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Clinical Consultations Flashcards

1
Q

What are systemic complications of RA? (11)

A

Osteoporosis
Dry eyes and mouth - sjogrens
Infections
Carpal tunnel syndrome
Heart - peri/myocarditis, IHD, pericardial effusion
Lung- ILD, pleural effusion, pleurisy
Metabolic syndrome
Felty syndrome - neutropenia and splenomegaly
Vasculitis
Amyloidosis
Renal- amyloid, drugs, glomerulonephritis

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2
Q

What are complications associated with drug treatment of RA? (5)

A

Gastric ulcers - NSAIDs
Infections - steroids and immunosuppressants
Liver toxicity - methotrexate
Skin malignancy - TNF alpha inhibitors
Osteoporosis - steroids

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3
Q

What defines nephrotic syndrome? (3)

A

Heavy proteinuria >3.5g/day
Hypoalbuminaemia <30
Peripheral oedema

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4
Q

What are causes of primary nephrotic syndrome? (4)

A

Minimal change disease
FSGS
Membranous nephropathy
Membranoproliferative glomerulonephritis

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5
Q

What are secondary causes of nephrotic syndrome? (9)

A

Infection - bacterial, viral, parasitic
Immunological - SLE, RA, PN, HSP, vasculitis, sarcoidosis
Metabolic - diabetes, amyloidosis
Inherited - alports, sickle cell
Malignant - myeloma, melanoma, leukaemia, cancer of breast, lung, colon, stomach
Drugs - NSAIDs, lithium, pamidronate, interferon alpha
Toxins - snake bite, insect sting
Pregnancy - pre eclampsia
Transplant rejection

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6
Q

What are symptoms of nephrotic syndrome? (7)

A

Oedema - Leg swelling, Abdominal distension, SOB, weight gain
Hypovolaemia - dizziness
Infection - fever, rash
Frothy urine
Hypercoagulability - DVT, MI
Fatigue
Poor appetite

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7
Q

What are signs of nephrotic syndrome and causes? (5)

A

Oedema including facial
Tachypnoea
Dyslipidaemia
Rash, purpura, joint swelling
Muehrckes lines - hypoalbuminaemia

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8
Q

What investigations would you do for nephrotic syndrome? (5)

A

Urine dipstick, MSU
ACR
Bloods: FBC, clotting, U&Es, LFTs, Bone profile, Fasting glucose, Lipid profile, ESR/CRP, Immunoglobulins/serum electrophoresis, Hep B/C, HIV, TFTs
Renal USS
Renal biopsy

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9
Q

What are treatment options for nephrotic syndrome oedema? (5)

A

Low salt diet
Fluid restriction
Loop diuretic
Potassium sparing diuretic
Thiazide diuretic
ACEi - reduce proteinuria

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10
Q

What are treatments for nephrotic syndrome? (4)

A

Steroids
Immunosuppression - calcineurin inhibitors (ciclosporin or tacrolimus), alkylating agents (cyclophosphamide or chlorambucil), rituximab, mycophenolate
Diuretics
ACEi

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11
Q

What are complications of nephrotic syndrome? (7)

A

Infection - urinary immunoglobulin loss
VTE risk - loss of anticoagulant proteins
AKI and CKD
End stage renal failure
Osteomalacia and osteitis fibrosa cystica
Hypothyroidism
Anaemia - loss of iron/transferrin

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12
Q

What are complications of diabetes? (4)

A

Retinopathy
Neuropathy
Nephropathy
Atherosclerosis

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13
Q

What is uthoffs phenomenon?

A

Worsening of MS symptoms in heat eg hot bath

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14
Q

What are symptoms/features of MS? (9)

A

Numbness or weakness in limbs
Lhermitte’s sign - electric shock on neck forwards
Uthoffs phenomenon - worse in heat
Fatigue
Truncal ataxia
Optic neuritis
Double vision
Dysarthria
Urinary incontinence

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15
Q

How do you investigate MS? (3)

A

MRI - dissemination of lesions in time and space
LP - slightly raised protein, oligoclonal bands, raised lymphocytes
Visual evoked potentials

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16
Q

What are different types of MS? (3)

A

Relapsing remitting 85%
Secondary progressive 66% of RR patients
Primary progressive 10-15%

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17
Q

What is clinically isolated syndrome in the context of MS?

A

First MS episode associated with other asymptomatic demyelinating lesions

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18
Q

What is McDonald criteria for MS?

A

Need to show evidence of dissemination in time and space either clinically or radiologically or combination

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19
Q

What investigations help to exclude alternative causes in MS? (9)

A

FBC
Inflammatory markers
U&Es
LFTs
TFTs
Glucose
HIV serology
Calcium
B12 levels

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20
Q

What should be in MDT for MS? (12)

A

specialist nurse
neurologist
physio
OT
SLT
psychologist
dietician
social worker
continence specialist
Pharmacist
GP
Rehab medics

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21
Q

What are treatment options in MS for relapsing remitting disease? (3)

A

Treating a relapse - methyprednisolone 0.5g daily for 5 days or 1g IV if severe
DMARDs - interferon beta, glatiramer acetate, teriflunomide, dimethyl fumarate
More active disease - natalizumab or almetuzumab, fingolimod

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22
Q

What are treatment options for secondary progressive MS? (2)

A

Interferon beta 1b
Siponimod

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23
Q

What management options can be used as adjuncts in MS? (13)

A

Vestibular rehabilitation
Supervised exercise programme
Functional electrical stimulation for foot drop
Analgesia
CBT
Gabapentin for nystagmus visual impairment
SLT involvement for speech
Baclofen or gabapentin for spasticity
THC:CBD spray for spasticity
Stretching and serial plasters for contractures
Botox for spasticity and overactive bladder
Anticholinergics for overactive bladder
Linoleic acid and fish oils

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24
Q

What are differential diagnosis for headaches? (10)

A

Tension
Cluster
Migraine
SOL
Bleed - SAH or subdural
Meningitis
Sinusitis
Hypertensive encephalopathy
Benign intracranial HTN
CVST

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25
Q

What is the management of acute pericarditis? (6)

A

Anti inflammatories - ibuprofen
Colchicine
Steroids
Treat underlying cause
Pericardiocentesis if life threatening effusion
Pericardectomy if constrictive pericarditis

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26
Q

What are causes of pericarditis? (10)

A

Virus - Coxsackieviruses, echoviruses, influenza viruses, adenoviruses, mumps virus, HIV and hepatitis
Bacterial - TB, syphilis
Uraemia
MI
Post surgery
Traumatic
Inflammatory diseases - SLE, RA, PN, scleroderma
Radiotherapy
Cancer

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27
Q

What are skin/joint presentations of SLE? (8)

A

Arthralgia
Joint deformity - jaccouds arthropathy
Raynaud’s phenomenon
Photosensitive butterfly rash
Discoid lupus
Alopecia
Vasculitis
Mouth ulcers

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28
Q

What lung involvement can occur in SLE? (4)

A

Pleurisy
Fibrosing alveolitis
Obliterative bronchiolitis
PE if antiphospholipid syndrome

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29
Q

What cardiovascular involvement can occur in SLE? (4)

A

Pericarditis
HTN
Libman sacks endocarditis
IHD

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30
Q

What renal involvement can occur in SLE?

A

Lupus Nephritis - proteinuria, haematuria, HTN

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31
Q

What neurological involvement can occur in SLE? (7)

A

Anxiety and depression
Psychosis
Seizures
Neuropathy
Meningitis
Organic brain syndrome
Stroke if antiphospholipid syndrome

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32
Q

What are investigations for SLE? (9)

A

FBC
ESR
ANA
Urinalysis
Anti dsDNA , Anti smith
Lupus anticoagulant, anti cardiolipin or anti beta2glycoprotein-1 for APS
MRI if neuro
Echo if cardio
Renal biopsy

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33
Q

What are complications of SLE? (9)

A

Anti phospholipid syndrome
Drug allergies
Atherosclerosis
HTN
Dyslipidaemia
Diabetes
Osteoporosis
Avascular necrosis
Non Hodgkin lymphoma

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34
Q

What are management options for SLE? (10)

A

NSAIDs
Steroids
Hydroxychloroquine and methotrexate
Cyclophosphamide for life threatening disease - lupus nephritis/vasculitis/cerebral disease
Mycophenolate mofetil
Azathioprine
Belimumab or rituximab adjunct if disease remains active
Plasma exchange whilst awaiting immunosuppressants take effect
Flu vaccine - avoid live
High factor sunscreen

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35
Q

What are pregnancy related complications in SLE? (5)

A

Recurrent miscarriage
Pre-eclampsia
IUGR
Pre-term delivery
Increased thrombosis risk

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36
Q

What are criteria for APLS? (5)

A

Vascular thrombosis - arterial, venous or small vessel
Pregnancy morbidity - death of 1 foetus after 10 weeks, preterm birth before 34 weeks due to pre-eclampsia or placental insufficiency, 3 or more unexplained miscarriages
Lupus anticoagulant on 2 occasions 12 weeks apart
Anti cardiolipin on 2 occasions 12 weeks apart
Anti b2glycolrotein 1 on 2 occasions 12 weeks apart

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37
Q

What proportion of people with SLE have anti phospholipid antibodies?

A

30%

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38
Q

What are causes of bloody diarrhoea? (6)

A

IBD
Infection: Shigella, Salmonella, Amoebic dysentery
Malignancy
Diverticulosis
Ischaemic colitis
Radiation proctitis

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39
Q

What are extra intestinal manifestations of UC? (9)

A

Erythema nodosum
Aphthous ulcers
Episcleritis
Arthropathy affecting large joints
Pyoderma gangrenosum
Anterior uveitis
Sacroiliitis
Ankylosing spondylitis
Primary sclerosing cholangitis

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40
Q

What are causes of erythema nodosum? (7)

A

No cause in 60%
Drugs: sulfonamides, amoxicillin
Oral contraceptives
Sarcoidosis /lofgrens
Ulcerative colitis/ crohns
Micro: TB, HIV, hepatitis, campylobacter, syphillis, giardia
Bechets

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41
Q

What are investigations for UC? (7)

A

Bloods: FBC, LFTs, U&Es, CRP, iron, B12, folate
Faecal calprotectin
Stool culture
CMV
Sigmoidoscopy and biopsy or full colon
AXR for ? Toxic megacolon
CT

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42
Q

How is disease severity assessed in UC?

