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Medical Shorts Mushkies Flashcards

1
Q

Psoriasis examination?

A
  1. Skin
  2. Nails
  3. Joints
  4. Completion
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2
Q

Psoriasis skin findings?

A
  1. Symmetrical well defined salmon-pink plaques with a silvery, micaceous scale
  2. Location = extensors, behind ears, scalp, umbilicus, Koebner
  3. Skin staining from Rx = coal tar (brown), dithranol (purple)
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3
Q

Psoriasis nail findings?

A
  1. Discoloration
  2. Pitting
  3. Onycholysis
  4. Subungual hyperkeratosis
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4
Q

Psoriasis joints findings?

A

Inflammatory arthropathy

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5
Q

Psoriasis exam completion?

A
  1. Inspect common areas and assess joints

2. Auspitz’ sign = pinpoint bleeding on scraping scale

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6
Q

Psoriasis Ddx?

A
  1. Bowen’s disease
  2. Lichen planus
  3. Dermatitis
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7
Q

Onycholysis Ddx?

A
  1. Psoriasis
  2. Fungal infection
  3. Trauma
  4. Thyrotoxicosis
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8
Q

Nail pitting causes?

A
  1. Psoriasis
  2. Fungal infection
  3. Lichen planus
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9
Q

Koebner phenomenon causes?

A
  1. Psoriasis
  2. Lichen planus
  3. Viral warts
  4. Vitiligo
  5. Sarcoid
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10
Q

4 Psoriasis triggers?

A
  1. Smoking
  2. Stress
  3. Injury
  4. Drugs = BB, EtOH
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11
Q

Pathophysiology of psoriasis?

A
  1. T4 driven hypersensitivity reaction

2. Hyperkeratosis, parakeratosis, and intra-epidermal microabscesses of Munro

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12
Q

What is parakeratosis?

A

Nuclei in the stratum corneum

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13
Q

Psoriasis subtypes?

A
  1. Plaque
  2. Guttate
  3. Pustular = generalised or palmoplantar
  4. Flexural = not scaly
  5. Erythroderma
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14
Q

Psoriatic arthritis features?

A

A Seronegative arthritis that develops in 10-40%, can be:

  1. Asymmetric oligoarthritis
  2. Symmetric polyarthritis
  3. Distal arthritis
  4. Spondylitis
  5. Arthritis mutilans
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15
Q

Psoriasis Mx?

A
  1. General = MDT (GP, dermatologist), avoid precipitants
  2. Topical
  3. Phototherapy
  4. Systemic
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16
Q

Topical psoriasis Mx?

A
  1. Emollients
  2. Steroids = betamethasone
  3. Vit D analogues = Calcipotriol
  4. Coal tar
  5. Dithranol
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17
Q

Phototherapy psoriasis Mx?

A
  1. PUVA

2. Narrow-band UVB

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18
Q

Systemic psoriasis Mx?

A
  1. Cytotoxics = ciclosporin, methotrexate
  2. Retinoids = acetretin
  3. Biologics = anti-TNF
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19
Q

Dermatitis description?

A

Erythematous lichenified patches, predominantly on the flexors, with excoriations and painful fissures

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20
Q

Mx of dermatitis?

A
  1. General = MDT, avoid precipitants
  2. Adjuvants = antihistamins, antibiotics
  3. Topical = emollients, soap substitutes, steroids, tacrolimus
  4. Systemic = steroids, ciclosporin
  5. Phototherapy
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21
Q

Cutaneous manifestations of DM?

A
  1. Hands = cheiroarthropathy, granuloma annulare, skin pricks
  2. Injection sites = lipodystrophy
  3. Shins = necrobiosis lipoidica diabeticorum
  4. Feet = Charcot’s joints, ulcers
  5. Other = infections, eruptive tendon xanthomas secondary to hyperlipidaemia
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22
Q

Cheiroarthropathy?

A

Tight waxy skin that limits finger extension (prayer sign)

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23
Q

Granuloma annulare?

A

Flesh coloured papules in annular configuration, usually on dorsum of hand, 10% associated with DM

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24
Q

BCC description?

