9/11/21 Flashcards
Mechanism of Injury of an AC joint injury.
Injury to the AC joint usually occurs from direct trauma to the superior or lateral aspect of the shoulder (acromion) while the arm is adducted, such as a direct blow or falling onto the shoulder.
Examination findings in an AC joint injury (2 point)
- Reveals tenderness directly over the AC joint and possible deformity
- Passive cross-body adduction of the arm to compress the AC joint can help to confirm the diagnosis
Managmenet options. General. What does the management depend on?
- Rest, Ice and Protection using a Sling
- Minor (Type 1 and 2) → non-operatively
- Type 3 → operative management does not appear to improve functional outcome comapred to conservative management. So NON-OPERATIVE management for 3 too.
- Major (Type 4-6) → referral to orthopaedic surgeon for operative management
common clinicl features of Primary Adrenal Insufficiency (5 points + 1 main)
- Chronic Malaise
- Lassitude
- Fatigue → worsened by exertion and improved with bed rest
- Weakness
- Anorexia
- Weight Loss
- Other Clinical Manifestations:
- GIT symptoms
- Hypotension
- Electrolyte Abnormalities
-
Hyperpigmentation
- MOST CHARACTERISTIC PHYSICAL FINDING
- Generalised hyperpigmentation but most noted in areas exposed to light and areas exposed to chronic friction of pressure
- Prominent in the palmar creases → escapes being worn away by friction
Investigations for Primary Adrenal Insuffiency (2 points)
-
Morning Serum Cortisol Concentration
- Low → strongly suggestive of adrenal insufficiency
- **Short ACTH Stimulation Tests aka Synacthen Test
- should be performed in all patients in which the diagnosis of adrenal insuffiency is being considered
- blood sample is collected → Synacthen injected into the vein → blood sample collected 30mins later
- Synacthen acts like ACTH by stimulating the adrenal gland to produce more cortisol
Treatment for Atypical Pneumonia?
- doxycycline 100mg orally, 12 hourly for 5-7 days
Clinical Features of Sarcoidosis (2 CXR findings + 3 resp findings + other)
- bilateral hilar adenopathy (see below)
- pulmonary reticular opacities
- skin, joint and/or eye lesions
Common presenting respiratory symptoms:
- Cough
- Dyspnoea
- Chest Pain
- Accompanied by: fatigue, malaise, fever and weight loss
- Systemic inflammation → muscle weakness and exercise intolerance
Diagnosis of Sarcoidosis (3 points + 1 bonus)
Diagnosis requires 3 elements:
- Compatible clinical and radiographic manifestations
- Exclusion of other diseases that may present similarly
- Histopathologic detection of noncaseating granulomas - via biopsy → Ultrasound Guided Endoscopy or Flexible Bronchoscopy with Encobronchial Biopsy
DO NOT biopsy erythema nodosum as it will be reported as panniculitis even is sarcoidosis exists.
Incubation period of varicella?
10-21 days
Clinical features of varicella. Natural Progression and Infectious period? Return to School
- Prodrome: Fever, Lethargy, Anorexia
- Rash erupts after 3-5 days → crops of small papules that quickly become vesicular then crust over after the vesicles have ruptured
- Recurrence of Infection → can spread over more than one dermatome, but usually milder than in adults.
- Lesions are fully crusted over by 10 years
- Infectious from 1-2 days before the onset of the rash until the lesions have been fully crusted over. Children should be excluded from school until fully recovered (all lesions crusted over) or at least one week after the eruptions first appears.
When do you need to give anti-viral therapy?
Children with pre-existing skin disease
non preg adults within 36 hours of onset of rash
preg adults within 72 hours of onset of rash
How soon after exposure is preferrable to give varicella vaccination? What is the purpose of the vaccination post-exposure?
- Reduces the likelihood of varicella infection after exposure → by vaccinating exposed people during outbreaks, prevents further cases and controls outbreaks
- People should receive the varicella vaccination within 5 days of exposure, PREFERRABLY WITHIN 3 DAYS
Who qualifies for Zoster Immunoglobulin? 5 points
- Pregnant women who are presumed to be susceptible to varicella infection
- Neonates whose mothers develop primary varicella infection within 7 days before delivery to 2 days after delivery → neonates must receive ZIG as early as possible
- Neonates exposed to varicella in the 1st month of life, if mother has no personal history of infection with varicella virus and is seronegative
- Premature infants (<28 weeks) who are exposed to varicella while still hospitalised → should receive ZIG despite mothers serology status
- Patients with primary or acquired diseases associated with cellular immune deficiency and people receiving immunosuppressive therapy. If contact is immunocompromised patients has recent evidence of detectable antibodies - do NOT need ZIG.
