__One2one Flashcards
Bruising on face in a Cardio exam?
Evidence of anti-coagulation
Think AF or valve replacement
Potentially also evidence of a fall with LOC (if face hit)
Cardio exam
Midline sternotomy scar
Differentials? (X3)
- Valve replacement (look for Warfarin, listen HS)
- CABG (look for saphenous graft scar, tar staining, xanthelasma)
- Congenital cardiac disease repair (if young, more rare)
Graft options in CABG (x3)
Great saphaenous vein
Left internal mammary artery (aka internal thoracic)
Radial artery
No scar
No Warfarin
Normal pulse
Ejection systolic murmur
Differentials? (x3)
Aortic stenosis (slow rising pulse, narrow pulse pressure) Aortic sclerosis
+- CCF (look at JVP, lungs, oedema)
Cardio exam
No scar, no Warfarin, normal pulse
Most likely differentials? (x2)
Valvular disease (see pulse, BP, HS) CCF (look for JVP, lungs, oedema)
What is a slow rising pulse?
Seen in Aortic stenosis
No quick upstroke
Peak pressure is prolonged over a period of time
Define pulse pressure
What is considered a narrow pulse pressure?
Where is this seen?
Difference between systolic and diastolic BP
Narrow if difference is <25% of the systolic
Seen in aortic stenosis
Stenosis means pressures are very similar before and after due to restriction of flow
Cause of narrow pulse pressure? (x4)
Cause of wide pulse pressure? (x4)
Narrow - aortic stenosis, HF, shock, tamponade
Wide - pp increases with exercise, wider in athletes
If prolonged - stiffness of great vessels, aortic regurg, AVM
Systolic murmur differentials (x3)
Aortic stenosis/sclerosis - Loudest in upper chest, radiates around chest wall
Mitral regurgitation - (Only) heard at apex
Aortic stenosis vs sclerosis
Stenosis - radiates to carotids, slow-rising, narrow PP, heaving apex beat (sign of severity)
Sclerosis - murmur only
Things to remember when presenting a murmur?
TIPQRS
Type - sys/dias Intensity (usually 3/6) Position Quality Radiation Systemic features
Main symptoms of aortic stenosis (x3)
Main causes (x2)
SAD
Syncope
Angina
Dyspnoea - with LV failure
Causes: calcific degeneration, bicuspid valve (presents 10 yrs earlier)
Signs of severity in Aortic stenosis
x5
Haemodynamic involvement - Narrow pulse pressure
Delayed closure of A2 (due to prolonged time for SV to leave heart)
Heaving apex beat (LVH, cardiac remodelling)
Features of CCF
Symptomatic
(i.e. NOT the intensity of the murmur)
Indications for surgery in aortic stenosis (x4)
Symptomatic
CCF
Mean transvalvular pressure gradient >44mmHg
Concomitant CABG
Overall relies on clinical judgement of pt suitability
Grading of murmurs
1 - just audible to expert 2 - just audible to non-expert 3 - clearly audible 4 - clearly audible with thrill 5 - audible with stethoscope only lightly applied 6 - audible without stethoscope
Cardio exam
Sternotomy scar and evidence of Warfarin use
Top differentials?
Metallic valve
(possibly tissue valve)
Also possibly AF or CCF
Metallic vs tissue valves
Metallic valve - clicks, evidence of Warfarin
Lasts 20 years
Flow murmur okay but regurg indicates failure
Tissue valve - no click, lasts 10 years (although improving)
Small amount of regurg is okay
Metallic valves have higher INR targets (cannot use DOAC, must be warfarin) with life ling Warfarin - vs aspirin after 3 months for tissue
Major surgery with a metallic valve
How to manage anticoagulation?
