__One2one Flashcards
1
Q
Bruising on face in a Cardio exam?
A
Evidence of anti-coagulation
Think AF or valve replacement
Potentially also evidence of a fall with LOC (if face hit)
2
Q
Cardio exam
Midline sternotomy scar
Differentials? (X3)
A
- Valve replacement (look for Warfarin, listen HS)
- CABG (look for saphenous graft scar, tar staining, xanthelasma)
- Congenital cardiac disease repair (if young, more rare)
3
Q
Graft options in CABG (x3)
A
Great saphaenous vein
Left internal mammary artery (aka internal thoracic)
Radial artery
4
Q
No scar
No Warfarin
Normal pulse
Ejection systolic murmur
Differentials? (x3)
A
Aortic stenosis (slow rising pulse, narrow pulse pressure) Aortic sclerosis
+- CCF (look at JVP, lungs, oedema)
5
Q
Cardio exam
No scar, no Warfarin, normal pulse
Most likely differentials? (x2)
A
Valvular disease (see pulse, BP, HS) CCF (look for JVP, lungs, oedema)
6
Q
What is a slow rising pulse?
A
Seen in Aortic stenosis
No quick upstroke
Peak pressure is prolonged over a period of time
7
Q
Define pulse pressure
What is considered a narrow pulse pressure?
Where is this seen?
A
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
8
Q
Cause of narrow pulse pressure? (x4)
Cause of wide pulse pressure? (x4)
A
Narrow - aortic stenosis, HF, shock, tamponade
Wide - pp increases with exercise, wider in athletes
If prolonged - stiffness of great vessels, aortic regurg, AVM
9
Q
Systolic murmur differentials (x3)
A
Aortic stenosis/sclerosis - Loudest in upper chest, radiates around chest wall
Mitral regurgitation - (Only) heard at apex
10
Q
Aortic stenosis vs sclerosis
A
Stenosis - radiates to carotids, slow-rising, narrow PP, heaving apex beat (sign of severity)
Sclerosis - murmur only
11
Q
Things to remember when presenting a murmur?
A
TIPQRS
Type - sys/dias Intensity (usually 3/6) Position Quality Radiation Systemic features
12
Q
Main symptoms of aortic stenosis (x3)
Main causes (x2)
A
SAD
Syncope
Angina
Dyspnoea - with LV failure
Causes: calcific degeneration, bicuspid valve (presents 10 yrs earlier)
13
Q
Signs of severity in Aortic stenosis
x5
A
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)
14
Q
Indications for surgery in aortic stenosis (x4)
A
Symptomatic
CCF
Mean transvalvular pressure gradient >44mmHg
Concomitant CABG
Overall relies on clinical judgement of pt suitability
15
Q
Grading of murmurs
A
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
16
Q
Cardio exam
Sternotomy scar and evidence of Warfarin use
Top differentials?
A
Metallic valve
(possibly tissue valve)
Also possibly AF or CCF
17
Q
Metallic vs tissue valves
A
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
18
Q
Major surgery with a metallic valve
How to manage anticoagulation?
