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Clinical Consultations Flashcards

1
Q

What symptoms are associated with yellow nail syndrome

A

Lymphoedema (80%)
Pleural effusions (36%)
Chronic sinusitis
Bronchiectasis

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2
Q

Which underlying conditions are associated with yellow nail syndrome

A

Chronic bronchiectasis, rheumatoid arthritis, hypogammaglobulinaemia, malignancy, thyroid disease

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3
Q

What are the causes of a high-arched palate

A
  • Freidrich’s ataxia
  • Marfan’s syndrome
  • Turner’s syndrome
  • Tuberous sclerosis
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4
Q

Which blood test is helpful in differentiating graves and toxic multinodular goitre

A

TSH receptor Abs (positive in Grave’s)

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5
Q

Which test is helpful in differentiating Grave’s and thyroiditis

A

Radioisotope scanning (increased uptake in grave’s, reduced in thyroiditis)

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6
Q

When can’t radioiodine treatment be used for hyperthyroidism

A

Thyroid eye disease, pregnancy

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7
Q

What causes a saddle nose appearance

A

Granulomatosis with polyangiitis

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8
Q

What exam findings may be present in ankylosing spondylitis

A
  • question mark posture
  • reduced ROM throughout spine
  • occipital-wall distance >5cm
  • Schober’s test positive
  • signs of aortic regurgitation
  • apical fine crackles
  • eye redness, Achilles tendinitis
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9
Q

What can be seen on spine XR in ankylosing spondylitis

A
  • sclerosis of sacroiliac joint
  • syndesmophytes
  • loss of lumbar lordosis
  • bamboo spine
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10
Q

What can cause breathlessness in ankylosing spondylitis

A
  • anemia (chronic disease, GI loss)
  • kyphoscoliosis
  • apical fibrosis
  • aortic regurgitation
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11
Q

What is the pharmacological management of Ankylosing spondylitis

A
  1. NSAIDs
  2. If uncontrolled with NSAIDs, DMARDS (anti TNF e.g. adalimumab, etanercept)
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12
Q

What complications are associated with ankylosing spondylitis

A
  1. Anterior uveitis
  2. Apical lung fibrosis
  3. Aortic regurgitation
  4. AV block
  5. Arthritis
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13
Q

What are the seronegative spondyloarthropathies

A
  • ankylosing spondylitis
  • psoriatic arthritis
  • IBD associated arthritis
  • reactive arthritis
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14
Q

How does anterior uveitis present

A

Painful red eye, reduced acuity, excess lacrimation, ciliary flush, abnormally shaped pupil

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15
Q

What are the causes of anterior uveitis

A
  • seronegative spondyloarthropathies
  • IBD
  • Bechet’s
  • sarcoidosis
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16
Q

What are the grades of hypertensive retinopathy

A
  • Grade 1: silver wiring
  • Grade 2: plus AV nipping
  • Grade 3: plus cotton wool spots and flame haemorrhages
  • Grade 4: plus papilloedema
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17
Q

What are most common causes of secondary hypertension

A
  1. Renal (CKD - GN, PKD, renovascular)
  2. Endocrine (Conn’s, cushing’s, acromegaly, phaeochromocytoma)
  3. Aortic coarctation
  4. Pre-eclampsia
  5. OSA
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18
Q

When should stage 1 hypertension (>140/90) be treated

A

Evidence of end-organ damage, IHD, diabetes, CKD, 10-year cardiovascular risk >20%

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19
Q

When should patients with hypertension be admitted

A

Severe hypertension (>180 or >110) and grade 3/4 retinopathy or end organ damage

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20
Q

When should a patient with IBD be admitted to hospital

A

Systemically unwell with symptoms such as bloody diarrhoea, fever, tachycardia or hypotension

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21
Q

What are the physical signs associated with acromegaly

A

Spade like hands, tight rings, coarse sweaty skin, protruding jaw, widely spaced teeth, macroglossia, prominent supra-orbital ridges

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22
Q

What are the complications of acromegaly

A
  • diabetes
  • HTN
  • heart failure
  • field defects
  • lactation
  • carpal tunnel syndrome
  • OSA
  • proximal myopathy
  • goitre
  • GI malignancy
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23
Q

What are the diagnostic tests of acromegaly

A
  • IGF-1 (raised)
  • OGTT (no suppression of GH)
  • MRI pituitary (adenoma)
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24
Q

