Consultations Flashcards
Clinical findings of ankylosing spondylitis
Reduced mobility across spinal axis
Increased wall to tragus distance
+ve Schober’s test
What is a postive schober’s test?
Mark L5 and 2nd mark 10cm above
Ask to fully flex forwards
Increase <5cm is positive finding
Lung findings in ankylosing spondylitis
Apical, pulmonary fibrosis
Cardiac finding associated with ankylosing spondylitis
Aortic regurgitation
Investigations in ankylosing spondylitis
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
Lung function test findings in pulmonary fibrosis associated with ankylosing spondylitis
Restrictive pattern with reduced FEV1 and reduced FVC, but maintained ratio
How to associate between mechanical and lung restriction, and pulmonary fibrosis, secondary to ankylosing spondylitis
Look at transfer factor
Transfer factor will be preserved with mechanical restriction, but reduced in fibrosis due to underlying lung damage
Treatment of ankylosing spondylitis
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
Considerations before starting anti-TNF therapy
Ensure patients are up-to-date with regular vaccinations
Screen for TB including chest x-ray
Character of back, pain in ankylosing spondylitis
Worse in the morning
Gets better throughout the day
Better with exercise
Response to non-steroidal anti-inflammatory medication
Differentials of backpain and associated questions
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
What needs to be ruled out with back pain
Cauda equina syndrome
Examination in suspected ankylosing spondylitis
Check full range of spinal movements
Modified Schober’s test
Check Wall to tragus distance
Management of acute flare of IBD
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
Activity monitoring score in ankylosing spondylitis
Bath, ankylosing, spondylitis, disease, activity, index
Out of 10, score > 4 = active disease
Complications requiring surgery in Crohn’s
Colon dilatation
Fistualting disease
Refeactory to full medical management
Surgery, more likely in current disease due to transmural disease activity
Management of IBD patient after discharge
Tapering course of steroids
Vitamin D and Ca supplementation
Ensure has Gastro plan re Disease-modifying agents (?does she need infliximab)
Malignancy associated with IBD
Particularly in patients with colitis
Patients may need surveillance colonoscopy after 10 years +/- biopsies
Skin rashes associated with IBD
Pyoderma gangrenosum
Erythema nodosum
Association between smoking and Crohn’s disease
Smokers are twice as likely to develop Crohn’s disease
Curative treatment of ulcerative colitis
Total colectomy as disease is only limited to the large colon
Causes of myelopathy
Acute:
Trauma
Vascular
Subacute:
Subacute combined degeneration of cord (most commonly B12 deficiency)
Acute on Chronic:
Relapsing-remitting - e.g. demyelination
Chronic:
Degenerative
How to localise a level of myelopathy
Check for a sensory level - expect upper motor neuron features below the level and potentially lower motor features at the level of lesion
Investigations in a patient with a myelopathy
Bloods - FBC, haematinics, ESR, consider AI screen, renal, liver, U&Es, copper studies
Urgent MRI spine
Management of degenerative, cervical myelopathy
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
Pyramidal signs in one limb with hyperaethesia to sharp touch on contralateral signs
Partial brown-sequard syndrome
What always needs to be done with a suspected myeloapthy
Check for sensory level
Timing of MRI spine in myelopathy
Urgency should be reflected characterised by timing of onset of symptoms. In patients with acute onset symptoms same day, MRI should be performed.