Stop Warfain 1 week before
Use LMWH as bridging until day before
Then switch to unfrationated heparin the day before (as reversible)
Cardio exam
Sternotomy scar
Normal pulse
No Warfarin
No click
Differentials? (x2)
Tissue valve
CABG (look for graft sites, tar staining, xanthelasma)
Indications for CABG (x4)
Failure of medical management
Left main stem disease
2 or more vessel disease
Concomitant valvular replacement
Types of saphenous graft scars
Longitudinal (old) scar down medial aspect of leg
Newer shorter endoscopic scars
Medication post CABG
Dual antiplatelets (aspirin and clopidogral/ticagralor) For 12 months then aspirin alone
ACE-inhibitor (or ARB)
Beta-blocker (eg. bisoprolol)
If HF assoc CABG then add Spironalactone
Causes of mitral regurg (x4)
Chronic - myxomatous degeneration (CTD), functional (with LV dilatation and distortion of papillary muscles)
Acute - infective endocarditis, papillary muscle rupture (2ndary to inf/post MI)
Signs of severity in mitral regurg (x3)
Symptoms - eg. CCF
LVF
Displaced or thrusting apex beat
Raised JVP in cardio exam
Right sided HF
Congestive cardiac failure (indicates increased R heart pressure)
Signs of R HF vs L HF
Right ventricular failure:
- Acute: raised JVP, hepatomegaly (deranged LFTs)
- Chronic: pedal/sacral oedema, ascites
Left ventricular failure:
- Acute/chronic: pulmonary oedema, poor peripheral perfusion, tachyopnoea, tachycardia
Causes of R HF and L HF
(acute and chronic)
(x9)
Right ventricular failure:
- Acute: MI, PE, infective endocarditis
- Chronic: LVF, cor pulmonale
Left ventricular failure:
- Acute: MI, infective endocarditis
- Chronic: cardiomyopathy (ischaemia or hypertensive), valvular heart disease
Management of CCF
Conservative:
Lifestyle (smoking), Education, Monitoring (disease and complications), Nutrition
Long term O2 for cor pulmonale
Medical:
ACE-i, BB, tx underlying cause (HTN, AF)
Aggressive management of RFs
Surgical:
LVAD or transplant
Stages of clubbing
Staging of clubbing (FACE)
- Fluctuancy of nail bed increased
- Angle Loss
- Curvature increased
- Expansion (drumsticking)
Causes of clubbing
Resp - pulmonary fibrosis, malignancy, suppurative lung diseases (bronchiectasis, abscess, empyema, CF)
Cardio - infective endocarditis, atrial myoxma, congenital cyanotic HD
Abdo - coeliac/malabsorption, IBD (crohn’s/UC), malignancy, cirrhosis
Spider naevi
What number are abnormal?
Definining features?
What conditions are they seen in?
> 3 is abnormal
Found in distribution of SVC
Fill from CENTER when blanched
Seen in chronic liver disease
also pregnancy, HRT (due to increased oestrogen)
Signs of chronic liver disease?
General, face, hands, abdo
General - cachexia, jaundice, excoriations, bruising
Hands - Dupuytren’s, palmer erythema, digital clubbing
Face - icteric sclerae
Abdo - spider naevi, caput medisae, gynaecomastia, ascities, splenomegaly
Chronic liver disease signs plus obesity, diabetes
Think NAFLD (increasingly common cause of CLD)
Chronic liver disease signs and xanthelasma
Think of cholestatic disorders (PSC, PBC)
Traube’s space and relevance to abdo exam
Below left hemidiaphragm above spleen
Should be resonant on percussion due to stomach
Dull to percussion if splenomegaly as spleen moves into this space
Causes of chronic liver disease
How would you investigate specifically for these?
