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Consultations Flashcards

1
Q

Clinical findings of ankylosing spondylitis

A

Reduced mobility across spinal axis
Increased wall to tragus distance
+ve Schober’s test

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2
Q

What is a postive schober’s test?

A

Mark L5 and 2nd mark 10cm above
Ask to fully flex forwards
Increase <5cm is positive finding

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3
Q

Lung findings in ankylosing spondylitis

A

Apical, pulmonary fibrosis

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4
Q

Cardiac finding associated with ankylosing spondylitis

A

Aortic regurgitation

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5
Q

Investigations in ankylosing spondylitis

A

Bloods - FBC, Renal, Liver, ESR + CRP, HLA-B27

Radiographs of spine and pelvis - looking for sacral ileitis and fusion

If radiographs are normal, consider spine and pelvis MRI

If lung findings, CXR and lung function tests and consider HRCT

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6
Q

Lung function test findings in pulmonary fibrosis associated with ankylosing spondylitis

A

Restrictive pattern with reduced FEV1 and reduced FVC, but maintained ratio

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7
Q

How to associate between mechanical and lung restriction, and pulmonary fibrosis, secondary to ankylosing spondylitis

A

Look at transfer factor

Transfer factor will be preserved with mechanical restriction, but reduced in fibrosis due to underlying lung damage

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8
Q

Treatment of ankylosing spondylitis

A

And take a MDT approach

The medical perspective gives regular non-steroidal anti-inflammatory medications to control pain plus or minus PPI. In severe disease may want to consider immuno modulator therapies, such as TNF alpha inhibitors - infliximab. Refractory disease may need anti-Il17 therapy of JAK inhibtors

Regular physiotherapy to maintain mobility

Occupational therapy assessment to optimise home and work environments

Refer to smoking cessation as smoking increases disease activity

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9
Q

Considerations before starting anti-TNF therapy

A

Ensure patients are up-to-date with regular vaccinations

Screen for TB including chest x-ray

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9
Q

Character of back, pain in ankylosing spondylitis

A

Worse in the morning

Gets better throughout the day

Better with exercise
Response to non-steroidal anti-inflammatory medication

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9
Q

Differentials of backpain and associated questions

A

Degenerative
Traumatic
Neoplastic, ask about weight loss and loss of appetite
Infective ask about fever at night sweats
Systemic inflammatory conditions, such as psoriatic arthropathy ask about rash and inflammatory bowel disease ask about GI symptoms

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9
Q

What needs to be ruled out with back pain

A

Cauda equina syndrome

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9
Q

Examination in suspected ankylosing spondylitis

A

Check full range of spinal movements
Modified Schober’s test
Check Wall to tragus distance

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9
Q

Management of acute flare of IBD

A

Admit patient
Full set of observations
Send three stool cultures & faecal calprotectin
Bloods - FBC, CRP, Renal and liver, U&Es
Abdominal XR ?bowel loop dilatation

Treat with analgesia and IV steroids (hydocort 100mg QDS)
IV fluids +/- electrolyte replacement
Consider IV antibiotics if evidence of infection

Start VTEp as at high risk due to prothrombotic state

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9
Q

Activity monitoring score in ankylosing spondylitis

A

Bath, ankylosing, spondylitis, disease, activity, index

Out of 10, score > 4 = active disease

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9
Q

Complications requiring surgery in Crohn’s

A

Colon dilatation
Fistualting disease
Refeactory to full medical management

Surgery, more likely in current disease due to transmural disease activity

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10
Q

Management of IBD patient after discharge

A

Tapering course of steroids
Vitamin D and Ca supplementation
Ensure has Gastro plan re Disease-modifying agents (?does she need infliximab)

