AS PACES Shorts

Question 1

Locations of psoriasis

Answer 1

Extensors, behind ears, scalp, umbilicus, trauma (Koebner phenomenon)
Nails - pitting, discolouration, onycholysis, subungal hyperkeratosis

Question 2

DDx Keobner phenomenon

Answer 2

Psoriasis, lichen planus, viral warts, vitiligo, sarcoid

Question 3

Pathogenesis of psoriasis

Answer 3

Type IV T cell driven
Hyperkeratosis
Parakeratosis (nuclei in stratum corneum)
Intra-epidermal micro abscesses of Munro

Question 4

Subtypes of psoriasis

Answer 4

Guttate (drop like lesions, children often post Strep)
Pustular
Erythrodema
Flexural

Question 5

Psoriasis Mx

Answer 5

Conservative –> avoid precipitants, MDT
Medical –> Emollients (diprobase), Steroids, Vit D analogues, Phototherapy (PUVA, narrow band UVB), Systemic retinoids, methotrexate, ciclosporin, anti TNF

Question 6

Malignant melanoma features

Answer 6

ABCDE
Asymmetry
Boarder
Colour 
Diameter <6mm
Evolution

Question 7

MM classification

Answer 7

Superficial spreading 80%
Lentigo maligna melanoma: elderly
Acral lentiginousL blacks, soles, palms
Nodular: younger
Amelanotic: delayed Dx

Question 8

Signs of NF

Answer 8

Cafe au Lait spots >6 >15 mm
Axillary freckling
Neurofibromatomas - gelatinous, violaceous nodules
Eyes –> Lich nodules (melanocytic hamartomas of the iris
BP - phaeo / RAS
Back - scoliosis
Acuity - optic glioma

Question 9

Tuberous sclerosis - O/E

Answer 9

Facial adenoma sebaceum (perinasal angiofibroma)
Periungal fibromas - hands and feet
Shagreen patch (sacrum)
Ash leaf macules
Cafe au laid spots
Cystic lung disease, cystic renal disease,
Gingival hypertrophy and hirsuitism 2* to phenytoin (majority epileptic)
AD chr 16

Question 10

OWR syndrome (HHT) O/E

Answer 10

Telangectasia on face, lips, buccal mucosa; cyanosis if large AVMs, no signs of CREST
DDx CREST, CLD
AD, AVM in lungs, brain, liver
Epistaxis, GI haemorrhage, haemoptysis, SAH, HOCF,

Question 11

Peutz Jeghers

Answer 11

Small pigmented macules on lips, oral mucosa, palms and soles
DDx PJ, simple freckles
AD STK11 chr 19
GI hamartomas (bleeding, intussusception) and mucocutaneous macules
CRC 20% lifetime risk; + pancreatic endocrine tumours

Question 12

Erythema multiforme - O/E

Answer 12

Symmetrical target lesions esp extensor surfaces
Ddx EM, discoid eczema,
2* to infections (HSV 70%, mycoplasma) or drugs (NSAIDS, allopurinol, penicillin, phenytoin, sulfonamides)
If V severe SJS/TEN

Question 13

Erythema nodosum - O/E + causes

Answer 13

Tender blue/red smooth shiny nodules on shins

Systemic (sarcoid, IBD, Behcet’s), Infection (strep, TB), Drugs (sulphonamides, OCP)

Question 14

Lupus pernio - appearance

Answer 14

Blown plaques on nose, skin manifestation of sarcoidosis

Question 15

Extra-articular features

Answer 15

Nodules
Tenosynovitis (de Quervains and atlanto-axial subluxation)
Immune (vasculitis, amyloidosis, Sjogren's, AIHA)
Cardiac (pericarditis ± effusion)
Carpal tunnel
Pulmonary fibrosis ± effusions
Opthalmic: episcleriis, scleritits 
Renal: 2* to amyloid deposition
Felty's