Infective - hep B, hep C
Toxic - alcohol
Metabolic - NAFLD, (Wilsons, haemochomatosis A1AT)
Autoimmune - AI hep, PSC, PBC
Hp B/C serology
Hx of alcohol
Bloods - ferritin, A1AT, caeruloplasmin
Immunoglobulins, autoabs
Signs of decompensation in chronic liver disease
ABC
Ascites
Bilirubin - worsening jaundice
Coagulopathy
Encephalopathy - asterixes
Hypoglycaemia (late stage sign)
Complications of cirrhosis
Portal HTN - variceal haemorrhage, SBP (ascites), thrombocytopaenia (splenomegaly)
Hepatocellular failure - encephalopathy, HCC, hypoalbuminaemia, coagulopathy
Causes of splenomegaly
4 main categories
Haem - CML, myelofibrosis ,spherocytosis
Infective - malaria, EBV
Congestion - portal HTN, RHF, thrombosis/blockage (Budd Chiari)
Infiltration - amyloidosis
Differentials for splenomegaly AND hepatomegaly
x4
CML, infective (malaria, EBV), infiltration eg. amyloidosis, sarcoidosis
Indications for splenectomy (x4)
Traumatic rupture
Spherocytosis
Idiopathic thrombocytopaenia (less common now better meds)
Sometimes in lymphoma to reduce sx of hypersplenism
Signs to look for in renal transplant (x6)
Scar and abdo mass Signs of renal failure AV fistula (old or active) Insulin injection sites (aetiology) Cushingoid Skin malignancy (immunosupp)
RRT scar (Rutherford Morrison) and nephrectomy scars?
Old kidneys usually left in in RRT
There would need to be an indication for their removal eg. polycystic kidney disease, renal cell carcinoma, haemorrhage (cyst)
Indications for renal transplant (x3)
Diabetic nephropathy
Polycystic kidney disease
Glomerulonephritis
Complications of renal transplant (x43
Short term - bleeding, infection, thrombosis, acute rejection (+ renal failure)
Long term - immunosuppresant side effects (skin malignancy, gum hypertrophy, increased infection risk, high BP)
Cushing syndrome
Signs of renal failure to look for in exam (x4)
Scars - old AV fistula, neck line, peritoneal dialysis catheters
Cachexia
Pulmonary and peripheral oedema
Pallor
Stoma differentials (x4)
IBD - if YOUNG, pallor, ileostomy
Diverticulitis - elderly, colonostomy
Malignancy
Urostomy
Signs of IBD on examination (x6)
Young pt
Pallor, slim
Oral ulcers
Pyoderma gangrenosum (or erythema nodosum)
Clubbing
Medications at the bedside (sulfasalazine, azathioprines, steroids)
Signs of complications of IBD to look for on examination (x5)
Scars from Hickmann lines (for parental nutrition) Cushingoid Gum hypertrophy and HTN (ciclosporin) Jaundice (PSC) Hepato-splenomegaly - amyloidosis
Extra-intestinal manifestations of IBD?
Eyes - episcleritis, posterior uveitis, scleritis
Skin - pyoderma gangernaosum, erythema nordosum
Other - clubbing, oligoarthritis, anaemia
Complications of IBD (x6)
Crohn’s - strictures, obstruction, fistulae
UC - toxic megacolon, colonic carcinoma, PSC
Indication for stoma in IBD (x5)
Failure of medical management (severe disease activity) Obstruction (from strictures) Fistulae Toxic megacolon Malignancy
Complications of PKD (x4)
HTN UTI Cyst haemorrhage Haematuria End stage renal failure
Associations with PKD
Hepatic cysts
Berry aneurysms
Mitral valve prolapse
Differentials for bilateral renal masses (x6)
Polycystic kidney disease Bilateral renal cysts/RCC Bilateral hydronephrosis Hepatomegaly and splenomegaly Amyloidosis Tuberous sclerosis
Definition of COPD
Chronic bronchitis - cough with sputum for most days fro 3 months of 2 years (clinical diagnosis)
Emphysema - permanent dilation with destruction of alveolar walls distal to terminal bronchioles (histological diagnosis)
FEV1/FVC <0.7 and FEV1 <80% predicted
COPD vs alpha1-AT deficiency histologically?
