Gardens Flashcards
Sub Arachnoid Haemorrhage
Radiodense material in the ventricles, sulci, basal cisterns and fissures is blood in the subarachnoid space
Don’t confuse with a calcified choroid (normal finding)
Image Modality = CT (note the bones are white and fluid is normally black)
MR Venography
Contrast study taken in the venous phase to see the intracranial sinuses
used to identify VEnous sinus thromboses
(V. Unlikely to come in an exam but just in case)
MRI Head
Magnetic Resonance Imaging (radiosignals cause protons to spin and as they turn back to normal position the signal is detected via radiofrequency detection)
Excellent soft tissue resolution (note how bone is dark)
T1- structural visulisation. fluid = low attenutaiton. fat= high attenutation
can use with gadolinium (high attenuation)
Can suppress fat
T2. - Good for fluid. Fluid = high attenuation. fat = high attenuation
Can suppress fat.
FLAIR = Fluid attenuating. Good for visualising fluid in tissues where it’s not meant to be (parenchymal oedema) as it attenuates CSF for example
Diffusion weighted = asses how freely fluid moves around. If moves less = infarctive pathology
Subdural Haemorrhage
There is a hyperdense crescenteric area overlying the right frontal and temporal areas of this image. There is associated ventricular effacement and midline shift
This is likely to be an acute SDH as the blood is white —> turns dark overtime as the clot becomes chronic.
mx:
i) Craniostomy with burr hole irrigation
ii) craniotomy
Extra Dural Haematoma
There is a hyperdense eliptical region overlying the right fronto-temporo-parietal region. It is associated with ventricular effacement and midline shift
The image modality is a CT scan
Mx
i) Craniectomy
medical:
Nueroprotective ventilation: High O2 with maintenance of normocapnea
Mannitol/ Hypertonic Saline
Cerebral Abscess
(Pre and Post contrast CT is common practice/ unless MRI is planned) DW MRI is the best
Ring enhancing lesion (iso/hyper dense rim with central low attenuation area) surrounding by low attenuation area of vasogenic oedema. Can be associated with midline shift and effacement of ventricles if large enough. if more than one ring enhancing lesion ? other diagnosis i.e.e (diffuse primary cerebral malignancy)
Causes - Ear infection, throat infection, Teeth infection, Bronchiectasis, Immunosuppression, Cardiac disease
Battle Sign ( Mastoid Ecchymycoses)
Sign of base of skull fracture
Racoon Eyes
periorbital echhymyosis
Sign of base of skull fracture
Rarely - in older people in the absence of head injury or possibility of SOL etc. etc. —> Periorbital purpura. Sign of primary amyloidosis
Tonsillar herniation
The arrow points to herniation of cerebellar tonsil through the foramen magnum due to raised ICP (or the introduction of LP when there is already raised ICP) —> leading to compression of the brainstem.
Nearly always fatal —> leads to brainstem death
Raised hemidiaphragm
Phrenic nerve palsy
Thenar wasting
Median nerve palsy
Hypothenar Wasting
Ulnar nerve
Charcot Marie tooth
Inverse champagne bottle legs (peroneal muscle atrophy)
Pes Cavus
Joint deformities
UL - Claw hands, hand wasting
Charcot Joint
manifestation of long term destruction to a weight bearing joint as a result of sensory neuropathy
Myotonic Dystrophy
long expressionless face
bilateral ptosis
facial muscle wasting
Look for - hand wasting, Difficulty inr elaxin when hand shake, percussion myotonia
Myasthaenia Gravis
bilateral ptosis
Myasthaenic snarl on smiling
Voice will tire counting to 50
Fatiguability in muscle groups
eyes droop on prolonged upward gaze
Cafe au lait
NF
Mccune Albright
?urticaria pigmentosa, Multiple lentigenes
Axillary freckling
NF
Ash Leaf
Tuberous Sclerosis
Shagreen patch
Tuberous sclerosis
Neurofibroma
NF
can be itchy, violaceous, may bleed
overgrowth of nerve trunk, large cutaneous trunk
iris hamartoma
NF
Ret Hamart
TS
vest schwann
this is an MRI of a brain in the transverse plane. It is in line with the globes and the cerebellum. there is a gad-enhancing lesion situated at the CPA.