A

Pearly nodule with rolled, telangiectatic edge, on the face and sun exposed areas

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25
Most common skin cancer?
BCC
26
Do BCCs metastasise?
No
27
Mx of BCC?
1. Superficial = curettage | 2. Deep = surgical excision +/- radiotherapy
28
SCC description?
Ulcerated lesion with everted edge found in sun exposed areas, alongside Actinic Keratoses and Bowen's lesions
29
Actinic keratosis description?
Irregular, crusty, warty lesions
30
Bowen's disease description?
Red/brown, scaly plaques
31
Evolution of SCC?
Actinic keratosis --> Bowen's disease --> SCC
32
RFs for SCC?
1. Sun exposure 2. Immunosuppression 3. Genetic = xerodermapigmentosum 4. Chronic trauma = Marjolin's ulcer
33
Dx of SCC?
Excisional biopsy
34
Mx of SCC/
Surgery +/- radiotherapy
35
Malignant melanoma pt characteristics?
1. Fair skin with freckles 2. Blue eyes 3. Light hair
36
Malignant melanoma desciprtion?
ABCDE 1. Asymmetry 2. Irregular border 3. Non-uniform colour 4. Diameter > 6mm 5. Evolving/elevation
37
Additional parts of skin exam?
1. Regional lymph nodes 2. Rest of skin 3. Fundoscopy 4. Liver
38
Glass eye + ascites?
Ocular melanoma
39
RFs for malignant melanoma?
1. Sun exposure, esp. when young 2. Low Fitzpatrick skin type 3. Lots of common moles 4. Age 5. FHx 6. Immunosuppression
40
5 types of malignant melanoma?
SLANA 1. Superficial spreading = 80% 2. Lentigo maligna melanoma = elderly 3. Acral lentiginous = blacks, soles, palms 4. Nodular = younger, new lesion 5. Amelanotic = Delayed Dx
41
Staging of malignant melanoma?
Breslow Thickness
42
Malignant melanoma Mx?
1. Excision biopsy for staging 2. Secondary excision margin depends on stage 3. +/- lymphadenectomy 4. +/- adjuvant chemotherapy
43
Neurofibromatosis features?
1. Skin 2. Eyes 3. Extras
44
Skin fx of NF?
1. Cafe au lait spots (>=6, >=15mm diameter) 2. Axillary freckling 3. Neurofibromas
45
Neurofibromas description?
Gelatinous violaceous nodules
46
Eye fx of NF?
1. Lisch nodules | 2. Optic glioma --> altered acuity
47
What is a Lisch nodule?
Melanocytic hamartomatas of the iris
48
Extra fx of NF?
1. Back = scoliosis 2. Abdomen = RAS + phaeochromocytoma 3. Palpable nerves + lymphadenopathy
49
NF inheritance?
AD
50
NF1 Chr and prevalence?
Chr17, 1/2500
51
NF2 Chr and prevalence?
Chr22, 1/35,000
52
4 complications of NF?
1. Sarcomatous change = 5% 2. Scoliosis 3. Epidemiology 4. Learning difficulty = 10%
53
NF Mx?
1. MDT = GP and neurologist 2. Excise some neurofibromas 3. Genetic complications 4. Complications = yearly BP review and cutaneous review, epilepsy rx
54
DDx of Cafe au Lait Spots?
1. NF 2. Tuberous Sclerosis 3. McCune Albright syndrome
55
McCune Albright Syndrome?
1. Cafe au lait spots 2. Polyostotic fibrous dysplasia 3. Precocious puberty
56
How can you classify the features of tuberous sclerosis?
1. Cutaneous 2. Neurological 3. Other
57
What are the cutaneous features of tuberous sclerosis?
``` 1. Ash leaf spots under UV 2 .Shagreen patch 3. Nose angiofibromas 4. Subungual fibromata 5. Cafe au lait spots ```
58
What are the neurological features of tuberous sclerosis?
1. Developmental delay 2. Epilepsy 3. Intellectual impairment
59
What are the 'other' features of tuberous sclerosis? x5
1. Retinal hamartomas 2. Rhabdomyomas of the heart 3. Gliomatous changes in the brain 4. Polycystic kidneys 5. Lymphoangioleiomyomatosis
60
Tuberous sclerosis Chr and inheritance?
Chr16, AD
61
Tuberous sclerosis Ix?
1. Skull films = railroad track calcification 2. CT/MRI brain = tuberous mass in cortex 3. Abdo US = renal cysts 4. Eccho = cardiomyopathies
62
HHT aka?
Osler-Weber Rendu syndrome
63
HHT examination?
1. Multiple telangiectasia on face, lips and buccal mucosa 2. Cyanosis = large pulmonary AVMs 3. No signs of CREST
64
DDx for multiple telangiectasias?
1. HHT 2. CREST 3. Chronic liver disease 4. Ataxia telangiectasia
65
