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RACP Exam > Clinical Exam > Flashcards

Clinical Exam Flashcards

1
Q

What does double apex beat correspond with?

A

Hypertrophic cardiomyopathy

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2
Q

What is Schamroth’s sign?

A

Fingernail ‘diamond’ test for clubbing

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3
Q

JVP: cause of dominant a-wave (3)

A

Tricuspid stenosis
Pulmonary stenosis
Pulmonary HTN

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4
Q

JVP: cause of dominant v-wave

A

Tricuspid regurgitation

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5
Q

Causes of canon a-waves (3)

A

3rd degree heart block
SVT
VT

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6
Q

What does left parasternal heave suggest? (2)

A

RV hypertrophy

LA enlargement

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7
Q

On heart palpation, what does ‘tapping’ apex beat indicate?

A

Mitral stenosis

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8
Q

What does fixed splitting of S2 suggest?

A

ASD

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9
Q

Kussmaul sign

  • What is it?
  • Causes (4)
A

Paradoxical RISE in JVP with inspiration (would usually fall) - inability of the heart to accept the increase in RV volume without an increase in filling pressure.

Restrictive cardiomyopathy, constrictive pericarditis, severe R) heart failure, tamponade

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10
Q

What is Ebstein’s anomaly?

A

Apical displacement of tricuspid valve –> Tricuspid regurgitation

Associated with WPW and R) conduction defects

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11
Q

True / false: you can hear diastolic murmurs in HOCM

A

False

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12
Q

Causes of pitting oedema (8)

A 
Medications (CCBs)
Heart failure
Nephrotic syndrome
Liver failure
Malabsorption / starvation (beri beri, B1)
Protein-losing enteropathy
Myxoedema
Cyclical oedema
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13
Q

Causes of non-pitting oedema (2)

A

Lymphoedema (malignancy, congenital, filariasis)

Myxoedema

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14
Q

Define pulsus paradoxus

A

Fall of systolic blood pressure of >10 mmHg during the inspiratory phase.

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15
Q

True / false: clubbing occurs with sarcoidosis

A

False

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16
Q

True / false: clubbing occurs with COPD

A

False

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17
Q

Light’s criteria for exudate (3)

A

Pleural:serum protein >0.5
Pleural:serum LDH >0.6
Pleural LDH >2/3 ULN

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18
Q

Arthritides involving DIPs (3)

A

OA
Gout
Psoriatic

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19
Q

Nerve root for biceps reflex

A

C5/6

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20
Q

How to test for ulnar nerve lesion

A

Fromet’s sign

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21
Q

How to test for median nerve lesion

A

pen touching test (thumb abduction)

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22
Q

Components of dominant parietal lobe assessment (4)

Gerstmann syndrome

A 
'AALF'
A - acalculia
A - agraphia
L - left-right disorientation
F - finger agnosia (name fingers)

(Often dysphasia as well)

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23
Q

Signs of chronic liver disease:

  • General (4)
  • Hands (4)
  • Face (4)
  • Chest / abdomen (5)
A

Cachexia, jaundice (or grey if haemochromatosis), excoriation, bruising

Clubbing, palmar erythema, contractures, leukonychia

Fetor hepaticus, icterus, dentition, parotid swelling

Spider naevi, caput medusae, gynaecomastia, reduced hair, testicular atrophy

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24
Q

Signs (definitions) of liver decompensation (7)

A 
Ascites / SBP
Encephalopathy / Asterixis
Variceal bleed
Jaundice
Hydrothorax
HCC
Hepatorenal syndrome
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25
Q

Causes of hepatomegaly (‘CCC’ + ‘III’)

A

Cirrhosis - alcohol
Cancer (secondaries)
Congestion

Infection (HBV, HCV, EBV, CMV)
Infiltrate / deposit (amyloid, myeloproliferative, haemochromatosis, Wilson’s)
Immune (PSC, PBC, AIH)

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26
Q

Complications of cirrhosis (3)

A

Variceal haemorrhage
SBP
Encephalopathy

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27
Q

Complications of haemochromatosis (5)

A 
Diabetes
Arthropathy
Cardiomyopathy
Hypogonadism
Cirrhosis + HCC
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28
Q

Findings of splenomegaly (4)

A 
Mass moves with inspiration
Dull to percuss
Palpable notch
Can not get above
Not ballotable
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29
Q

Causes of massive splenomegaly (>8cm) (2)

A 
Myeloproliferative disease (CML, myelofibrosis)
Tropical infections (malaria, leishmaniasis)
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30
Q

Causes of moderate splenomegaly (4-8cm) (2)

A 
Myelo / lymphoproliferative disorders
Infiltrative disease (amyloid, Gaucher's)
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31
Q

Causes of mild splenomegaly (<4cm) (4)

A

Myelo / lymphoproliferative disorders
Portal HTN
Infection
Haemolytic anaemia

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32
Q

Splenectomy management (3)

A

Vaccination (ideally 2/52 prior to removal) for encapsulated organisms (Pneumococcus, meningococcus, haemophilus)

Prophylactic penicillin

Medical alert bracelet / education

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33
Q

Findings of palpable kidney (3)

A

Ballotable
Can get ‘above’
Moves with respiration

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34
Q

Causes of kidney enlargement:

  • Unilateral (4)
  • Bilateral (4)
A

PCKD, RCC, hydronephrosis, simple cyst

PCKD, bilateral hydronephrosis, tuberouscelrosis (AML), amyloidosis

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35
Q

Other organs involved in PCKD (3)

A

Liver cysts / hepatomegaly
Berry aneurysms
Mitral valve prolapse

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36
Q

Scars in renal patient (3)

A

Iliac fossa - new transplant
Flank - nephrectomy (PCKD, RCC)
Peri-umbilical - previous PD catheters

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37
Q

HRCT findings in UIP (4)

A

Sub-pleural reticulation
Basal-predominant
Traction bronchiectasis
Honeycombing

(IPF has UIP pattern only)

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38
Q

HRCT findings in NSIP (4)

A

Sup-pleural sparing
Ground glass
Traction bronchiectasis
Basal predominance

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39
Q

Expected spirometry / LFTs in restrictive disease

A

FEV1/FVC >0.8
Small TLC
Low DLCO and KCO

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40
Q

Bronchiectasis DDx / Causes (6)

A 
Kartagener's
Cystic fibrosis
Hypogammaglobulinaemia / CVID
Aspergillosis / ABPA
Rheumatoid lung
Chronic aspiration (alcohol, GORD)
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41
Q

Causes of apical fibrosis (CHARTS)

A 
Coal worker's lung
Hypersensitivity pneumonitis (AKA extrinsic allergic alveolitis) + Histiocytosis X
Ankylosing spondylitis
TB
Radiation
Sarcoidosis
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42
Q

Lung transplant:

  • Common reasons for single lung transplant (2)
  • Common reasons for double lung transplant 3)
A

‘Dry lung’ - COPD, pulmonary fibrosis

‘Wet lung’ - bronchiectasis, CF, pulmonary HTN

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43
Q

Indications for home O2

A

pO2 <7.3kPa (55mmHg)

or if cor pulmonale:
pO2 <8kPa (60mmHg)

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44
Q

Surgical options for COPD (4)

A

Bullectomy
Lung reduction surgery
Endobronchial valve placement
Single lung transplant

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45
Q

Aortic stenosis vs aortic sclerosis

A

In aortic sclerosis, there is a normal pulse character and no radiation of the murmur

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46
Q

Aortic stenosis DDx (5)

A 
Other systolic murmur e.g. MR, TR
HOCM
VSD
Aortic sclerosis
High output clinical state (pregnancy, anaemia, sepsis)
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47
Q

Causes of aortic stenosis (4)

A

Congenital bicuspid valve
Age-related / calcification
Chronic rheumatic heart disease
Infective endocarditis

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48
Q

Order of worsening symptoms for aortic stenosis

A

Angina - 5 years
Syncope - 3 years
SOB - 2 years

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49
Q

Clinical features of aortic stenosis (5)