COPD - centriacinar emphysema
A1AT - panacinar emphysema
Chronic COPD management
Smoking cessation, annual influenza, one-off pneumococcal
- SABA or SAMA first line
- 2nd line:
- FEV1 >50% - LABA or LAMA
- FEV1 <50% - [LABA and ICS] combo or [LAMA]
Note: discontinue SAMA when starting LAMA
- If persistent SOB or exacerbations
- If taking LABA switch to [LABA + ICS] combo
- Or give triple therapy: LAMA and [LABA + ICS]
Consider theophylline if above therapies ineffective
Consider mucolytics if chronic productive cough
Smoking cessation and long term O2 only factors that improve survival
SABA – salbutamol or terbutaline
LABA – salmeterol or forameterol
LAMA – tiotropium
ICS – fluticasone
When do you give long term O2?
Non smoker
PaO2 <7.3
PaO2 <8 AND evidence of pulm HTN, polycythamia, paroxysmal nocturnal dyspnoea, pulm effusion
Pallative
Resp exam
Clubbing, dry cough, fine crackles
Fibrosis
Causes of pulmonary fibrosis (apical and basal)
Apical - CHARTS
Coal miners lung Hypersensitivity pneumonitis Ankylosing spondylutus Radiotherapy TB Sarcoidosis/silicosis
Basal:
Idiopathic
Connective tissue disease (rheumatoid arthirtis, SLE, systemic sarcoidosis)
Asbestos
Recurrent aspiration
4 most common causes of pulmonary fibrosis
Idiopathic
Rheumatoid arthitis
Drugs - methotraxate, amiodarine, nitrofuratoin
Hypersensitivity
Differentials for chest asymmetry when testing expansion (x4)
Pneumothorax (not in PACES)
Kyphoscoliosis
Effusion
Lobectomy (/pneumonectomy)
Most likely reasons for lobectomy
chest asymmetry and a scar
Malignancy (look for tar staining) Old TB (>60 years, old management, absent ribs)
Signs of old TB on examination (x6)
Scars, deformity, absent ribs Apical fibrosis with tracheal traction Crackles, bronchial breathing Reduced expansion Kyphosis (Pott's disease) Dullness on percusion (if pneumonectomy - with lobectomy, healthy lung tends to expand into space)
Current TB treatment and their SEs?
RIPE
Rifampacin - hepatitis, orange secretions
Isoniazid - hepatitis, peripheral neuropathy (give with pyridoxine)
Pyrazinamide - hepatitis
Ethambutol - hepatitis
Resp exam
Wet cough, SOB
Top two differentials?
Bronchiectasis (look for signs of CF)
pneumonia (less likely in PACES)
CF observations on exam (x6)
Young and thin Gastostomy (PEG) Creon at bedside Port-a-cath Transverse abso scar (meconium ileus, obstruction) PEP devices (+ve expiratory pressure)
CF treatment
Conservative - postural drainage, active cycle breathing, nutrition
Medical - Creon and fat soluble vitamens, immunisations
DNase, abx (prophylactic and exacerbations)
Surgical - lung transplant
Causes of bronchiectasis (3 main categories)
Post-infectious - severe pneumonia, recurrent aspiraitons, TB, pertussis, ABPA
Congenital - CF (50%), primary ciliary dyskinesia
Mechanical - foreign body, obstructing tumour
Causes of pleural effusion
Transudate (protein <25g/L) - cardiac failure, renal failure, liver failure, hypoalbuminaemia
Exudate (protein >35 g/L) - parapneumonic effusion, empyema, malignancy, inflammatory pleuritis (RA, SLE)
Pleural effusions - what parameters define transudate and exudate?