What investigations should be performed to look for complications of acromegaly

A
  • blood pressure
  • ECG (ischaemia), CXR (cardiomegaly)
  • BM, HbA1c
  • pituitary function tests
  • visual field defects
  • sleep studies
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25
Q

What is the follow up for acromegaly

A

Annual GH, prolactin, ECG, visual fields and CXR +/- CT head

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26
Q

What are the features of MEN1

A
  • parathyroid hyperplasia (raised Ca)
  • pituitary tumours
  • pacreatic tumours (gastrinomas)
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27
Q

What are the causes of macroglossia

A

Acromegaly
Amyloidosis
Hypothyroidism
Down’s syndrome

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28
Q

What is acanthosis nigricans associated with

A
  • obesity
  • T2DM
  • acromegaly
  • cushing’s
  • malignancy (gastric cancer)
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29
Q

What are the causes of retinal angioid streaks

A

PEPSI

Pseudoxanthoma elasticum
Ehler-Danlos syndrome
Paget’s disease of the bone
Sickle cell disease
Idiopathic

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30
Q

What are the causes of proximal myopathy

A
  • inherited (myotonic dystrophy, muscular dystrophy)
  • endocrine (cushings, thyrotoxicosis, diabetic amyotrophy)
  • inflammatory (polymoyositis, RA)
  • LEMS
  • Drugs (alcohol, steroids)
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31
Q

What are the causes of optic atrophy

A

PALE DISCS

P = pressure
A = ataxia (Friedrich’s)
LE = Leber’s
D = diet (B12), degenerative (RP)
I = ischaemia (CRAO)
S = syphilis
C = cyanide and other toxins
S = MS

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32
Q

What are the 2 most common causes of optic atrophy

A
  1. Increased pressure (eg glaucoma)
  2. MS
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33
Q

What are the causes of tunnel vision

A
  • retinitis pigmentosa
  • papilloedema
  • glaucoma
  • choroidoretinitis
  • migraine
  • histeria
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34
Q

What are the causes of a retinal artery occlusion

A
  1. Embolic - carotid/cardiac (AF)
  2. GCA
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35
Q

What does a cherry red spot and pale retina suggest on fundoscopy

A

Retinal artery occlusion

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36
Q

What are the causes of retinal vein occlusion

A
  • hypertension
  • hyperglycaemia (diabetes)
  • hyperviscosity (Waldenstroms, MM)
  • high pressure (glaucoma)
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37
Q

What does flame haemorrhages radiating from a swollen optic disc suggest on fundoscopy

A

Retinal vein occlusion

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38
Q

What are the causes of sudden unilateral painless vision loss

A
  • retinal detachment
  • retinal artery or vein occlusion
  • vitreous detachment/haemorrhage
  • ischaemic optic neuropathy
  • amaurosis fugax
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39
Q

What are the causes of painless bilateral vision loss

A
  • medication/drugs
  • stroke (hemianopia)
  • metabolic derangement
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40
Q

What are the causes of painful unilateral vision loss

A
  • optic neuritis
  • temporal arteritis (GCA)
  • iritis, uveitis
  • acute angle closure glaucoma
  • infection
  • cavernous sinus thrombosis
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41
Q

What are the causes of dactylitis

A
  • spondyloarthropathies
  • sickle cell
  • sarcoidosis
  • syphilis
  • TB
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42
Q

What ANA pattern is associated with limited cutaneous systemic sclerosis

A

Anti-centromere

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43
Q

What ANA pattern is associated with diffuse cutaneous systemic sclerosis

A

Scl-70 / topoisomerase-1

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44
Q

What is the difference in age of onset between Friedrich’s ataxia and ataxia telangiectasia

A
  • Friedrich’s = 10-15 years
  • AT = 1-5 years
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45
Q

What does ataxia telangiectasia predispose patients to

A
  1. Recurrent infections (IgA deficiency)
  2. Cancer (ATM repairs DNA breaks)
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46
Q

What are the typical ocular features seen in Kearns-Sayre syndrome

A
  1. Complex ophthalmoplegia
  2. Bilateral ptosis
  3. Retinitis pigmentosa
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47
Q