A
Stop Warfain 1 week before
Use LMWH as bridging until day before
Then switch to unfrationated heparin the day before (as reversible)
19
Q
Cardio exam
Sternotomy scar
Normal pulse
No Warfarin
No click
Differentials? (x2)
A
Tissue valve
CABG (look for graft sites, tar staining, xanthelasma)
20
Q
Indications for CABG (x4)
A
Failure of medical management
Left main stem disease
2 or more vessel disease
Concomitant valvular replacement
21
Q
Types of saphenous graft scars
A
Longitudinal (old) scar down medial aspect of leg
Newer shorter endoscopic scars
22
Q
Medication post CABG
A
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
23
Q
Causes of mitral regurg (x4)
A
Chronic - myxomatous degeneration (CTD), functional (with LV dilatation and distortion of papillary muscles)
Acute - infective endocarditis, papillary muscle rupture (2ndary to inf/post MI)
24
Q
Signs of severity in mitral regurg (x3)
A
Symptoms - eg. CCF
LVF
Displaced or thrusting apex beat
25
Raised JVP in cardio exam
Right sided HF
| Congestive cardiac failure (indicates increased R heart pressure)
26
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
27
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
28
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
29
Stages of clubbing
Staging of clubbing (FACE)
* Fluctuancy of nail bed increased
* Angle Loss
* Curvature increased
* Expansion (drumsticking)
30
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
31
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)
32
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
33
Chronic liver disease signs plus obesity, diabetes
Think NAFLD (increasingly common cause of CLD)
34
Chronic liver disease signs and xanthelasma
Think of cholestatic disorders (PSC, PBC)
35
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
36
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
37
Signs of decompensation in chronic liver disease
ABC
Ascites
Bilirubin - worsening jaundice
Coagulopathy
Encephalopathy - asterixes
Hypoglycaemia (late stage sign)
38
Complications of cirrhosis
Portal HTN - variceal haemorrhage, SBP (ascites), thrombocytopaenia (splenomegaly)
Hepatocellular failure - encephalopathy, HCC, hypoalbuminaemia, coagulopathy
39
Causes of splenomegaly
| 4 main categories
Haem - CML, myelofibrosis ,spherocytosis
Infective - malaria, EBV
Congestion - portal HTN, RHF, thrombosis/blockage (Budd Chiari)
Infiltration - amyloidosis
40
Differentials for splenomegaly AND hepatomegaly
| x4
CML, infective (malaria, EBV), infiltration eg. amyloidosis, sarcoidosis
41
Indications for splenectomy (x4)
Traumatic rupture
Spherocytosis
Idiopathic thrombocytopaenia (less common now better meds)
Sometimes in lymphoma to reduce sx of hypersplenism
42
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)
```
43
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)
44
Indications for renal transplant (x3)
Diabetic nephropathy
Polycystic kidney disease
Glomerulonephritis
45
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
46
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
47
Stoma differentials (x4)
IBD - if YOUNG, pallor, ileostomy
Diverticulitis - elderly, colonostomy
Malignancy
Urostomy
48
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)
49
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
```
50
Extra-intestinal manifestations of IBD?
Eyes - episcleritis, posterior uveitis, scleritis
Skin - pyoderma gangernaosum, erythema nordosum
Other - clubbing, oligoarthritis, anaemia
51
Complications of IBD (x6)
Crohn's - strictures, obstruction, fistulae
| UC - toxic megacolon, colonic carcinoma, PSC
52
Indication for stoma in IBD (x5)
```
Failure of medical management (severe disease activity)
Obstruction (from strictures)
Fistulae
Toxic megacolon
Malignancy
```
53
Complications of PKD (x4)
```
HTN
UTI
Cyst haemorrhage
Haematuria
End stage renal failure
```
54
Associations with PKD
Hepatic cysts
Berry aneurysms
Mitral valve prolapse
55
Differentials for bilateral renal masses (x6)
```
Polycystic kidney disease
Bilateral renal cysts/RCC
Bilateral hydronephrosis
Hepatomegaly and splenomegaly
Amyloidosis
Tuberous sclerosis
```
56
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
57
COPD vs alpha1-AT deficiency histologically?
COPD - centriacinar emphysema
A1AT - panacinar emphysema
58
Chronic COPD management
Smoking cessation, annual influenza, one-off pneumococcal
1. SABA or SAMA first line
2. 2nd line:
- FEV1 >50% - LABA or LAMA
- FEV1 <50% - [LABA and ICS] combo or [LAMA]
Note: discontinue SAMA when starting LAMA
3. 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
59
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
60
Resp exam
Clubbing, dry cough, fine crackles
Fibrosis
61
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
62
4 most common causes of pulmonary fibrosis
Idiopathic
Rheumatoid arthitis
Drugs - methotraxate, amiodarine, nitrofuratoin
Hypersensitivity
63
Differentials for chest asymmetry when testing expansion (x4)
Pneumothorax (not in PACES)
Kyphoscoliosis
Effusion
Lobectomy (/pneumonectomy)
64
Most likely reasons for lobectomy
| chest asymmetry and a scar
```
Malignancy (look for tar staining)
Old TB (>60 years, old management, absent ribs)
```
65
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)
```
66
Current TB treatment and their SEs?