A 
Slow rising pulse
Narrow PP
Right sternal thrill
Pressure loaded apex
Ejection systolic murmur / crescendo-decrescendo
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50
Q

Clinical features of aortic regurgitation (5)

A 
Collapsing / waterhammer pulse
Wide pulse pressure
Corrigan's pulse
Hyperkinetic (volume-loaded) apex beat
Early diastolic murmur +/- Austin-Flint
 - Loudest leaning forward, left, lower sternal edge

(And many other eponymous signs)

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51
Q

Causes of aortic regurgitation:

  • Acute (3)
  • Chronic (6)
A

‘DIT CHARMA’

Dissection
Infective endocarditis
Trauma

Congenital bicuspid valve
Hypertension
Ankylosing spondylitis
Rheumatic fever
Marfan's / Ehlers-Danlos
Aortitis (Syphilis, Takayasu's)
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52
Q

When to do surgery for aortic regurgitation:

  • Acute (2)
  • Chronic (4)
A

Aortic dissection
Aortic root abscess

NYHA > II heart failure
PP >100mmHg
ECG changes on ETT
LV >5.5cm or EF <50%

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53
Q

Clinical signs of mitral stenosis (5)

A 
Irregular pulse (likely to have AF)
Malar flush
Tapping apex
Auscultation: opening 'snap' of stiff leaflets + diastolic murmur
Often features of pulmonary HTN
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54
Q

Features of pulmonary HTN (5)

A 
Elevated JVP
Loud P2
RV heave
Tricuspid regurgitation
Overload / oedema
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55
Q

Causes of mitral stenosis (4)

A

Rheumatic heart disease
Congenital mitral stenosis
Mitral annular calcification
Endocarditis

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56
Q

Differentials for diastolic murmur (4)

A

Aortic regurgitation
Mitral stenosis
Austin flint murmur
Atrial myxoma

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57
Q

Management options in mitral stenosis (3)

A

Medical - manage AF and failure
Balloon valvuloplasty
Surgical valvotomy / replacement

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58
Q

Clinical signs of mitral regurgitation (6)

A

Atrial fibrillation
Scars e.g. valvuloplasty
Displaced and volume-loaded apex +/- thrill
Pan-systolic murmur (radiating to axilla)
+/- S3
Widely split S2 (because LV empties sooner)

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59
Q

Features that suggest severity of MR (2)

A 
LV failure 
Atrial fibrillation (a late sign)

NOT murmur intensity (which just reflects flow)

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60
Q

Causes of mitral regurgitation

  • Acute (3)
  • Chronic (5)
A

Endocarditis
Trauma
Ischaemia

Mitral annular calcification
Valve prolapse - Marfan's, amyloid
Rheumatic heart disease
Papillary muscle dysfunction
Connective tissue disease

(Can also be due to ‘secondary’ causes - I.e. LV dilatation causing valve incompetence)

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61
Q

ECG findings in mitral valve disease (3)

A

P-mitrale (bifid + broad p-waves)
Atrial fibrillation
+/- Q-waves

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62
Q

Clinical findings of tricuspid regurgitation (5)

A 
Prominent V-waves
Thrill on palpation
Pan systolic murmur
Pulsatile liver (tender)
Peripheral oedema / ascites
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63
Q

Causes of tricuspid regurgitation (5)

A 
Ebstein's anomaly
Endocarditis
Functional (commonest)
Rheumatic heart disease
Carcinoid syndrome (secreted mediators cause right heart valve fibrosis)
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64
Q

Clinical signs of pulmonary stenosis (4)

A

Prominent a-wave on JVP
Left parasternal heave + thrill
Ejection systolic murmur
Signs of right-heart failure

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65
Q

Causes of pulmonary stenosis (5)

A 
Carcinoid
Noonan's syndrome
William's syndrome
Rubella
Tetralogy of Fallot
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66
Q

Late complications of prosthetic valves (6)

A 
Valve failure - can sometimes do valve-in-valve for bioprosthetic
Endocarditis
Haemolysis
Heart failure
AF (esp. if mitral valve)
Warfarin-related complications
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67
Q

Indications for ICD insertion (2, 3)

A

Primary prevention

  • > 4 weeks post MI with associated high risk features
  • FHx cardiac conduction syndrome with high risk features

Secondary

  • Cardiac arrest due to VT / VF
  • Previous haemodynamically unstable VT
  • Any VT with EF <35%
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68
Q

How to differentiate constrictive pericarditis vs restrictive cardiomyopathy

A

Ventricular interdependence (seen on ECHO) supports Dx of constrictive process.

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69
Q

Cyanotic heart disease

  • Due to
  • Causes (5)
A

Right-to-left shunt

Truncus arteriosus
Transposition of the great arteries
Tricuspid atresia
Tetralogy of Fallot
Total anomalous pulmonary venous return
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70
Q

Acyanotic heart disease

  • Due to
  • Complication
  • Causes (4)
A

Left-to-right shunt
Eisenmenger’s syndrome

VSD
ASD
AVSD
PDA

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71
Q

Complications of septal defects (3)

A

Eisenmengers / pulmonary HTN
Atrial arrhythmia
Emboli

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72
Q

Auscultation of septal defects (2)

A

Usually systolic murmur

Note: as Eisenmenger’s develops, and the gradient reduces, the murmur may actually SOFTEN

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73
Q

Causes of absent radial pulse

  • Acute (3)
  • Chronic (4)
A

Embolisation
Trauma (e.g. catheterisation)
Dissection

Surgery e.g. procedure for Tetralogy of Fallot
Takayasu’s disease
Atherosclerosis
Coarctation

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74
Q

Findings in coarctation (4)

A

HTN right arm +/- left
Reduced / absent left radial pulse
Reduced femoral pulses
Continuous murmur +/- radiates to back (from collateral vessels)

Note:
CXR shows ‘3 sign’ and rib notching (due to pulsatile intercostal arteries)

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75
Q

Systolic murmur Ddx (4, 2)

A

AS
MR
TR
PS

HOCM
L-to-R shunts

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76
Q

Findings of HOCM (6)

A 
Prominent a-wave on JVP
Double apex impulse +/- thrill
ESM (due to LVOTO)
PSM (due to mitral prolapse / SAM)
S4 ('A Stiff Heart')
Dynamic maneuvers
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77
Q

HOCM dynamic maneuvers (2, 2)

A

Increased by: Valsalva (reduced LV filling), or low afterload (vasodilators)
Decreased by: squatting (increased preload), handgrip (increased afterload)

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78
Q

HOCM management / prognostic factors (6 + 2)

A 
Avoid triggers (exercise, vasodilators, dehydration)
Beta-blocker (reduces O2 use and gradient)
Septum - alcohol ablation or myomectomy
 - Esp. if >3cm thick
ICD
 - Esp. if FHx SCD, syncope or young age
Cardiac transplant
Genetic counselling
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79
Q

Cerebellar exam signs

A

DANISH:

Dysdiadochokinesia
Ataxia
Nystagmus
 - Cerebellar lesion: nystagmus towards lesion
 - VIII lesion: nystagmus away from lesion
Intention tremor
Staccato speech (scanning dysarthria)
Hypotonia / hyporeflexia

(Also rebound phenomenon - Holmes’ sign)

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80
Q

Causes for cerebellar disease

A

PASTRIES:

Paraneoplastic
Alcohol
Sclerosis (MS)
Tumour
Rare (Friedriech's, trinucleotide repeat disorders, congenital, mitochondrial)
Iatrogenic (drugs, e.g. phenytoin)
Endocrine (hypothyroidism, low b12/folate, low vit E)
Stroke (posterior circ)
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81
Q

DDx for proximal myopathy (8, 3)

A 
Acquired - 'PACEPODS'
Polymyositis
Alcohol
Carcinoma
Endocrinopathies
Periodic paralysis
Osteomalacia
Drugs: steroids
Sarcoidosis

Other:
Hereditary muscular dystrophies e.g. FSH, Duchenne’s
Congenital myopathies e.g. myotonic dystrophy
Degenerative myopathies e.g. IBM

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82
Q

MS diagnostic Ix (5)