3 sites of AVMS in HHT?
Lungs, liver, brain
66
3 complications of HHT?
1. Haemorrhage = epistaxis, GI haemorrhage, haemoptysis, SAH 2. High output HF 3. Colorectal cancer if SMAD4 mutation
67
Peutz-Jeghers examination?
Small pigmented macules on lips, oral mucosa, palms and soles
68
Macules around lips and mouth DDx?
1. Peutz-Jeghers 2. Carney complex 3. McCune-Albright 4. Simple freckles
69
Peutz Jeghers?
AD mutation of STK11 gene on Chr19 characterised by mucocutaneous macules and multiple hamartomatous GI polyps
70
3 complications of Peutz Jeghers?
1. GI hamartomas = intussusception, haemorrhage 2. Pancreatic endocrine tumours 3. Colorectal cancer
71
Erythema multiforme description?
Multiple symmetrical targetoid lesions, especially on extensor surfaces of the peripheries
72
Ddx of lesions with central clearing?
1. Erthema multiforme 2. Discoid eczema 3. Tinea
73
Causes of erythema multiforme?
1. Infections | 2. Drugs
74
Infections that cause erythema multiforme?
1. HSV (70%) | 2. Mycoplasma
75
Drugs that cause erythema multiforme?
1. NSAIDs 2. Phenytoin 3. Penicillin 4. Sulfonamides 5. Allopurinol
76
Mx of SJS and TEN?
Dexamethasone, IVIG
77
Erythema nodosum examination?
Tender, blue/red, smooth shiny nodules commonly found on shins
78
Causes of erythema nodosum?
1. Systemic disease = Sarcoidosis, IBD, Behcets 2. Infection = Strep, TB 3. Drugs = sulphonamides, OCP
79
Rheumatoid hand examination?
1. Look 2. Feel = active synovitis (hot swollen painful joints) 3. Move = fixed flexion in prayer position, decreased ROM 4. Function = precision, power, aids
80
What causes fibromyalgia?
Theta waves
81
What to look for in rheumatoid hand examination?
1. Skin = joint erythema, palmar erythema a. Swelling = MCPs and PIPs b. Muscle wasting = interossei, thenar eminence c. Deformity 2 .Surgical scars = carpal tunnel release 3. Wrist 4. Elbow = nodules
82
Rheumatoid hand description?
Symmetrical deforming polyarthropathy
83
DDx for rheumatoid hands?
1. Psoriatic Arthritis | 2. Jacoud's Arthropathy
84
Jacoud's arthropathy?
1. A chronic non-erosive reversible joint disorder that may occur after repeated bouts of arthritis. 2. It is caused by inflammation of the joint capsule and subsequent fibrotic retraction, causing ulnar deviation of the fingers, through MCP subluxation , 3. Joints in the feet, knees and shoulders may also get affected. 4. It is commonly associated with SLE and occurs in roughly 5% of all cases
85
Rheumatoid examination?
1. Hands 2. Skin = steroid use 3. BP and pulse = AF, CVD 4. Eye = epi/scleritis, keratoconjunctivitis sicca, anaeima 5. Neck = atlantoaxial subluxation 6. Heart = Pericardial rub 7. Lungs = fibrosis, effusions, rub 8. Abdomen = splenomegaly 9. Urine dip = nephrotic syndrome/amyloid
86
3 symptoms of rheumatoid?
1. Early morning stiffness 2. Pain 3. Swelling
87
RhA DLA?
HLA DR 3/4
88
RhA Ab?
anti-CCP = 98% specific, 75% sensitive
89
RhA X ray?
LESD 1. Loss of joint space 2. Periarticular erosions and osteopenia 3. Soft tissue swelling 4. Deformity
90
RhA Mx?
1. MDT = GP, physio, OT, rheum, orthopod 2. Conservative = physio, OT (aids and splints) 3. Medical = Analgesia, Steroids (IM/PO/intra-articular), DMARDS, biologics 4. Surgical = carpal tunnel decompression, tendon repairs and transfers, ulna stylectomy, arthroplasty
91
Extra-articular features of RhA?
aNTI CCP OR RF 1. Nodules 2. Tenosynovitis e.g. de Quervains 3. Immune = vasculitis, amyloidosis, AIHA, Sjogrens 4. Cardiac = pericarditis +/- effusion 5. Carpal tunnel 6. Pulmonary = fibrosis, effusions 7. Ophthalmic = episcleritis, scleritis, Sjogrens 8. Renal = nephrosis secondary to amyloidosis 9. Raynaud's 10. Felty's
92
Boutonniere's deformity?
Rupture of central slip of extensor expansion --> PIPJ prolapse through 'button-hole' created by 2 lateral slips
93
Swan-neck deformity?
Rupture of lateral slips --> PIPJ hyperextension
94
DMARDS for RhA?
