Cases Book Flashcards
List triad of Sx in CCF
SOB, Na and water retention (oedema)
List signs O/E of CCF
S3 gallop rhythm
Cardiomegaly
Neck vein distention
List Ix for CCF
BNP, FBC, U&Es, BGC, LFTs
Echo, ECG, CXR
How is CCF categorised?
NYHA
List categories of NYHA classification
I = mild II = Limited physical activity III = Moderate, gentle activity causes Sx IV = Severe, Sx at rest
List Mx of CCF
Diuretics, ACEi, B blockers, valsartan
Define PBC
Chronic disease of small intra hepatic ducts characterised by progressive bile duct damage and portal tract inflammation
List risks of developing PBC
Female, 45-60y/o
PMH or FH of AIDs
Sjorgens / scleroderma / coeliac / RA / thyroid problems
What AB is positive in PBC?
Anti mitochondrial antibodies
Sx of PBC?
Can be none
Jaundice, fatigue, pruritis, xs pigment, xanthelasma
Ix for PBC?
LFTs (ALP and GGT raised)
AB screen
USS abdo
Clotting and lipids
Describe pathophysiology of MG
Faulty ACh Rs causing auto antibodies to ACh R
What is defining feature of MG?
Fatiguability (worse on exertion, better with rest)
What is MG linked to?
Thyroid hyperplasia
What is pathophysiology of Lambert Easton?
ABs to VGCC causing weakness which is better with activity
List types of pneumoconiosis
Asbestosis, silicosis, coal workers lung
List Sx of pneumoconiosis
Nothing
Gradual SoB, dry cough, reduced exercise tolerance
List CXR findings of pneumoconiosis
Upper zone = egg shell calcification
Round opacities
Lower zone = interstitial fibrosis and pleural thickening
What causes MM?
Clonal proliferation of plasma cells in bone marrow
Sx of MM?
CRAB
C = hypercalcaemia Sx (stones, bones, throans, abdo moans, psychic groans)
R = renal failure - dark urine, recurrent UTI
A = anaemia (pale, SoB, fatigue)
B = bones (pain, fractures)
List Ix and results for MM
Blood film –> bence jones proteins
LFTs –> all normal inc NORMAL ALP
Serum/urine electrophoresis –> increased protein
Bone marrow biopsy –> >30% plasma cells
What is triad of anti-phospholipid syndrome?
Thromboses - DVT, PVD, stroke
Pregnancy loss - miscarriage, pre-eclampsia
Anti PL ABs - lupus anticoagulant, anti-cardiolipin
List Sx of SLE
SOAP BRAIN MD Serositis (pleuritis, pericarditis) Oral ulcers Arthritis Photosensitivity
Blood disorders (low platelets, haemolytic anaemia, low leukocytes) Renal problems (proteinuria, red cell casts) Anti-nuclear ABs Immunology (anti double stranded DNA, anti smooth muscle) Neuro Sx (psychosis, seizures)
Malar rash
Discoid rash
What is the key AB of SLE?
Anti nuclear ABs
Who is the typical SLE patient?
15-45y/o, Afro/Asian female
What is achalasia?
Motor disorder with loss of O peristalsis and failure of lower O sphincter to relax post swallow
What causes achalasia?
Loss of neurones in myenteric plexus
Sx /signs of achalasia?
Dysphagia to solids and liquids Regurgitation Pain Weight loss Nausea and vomitting
Ix and result of achalasia?
Barium swallow - bird beak appearance
Define PSC
Inflammation and injury of medium/large bile ducts leading to fibrosis and strictures
Describe typical PSC patient
Male, 40-50y/o, with UC
Sx of PSC?
Abdo pain, pruritus, fatigue, weight loss, fever, jaundice
What AB is positive in PSC?
pANCA
What complication is linked to PSC?
Cholangiocarcinoma
Ejection systolic murmur
Aortic stenosis
Early diastolic murmur
Aortic regurg
Mid diastolic murmur with opening snap
Mitral stenosis
Pansystolic murmur
Mitral regurg
Collapsing pulse, wide pulse pressure
Aortic regurg
Quiet S1, split S2 in severe. Blowing sound.