A 
MRI - time and space
CSF oligoclonal bands
VEPs
OCT
Antibodies for DDx
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83
Q

Multiple sclerosis DDx (8)

A 
Cord compression
Transverse myelitis
MND
Multiple strokes (embolic)
B12 deficiency
Hereditary spastic paraparesis
Cerebral palsy
Cerebral vasculitis
SLE
Paraneoplastic
Neurosyphilis
ADEM
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84
Q

DDx for spastic legs (10)

A 
Stroke 
Spinal cord infarct
MS
Spinal cord compression
Trauma / surgery
Motor neuron disease (no sensory signs)
Cerebral palsy
Hereditary spastic paresis
Subacute combined degeneration of the cord
Friedreich's ataxia

Hint: look for sensory level (suggests spinal lesion)

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85
Q

Motor neuron disease DDx (7)

A

Consider if mixed LMN and UMN findings

Multifocal motor neuropathy
Spinomuscular atrophy
CIDP
Cervical myelopathy
Brain stem lesion (if bulbar-predominant disease)
Polio
Syringomyelia
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86
Q

Features suggesting neuropathy (7)

A 
Distal weakness +/- foot drop
\+/- associated sensory signs in glove/stocking pattern
Absent reflexes
May have fasciculations
No contractures
Can see autonomic dysfunction
Wasting of intrinsic muscles of hands
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87
Q

Features suggesting myopathy (6)

A 
Proximal weakness
Usually no sensory loss
Preserved reflexes
No fasciculations
Tender muscles
Look for cardiac complications
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88
Q

Causes for pes cavus of foot (2)

A

Charcot-Marie-Tooth Disease (AKA hereditary sensorimotor neuropathy)
Friedreich’s ataxia

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89
Q

DDx for sensory neuropathy (4)

A

Diabetes
Alcohol
B12 deficiency
Drugs e.g. chemo, isoniazid

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90
Q

DDx for motor neuropathy (6)

A 
GBS or botulism (acute)
Lead toxicity
Porphyria
HSMN
Polio
MMN
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91
Q

Causes for mononeuritis multiplex (5)

A 
Diabetes
Vasculitis (PAN, EGPA)
Connective tissue disease
Infection (HIV)
Malignancy
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92
Q

Nerves of cerebellar-pontine angle (4)

A

V, VI, VII, VIII

and cerebellar signs

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93
Q

Unilateral 7th CN palsy DDx (5)

A 
Bell's palsy
Mononeuritis (diabetes, sarcoid, Lyme)
Tumour/trauma
MS
Stroke
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94
Q

Bilateral 7th CN palsy DDx (5)

A 
Myasthenia gravis
Sarcoidosis
Lyme
GBS
Bilateral Bell's palsy
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95
Q

‘Extras’ in myasthenia exam (3)

A

Myasthenic snarl (when attempting to smile)
Thymectomy scar
Ask for FVC

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96
Q

Tuberous sclerosis skin findings (4)

A

Angiofibromas (butterfly distribution)
Shagreen’s patch
Ash-leaf macules
Periungal fibroma

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97
Q

Tuberous sclerosis systemic complications (5)

A 
Epilepsy
Intellectual impairment
Cystic lung disease
Angiomyolipomas / renal failure
Retinal phakoma
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98
Q

Clinical features of neurofibromatosis (4)

A

Cutaneous neurofibromas
Cafe au lait patches
Axillary freckling
Lisch nodules

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99
Q

Complications of neurofibromatosis (7)

A

‘HELPLES’

Hypertension (renal a. stenosis)
Epilepsy
Lung fibrosis/cysts
Phaeochromocytoma
Leukaemia risk
Enlarged palpable nerves
Schwannomas and neurofibromas
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100
Q

Holmes-Adie pupil vs Argyll-Robertson pupil

A

Adies: poor reaction to light AND slow accommodation (and diminished leg reflexes)

Argyll: accommodates but doesn’t react (and sensory ataxia - tabes dorsalis)

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101
Q

Medical causes of third nerve palsy (4)

A

4x M’s - consider when ‘down and out pupil’ but not dilated pupil.

MS
Midbrain infarct
Mononeuritis multiplex (DM)
Migraine

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102
Q

Wrist/hand findings in RA (7)

A 
Ulnar deviation
Wrist subluxation
Swan neck deformity (bent DIP)
Boutonniere's deformity (bent PIP)
Z-thumb
Disuse atrophy
Surgical scars (carpal tunnel)
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103
Q

X-ray findings in RA (4)

A

‘SLAP’

Soft tissue swelling
Loss of joint space
Articular erosions
Periarticular osteopaenia

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104
Q

Complications of ank spond (5)

A

5x A’s:

Apical fibrosis
Aortic regurgitation
Arthritis
Anterior uveitis
AV node block
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105
Q

X-ray features of osteoarthritis (4)

A

‘LOSS’

Loss of joint space
Osteophytes
Subchondral sclerosis
Subchondral cysts

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106
Q

‘Golden’ long case questions (4)

A

What are your main concerns?
What are your goals for the future?
What do you think the future will look like?
(where would you want to be when ‘the time comes’?)
If we could fix on thing, what would it be?

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107
Q

DDx for causes underlying a lung surgery scar (7)

A

Cancer (look for adenopathy and evidence of smoking)
COPD (bullectomy, cyst deroofing)
Bronchiectasis
TB
Congenital lung malformations
Haemoptysis
Transplant - consider if ‘normal exam’ otherwise

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108
Q

Features of liver on exam (6)

A 
RUQ
Can't get above
Moves with respiration
Crosses midline
Dull to percussion
Positive 'scratch test' (if abuts against abdominal wall)
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109
Q

Features of spleen on exam (7)

A 
LUQ
Can't get above
Extends infero-medially
Palpable notch
Moves with respiration
Dull to percussion
Positive 'scratch test'
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110
Q

Features of kidney on exam (6)

A 
Able to get above
Full flanks on inspection
Never cross midline
Usually resonant on percussion
Move with respiration
Ballotable

(Will often see fistula or old PD catheter scar)
(Consider concurrent cystic liver)

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111
Q

Hand x-ray clues:

  • New bone formation
  • Bone erosion
  • Calcinosis
  • Marked deformity but N x-ray
A

OA or psoriatic
RA or gout
Scleroderma
SLE (Jaccoud’s arthropathy)

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112
Q

Describing / summarising rheum exam findings (5)

A
  1. Deforming vs non-deforming
  2. Symmetrical vs asymmetrical
  3. Poly / oligo / monoarticular
  4. Predominantly affecting the … joints
  5. Active vs inactive

Then go on to DDx and why.

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113
Q

Diseases affecting basal ganglia (3)

A

Parkinson’s
Wilson’s disease
Huntington’s

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114
Q

‘National Asthma Plan’ Steps (6)

A
  1. Assess severity
  2. Optimise lung function
  3. Maintain lung function - avoid triggers
  4. Maintain lung function - medications
  5. Develop an action plan
  6. Education / regular review
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115
Q

Complications to ask about in HIV (6)

A 
Medication side-effects
Cardiovascular
Renal
Osteoporosis
HIV-associated neuro and dementia
Sexual health
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116
Q

Steps to help patient quit smoking (3)

A
  1. Assess dependency
    E.g. smoke on waking, smoke when sick, how many per day, smoke in forbidden areas?
  2. Assess willingness to quit
    E.g. not ready to quit, ready to quit in 6/12, ready to quit in 1/12
  3. Treat with behavioural, psychological and medical interventions
    E.g. set quit date, social support, ID high risk situations, NRT, regular follow-up
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117
Q

Managing obesity template:

  • Initial considerations (6)
  • Approaches (5)
A

Address underlying causes e.g. steroid, thyroid
Assess for comorbidity e.g. diabetes, OSA
Assess underlying / associated risk factors / drivers e.g. smoking, FHx
Manage complications e.g. OA, gout, ca risk
Assess risk e.g. calculators, waist circumference
Assess psychological readiness / address barriers

5-stage approach:

  • Diet
  • Exercise
  • Behavioural therapy
  • Pharmacological
  • Bariatric surgery
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118
Q

Weight loss goals (1, 2)

A

Aim to lose 10% of weight over 6 months.

