Illness scripts Flashcards
1
Q
Severe, ‘lightning shock’ pain over face
May be triggered by eating, jaw movements, touch
A
Trigeminal neuralgia
- MX 1st line = carbamazepine 100mg BD
- Other = microvascular decompression of abnormal loop of artery (usually superior cerebellar)
2
Q
Heel pain worse in the morning, better with activity
A
Plantar fasciitis
MX = plantar fascia stretching exercises
3
Q
- 25 yo female
- Weakness when chewing and lifting things with arms
- Fatigability
A
Myasthenia gravis
- IX = ACh receptor Abs or MUSK Abs, nerve conduction studies/ EMG
- MX = acetylcholinesterase inhibitors e.g. pyridostigmine
4
Q
- 1 week of bilateral upper limb weakness, worsening over time
- Initially only hands affected
- Reduced supinator reflex bilaterally
- Recent gastroenteritis infection
A
Guillain-Barre syndrome (aka acute inflammatory polyradiculoneuropathy)
- Demyelination of nerves - may have preceding infection
- Symmetrical limb weakness, starting peripherally +/- sensory disturbance
- Maximum disability by 3-4 weeks - possibly to complete quadriplegia and respiratory paralysis
- IX = LP (elevated proteins), nerve conduction studies (abnormal)
- MX = plasma exchange or IV immunoglobulin
5
Q
- 72 yo male
- Localised tenderness to upper thigh gradual onset, nil trauma
- PMH OA
- Bloods show high ALP, normal calcium
A
Paget disease
- High ALP, normal Ca
- Excessive abnormal bone remodelling - enlarges and deforms bone
- Unknown cause
- Usually >50yo
- IX = high ALP + paget lesions on x-ray or bone scan
- MX = bisphosphanate if symptomatic or site at risk of complication (e.g. #, deformity)
- 1st line = 5mg IV zoledronic acid (over 15 mins)
6
Q
- 67 yo male
- Notices his cap doesn’t fit him anymore
- Otherwise asymptomatic
A
Paget disease
- MX = bisphosphanate (if symptomatic or at risk of complication - e.g. in this case already has deformity affecting activities)
- 1st line = 5mg IV zoledronic acid (over 15 mins)
7
Q
- 2 month old baby
- ‘Salty’ skin
- Frequent loose and oily bowel motions
- Recurrent ‘wet’ sounding cough
- Poor weight gain
A
Cystic fibrosis
- Up to 90% detected on newborn screening
- Autosomal recessive
- Abnormally thick and sticky secretions
- IX = sweat test (?high chloride), CF genotype
- MX = management of complications, early aggressive Abs, chest phyiotherapy, mucolytics, multidisciplinaty CF team care
- Pseudomonas = common lung coloniser
8
Q
- 4 week old boy
- Projectile vomiting after feeding - progressively worsening over last week
- No diarrhoea
- Weight gain faltering over last week
A
Pyloric stenosis
- Often presents 2-6 weeks of age
- M>F, may have family history
- Vomiting non-bilious, blood-stained in 10%
- IX = capillary/ venous blood gas and electrolytes, abdo US detects 95% of cases
- May seen hypochloraemic hypokalaemic metabolic alkalosis
- MX = NBM, NGT, IV hydration, electrolyte correction -> then surgical correction
9
Q
- …
A
Ankylosing spondylitis
- …
10
Q
- 48yo male
- Recurrent blocked nose, history of allergic rhinitis
- Grape-like mass seen in left nostril
A
Nasal polyps
- Overgrowth of sinus lining
- Risk factors = allergic or infective rhinosinusitis
- MX = intranasal corticosteroid spray e.g. mometasone intranasal 2 sprays nostril OD
- Surgery -> 50% will recur
11
Q
- Vertigo with certain head movements
- Brief duration
- Rotational nystagmus
- Nausea
A
BPPV [benign paroxsymal positional vertigo]
- DX = Hallpike manouvre
- MX = avoid exacerbating movements, Epley manouvre
12
Q
How can vestibular migraine be differentiated from BPPV?