A

Truelove and witts criteria:

Mild: fewer than 4 stools per day, minimal blood, no anaemia, pulse not above 90, no fever, normal CRP/ESR

Moderate: 4-6 stools per day, more blood than mild, no anaemia, pulse not above 90, no fever, normal CRP/ESR

Severe: 6 or more stools per day, visible blood, at least one of temp, pulse over 90, anaemia, ESR above 30

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43
Q

What are indications for urgent hospital referral in UC?

A

Severe colitis as per truelove and witts
Moderate disease fail to respond to steroids in 2 weeks

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44
Q

What are management steps for UC? (6)

A

Topical aminosalicylates if local disease - mild to moderate
Steroids to induce remission
Oral mesalazine to maintain remission
Azathioprine if steroids not tolerated, need multiple courses, relapse when tapering or stopped
Ciclosporin for severe refractory colitis
Infliximab/adadlimumab, golimumab if not responding to conventional therapy

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45
Q

What are complications of UC? (4)

A

Colectomy
Colorectal cancer
Toxic megacolon
Osteoporosis

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46
Q

What are causes of jaundice? (7)

A

Cirrhosis: ALD, Wilson’s, haemochromatosis, NASH, PBC, PSC
Obstruction: CBD stone, pancreatic cancer
Hepatitis: Viral, Autoimmune
Isolated bilirubinaemia: Giberts, crigler najjar, rotor, Dubin Johnson
Infection: Leptospirosis
Drug induced liver disease
Haemolysis, hereditary spherocytosis

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47
Q

What is the inheritance pattern of hereditary haemochromatosis?

A

Autosomal recessive
HFE gene
Chromosome 6
Variable penetrance

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48
Q

What are symptoms of hereditary haemochromatosis? (9)

A

Fatigue
Weakness
Arthropathy
Abdominal pain
Erectile dysfunction
Arrhythmias
Bronze skin
New diabetes
Psychiatric symptoms

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49
Q

What are investigations for hereditary haemochromatosis? (7)

A

Iron studies
Ferritin
HFE gene testing if increased trans sat
LFTs
Blood sugars
FBC
NILS screen

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50
Q

What are differential diagnosis for hereditary haemochromatosis? (5)

A

Secondary iron overload: thalassaemia, myelodysplastic syndrome, repeated transfusions
Drug toxicity
Chronic haemodialysis
Hepatitis, alcohol misuse, NASH
Porphyria cutanea tarda

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51
Q

What are treatments for hereditary haemochromatosis? (4)

A

Phlebotomy - removing 500ml blood 1-2 times per week until stable iron levels achieved
Once stable 3-4 times per year
Aiming for ferritin less than 50
Treat diabetes if present
Immunise against hep a and b
Liver transplantation

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52
Q

What are different types of pituitary adenoma? (6)

A

Non functioning adenoma
Prolactinoma
GH secreting
ACTH secreting
TSH secreting
LH/FSH secreting

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53
Q

What are symptoms of prolactinoma in women? (8)

A

Amenorrhoea
Galacotorrhoea
Infertility
Hirsutism
Reduced libido
Headache
Visual disturbance - bitemporal hemianopia
Cranial nerve palsy

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54
Q

What are symptoms of prolactinoma in men? (9)

A

Reduced libido
Erectile dysfunction
Reduced facial hair
Gynaecomastia
Galactorrhoea
Azoospermia
Headache
Visual disturbance - bitemporal hemianopia
Cranial nerve palsy

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55
Q

What investigations should be done for prolactinoma? (7)

A

TFTs
Pregnancy test
Basal serum prolactin
Visual field testing
MRI pituitary
Anterior Pituitary function tests: GnRH, TRH, IGF1, synacthen test
Posterior pituitary test: plasma and serum osmolality, water deprivation test

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56
Q

What are causes of hyperprolactinaemia? (11)

A

Pregnancy and Breast feeding
Pituitary tumour
Head injury and brain surgery
Post seizure
Hypothyroidism
Cushing’s syndrome
Liver cirrhosis
PCOS
Drugs: dopamine receptor antagonists , antidepressants, oestrogens
Sarcoidosis
Langerhans cell histiocytosis

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57
Q

What are treatments of prolactinoma? (3)

A

Most don’t need treatment - only if adverse effects of tumour size or hyperprolactinaemia
Dopamine agonists: cabergoline, bromocriptine
Surgery

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58
Q

What are complications of prolactinoma? (5)

A

Osteoporosis
Reduced fertility
Erectile dysfunction
Visual loss
Pituitary apoplexy - haemorrhage or infarction

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59
Q

What are the different types of hyperparathyroidism?

A

Primary: excess PTH production
Secondary: increased PTH in response to low calcium due to renal, liver or bowel disease
Tertiary: autonomous pth secretion after glands enlarge from long-standing secondary

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60
Q

What are the functions of PTH? (4)

A

Increases calcium resorption from bone
Increases calcium reabsorption by kidney
Increases phosphate excretion
Increases renal production of 25 hydroxyvitamin d3 which increases intestinal absorption of calcium

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61
Q

What are causes of hyperparathyroidism? (4)

A

Single parathyroid adenoma 85%
Parathyroid hyperplasia 10%
Double adenomas 5%
Parathyroid carcinoma 1%

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62
Q

What are presenting symptoms of hyperparathyroidism? (5)

A

Most asymptomatic
Bones: Osteopenia/osteoporosis
Moans: depression, dementia
Stones: Renal calculi
Groans: Muscle weakness and fatigue, Nausea and vomiting, Abdo pain
Constipation

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63
Q

What are causes of hypercalcaemia? (7)

A

Malignancy
Hyperparathyroidism
Thyrotoxicosis
Sarcoidosis
Paget’s disease of the bone
Addisons disease
Lithium induced

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64
Q

What are investigations for hyperparathyroidism? (7)

A

Bone profile
PTH
Vitamin D
24 hour urinary calcium excretion
Renal function
DEXA scan
USS Renal tract

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65
Q

What are treatments for hyperparathyroidism? (6)

A

Replace vit d
High fluid intake
Avoid thiazide diuretics
Parathyroid surgery
Calcinet if symptomatic and surgery unsuccessful or unsuitable
Bisphosphonate to reduce fracture risk

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66
Q

What are complications of parathyroid surgery? (3)

A

Hypocalcaemia - hungry bone syndrome
Recurrent laryngeal nerve injury
Haematoma formation

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67
Q

What are the different types of MEN?

A

MEN1: parathyroid adenoma, gastrinoma, insulinoma, carcinoid tumours, prolactinoma

MEN2A: medullary thyroid cancer, pheochromocytoma, hyperparathyroidism

MEN2B: medullary thyroid cancer, pheochromocytoma, mucosal neuroma, marfanoid habitus, hyperparathyroidism

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68
Q

What are differentials for generalised lymphadenopathy? (7)

A

Viral: EBV, CMV, rubella, varicella, measles, HIV, hep A/B, dengue
Bacterial: typhoid, TB, syphilis, plague, Lyme disease, brucellosis
Protozoal: toxoplasmosis, leishmaniasis, Chagas’ disease
Autoimmune: juvenile idiopathic arthritis, SLE
Storage diseases: gauchers, Niemann pick disease
Neoplastic: leukaemia, lymphoma, neuroblastoma, histiocytosis
Sarcoidosis

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69
Q

What are investigations for generalised lymphadenopathy? (14)

A

FBC
Blood film
ESR/CRP
LFTs
Infection swabs
Viral titres: EBV, hep, HIV
TB: mantoux, IGRA, sputum for AFB
Syphilis serology
Blood cultures
Autoantibody screen
CXR
CT staging
FNA biopsy or excisional
PET

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70
Q

How is Hodgkin’s lymphoma staged?

A

Stage 1: one lymph node region or structure
Stage 2: two or more on same side of diaphragm
Stage 3: nodes on both sides of diaphragm
Stage 4: involvement of extra nodal sites
A: no symptoms
B: fever, night sweats, weight loss over 10% in 6 months
X: bulky disease
E: single or proximal extranodal site

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71
Q

How is Hodgkin’s lymphoma classified? (2)

A

Classic: nodular sclerosis, mixed cellularity, lymphocyte rich, lymphocyte depleted

Nodular lymphocyte predominant

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72
Q

What are risk factors for Hodgkin’s lymphoma? (4)

A

EBV
HIV
Immunosuppression
Cigarette smoking

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73
Q

How does Hodgkin’s Lymphoma present? (5)

A

Enlarged lymph node in neck
Mediastinal mass on CXR
Chest pain/cough/dyspnoea
B symptoms: Night sweats, fever, weight loss
Alcohol induced pain in nodes

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74
Q

What are differentials of Hodgkins lymphoma? (10)

A

EBV
HIV
Non Hodgkin’s Lymphoma
TB
Leukaemia
Sarcoidosis
Myeloma
Toxoplasmosis
CMV
Tularaemia

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75
Q

What are difference between Hodgkin’s and non Hodgkin’s lymphoma? (5)

A

Presence of reed sternberg cells in Hodgkin’s
Non Hodgkin’s more common
Younger patients Hodgkin’s
Neck nodes predominant in Hodgkin’s
Hodgkin’s more predictable and easier to treat

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76
Q

What are management steps for Hodgkin’s lymphoma? (6)

