Clinical Consultation Flashcards
Causes of breathlessness in ankylosing spondylitis
Anaemia
Apical pulmonary fibrosis
Aortic regurgitation
Mechanical restriction
Treatment in ankylosing spondylitis
Patient education
PT/OT
Hydrotherapy
Smoking cessation
NSAIDS - naproxen/meloxicam
Anti-TNF agents eg adalimumab
Anti-Il-17 - secukinumab
Jak inhibitors - upadacitinib
Pretreatment considerations with Anti-TNF treatment
Immunisations
Screen for latent/active Tb
Ix in ankylosing spondylitis
FBC - Anaemia
CRP and ESR
U&Es and LFTS
HLA-B27
CXR if chest symptoms
XR of spine and pelvis - syndesmophytes and sacroilitis, fusion of spine
MRI spine can consider
AS symptom index - out of ten- >4 - active disease
Management of acute IBD
FBC
CRP
U&Es and LFTs
Stool culture
Faecal calprotectin
AXR
Analgesia
IV hydrocortisone
IVF
pLMWH
Complications of IBD
Dilatation of bowel loops
Fistulating disease
Perforation
Abscess formation
Refractory to medical management
Tx following acute flare of IBD
Tapering course of steroids
Escalation of DMARDs eg anti-TNF agent
IBD nurse
Dietician
Flexi Sig
Differences between Crohns and UC on sigmoidoscopy
Crohns- aphthous ulcers, skip lesions, cobblestone appearances, transmural inflammation, normal rectum
UC - superficial inflammation restricted to mucosa/submucosa, crypt abscesses
Malignancy risk in IBD
Increased risk of colon cancer, have a colonoscopy 10 years post diagnosis, and further scopes as per risk category
Steroid sparing agents in IBD
Methotrexate
Azathioprine
Ciclosporin
Anti-TNF for refractory Crohns
Rectal steroids
Lhermitte’s Phenomenom
Electric shock sensation on flexion of the neck often going down the back
Hoffmans sign
Hold the PIPs of the middle finger, flick the tip of the middle finger - positive if the index or thumb extend signifying an UMN lesion in keeping with cervical myelopathy
Causes of myelopathy
Trauma
Neoplastic
MS
Vascular
Hereditary spastic neuropathy
Ix of myelopathy
FBC
ESR
Autoimmune screen
U&Es and LFTs
B12
Copper studies
Urgent MRI
Management of degenerative cervical myelopathy
Referral to neurosurgery
Analgesia
PT with neurorehab
OT
Findings in spastic paraparesis
Muscle weakness and spasticity
Urinary retention
Pyramidal signs
Hyperreflexia
Weakness especially in extensors
Spasticity
Babinski positive
Management of suspected meningitis
A-E approach
FBC - WCC
CRP
U&Es and LFTS
Coag
Broad spectrum abs
Dexamethasone
IVF
CT head - if signs of raised ICP, papilloedema, seizures or focal neurology
LP - CSF protein, glucose (and paired serum) viral PCR, cultures
Differences between LP results in viral vs bacterial
Turbid appearance in bacterial, can be clear in viral
High protein in bacterial, may be normal in viral
Low Glucose in bacterial, may be normal in viral
Positive gram stain in bacterial
Neutrophil predominant high WCC in bacterial, lymphocyte predominant in viral
Complications of bacterial meningitis
Death
Deafness
Blindness
Cognitive issues
Amputation as a result of sepsis
Treatment of migraine
Simple analgesia - paracetamol and NSAIDS
Triptan
Antiemetic
Prophylaxis can be given dependent on p
Investigations in acromegaly
ECG
FBC
U&Es and LFTs
Random IGF1
OGTT with serial GH measurements
MRI brainn with pituitary views
Complications of acromegaly
Bilateral carpal tunnel syndrome
Cardiomyopathy
IHD
HTN
T2DM
Visual impairment
Treatments in acromegaly
Trans-sphenoidal resection
Dopamine receptor agonists - bromocriptine and cabergoline
Somatostatin analogues - octreotide
Radiotherapy
Complications of pituitary resection in acromegaly
Pan hypopituitarism
Epworth score
Score >11 signifies presence of OSA
Treatment of OSA
If confirmed on polysomnography can trial CPAP overnight
Scar present in renal transplant
Rutherford-Morrison
Secondary issues in Osteogenesis Imperfecta
Bicuspid aortic valve
Aortic degneration
Poor hearing
Small stature
Barrel chested
Scoliosis
Translucent teeth
Bowing of long bones
Joint hypermobility
Skin hyper laxity
Retinal detachment and haemorrhages
Genetic basis ofbsteogenesis imperfecta
Usually AD
Can be de novo
Side effects of bisphosphonates
Oesophagitis/gastritis
Osteonecrosis of the jaw
Findings in Ehlers-Danlos
Fragile skin - ecchymoses and fish mouth scars
Hyperextensible skin
Joint hyper mobility
Mitral valve prolapse
Aortic dilatation - risk of dissection/rupture
Aneurysm rupture and dissection
Bowel perforation and bleeding
Causes of combined venous and arterial clots
APLS
MPN e.g PV, myelofibrosis and essential thrombocytosis
Complications of anti phospholipid syndrome
TIA/Stroke
DVT
PE
Livido reticularis
Thrombocytopenia
Thrombophlebitis
Foetal loss
Causes of CVA in younger patients
APLS
Extra cranial haemorrhage
Vasculitis
Cardiac Myxoma
Subacute infective endocarditis
AF
Sickle cell disease
Premature atheroma
Substance abuse - cocaine and methamphetamine
Mitochondrial problems eg MELAS
Hypertensive disorders of pregnancy
Chronic hypertension:
- Presents prior to pregnancy or at booking <20 weeks
Gestational hypertension:
- New hypertension >20 week without proteinuria
- Relabeled as chronic/primary hypertension if >12 weeks post partum
Pre eclampsia:
- New hypertension >20 weeks of pregnancy with one or both of proteinuria (PCR >30mg/mmol), OR renal/liver involvement, haematological complications, uteroplacental dysfunction
anti-hypertensive agents in pregnancy
Labetolol
Nifedipine - 1st choice in afro-Caribbean women
Methylodopa
Can also give aspirin 150mg ON to decrease risk of pre eclampsia
Target BP in pregnancy
Aim for BP <135/85
Initiate treatment in women with BP >140/90
Pre eclampsia features
Maternal AKI
Liver dysfunction - especially increase in ALT
Neurological features - headache/confusion/flashing lights
Haemolysis or thrombocytopenia
Fetal growth restriction
Ix in pre-eclampsia
Urine dip
PCR or ACR
Placental growth factors
Growth scans
Long term risks of hypertension in pregnancy
20% risk of hypertension
20% risk of pre-eclampsia
Long term CV risks
Causes of breathlessness in pregnancy
Asthma
LRTI
PE
Pneumothorax
Peripartum cardiomyopathy
DKA
Management of peripartum cardiomyopathy
Oxygen
Diurese with furosemide
Nitrates
ACEi - only in postpartum
Consider beta-blockers after liaising with obstetric cardiologists
Liaise with obstetric team for delivery
Risk factors for PE in pregnancy
No validated scoring systems
> 35 years
BMI >30
Multiple pregnancy
Para 3+
Hyperemesis
Post partum after prolonger labour, operative delivery or PPH >1L
Length of anticoagulation in pregnancy
Continue for full duration of pregnancy, for at least 3 months in total and for at least 6 weeks post partum
Contraindications for thrombolysis in stroke
Complications post stroke
VTE - IPC
Further stroke
Haemorrhagic transformation
Malignant middle cerebral artery syndrome
Seizures
Aspiration pneumonia
Spasticity
Falls
urinary and faecal incontinence
Secondary prevention in stroke management
Antiplatelets if no AF - clopidogrel long term
Anticoagulation if AF found
Statin
Weight loss
Stop smoking
Optimisation of blood pressure and diabetes
Endarcterectomy if >70% stenosis in carotid artery on ipsilateral side to stroke
What territory of infarct corresponds to homonymous hemianopia without macular sparing
MCA - in posterior stroke macula will be spared due to occipital pole receiving blood supply from the MCA
Differential for bilateral visual loss
Pituitary tumour
Glaucoma
Diabetic retinopathy and maculopathy
Bilateral cataracts
Idiopathic intracranial hypertension
Leber’s hereditary optic neuropathy
Retinitis pigmentosa
Vitamin A deficiency
What is retinitis pigmentosa
Progressive inherited retinal degeneration chcarcterised by by loss of photo receptors
No treatment, though vitamin A may slow progression
What conditions are associated with retinitis pigmentosa?