A
- Vertigo not associated with movement
- Hallpike will not trigger attack
- May be associated with a headache
13
Q
- Sudden onset continuous rotational vertigo
- Nausea, vomiting
- Reduced hearing
- No relief with any position
- Loss of vestibulo-ocular reflex (ability to keep eyes focused on object with quick movement of eyes)
A
Vestibular neuritis (labyrinthitis)
- DX = head thrust test (loss of vestibulo-ocular reflex on one side)
- MX = supportive (e.g. anti-emetics)
- Lasts days
- May be associated with URTI/ otitis media
14
Q
- Episodes of reduced hearing, tinnitus, vertigo
- Well in between
- Age >60yo
A
Meniere’s disease
- Unknown aetiology - ?increased fluid in cochlear
- Fluctuation sensori-neural hearing loss -> eventually permanent hearing loss
- <10% may get ‘drop attacks’ - sudden fall, no LOC, immediate recovery
- MX = no known cure, betahistine is 1st line (vasodilator), surgery has variable effect
15
Q
List 5 differentials for vertigo
A
- BPPV
- Meniere’s disease
- Vestibular neuritis (labyrinthitis)
- Vestibular migraine
- Cerebellar stroke
IX = Hallpike manouvre (BPPV), head thrust test (vestibular neuritis), CN + neuro exam (?nystagmus, CN deficit + upgoing plantars in cerebellar stroke), +/- CT/ MRI brain, hearing assessment
16
Q
Painless swelling
A
Ganglion
- Firm swelling, trans-illuminates
- Most common around wrist/ hand and ankle/ foot
- MX = monitor (may resolve on own), needle aspiration, surgical removal
17
Q
- 50yo female
- Bilateral tingling/ reduced sensation in thumbs and 2-3rd fingers
- Worse overnight and in the morning
A
Carpal tunnel syndrome
- Median nerve entrapment
- Risk factors = acromegaly, pregnancy, obesity, repetitive movements of wrist, female, age >30yo, rheumatoid arthritis
- CF = numbness/ tingling in thumb, 2-3rd fingers, half of 4th finger, aching wrist, clumsiness
- DX = EMG/ peripheral nerve conduction study (Tinel and Phalen -> variable sensitivity)
- MX = wrist splint at night, corticosteroid injection, surgical release
18
Q
- 60yo woman
- Pain/swelling over wrist on back of thumb
- Pain with moving thumb
- Works as typist
A
De quervains tenosynovitis
- Thumb extensor tendonitis (responsible for ‘thumbs up’) - of abductor pollicis longus & extensor pollicis brevis
- CF = diffculty moving thumb, pain/ swelling between wrist and thumb
- IX = US
- MX = splinting, oral NSAIDs, massage, exercises (OT), corticosteroid injection, surgical release
19
Q
- 14 yo boy
- Delayed puberty, small penis
- No sense of smell
A
Kallman syndrome
- M>F 5:1
- Inherited condition
- GnRH deficiency (hypogonadotrophic hypogonadism)
- Causes delayed puberty, infertility
- MX = hormone replacement
20
Q
2yo
Acute onset refusing to stand on R leg
A
Toddler’s fracture
- Usuallu 9mo - 3yo
- Undisplaced spiral or oblique tibial fracture
- X-ray often normal - repeat in 7-10 days
- Apply backslab + review in # clinic 2/52
21
Q
- Persistent arthritis that begins <16yo
- Mild-moderate pain
- Large joints more commonly affected
A
Juvenile idiopathic arthritis
- DX = often clinical
- IX = ESR/ CRP may be elevated, FBC may show anaemia of chronic disease
- If RF/ ANA positive -> poorer prognosis
- US confirms joint effusion
- Uveitis = most common extra-articular manifestation of JIA
- MX = 1st line NSAIDs
- Also panadol, low dose opioids
- +/- methotrexate
- +/- corticosteroids
- +/- biologic agents
- Prognosis = ~50% into adulthood will be in remission
22
Q
- Child
- Highly active
- Gradual onset heel pain
- Limping after activity
- Common
A
Sever’s disease (calcaneal apophysitis)
- X-ray likely normal -> diagnosis is clinical
- MX = supportive
- Calf stretching exercises (before & after exercise)
- Simple analgesia + ice if sore
- Trial gel heel pads into shoes
- Modify activities if causing pain
- Prognosis = settles within 6-12 months (sometimes up to 2 years)
23
Q
- 2yo
- Sore arm after being pulled up from the ground
- Not using the arm - elbow held in extension
- No redness/ swelling/ bruising
A
Pulled elbow (subluxation/ partial dislocation of radial head)
- 50% have no history of being pulled
- 1-4yo most common age
- Distressed with elbow movement
- DX = clinical (x-ray only if swelling/ bruising/ deformity, or failed reduction)