1. Methotrexate 2. Sulfasalazine 3. Hydroxychloroquine 4. Penicillamine 5. Gold
95
2 s/e of penicillamine?
1. Drug induced lupus | 2. Nephrotic syndrome
96
S/e of gold?
Nephrotic syndrome
97
4 s/e of sulfasalazine?
1. BM suppression 2. Skin rashes 3. Hepatitis 4. Reduced sperm count
98
Indication for Mx of RhA with biologics?
Severe RhA not responding to DMARDS
99
3 Anti-TNFa agents?
1. Infliximab 2. Etanercept 3. Adalimumab
100
B cell depletion agent for RhA?
Rituximab (anti CD20 mAb)
101
Rheumatoid Factor quick facts?
1. Anti-IgG IgM 2. Present in 70% with RhA 3. Also present in 10% normal people
102
Sjogrens RhF prevalence?
100%
103
SLE RhF prevalence?
<=40%
104
Higher titres of RhA associated with?
1. More severe disease 2. Erosions 3. Extra-articular manifestations
105
What is seronegative RhA?
RhA in the absence of RhF
106
What % of RhA are seronegative?
30%
107
Seronegative RhA features?
Less severe disease and much less likely to have extra-articular features
108
Cause of atlanto-axial subluxation in RhA?
Rheumatoid tenosynovitis --> weakening of ligaments supporting the top of the cervical spine
109
Systemic Sclerosis examination?
1. Hands = calcinosis, Raynauds (ulceration), sclerodactyly 2. Face = beaked nose (nasal skin tethering), microstomia, telangiectasia, coup de sabre 3. BP 4. Lungs = pulmonary fibrosis 5. Heart = pulmonary HTN, heave, raised JVP, loud P2 6. Morphea = patches of sclerotic skin
110
En coup de sabre?
Scar down central forehead found in systemic sclerosis
111
Morphea?
Form of systemic sclerosis that involves isolated patches of hardened skin on the face, hands, and feet, or anywhere else on the body, with no internal organ involvement
112
Classification of systemic sclerosis?
1. Localised = morphea | 2. Systemic = Diffuse (30%) or Limites (70%, incl. CREST)
113
Limited systemic sclerosis Fx?
1. Distribution limited to below elbow, knees and face 2. Slow progression = years 3. Pulmonary HTN in 15% 4. CREST = calcinosis, raynaud's, oesophageal dysmotility, sclerodactyly, telangiectasia
114
Diffuse systemic sclerosis?
1. Widespread cutaneous and early visceral involvement | 2. Rapid progression = months
115
Limited SS Ab?
Anti-centromere
116
Diffuse SS Ab?
Anti-scl70 (topoisomerase)
117
Systemic sclerosis prognosis?
50% 5 year survival
118
SLE features?
4/11 of SOAP BRAIN MD: 1. Serositis (pleuritis, pericarditis) 2. Oral Ulcers 3. Arthritis 4. Photosensitivity 5. Blood = pancytopenia 6. Renal = proteinuria 7. ANA 8. Immunologic = dsDNA 9. Neuro = psych, seizures 10. Malar rash 11. Discoid rash
119
SLE examination?
1. Hands = vasculitic lesions (nail fold infarcts), Raynaud's (digital ulceration), Jacoud's arthropathy 2. Skin = purpura, livedo reticularis 3. Face = malar rash, discoid rash, oral ulceration, anaemia 4. Eyes = keratoconjunctivitis sicca 5. Lungs = pleural rub, effusion, fibrosis 6. Cardio = pulmonary HN 7. Renal = HTN, dipstick 8. Neuro = focal neurology, chorea
120
Malar rash spares?
Nasolabial folds
121
Discoid lupus description?
Hyperkeratotic papules
122
SLE defn?
A multisystem inflammatory disease characterised by a T3 hypersensitivity reaction against circulating immune complexes
123
SLE M:F?
9F:1M
124
Races more affected by SLE?
Afro-Caribbeans and Asians
125
SLE ANA prevalence?
100%
126
SLE most specific Ab?
dsDNA, although 60% sensitive
127
SLE Abs?
1. ANA 2. dsDNA 3. anti-cardiolipin 4. lupus anticoagulant
128
SLE activity monitoring?
1. Raised ESR 2. Low C3, C4 3. Raised dsDNA titre
129
SLE Mx?
1. MDT = GP, rheum in specialist SLE clinics 2. Mild disease = cutaneous and joints only 3. Moderate disease = organ involvement 3. Severe disease = AIHA, nephritis, pericarditis, CNS
130
Mild SLE Mx?
1. Topical corticosteroids 2. HCQ 3. Suncream
131
Moderate SLE Mx?
1. Prednisolone | 2. Azathioprine
132
Severe SLE Mx?
1. High dose methylprednisolone | 2. Cyclophosphamide