Refsum’s syndrome - muscle weakness and ataxia
Usher’s syndrome - sensorineural deafness
Kearn-Sayre’s syndrome
Abetalipoproeinaemia
Mx of reactive arthritis
Analgesia
Treating underlying cause
Causes of reactie arthritis
STI - chlamydia
Diarrhoeal illnesses
Genetic links with reactive arthritis
HLA B27
Associated with seronegative spondyloarthropathies - enteric arthritis, psoriatic arthritis, ankylosing spondylitis
Causes of hypothyroism
Hashimoto’s thyroiditis - lymphocytic destruction of thryroid follicles
De quervains thyroiditis
Iatrogenic hypothyroidism - post thyroidectomy or radio-iodine, amiodarone, lithium, carbimazole, propyl thiouracil
Post partum thyroiditis
Iodine deficiency
Symptoms in hypothyroidism
Tired and low energy levels
Constipation
Cold intoleranceMental slowing
Weight gain
Hair loss
Decreased libido
Oedema
Ix in hypothyroidism
TFTs - T3, T4 and TSH
TPO and anti-thyroglobulin - positive in Hashimoto’s
Lipid profile
FBC - microcytic anaemia
U&Es - Na
USS thyroid - goitre/FNA
CXR - retrosternal extension of goitre
Cortisol - to screen for Cushing’s
Associated conditions with hypothyroidism
T1DM
Vitiligo
Addison’s disease
Hypercholesterolaemia
Clinical findings in hypothyoidism
Bradycardi
Cool peripheries
Peaches and cream complexion - anaemia and carotenaemia
Peri-orbital oedema
Loss of eyebrows
Xanthelasma
Thinning hair
Goitre or thyroidectomy scar
Slow relaxing ankle jerk
Complications of hypothyroidism
Pericardial effusion
CCF
Carpel tunnel syndrome
Proximal myopathy
Ataxia
Conditions to be aware of when starting thyroid replacement in hypothyroidism
May unmask Addisons - precipitate crisis
May precipitate angina
Management of thyroid crisis
IV beta blockers - e.g propranolol unless contraindicated e.g. severe asthma (then use CCB - diltiazem)
Lugol’s iodine
Carbimazole/propylthiouracil
Hydrocortisone
Patients who fail medical therapy should be treated with plasma exchange or thyroidectomy
Causes of thyroid storm
Illness/infection
Recent iodine contrast
Trauma
Withdrawal or non-compliance of thyroid treatment
Myocardial infarction or stroke
DKA
Overdose of levothyroxine
Management of myxoedema coma
May require ITU
Ventilation if needed - rest failure from airway obstruction or macroglossia
Hydrocortisone
IV/PO thyroid
IV fluids
Differentials for myasthenia gravis
Guillain Barre
Miller Fischer syndrome
Lambert Eaton syndrome
Ix in myasthenia gravis
Anti-acetylcholinesterase (positive in 20%) and Anti-MuSK (positive in 15%)
TFTs - graves present in 5%
CXR
CT chest - ?thymoma (present in 10%)
MRI head if bulbar involvement present
CT/MRI orbits if thyroid opthalmoplegia suspected
Nerve conduction studies -decrement of compound muscle action amplitude with repetitive stimulation
Tension test - less commonly less
Mx in myasthenia gravis
Pyridostigmine
Steroids
Steroid sparing treatments - azathioprine (check TPMT levels prior) or MMF
IVIG or plasma exchange
Note have steroid dip - symptoms may worsen when starting
Thymectomy in some groups
Associations with myasthenia gravis
Other autoimmune disease - diabetes mellitus, RA, thyrotoxicosis, SLE, thymomas
Lambert Eaton Myasthenia Syndroma
Paraneoplastic - VGCC abs present, association with SCLC
EMG - increment on repetitive stimulation
Diminished reflexes that become brisker after exercise
Associated conditions with spina bifida
Neuropathic bladder
Constipation
Leg spasticity
Hydrocephalus - sometimes requiring VP shunts
Arnold-Chiari malformations
Recurrent meningitis
Syrinxes
Risk factors developing spina bifida
Deficiency of folate during 1st trimester
Family history of NTDs
Anti-epileptics - sodium valproate
Methotrexate
Poorly controlled diabetes
Why does the murmur of a VSD sound louder on expiration
Expiration increases venous return and therefore increases the amount of blood going through the VSD
Management of VSD
If evidence of left ventricular failure or reversal of shunt (right to left) - will need to consider closure of VSD either through patch or VSD closure device
Management of coarctation of aorta
Endovascular stenting - balloon angioplasty and stent placement
Surgical open repair - resection and end-end anastomosis
Signs in infective endocarditis
Oslers nodes
Janeway lesions
Splinter haemorrhages
Roth spots in eyes
Septic emboli distally
Poor dentition
Intravenous drug use
Haematuria on urine dipstick
Associations with coarctation of the aorta
PDA
VSD
Berry aneurysms
Turner syndrome
Presentation of coarctation of Aorta
Heart failure in Children
Hypertension
Heart failure in adults
Leg claudication
Headaches
Epistaxis
Clinical signs in coarctation of aorta
Radio-radial delay
Weak femoral pulses
Radio-femoral delay
Systolic ejection click (bicuspid vale)
Pansystolic murmur - VSD
Adjacent bruits - arterial collaterals e.g scapula, anterior axillary area,
Mid systolic murmur in infraclavicular area or posteriorly over left scapula
ECG - LV hypertrophy
CXR - posterior rib notching, figure 3 sign
Complications of coarctation of aorta
Stroke
Heart failure
Aortic rupture
Side effects of methotrexate
Anaemia
Bone marrow suppression
Pulmonary fibrosis
Liver dysfunction
Extra-articular side effects of Rheumatoid arthritis
Eyes/face:
Sicca symptoms - dry eyes, throat
Scleritis (pain and redness) or episcleritis (redness)
- scleromalacia (blue grey discolouration of eye)
Kerotconjunctivits sicca
Steroid induced cataracts
Fatigue
Lungs:
Pulmonary fibrosis
Fibrosing alveoli’s
Obliterative bronchiolitis
Lung nodules
Pleural effusion
Heart:
Pericarditis (constrictive)
Pericardial effusion
Renal:
Nephrotic syndrome - membranous glomerulonephritis
Renal amyloidosis
Neuro:
Carpal tunnel syndrome
Peripheral neuropathies
Felty’s Syndrome - splenomegaly and neutropenia
Causes of anaemia in rheumatoid arthritis
Anaemia of chronic disease
Secondary to renal disease
Iron deficiency anaemia - due to gastric ulceration with medications (NSAIDs)
B12 deficiency - pernicious anaemia
Bone marrow suppression with DMARDs