- MX = reduction - ‘pronation/ flexion manouvre’ (pressure over radial head -> fully pronate arm & flex elbow)
- Review after 10 minutes -> if failed, for ED/ x-ray
24
Q
- 14yo boy
- Knee pain for >2 weeks
- Active - plays sports
- Worse with running/ jumping
- Pain localised to tibial tuberosity
A
Osgood Schlatter syndrome
- Common, 10-15yo, M>F
- Repeated micro-trauma of patella tendon insertion at tibial tuberosity (vulnerable in early adolescence)
- Bilateral in up to 50% of cases
- DX = clinical
- Pain +/- swelling over tibial tuberosity
- Pain with straightening flexed knee against resistance
- X-ray can confirm diagnosis if unsure -> may show fragmentation of bone
- MX = conservative
- Ice packs, simple analgesia, avoid exacerbating activity/ modify activity, quadricep + hamstring strengthening exercises, +/- physiotherapy
- Rarely - surgery (excision of bone fragments/ free cartilage), if symptomatic despite conservative management
25
List 4 key features of chronic fatigue syndrome (aka myalgic encephalomyelitis)
* Still largely not well understood - further research being done
* Diagnosis of exclusion, no reliable biochemical marker
* Peak incidence 20-40yo, F\>M, may be preceding infection or psychological trauma
* CF = \>6 months of persistent or relapsing fatigue, not improved by rest, post-exertion malaise \>24hrs, unrefreshing sleep, impaired memory/ concentration, myalgia, arthralgia, headache, tender cervical/ axillary LN, sore throat
* May resolve spontaneously - MX is supportive (graded exercise, +/- CBT)
26
* 28yo male
* 2-3 year history of back pain, worse in the morning
* No trauma reported
* Ibuprofen helps
* HLA-B27 genotype positive
Ankylosing spondylitis
* 1 in 200, onset \<40yo, M\>F, +/- 1st degree relative affected
* Gradual onset, morning stiffness, improves with activity
* Reduced spinal mobility (modified Schober test) - normal in early disease
* CF:
* SIJ pain, back pain
* +/- peripheral arthritis, enthesitis (insertion of tendons)
* Uniocular anterior uveitis 40% (acute painful red eye, blurred vision, photophobia) -\> eye specialist
* Complications = osteoporosis, pulmonary fibrosis 15%, aortic valve incompetence 10%
* IX:
* ESR/ CRP elevated in ~50-75%
* HLA-B27 positive in 85-90% of patients
* Pelvic x-ray, lumbar x-ray (mild to advanced changes)
* MX = exercise/ stretching program, NSAIDs, +/- TNF inhibitors, +/- DMARDs (more useful for ass. arthritis)
27
* Polyarthritis
* Acute gastroenteritis 2 weeks ago
* Intermittent urinary frequency
* Eyes feel gritty, teary
Reactive arthritis
* Post-infective inflammatory arthritis - usually 2-3 weeks post infection (may not always have clear Hx of infection)
* Usually post gastroenteritis (bacterial), genitourinary (especially chlamydia)
* Uncommon ~3 in 10,000 people per year
* CF:
* Asymmetrical arthritis \<4 joints, usually lower limbs
* +/- dactylitis (inflamed entire finger or toe, 'sausage')
* +/- conjunctivitis (1/3 pts)
* +/- urethritis/ prostatitis/ balanitis
* +/- pustular rash on hands and feet
* MX = NSAIDs, +/- corticosteroids
* Prognosis = 80% resolve within 6 months, 20% develop chronic reactive arthritis
28
List 5 key features of fibromyalgia
Fibromyalgia
* Chronic diffuse non-inflammatory soft tissue pain
* Common, poorly understood, more research being done
* +/- fatigue, cognitive 'clouding', sleep disturbance, low mood, irritable bowel or bladder
* CF = diffuse soft tissue pain, allodynia (pain induced by normal touch)
* IX generally normal (ESR/ CRP/ ANA/ RF)
* MX (consider rheumatology referral if DX uncertain):
* Patient education, graded aerobic exercise, +/- CBT, sleep hygiene, yoga/ tai chi
* Medications (TCA e.g. amitriptyline 10mg nocte, gabapentinoid e.g. pregabalin 25mg nocte, SNRI e.g. duloxetine 30mg)
29
* Asymmetric sensorineural hearing loss
* Gradual onset
* Older patient
* +/- tinnitus and vertigo
Acoustic neuroma
* AKA vestibular Schwannoma -\> benign tumour of Schwann cells of vestibular nerve (part of CN VIII)
* MRI brain = diagnosis
* MX = surgical resection vs monitoring
30
Most dental infections can be adequately treated with local dental treatment alone. If local swelling and systemic signs (e.g. fever), what antibiotics are indicated?