RIPE
Rifampacin - hepatitis, orange secretions
Isoniazid - hepatitis, peripheral neuropathy (give with pyridoxine)
Pyrazinamide - hepatitis
Ethambutol - hepatitis
67
Resp exam
Wet cough, SOB
Top two differentials?
Bronchiectasis (look for signs of CF)
| pneumonia (less likely in PACES)
68
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)
```
69
CF treatment
Conservative - postural drainage, active cycle breathing, nutrition
Medical - Creon and fat soluble vitamens, immunisations
DNase, abx (prophylactic and exacerbations)
Surgical - lung transplant
70
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
71
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)
72
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
73
Neuro exam
Abnormal gait
Flexed arm, extended leg
Hemiplegia - pyramidal weakness
| Likely stroke
74
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
```
75
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
76
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
```
77
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
78
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
79
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
80
Neuro exam
Broad and unsteady gait
Ataxia
| Look for further cerebellar signs
81
Cerebellar signs in the arms (x5)
Rebound overshoot
Dysdiadochokinesia
Hypotonia, hyporeflexia
Past-pointing and intention tremor
82
Cerebellar sign localisation within the cerebellum?
Cerebellar vermis - more trucal ataxia, minimal limb signs
Cerebellar hemisphere lesions - ipsilateral limb signs, less truncal involvement
83
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
84
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
85
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
86
Facial palsy PLUS corticospinal tract signs, VI palsy
Site of lesion and underlying cause?
Pons
Stroke or MR
87
Facial palsy PLUS V, VI, VIII and cerebellar signs
Site of lesion and underlying cause?
Cerebello-pontine angle
Acoustic neuroma
88
Facial palsy PLUS VIII palsy
Site of lesion and underlying cause?
Inner ear
eg cholesteatoma
89
Facial palsy PLUS parotid scar/swelling
Site of lesion and underlying cause?
Parotid tumour
90
Treatment of Bell's palsy?
Eye protection
Prednisolone if <72 hours
(acyclovir no longer recommended)
75% make a full recovery
91
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
92
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
93
Gen surg
Oedematous and pigmented legs differential?
Chronic venous insufficiency
94
Gen surg
Toe amputations
Diabetic foot disease
95
Gen surg
Shiny, pale legs differential?
Peripheral arterial disease
96
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
97
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
98
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)
99
Anatomy of direct inguinal hernias?
Hesselbach's triangle
Inf - inguinal ligament
Lat - inferior epigastric artery
Med - rectus abdominus
100
Gen surg
On examination of the lower limb:
Callus and toe amputations
Differential?
Diabetic foot
101
Gen surg
On examination of lower limb:
Trophic changes, reduced pulses, necrosis
Differential?
Arterial disease
102
Gen Surg
On examination of the lower limbs:
Oedema, normal puses, ulcers
Differential?
Venous insufficiency
103
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)
```
104
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
105
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
106
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
107
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
108
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)
109
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
110
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
111
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
112
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
113
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
114
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
115
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)
116
Most common area for venous ulcer?
Gaiter area
(superior to medial malleolus lateral and medial)
due to anatomical venous drainage, less efficient perforating veins
117
Signs of chronic venous insufficiency on examination (x7)
```
Oedema
Lipodermatosclerosis
Eczema
Venous ulcers
Varicose veins
Warfarin (prev DVT)
Abdo mass with compression
```
118
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
119
Trendelenburg's test
1. Lie pt down, empty blood out of veins
2. Compress sapheno-femoral junction
3. 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
120
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
```
121
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
122
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)
123
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
```
124
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
125
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
126
RA management
Conservative - adaptations, physio
NSAIDs - symptoms
DMARDS - methotrexate, steroids, hydroxychloroquinine
Anti-TNFs - infliximab, gadalinumab (if tried >2 DMARDS)
127
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
```
128
Osteoarthritis xray changes
Loss of Joint Space
Osteophytes
Subchondral cysts
Subchondral sclerosis
129
Nail pitting in the hands?
| Joint examination
Psoriasis
| Think psoriatic arthritis
130
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
131
Psoriatic arthropathy types (x5)
LASSA
```
Large joint mono/oligo-arthitis
Arthitis mutilans
Sacroilitis
Seronegative (similar to RA)
Asymmetrical polyarthritis (including DIP, similar to OA)
```
132
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
133
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