What are the causes of erythema nodosum

A
  • Inflammatory (Sarcoidosis, IBD)
  • Infection (Strep, TB, Histoplasmosis, Brucellosis)
  • Malignancy (Lymphoma)
  • Pregnancy
  • COCP
  • Idiopathic
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48
Q

What are the skin manifestations of sarcoidosis

A
  • erythema nodosum
  • nodules and papules (red/brown around face, nose, ears and neck that demonstrate koebner’s phenomenon)
  • lupus pernio
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49
Q

What are the side effects of NSAIDs

A
  • renal failure
  • GI bleeding
  • Cardiovascular disease
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50
Q

What are the side effects of steroids

A
  • Diabetes
  • Osteoporosis
  • Hypertension
  • Infection
  • Avascular necrosis of hip
  • Striae and weight gain (cushing’s)
  • Cataracts
  • Increased ICP
  • Myopathy
  • Pancreatitis
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51
Q

What are the features of osteogenesis imperfecta

A
  • multiple fractures (low impact)
  • blue sclera
  • discoloured, translucent teeth
  • aortic regurgitation
  • hearing impairment
  • small stature, spinal scoliosis, curvature of long bones
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52
Q

What are the causes of blue sclera

A
  • osteogenesis imperfecta
  • pseudoxanthoma elasticum
  • Ehler Danlos syndrome
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53
Q

What are the causes of secondary raynauds

A
  1. Systemic sclerosis
  2. SLE
  3. Dermatomyositis
  4. Sjogren syndrome
  5. GPA
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54
Q

What is the inheritance pattern of HHT

A

Autosomal dominant

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55
Q

What are the complications of HHT

A
  • bleeding -> IDA
  • stroke (paradoxical emboli)
  • subarachnoid haemorrhage
  • pulmonary hypertension
56
Q

What is the main difference between complications in PXE and EDS

A

PXE increases risk of coronary artery disease and MI

57
Q

List 9 autosomal recessive conditions

A

Ataxia telangiectasia
Cystic fibrosis
Friedrich’s ataxia
Haemochromatosis
Homoscystinuria
Pseudoxanthoma Elasticum
Sickle cell disease
Thalassaemia
Wilson’s

58
Q

What percentage of discoid lupus progresses to SLE

A

5%

59
Q

What are the causes of carpal tunnel syndrome

A
  • hypothyroidism
  • pregnancy
  • obesity
  • wrist trauma
  • diabetes
  • rheumatoid arthritis
  • acromegaly
60
Q

What are the causes of a bulbar palsy (CN IX, X and XII)

A
  • MND
  • Syringobulbia
  • Guillian-Barre
  • Poliomyelitis
  • Neurosyphilis
  • Brainstem CVA
61
Q

What are the causes of a pseudobulbar palsy (CN IX, X and XII)

A
  • MS
  • MND
  • High brainstem tumours
62
Q

What is Jaccoud’s arthropathy

A

Seen in SLE - mimics RA but due to tendon contractures

63
Q

What are the systemic effects of SLE

A
  1. Resp - pleural effusion, rub, fibrosis
  2. Neuro - chorea, ataxia, focal neurology
  3. Renal - CKD, nephrotic syndrome, HTN
64
Q

What can be used to measure disease activity in SLE

A
  • raised ESR (But normal CRP)
  • raised immunoglobulins
  • reduced C4
  • UEs, urine microscopy
65
Q

What are the 11 criteria that 4 of which are required to diagnose SLE

A

SOAP BRAIN MD

  • serositis (pleuritis, pericarditis)
  • oral ulcers
  • arthritis
  • photosensitivity
  • blood disorders (eg AIHA)
  • renal involvement (eg proteinuria)
  • ANA+
  • immunology (anti-DsDNA)
  • neurological disorders (eg seizures)
  • malar rash
  • discoid rash
66
Q

What is the management of mild SLE with cutaneous/joint involvement only

A
  • topical corticosteroids
  • hydroxychloroquine
67
Q

What is the management of moderate SLE with cutaneous/joint involvement + other organ involvement

A
  • prednisolone
  • azathioprine
68
Q

What is the management of severe SLE with severe inflammation of vital organs

A
  • methylprednisolone
  • MMF
  • cyclophosphamide
  • azathioprine
69
Q

What are the side effects of cyclophosphamide

A

Haemorrhagic cystitis
Infertility
Teratogenicity

70
Q

What are the classical facial appearances in systemic sclerosis

A
  • tight skin
  • beaked nose
  • microstomia
  • peri-oral furrowing
  • telangiectasia
  • alopecia
71
Q