Question 16

SE Methotrexate

Answer 16

BM supression, hepatotoxicity, pulmonary fibrosis

Monitor FBC, LFTs, CXR

Question 17

SE sulfasalazine

Answer 17

BM suppression, skin rashes, hepatitis, lowered sperm count

Question 18

SE hydroxychloroquine

Answer 18

Retinopathy

Question 19

SE penicillamine and gold

Answer 19

Nephrotic syndrome

Question 20

Atlanto-axial subluxation in RA patients

Answer 20

Rheumatoid tenosynovitis leads to weakening of ligaments supporting the top of the C spine
Posterior subluxation of odontoid peg can compress spinal cord leading to progressive spastic paraparesis or if v acute cardiac arrest.
Pre op XR C spine in gentle flexion

Question 21

Mx Raynauds

Answer 21

Gloves and hand warmers
CCB (e.g. nifedipine)
If severe prostacyclin infusion

Question 22

SLE medical management

Answer 22

Mild - cutaneous and joints. Topical roids, hydroxychloroquine
Moderate - organ involvement. Pred + Azathioprine
Severe - AIHA, serositis, CNS disease. High dose methylprednisolone, cyclophosphamide

Question 23

Ank Spond - O/E

Answer 23

Thoracic kyphosis + neck hyperextended - question mark movement
Occiput to wall distance >5cm; Schober’s >5cm; reduced chest expansion <5cm
Sacroilitis - pain on hip adduction of hip, direct pressure
Extra: anterior uveitis, apical lung fibrosis, aortic regurg, achilles tendonitis, psoriatic plaque
ECG - AV block 10%
Dipstick - protein if amyloidosis
Ix ECG, FBC, ESR, HLAB27, XR spine, CXR, DEXA

Question 24

Ank spond - bamboo spine

Answer 24

Syndesmophytes, ligamental calcification, periosteal bone formation
Sx - spinal osteotomy

Question 25

Marfan’s syndrome - O/E

Answer 25

Arm-span:height ratio >1.05
Arachnodactyly
Hyperextension of joints
RR delay - coarctation, collapsing
High arched palate + lens dislocation (upwards)
Pectus carinatum/excavatum
AR / MVP
Thyroid mass
AD chr 15 fibrillin gene
Echo - aortic root dilatation (monitor annually)

Question 26

Mx Gout

Answer 26

Conservative: Remove cause, good hydration
Medial: Indomethacin / diclofenac; 2nd line colchicine; 3rd line steroids
Chronic: Allopurinol (XO inhibitor)

Question 27

Mx Thyrotoxicosis

Answer 27

Medical: Propranolol; Carbimazole (block and replace)
Radio I: CI pregnancy and around children
Surgical: thyroidectomy (SE haematoma, RLN injury, hypo PTH, hypothyroid)

Question 28

DDx hypothyroid

Answer 28

AI (Hashimoto’s, 1* atrophic)
Iatrogenic (drugs, surgery, RI)
Iodine deficiency

Question 29

DDx Macroglossia

Answer 29

Acromegaly
Amyloidosis
Hypothyroidism
Down’s syndrome

Question 30

Acromegaly: Hx

Answer 30

Headaches, vision problems, 
Change in appearance - hat and ring size
Carpal tunnel
OSA
Chest pain, SoB, palpitations, change in bowel habit
Polyuria and polydipsia

Question 31

Acromegaly Ix

Answer 31

Bloods - increased IGF1, OGGT (will not suppress GH), glucose
CXR - cardiomegaly
MRI - pituitary adenoma

Question 32

Acromegaly Mx

Answer 32

MDT, CV risk factors
Medical: Somatostatin analogues (octreotide); Da agonists (cabergoline); GH antagonists
Surgery: trans-sphenoidal excision

Question 33

Cushing’s Ix

Answer 33

Urine dip - glycosuria
24h urinary free corotisol, dexamethasone suppression test (low and high dose)
MRI pituitary ± while body CT