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1
Q

Further questions for ?RA

A

GI upset
Dry eyes
Rash
Mouth/swallowing
Weight loss
Fevers
Function/job
SOB
FHx

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2
Q

How would you manage newly diagnosed RA?

A

MDT (PT, OT)
Analgesia
NSAIDs w GI protection
If acute flair - high dose steroids then taper
DMARDs later

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3
Q

What disease modifying therapies are you aware of?

A

methotrexate
• azathioprine
• cylosporin
• sulphasalazine
• gold.

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4
Q

Tell me about methotrexate

A

Weekly
Inhibits purine synthesis - needs folic acid replacement
Regular FBC and LFTs
Counsel on risk of myelosuppresion

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5
Q

Describe RA

A

Symmetrical deforming polyarthopathy
Mainly small joints of hands and feet
Mainly PIP and MCPs

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6
Q

Extra articular features of RA

A

Scleritis/episcleritis
Fibrosis/pleural effusion
Pericarditis/cardiomyopathy
Splenomegaly (Feltys syndrome)
Carpal tunnel

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7
Q

Causes of anaemia in RA

A

Anaemia of chronic disease
GI bleeding from NSAIDs
Bone marrow suppression from methotrexate
Megaloblastic anaemia
Haemolytic anaemia

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8
Q

Rules for single isolated seizure with normal Ix and category 1 liscence

A

6 months

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9
Q

Things to consider if new epilepsy diagnosis and female

A

Tetrogenicity of meds
Needs contraception

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10
Q

Why is patient confidentiality important?

A

to protect the patient.
o risk of exploitation if information shared
without approval.
o Doctor - patient relationship specific + wider

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11
Q

Under what circumstances may you break patient confidentiality?

A
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12
Q

What are the possible consequences of breaking patient confidentiality?

A
  • trust with you
  • trust with others
  • GMC if inappropriate
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13
Q

Should medical information remain confidential after a patient’s death?

A

o Patient sensitive data remains confidential even after death
o It would only be with the express permission of the executer you would be
allowed to share confidential information

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14
Q

Conditions for DLVA

A

Epilepsy
Stroke/TIA
Sleep apnoea
Diabetes w severe hypo
MI
PCI
ICD

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15
Q
A

Cigarette paper scars

Ehler Danos

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16
Q

What Ix would you do for aortic dilatation in Ehler Danos

A

ECG

B/L BP

CXR

Echo

CT/MRI aorta

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17
Q

Cardiovascular complications of Ehler Danos

A

Aortic regurg

Aortic dilatation

MVP

Cardiac conduction deficit

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18
Q

There are different types of Ehlers Danlos syndrome – do you know the different types?

A
  • most common - hypermobile type joints are mainly affected.
  • next most common - classical type where the skin is most affected
  • vascular type, which can lead to a higher risk of internal haemorrhage. (reduced life expectancy, mddle age)
  • kyphoscoliotic
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19
Q

Ehler Danos genetics

A

connective tissue disoder caused by absent or defective collagen

Multiple different genetic mutations

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20
Q

Management of EDS

A

Supportive - PT/OT/orthotics

normal life span

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21
Q
A

Sarcoid

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22
Q

Ix for sarcoid

A

FBC/U+Es/LFTs/bone ?hypercalcaemia

ACE increased

Spirometry

CXR

Echo

HRCT

Possibly tissue biopsy to rule out TB

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23
Q

Stages of sarcoidosis on CXR

A

Stage 0 is a normal chest X-ray

Stage 1 is bilateral hilar lymphadenopathy

Stage 2 is bilateral hilar lymphadenopathy with pulmonary infiltrates

Stage 3 is diffuse pulmonary infiltrates

Stage 4 is pulmonary fibrosis.

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24
Q

What would you expect PFTs to show in sarcoidosis?

A

Restrive with reduced transfer factor

restrictive = reduced FEV1 (forced expiratory volume) and reduced FVC (forced vital capacity) with a maintained ratio.