Autoimmune haemolytic anaemia
Felty’s syndrome (splenomegaly)
Radiological features in RA
Soft tissue swelling
Loss of joint space with subluxation
Periarticular osteopenia
Joint erosions
Genetic predisposition in RA
HLA DR4
Hand findings in RA
Volar subluxation and ulnar deviation at the MCPJs
Swan neck - Hyperextension of of PIPJ and flexion of the DIPJ
Boutonieres deformities - Flexion of the PIPJ and hyperextension of the PIPJ
Z shaped deformity of thumbs
Swelling and subluxation of the ulnar styloid
Carpal tunnel scar
Wasting of the dorsal interosseous muscles
Pain, swelling and restriction of joints in RA
How to measure disease activity in RA
DAS28
- Involves number of swollen and tender joints, ESR/CRP and objective assessment of the patients global health
DAS >5.1 - Active disease
DAS <2.8 - remission
Poor prognostic factors in RA
Seropositive disease - rheumatoid factor or anti-ccp
Articular erosions at onset
Severe disease activity at onset
Biologics used in RA
Anti-TNF alphas - adalimumab, etanercept, inflixamab
Anti-CD20 - rituximab
T cell co-receptor blocker - Abatercept
Anti IL-6 - Rocilizumab
DMARDs used in RA
Methotrexate
Leflunamide
Sulphasalazine
Hydroxychloroquire
Mode of inheritance in ataxia Telangiectasia
Autosomal dominant in ATM gene
Symptoms in ataxia telangiectasia
Ataxia
Dysarthria and dysphasia
Nystagmus
Dysdiadokinesia
Susceptibility to infections
Increased risk of cancer esp leukaemia and lymphoma
Telangiectasia
Average onset of symptoms in ataxia telangiectasia
Before age of 5 years
Mode of inheritance in Friedrich’s Ataxia
Autosomal recessive
Gene implicated in Friedrich’s ataxia
Frataxin - anticipation
Signs in Friedrich’s Ataxia
Wheelchair user
Pes cavus
Bilateral cerebellar signs
Combined UMN and LMN signs
- Leg wasting with absent reflexes and bilateral upping planters
Posterior column signs - loss of vibration and joint position senses
Kyphoscoliosis
optic atrophy - 30%
High arched palate
Sensorineural deafness
Murmur associated with HOCM
Diabetes testing - 10% develop diabetes
Causes of clubbing
Familial
Cardiac disease:
- Infective endocarditis
- Congenital heart disease
Respiratory disease:
- Lung cancer
- ILD
- Bronchiectasis
- Cystic fibrosis
- Asbestosis
- EAA
- Lung abscess
- HHT with pulmonary AVMs
Coeliac disease
Cirrhosis of the liver
Ulcerative colitis
Hyperactive thyroid
Genetics in HHT
Autosomal dominant
Clinical symptoms in HHT
Vascular dysplasia causing telangiectasia and AVMs
Epistaxis
Telangiectasia and AVMs in the GI tract causing acute haemorrhage or chronic slow bleeding with resulting iron-deficiency anaemia.
Pulmonary AVMs occur may present as dyspnoea, cyanosis, bruits, high-output heart failure, clubbing and paradoxical cerebral emboli that may cause stroke and cerebral abscess. They can also lead to haemoptysis and haemothorax. Pulmonary hypertension can occur.
AVMs in the liver can cause high-output cardiac failure or cirrhosis.
Some patients have cerebral involvement resulting in headache, seizures or epilepsy, intracranial haemorrhage and stroke.
Differentials in bihilar lymphadenopathy
Sarcoidosis
Thymoma
Lymphoma
TB
Pneumoconiosis e.g silicosis, berylliosis
Treatment in sarcoidosis
NSAIDs for arthralgia
Referral to respiratory and ophthalmology
Steroids indicated if:
- Stage 2-4 on CXR e.g BHL + infiltrates, infiltrates or fibrosis
- Eye involvement
- Hypercalcaemia
- Neurological involvement
- Cardiac involvement
40mg prednisolone with GI and bone protection
Monitor with ESR and ACE
Steroid sparing agents = methotrexate, hydroxychloroquine, ciclosporin, cyclophosphamide, infliximab
Surgery- lung transplant, pacemaker
Investigations in SLE
FBC, U&E, LFTs, Clotting
ESR, CRP
ANA, RF, anti-CCP, ANCA (+PR3/MPO), Immunoglobulins, complement (+/- cryoglobulins)
Antiphospholipid Abs (anticardiolipin, antiB2GPI), lupus anticoagulant screen
Anti-dsDNA, antiscl70, anticentromere Ab, AntiRo, AntiRNP, antism, Antijo1, AntiLa, Antism/RNP, antichromatin, antihistone
Miscellaneous: ACE (sarcoid), ferritin (stills),anti-GBM (goodpastures)
Nailfold capillaroscopy
Pregnancy test
Renal: BP, urine dipstick for blood and protein, urine PCR, renal USS, renal biopsy
Joints/Spine: Xrays/USS, aspiration, MRI
CVS: ECG, troponin, ECHO, BNP, cMRI
Resp: Sats, ABG, CXR, pulmonary function tests, HRCT, Right heart catheterisation, BAL, broncoscopy
Antibodies found in SLE
ANA (95% sensitive, low specificity). Positive in 98% of SLE patients.
Antiribosomal P (specific, can be positive in ANA negative patients).
AntidsDNA (70% of SLE, 95% specific)
Antism (pathognomic for SLE) Positive in 10-30%
Antiphospholipid Abs positive in 30-50%
Anti Ro and La (neonatal lupus, heart block)
Anti-RNP (mixed connective tissue disease)
RF (positive in 40%)
Antihistone antibodies for drug induced lupus
Diagnosis of SLE
ACR criteria - 4 out of 11 of SOAP BRAIN MD
Serositis - pericarditis/pleuritis
Oral mucosa
Arthritis
Photosensitivity
Blood
- lymphopenia
- Haemolytic anaemia
- Leucopenia
Renal
ANA
Immunological
Neurological - seizures and psychosis
Malar rash
Discoid rash
Treatment in SLE
Conservative: Sunscreen, pregnancy advice
Medical: Manage CVS risk factors. ACEI for proteinuria.
Mild-moderate lupus (MSK and mucocutaneous features): low dose oral prednisolone and bone and GI protection, hydroxychloroquine, azathioprine, methotrexate. NSAIDs for joint pain (watch U+E)
Severe (major organ involvement): iv methylprednisolone, cyclophosphamide, mycophenolate mofetil, rituximab/belimumab
Surgical: renal transplant
Causes of erythema nodosum
Streptococcus
OCP
Rickettsia
Eponymous - Behcets
Sarcoidosis
Hansen’s disease - leprosy
IBD - usually UC
Infections - TB (cutaneous)
Idiopathic
NHL
Sulfonamides
Pregnancy
Diagnosis of HHT
Diagnosis is made using the Curacao Criteria. If 3 criteria are present the diagnosis is definite. If 2 criteria are present, the diagnosis is suspected or possible. If only 1 criterion is present the diagnosis is unlikely.