How soon after exposure should patients receive ZIG?
- People must receive ZIG within the first 96 hours and up to 10 days following exposure
What is the dose and drug to treat chickepox in children with history of skin disease?
aciclovir 20mg/kg up to 800mg 5 times daily for 7/7
What is the drug and dose to treat chickenpox in an adult?
valciclovir 1g TDS for 7/7
If high risk wells score in context of PE, next step?
CTPA or V/Q
Most common cause of lateral hip pain in adults?
Greater Trochanteric Pain Syndrome
Risk Factors of Greater Trochanteric Pain Syndrome
- Female
- Obesity
- Lower Back Pain
- Scoliosis
- Leg Length Discrepancy
- Hip and Knee Arthritis
- Painful Foot Disorders → Plantar Fasciitis
Examination of Greater Trochanteric Pain Syndrome
Tenderess on palpation of the greater trochanter
Management of Greater Trochanteric Pain Syndrome (4 points
- Self-limiting condition
- Exercise and Activity Modification - referral for physical therapy
- NSAIDS
- Glucocorticoid Injection - immediate pain relief
Who should be treated for shingles?
- Rash <72 hours
2. Immunocompromised individuals any time
Treatment for shingles?
- valaciclovir 1g TDS for 7/7 (children >2yo -> 20mg/kg up to 1g)
Characteristics Manifestations of Marfan’s Syndrome
Aortic Root dilation/dissection
Ectopia Lentis
other: excess linear growth of long bones and joint laxity, mitral valve prolapse, dural ectasia, pneumothorax, skin striae
Characteristics of Wernickes Encephalopathy (3 points)
opthalmoplegia/oculomotor dysfunction, gait ataxia and confusion/encephalopathy
Management of Wernicke’s Encephalopathy (1 point)
- Thiamine 500mg TDS IV for 5-7 days. DO NOT NEED TO WAIT TO CONFIRM DIAGNOSIS -> GIVE THIAMINE
Mechanism of Injury for Scapholunate Dissociation?
Mechanism: Fall back onto an outstretched, extended wrist that disrupts the supporting ligaments forcing the carpal bones to shift dorsally.
Clinical Features of Scapholunate Dysfunction (5 poins)
- Swelling and Pain over the dorsoradial aspect of the wrist (overlying the scaphoid and lunate)
- Grip Weakness
- Painful or Decreased Wrist ROM
- Tenderness over the scapholunate junction
- Scaphoid shift test → can detect ligamentous instability
Imaging findings and management of Scapholunate Dissociation?
- *Imaging**
- Interosseous distance >3mm between scaphoid and lunate on the plain radiograph suggests a ligamentous injury
- *Management**
- Refer to hand surgeon
Mechanism of Eustachian Tube Dysfunction
Eustachian Tube is blocked or does not open normally to allow air into the middle ear from the nose → air pressure across the tympanic membrane is unequal (outside drum pressure > inside drum pressure) → drum is pushed inward → tense and dysfunctional.
Symptoms associated with Eustachian Tube Dysfunction (5 points)
- Hearing loss - muffled or dull (main symptom)
- Sensation of fullness in the ear
- Ear pain (not always and variable)
- Buzzing or ringing in the ear (tinnitus)
- Popping noises in the affected ear
Treatment for Eustachian Tube Dysfunction (3 points)
- If mild - no treatment other than clearing the snuffly nose. can use steam inhalation or menthol.
- Valsalva manoeuvre - can unblock mucous in the tube
- Systemic decongestants can help with nasal congestive symptoms but unclear as to whether will help clear TM retraction
- Topical decongestants can reduce difficulty in clearing ears during flights and scuba diving to prevent barotrauma.
What is Rheumatoid Arthritis and how does it cause damage?