Low likelihood of response if <2kg lost in first month
(If immobile, patient will gain 6-12kg/year)

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119
Q

General ‘managing a medical condition’ framework (5)

A 
Treat reversible causes / triggers
Treat underlying disease
Prevent further deterioration
Manage complications of disease/treatment
Disease-specific therapy
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120
Q

Depression mnemonic

I.e. the neurovegetative symptoms

A

‘DSIGECAPS’

Depression
Sleep impairment
Interest (loss)
Guilt
Energy (low)
Concentration (reduced)
Appetite (low)
Psychomotor agitation
Suicidality
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121
Q

Assessing alcohol dependence (or other substances) (4)

A

‘CAGE’

Have you ever felt the need to CUT down?
ANNOYED at someone telling you to quit?
Feel GUILT about your use?
EYE opener?

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122
Q

Managing substance dependence framework (6)

A 
Set goals
Brief intervention ('FRAMES' approach)
Counselling (or appropriate services)
Pharmacotherapy
Detox referral
Manage complications
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123
Q

Annual stroke risk if CHADS-VASc = 2

A

2.2% per year

Goes up roughly one percent for each extra point

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124
Q

Implication of high HAS-BLED score

A

Caution and regular review of benefit / risk (but no an indication to stopping!)

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125
Q

DDx for massive hepatomegaly (5)

A

‘HAMMR’

HCC
Alcoholic liver with fatty infiltrate
Metastases
Myeloproliferative disease (PRV, ET, myelofibrosis)
Right heart failure
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126
Q

DDx for non-massive hepatomegaly (6)

A

‘HI CHAF’

Haematological cancer (CML, lymphoma)
Infection e.g. malaria, hydatid, HIV
Cirrhosis
Haemochromatosis
Amyloid
Fatty liver disease
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127
Q

DDx for pulsatile liver (2)

128
Q

DDx for firm + irregular liver (4)

A

Cirrhosis
Hydatid disease
Metastic disease
Infiltrative disease

129
Q

DDx for large kidney (5)

A 
Polycystic kidney
Renal cancer
Renal vein thrombosis
Hydronephrosis
Infiltrative disease e.g. amyloid, lymphoma
130
Q

DDx for massive splenomegaly (3)

A

‘CML’

CML
Myelofibrosis
Lymphoma (primary)

131
Q

DDx for non-massive splenomegaly (8)

A

‘SO PITCHI’

Storage disease e.g. Gaucher's
Other haematological malignancy
Portal HTN
Infiltrative disease e.g. sarcoid, amyloid
Thalassaemia
Connective tissue disease
Haemolytic anaemia
Infection e.g. EBV, malaria
(Idiopathic is the most common cause)
132
Q

Why does valsalva make HOCM louder?

A

By decreasing left ventricular filling, the left ventricular outflow tract obstruction worsens, making the murmur louder.

133
Q

Mitral stenosis indications for surgery (4, 1)

A

Worsening dyspnoea
Falling valve area <1cm2
Pulmonary HTN
Recurrent thromboembolism

(Do surgery before pulmonary oedema or haemoptysis arises)

134
Q

Mitral regurgitation indications for surgery (2)

A

Usually mitral valve REPAIR (rather than replacement)

NYHA III or IV symptoms or worsening LV dysfunction (try to do before LV has become too damaged, i.e. before EF <30%)

135
Q

Aortic regurgitation indications for surgery (3)

A

Worsening dyspnoea
Worsening LV function
LV dilatation >5.5cm

136
Q

Most common type of ASD in adults

A

Ostium secundum

137
Q

DDx for digital clubbing (9)

A 
Non-small cell lung cancer
Suppurative lung disease: bronchiectasis, CF, PCD
ILD
Cyanotic heart disease
Lymphoma
Endocarditis
IBD
Cirrhosis
Thyrotoxicosis (achropachy)
138
Q

Cushingoid patient with thoracotomy scar; consider:

A

Lung transplant

139
Q

Complications of portal HTN (5)

A 
Ascites +/- SBP
Varices +/- bleed
Encephalopathy
Hydrothorax
Hepatorenal syndrome
140
Q

DDx for hepatosplenomegaly (6)

A

‘IPMAIL’

Infection
Portal HTN
Myeloproliferative disease
Acromegaly
Infiltrative
Lupus
141
Q

Complications of Autologous SCT (6)

A 
Mucositis
Infection
Marrow suppression
Sinusoidal obstruction syndrome (liver Sx)
Secondary cancer
Fertility issues
142
Q

Post-SCT-transplant management (3)

A

Transfusion support
Infective prophylaxis e.g. cotrimoxazole, valaciclovir, fluconazole
Vaccinations

143
Q

Things to ask about in allogenic SCT (5)

A 
When/why
Donor source: syngeneic, matched sibling, MUD, haploidentical, cord blood
Donor: HLA match, CMV status
Recipient: CMV status
Conditioning regimen
144
Q

Complications of allogeneic SCT

- Infectious (4)

A

Fungal
Viral: herpes, varicella, CMV/EBV, BK, JC
Bacterial: mycobacterium, pneumococcus
Protozoal: pneumocystis, toxoplasmosis

145
Q

Allogeneic SCT: post-transplant management (5)

A

Long-term immunosuppression (cf. autologous SCT)
Transfusion support
GvHD prophylaxis (MTX, cyclosporin)
Infection prophylaxis: cotrimoxazole, valaciclovir, fluconazole
Vaccinations

146
Q

Complications of allogeneic SCT

  • Acute (6)
  • Chronic (5)
A 
Mucositis
Marrow suppression
GvHD - acute/chronic
Infection
Sinusoidal obstructive syndrome
Rejection
PTLD
Disease relapse
Infertility
Secondary malignancy
Long-term increase in cardiovascular risk
147
Q

CKD; complications + management

A

‘AABCDEFGHI + UM’

Acidosis - bicarb
Anaemia - iron + EPO
Bones - phosphate binders
Calcium - vit D sups, parathyroidectomy
Diabetes - screen +/- manage
Electrolytes - monitor (K+ and Mg2+)
Fluid - restriction +/- frusemide
Gout - monitor +/- treat
Hypertension / CARDIOVASCULAR - address/treat risk factors (statin, aspirin)
Immunisations
Uraemia - encephalopathy, pericarditis
Malnutrition - high protein
148
Q

Causes for bronchiectasis (6)

A

‘PIC CAT’

Primary ciliary dyskinesia / Kartagener's
Immune deficiency / infection
Cystic fibrosis
Connective tissue disease
ABPA
TB
149
Q

Bronchiectasis key HRCT findings (4)

A

Bronchial wall thickening
Bronchial dilatation (bigger than adjacent vessel)
Signet rings
‘Tree in bud’

150
Q

X-ray findings in psoriatic arthritis (5)

A 
Narrowed joint space
NO periarticular osteopaenia (cf RA)
Pencil in cup
Joint tuft erosion
Arthritis mutilans
151
Q

Key x-ray finding in gout

A

‘Punched out’ erosions

152
Q

Causes /groups for interstitial lung disease (7)

A 
Idiopathic
Connective tissue disease
Drug related
Hypersensitivity pneumonitis
Occupational exposure
Smoking-related
Sarcoidosis
153
Q

If finding ILD on exam, where to proceed to (2)

A

Look for pulmonary HTN

Look for connective tissue disease (RA, scleroderma, nodules etc.)

154
Q

Normal liver span

A

8-12cm (midclavicular line)

Depends on age, size etc.