This is a vestibular schwannoma
Bouchard Node
Swelling of the PIP
OA
Bony spur
Heberden Nodes
Swelling of the DIP
OA
bony spurs
Squaring of the thumb/Carpo metacarpal joint
OA
Swan Neck Deformity
Hyperextension of PIP / Hyperflexion of DIP
RA
Boutonniere deformity
Hyperflexion of PIP, hyperextension of DIP
RA
Z thumb deformity
Extension of CMC Joint and Flexion of IP
RA
Ulnar deviation
Ulnar deviation of hand joints
RA
Gouty Tophi
Collections in pinna and tendons
Gouty Podagra
Classic inflammation of the base of first metatarsal phalangeal joint
X ray of gout
Soft tissue swelling
Joint effusion
Well defined punched out eccentric erosion
Joint space is preserved to late disease
Pencil in cup
Psoriatic arthritis (NB this is last sign)
Moreso resembles RA but without the juxtarticular osteopenia
CREST syndrome
Limited Systemic sclerosis - CREST features and skin changes on hands, feet, face
This image shows – microstomia and multiple telangiectasia
Smiling can elicit a sclerosis grimace
Sclerodactyly - CREST syndrome
Localised thickness and tightening of the digits
Calcinosis
Yellow, white cutaneous deposits
CREST syndrome
Heliotrope rash
Dermatomyositis
Shawl Sign
Maculopapular rash over hsoulders and back
Dermatomyositis
Nailford erythema
Dermatomyositsi
Gottron’s Papules
Dermatomyositis
Jaccoud’s arthropathy
Non erosive arthropathy characteristically ulnar deviation of 2-5 digits.
Seen in - Post rheumatic fever, SLE, RA, Psoriatic arth etc.
malar rash
Clasically spares nasolabial folds
SLE
Discoid Lupus
NB can affect the scalp causing a scarring alopecia
Bamboo spine / Dagger Sign
Bamboo = ossification of the vertbrae
Dagger sign = ossification of the suprasinatous and interspinous ligaments
Ank Spond
Syndesmophytes
Bone growth occuring from inside a ligmaent
Nodular + Reticulonodular opacities in a patchy distribution (Nb can also be confluent)
Lung bases involved and is bilateral but asymmetrical
Bronchopneumonia
- Key to this one is that the distribution is patchy and bilateral but asymmetrical
Opacification of the right lung in the distribution of the middle lobe as represented by obscured right heart border.
Lobar pneumonia - RML
RUL Collapse
Horizontal fissure has been displaced upwards
Mediastinum is enlarged
Apparent volume reduction of the right lung
Pleural Effusion
Empyema
Distinguishing from PE
- Wide angle with chest wall
- Convex shape
- unilateral/ asymmetrical
Pulmonary Abscess
Radiodense rim
Radiolucent centre
with an air fluid level
Fine reticular interstitial pattern
This is actually PCP pneumonia
- Other features pleural effusions, pneumatocoels, blebs
Peribronch/perivasc infiltrates (lines tracking outward from hilar region)
Basal airspace consolidation
This is actually mycoplasma
Consolidation in RUL
Bulging fissure sign - Horizontal fissure being pushed downward
This is acutally klebsiella pneumonia
Lobar consolidation of the left lower lobe (can’t see the diaphragm but can kind of make out the heart)
Strep pneum
Tram Track opacities
Thickened bronchioled seen in Coronal plane
Increased broncho vascular marking
air fluid levels
mucus pooling
Bronchiectasis, ABPA, CF
Mycetoma
Note there is a mass, in a pre-existing cavity, that is surrounded by a crescent of air.