MR
Loud S1, with S3 present and displaced apex beat. Rumble sound
MS
Soft S2. S4 present.
AS
Syncope, angina and dyspnoea.
AS
Quinckes and de MUssets?
AR
Causes include rheumatic fever, IE, Marfans, MV prolpase
MR
Graham Steel murmur
MS causing pulm HTN
Tapping apex beat
MS
Displaced apex beat
MR
S3 present
MR
S4 present
AS
Narrow pulse pressure and slow rising pulse
AS
Heaving apex beat
AS
Pistol shot over femorals
AR
Rheumatic heart disease, AF and malar rash
MS
The most common murmur
AS
What is carcinoid syndrome?
Tumour of ileum enterochromaffin cells (release serotonin) which metastasise to liver
What precipitates carcinoid syndrome?
Stress, alcohol, caffeine
Sx carcinoid syndrome?
CARC - cutaneous flushing - asthmatic wheeze - R murmur - cramps and diarrhoea Low BP
Ix for carcinoid syndrome?
Urinary 5-HIAA (serotonin)
Which IBD: has bloody diarrhoea and tenesmus?
UC
Which IBD: has diffuse pain ?
UC
Which IBD: has ulcers and perianal abcesses?
CD
Which IBD: has RIF pain?
CD
Which IBD: has risk of gallstones and fistula?
CD
Which IBD: PSC and colorectal cancer?
UC
Which IBD: has skip lesions?
CD
Which IBD: is continous?
UC
Where does UC effect?
Rectum to ileocaecal valve
Which layers does UC affect?
Mucosa and submucosa
Which IBD: affects all layers?
CD
What is histology of UC?
Depletion of goblet cells
Crypt abcesses
Pseudopolyps
What is histology of CD?
Goblet cell hyperplasia
Granulomas
Cobblestone on colonoscopy
What is AXR of CD?
Strictures
Rose thorn ulcers
What is AXR of UC?
Loss of haustra
Drainpipe colon
List 3 common extra GI features of IBD
Arthritis
Erythema nodosum
Pyoderma gangrenosum
How do you induce remission for UC?
Aminosalicylates +/- steroids
How do you induce remission for CD?
Glucocoticosteroids or budesonide
How do you maintain remission for UC?
Aminosalicylates & azothioprine
How do you maintain remission for CD?
Smoking cessation
Azothioprine or mercaptopurine
List types of SVT
AF, WPW, Atrial flutter, paroxysmal SVT
List Sx of SVT
Palpitations, SoB, chest pain, dizziness, syncope
What is the Mx of SVT?
Adenosine or flecainide
How do you Mx AF?
Rate control: beta blocker or CCB
Rhythm control: Dc cardiovert
What is WPW?
Re-entry circuit (bundle of kent)
What is seen on ECG of WPW?
Delta wave (wide QRS with slurred upstroke) Short PR interval
What is WPW associated with?
Ebsteins anomaly
Describe pathophysiology of Alzheimers?
Cerebral atrophy
Type A beta amyloid plaque deposition
Tau protein tangles
List Sx of Alzheimers
Memory and language problems
Global deficits
List Sx of vascular dementia
CVD risk factors
Focal problems - visual / sensory /etc
Sudden, STEPWISE deterioration
Describe pathophysiology of Lewy Body dementia?
Lewy bodies in substantia nigra, paralimbic and neocortex
List Sx of Lewy Body dementia
Visual hallucinations Progressive cognitive impairments - attention and executive function are first to go - can be fluctuating PD Sx
List Sx of fronto-temporal dementia
Disinhibition and change in personality
Hyperorality
Vertigo, tinnitus and sensorineural hearing loss over minutes to hours in one ear only. Dx?
Menieres
Sudden onset dizziness and vertigo due to changes in head position with nausea. Dx?
BPPV
Ix for BPPV?
Dix-Hallpike manoeuvre
What is positive sign in Dix Hallpike for BPPV?
Delayed onset (>2s) torsional nystagmus unilaterally
Mx of BPPV?