A

Cardiac and pulmonary function tests pre treatment
Reproductive counselling pre treatment
Chemo +/- radiotherapy
Autologous stem cell transplant if relapse
Vaccinations
Antibiotic prophylaxis and gCSF if neutropenia

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77
Q

What are complications of Hodgkin’s lymphoma? (10)

A

Leukaemia post chemo/radiotherapy
Second solid tumours - colon, lung, bone, breast, thyroid post radiotherapy
Melanoma
Non Hodgkin’s lymphoma
Soft tissue sarcoma
Salivary gland cancers
Pancreatic cancer
Hypothyroidism
Cardiovascular disease
Infertility

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78
Q

What are poor prognostic features in Hodgkin’s lymphoma? (9)

A

Increasing tumour burden
Increasing age
Male
Presence of B symptoms
Anaemia, lymphopenia, monocytosis
Low albumin
Increasing ESR
Elevated beta2 microglobulin
EBV presence

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79
Q

What are differentials of lymphadenopathy? (9)

A

Lymphoma
HIV
Glandular fever
TB
Sarcoidosis
Connective tissue disease
Adenocarcinoma
Melanoma
Drugs

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80
Q

What investigations are done for Hodgkin’s lymphoma? (9)

A

FBC
ESR (above 70 unfavourable)
EBV serology
LFTs (albumin)
LDH
HIV test
Lymph node biopsy
CT TAP staging /PET CT
Bone marrow biopsy for staging

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81
Q

What are some provoking causes of seizures? (9)

A

Fever.
Head injury.
Excessive alcohol intake; withdrawal from alcohol or drugs.
Hypoglycaemia;
electrolyte disturbance.
Brain infection: meningitis, encephalitis.
Ischaemic stroke, intracranial haemorrhage / SOL
Eclampsia.
Potentially proconvulsive drugs - eg, tramadol, theophylline, baclofen.

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82
Q

What are differentials for seizures? (7)

A

Syncope
Transient ischaemic attack
Metabolic encephalopathy
Sleep-walking / Night terrors
Complex migraines.
Cardiac arrhythmias.
Psychogenic non-epileptic seizures

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83
Q

What tests should be used to investigate seizures? (5)

A

Video of episodes if available
Bloods: fbc, u&e, lfts, blood sugars
CT acute or MRI head
EEG
ECG/ 24 hour tape if cardiac cause suspected

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84
Q

What are driving rules for first seizures?

A

Group 1: 1 off seizure with low risk for further (no changes on MRI) then 6 months. If high risk or more than 1 - 12 months
Group 2: 1 off - 5 years seizure free and not on meds. 10 years if more than 1 seizure

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85
Q

What are some causes of erratic INR? (5)

A

Poor compliance
Alcohol
Poor diet - lacking vitamin k
Drug interactions - erythromycin/ciprofloxacin, St John’s wort etc
Anti phospholipid syndrome

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86
Q

What are treatment durations for anticoagulation in PE?

A

Provoked: 3-6 months
Unprovoked: lifelong

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87
Q

What screening should be done for prothrombotic states? (7)

A

Antithrombin III
Protein C
Protein S
APS: Lupus Anticoagulant and anti-cardiolipin antibodies
Factor V Leiden
Prothrombin Gene Mutation
anti-β-2-Glycoprotein-1 antibodies

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88
Q

Who should have thrombophilia screening? (5)

A

VTE or arterial thrombus under 40
Recurrent VTE
Unusual site thrombosis
Strong family history of thrombophilia /clots
Recurrent miscarriage

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89
Q

How long does warfarin need to be held prior to liver biopsy?

A

5 days

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90
Q

How long does DOAC need to be stopped prior to surgery?

A

1-2 days depending on bleeding risk

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91
Q

What are guidelines for emergency reversal of warfarin in bleeding?

A

life threatening bleeding: Vitamin K 5 mg IV, Prothrombin complex concentrate IV
Significant bleeding: Vitamin K 2 mg IV
Minor bleeding: vitamin K 2mg PO

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92
Q

What are guidelines for warfarin reversal if not bleeding?

A

INR > 8: vitamin k 1-2mg PO
INR 5-7.9: omit dose or 1-2mg vit k if high risk bleeding
INR <5: omit dose

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93
Q

What risk scoring systems can be used for MI? (3)

A

HEART score
Grace score
TIMI score

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94
Q

What is emergency treatment of ACS? (9)

A

DAPT
Tirofiban if high Grace or TIMI score
PPCI if stemi, angio if NSTEMI
GTN
IV morphine
Beta blocker
ACEi
Statin
? CABG if multi vessel disease

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95
Q

What further investigations should be done if cardiac sounding chest pain but trop and ECG negative? (4)

A

exercise stress test
myocardial perfusion scan (nuclear medicine)
Dobutamine stress echo
cardiac MRI

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96
Q

What anti anginals can be used for ongoing angina symptoms in a stable patient? (5)

A

GTN
Beta blocker or calcium channel blocker first line (nifedipine/amlodipine)
Then switch to other or both BB/CCB
Then add long acting nitrate or ivabradine or nicorandil or ranolazine
Only add 3rd if awaiting recasc or not a candidate

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97
Q

What are localising neuro signs? (3)

A

Upper limb pronator drift
Extensor plantar reflex
Cranial nerve palsy

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98
Q

How would you investigate someone with a headache with concern for meningitis? (3)

A

Blood cultures and bloods for inflammation markers
CT head exclude raised ICP
LP: MC&S, glucose, protein, virology, xanthochromia to exclude SAH

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99
Q

How would you treat suspected meningitis? (2)

A

High dose penicillin IV
Notifiable disease - contact tracing

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100
Q

What are risk factors for DVT? (9)

A

Cancer
Heart failure
Immobility
Recent flight
Surgery (esp orthopedic)
Stroke
Previous DVT or PE
FH VTE
OCP use

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101
Q

What clinical finding fit with DVT? (3)

A

Calf swelling >3cm difference, 10cm below tibial tuberosity
Superficial venous engorgement
Pitting oedema

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102
Q

What else might you examine in someone with a DVT? (4)

A

Abdo and pelvis for masses
Signs of Thrombophlebitis
Signs of PE: pleural rub or RV failure
Peripheral pulses for ?compression stockings

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103
Q

What are investigations for DVT? (6)

A

D dimer (sensitive but not specific)
Doppler
Consider thrombophilia screen if recurrent or strong FH
CT AP if over 50
Mammogram for females
PR and PSA in men

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104
Q

What are management steps for DVT? (2)

A

Anticoagulation; 3 months if provoked, 6 months if unprovoked, lifelong if recurrent or high risk
Compression stockings to reduce post phlebitic syndrome

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105
Q

What are symptoms of DKA? (6)

A

Polyuria and polydipsia
Preceding illness/fever
Recent high sugar readings or increased insulin requirement
Nausea and vomiting
sweating
Breathlessness

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106
Q

What are risk factors for DKA? (2)

A

Poor compliance with insulin: Young
Change in social circumstances

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107
Q

What are differentials for DKA in someone who has been found drowsy and confused? (3)

A

Alcohol intoxication
Drug abuse
Hypoglycaemia

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108
Q

What examination findings help to look for DKA? (5)

A

GCS
Ketotic breath - pear drops
Hyperventilation/kussmauls breathing
Medic alert bracelet
Finger prick marks

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109
Q

What are 4 precipitating factors for DKA? (4)

A

Missed insulin
Infection
Infarction
Injury

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110
Q

What are complications of DKA? (3)

A

Retina: diabetic changes, papilloedema
Pulse and BP: haemodynamic compromise
Aspiration pneumonia (gastroparesis due to autonomic neuropathy)

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111
Q

How do you investigate DKA? (6)

A

Bedside sugar and ketones
ABG: metabolic acidosis with resp compensation
FBC, U&E, CRP, LFT
ECG (silent MI)
Blood and urine cultures
CXR

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112
Q

What is the treatment for DKA? (7)

A

ABCDE approach
Early ITU input if required
Fluid resuscitation + K replacement later
Fixed rate insulin IV
Consider NG to prevent aspiration
VTE prophylaxis
Antibiotics if infection suspected

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113
Q

What are differentials for causes of IDA? (4)

A

Chronic GI blood loss
Dietary
Coeliac
Inherited haemoglobinopathy

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114
Q

What symptoms do you need to ask about in history of anaemia? (12)

A

lethargy/tiredness/ breathlessness
Angina
Change in bowel habit/ Foul smelling hard to flush stools/ Melena
Weight loss
GORD/ Dysphagia/ NSAID use
Abdo pain/bloating/wheat intolerance
Previous abdo surgery or ulcers
History of IBD/polyps
Heavy periods or PV bleeding
FH GI malignancy or anaemia
Risk factors for hookworm or tropical sprue
Previous blood transfusions

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115
Q

What would you examine in an anaemia case? (9)

A

Look for pallor and pale conjunctivae
Koilonychia in nails (IDA)
Glossitis (IDA) and angular stomatitis (B12 def)
Sentinel cervical lymph node
Abdominal mass and hepatomegaly
Epigastric tenderness
Abdo scars (resections)
Offer rectal +/- PV exam
Pulse and BP: haemodynamic stability

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116
Q

What are investigations for IDA? (8)

A

FBC: microcytic hypochromic anaemia, target cells on film
Low iron and ferritin, increased TIBC
Check B12 and folate
Hb electrophoresis if suspected Hbopathy
Faecal occult blood
Endoscopy
CT AP
Barium studies

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117
Q

What is hereditary haemorrhagic telangiectasia and what are features? (4)

A

Autosomal dominant condition
Multiple telangiectasia on face, lips and buccal mucosa
Increased risk GI bleed, epistaxis and haemoptysis
Vascular malformations: pulmonary shunts, intracranial aneurysms

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118
Q

What are differentials for haemoptysis? (4)

A

Bronchial carcinoma
PE
Pneumonia
Pulmonary oedema

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119
Q

What are symptoms in a history of haemoptysis that you need to ask, particularly if malignant cause suspected? (11)