133
Ankylosing spondylitis defn?
A chronic seronegative spondylarthropathy leading to inflammatory arthritis of the axial skeleton and associated extra-articular features
134
Extra-articular features of ankylosing spondylitis?
1. Anterior uveitis 2. Apical lung fibrosis 3. Aortitis 4. Aortic regurgitation 5. AVN block 6. Amyloidosis --> glomerulonephritis 7. Achilles tendon enthesitis (+other tendons)
135
Ankylosing spondylitis examination?
1. Back 2. Movement 3. Sacroiliitis 4. Extra = ECG, dipstick
136
Ank spond back exam?
1. Question mark posture = thoracic kyphosis and neck hyperextension 2. ROM throughout spine 3. Protuberant abdomen = diaphragmatic breathing
137
Ank spond movement?
1. Schobers test = <5cm | 2. .Chest expansion <5cm (@nipples)
138
Ank spond sacroiliitis test?
1. Direct pressure | 2. Sacroiliac stretch = pain on adduction of hip with hip and knee flexed
139
Ankylosing spondylitis bloods?
1. FBC = anaemia 2. Raised ESR 3. Raised CRP 4. HLA B27 +ive in 95%
140
Ank spond spine imaging features?
1. Sacroiliitis = sclerosis, erosions | 2. Bamboo spine = vertebral body fusion by marginal syndesmophytes
141
Ank spond Mx?
1. Conservative = exercise and physio 2. Medical = NSAIDs, local steroid injections, anti-TNF, bisphosphonates 3. Surgery = hip replacement, spinal osteotomy
142
Marfans syndrome triad?
1. Skeletal features 2. CVS features 3. Eye features
143
Marfans defn?
Genetic disorder of the connective tissue primarily affecting the eyes, skeleton and cardiovascular system
144
Marfans examination?
1. General = tall and thin, scoliosis 2. Hands and arms= arachnodactyly (encircle wrist with hands), wide arm span, flexible joints, pulse (radio-radio delay, collapsing) 3. Face = long thin face, upwards lens dislocation, myopia, high arched palate 4. Chest and abdomen = pectus excavatum/carinatum, scars from cardiothoracic surgery, stretch mars 5. Legs and feet = long legs, flat feet
145
Marfans DDx?
1. MEN2B | 2. Homocystinuria
146
Homocystinuria fx?
1. Low IQ | 2. Downward lens dislocation
147
Marfans syndrome cause?
AD mutation in fibrillin-1 gene, a major protein of elastin in connective tissues
148
Marfans Ix?
1. Genetic testing 2. Eye exam 3. Echo = aortic root dilatation
149
Marfan's Mx?
1. Screen family members 2. Surveillance for complications = MDT regular check ups 3. Medical = BB and ACEi can slow aortic root dilatation, pre-emptive aortic root surgery to prevent dissection/rupture
150
Gout definition?
A mono/oligoarthropathy caused by deposition of monosodium urate crystals in the joints
151
Hyperuricaemia RFs?
1. Male 2. Obese 3. CKD 4. Diuretics 5. Purine rich diet = alcohol, meat, seafood 6. Increased turnover = leukaemia, lymphoma, psoriasis
152
Main gout goint?
1st MTP
153
Gout DDx?
1. Pseudogout 2. Septic arthritis 3. Calcinosis from CREST
154
Gout Ix?
1. Bloods = uric acid, lipids, glucose 2. Joint aspiration with polarised microscopy = negatively birefringent needle-shaped crystals 3. X-ray = punched out peri-articular erosion
155
Gout Mx?
1. Conservative = weight loss, keep hydrated, diet, avoid fasting, stop offending drugs 2. Acute = indomethacin/diclofenac, colchicine, steroids 3. Chronic = Allopurinol
156
Why wait 2 weeks after an acute gout attack to prescribe allopurinol?
Can paradoxically trigger a bout of gout when initiated, so offer NSAID and colchicine cover for 1-3 months initially
157
Osteoarthritis defn?
Mechanical joint degradation with degeneration of articular cartilage, peri-articular bone remodelling and inflammation
158
Osteoarthritis RFs?
1. Primary = Age, obesity, FHx, female | 2. Secondary = pre-existing joint damage, metabolic disease, systemic disease
159
Pre-existing joint damage that can cause secondary osteoarthritis?
1. Trauma 2. RA 3. Gout 4. Pagets 5. AVN 6. Septic arthritis 7. Spondylarthropathy
160
Metabolic disease that can causes secondary osteoarthritis?