Epley manouvre
What is haemochromatosis?
Autosomal recessive disorder of iron absorption and metabolism resulting in iron accumulation
Sx of haemochromatosis?
Bronze skin
DM
Fatigue, ED, arthralgia
Liver disease
What does a target cell on blood film indicate?
Sickle cell Thalassaemia Iron deficiency anaemia Hyposplenism Liver disease
What does a tear drop cell / poikilocyte on blood film indicate?
Myelofibrosis
What does a spherocyte cell on blood film indicate?
Hereditary spherocytosis
AI haemolytic anaemia
What does a Howel Jolly body cell on blood film indicate?
Hyposplenism
What does a Heinz body on blood film indicate?
G6PD deficiency
Alpha thalassaemia
What does a schistocyte on blood film indicate?
Haemolysis
DIC
Mechanical heart valve
What does a poikilocyte / pencil cell on blood film indicate?
Iron deficiency anaemia
What does a burr cell on blood film indicate?
Uraemia
Pyruvate kinase deficiency
What does a rouleaux on blood film indicate?
MM
What does a smear / smudge cell on blood film indicate?
CLL
What does an auer rod on blood film indicate?
AML
What does hypersegmented neutrophil on blood film indicate?
Vit B12 deficiency
What does a reed steenberg cell on blood film indicate?
Hodgkins lymphoma
Which skin infection is in the dermis and sub cut fat?
Cellulitis
Where does erysipelas effect?
Epidermis
Which skin infection is well demarcated?
Erysipelas
Which skin infection has systemic Sx such as fevers and rigors?
Erysipelas
Which skin infection has a risk of sepsis?
Cellulitis
List risks of cellulitis / erysipelas
Wounds, ulcers, bites, cannula, immunosuppression
List complications of cellulitis
Abscess, sepsis, necrotising fasciitis, periorbital cellulitis
Mx of cellultiis / erysipelas?
Draw a line around the border to monitor spread
Analgesia, fluids
Oral ABx - flucloxacillin
List classical findings of TLS
High K
High PO43
High uric acid
LOW Ca
List Sx of TLS
Arrhythmias Gout Seizures Anorexia, N/V, diarrhoea Muscle cramps
List risks of developing GN
Infection - Hep B/C, group A strep, IE, HIV, RTI, GIT infections
Connective tissue disorders eg SLE, vasculitides
Cancer - HL, lung, colorectal, blood
HUS
Drugs
List Ix for GN
Urinalysis and MC&S
LFTs, FBC, lipids
Albumin, creatinine, GFR
Kidney USS
List Sx of pilonidal sinus
Discharge / pain / swelling / sinus tract in sacrococcygeal areas
What is a pilonidal sinus
Acquired disease in which a hair follicle becomes inserted in skin, creating chornic sinus tract in natal cleft
Who gets pilonidal sinuses?
16-40y/o males with PMH natal cleft
What is Mx of pilonidal sinus?
1st = hair removal and hygiene
If Sx - surgical closure
If abscess - surgical drainage
What do erythema multiforme look like?
Target lesions which are symmetrical with a central blister
Where do you get erythema multiforme?
Start on hands then spread to palms, soles of feet and limbs
What is Stevens Johnson syndrome?
Erythema multiforme + fever + mucosal involvement
List Sx of cerebral abscess
Fever, headache, seizures, raised ICP
List risks of developing a cerebral abscess
Facial infections eg sinusitis or otitis media
Endocarditis
Fractures
List Ix and Mx for cerebral abscess
Ix = CT head, ESR, blood cultures Mx = IV ABx
What ABx would you use for strep / anaerobes causing cerebral abscess ?
IV cef and met
What ABx would you use for staph causing cerebral abscess ?
IV fluclox and cef
What is sarcoidosis?
Multisystem granulomatous disorder of unknown causes
Who is the typical sarcoid patient?
20-40y/o Afro Carribean woman with HLA DRB1
List acute Sx of sarcoid
Fever Erythema nodosum Polyarthralgia Dry cough Progressive SoB
What is seen on CXR of sarcoid?