There isn’t an air fluid level
Aspergillosis can cause a spectrum of conditions:
Asthma
ABPA
Aspergilloma
Invasive aspergillosis
Extrinsic Allergic Alveolitis
Diffuse bilateral coalescent opacities. Alveolar ill-described pattern of shadowing ( looks fluffy). NB the patient is also clearly unwell considering all of the kit visibel on this radiograph
this is actually ARDS but could equally be pulmonary haemorrhage/oedema
Right upper lobe mass - with no air bronchograms
Right sided effusion
Highly suggestive of malignancy
RIght middle zone consolidation (obscuring of right heart border)
Outline of an irregular mass
Highly suggestive of malignancy due to the strangely shaped mass
Widened Mediastinum
Right hilar mass
Tracheal deviation to the right
Right pleural effusion
Suggestive of malignancy ( mediastinal enlargement due to LN involvement)
Veil like shadowin g over L side of heart
L diaphragm raised
Lung volume appears reduced
L upper lobe collapse
Multiple irregular opacities in both lung fields.
Metastatic lung cancer
Multiple well defined round opacities in both lung fields
Cannon ball mets–> highly suggestive of RCC
Bihilar Lymphadenopathy
Stage 1 sarcoid.
Other signs can be seen are - peripheral infiltrates, fibrosis (ground glass reticulonodular shadowing), bullae
DDx for bHL:
Sarcoid
Infections - TB
Malginancy - lymphoma,
Interstitial diseases - EAA, silicosis
Bilateral asymmetrical opacification of lower lobes
Reticular - lines
with some nodularity - blobs
Honeycombing
UL causes - APENT - ABPA, Pneumoconiosis - silicosis, EAA, Seronegative arthropathies- Ank Spond, TB
LL causes - STAIR. Sarcoid, Toxins- nitro, mtx, sulfasalazine, bleomycin, amiodarone, Asbestosis, IPF, Rheumatoid - RF, SLE, Sjogren
Lupus pernio
Hyperinflated chest (flattened diaphragm, “small looking heart”, ribs - more than 6 anterior/ 10 posterior ribs in MCL)
Increased bronchovascular markings
COPD
Remember - posterior ribs emerge near perpendicular to vertebrae then slope downwards
Bronchiectasis
- Tram lining in lower left zone
Pericarditis
Note widespread saddle shaped ST elevation
PR depression
Rx - NSAIDs
Causes
Metabolic
infectious - viral
inflammatory
Endo
Ischaemic
Idiopathic
Torsaides De Pointes
Polymorphic VT
IV Mg 2g IVI
P Mitrale
Bifid p wave due to LA elargement
P Pulmonale
Peaked p wave due to RA enlargement (PHTN, PS)
Left Ventricular hypertrophy + TWI
HOCM
Erythema Ab Igne
Iron deposition in the skin due to heat related haemolysis.
Sign of chronic pain
Erythema Marginatum
Rheumatic fever
Grade 4 hypertensive retinopathy
Cotton wool spots / soft exucdates
Blurred optic disc
Pretibial myxoedema
Grave’s
Thyroid ACropachy/ ?could also be clubbing as they’re very smilar
Pseudohypoparathyroidism/ pseudopseudohypoparathyroidism(normal biochem)
Shortened fourth and fifth fingers
Hyperpigmentation
Think Addison’s
Remember POMC –> MSH + ACTH
NB pigmentation won’t be present in secondary addisons
Cuti Verticis Gyrata
Can be sign of acromegaly
Wilson’s
Kayser Fleischer Ring
Sunflower cataracts
Lichen planus
Purple, polygonal, violacious with wickem’s straie
Lead Pipe
UC
Type of scan?