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25
Q

And how would you treat someone you suspect to have sarcoidosis?

A
  • usually supportive only
  • severe symptoms or CXR Stage 2 or above/ sx not resolving in 6 months steroids
  • then methorrexate/ anti TNF therapies eg infliximab, azothioprine
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26
Q

Causes of raised ACEi

A

lymphoma

pulmonary TB

asbestosis

silicosis

sarcoidosis (for seveirty not diagnosis)

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27
Q

Marfans syndrome vs Marfanoid habitus

A

Habitus - just skeletal abnormalities

syndrome - cardiac anad eye involvement

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28
Q

Why are Marfans/ Ehler Danos patients often on beta blockers?

A

aortic root dilation.

o BP Rx v important

o Beta-blockers slow down aortic route dilation

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29
Q

Specialities that should be involved for Marfans

A

Cardio

Opthal

PT/OT

Rheum

Pain Team

Orthotics/podiatrists

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30
Q

Questions to ask Marfans patients

A

Eye issues

heart problems

Lung collapse

Joint pain - detailed

FHx

Impact on job, life

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31
Q

Genetics marfans

A

Auto dom

fibrillin gene

chromsome 15

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32
Q

Differentials for hypermobility

A

Ehler Danos

Marfans

Pseudoxanthoma Elasticum

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33
Q

What Ix for ?Raynauds

A

Baseline bloods

Auto immune - Ds DNA, ESR, ANA, ENA

Urine dip - protein, blood

ECG - conduction disturbances, Right sided heart strain

+- Echo

CXR +- PFTs

Capillaroscopy

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34
Q

Drug treatment of Raynauds

A

Nifedipine - Ca2+ channel blocker

phospodiesterase inhibitors eg sildenafil

If incipent gangrene - vasodilators eg prostcyclin

Aspirin, topical GTN

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35
Q

Connective tissue disorders related to Raynauds

A

Systemic sclerosis

SLE

RA

Polymyositis

Dermatomyositis

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36
Q

Sx to ask about for Raynauds

A

Rashes/hair loss

Mouth ulcers/dysphagia/Reflux/Malabsorption

Joint pain

Pleurisy/chest pain/SOB

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37
Q

Things to examine in ?Raynauds

A

Nail fold changes

Radial pulses ?R-R delay

Hands/joints ?thickened skin ?sclerodactyly ?swollen joints

Muscle power (stand up arms crosssed)

Heart sounds ?Loud P2 PHTN

Lung creps

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38
Q

BP Cut off pregnancy

A

140/90

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39
Q

Urine dip in pre eclampsia tests

A

Proteinuria

PCR

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40
Q

What to examine for headache in pregnancy?

A

Fundoscopy

Eye movements

Visual and sensory inattention

Power/reflexes

Neck stiffness

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41
Q
A
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42
Q

Differentials for tiredness

A

Anaemia

Hypothyroid

CKD

T2DM

Adrenal insufficiency

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43
Q

What is secondary hypothyroidism?

A

Pituitary insufficiency means not enough TRH produced

So not enough TSH

So low/normal TSH and low T3, T4

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44
Q

How long after starting thyroxine do you recheck someones TFTs?

A

6 weeks

(aim to bring TSH into normal range unless secondary hypothyroidism)

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45
Q

Questions to ask in thyroid hx

A

Periods

Pregnancy plans

Smoking (Graves eye disease)

Other autoimmune conditions/sx

Eye issues

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46
Q
A

Thyroid acropatchy

Clubbing

Swellind adn thickening

Overgrown nail plates that lift off the nail bed

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47
Q
A

Thyroid eye disease

Exopthalmos, proptosis

Red conjunctiva

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48
Q
A

Pretibial myxedema

Ax with Graves disease

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49
Q

Rx of Graves disease

A

Carbimazole

Beta blockers (first couple of months for sx)

Radioactive iodine/surgery

STOP SMOKING

Eye disease (mab, steroids, surgery)

