Medical and Surgical shorts Flashcards
Sign of active inflammation in rheumatoid arthritis?
Hot swollen painful joints
Presentation of rheumatoid hands
Symmetrical polyarthritis
+/- signs of active synovitis
+/- signs of cause (nodules, psoriatic plaques)
Findings on systemic examination in rheumatoid arthritis
Skin - steroid use
BP/pulse - increased CVD risk
Eyes - anaemia, scleritis
Heart - pericardial rub
Lungs - pulmonary fibrosis, pleural rub
Abdomen - splenomegaly (Felty’s)
X-ray features of rheumatoid arthritis
Loss of joint space
Periarticular erosions
Deformity
Periarticular osteopenia
Mx of rheumatoid arthritis
Conservative:
PT
OT - aids + splints
Medical:
- Analgesia
- Steroids: IM, PO, periarticular
- DMARDS: Methotrexate
- Biologics
- -> treat CVD risk!!
Surgical:
- Carpal tunnel decompression
- Joint replacement
- Tendon repairs
Extra-articular features of rheumatoid arthritis
Nodules Carpal tunnel Scleritis Pericarditis Pulmonary fibrosis Splenomegaly (Felty's)
What should be monitored in pts receiving methotrexate?
FBC (BM suppression)
LFTs (hepatotoxicity)
CXR (fibrosis)
Name some biologics used to treat Rheumatoid arthritis? what needs to be done for patients first?
Require tuberculin skin test + CXR
Anti-TNF + rituximab
anti-CD20
What is Rheumatoid factor? what is its significance
anti-IgG IgM
Higher titres assoc. w more severe disease + extra-articular manifestations
C-spine problem seen in RA?
Atlanto-axial subluxation: occurs due to weak ligaments
- Can cause progressive spastic paresis due to cord compression
- Pre-op: main risk is during intubation
Facial features of scleroderma
Microstomia
Beaked nose
Telangiectasia
Diffuse vs limited scleroderma
Limited: distribution in limbs + face. progresses over years.
Diffuse; early visceral involvement. Progresses over months
Ix in scleroderma
- Urine dip: haematuria, proteinuria
- ECG: RV strain (st depression + t wave inversion)
- Bloods: FBC, U+Es, !!antibodies!!
- Imaging: CXR, HRCT, echo (pulm HTN)
- Lung function
- Barium swallow
Mx of scleroderma
Raynaud’s: Gloves + hand warmers +/-nifedipine
Oesophageal dysmotility: SALT review + PPI for reflux
Renal: aggressive BP control
pulmonary HTN: sildenafil
Mixed CTD?
RA SLE Scleroderma polymyositis Sjogrens
Mx of chronic limb iscehmia
Conservative: RF optimisation (= HTN/DM control, smoking cessation, diet + exercise)
Medical:
RF control: statin, clopidogrel
Analgesia
Surgical:
Stenting
Bypass surgery
Amputation :(
Critical limb ischemia features
Pain Pallor Pulseless Parasthesia Perishingly cold Paralysis
Causes of medical 3rd nerve palsy
- DM
- MS
- Midbrain infarction: Contralateral hemiplegia
- Migraine
Ddx for surgical 3rd nerve palsy
***PCA aneurysm!!!!
Cavernous sinus thrombosis
Trauma
Raised ICP: transtentorial herniation
initial mx of hip fracture
ABC: resus
Analgesia
Assess neurovascular status of limb
IMAGING - orthogonal views
Prep for theatre: Anaesthetist - inform + book for theatre Bloods - FBC, clotting, G+S, Xmatch, U+E CXR DVT prophylaxis ECG
Indications for amputation
Dead: PVD Sepsis Trauma Burns Frostbite
Complications of amputation
Early:
Bleeding, infection (cellulitis, gangrene, osteomyelitis), DVT
specific: MI/stroke/angina
Late:
Phantom limb pain
Contractures
Definition of varicose veins
Dilated + tortuous superficial veins
Causes of varicose veins
Prolonged standing
Obesity
OCP
Pregnancy
secondary: DVT, pelvic mass, AVM
Sx of varicose veins
Heaviness Tingling Cramping Pain Bleeding Oedema
NICE guidelines re management of varicose veins
Conservative: Compression stockings
Compression bandages for ulcers
Reduce time spent standing
Weight loss
Surgical: Laser ablation of superficial veins
(refer if CEAP4a or more)
NICE guidelines re management of varicose veins
Conservative: Reduce time spent standing Weight loss Grade 2 Compression stockings Compression bandages for ulcers
Medical: analgesia + piriton (pruritus)
Surgical: 1) Laser ablation 2) sclerotherapy 3) ligation + stripping
(refer if CEAP4a or more)
Complications of varicose veins
Chronic venous insufficiency
Ulcers
Thrombophlebitis –> infected thrombophlebitis
DVT
investigations in suspected testicular tumour
Markers: AFP, LDH, hCG
Scrotal USS
CT TAP
Mx of testicular cancer
inguinal orchidectomy
histology of biopsy
chemo/radiotherapy
- Bleomycin, etoposide, cisplatin
staging of testicular tumours
1) confined to testes
2) LNs below the diaphragm
3) LNs above and below the diaphragm
4) extra-lymphatic spread (lungs, liver)
Common skin rash in Coeliac disease - what does it look like? Fx? name?