What is it
Barium Enema
Irregular mucosa
Loss of haustral markings
No skip lesions
UC
Senitnal loop
Pancreatitis (proximal jejunal loop dilatation in LUQ)
Dermatitis herpeteformis
IgA intraepidermal deposition
Rugger jersey spine
Sclerotic vertebral end plates
Renal osteodystrophy
Rigler’s Triad
Gallstone Ileus
- Pneumobilia
- Gall stone at ileocaecal valve
- small bowel obstruction
Small bowel obstruction
Diameter >3
Central
Valvulae coniventes: completely across
LB gas absent
Many loops
Many, short fluid levels
Large Bowel Obstruction
>6cm (caecum >9cm)
Peripheral loccation
Haustra- partially across
LB gas present in rectum
Few loops
Few, long fluid levels
otitis externa
Inflammation/ Infection of external ear canal and structures
- Cons -lifestyle changes
Med - Analgesics
Top acetic acid
Top Abx +/- steroid
top steroid for eczema
Cx - Cholesteatoma, Ostemyelitis of temporal bone, Cerebral abscess —> malignant OE
Bullous Myringitis
Painful haemorrhagic blisters on TM and surrounding meatul structures
Associated with influenza
Otitis Media
Bulgind Red TM
Otitis MEdia with Effusion
Dull, retracted TM
Fluid level behind TM
Flat tympanogram
Chronic SUpparative OM
- Drum perforation with chronic effusoon and hearing loss
Mx - aural toilet
Abx/steroid ear drops
Cholsteatoma
Locally desctructive expansion of squamous epithelium in the middle ear
Mastoiditis
Boggy swelling at mastoid process
Protrusion of ear
Can ahve CNVI/ VII nerve palsies
MX
Iv antibitoics
Mastoidectomy
CN III Palsy
protpsosis, down and out pupil.
(+blown pupil f surgical)
Holmes Adie Pupil
No response to light
Sluggish response to accomodation
Absent reflexes, reduced bp
On slit lamp - iris streaming
Postganglionic parasympathetic nerve damage
Horner’s Syndrome
proptosis
Enopathalmus
Meiosis
(anhydrosis)
Acute glaucoma ( closing of the angle in anterior chamber)
Rfx - shallow anterior chamber, hypermetropia, Drugs - anti cholinergics
Cloudy pupil, red eye, dilated pupil
Very painful
Peripheral loss of vision first
Ix - Tonometry, Gonioscopy. Raised IOP >40 mmhg (normal is 5-20mmHg)
Mx - IV Acetozolamide, Pilocarpine, Timolol
IV mannitol
Peripheral Laser iridotomy
Look for eclipse sign with a flash light - broad shadow = narrow chambger = glaucoma
Anterior Uveitis (Iris, Uveitis = Ciliary Body and Choroid)
Pupil normal
Eye red
Pain on accomodaiton (Talbot’s)
Photophobia
Pain
Normal IOP
irregular pupil
Scleritis - remember to exclude wegener’s!
Causes - RA, SLE, idiopathic, wegener’s
Epscleritis - Vessels will blanche with epinephrine, localised reddening that can be moved over the sclera
Scleritis - doesn’t blanche, won’t move.
Corneal ulcer (Nb good differential is acnathamoeba - swimming pool contact lens wearers)
Bacterial, viral, fungal, inflammatory (RA)
Contact lens wearers
Need ophth referral
Dendritic ulcer
herpes simplex keratitis 5
Herpes Opthalmicum
Herpes Zoster in the CNVI
Hutchinson’s sign (nose tip involvement) —> indicator of imminent occular involvement
optic neuritis
pale optic disc
blurred disc margins
Vitreous Haemorrhage
Central retinal artery occlusion
pale retina, cherrry red macule
Afferent defect
Causes - GCA, THromboembolic causes
Mx - Reduce IOP
Occular massage, Antihyeprtensives, surgical removal of aqueous
Central retinal vein occlusion
- Unilateral visual loss, RAPD
- Stormy sunset appearance
Tortuous dilated vessel,s,
haemorrhages, cotton wool spots
Causes - Arteriosclerosis, DM, HTN, Polycythaemia
Retinal Vein Branch Occlusion
Looks like centreal retinal vein occlusion but the:
tortuosity, haemorrahges and cotton wool ischaemia are more localised
Retinal Detachment
4 Fs - Floaters, Flashes, Field loss, fall in acuity
Pianless
Urgent surgery - vitrectomy with gas tamponade
Optic atrophy ( right image) - think open angle glaucoma
increase cup to disc ratio (usually <0.7)
Mild NPDR
Microaneurysms
Potentially one haemorrhage towards the left of the image
Moderate NPDR
Microaneurysms
Several haemorrhages (look just adjaceent to many of hte aneurysms in this picture)
Severe NPDR
Intraretinal microvascular malformations
Microaneurysms
Haemorrhages
Cotton wool spots
Venous beading
Maculopathy
Cotton wool/ exudates one disc space from the macula
Prolfierative retinopathy
Neovascularisation - good pace to look is over the disc for the exam
IRMAs
Venous Beading
Lots of haemorhage
Lots of ischaemia
Septal haematoma
urgent evacuation and packing required as untreated will lead to cartilaginous necrosis.