What is the appearance of a discoid lupus rash

A
  • persistent scaly plaques
  • scalp, face and ears most affected
  • progress to scarring
  • hypo or hyperpigmentation
  • scarring alopecia
72
Q

What is the difference in progression between limited and diffuse systemic sclerosis

A

Limited - slow (years)
Diffuse - rapid (months)

73
Q

What investigations are important in systemic sclerosis

A
  1. Diagnosis - ANA, anti-centromere, Scl-70
  2. Hands - XRays (calcinosis)
  3. Lungs - CXR, HRCT, PFTs
  4. GI - contrast swallow, FBC, B12
  5. Renal - UE, urinalysis, ACR, biopsy
  6. Cardiac - ECG, echo
74
Q

What is the treatment of Systemic sclerosis

A

Symptomatic treatment only!

  • Reynauds - gloves, CCBs, prostacyclin infusion if severe
  • Renal - ACEi
  • GI - PPI
75
Q

What are most deaths due to in systemic sclerosis

A

Respiratory failure

76
Q

What are the 4 S’s to be asked in a rheumatological history

A

Sun sensitivity
Scalp involvement
Scarring
Systems involvement

77
Q

What is the management of thyroid eye disease

A
  1. Stop smoking, selenium
  2. Block and replace or titrate (carbimazole, PTU)
78
Q

What causes memory loss, ataxia and urinary incontinence

A

Normal pressure hydrocephalus

79
Q

What are the organic causes of memory loss

A
  • Alcohol inc korsakoff’s
  • hypothyroidism
  • B12 deficiency
  • infection e.g. HIV, Neurosyphilis
  • head injury
80
Q

What might be found on examination in Addison’s disease

A
  • medic alert bracelet
  • hyperpigmentation (skin folds, lips)
  • postural hypotension
  • bitemporal hemianopia (pituitary adenoma)
81
Q

What are the causes of Addison’s disease

A
  • 80% autoimmune
  • adrenal mets
  • adrenal tuberculosis
  • amyloidosis
  • adrenalectomy
  • Waterhouse-Friederichsen syndrome
82
Q

What is the treatment of an adrenal crisis

A
  • fluid resuscitation
  • IV hydrocortisone
83
Q

What is the classic presentation of diabetic lumbosacral radiculopathy (previously diabetic amyotrophy)

A

Sudden onset unilateral aching/burning pain in thigh and hip which becomes bilateral over weeks/months, can affect walking, leads to proximal weakness and wasting

84
Q

What complication can occur after transphenoidal surgery that leads to persistent runny nose

A

CSF leak

85
Q

What is the main risk associated with CSF leak

A

Infection - meningitis, encephalitis

86
Q

What are the differentials of a symmetrical deforming polyarthropathy

A
  • rheumatoid arthritis
  • psoriatic arthritis
  • osteoarthritis
  • JIA (diagnosis <16 years)
  • SLE
  • gout
87
Q

What can cause SOB in lupus

A
  • acute pneumonitis
  • ILD
  • pulmonary hypertension
  • anaemia
  • PE (secondary APLS)
88
Q

What nail changes are seen in lupus

A

None - patients may be prone to fungal nail infections though if on immunosuppression

89
Q

What increases the risk of hallux valgus (bunions)

A
  • arthritic conditions
  • neuromuscular diseases
  • ehler-danlos, Marfan’s
90
Q

What is the difference between erythema and purpura

A

erythema blanches, purpura does not blanch

91
Q

What are the causes of cranial diabetes insipidus

A
  • trauma (head injury)
  • tumours (eg craniopharyngioma)
  • infiltrative (eg sarcoid, Histiocytosis)
  • vascular (sickle cell, Sheehan’s)
  • iatrogenic (transphenoidal surgery)
92
Q

What are the causes of nephrogenic diabetes insipidus

A
  • inherited (x-linked recessive)
  • metabolic (hypercalcaemia, hypokalaemia)
  • drugs (demeclocycline, lithium)
  • chronic renal disease
93
Q

What are the 5 types of psoriatic arthritis

A
  1. Distal IP predominant
  2. Asymmetrical oligoarticular
  3. Symmetric polyarthritis
  4. Spondylitis
  5. Arthritis mutilans
94
Q