1 Epistaxis that is spontaneous and recurrent
2 Multiple mucocutaneous telangiectasia at characteristic sites such as the lips, nose, tongue and mucous membranes, fingers, conjunctiva
3 Visceral lesions- GI telangiectasia, Pulmonary, Hepatic, Cerebral AVMs
4 Family History in a first degree relative. Genetic testing can be performed to confirm the diagnosis if necessary.
Causes of epistaxis
Trauma
Low platelets
Drugs - antiplatelets etc
Malignancy
Cocaine
Wegener’s granulomatosis (now called Granulomatosis with Polyangiitis)
HHT
Management of HHT
Managing epistaxis
- Nasal humidification
- Ointments
- Saline spray
- Tamoxifen
- TXA
- Laser therapy or cauterisation
Blood transfusion if needed
Embolisation or ablation of GI AVMs
Treatment of iron deficiency
Clinical Presentation in MEN1
Autosomal dominant MEN gene defects
Pituitary adenoma
Parathyroid hyperplasia
Pancreatic tumours and gastronomes
Clinical Presentation in MEN2A
Autosomal dominant RET gene defects
Parathyroid hyperplasia
Medullary thyroid carcinoma
Phaechromocytoma
Clinical Presentation in MEN2B
Autosomal dominant RET gene defects
Marfanoid body habitus
Mucosal neuromas
Medullary thyroid carcinoma
Phaechromocytoma
What is Lofgren’s Disorder
Bihilar lymphadenopathy, erythema nodosum, fever, weight loss, arthralgia, uveitis
Investigation in sarcoidosis
Obs and urine dip
Bloods- ESR, CRP, FBC, LFTs, ACE, Calcium, Immunoglobulins, U+E, vitamin D, TFTs
24 hour urine for calcium if raised serum calcium
Respiratory tests: sats and ambulatory oximetry, CXR, spirometry, BAL, bronchoscopy and biopsy (send biopsy for mycobacterial and fungal testing and histology), HRCT
Cardio tests: ECG, echo, 24 hour Holter, cardiac MRI
Abdo tests: urine dipstick, USS, CT
Eye tests: slit lamp examination, visual acuity, fundoscopic examination
Neuro tests: CT/MRI, LP
LN biopsy/skin biopsy/peripheral nerve biopsy
Ocular manifestations of sarcoidosis
Uveitis
Granulomas which may causes visual impairment or retinal detachment
Conjunctivitis
Keratoconjunctivitis sick
Neurosarcoidosis - papilloedema, nystagmus, visual field defects
Differential diagnoses in SLE
Drug-induced lupus
RA
Stills disease
Undifferentiated or mixed connective tissue disease
Primary sjogrens
Antiphospholipid syndrome
Fibromyalgia
Lymphoma
Infection
Pulmonary-renal syndrome (goodpastures, ANCA-associated vasculitis)
Systemic sclerosis
Dermatomyositis
Blood tests showing lupus flare
Low lymphocytes
Low complement
Normal/low CRP
Raised ESR
Anaemia, thrombocytopenia
Raised antidsDNA
Diagnosis of APLS
Suspect if:
Arterial thrombosis <50 years old
Unprovoked venous thrombosis < 50 years old
Recurrent thrombosis
Both arterial and venous events
Unusual sites eg. renal, liver, cerebral sinuses, mesenteric, vena cava, retinal
Obstetrical: fetal loss (miscarriage after 10 weeks/3 unexplained miscarriages <10 weeks), recurrent miscarriages, early/severe preeclampsia, unexplained intrauterine growth restriction
Lab criteria on 2 occasions 12 weeks apart: anticardiolipin Abs, Anti-B2GPI, lupus anticoagulant, raised APTT.
Management of APLS
Avoid oestrogen contraceptives, prophylactic aspirin
Heparin for thrombosis then warfarin
Causes of morbidity and mortality in SLE
Infections,
Atherosclerosis
Osteoporosis
Malignancy especially lymphoma, lung cancer, cervical.
Causes of drug induced SLE
Hydralazine
procainamide
Isoniazid
Phenytoin
Interferon
Associated with anti-histone Abs
Symptoms in thyrotoxicosis
Weight loss
Anxiety
Palpitations
Tachycardia
Diarrhoea
Heat intolerance
Tremor
Sweating
Irritable mood
Breathlessness
Weakness going up stairs
Eye symptoms - grittiness, loss of vision, loss of colour, eye pain, blurred or double vision
Clinical course of Grave’s disease
50% chance of cure / 50% chance of relapse - can have further treatment with carbimazole or trial of radioactive iodine
Issues with radioactive iodine with thyroid eye disease
May exacerbate active thyroid eye disease
Treatment in Graves disease
Aim to treat medically - usually takes 1.5-2 years
If relapses can trial medical treatment again or radioactive iodine or surgery
Medical Management: beta-blocker for symptomatic relief (e.g. propranolol), carbimazole or propylthiouracil (during 1st trimester).
Indications for surgery: relapse after stopping antithyroid drugs, poor compliance with meds, intolerance of meds, cosmesis, compression, symptomatic and planning pregnancy, uncontrolled on meds, suspicious nodules
Complications of surgery: hypoparathyroidism, damage to recurrent laryngeal nerve, hypothyroidism, recurrence of hyperthyroidism
Antibody found in Grave’s Disease
Abs to TSHr
Worrying symptoms in thyroid eye disease
Optic neuropathy - visual acuity and colour vision
Exposure keratopathy
Double vision
Treatment in thyroid eye disease
If mild - selenium, and topical lubricants
If by NOSPECS criteria >3 (ie more than or equal to proptosis consider IV methylpred weekly for 6 weeks
Cyclosporin may be given as a steroid sparing agent
Can try orbital decompression or radiotherapy if still no benefit
Differential diagnosis for proptosis
Thyroid eye disease
Orbital tumour/met/granuloma
Caroticocavernous fistula
Orbital cellulitis
AVM
Cavernous sinus thrombosis
Causes of thyrotoxicosis
Graves disease
Toxic multi nodular goitre
Solitary toxic nodule
Excess levothyroxine replacement
Ectopic:
- Pituitary adenoma
- Hypothalamic mass
- Ovarian teratoma, choriocarcinoma
Thyroiditis:
- Subacute (de Quervains)
- Post radiation
- Post partum
- Drug induced e.g amiodarone
Extra renal manifestations of PCKD
Cysts in other areas particularly the liver leading to polycystic liver disease
Berry aneurysms
Mitral valve prolapse
What is Charcot’s arthropathy
Painless deformity and destruction a joint with new bone formation following repeated minor trauma secondary to loss of sensation
Causes of Charcot’s arthropathy
Tabes dorsalis - hip and knee
Diabetes - foot and ankle
Syringomelia - elbow and shoulder
Treatment in Charcot’s arthropathy
Immobilisation
Referral to orthopaedics for surgical intervention
Bisphosphonates can help
Causes of secondary hypertension
Renal:
- CKD secondary to glomerulonephritis
- ADPCKD
- Renovascular disease e.g renal artery dysplasia
Endocrine:
- Cushings
- Conns
- Bilateral adrenal hypertrophy
- Liddle’s (low potassium and metabolic alkolosis, acts on ENaC transporter, treated with amiloride)
- Acromegaly
- Phaechromocytoma
- Carcinoid
Aortic coarctation
Pre-eclampsia
Symptoms to ask in hypertension history
Symptoms for hypertensive emergency:
- Headache
- Visual disturbance
- Chest pain
Previous blood pressure reading
PMHx: renal disease, CVD or PVD, smoking, diabetes, thyroid disease, cardiac disease in childhood
Associated symptoms:
- Abdominal/flank pain
- Polyuria
- Muscle cramps (Conn’s)
- Frothy urine?
