patch Periungual fibromata Adenoma sebaceum 80% have epilepsy ``` Associated with lung cysts, polycystic kidneys and renal angiomyolipomas, retinal hamartomas and cardiac rhabdomyomas Mx: Topical sirolimus Screen for malignancy
56
How is lichen planus treated | What infection is it associated with
Steroids - intralesional or oral | Hep C
57
ABCD scoring criteria
``` Age >60 BP >140/90 CF - weakness = 2; speech diet = 1 Duration - >1hr = 2; <1hr = 1 DM ```
58
Criteria for admission for TIA ix
``` ABCD score 4 or above Crescendo TIA (more than 2 events in prev 7 days) Persistent neurology or fluctuating sx Chronic or paroxysmal AF Anticoagulated Prosthetic valve Young <50 with neck pain ```
59
Causes of headache and unilateral weakness in the young
``` Hemiplegic migraine Carotid or vertebral artery dissection TIA with underlying cause - APLS, SLE, Sjogrens, vasculitis, endocarditis Venous sinus thrombosis GCA ```
60
How can a carotid artery dissection present
``` Headache / neck pain TIA sx Amaurosis fugal Horners Focal weakness Neck swelling, tinnitus and bruit ```
61
Further assessment of someone presenting with parkinsonism
Vascular risk factors Autonomic sx - postural hypotension, urinary function, constipation Cerebellar features Supranuclear features Cognitive assessment and hallucinations - LBD Review drugs - neuroleptic and antiemetics
62
Causes of an isolated CN VI palsy
SOL- cavernous sinus and superior orbital fissure, MCA aneurysm Raised ICP MS Stroke / TIA - microvascular and thromboembolic Any cause of mononeuritis multiplex - DM, CTD/vasculitis, sarcoid, amyloidosis GBS - Miller Fisher variant (ataxia, ophthalmoplegia and areflexia) Infection - lyme, TB, viral GCA Cerebral lymphoma Wernickes encephalopathy Neurological cause - myositis affecting muscle, NMJ problem, nerve/nucleus problem
63
How to diagnose MS
McDonald Criteria | Two lesions separated in time and space, visible on contrast enhanced MR
64
How to tx MS
MDT - neurologist, PT/OT, SALT, dietician ``` Symptomatic Anticholinergics for overactive bladder +/- intermittent self catheterisation Baclofen and botox for spasticity Neuropathic pain relief Erectile dysfunction tx Antidepressants ``` Disease modifying Beta-interferon Glatiramer, fingolimod, natalizumab
65
Features of complicated malaria
``` Parasite count >2% Features of cerebral malaria - Decreased GCS Features of haemolysis - Hb <80 Hypoglycaemia ARDS DIC / coagulopathy Shock BP<90mmHg Renal impairment (AKI) Metabolic acidosis ```
66
Complications of malaria
``` AKI and metabolic acidosis ARDS Acute liver impairment Haemoglobinuria -> Blackwater fever Cerebral malaria -> seizures Splenic rupture Superimposed sepsis (usually GN) DIC Shock Hypoglycaemia ```
67
Causes of erythema nodosum
``` Sarcoidosis IBD - Crohns Drugs - penicillin, OCP Malignancy - haematological Rheumatic fever bacterial infection - strep, mycoplasma TB ```
68
Associations of sturge weber syndrome
``` temporal lobe epilepsy Glaucoma Strabismus optic atrophy SOL ```
69
Inclusion body myositis - features
Later onset (>50), distal myopathy with decreased reflexes Slow onset weakness Can causes foot drop No muscle tenderness
70
Ix of suspected polymyositis
``` CK ANA (Jo1 in dermatomyositis) CRP/ESR MRI of involved muscle Muscle biopsy EMG ``` Whole body for CT for underlying malignancy (lung, ovarian and breast commonest)
71
Mx of polymyositis / dermatomyositis
MDT Encourage physical activity to maintain strength - OT/PT Skin manifestations - Sunblock, topical antipruritics, topical corticosteroids +/- tacrolimus and hydroxychloroquine Steroids - High dose prednisolone, tapering down; DMARDs and steroid sparing agents IV Ig if refractory
72
Indication for biologic therapy in RA
Failure of 2 consecutive DMARDs, including methotrexate AND has two DAS28 scores >5.1, at least a month apart
73
What is the management of RA
Assess disease severity by DAS score Acute flares are treated with steroids Chronic disease mx: Cons, medical, surgical Cons - PT and exercise; analgesia Medical - DMARD - First line is methotrexate (CI if nodules present - worsens disease), sulfasalazine, hydroxychloroquine Second line - biologic therapy - infliximab, rituximab Usually in combination with methotrexate
74
What patterns can psoriatic arthritis take
DIP joint disease associated with onycholysis Rheumatoid pattern - Small joint polyarthropathy Large joint oligoarthritis Spondyloarthritis / sacroileitis Arthritis mutilans
75
Features of dermatomyositis on examination
Rash over bony prominences - extensor surfaces of phlanges, elbows Mechanics hands - dry cracked skin Nailfold erythema and periungual telangiectasia Heliotrope rash at the eyes Skin - photosensitive rash in sun-exposed areas Raynauds Alopecia Weakness +/- tenderness of muscles - proximal weakness
76
Complications of dermatomyositis
Underlying malignancy - GI, breast, prostate, ovarian ILD Myocarditis Arthralgia
77
Causes of nephrotic syndrome
``` DM GN - MCD, membranous, FSGS Amyloidosis Myeloma TIN - NSAIDs SLE / lupus nephritis Rhabdomyolysis HIV and Hep B/C ```
78
What are the criteria for an HGV licence in someone on insulin
``` No hypos within the past 12mths Under a diabetes consultant Can prove 3mths of blood sugar control Never had a hypo at the wheel Never needed third party assistance ```
79
Radiological changes seen in RA
Loss of joint space Soft tissue swelling Periarticular osteoporosis Articular erosions

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