Dermatitis herpetiformis
Blistering + itchy on EXTENSOR surfaces
Commonest cause of erythema multiforme
HSV
Causes of erythema multiforme
HSV Mycoplasma SLE Drugs: allopurinol, penicillin, NSAIDs Sarcoid Malignancy
causes of acanthosis nigricans
Endo–> increased weight:
DM, Cushings PCOS acromegaly
OCP
GI cancer
Pemphigus vs pemphigoid
Blisters are superficial in pemphigus(flaccid), deep in pemphigoid (tense)
Features of hypocalcemia
SPASMODIC
Spasms: Trousseau's sign (BP cuff) Paraesthesia Anxious Seizures Muscle tone increased = Hypertonia Orientation impaired = Confusion Dermatitis (atopic) Impetigo Chovstek's sign (tapping CN7), Cardiomyopathy
CAUSES of hypocalcemia
Commonest = CKD!!
Raised PO4: CKD, hypoPTH
Low PO4: active pancreatitis, osteomalacia
Mx of mild hypocalcemia
oral Ca QDS PO
Fx of hypercalcemia
Bones, Stones, Moans, Groans
Bone pain + pathological #s
Renal stones + nephrogenic DI
Depression
Abdominal pain + constipation
Causes of hypercalcemia
HyperPTH (or PTHrP in paraneoplastic)
Normal PTH:
Myeloma(normal ALP), bone mets (high ALP) or sarcoid
Ix in hypercalcemia
PTH
phosphate
FBC, CXR, protein electrophoresis, bone scan
Mx of hypercalcemia
FLUIDS 0.9% saline
Special mx of hypercalcemia of malignancy
Bisophosphonates
Psoriasis - describe the skin leasions
well defined salmon-pink plaques
On extensor surfaces + behind ears + scalp + sites of trauma (Koebner phenomenon)
Nail changes in psoriasis
Pitting
Onycholysis
Sublingual hyperkeratosis
Why might some psoriatic plaques be brown
Application of coal tar treatment
Causes of onycholysis
Psoriasis
Fungal infection
Trauma
HypERthyroidism
Causes of nail pitting
Psoriasis
Fungal infection
Lichen planus
Psoriasis - Sx? triggers?
Itch + arthritis
Triggers: stress, SMOKING, EtOH, b-blockers, injury
Subtypes of psoriasis
Guttate = drop-like lesions on trunk, commoner in children after strep infection
Pustular
Psoriatic arthritis: asymmetric olygoarthritis (mimics RA)
Mx of psoriasis
MDT: GP, dermatologist
Conservative: avoid triggers (EtOH, stress, smoking)
Topical:
Emollients (epaderm, diprobase)
Steroid cream
Coal tar
Phototherapy:
Narrow band UVB
Systemic:
Ciclosporin, retnoids, methotrexate
3 Skin features of dermatitis
LIchenification
Excoriations
Painful fissures
Differential for dermatitis
Atopic eczema
Contact dermatitis - just hands
Discoid
Seborrhoea dermatitis
Diff btw seborrheic dermatitis and psoriasis
Scales!!
Psoriasis = thick and silvery
seborrheic dermatitis = thin + white
proper name for dandruff
seborrheic dermatitis
Dandruff is a milder form, without associated inflammation (red skin)
Mx of dermatitis
MDT + avoid triggers
Topical steroids + emollients + soap subs
+ antihistamines
+ Abx for secondary infection
Phototherapy
If severe –> systemic steroids or cyclosporin
Cutaneous manifestations of DM - on hands?
on abdomen?
on shins?
on feet?