A

Cough: chronicity, mucous colour, blood
Breathlessness
Pleuritic chest pain
Weight loss
Bone pain (mets)
Tiredness (anaemia)
Paraneoplastic phenomena
Abdo pain (liver mets or hypercalcaemia)
Headache (brain mets)
Smoking history
Occupational exposure

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120
Q

What would you examine in suspected bronchial carcinoma? (11)

A

Cachexia
Nail clubbing
Tar stained fingers
Radiotherapy tattoo
Cervical lymphadenopathy
Tracheal deviation: lobar collapse
Dull percussion note: consolidation and effusion
Reduced air entry/bronchial breathing
Craggy hepatomegaly
Spinal tenderness
Focal neurology

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121
Q

What are investigations for bronchial carcinoma? (3)

A

CXR
CT chest / staging CT
Bronchoscopy / CT guided biopsy/ lymph node biopsy for tissue diagnosis

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122
Q

What are treatment options for bronchial carcinoma? (5)

A

Surgical resection: lobectomy or pneumonectomy
chemo - cisplatin/gemcitabine
Radiotherapy
Immunotherapy
Palliative care

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123
Q

What are important questions in a history of elderly patient with worsening mobility? (7)

A

Carer role and frequency
Mobility aids
Falls
Housing
History of Parkinson’s/stroke
Precipitant: infection, drug changes, pain
Legal aspects: advanced directives, LPA, DNACPR

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124
Q

What are important examination steps for an elderly patient with reduced mobility? (5)

A

Get them to walk
Rising from chair
Rombergs
Lying /standing BP
Neuro exam

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125
Q

What investigations would you do for an elderly patient with declining mobility? (2)

A

Sepsis screen: MSU, CXR, blood cultures
Consider CT head if falls/confused

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126
Q

What are management steps for an elderly patient with declining mobility? (7)

A

Antibiotics if suspect infection
Avoid poly pharmacy
MDT: nurse, social worker, OT, PT
Best interests meeting if lack capacity
Walking aids
Equipment / care at home
Discuss resus

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127
Q

What are differentials for persistent fever and malaise? (6)

A

Lymphoma
Endocarditis
TB/ Malaria
Inflammatory disease (joint or skin)
HIV
Drug induced (anti psychotics)

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128
Q

What would you examine for in someone with persistent fever and malaise? (9)

A

Needle tracks
Splinter haemorrhages
Roth spots on fundoscopy
Lymphadenopathy
Murmur
Craggy liver or mass
Splenomegaly
Urine dip: haematuria
Joints and skin

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129
Q

How would you investigate someone with persistent fever and malaise? (7)

A

Septic screen
Blood films inc thick and thin films
HIV test
Autoantibodies /immunoglobulins/complement levels
CK (malignant hyperthermia)
TOE
Consider bone marrow if haematological cause suspected

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130
Q

What are important symptom questions in an asthma history? (5)

A

Wheeze, SOB, cough
Triggers: allergy, excercise, cold, dust
URTI symptoms
Previous ITU admissions
Compliance with preventer therapy

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131
Q

What would you examine for in an asthma patient? (4)

A

Severity: conscious level, resp rate, breath count, pulse and BP, silent chest
Expansion and percussion note: exclude pneumothorax
Wheeze
Stridor, angioedema, tongue swelling
Urticaria

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132
Q

How would you investigate an asthma patient acutely? (4)

A

ABG
Peak flow
Septic screen
CXR

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133
Q

What are important history questions in a patient with syncope? (10)

A

Provocation: micturition, cough, stress
Prodrome: light headed, dizzy, tunnel vision, no warning
Posture: sitting/lying, standing, sudden head turning
Associated symptoms: palpitations, chest pain, headache, tongue biting, incontinence
Duration
Recovery
Injury
Eyewitness account
PMH of syncope, cardiac disease or neurological condition
Medications

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134
Q

How would you examine someone with syncope? (3)

A

Pulse and BP
Brief CV exam: murmur, PPM, scars
Brief neuro exam: fundoscopy, pronator drift, reflexes, Parkinson’s features with orthostatic hypotension (MSA)

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135
Q

What are differentials for syncope? (4)

A

Cardiac: Brady or tachyarrhythmia, obstructive lesion (AS, MS, HOCM, PE)
Neuro: epilepsy, vertebrobasilar insufficiency
Orthostatic hypotension
Vasovagal: stress, cough, micturition, defecation

136
Q

How would you investigate syncope? (6)

A

12 lead ECG, holter monitor, loop recorder depending on frequency of symptoms
EP study
ETT
Echo
Tilt table test if orthostatic
EEG and MRI head if epilepsy suspected

137
Q

What is management of syncope? (4)

A

Cardiac: PPM/ICD, revascularisation, valve surgery
Vasovagal: education on avoidance, isotonic muscle contraction
Orthostatic: salt and water replacement, support stockings, meds review, fludro or midodrine
Neuro: anti seizure drugs

138
Q

What are DVLA rules on syncope? (4)

A

If provocation, prodrome and postural features all present then likely benign and can continue to drive
If solitary with no clear cause: 6 month ban
Clear cause that is treated: 4 weeks
Recurrent syncope due to seizures: must be fit free for 1 year

139
Q

What are symptoms to ask in the history of atrial fibrillation? (6)

A

Onset and offset, frequency and duration
Breathless, chest pain, palpitations, syncope
Precipitants: alcohol, caffeine, exercise
Associated conditions; valvular heart disease, HTN, hyperthyroidism, stroke or TIA, lung disease including PE
Risk factors for bleeding with anticoag
Suitability for medical vs EP treatment

140
Q

What are important things to look for when examining a patient with AF? (5)

A

Pulse and BP
Murmurs: particularly mitral
CCF signs
Thyroid: tremor, goitre, eye disease
If stroke/TIA features then brief neuro

141
Q

What are investigations for AF? (3)

A

12 lead ECG or 24 hour holter
Echo: structural disease, LVH, LA size >4cm recurrence high
TFTs

142
Q

What are different types of AF? (3)

A

Paroxysmal: <7 days, self terminating
Persistent: >7 days, requires cardioversion
Permanent: >1 year or when no further attempts to restore sinus

143
Q

What is management of AF? (4)

A

Rhythm control: chemical or electrical cardioversion
Rate control: beta blocker, digoxin, PPM, AV node ablation
Pulmonary vein isolation; refractory symptomatic patients
Anticoagulation depending on CHADsVASc score

144
Q

What is chadsvasc score?

A

Congestive cardiac failure
Hypertension
Age >75 = 2
Diabetes
Stroke or TIA = 2
Vascular disease
Age 65-74 = 1
Sex female = 1
Score 0: low risk, no anti coag
Score 1: medium risk, patient preference
Score 2: high risk, anti coag recommended

145
Q

What are important history questions for possible IBD? (11)

A

Duration of symptoms
Precipitants: travel, antibiotics, infectious contacts, food, sexual history
Stool frequency and consistency
Blood: fresh PR, mixed with stools
Mucous
Urgency, incontinence, tennis
Abdo pain, bloating, association with eating
Systemic symptoms; fever, anorexia, weight loss
Rash and arthralgia
Mouth ulcers
FH

146
Q

What are important examination features in IBD? (12)

A

Pallor/ anaemia
Nutritional status
Pulse and BP
Oral ulceration
Surgical scars/stoma sites
Tenderness
Palpable masses
Examine for perianal disease
Steroid side effects
Ciclosporin; gum hypertrophy and HTN
Hickman lines/scars
Pyoderma gangrenosum

147
Q

What are investigations for IBD? (6)

A

Stool microscopy and culture
FBC and inflam markers
AXR: exclude toxic megacolon/obstruction
Flexi sig/colonoscopy with biopsy
Small bowel MRI in crohns
CT scan if unwell

148
Q

What are differentials for IBD? (6)

A

Infectious: campylobacter, TB, yersinia
Ischaemia
Drugs
Radiation
Malignancy
Diverticulitis

149
Q

What are treatments for crohns? (6)

A

Mild to moderate: oral steroids
Severe: IV steroid, biologics
Maintenance: azathioprine, methotrexate, inflixmab, adalimumab, ustekinumab
High fibre, Low residue diet
Abx if perianal infection/fistula or SBO
Surgical

150
Q

What are treatments for UC? (4)

A

Mild to modetate: oral or topical steroids, mesalazine
Severe: IV steroid, IV ciclosporin, infliximab
Maintenance: steroid, 5ASA, azathioprine, biologic
Surgery

151
Q

What are complications of crohns? (5)

A

Malabsorption
Anaemia
Abscess
Fistula
Obstruction from strictures

152
Q

What are complications of UC? (4)

A

Anaemia
Toxic dilatation
Perforation
Colonic carcinoma

153
Q

What surveillance is done for patients with UC?