Management of metastatic cord compression
Consider radiotherapy
What is Kernig’s sign
Neck pain on extension of the knees due to meningeal inflammation
Types of meningitis
Bacterial viral, fungal, protozoal, lyme
Also, can consider paraneoplastic or malignant
Management of suspected meningitis
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
LP findings in bacterial versus viral meningitis
Bacterial
- raised WBC - neutrophilia
- Raised protein
- Low glucose
- +ve gram stain
Viral
- Raised WBC - lymphocytes
- Serum:CSF glucose ratio should be normal
Complications of meningitis
Death
Neuro:
Deafness and blindness
Cognitive impairment
Vascular:
Amputations 2o sepsis syndrome
Headache DDx
Infective:
R/o meningitis
Could be associated with viral illness
Abscess
Neoplastic:
SOL
Vascular:
Subarachnoid haemorrhage
Venous sinus thrombosis
Tension type headache
Migraine
Management of migraine
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
High risk features in history of patient presenting with headache
Check for immunosuppression
previous HIV infection
Exposure to others with meningitis
Positive travel history
Migrainous, headaches, unilateral or bilateral
Unilateral
Typical migrainous, headaches features
Preceded by aura
Unilateral
Throbbing nature
Disabling for patient
Associated with nausea and photophobia
30% may have associated focal neurological deficit
Preciptants associated with migrainous headaches
Stress
Fatigue and sleep deprivation
Chocolate and red wine
Red flag features for headache
Age, more than 50 years
Limb weakness, or abnormal neurological features
Confusion
Woken from sleep
Worse with exertion, position, coughing or sneezing (raised ICP)
Issue with performing LP with raised ICP
Risk of brainstem herniation through foramen magnum
Screening test acromegaly
Insulin like growth factor one
Following this do glucose tolerance test and there should be failure to suppress growth hormone
Screening test for obstructive sleep apnoea
Consider overnight sleep studies and overnight pulse oxymetry
Imaging test in acromegaly
MRI head, looking for pituitary involvement
Organs affected in acromegaly
Multisystem disease
Cardiomyopathy & IHD
HTN & T2DM
Visual impairment
Visual disturbance in acromegaly
Typically, bitemporal hemianopia secondary to compression of the optic chiasm, due to pituitary adenoma
Treatment of acromegaly
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
Main complication of transphenoidal surgery in acromegaly
Panhypopituitarism
Why is acromegaly associated with obstructive sleep apnoea?
Secondary to soft tissue swelling in the face and neck, resulting in mechanical respiratory obstruction when lying flat
Sleepiness score in OSA
Epworth sleepiness scale
Out of 24, a score of more than 11 may indicate OSA
Why does OSA lead to daytime somnolence?
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
Main treatment of OSA
CPAP
Main features to examine in acromegaly
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
Kidney transplant scar name
Rutherford Morrison
Bony complication associated with steroid use
Avascular necrosis typically of the hip
Investigation to assess for failing, renal transplant graft
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
Weight loss in context of immunosuppression
Think malignancy - post-transplant lymphoma or skin malignancy
Also rule out chronic infection
Blue discolouration of eye and recurrent fractures
Osteogenesis imperfecta
Investigation’s osteogenesis imperfecta
Bloods - Bone, Vit D, PTH
Genetic testing
Radiographs of bones
DEXA
Echo
Tx osteogenesis imperfecta
Replace electrolytes as required
Consider bisphosphinates dependent on DEXA
OT/PT review ?walking aids ?orthotics
Cardiac complication associated with osteogenesis imperfecta
Bicuspid aortic valve
Can lead to AR over time due to a lack of valve collagen
Inheritance osteogenesis imperfecta
Auto dominant
8 variants
Bony complications of bisphosphonates
A vascular necrosis of jaw
Non bony complications of osteogenesis imperfecta
Translucent teeth
Hearing impairment
Bicuspid AV
Complications of Ehlers Danlos syndrome
Joint deformity secondary to hypermobility
CVS - MV prolapse or regurgitation, AR
Vascular aneurysm
Ophthalmology- risk of glaucoma and retinal issues
Treatment for Ehlers Danlos
Largely supportive
Ot pt
Analgesia for joint issues
Address complications as they arise
Genetics of Ehlers Danlos
Mixed
Can be autosomal dominant or recessive
Can also be caused by de novo mutations
Resulting in defective collagen synthesis
Initial is for suspected haem malignancy with neck mass and splenomegaly
Bloods - Fbc, blood film, u & electrolytes, monospot ? Infectious mononucleosis
Ando USS to characterise splenomegaly
Ct CAP ?primary ?lymphadenopathy
LN biopsy
PET scan
Young patient with neck lump and splenomegaly ddx
Infection ?infectious mononucleosis
Haematological- lymphoma, leukaemia
Difference between FNA and biopsy
Biopsy gives histology and cytology
FNA cytology only
Granuloma on biopsy
Ddx are TB (caseating) vs Sarcoidosis
Ix suspected Sarcoidosis
After histology shows granuloma
CXR ?bilateral hilar lymphadenopathy
Check Ca and serum ACE
Lung function tests
Stroke like symptoms in young female patient, what should you always ask?
Any pregnancy Hx? Any miscarriage? Risk of anti-phospholipid syndrome
Are they on OCP?