Hands:
- Cheiroarthropathy (prayer sign)
- Granuloma Annulare
Abdomen:
- Lipodystrophy (injection site)
Shins:
- Necrobiosis lipoidica
Feet:
- Charcot joint
- Ulcers
What are charcot joints? what does it look like?
Neuropathic osteoarthropathy
Progressive damage to weight bearing joint + bone due to lack of sensation
Loss of medial arch +
Rocker bottom deformity
Skin - SqCC
Appearance?
Pre-malignant forms?
Ulcerated + everted edge
Sun-exposed sites
Actinic keratoses: crusty lesion
Bowens: red/brown scaly plaque
Evolution of SqCC
Actinic keratoses –> bowens –> SqCC
Warty stuck-on appearance
Seborrheic keratoses
RFs for SqCC
Sun exposure
immunosuppression
RFs for malignant melanoma
Sun exposure Low Fitzpatrick skin type High # of common moles FH Age Immunosuppression
Staging of malignant melanoma
Breslow thickness
Neurofibromatosis - features on examination
Skin:
- Neurofibromas - gelatinous nodules
- Cafe au last spots >=6
- Axillary freckling
Neuro:
- Lisch nodules = posts on iris
- Peripheral neuropathy
Neurofibromatosis - complications? Types?
NF1 and NF2.
Both are autosomal dominant. NF1 is more common.
Complications: Epilepsy Learning difficulty Scoliosis Sarcomatous change of neurofibromas
Differential for cafe au lait spots
NF
TS
McCune Albright syndrome - precocious puberty
Cutaneous features of Tuberous Sclerosis
Ash leaf macule
Shagreen patch = leathery skin over sacrum
Facial adenoma sebaceum = pink/yellow papules on face (oil producing glands)
Tuberous sclerosis - noncutaneous problems
Neuro: epilepsy, LD
Cystic kidneys –> Renal transplant
Dense white patches on retina
Hereditary Haemorrhagic telangiectasia - what is it?
Autosomal dominant condition
Multiple telangiectasia due to AVMs
- in lungs, liver, brain, skin
HHT - on examination?
Differentials?
O/E: telangiectasia on face, lips, buccal mucosa
–> cyanosis from pulmonary AVMs
Ddx: CREST, CLD
Complications of HHT
HAEMORRHAGE
- epistaxis, GI bleed, haemoptysis, SAH
High output cardiac failure
Peutz Jeghers - features?
Hyper pigmented macules on face/oral mucosa/palms + soles!!
GI hamartamous polyps
Complications of Peutz Jeghers
- CRC
- Bleeding from polyps
- Pancreatic endocrine tumours
Ddx for erythema multiforme
Tinea
Discoid eczema
Erythema marginatum
Erythema migrans (Lyme, trunk distribution)
Causes of erythema multiforme
give 4 drugs
HSV
Mycoplasma
Drugs: trimethoprim, NSAIDs, penicillin, phenytoin
Severe erythema multiform? Mx?
Steven Johnsons syndrome
Mx: dexamethasone, IVIG
Causes of erythema nodosum - give 7
Systemic disease:
IBD, Sarcoid, Behcets
Infection:
TB
STREP
Drugs:
OCP
trimethoprim
Skin manifestations of sarcoid
Erythema nodosum
Lupus pernio = brown plaques, esp on nose
Red/brown nodules and papule
Key points to present in ?rheumatoid hands
Symmetrical deforming polyarthropathy
- signs of active synovitis (hot, swollen painful joints)
- signs of a cause: rheumatoid nodules, psoriatic plaques
Systemic features of RA
Rheumatoid nodules Carpal tunnel Episcleritis/scleritis pericarditis (rub) Pulmonary fibrosis Splenomegaly
Mx of RA
Conservative:
PT, OT, splints
Medical: DMARDs - methotrexate Analgesia Steroids Gastric protection + bone protection
Surgical: Carpal tunnel decompression Tendon repair and transfers Ulna sylectmy Arthroplasty
4 Diff DMARDs used to treat RA + their side effects
Methotrexate
- BM suppression + pulmonary fibrosis + hepatotoxic
Sulfasalazine
- BM suppression + skin rashes + hepatotoxic + SPERM count
Hydroxychloroquine
- RETINOPATHY
Penicillamine
- LUPUS, nephrotic syndrome
Significance of seronegative RA?
Less severe disease
Less likely to have extra-articular features
If DMARDs fail in treating RA, what is used next?