A

3 yearly colonoscopy if over 10 years duration
2 yearly if 20-30 years duration
Annually if over 30 years duration
Colectomy if dysplasia detected

154
Q

What are extra intestinal manifestations of IBD? (10)

A

Mouth ulcers
Erythema nodosum
Pyoderma gangrenosum
Clubbing
Large joint seronegative arthritis
Uveitis
Episcleritis
Iritis
PSC
Systemic amyloidosis

155
Q

What are important questions in a history of headache and raised BP? (9)

A

Duration of symptoms
Nature of headache
BP readings
Medical history: renal, CV disease, diabetes
Smoking
Drug history and alcohol
Visual disturbance
Paroxysmal symptoms (phaeo)
Pregnancy

156
Q

What are important examination findings in a patient with headache and HTN? (6)

A

Body habitus: obese, cushingoid, acromegalic
Radial pulse: AF, radio-radial/femoral delay
Check BP in both arms manually
CCF features
Renal: bruit, PKD, RRT, urine dip
Fundoscopy: hypertensive retinopathy

157
Q

What are findings of hypertensive retinopathy on fundoscopy? (4)

A

Grade 1: silver wiring
Grade 2: plus AV nipping
Grade 3: plus cotton wool spots and flame haemorrhages
Grade 4: plus papilloedema

158
Q

What are causes of HTN? (5)

A

Essential: age, obesity, salt, alcohol
Renal: CKD, ADPKD, renovascular disease
Endocrine: conns, cushings, acromegaly, phaeochromocytoma
Aortic coarctation
Pre eclampsia in pregnancy

159
Q

What are investigations for HTN looking for end organ damage? (5)

A

Fundoscopy
ECG: LVH
U&Es
Echo
CXR (pulmonary oedema)

160
Q

What are investigations for HTN looking to exclude underlying causes? (4)

A

Urinalysis and ACR
U&Es
Consider renin/aldosterone levels, plasma or urinary metanephrins
Pregnancy test

161
Q

What are the guidelines for diagnosing HTN? (7)

A

Clinic BP 140/90 then use 24h ABPM to confirm
Stage 1: >135/85 on ABPM
Stage 2: clinic BP 160/100, 150/95 ABPM
Severe: clinic 180/110
Treat if stage 1 and end organ damage, diabetes, or q risk >20%
Treat all stage 2 and above
Same day admission if severe and grade 3 or 4 retinopathy or renal impairment

162
Q

What are treatments for HTN? (7)

A

Lifestyle modification: smoking cessation, lose weight, increase exercise
ACEi or ARB if <55
CCB or thiazide like diuretic if >55 or Afro Caribbean
Then add in the other one
then all 3
Consider adding spiro, beta blocker, alpha blocker and specialist opinion
CV risk modification: aspirin, statin

163
Q

What is treatment for malignant hypertension? (2)

A

Grade 3/4 retinopathy and HTN: bed rest, oral anti hypertensives, aim for gradual reduction
Encephalopathy/stroke/MI/LV failure: parental venodilators and invasive BP monitoring, rapid BP decrease can cause watershed cerebral and retinal infarction

164
Q

What are causes of papilloedema? (3)

A

Raised ICP: SOL, BIH, cavernous sinus thrombosis
Accelerated HTN
Central retinal vein occlusion

165
Q

What is papillitis and what are features? (5)

A

Inflammation of head of optic nerve eg in MS
Usually unilateral
Reduced visual acuity
Central scotoma
Pain

166
Q

What are important questions in history of rash? (6)

A

Location, appearance, itchiness
Psychosocial impact, affect on work, relationships
Exacerbating factors: stress, alcohol, cigarettes, drugs
Atopy
Sun exposure
Irritants

167
Q

What are treatments for psoriasis? (6)

A

Emollients
Calcipotriol
Coal tar
Topical steroids
PUVA /UVB
Immunosuppression: ciclosporin/methotrexate, adalimbumab, retinoids

168
Q

What are examination features of psoriasis? (6)

A

Multiple, well demarcated, salmon pink, scaly plaques on extensor surfaces
Check behind ears, scalp and umbilicus
Koebner phenomenon
Skin staining from treatment
Nails; pitting, onycholysis, hyperkeratosis
Joints: psoriatic Arthropathy

169
Q

What are 5 forms of psoriatic Arthropathy?

A

DIPJ involvement (like OA)
Large joint mono/oligoarthritis
Seronegative (like RA)
Sacroiliitis (like ank spond)
Arthritis mutilans

170
Q

What is psoriasis?

A

Epidermal hyperproliferation and accumulation of inflammatory cells

171
Q

What is a life threatening complication of psoriasis?

A

Erythroderma

172
Q

What are causes of nail pitting? (4)

A

Psoriasis
Lichen planus
Alopecia areata
Fungal infections

173
Q

Which conditions cause koebner phenomenon? (5)

A

Psoriasis
Lichen planus
Viral warts
Vitiligo
Sarcoidosis

174
Q

What are examination findings in eczema? (6)

A

Erythematous and lichenified patches of skin on flexor surfaces
Painful fissures
Excoriations
Secondary bacterial infections
Atopy: wheeze
Systemic treatment effects: steroids

175
Q

What are investigations for eczema?

A

Patch testing for allergies

176
Q

What are treatments for eczema? (8)

A

Avoid Precipitants
Emollients
Topical Steroids
Topical Tacrolimus
Anti histamines
Antibiotics if secondary infection
UV light therapy
Systemic therapy if severe

177
Q

Which conditions are associated with leg ulcers? (8)

A

Venous: DVT, chronic venous insufficiency, varicose veins, CCF
Arterial: PVD
Neuropathic: sensory neuropathy, diabetes
Vasculitic: RA
Neoplastic: SCC
Infectious: syphilis
Haematological: sickle cell
Tropical: cutaneous leishmaniasis

178
Q

What are stigmata of venous hypertension on examination? (6)

A

Varicose veins
Scars from vein stripping
Oedema
Lipodermatosclerosis
Varicose eczema
Atrophie Blanche

179
Q

What are examination changes in PVD? (4)

A

Arterial ulcers in distal extremities and at pressure points
Hairless, paper thin, shiny skin
Cold with poor cap refill
Absent distal pulses

180
Q

What are examination findings with neuropathic ulcers? (3)

A

Pressure areas eg under metatarsal heads
Peripheral neuropathy
Charcot joints

181
Q

What are complications of chronic leg ulcers? (2)

A

Infection: temperature, pus, cellulitis
Malignant change; Marjolins ulcer, squamous cell carcinoma

182
Q

What are investigations for leg ulcers? (3)

A

Doppler USS
APBI <0.8 arterial insufficiency
Ateriorography

183
Q

What are treatments for leg ulcers? (3)

A

Venous: compression bandaging, varicose vein surgery
Arterial: angioplasty, amputation
Abx if infection

184
Q

What are causes of neuropathic ulcers? (3)

A

Diabetes
Tabes dorsalis
Syringomyelia

185
Q

What does necrobiosis lipoidica diabeticorum look like? (3)

A

Well demarcated plaques with waxy yellow centre and red-brown edges
May resemble a bruise in early stages
Prominent blood vessels

186
Q

What skin changes can be associated with diabetes? (8)

A

Necrobiosis lipoidica diabeticorum
Leg ulcers
Eruptive xanthomata (hyperlipidaemia)
Granuloma annulare
Lipoatrophy
Fat hypertrophy
Candidiasis in skin folds
Vitiligo (autoimmune association)

187
Q

What is treatment for necrobiosis lipoidica diabeticorum? (2)

A

Topical steroid
Support bandaging

188
Q

What are skin and eye signs of hypercholesterolaemia? (3)

A

Tendon xanthomata
Xanthelasma
Corneal arcus

189
Q

What are skin changes and eye changes of hypertriglyceridaemia? (2)

A

Eruptive xanthomata
Lipaemia retinalis

190
Q

What are causes of secondary hyperlipidaemia? (5)

A

Diabetes
Hypothyroidism
Nephrotic syndrome
Alcohol
Cholestasis

191
Q

What are causes of erythema nodosum? (9)

A

Sarcoidosis
Strep throat
Streptomycin, sulfonamides
OCP
Pregnancy
TB
IBD
Lymphoma
Idiopathic

192
Q

What are examination findings of erythema nodosum? (2)

A

Tender, red, smooth, shiny nodules on shins
Older lesions leave a bruise

193
Q

What is the pathophysiology of erythema nodosum?

A

Inflammation of subcutaneous fat - paniculitis

194
Q

What are skin manifestations of sarcoidosis? (3)

A

Erythema nodosum
Nodules and papules
Lupus Pernio

195
Q

What is the triad of symptoms of HSP? (3)

A

Purpuric rash usually on buttocks and legs
Arthritis
Abdominal pain

196
Q

What are Precipitants of HSP? (2)

A

Infections: strep, HSV, parvovirus b19
Drugs: abx

197
Q

What are complications of HSP? (2)

A

Renal involvement: IgA nephropathy, haematuria, proteinuria
HTN

198
Q

What are examination/bedside test findings of HSP? (4)

A

Purpuric rash on buttocks and legs
Arthritis
Raised BP
Proteinuria on urine dip

199
Q

What is HSP? (3)

A

Small vessel vasculitis IgA and C3 deposition
Normal or raised platelet count
Most spontaneously recover although some need steroids

200
Q

What are questions in a history for someone with a skin lump, possible malignancy? (7)

A

Location and rapidity of growth
Recent changes
Bleeding
Sun exposure
Occupation
FH or personal history skin cancer
Immunosuppression: solid organ transplant

201
Q

What are typical features of basal cell carcinoma? (4)

A

Sun exposed areas
Pearly nodule with rolled edge
Superficial telangiectasia
Ulceration in advanced lesions

202
Q

What are treatments for basal cell carcinoma? (2)

A

Curettage/cryotherpy if superficial
Surgical excision +/- radiotherapy

203
Q

What are clinical features of squamous cell carcinoma? (3)

A

Sun exposed areas
Actinic keratosis around
Keratotic nodule, polypoid mass, cutaneous ulcer

204
Q

What is treatment for SCC of skin?

A

Surgery +/- radiotherapy
5% metastasise

205
Q

What are risk factors for malignant melanoma? (5)

A

Fair skin with freckles
Light hair
Blue eyes
Sun exposure
FH

206
Q

What are concerning features for malignant melanoma? (5)

A

Asymmetrical
Border irregularities
Colour: black, irregular pigmentation
Diameter >6mm
Enlarging

207
Q

How is malignant melanoma staged?

A

Breslow thickness
<1.5mm = 90% 5 year survival
>3.5mm = 40% 5 year survival

208
Q

What might be the diagnosis if a patient has a glass eye and Ascites?

A

Ocular melanoma

209
Q

What is pseudoxanthoma elasticum?