155
Q

DDx for generalised adenopathy (7)

A 
Lymphoma
Leukaemia
Metastatic disease
Infection
Connective tissue disease
Sarcoidosis
Phenytoin (pseudolymphoma)
156
Q

Eye signs only found in Grave’s disease (but not other thyroid diseases) (5)

A 
Exophthalmos
Ophthalmoplegia (affects inferior rectus → difficulty with upward gaze)
Chemosis
Change in visual acuity,
Optic atrophy
157
Q

Causes for goitre (6, 2)

A 
Grave's
Iodine deficiency
Thyroiditis
Idiopathic
Peri-partum
Pendred syndrome (inborn error of T4 synthesis, a/w SNHL)

If irregular:

  • Multinodular goitre
  • Malignancy
158
Q

DDx for frontal bossing (5)

A 
Acromegaly
Paget's disease
Thalassaemia
Achondroplasia
Hydrocephalus
159
Q

How to assess disease activity in acromegaly (7)

A

Skin tag number
Hypertension
Worsening visual fields / new CN palsies (cavernous sinus)
Excessive sweating
Glycosuria
Headache
Increasing ring size, shoe size or dentures

160
Q

Exam ‘types’ to consider if given hand stem (4)

A

Rheum
Acromegaly
Peripheral neuropathy / isolated nerve lesion
Myopathy

161
Q

DDx for deforming polarthropathy (5)

A 
RA
Seronegative arthropathies e.g. PsA, Reiter's, enteropathic
Gout
OA
Haemochromatosis
162
Q

Geriatric giants (5)

A

Think about this when doing a geriatric style long case:

  • Immobility / instability (falls)
  • Incontinence
  • Confusion / memory / dementia
  • Iatrogenic (polypharmacy)
  • Impaired self-care
163
Q

Considerations re: illness that started in childhood (4)

A

Impact on missed school
Playing sports
Making / playing with friends
Final education level

164
Q

‘Niche’ questions in renal long case (5)

A

Dry weight
Still passing urine? (residual renal function)
Current Hb / EPO / iron use
Salt / fluid restriction
Post-dialysis Sx e.g. nausea, hypotension, cramps

165
Q

Long-term complication of analgesic nephropathy (other than ESRF)

A

Transitional cell carcinoma

166
Q

Most common causes of ESRF in NZ (4)

A

Diabetes - 50%
GN - 25%
HTN - 9%
Idiopathic

167
Q

eGFR considerations (5)

A

Start dialysis at eGFR ~10-15
Plan vascular access for HD at eGFR ~20
Pre-emptive renal transplant performed at eGFR ~15
eGFR starts to fall from ~35 years of age
Many confounders e.g. amputees, AKI, weight loss

168
Q

IgA nephropathy associations (4)

A

HIV
IBD
Chronic liver disease
Coeliac disease

169
Q

Cons of peritoneal dialysis (5)

A 
Infection risk (peritonitis, tunnel site)
Diabetes worsening
Peritoneal fibrosis
Protein loss
Hernias
170
Q

DDx for livedo reticularis (3)

A

Cholesterol emboli
Anti-phospholipid syndrome
Vasculitis

171
Q

Antibodies associated with GPA (2)

A

cANCA

anti-pr3

172
Q

Systemic vasculitides associated with pANCA (2)

Other conditions with positive pANCA but negative MPO (3)

A

EGPA
MPA

Also have positive MPO antibodies

  • IBD
  • Autoimmune hepatitis
  • PSC
173
Q

Key toxicities of cyclophosphamide (5)

A 
Cytopaenia
Haemorrhagic cystitis (manage with mesna) / bladder cancer
Infertility / premature menopause
Opportunistic infection
Increased malignancy (haem/skin)

Mechanism: DNA cross-linking

174
Q

Classifying tremor (3)

A

Parkinsonian
Action / Postural (drug, thyroid, alcohol/toxin, essential)
Cerebellar - intention vs outflow tract

175
Q

Seronegative spondyloarthropathies (5)

A 
Psoriatic arthritis
Ankylosing spondylitis
Reactive arthritis
Enteropathic Arthritis
Juvenile spondyloarthritis
176
Q

When to use DMARDs in ankylosing spondylitis?

A

If there is also peripheral joint involvement.

(Can use anti-TNF-alpha for axial and peripheral disease as second line).

177
Q

Ankylosing Spondylitis: non-medical management (7)

A

Regular exercise and daily stretch (or hydrotherapy)
Self-help groups
Stop smoking
Education re: iritis - needs urgent review
Education re: maintaining good posture
Firm mattress - offers symptomatic benefit
Monitor cardiovascular risk (main cause of early mortality)

178
Q

Indications for ASD / PFO closure (4)

A

Asymptomatic but haemodynamically-significant shunt e.g. RV enlargement

Some pulmonary hypertension (prior to right-to-left shunt developing)

Paradoxical embolic stroke in patient <60

Platypnoea-orthodeoxia syndrome

179
Q

Cut-off in FEV1 of how much is clinically important in lung transplant?

180
Q

Why is diltiazem still used in patients after they have had a heart transplant?

A

Slows metabolism of cyclosporin - can use lower doses, and is cheaper.

181
Q

Angiography after heart transplant (2)

A

Performed 1-2x / year

For coronary artery intimal proliferation (AKA coronary artery vasculopathy)

182
Q

Scars to look for in heart transplant (2)

A

Sternotomy

Small neck scars (from endomyocardial biopsy forceps)

183
Q

Components of MELD score (3)

A

INR
Bilirubin
Creatinine

+/- extra points for haemodialysis or liver cancer

184
Q

Components of Child-Pugh score (5)

A 
Ascites
Encephalopathy
Bilirubin
Albumin
INR
185
Q

Things addressed at cardiac rehab class (4)

A

Safe exercise
Weight reduction strategies
Changes to diet
Smoking reduction

186
Q

Possible examination finding if only LIMA graft CABG performed (2)

A

Sternotomy

Numbness to left side of sternum

187
Q

Patients who would benefit from CABG > angio (3)

A

LMS disease
3x vessel disease
Diabetics

188
Q

Indications for surgery in infective endocarditis (5)

A 
Valve / root abscess or conduction disturbance
Persistent bacteraemia despite Rx
Heart failure secondary to valve failure
Resistant organisms (e.g. fungi)
Recurrent major embolic phenomena

I.e. not just an isolated vegetation

189
Q

NYHA classification

A

I - no limitation on physical activity
II - Sx on moderate activity
III - Sx on mild activity
IV - Sx at rest

190
Q

DDx for wheeze (7)

A 
Asthma
COPD
Bronchiectasis
L) heart failure
Polyarteritis nodosa
EGPA
External compression e.g. tumour
191
Q

Complications of bronchiectasis (5)

A 
Recurrent infections
Sinusitis
Haemoptysis
Brain abscess
Amyloidosis
192
Q

Components of Kartagener’s syndrome (3)

A

Bronchiectasis
Sintus inversus
Chronic sinusitis

193
Q

Which systems have irreversible damage from haemochromatosis? (2)

A

Joints

Endocrine

194
Q

Extrahepatic complications of hepatitis C (6)

A 
GN (membranoproliferative)
Cryoglobulinaemia
Porphyria cutanea tarda
Vasculitis
Polyarthralgias
B cell lymphomas
195
Q

Key features of nephrotic syndrome (4)

A

Proteinuria >3.5g / day
Hypoalbuminaemia
Oedema
Hyperlipidaemia

196
Q

Extra-colonic complications of UC (8)

A 
Pyoderma gangrenosum
Erythema nodosum
Oral ulcers
Eye: uveitis
Liver: PSC, cirrhosis
Anaemia
Amyloidosis
Arthropathy
197
Q

Bowel-related complications of UC and CD (4, 2)

A 
Both:
Pain / bleeding
Strictures / obstruction
Perforation
Malignancy

Crohn’s:
Malnutrition
Peri-anal disease

198
Q

Evaluating stricture in Crohn’s (3, 1)

A

CT enterography
MR enterography
Push endoscopy

Pill cam has high risk of worsening obstruction

199
Q

Why is budesonide useful in IBD?

A

Acts locally in bowel, but is 90% metabolised by liver thereby reducing systemic effects.

200
Q

Major AZA side-effects (4)

A

Cytopaenia
Pancreatitis
Rashes
Lymphoma

201
Q

Key CIDP exam findings (3,1)

A

Proximal > distal weakness
Stocking/glove sensory loss (all modalities)
Absent reflexes

+/- sensory ataxia

202
Q

CIDP DDx (4)

A

Guillain-Barre
HMSN (Charcot’s)
MMN
Neuropathy due to MGUS, diabetes, vasculitis, drugs etc.