Transudate (protein <25g/L)
Exudate (protein >35 g/L)
Light’s criteria if between 25-35
Effusion albumin/plasma alb >0.5
Effusion LDH/plasma LDH >0.6
Effusion LDH >2/3 x upper limit of normal for plasma LDH
Neuro exam
Abnormal gait
Flexed arm, extended leg
Hemiplegia - pyramidal weakness
Likely stroke
Post-stroke signs on neuro exam (x7)
Pyramidal weakness (flexed arm, extended leg) Walking aids Wasting on affected side Increased tone and clonus Clasp knife spasticity 7th nerve palsy in UMN distribution Brisk reflexes, upgoing plantars
Additional examinations you would like in a stroke patient (as well as the neuro limbs)
(x5)
Gag and swallow assessment (aspiration risk and nutrition, need for PEG or NGT)
Visual fields and neglect (needed for Bamford stroke classification)
Blood pressure (cause: hypertensive haemorrhagic stroke)
AF - as a cause
Carotid bruit if anterior circulation stroke
MRC grading of power
0 - none 1 - flicker 2 - moves with gravity neutralised 3 - vs gravity but not resistance 4 - reduced power vs resistance 5 - normal
Bamford classification of stroke
Clinical classification
Total anterior circulation stroke - hemiplegia, homonymous hemianopia, higher cortical dysfunction
Partial anterior circulation stroke - 2 of 3
Lacunar circulation stroke - hemi-motor or hemi-sensory only
Posterior circulation stroke - cerebellar, brainstem
Parkinsonism signs
Gait - slow, shuffling, slow start/turn, limited arm swing
Face - expressionless, glabellar tap +ve, slow monotonous speech
Pill rolling tremor, bradykinesia, rigidity
Cogwheel rigidity
Parkinsonism causes and features of each
Idiopathic parkinsons disease
Lewy body dementia - dementia present also
Drug-induced - look at med hx (anti-psychotics)
Parkinson plus syndromes:
- Multisystem atrophy: low BP (postural hypotension)
- Progressive supranuclear palsy: palsy of vertical eye movements
- Corticobasal degeneration: apraxia, myoclonus, acalculia
Neuro exam
Broad and unsteady gait
Ataxia
Look for further cerebellar signs
Cerebellar signs in the arms (x5)
Rebound overshoot
Dysdiadochokinesia
Hypotonia, hyporeflexia
Past-pointing and intention tremor
Cerebellar sign localisation within the cerebellum?
Cerebellar vermis - more trucal ataxia, minimal limb signs
Cerebellar hemisphere lesions - ipsilateral limb signs, less truncal involvement
Cerebellar syndrome causes and features (x4)
Multiple sclerosis - young, female, spasticity, internuclear opthalmoplegia
Stroke - older, AF, CABG, tar staining
Alcohol - chronic liver disease
Phenytoin - gingival hypertrophy
What is internuclear opthalmoplegia?
What is seen?
Failure of lateral conjugate gaze
lesion of median longitudinal fasiculus tract which connects the nuclei of CN III IV, VI
On examination:
- Ipsilateral - failure of ADduction
- Contralateral - nystagmus when in ABduction
Can be bilateral
Main two categories of a facial palsy-causing lesion
Cerebral hemispheric lesion - contralateral and preservation of frontalis
Facial nerve (or nucleus) lesion - ipsilateral and frontalis wekaness
Facial palsy PLUS corticospinal tract signs, VI palsy
Site of lesion and underlying cause?
Pons
Stroke or MR
Facial palsy PLUS V, VI, VIII and cerebellar signs
Site of lesion and underlying cause?
Cerebello-pontine angle
Acoustic neuroma
Facial palsy PLUS VIII palsy
Site of lesion and underlying cause?
Inner ear
eg cholesteatoma
Facial palsy PLUS parotid scar/swelling
Site of lesion and underlying cause?
Parotid tumour
Treatment of Bell’s palsy?
Eye protection
Prednisolone if <72 hours
(acyclovir no longer recommended)
75% make a full recovery
Secondary causes of Facial Palsy
(x7)
Unilateral and bilateral?