What are the causes of livedo reticularis

A
  • Antiphospholipid syndrome
  • SLE
  • PAN
  • cryoglobulinaemia
  • EDS
  • homocystinuria
  • idiopathic
95
Q

What are the common causes of secondary amenorrhoea

A
  • hypopituitarism
  • hyperprolactinaemia
  • PCOS
  • premature ovarian insufficiency
  • functional hypothalamic (eg weight loss, excessive exercise)
  • hypothyroidism
  • pregnancy
  • drugs/meds
96
Q

What are the causes of scarring alopecia

A
  • discoid lupus
  • Trauma/burns
  • radiotherapy
  • lichen planus
  • tinea capitis
97
Q

What are the causes of non-scarring alopecia

A
  • alopecia areata
  • cytotoxic drugs
  • nutritional e.g. iron deficiency
  • male pattern baldness
98
Q

Which autoimmune conditions classically improve during pregnancy

A

Rheumatoid arthritis, multiple sclerosis

99
Q

What are the potential causes of breathlessness in rheumatoid arthritis

A
  • ILD
  • drug related (MTX)
  • pleural effusion
  • Bronchiolitis obliterans
  • anaemia of chronic disease
  • anaemia from GIB (steroids/NSAIDS)
  • pericardial effusion
100
Q

Why is it important to ask about constitutional symptoms in a patient with rheumatoid arthritis

A
  • increased risk of infection with active RA
  • may be immunocompromised (e.g. MTX)
  • Felty’s syndrome
  • increased risk of lymphoma with RA
101
Q

Which joints are most commonly affected in rheumatoid arthritis

A

MCP and PIP

102
Q

Which infections are linked to reactive arthritis

A
  • GI: campylobacter, shigella, salmonella
  • GU: chlamydia
103
Q

How long after infection does reactive arthritis take to develop

A

1-4 weeks

104
Q

What pattern of joint involvement is typically seen in reactive arthritis

A

Asymmetrical oligoarthritis of the lower limbs

105
Q

What is the first line management of reactive arthritis

A

Oral NSAIDs

106
Q

What are the causes of small vessel vasculitis

A
  • anti-GBM disease
  • IgA vasculitis
  • cryoglobulinaemic vasculitis
  • Microscopic polyangiitis
  • GPA
  • EGPA
107
Q

What symptoms do all vasculitides have in common

A

Constitutional symptoms:
- Fever
- Malaise
- Arthralgia
- Myalgia
- Weight loss

108
Q

What are the symptoms of small vessel vasculitis

A
  • Palpable purpura
  • Haematuria
  • Nasal symptoms
  • Sinus pain
  • Wheeze
  • Haemoptysis
  • Ear pain
109
Q

What are the symptoms of medium vessel vasculitis

A
  • foot/wrist drop (MNM)
  • cutaneous ulcers
  • livedo reticularis
  • digital gangrene
  • abdominal pain
110
Q

What are the symptoms of large vessel vasculitis

A
  • headache, scalp tenderness (GCA)
  • visual changes
  • limb claudication
  • asymmetrical brachial pulses
  • bruits
111
Q

What are the first investigations to order for suspected vasculitis

A
  • ESR, CRP
  • ANCA
  • UEs, urine dip, urine ACR
  • Biopsy of affected tissue
112
Q

What are the causes of a purpuric rash

A
  1. Vasculitides
  2. Platelet disorders - ITP, TTP
  3. Coagulation disorders - DIC, HIT
113
Q

What are the causes of limb claudication

A

Main cause = atherosclerosis

Other causes:
- large vessel vasculitis
- pseudoxanthoma elasticum
- aortic coarctation
- arterial compression (eg tumour)

114
Q

Which eye signs are specific to Grave’s disease

A
  • Proptosis/exophthalmos
  • chemosis (blistering conjunctivae)
  • ophthalmoplegia
  • exposure keratitis
115
Q

Which red flags of thyroid eye disease require urgent referral to ophthalmology

A
  • vision loss
  • ophthalmoplegia
116
Q

What are the causes of thyrotoxicosis

A
  1. Graves disease
  2. Toxic multinodular goitre

Rarer causes:
- single toxic nodule
- thyroiditis (post-infectious, post-partum)
- medication