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11
Q

Malignancy associated with IBD

A

Particularly in patients with colitis

Patients may need surveillance colonoscopy after 10 years +/- biopsies

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12
Q

Skin rashes associated with IBD

A

Pyoderma gangrenosum
Erythema nodosum

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13
Q

Association between smoking and Crohn’s disease

A

Smokers are twice as likely to develop Crohn’s disease

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14
Q

Curative treatment of ulcerative colitis

A

Total colectomy as disease is only limited to the large colon

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15
Q

Causes of myelopathy

A

Acute:
Trauma
Vascular

Subacute:
Subacute combined degeneration of cord (most commonly B12 deficiency)

Acute on Chronic:
Relapsing-remitting - e.g. demyelination

Chronic:
Degenerative

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16
Q

How to localise a level of myelopathy

A

Check for a sensory level - expect upper motor neuron features below the level and potentially lower motor features at the level of lesion

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17
Q

Investigations in a patient with a myelopathy

A

Bloods - FBC, haematinics, ESR, consider AI screen, renal, liver, U&Es, copper studies

Urgent MRI spine

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18
Q

Management of degenerative, cervical myelopathy

A

Refer to neurosurgeons for consideration of surgical intervention - urgent intervention warranted with cord compression or impingement

Consider physiotherapy input timing dependent on surgical intervention

Occupational therapy review to optimise home and work setting

Referral to the neuro rehabilitation MDT meeting

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19
Q

Pyramidal signs in one limb with hyperaethesia to sharp touch on contralateral signs

A

Partial brown-sequard syndrome

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20
Q

What always needs to be done with a suspected myeloapthy

A

Check for sensory level

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21
Q

Timing of MRI spine in myelopathy

A

Urgency should be reflected characterised by timing of onset of symptoms. In patients with acute onset symptoms same day, MRI should be performed.

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22
Q

Management of metastatic cord compression

A

Consider radiotherapy

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23
Q

What is Kernig’s sign

A

Neck pain on extension of the knees due to meningeal inflammation

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24
Q

Types of meningitis

A

Bacterial viral, fungal, protozoal, lyme
Also, can consider paraneoplastic or malignant

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25
Q

Management of suspected meningitis

A

Admit patient
Bloods, inc. FBC, CRP, Renal, U&Es, Liver, Clotting, glucose and lactate
CT Head
Perfrom fundoscopy & otoscopy
Lumbar Puncture - cell count, culture, protein, paired glucose + lactate, viral studies
Start broad-spectrum IV antibiotics and antiviral
Give IV fluids and complete sepsis 6 bundle

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26
Q

LP findings in bacterial versus viral meningitis

A

Bacterial
- raised WBC - neutrophilia
- Raised protein
- Low glucose
- +ve gram stain

Viral
- Raised WBC - lymphocytes
- Serum:CSF glucose ratio should be normal

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27
Q

Complications of meningitis

A

Death

Neuro:
Deafness and blindness
Cognitive impairment

Vascular:
Amputations 2o sepsis syndrome

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28
Q

Headache DDx

A

Infective:
R/o meningitis
Could be associated with viral illness
Abscess

Neoplastic:
SOL

Vascular:
Subarachnoid haemorrhage
Venous sinus thrombosis

Tension type headache
Migraine

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29
Q

Management of migraine

A

Prophylaxis
- lifestyle adjustments, healthy diet and exercise
- Consider prophylactic agents if recurrent - e.g. propranolol - consider patients individually

Acute treatment
- Simple analgesia - paracetamol / NSAIDs
- If early, consider triptans

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30
Q

High risk features in history of patient presenting with headache

A

Check for immunosuppression
previous HIV infection
Exposure to others with meningitis
Positive travel history

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31
Q

Migrainous, headaches, unilateral or bilateral

A

Unilateral

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32
Q

Typical migrainous, headaches features

A

Preceded by aura

Unilateral
Throbbing nature

Disabling for patient
Associated with nausea and photophobia
30% may have associated focal neurological deficit

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33
Q

Preciptants associated with migrainous headaches

A

Stress
Fatigue and sleep deprivation
Chocolate and red wine

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34
Q

Red flag features for headache

A

Age, more than 50 years
Limb weakness, or abnormal neurological features
Confusion