- Change in hand size
- Flushing or dumping sx
- Anxiety or palpitations or sweating
Illicit drug use
?Pregnancy
Blood pressure targets
HTN if in clinic BP >140/90 on two measurements - use ABPM to confirm diagnosis (135/85 on ABPM)
Graded by British hypertension society guidelines:
Stage 1. Clinic BP >140/90 or ABPM >135/85
Stage 2. Clinic BP >160/100 or ABPM >150/95
Stage 3. Clinic SBP >180 or DBP >120
Treat if stage 1 hypertension and evidence of end organ damage, IHD, diabetes, CKD or 10 year CVS risk >10%
Treat all stage 2 hypertension
Arrange same day admission if severe hypertension and grade 3 or 4 retinopathy (or other concerns e.g. new renal impairment)
Findings in hypertensive retinopathy
Grade 1. Silver wiring
Grade 2. Plus arteriovenous nipping
Grade 3. Plus cotton wool spots and flame haemorrhages
Grade 4 Plus papilloedema
Ix in hypertension
x2 BP readings, and alternate BP readings on arms
Urine dip with PCR
ECG - LVH
Bloods:
- FBC
- U&Es - renal impairment low bicarb (conns)
- LFTs
- Aldosterone and renin ratio
CXR
ECHO
USS kidney
Special tests:
- Plasma meatnephrines
- Dexamethasone suppression tests
- IGF1
- MRA renal arteries
- PET - adrenal tumours
- MIBG - for phaechromocytomas
Treatment in Hypertension
Lifestyle advice firstling - increase exercise, salt restriction, lose weight, reduce alcohol, stop smoking
ACEi or ARB if <55yrs first line
CCB if afro-Caribbean or >55yrs
A+B second line
A+B+D (thiazide-like diuretic 3rd line e.g. indapamide)
Then consider spironolactone, beta blocker or alpha blocker
Aim <140/90, except
- >80yrs - aim <150/90
- If ACR >70 - aim <130/80
Consider cardiovascular risk and consider statin and aspirin
Conditions seen in malignant hypertension
Aortic dissection
PRES - posterior reversible encephalopathy syndrome
Aortic aneurysm
MI
Stroke
Left ventricular failure
If above conditions present invasive blood pressure monitoring and IV anti-hypertensive agents e.g GTN, labetalol and alpha blocker if considering phaechromocytoma
Conditions in MEN syndromes
MEN1 (MEN oncogene):
- Pituitary
- Parathyroid hyperplasia
- Pancreas
MEN2A (RET oncogene):
- Parathyroid hyperplasia
- Phaechromocytoma
- Medullary carcinoma
MEN2B (RET oncogene)
- Phaechromocytoma
- Medullary hyperplasia
- Mucosal neuromas
- Marfanoid habitus
Grading of diabetic retinopathy
- Background retinopathy +/- maculopathy
- Hard exudates
- Flame and dot haemorrhages
- Microaneurysms
- Annual retinal screening - Pre-proliferative retinopathy +/- maculopathy
- Multiple cotton wool spots
Multiple dot haemorrhages
- Venous beading
- Intraretinal microvascular abnormalities
- Routine referral to ophthalmology - Proliferative retinopathy +/- maculopathy
- Neovascularisation of the disease
- New vessels elsewhere
- pan retinal photocoagulation from previous treatment
- Urgent referral to ophthalmology
Diabetic maculopathy - macular oedema or hard exudates with one disc space of the fovea - routine referral to ophthalmology unless reduced vision (then urgent)
Treatment of diabetic retinopathy
Tight glycemic control
Treat other factors - hypertension, hypercholesterolaemia, smoking cessation
VEGF inhibitors
Photocoagulation
Complications of proliferative diabetic retinopathy
Vitreous haemorrhage
Traction retinal detachment
Neovascular glaucoma due to rubeosis irisis
Symptoms in ankylosing spondylitis
Back and joint pain/stiffnes - >1hr in the morning
Enthesitis - tenderness at the tendon insertion points e.g. Achilles heel, planter fasciitis
Fever
Fatigue
Special test in Ankylosing spondylitis
Schober’s test - mark a spot and then measure 5cm inferiorly and 10cm superiorly on the dorsal spine - if expands <5cm on forward flexion positive test
Associated conditions with ankylosing spondylitis
Anterior uveitis
Aortic regurgitation
Apical fibrosis
AV block
Arthropathy e.g psoriatic and psoriasis
Risk scores used in ACS syndrome
GRACE score - 6 month mortality
TIMI score - 14 day risk of mortality, new or recurrent MI, or severe recurrent ischaemia necessitating cardiac revasculairsation
Causes of pericarditis
Infection:
- Viral
- HIV
Autoimmune:
- SLE
- Rheumatoid
Post MI - Dresslers
Uraemia
Cancer
Clinical signs of cardiac tamponade
Beck’s Triad
Hypotension
Raised JVP
Muffled heart sounds
Tachycardia will also be an early sign
Pathophysiology of Eisenmenger’s syndrome
Large often congenital heart defects e.g. VSD, PDA, ToF, AVSD
Permenant vascular changes, PAH and elevated pulmonary vascular resistance
Reversal of the shunt direction to RTL causing cyanosis
Treatment of Eisenmenger’s
Poor prognosis - 50% mortality at one year
Medical:
- Pulmonary vasodilator therapy e.g. endothelia receptor antagonist, PDE5 inhibitor, epoprostenol
- Anticoagulation
- Symptomatic - iron supplementation, diuretic, anti-arrhythmic, oxygen (if hypoxaemia responsive)
- Supportive - contraception (pregnancy contraindicated), avoidance of extreme heat or dehydration
Surgical:
- Correction of shunt generally contraindicated
- Heart lung transplant
Common types of headache
Migraine:
- Associated with aura, photo- and photophobia, last <72 hours, unliateral
- Triptans, aspirin and NSAIDs in acute
- Topiramate, propranolol, amitriptyline in chronic
Tension:
- Bilateral, throbbing
Cluster headache:
- Very intense, lasting 15 mins, supraorbital, associated with lacrimation and rhinorrhea
- Verapamil for prophylaxis, oxygen and triptans in acute
Medication overuse
- Episodic headache in patients using analgesia >10 days/month for >3 months
Trigeminal neuralgia:
- Stabbing pain in trigeminal nerve distribution
Screening tool for Osteoporosis
FRAX - calculates the ten year probability of fracture
Ix in osteoporosis
Bloods:
- FBC
- U&Es, LFTs
- TFTs
- CRP and ESR
- Calcium and phosphate (Pagets)
- Vitamin D
- Immunoglobulins and protein electrophoresis
X rays of affected area
DEXA scan - if for primary prevention refer if >10% risk of fracture in ten years in scoring tools
Treatment in osteoporosis
IF T score <-2.5:
- Oral bisphophonates
- If not tolerated can suggest zolendronic acid, raloxifene and denosumab
Treatment severity score in psoriasis
Psoriasis area and severity Index (PASI)