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50
Q

Counselling for carbimazole for Graves

A
  • sx improve 2 weeks
  • bloods change 6-8 weeks
  • 50% chance cure, 50% relapse
  • Can take again in future if it flares up again
  • Can cause agranulocytosis for watch for sore throat - urgent
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51
Q

Counselling for thyroid eye disease

A

Stop smoking

eye drops

raised head bed for swellig

Opthal referral for scan

Reg flags - loss of color, blurring, not being able to shut eyes

Can have steroids, carbimazole

need to stop driving if getting visual problems

NOSPECS score - exoc muscle, proptosis, soft tissue

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52
Q

Counselling for radioiodine

A

90% respond, 10% need second dose

SE; hypothyroidism, worsening eye disease (cover w steroids)

can’t have kids for 6 months

need to keep away from kids, preggo, pets after

risk of lymphoma/leukaemia in future

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53
Q

Counselling for thyrid surgery

A

90% chance of cure

risks; laryngeal nerve palsy, removal of parathyroids - low calcium, hypothyroid (lifelong thyroxine)

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54
Q

Tell me about Graves disease

A

most common cause of thyrotoxicosis

autoimmune, hyper

antibody to TSH receptor

relapsing remitting F>M

tx medically first

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55
Q

Causes of thyrotoxicosis

A

Hashimotos (period of hyperthyroid before becoming hypo)

Toxic adenoma/multinodular goitre

Iatrogenic - too much thyroxine, amiodarone

Ectopic - pituitary adenoma, hypothalamic mass

Thyroiditis - De Quervains, radiation, postpartum

56
Q

Thyroid antibodies

A

Anti TPO - Hashimotos/Graves

Anti TSH - Grave

57
Q

Parkisons examination

A

Tremor = asymmetical pill rolling, reduced with finger nose, worse on distraction

Gait - shuffling, festinating, hesitant, lack of arm swing, unsteadiness, stooped posture

Face - mask/hypomimia, drooling, glabella tap

Speech - quiet (hypophonia)

Limbs - increased tone cogwheel rigidity, bradykinesia, function/writing

Eye movements - up/down limited in PSP, horizontal nystagmus MSA

58
Q

Parkinsons plus syndromes

A

Multi systems atrophy - cerebellar signs, postural drop

Lewy body - confusion

Progressive supranuclear palsy - neck/trunk stiffness, vertical limitation

Corticobulbar degeneration

59
Q

Causes of Parkinsons

A

PD

Drugs - anti psychotics, metocloperamide

Parkinsons plus

Wilsons

60
Q

Parkinsons Quadrad

A

Tremor

Rigidity

Bradykinesia

Postural instability

61
Q

Parkinsons management

A

Supportive - PT, OT, SN, SALT, dirivng

Levodopa (if sx impact of QoL, can cause on/off freezing or dyskinesias, wearing off)

MOo-BIs - selegiline, rasagiline

Dopamine agonists - pramipexole, ropinirole

Anticholinergic

62
Q

Sx of pseudohypoparathyroidisim (low calcium)

A

Muscle spasms/twitching, cramps

SOB (bronchospasm)