Unilateral - Herpes Zoster (Ramsey-Hunt syndrome), Diabetes mononeuropathy, tumour
Bilateral - Guillian Barre syndrome, Lyme disease, Sarcoidosis, Myesthenia Gravis
Differential for mixed UMN and LMN signs
Motor neurone disease
Dual pathology (e.g. peripheral nephropathy (DM) and stroke)
Cons medullaris lesion (traumatic cauda equina)
B12 deficiency - causes peripheral neuropathy and subacute combined degeneration of the spine
Gen surg
Oedematous and pigmented legs differential?
Chronic venous insufficiency
Gen surg
Toe amputations
Diabetic foot disease
Gen surg
Shiny, pale legs differential?
Peripheral arterial disease
Differentials for Groin Lump (x6)
Lateral to medial
Lat to med
Psoas abscess (rare)
Femoral artery aneurysms
Vascular - varicose veins, saphena varix (dilation at top of great saphenous) - bluish tinge, disappears on lying down
Inguinal hernia (above inguinal ligament)
Femoral hernia (below inguinal ligament, more rare)
Lymphadenopathy
Inguinal hernia signs on examination (x5)
Show antomical landmarks (neck lies above inguinal ligament - ASIS to pubic tubercle)
Reduces when lying down, protrudes with cough
Bowel sounds present (exclude obstruction)
Comment on scrotal extension
Indirect - compression at deep ring (just above midpoint of inguinal ligament) prevents protrusion
Direct - still appears
Differences between femoral and inguinal hernias?
Anatomy - Inguinal (75% indirect, 25% direct through inguinal canal), femoral (through femoral canal, neck inf and lar to pubic tubercle)
Epidiemiology - inguinal much more common
Management - inguinal elective repair (unless irreducible)
Femoral - urgent surgery, at increased risk of strangulation (narrower canal)
Anatomy of direct inguinal hernias?
Hesselbach’s triangle
Inf - inguinal ligament
Lat - inferior epigastric artery
Med - rectus abdominus
Gen surg
On examination of the lower limb:
Callus and toe amputations
Differential?
Diabetic foot
Gen surg
On examination of lower limb:
Trophic changes, reduced pulses, necrosis
Differential?
Arterial disease
Gen Surg
On examination of the lower limbs:
Oedema, normal puses, ulcers
Differential?
Venous insufficiency
Arterial vs venous skin changes in vascular disease?
x5 each
ARTERIAL insufficiency: Thin, scaly, dry skin Hair loss No oedema Cold Distal gangrene (at most peripheral part)
VENOUS insufficiency: Oedema Lipodermatosclerosis Eczema Varicose veins White, stellate scars from prev ulcers (atrophie blanche)
How to measure ABPI?
Which pulses to use?
When might it be unreliable?
What value suggests periperal vasc disease?
What value suggests critical ischaemia?
1) Doppler US over pulse
2) Cuff inflated proximal to artery
3) Inflate until doppler pulse stops, then deflate slowly until it returns
- This is the systolic pressure in that artery
Do brachial artery pulse in BOTH arms
Take highest of left and right arm
Do posterior tibial AND dorsalis pedis artery
Take the higher of the two values
- ABPI is the pressure in the leg divided by the arm
Unreliable in pt with arterial calcification (due to incompressible arteries), such as in diabetic pts
<0.9 in PVD
<0.3-0.5 in critical ischaemia
Buerger’s test?
Elevation pallor and venous guttering
Legs go white when raised off the bed
Then sit over side of bed with legs hanging down
Sunset sign - rubor of dependancy, purple/red colour
Reactive hyperaemia - all vessles maximally dilated following elevation
Where is the location of disease?
1) Absent pulses bilaterally?
2) Absent in one leg only, below femorals?
3) Absent dorsalis pedis only?
4) Absent posterior tibial only?