1. Chondrocalcinosis 2. Haemochromatosis 3. Acromegaly
161
Systemic disease that can cause secondary osteoarthritis?
1. Haemophilia (haemarthrosis) 2. Neuropathy 3. Haemoglobinopathy
162
Osteoarthritis hand examination?
1. Heberden's 2. Bouchard's 3. Squaring of carpometacarpal joint of thumb 4. Reduced function 5. Disuse atrophy 6. Fixed flexion
163
Osteoarthritic joint description?
1. Crepitus 2. Pain on movement 3. Reduced range of movement 4. Bony swellings (osteophytes) 5. Joint instability 6. Joint effusion
164
Commonly affected OA joints?
1. IP joints of fingers 2. CMC joint of thumb 3. Knees 4. Hips
165
OA joint pain features w/ regards to pt?
1. Worse on exercise and relieved on rest | 2. Morning pain <30mins
166
Radiographic features of OA?
1. Loss of joint space 2. Osteophytes 3. Subchondral cysts 4. Subchondral sclerosis 5. Deformity
167
OA Ix?
1. X-Ray | 2. FBC, CRP/ESR (only useful for ruling out inflammatory and infective causes)
168
OA Mx?
1. Conservative = exercise, physio, weight loss, walking waids 2. Analgesia = Paracetamol +/- NSAIDs, codeine, oral NSAIDs for flare ups 3. Intra-articular joint injection 4. Surgery = joint replacement
169
Thyrotoxicosis examination?
1. General = thin, anxious 2. Hands = thyroid acropachy, erythema, sweaty palms, tachycardia, AF 3. Arms = proximal myopathy 4. Neck = smooth, diffuse goitre +/- bruit 5. Eyes = non specific vs. Graves 6. Legs = pretibiial myxoedema, proximal myopathy
170
Non-specific thyrotoxicosis eye signs?
1. Lid-lag | 2. Lid retraction (increased tone of superior tarsal muscle)
171
Graves' eye signs?
1. Exophthalmos 2. Ophthalmoplegia 3. Chemosis
172
Chemosis defn?
Conjunctival oedema
173
3 triggers of thyrotoxicosis?
1. Child birth 2. Stress 3. Infection
174
Goitre defn?
Enlargement and swelling of the thyroid gland
175
Most common causes of goitre in UK?
1. Graves 2. Multinodular goitre (actually feels smooth, nodules are an USS Dx) 3. Physiological = pregnancy/puberty
176
Classification of causes of goitre?
1. Diffuse | 2. Nodular
177
Causes of diffuse goitre?
1. Simple = physiological, iodine deficiency, iatrogenic (e.g. lithium) 2. AI = Graves, Hashimoto's, Riedel's 3. Infective = acute viral thyroiditis
178
Causes of nodular goitre?
1. Multinodular goitre = euthryoid 2. Toxic multinodular goitre = hyperthyroid 3. Solitary nodule = Cancer, Plummer's solitary nodule 4. Multiple adenomas
179
Thyrotoxicosis Ix?
1. Bloods = FBC, TFTs, Abs (TSH, TPO), Ca, ESR 2. Imaging = US, CT, CXR, radionuclide uptake scane 3. Needle aspiration 4. Biopsy
180
Graves FBC effect?
May be mild anaemia and neutropenia
181
Why CXR/CT in goitre?
To check for retrosternal goitre
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Goitre complications?
1. Of hyper/hypothyoidism 2. Compression of surrounding structures 3. Cosmetic
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Goitre compression complications?
1. Trachea = SOB 2. RLN = dysphonia 3. Oesophagus = dysphagia 4. SVC = SVCS
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Thyrotoxicosis Mx?
1. Medical 2. Radioiodine 3. Thyroidectomy 4. Thyroid eye disease
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Medical Mx of thyrotoxicosis?
1. Propranolol | 2. Carbimazole (titrate OR block & replace)
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How long to tx with carbimazole for?
12-18 months
187
Radioiodine s/e?
1. May worsen thyroid eye disease 2. Most pts become hypothyroid 3. C/I in pregnancy and those around children
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Thyroidectomy s/e?
1. Early = haematoma. RLNP, thyroid storm, hypocalcaemia | 2. Late = hypothyroidism, hypoparathyroidism, keloid scar
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Thyroid eye disease Mx?
1. Stop smoking 2. Symptomatic = artificial tears, dark glasses, elevate bed 3. Severe = high dose steroids, surgical decompression