- Chronic autoimmune disease → persistent synovitis, systemic inflammation and presence of autoantibodies
- Persistent joint inflammation can lead to development of bony erosions, cartilage and tendon degradation and joint deformity
Symptomatic patients + Positive RF or anti-CCP -> ?
immediate referral as early joint damage is likely
- Persistently swollen joints + Negative for RF or anti-CCP → ?
referral within 6 weeks
History of Rheumatoid Arthritis (6 points - clinical features, timeline, other history poitns)
- Joint Pain + Swelling and/or Fever
- Morning Stiffness >30mins
- Previous Episodes
- Family History of RA
- Systemic Flu-Like Features and Fatigue
- Symptoms lasting longer than 6 weeks
Examination findings of Rheumatoid Arthritis (4 points)
- ≥3 tender and swollen joint areas
- symmetrical joint involvement in hands and/or feet
- Positive squeeze at MCP or MTP joints
- Presence of Rheumatoid Nodules
Lab Investigations in Rheumatoid Arthritis (4 points)
- Rheumatoid Factor
- Anti-Cyclic Citrullinated Peptides (anti-CCP)
- Raised inflammatory markers (ESR and CRP) in the absence of infection
X-ray Findings in Rheumatoid Arthritis. (2 points)
Bony Erosions
Joint Space Narrowing
Symmetrical + Bilateral Involvement
Key Indicators of Poor Prognosis in RA
- High RF Titre and/or Positive anti-CCP antibody test
- Sustained High ESR and CRP
- Swelling in more than 20 joints
- Impaired Function early in disease
- Body Erosions evident on X-Rays early in disease
- Smoking
Role of DMARDs in Rheumatoid Arthritis.
- conventional synthetic DMARDs (csDMARDs) should be started as soon as possible → used in order to induce and then maintain clinical remission of rheumatoid arthritis
Role of corticosteroids in management of Rheumatoid Arthritis.
- used by specialists to achieve rapid symptom control at presentation or during an exacerbation of disease, usually used in induction phase while awaiting a response to the csDMARD therapy which can take 6-12 weeks.
csDMARD of choice in management of RA?
- Methotrexate 10mg orally, on one specified day once weekly, increasing up to 25mg orally or subcutaneously, one one specified day once weekly
- PLUS folic acid 5 to 10mg orally, per week (preferably NOT on the day that methotrexate is taken)
When can you use frusemide in CKD? At what eGFR?
- Frusemide can be used safely for management of fluid overload in all cases of CKD, including when eGFR <30.
- Typical doses are 20-120mg/day → but higher doses may be required.
Dose changes of metformin in CKD?
30-60 -> dose reduction
<30 -> contraindicated
Dose changes in SGLT2 (flozin) in CKD?
<45 - contrindicated
Dose changes in DPP4 (gliptins) in CKD?
Dose adjustment at 60
no dose adjustment for linagliptin
Dose changes in GLP1 (tides) in CKD?
Contraindicated <30
Dose changes in sulphomylureas in CKD?
Dose reduction at eGFR <30 -> risk of hypoglycaemia increases)
First step to spirometry interpretation?
FEV1/FVC < LLN
Second Step: after FEV1 next step?
FVC < LLN
If FEV1/FVC ??
Obstruction (possible mixed picture)
if FEV1/FVCLLN -> ??
Obstruction
if FEV1/FVC>LLN + FVC> LLN -> ??
normal Spirometry
If FEV1/FVC >LLN + FVC ?
Restrictive
Causes of Obstructive Lung Disease
CANNOT BLOW OUT QUICKLY
- COPD
- Asthma
- Bronchiectasis
- Cystic Fibrosis
- Bronchiolitis
- Alpha1-Antitrypsin Deficiency
Causes of Restrictive Lung Disease
SMALL LUNGS
- Pulmonary Fibrosis
- Neuromuscular Disorders
- Congestive Cardiac Failure
- Sarcoidosis
- Obesity
- ILD
- Pneumonia
- Pleural Disease → pleural effusion or diffuse pleural thickening
Clinical Features: History of Interstitial Lung Disease?
- Insidious nature of breathlessness
- Exertional Dyspnoea
- Non-Productive Cough
- Decreased Exercise Tolerance
- Risk Factors - FHx + Smoking
Clinical Features: Examination in Interstitial Lung Disease?