203
Q

Mitral stenosis: signs of severity (5)

A 
Small pulse pressure
'Opening snap'
Signs of pulmonary HTN
Diastolic thrill
Short distance between S1 and S2
204
Q

Mitral regurgitation: signs of severity (4)

A

LV displacement
LV failure
Pulmonary HTN
Early diastolic murmur

205
Q

Aortic regurgitation: signs of severity (6)

A 
Wide pulse pressure
Collapsing pulse
Quinke's nails
Corrigan's pulse
Austin flint murmur
LV failure
206
Q

Aortic stenosis: signs of severity (6)

A 
Narrow pulse pressure
Aortic thrill
Loss of heart sounds
S4 presence
Radiates to carotids
CP / SOB / syncope (LV failure)
207
Q

Cancer screening in NZ (4)

A

Prostate - not routine if asymptomatic

Bowel - 60-74 years (kit +/- scope)

Breast - 45 - 69 years (mammogram)

Cervical - 25 - 69 (smear)

208
Q

Key side-effect of protease inhibitors

A

E.g. saquinavir

Increased CVD risk - e.g. via diabetes, increased lipids

Use pravastatin - has less interaction with antivirals

209
Q

DDx for chorea (6)

A 
Sydenham's chorea
Huntington's
Wilson's disease
SLE
Basal ganglia infarcts
Chorea gravidarum
210
Q

ABCs approach for substance misuse

A

A - ask about current patterns of use. Can quantify risk using ‘AUDIT C’ score
B - brief interventions / advice
C - counselling (this may involved community / allied health services)

211
Q

Alcoholism - potential drugs (3)

A

Disulfiram - aldehyde dehydrogenase inhibitor (no change in cravings)
Topiramate - reduced cravings and withdrawal Sx
Naltrexone - opioid receptor antagonist (reduces urge to drink)

212
Q

Mechanical valve INR targets (3, 1, 1)

A

Newest AVRs (‘On-X’) - 1.5 - 2.0
AVR with no other risk - 2 - 3
AVR with other thromboembolic risks, or old valves 2.5 - 3.5

Mitral or tricuspid valves - 2.5 - 3.5

UpToDate recommends concurrent aspirin in all patients with a mechanical prosthetic valve

213
Q

‘Extras’ in renal transplant exam (7)

A 
Prednisone complications - skin, myopathy, Cushings
Gouty tophi
Mouth - gum hypertrophy, candida
Diabetes screening exam
Skin cancers
Parathyroidectomy scar
Fistula function
214
Q

General principles for pre-op assessment (4)

A

Consider the operation: what is planned, is there something safer

Assess comorbidity / severity + optimise

Manage medications: blood thinners, insulin, BP meds, stress dosing etc.

Planned post-op care e.g. incentive spirometry, warfarin bridging, stress dosing, temporary dialysis

215
Q

Components of CHADS-VASc with 2 points

A

Age >75
Prior stroke / TIA
(all others are 1 point)

216
Q

Oestrogen-related breast cancer risks (4)

A

Nulliparity
First pregnancy >30 years
Early menarche / late menopause
Obesity

217
Q

Tamoxifen key side effects (3, 1)

A

Thromboembolism
Hot flushes
Endometrial hyperplasia

(Via CYP2D6 inhibition from SSRIs, the conversion of tamoxifen to its active metabolite is slowed)

218
Q

Multiple myeloma prognostic factors

A

Beta-2-microglobulin conc.
Albumin level
Patient age
Cytogenetics

219
Q

Key side effect of myeloma chemotherapy (lenalidomide / bortezomib)

A

Peripheral neuropathy

220
Q

Criteria for bariatric surgery (2)

A

BMI >40
or BMI >35 and complications present (e.g. OSA, diabetes)

Both need to have tried and failed optimal medical therapy and be smoke-free

221
Q

Trachea deviates away from (2)

A

Tension PTX

Large pleural effusion

222
Q

Trachea deviates towards … (2)

A

Lobectomy / pneumonectomy

Lobar collapse

223
Q 
Tactile fremitus: 
Increased by (1)
Decreased by (3)
A

Consolidation

Effusion, pneumothorax, emphysema

224
Q

Normal spleen size

225
Q

Metabolic syndrome criteria (5)

A

3 of 5 of:

  • Increased waist circumference (102cm M, 88cm F)
  • Increased triglycerides
  • Decreased HDL
  • Increased BP (>130/85)
  • Increased BSLs

(Or on treatment for any of the above factors)

226
Q

Heart failure pharmacotherapy (6, 2)

A 
ACEi - key agent
Beta blockers
Mineralocorticoid receptor antagonists
ARNIs
Ivabridine

(These all have hospitalisation and mortality benefit)

Emerging evidence for SGLT-2 inhibitors

Frusemide is symptomatic only

227
Q

Heart failure lifestyle management (3,1)

A

Fluid restriction
Salt restriction
Daily weights

(Think of ‘rule of 2’s ‘)

Iron store optimisation

228
Q

Heart failure devices (4)

A

CRT
ICD (primary vs secondary)
Ventricular assist device
Intra-aortic balloon pump

229
Q

Indications for heart transplant (3, 1)

A

Severe AND symptomatic HF (despite optimal Tx)
Frequent discharges from ICD
Intractable angina

NOT just for low ejection fraction

230
Q

Causes for late mortality after heart transplant (4)

A

Graft failure
Infection
Malignancy
Coronary artery vasculopathy (neointimal proliferation)

231
Q

How to monitor myeloma progression (2)

A

‘CRAB’ criteria

Or increase in M-protein band

232
Q

Medication that causes false-positive Coomb’s test

A

Daratumumab

anti-CD38, used in myeloma, which causes cross linking of RBCs

233
Q

Engraftment

  • What is it?
  • How long to occur?
  • How to measure?
A

Establishment of transplanted haematopoietic stem cells

2-3 weeks usually

Chimerism studies (seeing what proportion of peripheral cells are derived from donor vs recipient haematopoiesis)

234
Q

How to assess for hyposplenism (3)

A

Howell-Jolly bodies on blood film
Pitted erythrocytes
Technecium-99 imaging

235
Q

How to distinguish HOCM from hypertensive heart disease (3)

A

Predictors of hypertensive disease include:
Elevated indexed left ventricular mass
Absence of SAM
Absence of midwall LGE

236
Q

Indications for ICD in HOCM (6)

A 
Arrest from VF or sustained VT
FHx of sudden cardiac death
Septal wall thickness >30mm
Unexplained syncope
Young patient age
High LV outflow tract gradient
237
Q

HOCM screening (2, 1)

A

Autosomal dominant disease, with hypertrophy developing in second decade. As such:

  • Screen 1st degree relatives aged 12-18 annually (Hx, Ex, ECG, ECHO)
  • Screen 1st degree relatives >18 every 5 years

(Usually only then do diagnostic / genetic testing if positive screening. I.e. don’t screen via genetic testing)

238
Q

What is the Fontan procedure (4)

A

Done for ‘univentricular’ congenital heart diseases, e.g. hypoplastic left heart syndrome.

SVC and IVC get directed straight to pulmonary arteries and into lungs, i.e. bypassing the heart.

The RV (via and ASD/VSD) then acts as the only pump around the body for blood returning from the lungs

Palliative procedure only - 10-20 years. Will eventually need heart/lung transplant.

239
Q

How to diagnose heart transplant rejection

A

Endomyocardial biopsy (showing T-cell predominant inflammation).

(Note, complication of repeated biopsies = TR)

240
Q

In which direction:

  • Does the uvula deviate?
  • Does the tongue deviate?
A

Uvula - away from lesion

Tongue - towards side of lesion

241
Q

What does positive Romberg’s indicate?

A

Dorsal column disease (i.e. sensory ataxia)

(Normally, vision will compensate for the sensory loss. Cerebellar and vestibular disease is indicated if patient cannot stand with their feet together regardless if their eyes are open or closed).