1) Aorto-iliac
2) Femoral-popliteal on affected side
3) Anterior tibial (dor pedis is a continuation of this)
4) Posterior tibial
Features of critical limb ischaemia?
x6
- Rest pain (often worse at night)
- Absent foot pulses, reduced cap refill
- Dependant rubor (red/purple colour)
- Early pallor on elevation (Buerger’s angle <20 degrees)
- Skin changes, ulcers, gangrene
ABPI <0.5
Management of peripheral arterial disease
Smoking cessation, exercise
Medical - ACE-i, clopidogrel, statins, diabetes
Need to agressively manage RISK FACTORS (risk of MI, stroke)
Step up to - angioplasty, stenting, bypass grafting
Last resort - amputation (needs to be quite proximal to ischaemia to enable healing)
Top neck lump differentials and defining features on examination (x4)
Goitre - midline, firm, thyroid status, moves on swallowing, NOT tongue protrusion
Thyroglossal cyst - in the midline, higher up, moves with tongue
Lymph node - reactive or malignant, will be ant/post cervical chain (not midline), malignant is harder, fixed, larger
Always FLAWS a solitary lymph node
Brachial cyst - fluctuant, in the anterior triangle
Thyroid differentials
1) smooth and hyperthyroid
2) nodular and hyperthyroid
3) nodular and euthyroid
4) single nodule and euthyroid
5) smooth and hypothyroid
1) Graves
2) Toxic multinodular goitre
3) Non-toxic multinodular goitre
4) Malignancy, adenoma, cyst
5) Hashimoto’s, iodine def
Complications of a goitre (x6)
Due to underlying cause: eg. malignancy, Graves (arrythmias, bone loss, eye damage if can’t close completely)
Local causes:
- Thoracic outlet obstruction
- Dysphagia
- Upper airway obstruction
- Recurrent laryngeal nerve compression (hoarseness
Treatment of Grave’s disease
And key side effects?
Propranolol (symptomatic)
Propylthiouracil or carbimazole for 18-24 months
(Thyroid peroxidase inhibitors)
- Agranulocytosis with carbimazole
- Both teratogenic
Radio-iodine as tx of choice to cure
May worsen eye disease, contraindicated in preg
May show late hypothyroidism
Alternative is bilateral subtotal thyroidectomy
Vasucular exam
Toe amputations (alongside other healthy toes)
Neuropathic ulcers
Callus
Diabetic foot
Callus due to lack of sympathetic innervation, lack of sweating so dry skin
Single toes due to localised osteomyelitis
Check insuline injection sites, fingers for BG monitoring
Arterial vs venous vs neuropathic ulcers?
Arterial - deep, pale, necrotic
Tend to be distal, +++pain
Venous - shallow, red, scaly, weepy
Tend to be lower leg, achy
May see oedema, haemosiderin
Neuropathic - deep, pink/red, surrounding callus
Tend to be on plantar aspect, pressure points
May see foot deformity, decreased sensation
Diabetic foot management (x7)
Annual review - med and podiatry
Avoid high risk behaviours (e.g. walking barefoot)
Orthotics with pressure relief
Callus debridement (avoid build up of pressure beneath callus and ulcer progression)
Good glycaemic control
IV abx if infected
MRI if abscess/osteomyelitis (+- drain or amputation)
Most common area for venous ulcer?
Gaiter area
(superior to medial malleolus lateral and medial)
due to anatomical venous drainage, less efficient perforating veins
Signs of chronic venous insufficiency on examination (x7)
Oedema Lipodermatosclerosis Eczema Venous ulcers Varicose veins Warfarin (prev DVT) Abdo mass with compression
Two main types of varicose veins?