Ix suspected TIA
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
Management post TIA
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
Treatment of antiphospholipid syndrome
Anticoagulation
Warfarin recommended over DOAC
But to be discussed with haematology & refer to local guidance
Cause of stroke or TIA in young patient
Anti-phospholipidsyndrome
Carotid/vertebral artery dissection secondary to trauma
Vasculitis
Substance abuse - Cocaine / amphetamines
Rarer - mitochondrial disorders - MELAS
Stroke in young afro-carribean patient
Think of sickle cell disease
Patient with lung transplant presenting with progressive breathlessness - what to think about?
Immunocomprised - ?PJP ?CMV ?fungal
Chronic rejection of lung - this give an obstructive picture on LFTs, in keeping with bronchiolitis obliterans
Anticoagulation duration in provoked, pulmonary embolism
Three months
Pleuritic chest pain & haemopytisis DDx
PE
Pneumothorax
Infection
Features of the pericarditis chest pain
Worse on lying down and relieved by leaning forward
What risk or can we used to Stratified patients with Venous thromboembolic disease.
Wells score
When use V/Q scan over CTPA
Pregnant patients
Renal impairement cannot tolerate contrast
Stroke complications
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
2o prevention stroke
Antiplatelets - Clopi following high dose aspirin for 2 weeks
High dose statin therapy
Control RFs - HTN / Glycaemic control / stop smoking / improve diet and exercise
Retinitis pigmentosa findings
bone spicule pigmentation of retina
Bilateral progressive visual loss DDx
Glaucoma
Cataracts
Diabetic Retinopathy
Vit A deficiency
Macula degeneration
Pipilloedema 2o IIH
Retinitis Pigmentosa
Management of Retinitis Pigmentosa
Confirm diagnosis via Opthalmology
Genetic counselling
Supportive therapy - visual aids
Inheritance of retinitis pigmentosa
AD / AR / X-linked
30% de novo
Syndromes associated with retinitis pigmentosa
Multiple syndromes
Inc. Ushers & Kearns-Sayers
Retinitis Pigmentosa & Driving
Need to inform DVLA - strict guidelines on visual acuity and visual field loss
Joint pain following infection
Reactive arthritis
Sti leading to reactive arthritis
Chlamydia
Arthritis caused by gonococcal infection
Typically septic arthritis
Treatment of reactive arthritis
Supportive
Analgesia
Maintain mobility possibly with PT input
Treat underlying cause - eg infection / abx
Genetic association with reactive arthritis
Associated with HLA B27
Seronegative spondyloarthropathies
Associated with psoriatic / enteric / reactive arthritis and ank spond
Organisms causing reactive arthritis
Chlamydia
Salmonella
Campylobacter
Bloods to send in suspected reactive arthritis
Fbc crp lft renal urate RF esr anti-ccp
What is hashimotos thyroiditis
Most common cause hypothyroidism
Due to lymphocytic infiltration, subsequent inflammation and fibrosis of thyroid gland
Antibodies for Hasimotos
Anti tpo
Anti thyroglobulin
Diseases associated with hashimotos
Autoimmune conditions
Vitiligo
Addisons disease
De quervains thyroiditis
Period of hyperthyroidism due to thyroid follicle destruction followed by hypothyroidism when thyroid regenerates. Then back to euthyroid.
Symptoms and signs of hypothyroidism
Lethargy
Muscle weakness
Cold intolerance
Weight gain
Low mood
What is myxoedema
Periorbital oedema
Thick waxy skin
Brittle hair
Hypothyroidism DDx
Hashimotos
De quervains
Drugs - carbimazole / propylthiouracial / Li / interferons
Radiodine therapy
Hypothyroidism DDx
Hashimotos
De quervains
Drugs - carbimazole / propylthiouracial / Li / interferons
Radiodine therapy
Screening test for Addisons disease
9am cortisol
Starting dose of levothyroxine
25-75ug
Lower in elderly
Titrate to TFTs
Complications associated with prolonged use of Steroids
Development of cushingoid appearance
Increase risk of IHD
Diabetes
Thin skin & easy bruising
Adrenal failure
Triggers of myasthenic crisis
Infection
Stress e.g. operation
Withdrawal of steroids / immunosuppression
Patient with suspected MG what do we need to check
Resp function - spirometry and serial FVC
Pathophysiology of MG
Post-synaptic destruction of ACh receptors
DDx ocular myasthenia gravis
Thyroid ocular myopathy
Cranial nerve / brainstem weakness
Myotonic dystrophy
DDx generalised myasthenia
Generalised fatigued 2o anaemia
MND
Botulism (involves pupillary muscle)
Lambert-Eaton Syndrome - a/w SCLC
Antibody in Lambert-Eaton
Voltage-gated Ca channel antibodies
MG with bulbar symptoms - Ix
MRI brain
What needs to be checked prior to commencing azathioprine
TPMT levels
Why does spina bifida predisopse to recurrent UTI
Neuropathic bladder results in structural changes that increase likelihood of infection
Conditions associated with spina bifida
Limb spasticity
Hydrocephalus (requiring VP shunt)
Arnold-Chiari malformation
Bladder and bowel dysfunction
What is a spina bifida?