Bilateral hilar lymphadenopathy
List non resp Sx of sarcoid
Lymphadenopathy Hepatosplenomegaly Conjunctivitis / glaucoma / uveitis Parotid enlargement --> Bells palsy Erythema nodosum
List Ix for sarcoid
BLOODS: ESR, FBC, LFT, ACE, Ca
CXR
Tissue biopsy (transbronchial)
What are the blood results for sarcoid?
Raised Ca and ACE
What is the tissue biopsy result of sarcoid?
Non caseating granulomas
What is the Tx for mild sarcoid?
Bed rest and NSAIDs
What is the Tx for symptomatic sarcoid?
Prednisolone 40mg for 4-6weeks
Name and describe 2 types of hiatus hernias
Sliding = stomach pushes up oesophagus Rolling = stomach squishes up next to oesophagus
Which type of hiatus hernia is more common?
Sliding (80%)
List risks of developing a hiatus hernia
Obesity
Previous GI surgery
Raised intra-abdo pressure
List a key sign of a hiatus hernia O/E ?
Bowel sounds in chest
List Sx of hiatus hernia
Symptomatic GORD
Lower dysphagia
Painless regurg of food
List gold standard Ix for haitus hernia
Barium swallow
What condition is suggested by the auto antibody anti TPO?
Hashimotos
What condition is suggested by the auto antibody Anti TSH R?
Graves
What condition is suggested by the auto antibody anti soluble liver Ag?
AI hepatitis type III
What condition is suggested by the auto antibody anti mitochondrial AB?
PBC
What condition is suggested by the auto antibody anti smooth muscle?
AI hepatitis type I
What condition is suggested by the auto antibody anti GBM?
Goodpastures
What condition is suggested by the auto antibody anti cardolipin?
Anti phospholipid syndrome
What condition is suggested by the auto antibody anti parietal cell?
pernicious anaemia
What condition is suggested by the auto antibody anti CCP?
RA
What condition is suggested by the auto antibody anti adrenocortical ?
Addisons
What condition is suggested by the auto antibody cANCA?
Granulomatosis with polyangiitis
What conditions are suggested by the auto antibody pANCA?
UC, PSC, eosinophilic granulomatosis with polyangiitis
What condition is suggested by the auto antibody anti nuclear ABs?
systemic sclerosis
What condition is suggested by the auto antibody anti centromere?
Systemic sclerosis
What condition is suggested by the auto antibody anti-topoisomerase II?
DIffuse cutaneous sclerosis
What condition is suggested by the auto antibody anti dsDNA?
SLE
What condition is suggested by the auto antibody anti Lo and anti Ra?
Sjorgrens
Name 3 types of cardiomyopathy
Dilated, restrictive and hypertrophic
Describe aetiology of dilated cardiomyopathy
viral, alcoholic, cocaine, FHx, hyperthyroidism, haemochromatosis
Describe aetiology of hypertrophic cardiomyopathy
Genetic (Beta myosin / troponin T / alpha tropomyosin)
Describe aetiology of restrictive cardiomyopathy
Amyloidosis, sarcoidosis, haemochromatosis
Describe Sx of dilated cardiomyopathy
Heart failure Sx, arrhythmia, embolus, FH sudden death
Describe Sx of hypertrophic cardiomyopathy
None - sudden death
Syncope / angina / arrhythmia
Describe Sx of restrictive cardiomyopathy
dyspnoea, fatigue, swelling
Describe signs O/E of dilated cardiomyopathy
Raised JVP, displaced apex beat, S3, MR/TR
Describe signs O/E of hypertrophic cardiomyopathy
Jerky carotid pulse
Double apex beat
Describe signs O/E of restrcitive cardiomyopathy
Raised JVP
Kussmauls sign
S3
Swelling
List Ix for cardiomyopathy
CXR
ECG
Echo
What will hypertrophic cardiomyopathy show on ECG?
Left axis deviation
LVH
Q waves in inf/lat
What will echo show for dilated cardiomyopthy?
Baggy ventricles
What will echo show for hypertrophic cardiomyopthy?
Ventricular hypertrophy, esp septum
What will echo show for restrictive cardiomyopthy?