A

Hereditary: 80% autosomal recessive
Degenerative elastic fibres in skin, blood vessels and eyes
Loose skin folds neck and axillae with yellow pseudoxanthomatous plaques

210
Q

What issues are associated with pseudoxanthoma elasticum? (7)

A

Plucked chicken skin appearance
Hyperextensible joints
Reduced visual acuity
HTN
MI or CVA
GI bleed
Mitral valve prolapse

211
Q

What eye changes can be seen in pseudoxathoma elasticum? (2)

A

Blue sclerae
Retinal angioid streaks

212
Q

What is inheritance pattern of ehlers Danlos and what is it?

A

Autosomal dominant
Defect in collagen causing increased skin elasticity

213
Q

What findings might be present in ehlers danlos? (5)

A

Fragile skin: multiple ecchymoses, scarring
Hyperextensible skin: able to tent skin when pulled
Joint hypermobility and dislocation (scar from repair or replacement)
Mitral valve prolapse murmur
Abdominal scar: aneurysm rupture and dissection, bowel perforation

214
Q

What are examination findings of RA in the hands? (10)

A

Symmetrical and deforming polyarthropathy
Volar subluxation and ulnar deviation at MCPJs
Subluxation at wrist
Swan neck deformity
Boutonnières deformity
Z thumbs
Muscle wasting: disuse atrophy
Carpal tunnel release scar
Joint replacement scar
Rheumatoid nodules (elbows)

215
Q

What are systemic manifestations of RA? (6)

A

Pulmonary: effusion, fibrosing alveolitis, obliterative bronchiolitis, caplans nodules
Eyes: secondary sjogrens, scleritis
Neuro: carpal tunnel, atlanto-axial subluxation - quadriplegia, peripheral neuropathy
Haem: feltys (RA, splenomegaly, neutropenia), Anaemia
Cardiac: pericarditis
Renal: nephrotic syndrome (amyloid or membranous glomerulonephritis)

216
Q

What are radiological changes of RA? (4)

A

Soft tissue swelling
Loss of joint space
Articular errosions
Periarticular osteoporosis

217
Q

What features are required for diagnosis of RA? (7)

A

4/7 of:
Morning stiffness
Arthritis in 3+ joint areas
Arthritis of hands
Symmetrical arthritis
Rheumatoid nodules
Positive RhF
Erosions on imaging

218
Q

What are treatments for RA? (5)

A

NSAIDs
Steroid injections and tablets
DMARDs
Anti TNF therapy
B cell depletion therapy
Supportive: education, exercise and physio, OT and social support
Surgery: joint replacement, tendon transfer

219
Q

What are important symptoms to ask about in a history of someone with suspected lupus? (8)

A

Face rash, photosensitivity
Raynauds
Dry eyes and mouth
Psychosocial impact
Family planning
Protein or haematuria (renal involvement)
HTN (renal)
Immunosuppression: infections, skin changes

220
Q

What might be found on examination of someone with lupus? (9)

A

Malar rash
Discoid rash and scarring
Oral ulceration
Scarring Alopecia
Nail fold infarcts (vasculitic lesions)
Jaccouds Arthropathy (tendon contractures)
Resp: pleural effusion, pleural rub, fibrosing alveolitis
Neuro: chorea, focal neurology, ataxia
Renal: HTN

221
Q

What are investigations for lupus? (6)

A

Autoantibodies: ANA and anti dsDNA
Raised ESR, normal CRP
Immunoglobulins raised
Reduced C4 complement
U&Es
Urine microscopy

222
Q

What is required for diagnosis of lupus? (11)

A

4/11 of:
Malar rash
Discoid rash
Photosensitivity
Oral ulcers
Arthritis
Serositis: pleuritis or pericarditis
Renal: proteinuria or casts
Neurology: seizures or psychosis
Haem: autoimmune haemolytic anaemia or pancytopenia
Positive auto antibodies dsDNA or Sm
Elevated ANA

223
Q

What are treatment options for lupus? (3)

A

Mild (cutaneous/joints): topical steroid, hydroxychloroquine
Moderate (other organs): prednisolone, azathioprine
Severe: methylpred, mycophenolate, cyclophosphamide, azathioprine

224
Q

What are side effects of cyclophosphamide? (8)

A

Thrombocytopenia
Anaemia
Haemorrhagic cystitis
Infertility
Tetatogenicity
Infection
Hair loss
Deranged LFTs

225
Q

What are important symptoms to ask in a history for systemic sclerosis? (6)

A

Raynaud’s phenomenon: white, blue, red
Function: ADLs, work
HTN
Heart problems
Lung problems
Dysphagia /GORD

226
Q

What are features on examination if hands and face of a patient with systemic sclerosis? (11)

A

Sclerodactyly
Calcinosis
Digital ulcers
Nail fold capillary abnormalities
Tight skin on face
Beaked nose
Microstomia
Peri oral furrowing
Telangiectasia
Alopecia
En coup de sabre: scar down central forehead

227
Q

What systemic features can be found on examination of a patient with systemic sclerosis? (3)

A

HTN
Resp: interstitial fibrosis
Cardiac; pulmonary HTN (RV heave, loud p2 and TR), CCF, pericardial rib

228
Q

What are differences between limited and diffuse systemic sclerosis?

A

Limited: distal limbs only, below elbows, knees and face. Slow progression over years
Diffuse: widespread, early visceral involvement. Rapid progression over months

229
Q

What is CREST?

A

Calcinosis
Raynaud’s phenomenon
Esophageal dysmotility
Sclerodactyly
Telangiectasia

230
Q

What are investigations for systemic sclerosis? (11)

A

Auto antibodies: ANA in 90%, anti centromere in limited, Scl 70 in diffuse
Hand xray: Calcinosis
CXR: lower lobe fibrosis, aspiration pneumonia
HRCT
Pulmonary function tests
Barium swallow
B12/ folate: malabsorption
U&Es, urinalysis, microscopy
Consider renal biopsy
ECG
Echo

231
Q

What are investigations for systemic sclerosis? (11)

A

Auto antibodies: ANA in 90%, anti centromere in limited, Scl 70 in diffuse
Hand xray: Calcinosis
CXR: lower lobe fibrosis, aspiration pneumonia
HRCT
Pulmonary function tests
Barium swallow
B12/ folate: malabsorption
U&Es, urinalysis, microscopy
Consider renal biopsy
ECG
Echo

232
Q

What are investigations for systemic sclerosis? (11)

A

Auto antibodies: ANA in 90%, anti centromere in limited, Scl 70 in diffuse
Hand xray: Calcinosis
CXR: lower lobe fibrosis, aspiration pneumonia
HRCT
Pulmonary function tests
Barium swallow
B12/ folate: malabsorption
U&Es, urinalysis, microscopy
Consider renal biopsy
ECG
Echo

233
Q

What is scleroderma renal crisis? (6)

A

life-threatening complication
abrupt onset severe HTN
rapidly progressive renal failure
hypertensive encephalopathy
congestive heart failure
microangiopathic hemolytic anemia

234
Q

What are treatment options for systemic sclerosis? (11)

A

Expert patient programmes
Scleroderma Society
Physio
Camouflage creams
Gloves/hand warmers for Raynaud’s
Nifedipine or losartan
Prosacyclin infusion if severe
ACEi prevent HTN crisis and reduce mortality from renal failure
PPI for reflux
methotrexate, mycophenolate mofetil or cyclophosphamide if <3 years
Autologous stem cell transplant may be appropriate in some cases

235
Q

What symptoms are important to ask about in a patient with potential ank spond? (5)

A

Psychosocial impact: work, driving, ADLs
Explore back pain
Eye problems: uveitis
Pneumonia
Syncope: CHB

236
Q

What are findings on examination of a patient with ank spond? (5)

A

? Posture: fixed kyphoscoliosis
Protuberant abdomen: diaphragmatic breathing, reduced chest expansion
Increased occiput - wall distance >5cm
Reduced ROM in entire spine
Schobers test: two points marked 15cm apart on dorsal spine expand by less than 5cm on maximal forward flexion

237
Q

What are complications of ank spond? (5)

A

Anterior uveitis
Apical lung fibrosis
Aortic regurgitation
Atrio ventricular nodal heart block
Arthritis

238
Q

Which gene is linked with ank spond?

A

HLA B27

239
Q

What are treatment options for ank spond? (7)

A

Patient education
Support groups
Physio
Analgesia: NSAIDs
Steroid injections for Sacroiliitis
Refer rheumatology
Anti TNF: adalimumab, infliximab, etanercept

240
Q

What are important history questions for a patient with potential marfans? (5)

A

Need for glasses/ eye surgery
Heart surgery /screening
Stretch marks
Back/joint problems
History of pneumothorax

241
Q

What are examination findings of marfans? (12)

A

Tall with long extremities (arm span > height)
Arachnodactyly
Hyperextensible joints
High arched palate with crowded teeth
Iridodonesis (trembling lens) with upward lens dislocation
Pectus carinatum or excavatum
Scoliosis
Scars from cardiac surgery or chest drains
Aortic regurgitation with collapsing pulse
Mitral valve prolapse
Coarctation
Inguinal herniae

242
Q

What is marfans?