- Low-level SpO2
- Fine inspiratory crepitations - (DDx heart failure but if normal CV exam then less likely)
- Clubbing in advanced cases
Investigations for Interstitial Lung Disease
- Spirometry - restrictive lung disease, FEV1/FVC > LLN + FVC < LLN
- CXR - can show interstitial changes bilaterally
- HRCT - required to definitely diagnose ILD
Causative pathogen for Slapped Cheek? Age group?
Common viral infection caused by parvovirus 19 → usually ages 4-10
Clinical Features of Slapped Cheek. Incubation Period?
- Incubation period 4-14 days
- Early Symptoms → fever, headache, stomach upsets, aches and pains
- After a few days of being unwell → bright shiny red rash on the cheeks
- Can also develop a rash on the chest, back, arms and legs → look like a pink lace pattern on the skin
- Rash can come and go for several weeks, or even months, especially if the skin is exposed to sunlight or after exercise
Contagious Period for Slapped Cheek
- Contagious until 24 hours after fever has resolved → will not spread parvovirus to other people after this time even if the rash continues.
When does neonatal cephalic pustulosis develop?
- Pustular eruption arising on the face and/or scalp of newborn babies, often during the 3rd week. Can occur in babies 4-8 weeks
What is the natural progression of neonatal cephalic pustulosis and what is the baselie management of it?
- Usually self-resolves (in a few weeks) → treated with daily cleansing with soap and water and avoidance of exogenous oils and lotions
- Usually resolves spontaneously within a few months without scarring
If no improvement with basic management, what is the pharmacological management of neonatal cephalic pustolosis?
- Ketoconazole 2% cream topically, BD until skin is clear (2-3 days)
Difference between Neonatal Cephalic Pustulosis and Infantile Acne?
infantile acne is more severe
infantile acne can scar
infantile acne presents at 3-4 months, not early in life.
infantile acne only spontaneously resolves late in the first year of life
Management of infantile acne?
- mild inflam + sparse comedones
- lots of comedones + minimal inflam
- lots of comedones + inflammation
- Mild inflammation + Sparse comedones → benzoyl peroxide 5% gel topically, once daily -eTG
- Large and Numerous comedones + Minimal inflammation → adapalene 0.1% cream topically, nocte or tretinoin 0.025% topically nocte
- Numerous comedones + Inflammatory lesions → benzoyl peroxide + adapalene 2.5% + 0.1% gel topically, once daily
What is milaria?
- 15% of newborns in warm climates and is due to occlusion of the sweat duct
- Superficial → sweat collects below the stratum corneum (dead cells on the skin surface) forming a clear, thin-walled blister (milliaria cristallina)
Management of milaria?
- Settles within a few days on cooling and removing occlusive clothing
What are the main characteristics of borderline personality disorder?
- unstable sense of self and identity manifesting in chronic inner emptiness and boredom
- severe disturbance of interpersonal function
- developmental immaturity
- mood instability
- recurrent impulsive and maladaptive behaviours such as binge eating, stealing, drug use problems and deliberate self-harm
Management of Borderline Personality Disorder.
- Structured targeted psychological therapies to form short and long term goals → aim of remission and prevention of relapse
- Dialectical Behaviour Therapy → variation of cognitive behaviour therapy. Encourages the patient to accept the way they are, change in order to move forward to reach personal goals.
Management of Hairy Tongue
- Gentle tongue debridement, with tongue scraper or soft toothbrush and solution containing 3% hydrogen peroxide or baking soda
Presentation of Hairy Tongue
- Usually asymptomatic, main problem is unsightly appearance. Occasionally patient can complain of burning or tickling sensation on the tongue, nausea or halitosis (bad breath)
Who is high cardiovascular risk without using the calculator? (7 points)
- Diabetes + Age >60yo
- Diabetes with microalbuminuria (urinary ACR >2.5mg in male and >3.5mg in female)
- Moderate or Severe CKD → persistent proteinuria or eGFR <45)
- Previous diagnosis of Familial Hypercholesterolaemia
- Systolic Blood Pressure ≥ 180mmHg or Diastolic Blood Pressure ≥ 110 mmHg
- Serum Total Cholesterol > 7.5mmol/L
- Aboriginal or Torres Strait Islanders adults ≥ 74yo
Management for High Cardiovascular Risk Patients?
Start Lipid Lowering Therapy and BP Lowering Therapy
Lifestyle Management - diet, exercise, smoking cessation