Woken from sleep
Worse with exertion, position, coughing or sneezing (raised ICP)

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35
Q

Issue with performing LP with raised ICP

A

Risk of brainstem herniation through foramen magnum

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36
Q

Screening test acromegaly

A

Insulin like growth factor one

Following this do glucose tolerance test and there should be failure to suppress growth hormone

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37
Q

Screening test for obstructive sleep apnoea

A

Consider overnight sleep studies and overnight pulse oxymetry

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38
Q

Imaging test in acromegaly

A

MRI head, looking for pituitary involvement

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39
Q

Organs affected in acromegaly

A

Multisystem disease

Cardiomyopathy & IHD
HTN & T2DM
Visual impairment

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40
Q

Visual disturbance in acromegaly

A

Typically, bitemporal hemianopia secondary to compression of the optic chiasm, due to pituitary adenoma

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41
Q

Treatment of acromegaly

A

First line is curative transphenoidal surgery

Medical therapy with somatostatin analogues, such as ocreotide. Second line agents include bromocriptine

If failure of above can consider radiotherapy of pituitary

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42
Q

Main complication of transphenoidal surgery in acromegaly

A

Panhypopituitarism

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43
Q

Why is acromegaly associated with obstructive sleep apnoea?

A

Secondary to soft tissue swelling in the face and neck, resulting in mechanical respiratory obstruction when lying flat

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44
Q

Sleepiness score in OSA

A

Epworth sleepiness scale

Out of 24, a score of more than 11 may indicate OSA

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45
Q

Why does OSA lead to daytime somnolence?

A

Respiratory obstruction results in desaturation and compensatory tachycardia this results in the patient waking up frequently throughout the night, leading to restless sleep and subsequent daytime somnolence

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46
Q

Main treatment of OSA

A

CPAP

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47
Q

Main features to examine in acromegaly

A

Assessment of visual system, including cranial nerves 3, 4 and six

Examine hands, including Phalen’s test for carpal tunnel syndrome

Assess for Proximal myopathy

Assess for prominent browline, lips, jaw and tongue

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48
Q

Kidney transplant scar name

A

Rutherford Morrison

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49
Q

Bony complication associated with steroid use

A

Avascular necrosis typically of the hip

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50
Q

Investigation to assess for failing, renal transplant graft

A

Urinalysis looking for haematuria and proteinuria

Blood is particularly looking at renal function and urea and electrolytes

Tacrolimus level

US duplex looking at vascular flow

If really concerned about acute rejection, could consider a renal biopsy

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51
Q

Weight loss in context of immunosuppression

A

Think malignancy - post-transplant lymphoma or skin malignancy

Also rule out chronic infection

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52
Q
A
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53
Q

Blue discolouration of eye and recurrent fractures

A

Osteogenesis imperfecta

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54
Q

Investigation’s osteogenesis imperfecta

A

Bloods - Bone, Vit D, PTH
Genetic testing
Radiographs of bones
DEXA
Echo

55
Q

Tx osteogenesis imperfecta

A

Replace electrolytes as required
Consider bisphosphinates dependent on DEXA
OT/PT review ?walking aids ?orthotics

56
Q

Cardiac complication associated with osteogenesis imperfecta

A

Bicuspid aortic valve
Can lead to AR over time due to a lack of valve collagen

57
Q

Inheritance osteogenesis imperfecta

A

Auto dominant
8 variants

58
Q

Bony complications of bisphosphonates

A

A vascular necrosis of jaw

59
Q

Non bony complications of osteogenesis imperfecta

A

Translucent teeth
Hearing impairment
Bicuspid AV

60
Q

Complications of Ehlers Danlos syndrome

A

Joint deformity secondary to hypermobility
CVS - MV prolapse or regurgitation, AR
Vascular aneurysm
Ophthalmology- risk of glaucoma and retinal issues

61
Q

Treatment for Ehlers Danlos

A

Largely supportive
Ot pt
Analgesia for joint issues
Address complications as they arise