242
Q

Cerebellar gait (2)

A

Broad-based, lurching

Proceed with cerebellar exam

243
Q

Parkinsonian gait (3, 1)

A

Small, shuffling, fastination.
Loss of arm swing.
Slow initiation of gait.

Proceed with Parkinson’s exam

244
Q

Hemiplegic / hemiparetic gait (2, 1)

A

Slow, spastic - affected limb is lifted and circumducted. Upper limb is flexed + adducted.

Look for other UMN lesions

245
Q

Sensory ataxia gait (3)

A

Wide based, feet lifted high off ground, patient has to look at floor, feet slap to ground.

Look for positive Romberg’s and then to LL sensory exam.

Look for Argyll Robertson pupil

(DDx Friedreich’s ataxia, peripheral neuropathy, tabes dorsalis, subacute degeneration of the cord, MS, cord lesions)

246
Q

High stepping gait (2)

A

Due to foot drop

Proceed with foot drop isolation

247
Q

Scissor gait (paraparetic) (seen in + DDx + examine for)

A

Spastic paraplegia - legs can cross in front of one another

DDx: Hereditary spastic paraparesis, Friedreich’s ataxia, cord lesions, MS, cerebral palsy, transverse myelitis

Examine for LL UMN signs, sensory level, check spine, then check ULs to see if extended, then check cerebellum

248
Q

Waddling gait

A

Proximal myopathies

249
Q

Brown-Sequard syndrome key findings (3)

A

Below level of lesion:
Ipsilateral weakness (UMN pattern)
Ipsilateral dorsal column loss
Contralateral spinothalamic loss

At level of lesion:
Ipsilateral weakness (LMN pattern)
Ipsilateral sensory loss

250
Q

Brown-Sequard DDx (5)

A 
Syringomyelia
Trauma - stab, bullet
Spinal cord tumour
Multiple myeloma
Degenerative spine disease
251
Q

Bulbar palsy findings (5)

A 
Nasal speech
Wasting / fasciculating tongue
Weak soft palate
Absent gag reflex
Absent jaw jerk
252
Q

Dividing hypoglycaemic symptoms (2)

A

Neurogenic (adrenergic excess, e.g. tremor, agitation, anxiety, palpitations, sweating)

Neuroglycopaenic (low BSL e.g. delirium, coma, seizure)

253
Q

Management approach for diabetic with hypoglycaemia

  • Information gathering (3)
  • Planning (7)
A

History initially - how frequent events, what symptoms, needing the help of someone else (i.e. severe)?

Further information - BSL records, machine log, CGM

Further information - intercurrent illness, exercise, diet change

Establish plan:

  • Individualised regimen - balanced according to patient
  • May be reasonable to run higher / adjust injsulin
  • Run higher for 2-3 weeks to restore hypoglycaemic awareness
  • Increase monitoring frequency
  • Educate about symptoms, exercise, diet
  • Access to carbs / glucagon at home
  • Educate family/friends about Sx + emergency management
254
Q

Hypoglycaemia / driving stand-downs (3)

A

Mild - one hour if insulin, longer if sulfonylurea used
Severe - no driving for 24h
Severe event WHILE driving - no driving 1 month / until specialist review

255
Q

Vision standards for driving (2)

A

Class 1 - 6/12

Other classes - 6/9

256
Q

Key components of palliative care / optimising quality of life case to discuss (1, 5, 4)

A

“Each person has unique definition of quality of life” - needs wholistic approach. “What area is important to the patient?”

Areas:
Physical
Psychosocial
Spiritual
Cultural needs
Support family/friends - with caring role and with bereavement
During discussions, involve:
Patient / selected close contacts
Cultural support worker
Palliative care team
Hospice
257
Q

Findings in nerve conduction studies:
Compressive lesion

Demyelinating condition

Axonal condition

Proximal nerve root lesion (e.g. GBS)

A

Conduction block (sudden slowing of velocity >50%)

Slowed conduction velocity and temporal dispersion (signals arrive at different times)

Reduced conduction amplitude

Prolonged F-waves

258
Q

Findings in EMG studies:

Denervated muscles

Neuronal muscle disease

Myopathic muscle disease

A

Positive sharp waves and fibrillations (dead nerve –> upregulated AChRs –> start to respond to background ACh)
- Note fasciculation is what is seen clinically, not fibrillation

Increased motor unit amplitude, decreased recruitment

Small motor unit amplitude, increased recruitment
(Dive bomber sound in myotonic dystrophy)

259
Q

Pulmonary HTN exam findings (6)

A 
Parasternal heave
Loud P2, with splitting +/- S3 or S4
Tricupsid regurgitation
Elevated JVP
Pulsatile liver
Ascites / oedema

(Then to proceed to look for other causes, e.g. scleroderma)

260
Q

‘Rheum drugs’ key side-effects:

  • All of them
  • Methotrexate (5)
A

All cause GI upset commonly.

Mucositis, LFTs, cytopaenia, lung disease, teratogen.
Need to avoid other anti-folate Rx e.g. triprim

261
Q

‘Rheum drugs’ key side-effects:

Sulfasalazine (3)

A

Orange sweat/urine, LFTs, cytopaenia

Avoid in G6PD deficiency

262
Q

‘Rheum drugs’ key side-effects:

Hydroxychloroquine (2)

A

Photosensitivity, retinitis

Avoid in G6PD deficiency

263
Q

‘Rheum drugs’ key side-effects:

Leflunomide (4)

A

LFTs, neuropathy, cytopaenia, teratogen

Reverse with cholestyramine

264
Q

DDx for demyelinating disease other than MS (4)

A

ADEM
Devic’s disease
Leukodystrophies
Tuberous sclerosis

265
Q

Key features in MSA (5)

A 
Cerebellar signs / ataxia
Autonomic dysfunction
Incontinence
Hot cross bun sign on MRI
Poor L-dopa response
266
Q

Key features on exam for myasthenia gravis (8, 1)

A 
Ptosis, worsening with sustained upgaze.
Peek sign (can't keep eyes closed)
Diplopia 
Snarling instead of smile
Nasal speech
Count to 50 - voice deteriorates (bulbar features)
Proximal weakness, and weak neck flexion
- Can compare by moving one arm for 15 seconds, then testing both sides simultaneously
Thymectomy scar

NORMAL sensation and reflexes

267
Q

Key features LEMS (vs myasthenia) (4)

A

Improves with exercise
Absent reflexes
Rare to have bulbar symptoms
Positive anti-P/Q-calcium channel antibodies

268
Q

MRC dyspnoea scale (5)

A

Breathless on:

1 - strenuous exercise
2 - uphill / hurrying
3 - walking at pace on level / after 15min
4 - within 100m
5 - getting dressed / can't leave house
269
Q

What virus causes Kaposi’s sarcoma / multi-centric Castleman’s disease

A

HHV-8

Castleman’s managed with rituximab and doxorubicin, +/- ART if HIV+

270
Q

Barriers to medication adherence

  • ‘Patient-related’ (5)
  • Practical (3)
A

Psychiatric disease e.g. schiophrenia, bipolar
Low mood / ambivalence about condition
Low understanding / insight into condition + why on Rx
Stigma about taking Rx / denial
Doesn’t trust doctor

Finances / distance to pharmacy
Regimen too complex / can’t physically use (e.g. MDIs)
Previous side-effects

271
Q

Managing / improving medication adherence (1, 7)

A

Confirm the correct diagnosis - is the condition not improving because the right thing isn’t being treated?