Part of the neural tube does not develop or close properly, leading to defects in the spinal cord and bones of the spine
RFs for spina bifida
- Folate deficiency - folic acid supplementation during conception and pregnancy
- FHx neural tube defects
- Drugs - sodium valproate / methotrexate
- Poorly controlled DM
Treatment of bladder dysfunction in spina bifida
Regular bladder catheterisation
Anti-muscarinic drugs
Treatment of pyelonephrosis
Emergency - nephrostomy
Why are L sided murmurs louder on expiration?
Increased venous return to L side of heart
Peripheral signs of infective endocarditis
Splinter haemorrhages
Janeway lesions
Osler Nodes
Roth spots - Retinal emboli
Murmurs
Haematuria on dip stick
Evidence of peripheral septic emboli
What is coarctation of the aorta?
Congential narrowing - typically distal to L subclavian artery
Clinical signs of coarctation
Radio-radial & radio-femoral delay
systolic murmur, loudest posteriorly
Complications of aortic coarctation
Stroke
HF
Aortic rupture
Management of coarctation
Balloon angioplasty and stenting
Open resection and anastomosis - preferred
blue-grey discolouration of the eye ball
Scleromalacia
Anaemia secondary to rheumatoid arthritis
Anaemia of chronic disease
Iron-deficiency anaemia (secondary to peptic ulceration due to chronic NSAID use)
BM suppression secondary to DMARDs
AI haemolytic anaemia
Management of Rheumatoid Arthritis
MDT
PT - maintain mobility
OT - adapt home and work environments
Rheum - DMARDS - methotrexate / sulphasalazine - if fail 2 therapies consider biologics - rituximab / tociluzimab
Describe hand changes in RA
Symmetrical deforming poluyarthropathy
Genetic association with RA
HLA-DR4
Disease activity score in RA
DAS-28
Score >5.1 = active disease
Score <2.6 = remission
Extra-articular features of RA
EYES
Episcleritis - painless
Scleritis - painful
LUNGS
Pulmonary fibrosis / nodules / effusion
KIDNEY
Nephrotic syndromes
Extra renal manifestation ADPKD
Liver cysts
Berry aneurysms
Mv prolapse
Loin pain APCKD
Cyst enlargement rupture or haemorrhage
Renal stone
Infection
Complications of immunosuppression
Direct - tremor, htn, diabetes
Infection
Malignancy
Med to slow progression of ADPKD
Tolvaptan
Types of muscular dystrophy
Duchenne / Becker - severe weakness expected in childhood
Facioscapulohumeral
Limb girdle
Orophayngeal
Myotonic
Ix suspected muscular dystrophy
Complete neuro exams
Bloods inc CK
Nerve conduction and EMG
Muscle biopsy
Genetic testing
Management of muscular dystrophy
No disease modifying therapies
Supportive
OT / PT
SLT
Features of Parkinsonian gait
Stooped posture
Reduced arm swing
Shuffling
Difficult turning
Festination
Distraction technique to exacerbate Parkinsonism
Synkinesis
Causes of Parkinsonism
Idiopathic Parkinson’s disease
Parkinson’s plus syndrome
Vascular Parkinsonism
Lewy body dementia
Medication induced
Meds induced - Antipsychotics - Haloperidol
Pathophysiology of PD
Destruction of dopaminergic neurones in the substantia nigra
Eye complication of Marfans
Ectopia Lentis