62
Q

Genetics of Ehlers Danlos

A

Mixed
Can be autosomal dominant or recessive
Can also be caused by de novo mutations
Resulting in defective collagen synthesis

63
Q

Initial is for suspected haem malignancy with neck mass and splenomegaly

A

Bloods - Fbc, blood film, u & electrolytes, monospot ? Infectious mononucleosis

Ando USS to characterise splenomegaly

Ct CAP ?primary ?lymphadenopathy

LN biopsy

PET scan

64
Q

Young patient with neck lump and splenomegaly ddx

A

Infection ?infectious mononucleosis
Haematological- lymphoma, leukaemia

65
Q

Difference between FNA and biopsy

A

Biopsy gives histology and cytology

FNA cytology only

66
Q

Granuloma on biopsy

A

Ddx are TB (caseating) vs Sarcoidosis

67
Q

Ix suspected Sarcoidosis
After histology shows granuloma

A

CXR ?bilateral hilar lymphadenopathy
Check Ca and serum ACE
Lung function tests

68
Q

Stroke like symptoms in young female patient, what should you always ask?

A

Any pregnancy Hx? Any miscarriage? Risk of anti-phospholipid syndrome

Are they on OCP?

69
Q

Ix suspected TIA

A

Bloods - FBC, Renal, Liver, Clotting, AI screen - ANA, dsDNA, complement, anti-cardiolipin & antiphospholipud Abs

ECG & request 24hr ECG ?pAF

Echo, can consider bubble ?PFO

Carotid Doppler

MRI Brain - same day

70
Q

Management post TIA

A

Secondary prevention

Start regular clopidogrel

Manage BP, blood glucose, cholesterol (aim to reduce non-HDL cholesterol by >40%)
Healthy lifestyle - exercise, diet, stop smoking, reduce EtOH

Advise unable to drive for at least 1 month

71
Q

Treatment of antiphospholipid syndrome

A

Anticoagulation
Warfarin recommended over DOAC
But to be discussed with haematology & refer to local guidance

72
Q

Cause of stroke or TIA in young patient

A

Anti-phospholipidsyndrome
Carotid/vertebral artery dissection secondary to trauma
Vasculitis
Substance abuse - Cocaine / amphetamines
Rarer - mitochondrial disorders - MELAS

73
Q

Stroke in young afro-carribean patient

A

Think of sickle cell disease

74
Q

Patient with lung transplant presenting with progressive breathlessness - what to think about?

A

Immunocomprised - ?PJP ?CMV ?fungal

Chronic rejection of lung - this give an obstructive picture on LFTs, in keeping with bronchiolitis obliterans

75
Q

Anticoagulation duration in provoked, pulmonary embolism

A

Three months

76
Q

Pleuritic chest pain & haemopytisis DDx

A

PE
Pneumothorax
Infection

77
Q

Features of the pericarditis chest pain

A

Worse on lying down and relieved by leaning forward

78
Q

What risk or can we used to Stratified patients with Venous thromboembolic disease.

A

Wells score

79
Q

When use V/Q scan over CTPA

A

Pregnant patients
Renal impairement cannot tolerate contrast

80
Q

Stroke complications

A

Thromboembolic disease 2o immobilisation
Further stroke - haemorrhagic or ischameic
Risk of raised ICP 2o swelling
Seizures
Dysphagia - need swallow assessment
Spasticity - input from OT/PT +/- anti-spastic medications
Urinary/fecal incontinence

81
Q

2o prevention stroke

A

Antiplatelets - Clopi following high dose aspirin for 2 weeks
High dose statin therapy
Control RFs - HTN / Glycaemic control / stop smoking / improve diet and exercise

82
Q

Retinitis pigmentosa findings

A

bone spicule pigmentation of retina

83
Q

Bilateral progressive visual loss DDx

A

Glaucoma
Cataracts
Diabetic Retinopathy
Vit A deficiency
Macula degeneration
Pipilloedema 2o IIH
Retinitis Pigmentosa