  1. Establish partnership with patient - set a realistic and shared goal (avoid “therapeutic perfectionism”)
  2. Explore understanding / re-educate
  3. Assess perceived and practical barriers
  4. Simple / inexpensive regimen, clear written instructions
  5. Set alarms / reminders, involve family
  6. Strategies for managing with side-effects
  7. Regular follow-up / review on how it’s going
272
Q

Key features of PSP (2)

A

Axial rigidity

Vertical gaze palsies

273
Q

Mixed neuropathies (6)

A

‘DAD RUM’

Diabetes - amyotrophy
Alcohol
Drugs (cisplatin, vincristine, phenytoin)
Rheumatoid
Uraemia
Malignancy
274
Q

Motor neuropathies DDx (5)

A 
GBS
Charcot-Marie Tooth
Lead toxicity
Porphyria
Polio
275
Q

Sensory neuropathy DDx (5)

A 
Diabetes
Alcohol
B1/B12
Leprosy
Renal failure
276
Q

DDx / causes for pseudobulbar palsy (4)

A

Bilateral stroke
MS
MND
Parkinson’s

277
Q

DDx for bulbar palsy (4)

A

MND
GBS
Myasthenia
Myopathies

278
Q

Radial nerve lesion: high vs low (i.e. injury above/below middle of humerus) (4, 1)

A

In high lesion:

  • Loss of forearm flexion and supination (brachioradialis lost)
  • Loss of wrist extension
  • Loss of MCPJ extension
  • Loss of thumb abduction

(Whereas lower lesion only affects finger extension and thumb)

279
Q

Corneal reflex pathway

A

V –> VII

280
Q

Gag reflex pathway

281
Q

Subacute Combined Degeneration of the Cord;

  • key findings (4)
  • proceed to (4)
A

Brisk knee jerk reflex
Absent ankle reflex
Upgoing plantars
Posterior column sensory loss (and Romberg’s positive)

Mucous membranes (red tongue, anaemia)
Abdomen (gastrectomy scar)
Pupils - tabes dorsalis in DDx
Optic atrophy
282
Q

Categories for proximal weakness (3)

A

Myopathy - see ‘PACE PODS + others’
NMJ disease e.g. myasthenia, Grave’s
Neurogenic e.g. MND, demyelinating disease

283
Q

Wallenberg’s key features (2)

A

Face: ipsilateral Horner’s, Cerebellar signs, bulbar palsy and face/temp loss
Limbs: contralateral pain/temp loss

284
Q

Alcohol / smoking - management overview (6)

A
  1. ‘ABC’ approach (ask, brief intervention, cessation support/counselling)
    - Categorise severity via ‘CAGE’
    Set ‘QUIT DATE’
  2. Behavioural intervention e.g. AA, education, positive feedback, counselling, smoking helplines (Quitline), CAMS
  3. Pharmacological interventions
  4. Manage complications / side-effects
  5. Screen for other harmful substances
  6. Regular follow-up (GP probably)
285
Q

Smoking cessation medications (4)

A

NRT - based on time of first cigarette (<1h) and amount per day (>10)
Bupropion - atypical antidepressant, reduces cravings
Nortriptyline - TCA
Varenicline (Champix) - second line, blocks nACHrs in brain

286
Q

HIV medication classes: integrase inhibitors

A

Names ending in -‘gravir’ e.g. dolutegravir

287
Q

HIV medication classes: Non-nucleoside reverse transcriptase inhibitors

A

Names with ‘vir’ in the middle

288
Q

HIV medication classes: fusion inhibitors

A

Enfurvitide, maraviroc

289
Q

HIV medication classes: protease inhibutors

A

Names ending in -‘navir’

290
Q

HIV medication classes: nucleoside reverse transcriptase inhibitors

A

All other meds not covered by above ‘rules’

291
Q

Horner’s syndrome - why does internal carotid artery lesion only cause ptosis/miosis (but not anhidrosis)?

A

Sweating fibres are carried along external carotid artery branch, so these are unaffected. Would see ‘triad’ if lesion is proximal to the carotid bifurcation.

292
Q

Acronym for initial neuro inspection

A

‘SWIFT’

Scars
Wasting / walking aids
Involuntary movements (chorea)
Fasciculations
Tremor
293
Q

‘Overview’ for threatened independence (5)

A

Address / optimise underlying conditions

Involve family / friends / community groups

Optimise home e.g. OT, package of care

Access to transport e.g. bus, shuttle, driving miss daisy

‘Other’: counselling, capacity, finances, will/EPoA, St John’s alarm

294
Q

Splenectomy: Vaccines (5)

A

Conjugate vaccine first (PCV13 AKA Prevenar)
Then polysaccharide vaccine (PCV23 AKA Pneumovax)

Meningitis vaccines - both types

HiB vaccine

Annual influenza

295
Q

Secondary HTN screen (7)

A 
Renal function
Cortisol
ECHO - coarctation
Renal USS / angio
Plasma metanephrines
Renin-aldosterone ratio
Consider sleep study
296
Q

Vaccines in dialysis patients; key points (4)

A

Often generate lower immune / antibody response

Often get double hepatitis B vaccine dose

Annual flu vaccine

Routine for other vaccines

297
Q

When to perform screening for intracranial aneurysms in PCKD? (4)

A

FHx of PCKD + aneurysms
About to have major surgery
High risk occupation
Being anticoagulated

(Done at diagnosis, then again at 5 years once only)

298
Q

Structures that move upward (>2cm) on neck swallow assessment (2)

A

Goitre
Thyroglossal cyst

(Due to attachment to the larynx)

299
Q

Diabetic amyotrphy: key features (5)

A

An asymmetric motor polyneuropathy:

Proximal thigh/hip atrophy and weakness
Burning nerve pain
Sensory loss in thigh
Absent knee jerk reflex
Associated autonomic failure and weight loss
300
Q

What is the significance of rheumatoid nodules if found?

A

Suggests seropositive / more aggressive arthritis.

Can be found on hands, sacrum, elbow, tendons, lungs and myocardium

301
Q

Portal HTN features on USS (5)

A 
Small / nodular liver
Dilated portal vein
Reversal of flow in portal vein
Splenomegaly
Recanalisation of the umbilical vein

(Note, on bloods, also look at platelets)

302
Q

Causes of lipodystrophy (3)

A

Diabetes (inuslin injection)
Anti-retroviral therapy
CKD (MPGN)

303
Q

Antibody associated with drug-induced lupus

A

Anti-histrone Abs

304
Q

Expected findings on fundoscopy in diabetic eye exam (5)

A 
Cataract (loss of white reflex)
Blot haemorrhages
Cotton wool spots
Hard exudates
Macular oedema
305
Q

Glucose suppression test:

  • When to order
  • What to expect
A

In work-up for acromegaly if positive / elevated IGF-1

Oral glucose should lead to decrease in GH. This doesn’t occur in acromegaly.

306
Q

Medical management for acromegaly (4)

A

Somatostatin analogues (octreotide)
Cabergoline
Pegvisomant (GH-R antagonist)
RTx

307
Q

Order that hormones fall in hypopituitarism.

A

First: GH, FSH, LH
Then: TSH, ACTH
Last: ADH

308
Q

If extra time in aortic regurgitation exam, proceed to look for: (4)

A

Arm-span
High arch palate
Ank spond
Rheumatoid arthritis

309
Q

HOCM vs aortic stenosis (3)

A

Valsalva - decreases AS, increases HOCM murmur
Jerky pulse in HOCM
AS radiates to carotids, HOCM to axilla

310
Q

Long-term murmur after Tetralogy of Fallot repair

A

Pulmonary regurgitation

311
Q

Causes for mixed aortic valve disease (3)

A

Rheumatic heart disease
Bicuspid aortic valve
Degenerative/age-related disease

312
Q

Parkinson’s: key prodrome symptoms (4)

A

Anosmia
Constipation
REM behaviour sleep disorder
Mood / anxiety

313
Q

Why are dopamine agonists preferred in younger Parkinson’s patients?

Examples

Key caution

A

Delays use of L-dopa, thereby delaying onset of dyskinesia problems

E.g. ropinirole, pramipexole

Impulse control disorders, punting

314
Q

What is the benefit of amantidine in Parkinson’s treatment? (2)

A

Useful for mild Sx
Reduces dyskinesia

(Note caution in renal impairment)

315
Q

What type of medications are used for tremor-predominant Parkinson’s?

A

Anti-cholinergics

316
Q

COPD-X components

A 
Confirm Dx
Optimise disease
Prevent deterioration - e.g. smoking, imms
Develop plan - action plan, MDT
Manage exacerbations

RACP Exam (2 decks)

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