And what are the cautions taken when treating in this way?
Biologics - anti-TNF (Infliximab, etanercept) and B-cell depleters (rituximab)
Risk of opportunistic TB infection (do tuberculin skin test)
Risk of viral reactivation (HepB, PML)
Apart from RA, other diseases where RhF is common
Sjogrens = 100%
SLE
American College of RHeu Criteria for RA
4/7 of:
- Morning stiffness >1h
- 3+ joints involved
- Hand involvement
- Rheumatoid nodules
- +ve RhF
- SYMETRICAL
- XR changes
Abs in SLE
ANA (100%)
Anti-dsDNA
anticardiolipin and lupus anticoagulatn
Mx of SLE
MILD disease: topical steroids + sun cream + hydroxycloroquine
MODERATE disease(organ involvement) - Pred + AZT
Severe (AIHA/CNS/pericarditis)
- Cyclophosphamide
- High dose methylpred
Specific examination test for ANk SPon
Schooner’s test <5 cm
Ank spon - findings on back examination
Inspection:
- Thoracic kyphosis
- Neck hyperextension
Mvmt:
Reduced ROM throughout spine
Test:
Schober’s test <5cm (from PSIS to 10cm above)
Tests for sacroilitis
Pain on palpation
Pain on adduction of the hip, with the knee and hip flexed
Extra-articular features of Ankylosing Spondylitis
Anterior Uveitis (small pupil –> irregular)
Apical pulmonary fibrosis
Aortic regurgitation
Achilles tendonitis
Psoriatic plaques
Sx of Ank Spon?
Ix?
Morning stiffness
Back pain relieved by movement
Eye pain
SOB
Ix:
ECG - AV block is common!
Bloods: FBC, ESR, CRP, HLAB27
Imaging: spine XR - sacroileitis, bamboo spine
CXR - fibrosis
DEXA scan
Mx of Ank Spon
Conservative:
Physio, exercise
Medical:
NSAIDs
Steroid injection
Anti-TNF if severe
Surgery: ?hip replacement
Findings O/E of Marfan’s
Tall + long arm span
Hands: long fingers, hyper extensible
PULSE: radioradial delay (coarctation), collapsing pulse (AR)
Face: High arched palate, Lens dislocation
Chest: Deformity, AR
Cause of Marfans syndrome
Autosomal dominant inheritance
Fibrillin protein
Goitre + hypothyroidism
Hashimoto’s thyroiditis
Hands in Acromegaly
Spade like
Tight rings
Increased skin fold thickness
?thenar wasting if carpal tunnel
Features of acromegaly
Hands: spade like, rings are tight
Face: prognathism, prominent supraorbital ridges, large ears + nose, widely spaced teeth
HTN
Bitemporal hemianopia + headaches Acanthosis Nigerians Organomegaly Carpal Tunnel syndrome OSA
Ix in ?Acromegaly
OGTT
Urine dip: glucose BP: raised ECG: LVH CXR: cardiomegaly AbdoUSS: organomegaly Bloods: raised IGF, other pit hormones (bitemp hemianopia) - prolactin, TFTs, glucose
Mx of acromegaly
1st line? 2nd line?
1st line: SURGICAL - transphenoidal excision of pituitary
2nd line: Medical: OCTREOTIDE - ss analogue
F/U in acromegaly
Bloods: GH
Visual fields
ECG
MRI head
Side effects of steroids
Hands: thin skin, bruising
Arms: Proximal myopathy, HTN
Face: cataracts, glaucoma, psychosis
Trunk: DM, central adiposity, osteoporosis, DM
Infections
Suppression of ACTH –> need steroids for surgery and infection
Considerations in patients taking steroids
- Do not suddenly stop or reduce steroid dose
- Use lowest possible dose
- Increase dose if infection/surgery
- Consider bone and gastro protection
- Carry alert bracelet
MOA of CBZ and PTU?
of radio iodine?
CBZ + PTU - block T4 synthesis
Radioiodine - blocks T4 –> T3
Technetium scan of thyroid :
low uptake?
high uptake?
Low uptake = hashimoto’s
high uptake = graves
multiple hot and cold nodule = TMN
Sarcoidosis: features
Erythema nodosum + arthralgia = acute sarcoidosis
- Lupus pernio (raised, hard purpley skin on face)
- LNopathy
- Hepatosplenomegaly
- Enlarged parotids
- Cardiomyopathy
- Hypercalcemia
- BHL + pulmonary fibrosis