bone pain, abdo pain, headache

low mood, confusion

Seizures

Cataracts

Kidney stones

63
Q

Causes of low calcium

A

pseudo/hypoparathyroidism

CKD

Vit D deficiency

Pancreatitis

Autoimmune - thyroid, addisons, vitiligo

Blood transfusion

Wilsons, haemochromatosis, DM

Drugs - bisphosphonates, chemo

64
Q

Examination for hypocalcaemia/hypoparathyroidism

A

Pseudohypoparathyroidism - round face, short neck, short 4th 5th MCPs

Mouth/dental abnormalities

Feel neck/abdo ?thyroid surgery ?panretitis

Chvostek - tap cheek and twitching, Trousseaus - twitching w BP cuff

parathesiae

Ix - 24hr urinary calcium, QT, renal USS, ATCH/adrenal antibodies

65
Q
A

Pseudohypoparathyroidism

66
Q

Sx of hyperparathyroidism

A

Osteoporosis

Kidney stones

Polyuria

Abdo pain

Fatigue

Depression/confusion

Bone/joint pain

Frequent illness

Nausa/vom/loss of appetite

67
Q

Explain primary hyperparahtyroidism

A

Adenoma is most common cause

Paathyroid hyperplasia

Malignancy

Too much PTH causes high calcium

68
Q

Explain secondary hyperparathyroidism

A

LOW CALCIUM so PTH increases to try and compensate

Causes; severe hypocalcaemia, severe vit D deficiency, CKD

69
Q

Explain tertiary hyperparathyroidism

A

Had secondary for so long, even once calcium is treated PTH remains high

70
Q

Ix for hyperparathyroidism

A

DEXA

24 urine calcium

USS/XR kidneys

USS/radioactive parathyroid scan

71
Q

Management of hyperparathyroidism

A

Watch and wait if - only mildly high calcium, normal kidney w/o stones, normalish bone density, no other sx

Surgery - most common, can cause vocal nerve palsy, hypparathryoidism

Cinacalet (calcimimetic) if surg hasn’t worked or not good surg candidate

HRT, bisphosphonates

72
Q

Questions to ask in Cushings

A

Acne, weight, hair, face, skin changes

thirst, polyuria

Periods, erections, mood

Headaches, visual change, abdo pain, lung ca sx

BP

inc creams, nasal spray

73
Q

What is Cushing

A

Any condition that causes increased glucocorticoid levels and loss of normal feedback mechanisms of hypothalamic pituitary adrenal axis (HPA)

Most likely iatrogenic

When not iatrogenic 80 pituitary microadenoma (Cushings disease) secretes ATCH and stimulates adrenals, part of MEN1

Or adrenal adenoma/carcinoma/hyperplasia

Or ectopic ATCH from other tumours eg SCLC, bronchial carcinoid, ovarian

74
Q

Causes of pseudo Cushings

A

ETOH

Obesity

Pregnancy

75
Q

How would you Ix ?Cushings

A

BP, HbA1c, lipids, U+Es (low K+)

urine dip ?glucose, 24 free cortisol

Overnight dexamethsasone supression test - will fail to suppress

Start with low dose then high

Pituitary MRI +- CT TAP, adrenal CT, ACTH levels 9am

76
Q

Treatment of Cushings

A

Transphenoidal hypophysectomy

If surgery fails - carbegoline

+- pituitary irridation

77
Q

Cardiac causes of clubbing

A

Infective endocarditis

Cyanotic congential heart disease

Atrial myxoma

78
Q

Respiratory causes of clubbing

A

Lung ca (not small cell)

CF

Bronchiectasis

Lung abcess

Empyema

PF

NOT COPD

79
Q

Gastrointestinal causes of clubbing

A

IBD

Malabsoprtion

Cirrhosis

GI Lymphoma

80
Q

Other causes of clubbing

A

thryotoxicosis

Hereditary

81
Q

Features of clubbing

A

Loss of Lovibonds angle/Schamroth window

1st satge - periungual erythema and softening of nail bed

Bublous swelling of terminal phalanx

later hyper extension

82
Q
A
83
Q
A

Butterfly rash lupus

+- discoid

mouth ulcers

scarring alopecia

nail infarcts

Jaccouds arthropathy (looks like RA)

84
Q
A

Discoid lupus

photosensitive

85
Q

Ax conditions/sx for lupus

A

Raynauds

Sjorgens

Pleuritis/pericarditis

Arthritis

86
Q

Specific questions for lupus

A

Pregnancy

Photosensitive

87
Q

Respiratory effects of SLE

A

Pleural effusion

Pleural rub

Fibrosing alveolitis

88
Q

Neurology effects of SLE

A

Focal neuro (Finger nose, pronator drift)