A

Autosomal dominant
Chromosome 15
Defect in fibrillin protein in connective tissue

243
Q

What is management of marfans? (4)

A

Surveillance: monitoring of aortic root size with annual echo
Beta blocker and ARB to slow aortic root dilatation
Pre-emptive aortic root surgery to prevent dissection and rupture
Screen family members

244
Q

What is a differential diagnosis for the causes of lens dislocation? (4)

A

Marfans: upwards
Homocystinuria: downwards
Ehlers danlos
Trauma

245
Q

What are symptoms to ask in a history of a patient with Paget’s? (4)

A

Usually asymptomatic
Can have bone pain and tenderness
Entrapment neuropathy: carpal tunnel, visual problems, deafness
CCF

246
Q

What are examination findings of a patient with Paget’s? (6)

A

Bony enlargement: skull and long bones (sabre tibia)
Deafness: hearing aid
Pathological fractures: scars
Cardiac: high output failure
Neuro: carpal tunnel
Fundi: optic atrophy and angioid streaks

247
Q

What are investigations for Paget’s disease? (3)

A

ALP raised with normal calcium and phosphate
X-rays: moth eaten, osteoporosis circumscripta
Bone scan: increased uptake

248
Q

What are treatment options for pagets? (3)

A

Analgesia
Hearing aids
Bisphosphonates

249
Q

What are complications of Paget’s? (3)

A

Osteogenic sarcoma
Basilar invagination (cord compression)
Kidney stones

250
Q

What are causes of a sabre tibia? (3)

A

Pagets
Osteomalacia
Syphilis

251
Q

What are causes of angioid streaks? (3)

A

Pagets
Pseuodoxanthoma elasticum
Ehlers danlos

252
Q

What are causes of gout? (3)

A

Diet and alcohol: xanthine rich food
Drugs: diuretics
CKD

253
Q

What are examination findings in gout? (8)

A

Asymmetrical swelling of small joints of hands and feet
Gouty tophi: joints, ears, tendons
Reduced movement and function
Obesity
HTN
Nephrectomy scars: urate stones/nephropathy
Chronic renal failure: fistulae
Lymphoproliferative disorders: lymphadenopathy

254
Q

What are investigations for gout? (3)

A

Uric acid levels
Synovial fluid: needle shaped, negatively birefringent crystals
Xray: punched out periarticular changes

255
Q

What are treatments for gout? (2)

A

Acute: treat cause, increase hydration, NSAIDs, colchicine
Prevention: avoid Precipitants, allopurinol (xanthine oxidase inhibitor)

256
Q

What are symptoms and features to ask about in a history of OA? (6)

A

Joint stiffness and weakness
Not usually red or swollen
Assess ADLs and work
Mobility: walking stick, wheelchair etc
Joint replacements
NSAID use

257
Q

What are examination findings in OA? (8)

A

Asymmetrical DIPJ deformity
Heberdons nodes
Bouchards nodes
Disuse atrophy of hand muscles
Crepitations
Reduced movement and function
Carpal tunnel syndrome or scars
Joint replacement scars

258
Q

What are radiographic features of OA? (3)

A

Loss of joint space
Osteophytes
Periarticular sclerosis and cysts

259
Q

What are treatments for OA? (4)

A

Analgesia
Weight reduction
PT and OT
Joint replacement

260
Q

What are important questions in a history of diabetic retinopathy? (4)

A

Duration and nature of visual disturbance
Underlying medical problems eg diabetes
Previous eye problems or treatments
Have they had retinal screening?

261
Q

What are examination findings in diabetic retinopathy? (6)

A

White stick, braille
Glucometer
Background: hard exudates, blot haemorrhages, micro aneurysms
Pre proliferative: cotton wool spots, flame haemorrhages, venous beading and loops
Proliferative: neovascularisation of disc, panretinal photocoagulation scars
Diabetic maculopathy: macular oedema or hard exudates in one area of fovea

262
Q

In which conditions would red reflex be absent? (2)

A

Cataract
Vitreous haemorrhage

263
Q

What screening should be done for diabetic retinopathy? (2)

A

Annual retinal screening
Refer to ophthalmology of pre proliferative or changes near macula

264
Q

What is difference between type 1 and 2 diabetes when it comes to retinopathy?

A

Type 1: proliferative
Type 2: exudative

265
Q

What is treatment for diabetic retinopathy? (3)

A

Tight glycemic control
Treat other risk factors: HTN, cholesterol, smoking cessation
Photocoagulation if proliferative

266
Q

When can accelerated deterioration of diabetic retinopathy occur? (3)

A

Poor glycaemic control
HTN
Pregnancy

267
Q

What are indications for photocoagulation? (2)

A

Maculopathy
Proliferative and pre proliferative diabetic retinopathy

268
Q

By what mechanism does pan retinal photocoagulation help in diabetic retinopathy? (2)

A

Pan retinal: Prevents ischaemic retinal cells secreting angiogenesis factors causing neovascularisation
Focal: targets problem vessels at risk of bleeding

269
Q

What are complications of proliferative diabetic retinopathy? (3)

A

Vitreous haemorrhage
Traction retinal detachment
Neovascular glaucoma due to rubeosis iridis

270
Q

What are signs of cataracts? (4)

A

Loss of red reflex
Cloudy lens
RAPD
Associated with myotonic dystrophy (bilateral ptosis)

271
Q

What are causes of cataracts? (2)

A

Congenital: rubella, turners
Acquired: age, diabetes, steroids, radiation exposure, trauma, storage disorders, myotonic dystrophy

272
Q

What are treatments for cataracts? (2)

A

Surgery: phacoemulsification with prosthetic lens implant or yttrium aluminium garnet laser capsulotomy

273
Q

What are important symptoms to ask about in a history of graves? (9)

A

Goitre: non tender
Eye problems: keratitis, loss of colour vision, central scotoma, reduced VA
Sleep and energy levels
Heat intolerance
Sweating
Agitation and stress
Tremor
Appetite and weight loss
Palpitations

274
Q

What are eye signs in Graves’ disease? (6)

A

Proptosis
Chemosis
Exposure keratitis
Lid retraction
Lid lag
Ophthalmoplegia

275
Q

What are peripheral signs in Graves’ disease? (7)

A

Thyroid acropachy: clubbing, soft tissue swelling, periosteal bone formation
Pretibial myxoedema
Sweating
Tremor
Palmar erythema
Sinus tachy/AF
Brisk reflexes

276
Q

What are investigations for Graves’ disease? (3)

A

TFTs
Thyroid autoantibodies: TPO, thyroglobulin, TSH
Radioisotope scan: increased uptake of I131 in graves, reduced in thyroiditis

277
Q

What are treatments for Graves’ disease? (4)

A

Beta blockers
Carbimazole or propylthiouracil: block and replace with thyroxine or titrate dose, stop at 18 months and assess, 1/3 patients will remain euthyroid
If returns: further course thionamide, radioiodine, subtotal thyroidectomy
Eye disease: high dose steroids, orbital irradiation or surgical decompression

278
Q

What is contraindicated in thyroid eye disease?

A

Radioiodine

279
Q

What are symptoms and features of hypothyroidism to ask about in the history? (8)

A

Tiredness, low energy levels
Cold intolerance
Weight gain
Previous amiodarone, lithium or antithyroid drugs
Previous thyroid disease
Autoimmune history: Addisons, vitiligo and T1DM
Hypercholesterolaemia
IHD

280
Q

What might you find on examination of a patient with hypothyroidism? (14)

A

Bradycardia
Dry skin
Cool peripheries
Peaches and cream complexion: anaemia and carotenaemia
Peri orbital oedema
Loss of lateral eyebrows
Xanthelasma
Thinning hair
Goitre or thyroidectomy scar
Slow relaxing ankle jerk
Pericardial rub
CCF
Carpal tunnel
Proximal myopathy

281
Q

What are investigations for hypothyroidism? (8)

A

TSH raised in thyroid failure, low in pituitary failure, low T4
Autoantibodies
U&Es: hyponatraemia
Hypercholesterolaemia
FBC: macrocytic anaemia
Short synacthen test: exclude Addisons
ECG: pericardial effusion and ischaemia
CXR: pericardial effusion/oedema

282
Q

What are causes of hypothyroidism? (5)

A

Autoimmune: hashimotos thyroiditis, atrophic hypothyroidism
Iatrogenic: post thyroidectomy, radioiodine, amiodarone, lithium, anti thyroid drugs
Iodine deficiency: Derbyshire neck
Dyshormonogenesis
Genetic: pendreds syndrome

283
Q

What are causes of hypothyroidism? (5)

A

Autoimmune: hashimotos thyroiditis, atrophic hypothyroidism
Iatrogenic: post thyroidectomy, radioiodine, amiodarone, lithium, anti thyroid drugs
Iodine deficiency: Derbyshire neck
Dyshormonogenesis
Genetic: pendreds syndrome

284
Q

What are features in history of acromegaly to ask about? (7)

A

Headache: pituitary SOL, early morning, nausea
Visual problems: tunnel vision
Loss of libido
Lactation
Change in appearance/ photographs
Tight fitting jewellery /shoes
Diabetes

285
Q

What are examination findings of acromegaly? (16)

A

Hands: spade like, tight rings, coarse skin, sweaty
Face: prominent supra orbital ridges, prognathism, widely spaced teeth, macroglossia
Acanthosis nigrans
Raised BP
Carpal tunnel syndrome
Diabetes
Enlarged organs
Field defect: bitemporal hemianopia
Goitre
Heart failure
Hirsute
Hypopituitary
Joint Arthropathy
Kyphosis
Galactorrhoea
Proximal myopathy

286
Q

What are investigations for acromegaly? (9)

A

Non suppression of GH after oral glucose tolerance test
Raised IGF1
CT/MRI pituitary: pituitary adenoma
Other pituitary function bloods: t4, ACTH, PRL, testosterone
CXR: cardiomegaly
ECG: ischaemia
Glucose: diabetes
Visual perimetry: bitemporal hemianopia
Sleep studies: OSA due to macroglossia

287
Q

What are treatments for acromegaly? (3)

A

Surgery: trans-sphenoidal approach
Medical: somatostatin analogue (octreotide), dopamine agonist (cabergoline), GH antagonist (pegvisomant)
Radiotherapy if non surgical candidate

288
Q

What are follow up arrangements for acromegaly? (6)

A

Annual IGF1, PRL, ECG, visual fields, CXR, CT head

289
Q

What is MEN1?

A

Inherited tumours, autosomal dominant, chromosome 11
Parathyroid hyperplasia
Pituitary tumours
Pancreatic tumours; gastrinomas

290
Q

What is MEN2a?