Distriibution of short saphenous vein
Posterior aspect of calf up to knee
OR
Distribution of great saphenous vein
Medial aspect of the leg
From hallux to pubic tubercle
Trendelenburg’s test
- Lie pt down, empty blood out of veins
- Compress sapheno-femoral junction
- Stand pt up
If no refill whilst compressing (negative) - shows deep veins are competent
Then refill when compression removed (positive) - shows superficial veins are incompetent
The test is reported in two parts, the initial standing up of the patient (positive or negative based on rapid filling) and the second phase once the tourniquet is removed (positive or negative based upon rapid filling)
Superficial veins of the leg normally empty into deep veins, however retrograde filling occurs when valves are incompetent, leading to varicose veins
Management of venous insufficiency
x5
Compression bandaging Emollient (/steroid) for eczema/lipodermatosclerosis Analgesia if pain Elevate legs when possible Lose weight, keep active, avoid injury
Management of varicose veins
Lose weight, moderate exercise, elevate legs where possible
US prior to intervention (position of SFL is variable)
Refer to vascular for:
- Injection sclerothrerapy
- Surgical stripping or ligation
Carpal tunnel examination
Look for vertical scar on wrists/palm of hand over flexor retinaculae
Test abductor pollicis brevis (palm flat, move thumb to ceiling)
Loss of sensation over index finger
Thenar wasting
Phalen’s test (dorsum of hands together, 30-60s)
Tinel’s test (tap over nerve)
Associations of carpal tunned syndrome
(Any cause of swelling in carpal tunnel)
Trauma Pregnancy Rheumatoid arthritis Hypothyroidism Diabetes Acromegaly Exaggerated by occupational repetitive strain injury
Top hand differentials in PACES and distinguishing features (x4)
Rheumatoid - MCP swelling (tender with gentle squeeze), deformity (z-thumb, Swan-neck, boutonierre’s, ulnar deviation)
Osteoarthritis - bony nodules (Bouchard PIP, Heberdens DIP)
Systemic disease - sclerodactyl, calcinosis, nail changes, Reynauds, dupuytrens
Carpal tunnel - scar, thenar wasting
Extra-articular manifestations of rheumatoid arthritis
x11
Pulm - pleural effusions, pulm fiborosis, bronchiectasis
Eyes - scleritis
Neuro - carpal tunnel, atlanto-axial subluxation
Haem - anaemia, Felty’s syndrome
Cardiac - pericarditis
Renal - neptrotic synd, amyloidosis
RA management
Conservative - adaptations, physio
NSAIDs - symptoms
DMARDS - methotrexate, steroids, hydroxychloroquinine
Anti-TNFs - infliximab, gadalinumab (if tried >2 DMARDS)
Knee osteoarthritis management
Weight loss, exercise Physio to prevent fixed flexion deformity and preserve function OT Analgesia (NSAIDs and PPI cover) Intra-articular steroids Joint replacement
Osteoarthritis xray changes
Loss of Joint Space
Osteophytes
Subchondral cysts
Subchondral sclerosis
Nail pitting in the hands?
Joint examination
Psoriasis
Think psoriatic arthritis
Psoriasis signs (x3)
Extensor plaques with scales - erythematous base, dry scaly flakes on top
Also on scalp and behind ears
Note: auspitz sign (bleeding when scales removed)
Nails - Pitting, Oncholysis, Subungal Hyperkeratosis (POSH)
May see it present as Koebner phenomenom, Guttate psoriasis
Psoriatic arthropathy types (x5)
LASSA
Large joint mono/oligo-arthitis Arthitis mutilans Sacroilitis Seronegative (similar to RA) Asymmetrical polyarthritis (including DIP, similar to OA)
Management of psoriasis (x6)
Avoid precipitants - smoking, BB, stress, alcohol
Calcipotriol (vit D analogue)
Betamethasone (steroids)
Tar or dithranol (antiproliferative agents)
Psoralen and UVA (PUVA)
Methotraxate and anti-TNFs for arthritis
How do you confirm anaphylaxis on blood tests?
Tryptase
Do at time 0, 1 hour, 12-24 hours
Peak at 30 mins-1 hour post anaphylactic rxn
Fall back to baseline within a few hours
Tryptase contained in mast cells so spike in levels seen with mast cell degranulation