Chorea

Ataxia

89
Q

Renal effects of SLE

A

HTN

Haematuria

Frothy urine/proteinuria/edema

90
Q

Ix for ?SLE

A

DsDNA, ANA

High ESR normal CRP

Elevated immunoglobulins

Reduced complement

U+Es, urine microscopy

91
Q

Management of SLE

A

Mild disease - topical steroids, hydroxychloroquinine

Mod - pred, azothiaprine

Severe - MMF, Methylpred, cyclophosphamide, azothiaprine

92
Q

Side effects

A

Haematological

Haemorrhagic cysitis

Infertility

Tetratogenicity

93
Q

Osteoporosis definition

A

BMD >2.5 SD below the mean average at hip

94
Q

Endo causes of osteoporosis

A

Hypogonadism

Hyperthyroid

Hyperprolactinaemia

Cushing

Diabetes

95
Q

Gastro causes of Osteoporosis

A

Coeliac

IBD

Chronic liver disease

Pancreatitis

Malabsorption

96
Q

Management of osteoporosis

A

1st line - Replace calcium and vit D

2nd line - Bisphosphonates

3rd line - denusomab (reduces osteoclast activity, every 6 months)

MDT - PT/OT

STOP SMOKING

exercise etc

97
Q

Coeliac Ix

A

HL DQ2/DQ8

Anti TTG, IgA

Duodenal/jejunal biopsy

Modified March criteria

DEXA

98
Q

Complications of coeliac

A

Enteropathy Associated T cell lymphoma

GI malignancy

Dermatitis herpetiformis

Osteopaenia/porosis

Hyposlenism

Lactose intolerance, bacterial overgrowth, panceatic insuffiency

99
Q

Koebner phenomenom

A

Vitiligo worse at trauma sites

100
Q

How is vitiligo diagnosed?

A

Clinical diagnosis

Can look under wood lamp

101
Q

Management of vitiligo

A

Steroid creams

Cacineurin inhibitors eg tacrolimus ointment

Phototherapy

Sun protection

Skin protection

Make up/camouflage

102
Q
A

Gouty tophi

103
Q
A

Rheumatoid nodules

104
Q

Rheumatoid lung

(Type, tx)

A

Pleural effusions/pleuritis, obliterative bronchiolitis

Check for features of PHTN, Cor pulmonale, cyanosis

UIP(most common)/PF/NSIP

Can use steroids, anti fibrotics; nintedanib, pirfenidone

105
Q

Bugs causing reactive arthritis

A

Diarrhoea - salmonella, streptococcus, campylobacter

Chlamydia

Gonoccoal - more commonly septic joint

106
Q

Bloods to Ix ?Rheumatoid

A

RF Anti CCP HLA B27

107
Q

Score for Ank Spond

A

BASAI Bath Ank Spond Activity Index 4 out of 10 = severe disease

108
Q

Schobers

A

10cm measured up from L5 Should increase by >5cm

109
Q

Occiput wall test ank spond

A

2cm or less is normal

110
Q

How do you diagnose osteogenesis imperfecta?

A

Clinical features

FHx

Genetic testing

111
Q

Management of osteogenesis imperfecta

(Acute fractures/prevention of future fractures)

A

MDT - PT/OT/podiatry/orthotics

Analgesia

Bisphosphonates

ENT and cardio FU

Management of fractures

Exercise, idet, not smoking

Genetic screening

112
Q

Features of osteogenesis imperfecta

A

Hypermobile

Blue sclera

Hearing aids

Short stature

Affects type 1 collagen

Multiple fractures as a child

Aortic dilatation

113
Q

Differentials for osteogenesis imperfecta

A

Ehler Danos

Marfans

Pseudoxanthoma Elasticum

Vit D deficiency

Osteomalacia

Rickets

Non accidental injury

114
Q

Types of osteogenesis imperfecta

A

Type 1 - mild

Type 2 - Dx in utero w fractures, death in first year of life

Mainly auto dom (although some types are recessive)