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Hypothyroidism exam?
1. General = overweight, depressed, gruff voice 2. Hands = dry skin, bradycardia, cool, slow reflexes, proximal myopathy 3. Face = coarse, puffy, peaches and cream complexion, loss of lateral eyebrows, xanthelasma, thin hair 4. Neck = goitre, thyroidectomy scar
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3 AI diseases associated with thyroid disease?
1. Addisons 2. T1DM 3. Vitiligo
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Hypothyroidism Mx?
Thyroxine
193
Hypothyroidism Ddx?
1. Primary | 2. Secondary = hypopituitarism (v. rare)
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Primary causes of hypothyroidism?
1. AI = primary atrophic thyroiditis, Hashimoto's thyroiditis 2. Iatrogenic = drugs, radioiodine, surgery 3. Iodine deficiency = e.g. derbyshire neck 4. Genetic = thyroid agenesis
195
Hyperthyroidism Ddx?
1. High uptake | 2. Low uptake
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High uptake causes of hyperthyroidism?
1. Graves' 2. Toxic adenoma 3. Toxic multinodular goitre
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Low uptake causes of hyperthyroidism?
1. Subacute thyroiditis 2. Postpartum thyroiditis 3. Ectopic/exogenous
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Acromegaly definition?
Disorder resulting from excess release of growth hormone after the growth plates have fused, >99% due to a GH secreting pituitary macroadenoma
199
Clinical features of acromegaly?
1. Pituitary enlargement symptoms = hypopituitarism, bitemporal hemianopia, headache 2. Active acromegaly signs = excessive sweating, HTN 3. Excessive soft tissue growth
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Excessive soft tissue growth in acromegaly?
1. Hands = spade like, tight rings, sweaty, carpal tunnel syndrome (thenar wasting and loss of sensation) 2. Arms = HTN 3. Face = coarsening of features, prominent supra-orbital ridge, large nose, big ears, macroglossia, widely spaced teeth, prognathism 4. Eyes = bitemporal hemianopia 5. Neck = goitre and JVP 6. Armpits = acanthosis nigricans 7. Abdomen = organomegaly 8. Proximal myopathy = stand up 9. Previous photographs
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Causes of macroglossia?
1. Acromegaly 2. Amyloidosis 3. Hypothyroidism 4. Down's syndrome
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Causes of acanthosis nigricans?
1. Endo = metabolic syndrome, DM, Cushings, Acromegaly | 2. Malignancy = gastric, pancreatic
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Acromegaly Ix?
1. Bedside = glycosuria, LVH 2. Bloods = raised IGF1, OGTT, PFTs and serum prolactin 3. CXR = cardiomegaly 4. MRI = pituitary adenoma 5. Other = visual perimetry
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Acromegaly complications?
1. Impaired GT and DM 2. Cardiomyopathy and CVD (leading cause of death) 3. Colorectal cancer (colonoscopy at 50 years)
205
Acromegaly Mx?
1. General = MDT, CV risk 2. 1st line = trans-sphenoidal resection 2. 2nd line = medical = SS analogues (octreotide), GH antagonist (pegvisomant), Da agonist (cabergoline) 4. 3rd line = radiotherapy
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Acromegaly follow up?
Yearly 1. Bloods = GH, PRL 2. Visual fields 3. ECG 4. MRI head
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Cushings syndrome defn?
A metabolic disorder characterised by typical signs and symptoms caused by chronic glucocorticoid excess
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Cushings disease defn/
ACTH-producing pituitary tumour causing Cushings Syndrome
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Nelsons syndrome?
Symptoms resulting from rapid enlargement of a pre-existing pituitary tumour after a bilateral adrenelectomy