84
Q

Management of Retinitis Pigmentosa

A

Confirm diagnosis via Opthalmology
Genetic counselling
Supportive therapy - visual aids

85
Q

Inheritance of retinitis pigmentosa

A

AD / AR / X-linked
30% de novo

86
Q

Syndromes associated with retinitis pigmentosa

A

Multiple syndromes
Inc. Ushers & Kearns-Sayers

87
Q

Retinitis Pigmentosa & Driving

A

Need to inform DVLA - strict guidelines on visual acuity and visual field loss

88
Q

Joint pain following infection

A

Reactive arthritis

89
Q

Sti leading to reactive arthritis

A

Chlamydia

90
Q

Arthritis caused by gonococcal infection

A

Typically septic arthritis

91
Q

Treatment of reactive arthritis

A

Supportive
Analgesia
Maintain mobility possibly with PT input
Treat underlying cause - eg infection / abx

92
Q

Genetic association with reactive arthritis

A

Associated with HLA B27
Seronegative spondyloarthropathies
Associated with psoriatic / enteric / reactive arthritis and ank spond

93
Q

Organisms causing reactive arthritis

A

Chlamydia
Salmonella
Campylobacter

94
Q

Bloods to send in suspected reactive arthritis

A

Fbc crp lft renal urate RF esr anti-ccp

95
Q

What is hashimotos thyroiditis

A

Most common cause hypothyroidism
Due to lymphocytic infiltration, subsequent inflammation and fibrosis of thyroid gland

96
Q

Antibodies for Hasimotos

A

Anti tpo
Anti thyroglobulin

97
Q

Diseases associated with hashimotos

A

Autoimmune conditions
Vitiligo
Addisons disease

98
Q

De quervains thyroiditis

A

Period of hyperthyroidism due to thyroid follicle destruction followed by hypothyroidism when thyroid regenerates. Then back to euthyroid.

99
Q

Symptoms and signs of hypothyroidism

A

Lethargy
Muscle weakness
Cold intolerance
Weight gain
Low mood

100
Q

What is myxoedema

A

Periorbital oedema
Thick waxy skin
Brittle hair

101
Q

Hypothyroidism DDx

A

Hashimotos
De quervains
Drugs - carbimazole / propylthiouracial / Li / interferons
Radiodine therapy

102
Q

Hypothyroidism DDx

A

Hashimotos
De quervains
Drugs - carbimazole / propylthiouracial / Li / interferons
Radiodine therapy

103
Q

Screening test for Addisons disease

A

9am cortisol

104
Q

Starting dose of levothyroxine

A

25-75ug
Lower in elderly
Titrate to TFTs

105
Q

Complications associated with prolonged use of Steroids

A

Development of cushingoid appearance
Increase risk of IHD
Diabetes
Thin skin & easy bruising
Adrenal failure

106
Q

Triggers of myasthenic crisis

A

Infection
Stress e.g. operation
Withdrawal of steroids / immunosuppression

107
Q

Patient with suspected MG what do we need to check

A

Resp function - spirometry and serial FVC

108
Q

Pathophysiology of MG

A

Post-synaptic destruction of ACh receptors

109
Q

DDx ocular myasthenia gravis

A

Thyroid ocular myopathy
Cranial nerve / brainstem weakness
Myotonic dystrophy

110
Q

DDx generalised myasthenia

A

Generalised fatigued 2o anaemia
MND
Botulism (involves pupillary muscle)
Lambert-Eaton Syndrome - a/w SCLC

111
Q

Antibody in Lambert-Eaton

A

Voltage-gated Ca channel antibodies

112
Q

MG with bulbar symptoms - Ix

A

MRI brain

113
Q

What needs to be checked prior to commencing azathioprine

A

TPMT levels

114
Q

Why does spina bifida predisopse to recurrent UTI

A

Neuropathic bladder results in structural changes that increase likelihood of infection

115
Q

Conditions associated with spina bifida

A

Limb spasticity
Hydrocephalus (requiring VP shunt)
Arnold-Chiari malformation
Bladder and bowel dysfunction

116
Q

What is a spina bifida?