117
Q

What are the differentials of a neck lump

A
  • Graves’ disease
  • toxic multinodular goitre
  • thyroiditis (painful)
  • thyroid cancer
  • thyroid cyst
  • thyroid adenoma
118
Q

What can be seen on routine bloods in hypothyroidism

A
  • FBC: macrocytic anaemia
  • UE: hyponatraemia
  • Lipids: hypercholesterolaemia
119
Q

What are the causes of hypothyroidism

A
  • Autoimmune: Hashimoto’s, atrophic hypothyroidism
  • Iatrogenic: thyroidectomy, iodine, amiodarone, lithium
  • Dietary: iodine deficiency
  • Genetic: Pendred’s syndrome
120
Q

What are the features of subacute thyroiditis

A
  • usually hyperthyroidism
  • weeks to months after viral infection
  • painful tender goitre
  • self-limiting (carbimazole/PTU not effective)
121
Q

What are the features of post-partum thyroiditis

A
  • usually hypothyroidism
  • Anti-TPO Abs
  • 40% develop hypothyroidism
  • manage with low dose thyroxine
122
Q

What are the causes of male infertility

A
  • germ cell tumours
  • primary or secondary hypogonadism
  • genetic (klinefelter’s)
  • iatrogenic (medication)
  • ciliary dysfunction (kartagener’s, CF)

+ erectile dysfunction (spinal cord, meds, diabetes)

123
Q

What are the differentials of Crohn’s disease

A
  • Infection (yersinia, TB)
  • Coeliac
  • Lymphoma
  • Ulcerative colitis
  • IBS
  • GI malignancy
124
Q

What are the differentials for ulcerative colitis

A
  • Infection (shigella, campylobacter)
  • Ischaemia
  • Drugs
  • Crohn’s
  • Pseudomembranous colitis (C. Diff)
  • Diverticulitis
  • GI malignancy
125
Q

What should be performed during examination of a headache

A
  • Detailed CN exam, focused UL+LL
  • Fundoscopy
  • Otoscopy
  • Neck flexion
  • Kernig’s sign
  • Examine skin for rashes
126
Q

What are the diagnostic criteria for rheumatoid arthritis (American college of rheumatology)

A

4/7 of:
- morning stiffness
- arthritis in 3+ joint areas
- arthritis in hands
- symmetrical arthritis
- rheumatoid nodules
- positive RF
- erosions on XR

127
Q

What is used to measure disease activity in rheumatoid arthritis

A

DAS28 score

128
Q

What are the key features of Kearns-Sayre syndrome

A
  • onset before 20 years
  • chronic progressive complex ophthalmoplegia
  • bilateral ptosis
  • retinitis pigmentosa
  • cerebellar ataxia
  • proximal weakness
129
Q

What key features will be in the history of a patient with HHT

A
  • recurrent epistaxis
  • GI bleeding
  • Haemoptysis
  • Symptomatic anaemia
  • strong FHx (AD)
130
Q

What are the exam findings in HHT

A
  • mucocutaneous telangiectasia (check inside mouth)
  • resp: clubbing, cyanosis, RV heave, loud P2
  • cardio: pulmonary oedema
  • GI: pallor, signs of portal HTN
  • Neuro: pronator drift
131
Q

What are the causes of recurrent epistaxis

A
  • HHT
  • Trauma
  • Nasal polyps
  • Infection (chronic sinusitis)
  • Anticoagulation
  • ITP
  • GPA
132
Q

What are the cardiac complications of Ehlers Danlos syndrome

A
  • Mitral valve prolapse
  • Aortic aneurysm
  • Aortic dissection
133
Q

What are the complications of pseudoxanthoma elasticum

A
  • premature CAD
  • stroke
  • GI bleeding
  • vision loss (retinal angioid streaks)
  • mitral valve prolapse
134
Q

What are the causes of secondary reynauds

A
  • CTD/AI: SSc, SLE, myositis, Sjögren’s, PAN, APLS
  • Arterial disease: atherosclerosis, thromboangiitis obliterans
  • Hyperviscocity syndromes
  • Infection: Bacterial endocarditis
135
Q

Which type of drug should be avoided in systemic sclerosis

A

Steroids - can precipitate renal crisis!

136
Q

What are the main differences between reactive arthritis and gonococcal arthritis

A

Gonococcal normally presents with septic arthritis - fever, unwell, purulent urethral discharge

PACES (6 decks)

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