A

RET proto oncogene issue, autosomal dominant
Parathyroid hyperplasia
Medullary thyroid carcinoma
Phaeochromocytoma

291
Q

What is MEN2b?

A

Marfanoid body habitus
Medullary thyroid carcinoma
Phaeochromocytoma

292
Q

What are causes of macroglossia? (4)

A

Acromegaly
Amyloidosis
Hypothyroidism
Down’s syndrome

293
Q

What is acanthosis nigricans?

A

Brown, velvet like skin change found commonly round neck or axillae

294
Q

What is acanthosis nigricans associated with? (7)

A

Obesity
T2DM
Acromegaly
Cushings
Indian ethnicity
Gastric carcinoma
Lymphoma

295
Q

What are symptoms to ask about in a history of cushings? (5)

A

Proximal myopathy
Steroid history: endogenous vs exogenous
Visual disturbance: bitemporal hemianopia
Skin hyperpigmentation
Diabetes

296
Q

What are examination features of someone with cushings? (5)

A

Face: moon shaped, hirsute, acne
Skin: bruised, thin, purple striae
Back: buffalo hump
Abdomen: centripetal obesity
Legs: wasting, lemon on sticks body shape, oedema

297
Q

What are complications of cushings? (5)

A

HTN
Diabetes
Osteoporosis
Cellulitis
Proximal myopathy

298
Q

What are signs of the underlying causes of cushings? (2)

A

Signs of chronic condition: RA, COPD
Endogenous: bitemporal hemianopia and hyperpigmentation if raised ACTH

299
Q

What is the difference between Cushing’s syndrome and Cushing’s disease?

A

Disease: glucocorticoid excess due to ACTH secreting pituitary adenoma
Cushing’s syndrome: physical signs of glucocorticoid excess

300
Q

How do you investigate Cushing’s? (6)

A

Check High cortisol: 24 hour urinary collection, low dose or overnight dexamethasone suppression test
ACTH level: high if ectopic secreting tumour or pituitary adenoma, low if adrenal adenoma or carcinoma
MRI pituitary
adrenal CT /whole body CT
Bilateral inferior petrosal sinus vein sampling
High dose dexamethasone suppression test: if >50% then Cushing’s disease

301
Q

What is treatment for Cushing’s disease? (4)

A

Surgical: trans sphenoidal approach if pituitary tumour
Adrenalectomy for adrenal tumour
Pituitary irradiation
Medical: metyrapone

302
Q

What is Nelson’s syndrome?

A

Bilateral adrenalectomy to treat Cushing’s
Causes massive production of ACTH and melanocyte stimulating hormone
Due to lack of feedback inhibition
Leading to hyperpigmentation and pituitary overgrowth

303
Q

What is prognosis of Cushing’s?

A

50% mortality at 5 years due to accelerated IHD if untreated

304
Q

What are causes of proximal myopathy? (6)

A

Inherited: myotonic distrophy, muscular distrophy
Endocrine: Cushing’s, hyperparathyroidism, Thyrotoxicosis, diabetic amyotrophy
Inflammatory: polymyositis, RA
Metabolic: osteomalacia
Malignancy: paraneoplastic, lambert Eaton myasthenic syndrome
Drugs: alcohol, steroids

305
Q

What are symptoms of Addisons to ask about in the history? (10)

A

Fatigue
Muscle weakness
Low mood
Loss of appetite
Weight loss
Thirst
Darkened skin
Fainting
Cramps
Other autoimmune history

306
Q

What are differentials for Addisons? (Secondary causes of adrenal insufficiency)

A

Secondary adrenal insufficiency: pituitary adenoma or sudden discontinuation of steroids

307
Q

What might you find on examination of someone with Addisons? (4)

A

Medical alert bracelet
Hyperpigmentation: palmar creases, scars, nipples, buccal mucosa
Postural hypotension
Bitemporal hemianopia: secondary

308
Q

What is Addisons? And what are causes (3)

A

Primary adrenal insufficiency
80% autoimmune
Other causes: adrenal mets, adrenal TB, amyloidosis, adrenalectomy, Waterhouse friederichsen syndrome (adrenal infarction due to meningococcal sepsis)

309
Q

How does Addisons cause hyper pigmentation?

A

Pigmentation due to lack of feedback inhibition by coritsol on pituitary leading to raised ACTH and melanocyte stimulating hormone

310
Q

What are investigations for Addisons? (11)

A

8am cortisol
Short synacthen test: exclude Addisons if cortisol rises to adequate level
Long synacthen test: diagnose Addisons if not enough rise
Adrenal imaging (primary)
Pituitary imaging (secondary)
FBC: eosinophilia
U&E: low Na, raised K, raised urea
Glucose: low
Adrenal autoantibodies (21-hydroxylase and 17 alpha hydroxylase)
TFTs
CXR: malignancy or TB

311
Q

What are treatments for Addisons? (5)

A

Acute adrenal crisis: IV 0.9% saline
glucose
Hydrocortisone and fludrocortisone
Treatment may unmask diabetes insipidus
If on TB treatment, need higher doses of steroid as drugs increase clearance
Education: compliance, sick day rules
Medical alert bracelet

312
Q

What are symptoms in history of sickle cell? (7)

A

Fatigue
Breathlessness on exertion
Bone pains
Chest pains
Hospital admissions
Ulcers
Priapism

313
Q

What might be examination findings of sickle cell? (7)

A

Fever
Dyspnoea
Jaundice
Pale conjunctiva
Raised JVP, pansystolic murmur at left sternal edge: TR
Reduced chest expansion due to pain with coarse crackles
Small crusted ulcers on legs

314
Q

What is vaso occlusive crisis in sickle cell?

A

Sickling in small vessels of any organ
Precipitated by viral illness, exercise or hypoxia

315
Q

What are investigations for sickle cell? (8)

A

FBC: low Hb, high WCC and CRP
U&E: renal impairment
Blood film; sickling
CXR: linear atelectasis, cardiomegaly
Urinalysis; microscopic haematuria
ABG: T1RF if crisis
Echo; dilated right ventricle with impaired systolic function, TR
CTPA: linear atelectasis with patchy consolidation, acute PE

316
Q

What are treatment options for acute presentation of sickle cell? (5)

A

Oxygen +/- CPAP
IV fluids
Analgesia
Antibiotics
Blood transfusion/ exchange transfusion

317
Q

What are long term treatments for sickle cell? (5)

A

Hydroxycarbamide
Exchange transfusion program
Folic acid
Penicillin (hyposplenism)
May need right heart catheter to look for pulmonary HTN

318
Q

What blood tests should be done for hereditary spherocytosis? (5)

A

FBC: high retics, raised MCHC
Blood film: spherocytes
Haemolysis screen: bilirubin, LDH, haptoglobin
Coombs test: exclude autoimmune haemolysis
EMA binding test

319
Q

What are complications of hereditary spherocytosis? (4)

A

Gallstones
Haemolysis triggered by infections
Aplastic crisis: parvovirus B19
Megaloblastic crisis: folate deficiency

320
Q

What is treatment of spherocytosis? (3)

A

Folic acid supplementation
Splenectomy and cholecystectomy
Vaccines for encapsulated organisms

321
Q

What is treatment of spherocytosis? (4)

A

Folic acid supplementation
Splenectomy and cholecystectomy
Vaccines for encapsulated organisms
Blood transfusions

322
Q

What are history and investigations features to suggest pancreatic insufficiency? (6)

A

Weight loss
Steattorrhoea
Low faecal elastase
Low Albumin
Vit d def
Low magnesium

323
Q

What needs to be given alongside Creon?

A

PPI to prevent acid breakdown of enzymes

324
Q

How do you differentiate between viral and bacterial meningitis from CSF samples?

A

Bacterial: raised WCC - neutrophilia, elevated protein, low glucose
Viral; raised WCC - lymphocytes, elevated protein, normal glucose ratio

325
Q

What are causes of meningitis? (5)

A

Bacterial
Viral
TB
Fungal
Paraneoplastic

326
Q

What are important questions in suspected reactive arthritis? (5)

A

Recent illness - GI upset
Sexual history - chlamydia
Psoriasis/ank spond/IBD personal or family history
Eye symptoms: anterior uveitis, conjunctivitis
HIV risk factors

327
Q

What are causes of hypothyroidism? (7)

A

Hashimotos: autoimmune, progressive lymphocytic infiltration
De Quervains: initially hyper then hypo then resolve
Iatrogenic: over treatment of hyper
Post partum thyroiditis
Iodine deficiency
Drugs: amiodarone, lithium
Infiltration: amyloidosis, sarcoidosis

328
Q

What is thyroid myxoedema?

A

low body temperature
Anaemia
Heart failure
Confusion
Coma
From severe hypothyroidism

329
Q

What conditions can be associated with autoimmune hypothyroidism? (7)

A

Vitiligo
Addisons
T1DM
RA
Pernicious anaemia
Psoriasis
IBD

330
Q

Which autoantibodies are associated with Hashimoto’s disease? (2)

A

Anti TPO
Anti thyroglobulin

331
Q

Which antibodies are found in Graves’ disease?

A

Anti TSH receptor antibodies

332
Q

What are risk factors for spina bifida? (5)

A

Low folate during pregnancy
FH neural tube defects
Drugs: Sodium valproate / methotrexate during pregnancy
Obesity
Diabetes

333
Q

What are symptoms/ associated problems in spina bifida? (3)

A

Weakness of legs
Bowel and bladder issues: incontinence, neurogenic bladder and bowels, constipation, infections
Hydrocephalus

334
Q

What are symptoms/ associated problems in spina bifida? (3)

A

Weakness of legs
Bowel and bladder issues: incontinence, neurogenic bladder and bowels, constipation, infections
Hydrocephalus

335
Q

What are causes of anaemia in RA? (5)

A

Anaemia of chronic disease
Feltys syndrome
IDA from NSAID use
Autoimmune haemolytic anaemia
Bone marrow suppression from medication

PACES (6 decks)

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