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Causes of Cushing's syndrome classification?
1. ACTH-dependent | 2. ACTH-independent
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ACTH dependent causes of Cushing's syndrome?
1. Cushing's disease | 2. Ectopic ACTH (SCLC most common)
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ACTH independent causes of Cushing's syndrome?
1. Iatrogenic = most common 2. Adrenal adenoma/carcinoma 3. Adrenal hyperplasia 4. Carney complex
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Cushing's examination?
1. Hands = thin skin, RA 2. Arms = BP 3. Face = moon face, acne, hirsutism 4. Eyes = bitemporal hemianopia 5. Shoulders and back = buffalo hump, kyphosis, crush fracture --> back pain 6. Abdomen = central obesity, purple striae 7. Stand = proximal myopathy
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4 Cushings symptoms for pts?
1. Weight gain 2. Bruising 3. Headached 4. Visual disturbance
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Cushings Ix classification?
1. Confirm syndrome | 2. Localise lesion
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Cushings confirm syndrome Ix?
1. 24-hour urinary cortisol | 2. Low dose dexamethasone suppression test
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Cushings localise lesion Ix?
1. Plasma ACTH 2. Low ACTH --> CT adrenals 3. High ACTH --> High dose dexamethasone suppression test 3. Inferior petrosal sinus sampling 4. MRI pituitary fossa
218
Cushings Mx?
1. Complications = BP, DM, bisphosphonates | 2. Cause
219
Ectopic ACTH Mx?
1. Tumour excision | 2. Metyrapone (inhibits cortisol synthesis)
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Addisons disease signs?
1. Medic alert bracelet 2. Hyperpigmentation = palmar creases, scars, buccal mucosa 3. Postural hypotension
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Addisons disease Ab?
21-hydroxylase (+ive in 80% with AI disease)
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Addisons disease Dx?
1. 8am cortisol = low 2. 8am ACTH = high 3. SynACTHen test = no increase in cortisol
223
Addisons acute Mx?
1. 0.9% NS IV 2. 100mg hydrocortisone IV 3. Rx cause e.g. infection
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Addisons chronic Mx?
1. Replace = hydrocortisone and fludrocortisone | 2. Education and advice = dont stop steroids suddenly, increase dose during illness/stress, bracelet, carry steroid card
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Steroids s/e?
MEM ICE 1. MSK = proximal myopathy, osteoporosis 2. Endocrine = HPA suppression, obesity, DM 3. Metabolic = Na and fluid retention, HTN, hypokalaemia 4. Immune = infection 5. CNA = depression, psychosis 6. Cataracts, glaucoma
226
Steroids advice to pt?
1. Dont stop suddenly 2. Consult doctor when unwell 3. Carry steroid card/alert bracelet 4. Avoid OTC s.g. NSAIDs
227
What is hemiballismus?
1. Involuntary flinging motions of the extremities 2. Continuous and random 3. Isolated to one side of the body
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Cause of hemiballismus?
Damage to the subthalamic nucleus 1. Usually a small infarct in diabetics 2. MS 3. Any CNS pathology essentially
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Mx of hemiballismus?
1. Often resolves spontaneously | 2. Haloperidol
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Benign essential tremor features?
1. Action/postural tremor = worse with movement 2. Exacerbating factors = anxiety/caffeine 3. Relieving factors = alcohol/sleep
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Mx of BET?
1. Alcohol 2. Propranolol 3. Primidone = anti-epileptic
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DDx of solitary thyroid nodule?
1. Dominant nodule of multinodular goitre 2. Adenoma 3. Malignancy = PFMA 4. Cyst

Medicine and Surgery Mushkies (52 decks)

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