HHT - Oromucatenous telangiectasias
EBV tonsillitis
Greyish exudate covering tonsils
Tonsillitis
Most likely strep
Quinsy abscess (peritonsillar abscess)
Uvula is deviated
Mx - Admit, IV abx, I&D
Optic Atrophy
Retinitis Pigmentosa
- pale optic disc
- mid peripheral bony spicules, baring of the retinal pigmented epithelium, vessel attenuation and sparing of the central macula
Causes - mitochondiral cytopathies
- Retinitis pigmentosa AR/ AD
- Friedrich’s Ataxia
- Refsum’s Disease
- Usher’s Syndrome
- Kearne’s - Sayre’s syndrome
Post photocoagulation DM retinopathy
hordeolum Externum
(stye)
Abscess of the pit/ follicle of an eye lash.
Mx - Fusidic acid—-> surgical removal
hordeolum internum (meibomian cyst)
Abscess of meobomian gland
Ptosis
Bilateral causes : Primary ptosis (LPS weakness), MG, Myotonic Dystrophy
Unilateral - Horner’s, CNIII palsy
KW 1 hypertensive retinopathy
Silver wiring / Vessel tortuosity
KW 2 Hypertensive retinopathy
AV nicking
- to me just looks like big/medium vessels are crossing over each other
- look for silver wiring + vessel tortuosity if unsure
KW 3 Hypertensive retinopathy
Flame shaped haemmorhages
KW 4 Hypertensive retinopathy
Papilloedema
Boat Shaped Haemorrhage with pale centre
Roth spot
Infective endocarditis
Kayser Fleischer Ring
Wilson’s
Sunflower cataracts sometimes too
Buerger’s disease
Thromangitis obliteran
Young male smokers
Wet gangrene
Tissue death + infection
Tissue death
Pre gangrene
Gas Gangrene
Clostridium Perfriengens
Mx
Debridement
BenPen Metro
Hyperbaric O2
Venous stars
Haemosiddherosis
venous eczema
Lipodermatosclerosis
Atrophie Blanche
Venous ulcer - medial malleolus, lateral malleolus
Venous stockings
Improve arterial inflow , treat venous stasis issues
Pentoxyflline
Arterial Ulcer - Shin, top of feet, toes, pressure points
Punched out deep ulcer, usually dry
mx
- Improve arterial inflow (Endovascular, surgery, clopidogrel etc.)
- Dressings (manuka honey, alginate, silver, hydrocolloid dressings)
- Vac ( aims to create a closed wound, sub-atmospheric environment ) (reduces interstitial oedema, improves tissue oxdygenation)
- Use maggots for debridement/ surgical debridement , dressing debridement
Vac dressing
Neuropathic Ulcer
Punched out, painless ulcer with surrounding insensate skin
Dupuytren’s
Fibrotic thickening of the palmar fascia
BAD FIBERS
Bent penis - peryiones patch
AIDS, DM
FH
Idiopathic
Booze - ALD
R- retroperitoneal fibrosis, reidels thyroiditis
Epileptic medications - phenytoin
Smoking
hallux valgus
Deviation of the great toe laterally at the MTP joint. May be associated bunyon due to pressure against shoe
Due to inappropriate footwear
Mx - bunion pads, metatarsal osteotomy
