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Essential > Illness scripts > Flashcards

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)
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2
Q

Heel pain worse in the morning, better with activity

A

Plantar fasciitis

MX = plantar fascia stretching exercises

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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
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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
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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)
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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)
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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
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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
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9
Q
  • …
A

Ankylosing spondylitis

  • …
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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
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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
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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
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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
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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
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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

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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
Q

List 4 key features of chronic fatigue syndrome (aka myalgic encephalomyelitis)

A
  • 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
Q
  • 28yo male
  • 2-3 year history of back pain, worse in the morning
  • No trauma reported
  • Ibuprofen helps
  • HLA-B27 genotype positive
A

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
Q
  • Polyarthritis
  • Acute gastroenteritis 2 weeks ago
  • Intermittent urinary frequency
  • Eyes feel gritty, teary
A

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
Q

List 5 key features of fibromyalgia

A

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
Q
  • Asymmetric sensorineural hearing loss
  • Gradual onset
  • Older patient
  • +/- tinnitus and vertigo
A

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
Q

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?

A

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
Q
  • 28 yo female
  • ‘Clicking’ of jaw L>R
  • Some pain with chewing, opening mouth
A

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
Q
  • Infant
  • White patches in the mouth
  • Recent course of antibiotics for URTI
A

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
Q
  • 32yo male
  • Develops gradual onset SOB and wheeze
  • No history of asthma, non-smoker
  • No occupational hazard exposure
  • Imaging shows pan-acinar emphysema
A

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
Q

List 5 key features of sarcoidosis

A

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
Q
  • 5yo
  • Recent bout gastroenteritis - with bloody diarrhoea
  • Dehydrated
  • Dark coloured urine
  • Bloods show anaemia and thrombocytopenia
A

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
Q

List 4 key features of TTP

A

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

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