115
Q

Describe subacute combined degeneration of the cord

A

Affects dorsal and lateral columns

Sensory loss, weakness, ataxia, gait issues, parathesia

Can lead to spastic parapesis

Caused by B12 deficiency

116
Q

Types of meningitis

A
  • viral meningitis
  • meningitis caused by protozoa, fungal and tuberculosis (TB)
  • lyme meningitis
  • paraneoplastic meningitis
  • malarial meningitis.
  • bacteria
117
Q

Acute management of suspected meningitis

A
  • cultures and baseline bloods
  • LP - protein, glucose, virology, microscopy, culture, cell count
  • CT to exclude raised ICP first if concerned
  • broad spec ABx
118
Q
A

Retinitis pigmentosa

  • bone spicule pattern
  • pigmentation of retina
  • waxy pallor
119
Q

Management of retinitis pigmentosa

A

Opthlmogy

Genetic testing

120
Q

Ax syndromes retinitis pigmentosa

A

o Usher syndrome ( + sensorineural deafness)

o Bardet–Biedl syndrome

o Kearns–Sayre syndrome

o Refsum’s disease

o Alström’s disease.

  • Alports
121
Q

Inheritance of retinitis pigmentosa

A

Auto dom

Auto recesive

X linked

122
Q

How do you Ix acromegaly?

A

Check IGF 1 level

Then OGTT - acromegaly shows failure to suppress groh hormone

MRI pituitary

123
Q

Systemic features acromegaly

A

DM

HTN

IHD/cardiomyopathy

Bitemporal hemianopia

124
Q
A
125
Q

Tx of acromegaly

A

transphenoidal surgery

2nd line - dopamine agonists eg bromocriptine, somastatin (GH inihibitor) ananlogues eg ocreotide

3rd line pituitary radiatherapy

Can cause hypopituitarism

126
Q

Differentials of an acute joint

A

Reactive artritis - STI

Gout

Pseudo gout

IBD

Psoriasis

Infection

127
Q

Causes of Gout

A

Alcohol excess

Drugs: thiazides and loop diuretics, aspirin

Acidosis (lactate/diabetic ketoacidosis/respiratory)

CKD

Myelo/lymphproliferative disorders

Psoriasis

Tumour lysis secondary to chemo

Excess dietary purine intake

Lesch Nyhan syndrome

128
Q

X Ray features of Gout

A

soft tissue swelling

punched out mouse bite erosions

overhanging edges

calcification

Joint space preserved until late

129
Q

Managemnt of gout

A

Lifestyle, CV risk

NSAID + PPI

Steroids

Check urate 4-6 weeks

Allopurinol (xanthine oxidase inhibitor). Continue if already on it, otherwise start 2 weeks after sx settled

Monitor and titrate to urate <300

130
Q

Ulnar Nerve Palsy

A

Wasting of small muscles

Clawing of 4th and 5th fingers

131
Q
A
132
Q

Causes of carpal tunnel syndrome

A

Fluid retention - pregnancy, obesity, menopause

SOL - ganglion, osteophytes, fracture

DM, smoking, hypothyroid

133
Q

Presentation of carpal tunnel syndrome

A

Tingling, numbness, pain over median nerve distribution (palm from thumb to half of ring finger)

Loss of grip strength

Clumsiness

Pain - worse at night, gradual onset, Intermittent, relieved by shaking/moving hand

Reduced thumb abduction, wasting thenar eminence

134
Q

What tests can you do for carpal tunnel?

A

Phalen’s test: +ve if flexing the wrist for 60 secs pain/ paraesthesia in the median nerve distribution (inverted prayer)

Tinel’s test: +ve tapping lightly over the median nerve at the wrist paraesthesia/ pain in median nerve distribution.

Need to also examine C spine and neuro + MSK upper limb

135
Q

Ix/Rx carpal tunnel

A

EMG

NCS

USS

Splinting, physio, analgeesia

Steroids

Open/endoscopic surgery

136
Q

When does pre eclampsia occur

A

After 20 weeks

PACES (7 decks)

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