A

Part of the neural tube does not develop or close properly, leading to defects in the spinal cord and bones of the spine

117
Q

RFs for spina bifida

A
  1. Folate deficiency - folic acid supplementation during conception and pregnancy
  2. FHx neural tube defects
  3. Drugs - sodium valproate / methotrexate
  4. Poorly controlled DM
118
Q

Treatment of bladder dysfunction in spina bifida

A

Regular bladder catheterisation
Anti-muscarinic drugs

119
Q

Treatment of pyelonephrosis

A

Emergency - nephrostomy

120
Q

Why are L sided murmurs louder on expiration?

A

Increased venous return to L side of heart

121
Q

Peripheral signs of infective endocarditis

A

Splinter haemorrhages
Janeway lesions
Osler Nodes
Roth spots - Retinal emboli
Murmurs
Haematuria on dip stick
Evidence of peripheral septic emboli

122
Q

What is coarctation of the aorta?

A

Congential narrowing - typically distal to L subclavian artery

123
Q

Clinical signs of coarctation

A

Radio-radial & radio-femoral delay
systolic murmur, loudest posteriorly

124
Q

Complications of aortic coarctation

A

Stroke
HF
Aortic rupture

125
Q

Management of coarctation

A

Balloon angioplasty and stenting
Open resection and anastomosis - preferred

126
Q

blue-grey discolouration of the eye ball

A

Scleromalacia

127
Q

Anaemia secondary to rheumatoid arthritis

A

Anaemia of chronic disease
Iron-deficiency anaemia (secondary to peptic ulceration due to chronic NSAID use)
BM suppression secondary to DMARDs
AI haemolytic anaemia

128
Q

Management of Rheumatoid Arthritis

A

MDT

PT - maintain mobility
OT - adapt home and work environments

Rheum - DMARDS - methotrexate / sulphasalazine - if fail 2 therapies consider biologics - rituximab / tociluzimab

129
Q

Describe hand changes in RA

A

Symmetrical deforming poluyarthropathy

130
Q

Genetic association with RA

A

HLA-DR4

131
Q

Disease activity score in RA

A

DAS-28
Score >5.1 = active disease
Score <2.6 = remission

132
Q

Extra-articular features of RA

A

EYES
Episcleritis - painless
Scleritis - painful

LUNGS
Pulmonary fibrosis / nodules / effusion

KIDNEY
Nephrotic syndromes

133
Q

Extra renal manifestation ADPKD

A

Liver cysts
Berry aneurysms
Mv prolapse

134
Q

Loin pain APCKD

A

Cyst enlargement rupture or haemorrhage
Renal stone
Infection

135
Q

Complications of immunosuppression

A

Direct - tremor, htn, diabetes
Infection
Malignancy

136
Q

Med to slow progression of ADPKD

A

Tolvaptan

137
Q

Types of muscular dystrophy

A

Duchenne / Becker - severe weakness expected in childhood
Facioscapulohumeral
Limb girdle
Orophayngeal
Myotonic

138
Q

Ix suspected muscular dystrophy

A

Complete neuro exams
Bloods inc CK
Nerve conduction and EMG
Muscle biopsy
Genetic testing

139
Q

Management of muscular dystrophy

A

No disease modifying therapies
Supportive
OT / PT
SLT

140
Q

Features of Parkinsonian gait

A

Stooped posture
Reduced arm swing
Shuffling
Difficult turning
Festination

141
Q

Distraction technique to exacerbate Parkinsonism

A

Synkinesis

142
Q

Causes of Parkinsonism

A

Idiopathic Parkinson’s disease
Parkinson’s plus syndrome
Vascular Parkinsonism
Lewy body dementia
Medication induced
Meds induced - Antipsychotics - Haloperidol

143
Q

Pathophysiology of PD

A

Destruction of dopaminergic neurones in the substantia nigra

144
Q

Eye complication of Marfans

A

Ectopia Lentis

PACES (6 decks)

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