Management in psoriasis
Topical treatment first line:
- topical corticosteroids OD - can be increased to BD if satisfactory control not gained
- Vitamin D analogue OD - may be increased to BD if not satisfactory control
- Coal tar preparation, shampoos can be used in scalp psoriasis
- Dithranol
Phototherapy
- UVB
- UVA with psoralen (PO or topical)for palmoplantar pustulosis or plaque psoriasis - increased risk of cancer (especially SCC)
- Avoid PUVA in those at risk of SCCs in future ie younger patients, light skin types (Fitzpatrick 1 and 2), likely to require long term cyclosporin, or previous skin cancer
Systemic treatments
- Offered if psoriasis cannot be controlled with topical therapy, it has significant impact on psychological or social well-being and one of:
- - Psoriasis is extensive >10% of BSA or PASI score >10
- - Associated with significant functional impairment or high levels of distress
- - Phototherapy cannot be used or associated with rapid relapse
- Can use methotrexate, ciclosporin or acreitin (vitamin A analogue), apremilast (PDE4 inhibitor)
Can then use biologics - TNFa, IL-17 and IL-23
Risk factors for fragility fractures
Older age
Female sex
Low BMI
Smoking
Alcohol use
Early menopause
History of falls
Previous fragility fracture
Use of corticosteroids
Secondary causes of osteoporosis
Secondary causes of osteoporosis
Malabsoprtion:
- Coeliac disease
- Chronic pancreatitis (malabsorption)
Endocrine:
- Hyperthyroidism
- Hyperparathyroidism
- Diabetes
- Cushings
- Hypogonadism
Use of steroids:
- COPD
- Rheumatoid arthitis
Loss of nutrients:
- CKD
- Chronic liver failure
Medications:
- Steroids
- GNRH inhibitors
Fragility fracture treatment
MDT involvement
Orthopaedic team for surgical management if required
Analgesia
PT
OT
Dietician
Patient education - smoking, weight, alcohol
May require DEXA scan - NCE guidelines state if >75 and fragility fracture to treat accordingly
Calcium and vitamin D supplements
Bisphosphonates
Denosumab
Raloxifene
Teriparatide
HRT in younger women with premature menopause
Life threatening signs of asthma
A - Arrhythmia/altered conciseness level
C - cyanosis or normal PaCO2 4.6 - 6kPA
H - Hypoxia <8kPa, hypotension
E - exhaustion
S - silent chest
T - Threatening PEFR - <33%
92 - Sats <92%
Criteria for safe discharge post asthma exacerbation
PEFR >75% of predicted
Check inhaler technique and able to record PEFR
Written asthma management plan
Follow up arranged with Patients GP/asthma nurse and with hospital
Medical management of asthma
- SABA PRN - salbutamol
- SABA plus ICS
- SABA plus ICS plus LRTA (montelukast)
- SABA plus moderate dose ICS plus LABA plus LRTA (if helpful)
- Change ICS to high dose, can add theophylline
- Consider biologics e.g omalizumab
- Addition of steroids
If symptoms not controlled on moderate dose - check FeNO level and eosinophils - if raised refer to secondary care team
If symptoms not controlled on high dose ICS refer to secondary care team
Treatment in CTEPH (Group 4 PH)
Riociguat - stimulator of soluble guanlyte cyclase
Continued oral anticoagulation
Interventions:
- Balloon pulmonary angioplasty
- Pulmonary endarterectomy
Differentials in persistent fever
Infection:
- Infective endocarditis
- Malaria
- Abscess
- EBV, CMV, HIV
Inflammatory disease:
- Vasculitis
- SLE
- RA
Malignancy
Drug-induced
- Malignancy hyperpyrexia syndrome
Genetic:
- Familial Mediterranen fever
Factitious
Ix in persistent fever
Urine Dip
ECG - PR interval
Bloods:
- FBC
- U&Es and LFTs
- CRP and ESR
- ANCA and autoimmune screen
- Rh factor
- HIV, EBV and CMV
- Immunoglobulins and SPEP
- Malaria thick and thin films
- EBV monospot
- CK - malignant hyperthermia
Radiology:
- CXR
- CTTAP
- PET CT
- White cell scintigraphy
Diagnosis of coeliac disease
Anti-TTG and total IgA
Duodenal biopsy
Ix in anaemia
Bloods:
- FBC
- Iron studies and ferritin
- B12 and folate
- Hb electrophoresis - thalassaemia
- Anti-TTG and total IgA
Faecal occult blood
Endoscopy
CT abdomen
Complications of sickle cell disease
Acute:
- Vaso-occlusive crisis
- Acute chest syndrome
- Stroke
- PE
- Infection
- Gallstones
- Anaemia
- Aplastic crisis (parvovirus 19)
- Osteomyelitis
- AKI
Chronic complications:
- Pain
- Anaemia
- Pulmonary hypertension
- Chronic sickle lung
- Sickle retinopathy
- Leg ulcers
- Priapism
- CKD
Treatment of sickle cell disease
Treatment in acute crises:
- Oxygen +/- CPAP
- IV fluids
- Analgesia
- Antibiotics if evidence of infection
- Blood transfusion/exchange transfusion
Following acute crisis:
- Drink plenty of fluids
- Warm clothes - avoid sudden temp changes
- NSAIDs and paracetamol
- Hydroxycarbamide or exchange transfusions if frequent crises
- Long term folic acid
- Penicillin prophylaxis and vaccinations in patients with functional hyposplenism
- Patient education
Causes of arterial and venous thrombosis
APLS
Myeloproliferative disorders - ET, polycythaemia, myelofibrosis
Paraxysmal nocturnal haemoglobinuria
PFO/VSDs - venous clot into arterial system
Causes of polycythaemia
Primary polycythaemia:
- Polycythaemia rubra vera
Secondary polycythaemia:
- Respiratory disease e.g. COPD, OSA
- Cyanotic heart disease e.g. congenital heart disease
- Testosterone replacement/injection
- EPO secreting tumours - renal cell carcinoma, medullary haemangiomas, parathyroid tumours
- PCKD - secretion of EPO
Apparent polycythaemia:
- Dehydration
- Diuretics
- Smokers or alcoholics
Ix in polycythaemia
FBC - raised HCT
U&Es and LFTs
JAK2
EPO
Epworth score
Polysomnography
ABG
CXR
USS abdomen - spleen
CT abdo/pelvis
Red cell mass scintigraphy
Bone marrow biopsy
Complications of polycythaemia rubra vera
Thrombosis
AML
Treated with aspirin
Lifelong surveillance for AML
Investigations in nephrotic syndrome
Urine dip
UPCR
Bloods:
- FBC
- U&Es and LFTs
- Coagulation
- Lipids
- BBV
- ANCA
- Rh factor and ANA
- Complement
- Hba1c
- Anti-phospholipase A2 receptor abs (PLA2R)
- Immunoglobulin and SPEP
CXR
renal tract US
CTPA or doppler if concur for clots
Renal biopsy
Causes of glomerulonephritis
Primary:
- Membranous nephropathy
- FSGS
- Minimal change
- IgA Nephropathy
Secondary causes:
- Amyloidosis
- SLE
- RA