1st line = phenoxymethylpenicillin 500mg QID for 5 days PO
2nd line = amoxicillin 500mg TDS for 5 days
If penicillin immediate hypersensitivity -\> clindamycin 300mg TDS for 5 days
31
* 28 yo female
* 'Clicking' of jaw L\>R
* Some pain with chewing, opening mouth
TMJ dysfunction
* Peak incidence 20-40yo, F\>M
* Most cases resolve within a month of conservative mx
* RF = bruxism, chewing gym frequently, jaw clenching
* CF = clicking/ crepitus with jaw movements, tender TMJ, restricted jaw movement, pain with jaw movement
* DX = clinical
* MX = simple analgesia, rest from exacerbating movements (e.g. avoid gum, cut food into small pieces), TMJ exercises, review response in 2-4 weeks
* Dentist if bruxism - for splint
* Maxillofacial surgeon if persistent/ severe - intra-articular injection, rarely surgery
32
* Infant
* White patches in the mouth
* Recent course of antibiotics for URTI
Oral candida
* Risk factors = inhaled corticosteroids, antibiotics, immunosuppression (e.g. HIV, leukaemia), poor oral hygiene, dentures, dry mouth (salivary gland hypofunction)
* MX =
* Amphotericin lozenge 10mg QID after food for 7-14 days, or
* Miconazole gel 2% QID after food, or
* Nystatin 100,000U/mL 1mL QID after food
33
* 32yo male
* Develops gradual onset SOB and wheeze
* No history of asthma, non-smoker
* No occupational hazard exposure
* Imaging shows pan-acinar emphysema
Alpha 1 antitrypsin deficiency
* Autosomal co-dominant (1 allele milder than having 2)
* Onset usually 20-50yo, 1 in 2,500 people
* Smoking worsens prognosis
* Complications = COPD (emphysema), hepatitis, 15% adults liver cirrhosis, 10% of neonates develop jaundice, rare - panniculitis (skin involvement)
* DX = alpha 1 antitrypsin levels (acute phase reactant - may be falsely elevated), genotyping
* MX = manage complications (e.g. bronchodilators)
34
List 5 key features of sarcoidosis
Sarcoidosis
* Disease of unknown cause - development of non-caseating granulomas in multiple organs (most often lungs + LN)
* Most common 20-40yo
* Diagnosis of exclusion (no specific test)
* Common CF = fever, cough, polyarthralgia, erythema nodosum rash, bilateral hilar lymphadenopathy on CXR
* +/- high calcium, restrictive pattern on spirometry
* Most pts don't need treatment
* If needed - corticosteroids, DMARDs e.g. MTX
* Prognosis = good; remission in 70% of patients
35
* 5yo
* Recent bout gastroenteritis - with bloody diarrhoea
* Dehydrated
* Dark coloured urine
* Bloods show anaemia and thrombocytopenia
HUS [haemolytic uraemic syndrome]
* Type of thrombotic microcangiopathy (same as TTP)
* Follows infection - usually toxigenic Escheria coli infection, may also occur in Shigella and Strep pneumoniae
* AKI (high Cr, haematuria, proteinuria) + thrombocytopaenia + microangiopathic anaemia (type of haemolytic anaemia - burr cells, schistocytes on blood film)
* Usually children \<5yo
* High mortality (3-5%), 50% will need dialysis
* MX = supportive
36
List 4 key features of TTP
TTP [thrombotic thrombocytopaenic purpura]
* Type of thrombotic microcangiopathy (same as HUS)
* AKI more often in HUS, systemic sx and neurological injury more often in TTP
* Rare, may be inherited or acquired
* Multi-organ involvement -\> usual CF = purpura/ bruising, fever, jaundice or pallor, fatigue
* Haemolysis + thrombocytopaenia + renal dysfunction + neurological findings
* MX = fresh frozen plasma