Normal ventricles but large atria
List risks of developing HL
20-30 or >50y/o
Male
EBV
Describe Sx of HL
Painless enlarging neck mass in neck / axilla / groin
–> painful after alcohol
B Sx - FLAWS
Describe signs O/E of HL
Splenomegaly
Non tender, firm lymphadenopathy
List Ix for HL
FBC
Lymph node biopsy
Bone marrow aspirate
What will FBC show for HL
Low Hb, Raised WCC, Raised ESR
How do you stage HL?
Ann arbour staging
What is diagnostic of HL?
Reed Sternberg cells on histology
Name 2 types of focal seizures and differentiate between them
Simple partial (aware) and complex partial (impaired awareness)
List localising features of focal seizures in the temporal lobe
Hallucinations, automatisms, deja vu
List localising features of focal seizures in the frontal lobe
Head / leg movements, posturing
List localising features of focal seizures in the parietal lobes
Parasthesia
List localising features of focal seizures in the occipital lobes
Floaters / flashers
What is Mx of focal seizures?
Lamotrigine or cabamazepine
What is characteristic of generalised seizures?
LOC
Name 4 types of generalised seizures?
Tonic clonic
Abscence
Non convulsive status epilepticus
Myoclonic
List features of tonic clonic seizure
Vague aura Muscle spasms Incontinence Tongue biting Post ictal conufsion
List features of abscence seizures
LOC but retained posture
Blinking eyes / eyes roll up
No post ictal phase
List features of myoclonic seizures
In clusters after waking up
What is status epilepticus?
30+ mins of seizure
What is Mx of status epilepticus ?
ABCDE
Check glucose
IV lorazepam / PR diazepam
Not working? Transfer to ITU and give IV phenytoin on ECG monitoring
What causes ITP?
Anti platelet ABs from spleen attack GLP IIb - IIIa Ags
Who gets ITP?
Kids after a viral infection
Sx of ITP?
Easy bruising, mucosal bleeds, epistaxis
Ix and results for ITP?
FBC (low platelets) Clotting screen (normal)
List Sx of TTP
Fever, renal failure, haemolytic anaemia, thyrombocytopenia, neuro Sx
Who is the typical TTP patient?
39y/o black female
List Ix and results for TTP
FBC (anaemia, low platelets) Blood smear (schistocytes) LDH and BR (raised) Urinalysis (++ protein) U&Es (raised U & C)
Where is the lesion in the following strokes:
contralateral hemiparesis and sensory loss. Lower limb > upper limb ?
ACA
Where is the lesion in the following strokes:
contralateral hemiparesis and sensory loss. Upper limb > lower limb. Contralateral homoymous hemianopia and aphasia.
MCA
Where is the lesion in the following strokes:
homonymous hemianopia with macular sparing. Visual agnosia ?
PCA
Where is the lesion in the following strokes:
Ipsilateral CN 3 palsy. Contralateral limb weakness (webers syndrome) ?
Posterior branches to midbrain
Where is the lesion in the following strokes:
ipsilateral facial pain/temp loss. Contralateral limb/torso pain/temp loss. Ataxia, nystagmus (LMS)?
Posterior inferior cerebellar
Where is the lesion in the following strokes:
Ipsilateral facial paralysis and deafness. Similar Sx to Lateral Medullary Syndrome. (aka Lateral pontine syndrome) ?
Anterior inferior cerebellar
Where is the lesion in the following strokes:
Amarosis fugax ?
Retinal / opthalmic artery
Where is the lesion in the following strokes:
Locked in sydnrome ?
Basilar
Where is the lesion in the following strokes:
isolated hemiparesis / sensory loss / ataxia ?
Lacunar infarct
What type of inheritence is a1atd?
Autosomal recessive
What does alpha 1AT protect against?
Neutrophil elastase
Sx of A1AT deficiency?
Emphysema –> cough, SoB, freq URTI
Cirrhosis / HCC or cholestasis
Ix for A1AT deficiency?
A1AT levels / plasma AAT
Spirometry - obstructive
Phenotyping