- HIV
- Hep B and C
- Drugs: penicillamine, NSAIDs, heroin and gold
- Diabetes
- Malignancy - solid organ tumours, leukaemia, lymphoma, myeloma
Complications of PSC
Progression of PSC to cirrhosis
Development of new biliary stricture
Cholelithiasis - 1/3 of PSC patients develop gallstones
Cholangiocarcinoma
HCC
Gallbladder cancer
Bowel cancer with liver mets
Treatments in PSC
Mostly supportive
UCDA
Antihistamines
Opiates
Bile duct angioplasty/stent
Liver transplant
Treatment in Crohns disease
Mild:
- Oral mesalazine
- Oral steroids
Moderate:
- Iv steroids
- IV infliximab
Maintenance:
- Azathioprine
- Methotraxate
- TNFa agents
Treatment in UC
Mild:
- PR mesalazine
- Oral/topical steroids e.g. budesonide
Moderate:
- IV steroids
- IV ciclosporin
Maintenance:
- Azathioprine
- 5-ASA
Complications of IBD
Crohn’s:
- Anaemia
- Fistula
- Abscess formation
- Malnutrition
- Intestinal obstruction
UC:
- Anaemia
- Colon cancer
- Toxic dilatation
- Perforation
Extra-intestinal manifestations of IBD
Eyes:
- Anterior uveitis
- Episcleritis
- Iritis
Mouth:
- Aphthous ulcers
Joints:
- Large joint arthritis
- Seronegative arthritis
GI:
- PSC
- Systemic amyloidosis
Skin:
- Erythema nodosum
- Pyoderma gangrenous
- Clubbing
Associated disease with venous leg ulcers
Varicose veins
Chronic venous insufficiency
CCF
DVT
Investigations in venous ulceration
Doppler ultrasound
ABPI:
- 0.8 - 1.2 is normal
- >1.3 - calcified
- <08 implies arterial insufficiency
Arteriography
Forms of joint disease in psoriatic arthritis
DIPJ involvement
Large joint mono/oligo arthritis
Seronegative
Sacroilitis
Arthritis mutilans
Exacerbating factors in psoriasis
Trauma
Smoking
Stress
Alcohol
Beta blockers
Symptoms in Henoch-Scholein Purpura
Purpuric rash - Usually on extensor surfaces
Abdominal pain
Arthralgia
Precipitants of HSP
Infections:
- Streptococci, HSV, parvovirus B19
Drugs:
- Antibiotics
Complications of HSP
Renal involvements - IgA nephropathy - haematuria with proteinuria
Hypertension
What is HSP?
Small vessel vasculitis - IgA and C3 deposition
Normal or raised platelet count
Most spontaneous recover although steroids can help recovery and treat arthralgia
Concerning features in skin lesions
Asymmetrical
Border irregularity
Colour - black - often irregular pigmentation
Diameter >6mm
Enlarging
Treatment in malignant melanoma
Excision
Staged on Below thickness +/- sampling of draining lymph nodes
Surveillance for low risk node negative disease
High risk or node positive disease - immunotherapy
Treatment in SLE
Mild disease (cutaneous or joint involvement only):
- Topical steroids
- HCQ
Moderate disease (plus organ involvement):
- Prednisolone
- Azathioprine
Severe disease (+ severe inflammatory involvement of vital organs):
- Methylpred
- MMF
- Cyclophosphamide
- Azathioprine
With APS consider aspirin
Examination findings in systemic sclerosis
Hands:
- Raynauds
- sclerodactyly - prayer sign
- calcinosis - may ulcerate
- assess function
Face
- tight skin
- beaked nose
- microstomia
- telangiectasia
- alopecia
- peri oral furrowing
Skin:
- Morphoea - patches of sclerotic wkin
- en coup de sabre
Interstitial fibrosis
Cardiac
- pulmonary hypertension - RV heave, loud P2 and TR
- heart failure
- pericardial rub
Urine dip - proteinuria
Symptoms in limited systemic sclerosis
Distribution limited below elbows, below knees and face
Slow progression
CREST syndrome:
- Calcinosis
- Raynauds
- Esophageal dysmotility
- Sclerodactyly
- Telangiectasia
Symptoms in diffuse systemic sclerosis
Widespread cutaneous and early visceral involvement
Rapid progression
Antibodies in systemic sclerosis
ANA positive in 95%
Limited disease - anti Centromere
Diffuse disease - anti Scl 70 (anti-topoisomerase I)
Anti-RNA polymerase III - increased cancer risk in diffuse disease, increased risk of dermatological complications, and increased risk of renal crisis
Investigations in systemic sclerosis
Obs - HTN
Urine dip - proteinuria
ECG - conduction blocks, r axis deviation
Bloods:
- FBC
- U&ES
- LFTS
- Antibodies
Joint X rays
CXR
HRCT
PFTs
ECHO
Cardiac MRI
Right heart catheterisation
OGD
Esophageal manometry
Hydrogen breath tests for basterial overgrowth
Treatment in systemic sclerosis
MDT - OT, PT, SLT, dietician, palliative care, resp, GI, and cardio team
Derm:
- camouflage creams
- CCBs if raynauds
- PO PDE-5 inhibitors e.g. sildenafil
- gloves, hand warmers
- prostacyclin infusion if ulceration
Renal:
- ACEi
Gastro:
- PPI for gastric reflux
- If signs of bacterial overgrowth syndrome - rifaxamin
Immunomodulators:
- MMF
- Biologics - Rituximab (anti CD 20) and tociluzamab (IL-6) - trial evidence
- Evidence that anti-fibrotic agents such as nintedanib are beneficial
- IV cyclophosphamide
Avoid steroids to prevent precipitation of renal crisis
- If renal crisis use ACEi
Cardiac complications of Marfans
Mitral valve prolapse
Bicuspid aortic valve
Coarctation of the aorta
Management in Marfans
Surveillance:
- Monitoring of aortic root size with annual trans thoracic ECHO
Treatment:
- ACEi and Beta blockers to slow aortic root dilatation
- Pre-emptive aortic root surgery if diameter >5cm or increasing rapidly (>1cm/year)
Screen family members and genetic counselling of affected first degree relatives
Associated conditions with Paget’s disease
Entrapment neuropathy:
- Carpel tunnel
- visual problems - optic atrophy
- Cauda equina
- Deafness
Fragility fractures
Osteoarthritis
Arthralgia
Kidney stones
CCF - high output state
Osteogenic sarcoma
Causes of angioid streaks
Paget’s disease
Ehlers-Danlos
Pseudoxanthoma elasticum
Ix in Paget’s disease
Elevated ALP, normal calcium and phosphate
Radiology:
- Moth eaten bones
- Increased uptake on bone scans
Treatment of Pagets
Exercise, PT, OT
Symptomatic:
- Analgesia
- Hearing aid
- Carpel tunnel release
- Joint replacement
Medical:
- Vitamin D and bisphosphonates
Risk factors for gout
Alcohol
Red meat
Obesity
Drugs - diuretics or CNIs
CKD
Lymphoproliferative disorders
Treatment in gout
Acute:
- Increase fluid intake
- High dose NSAIDS
- Colchicine
- Prednisolone
Chronic:
- Titrate allopurinol upwards aiming urate <300
- Febuxostat (xanthine oxidase inhibitor)
Findings of OA on XR
LOSS
Loss of joint space
Osteophytes
Subchonral cysts
Sclerosis
Causes of hypercalcaemia
Primary Hyperparathyroidism
Malignancy:
- Lytic lesions
- PTHrp release - usually lung SCC
- Vitamin D release - lymphomas
Sarcoid
Addisons
Hyperthryoidism
Medications:
- Vitamin D
- Thiazide diuretics
- Lithium
Prolonged immobility
Causes of amenorrhoea
Primary causes:
- Genetic - e.g. Turners
Secondary:
- Pregnancy
- Postpartum and breastfeeding
- Pills e.g, OCP, risperidone, antidepressant e.g SSRIs, danazol (used in endometriosis), chemotherapy
- Premature menopause
- Polycystic ovarian syndrome
- Pituitary tumour - e.g. prolactinomas
Cardiovascular issues in Turner’s syndrome
ASD
Coarctation of aorta
Bicuspid aortic valve
Hypertension
Complications of Acromegaly
Acanthosis nigricans
BP high
Carpel tunnel - bilaterally
Diabetes mellitus
Enlarged organs
Field defect - bitemporal hemianopia
Goitre, GI malignancy
Heart failure, hirsutism, hypopituiatrism
IGF-1 high
Joint arthropthy
Kyphosis
Lactation - galactorrhoea
Myopathy
Ix in acromegaly
Diagnosis:
- IGF-1
- OGTT with serial GH measurement
- MRi pituiatry fossa
Also assess pituitary function:
- TFTs, LH and FSH, prolactin, ACTH, testosterone
Complications:
- CXR - cardiomegaly
- ECG - ischaemia
- Glucose and Hba1c
- Visual field testing
- Polysomnography - OSA due to macroglossia
Management in Acromegaly
Surgery: Trans-sphenoidal resection
Medical:
- Somatostatin analogues - ocreotide
- Dopamine agonists - cabergoline
- Pegvisomant - GH receptor antagonists
Radiotherapy
Follow ups:
- Blood monitoring - GH and prolactin
- MRI head
- ECG
- Visual fields
Causes of Cushing’s disease
ACTH dependent:
- Cushing’s disease - pituitary adenoma
- Ectopic secretion of ACTH e.g. SCLC
ACTH independent:
- Adrenal adenoma or carcinoma
- Exogenous steroids
Ix of Cushigns syndrome:
Confirm high cortisol:
- 24 hour urine collection
- Low dose dexamethasone suppression test
Suppressed cortisol - pseudo-bushings - alcohol/depression/obesity
Identify causes:
- ACTH level - if high ACTH dependent
- - High dose dexamethasone test - suppressed cortisol if pituitary cause, non-suppressed if ectopic or ACTH independent
- MRI pituitary
- CT abdo
- Bilateral inferior petrosal sinus vein sampling - to confirm pituitary
Treatment in Cushing’s
Surgical:
- Pituitary surgery - tran-sphenoidal
- Adrenalectomy
Pituitary irradiation
Medical
- Metyrapone
Causes of proximal myopathy
Inherited:
- Myotonic dystrophy
- Muscular dystrophy
Endocrine:
- Cushings
- Hyperparathyroidism
- Hyperthryoidism
Inflammatory:
- RA
- Polymyositis
Osteomalacia
Malignancy:
- Paraneoplastic
- Lambert-Eaton Syndrome
Drugs:
- Alcohol
- Steroids
Causes of Addison’s disease
Autoimmune
TB
Adrenal mets
Amyloidosis
Bilateral adrenalectomy
Waterhouse- Friedrichsen syndrome - meningococcal septicaemia and adrenal infarction
Investigations in Addisons
Bloods:
- Low Na, high K
- Urea high - dehydration
- Adrenal autoantibodies
- TFTs
Morning cortisol
Short Synacthen test
ACTH
CT abdo - adrenal imaging
Pituitary imaging - MRi
Renin/aldosterone level - concurrent mineralocorticoid deficiency
Causes of erythema nodosum
Idiopathic
Inflammatory disorders:
- IBD
- Sarcoidosis
- SLE
- Sjogrens
Infections:
- Streptococci
- URTI
- Mycoplasma
- TB
- Leprosy
Medications:
- OCP
- Penicillins
- Sulfonamides
Pregnancy
Malignancy:
- NHL
- AML
Treatment in dementia
MDT approach:
- OT - cognitive rehabilitation
- SW
- Dietician
- Support groups
Medical:
- Antidepressants
- AChEi - donepezil, galantamine or rivastigmine in mild/moderate disease
- Memantine if intolerant of AChEi or in severe disease
- Antipsychotics for BPSD - if not amenable to conservative measures and if patients at risk of harm to themselves or others
Driving restrictions for medical conditions:
- Stroke
- ACS
- CABG
- ICD
- Epilepsy
- Diabetes
- Syncope
- Brian tumours inc mets
Stroke/TIA:
- 1 month ban if recovers to good functioning, no need to tell DVLA unless residual loss of function
ACS:
- No driving for one week if successful PCI and no other interventions planned
- 4 weeks if no coronary intervention
- No driving if Group 2 and must notify DVLA
CABG:
- No driving for 4 weeks
ICD:
- No driving for 1 month and must inform DVLA
- No driving for Group 2
Epilepsy/seizure:
- First seizure - 6 months if seizure free
- Seizure while awake - 1 year
- If seizure due to medication change - 6 months
- For bus/lorry drivers - 5 years if single seizure, 10 years if epilepsy and on treatment
Diabetes:
- Inform DVLA if on insulin or having disabling hypoglycaemia
- If lorry driver inform if on any treatment
- Not to drive if having more than one episode of severe hypoglycaemia and inform DVLA
- Check BMs prior to starting journey and within two hors of starting journey
Syncope:
- Vasovagal -may drive
- Unexplained - may not drive for 6 months
Brain tumours
- Should not drive and should notify the DVLA
Causes of Raynauds
Primary Raynauds
Secondary causes:
- Rheumatological diseases
– Systemic sclerosis
– RA
– SLE
– Polymyositis
Vascular disease:
– Berger’s - IgA vasculitis
Medications
– Beta blockers
– ADHD medications - methylphenidate
Hypothyroidism
Occlusive vascular disease e.g. thoracic outlet obstruction
Peripheral nueropathies:
- Injury to nerves especially repetitive motions e.g. using jackhammer
- Carpal tunnel (unilateral)
- Chemotherapy
Differentiating primary vs secondary causes of Raynauds
Primary:
- Younger age of onset - teens, young 20s
- Bilateral
- No associated positive immunology
- Can have family history
- Should have complications e.g. digital ulceration
Secondary:
- Late onset - usually >30yrs
- May be unilateral or bilateral
- May have positive immunology
- Can have pitting ulcers/scarring
Clinical signs in neurofibromatosis
Cutaneous neurofibromas
Cafe au lait patches
Lisch nodules
Axillary freckling
Neuropathy with palpable nerves
Bibasal crackling - pulmonary fibrosis
Raised blood pressure - associated with phaechromocytomas and renal artery stenosis
Reduced visual acuity
Complications of neurofibromatosis
Phaechromocytoma
Renal artery stenosis
Intellectual disability
Epilepsy
Scoliosis
