Other Flashcards
Further questions for ?RA
GI upset
Dry eyes
Rash
Mouth/swallowing
Weight loss
Fevers
Function/job
SOB
FHx
How would you manage newly diagnosed RA?
MDT (PT, OT)
Analgesia
NSAIDs w GI protection
If acute flair - high dose steroids then taper
DMARDs later
What disease modifying therapies are you aware of?
methotrexate
• azathioprine
• cylosporin
• sulphasalazine
• gold.
Tell me about methotrexate
Weekly
Inhibits purine synthesis - needs folic acid replacement
Regular FBC and LFTs
Counsel on risk of myelosuppresion
Describe RA
Symmetrical deforming polyarthopathy
Mainly small joints of hands and feet
Mainly PIP and MCPs
Extra articular features of RA
Scleritis/episcleritis
Fibrosis/pleural effusion
Pericarditis/cardiomyopathy
Splenomegaly (Feltys syndrome)
Carpal tunnel
Causes of anaemia in RA
Anaemia of chronic disease
GI bleeding from NSAIDs
Bone marrow suppression from methotrexate
Megaloblastic anaemia
Haemolytic anaemia
Rules for single isolated seizure with normal Ix and category 1 liscence
6 months
Things to consider if new epilepsy diagnosis and female
Tetrogenicity of meds
Needs contraception
Why is patient confidentiality important?
to protect the patient.
o risk of exploitation if information shared
without approval.
o Doctor - patient relationship specific + wider
Under what circumstances may you break patient confidentiality?
What are the possible consequences of breaking patient confidentiality?
- trust with you
- trust with others
- GMC if inappropriate
Should medical information remain confidential after a patient’s death?
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
Conditions for DLVA
Epilepsy
Stroke/TIA
Sleep apnoea
Diabetes w severe hypo
MI
PCI
ICD
Cigarette paper scars
Ehler Danos
What Ix would you do for aortic dilatation in Ehler Danos
ECG
B/L BP
CXR
Echo
CT/MRI aorta
Cardiovascular complications of Ehler Danos
Aortic regurg
Aortic dilatation
MVP
Cardiac conduction deficit
There are different types of Ehlers Danlos syndrome – do you know the different types?
- 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
Ehler Danos genetics
connective tissue disoder caused by absent or defective collagen
Multiple different genetic mutations
Management of EDS
Supportive - PT/OT/orthotics
normal life span
Sarcoid
Ix for sarcoid
FBC/U+Es/LFTs/bone ?hypercalcaemia
ACE increased
Spirometry
CXR
Echo
HRCT
Possibly tissue biopsy to rule out TB
Stages of sarcoidosis on CXR
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.
What would you expect PFTs to show in sarcoidosis?
Restrive with reduced transfer factor
restrictive = reduced FEV1 (forced expiratory volume) and reduced FVC (forced vital capacity) with a maintained ratio.
And how would you treat someone you suspect to have sarcoidosis?
- 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
Causes of raised ACEi
lymphoma
pulmonary TB
asbestosis
silicosis
sarcoidosis (for seveirty not diagnosis)
Marfans syndrome vs Marfanoid habitus
Habitus - just skeletal abnormalities
syndrome - cardiac anad eye involvement
Why are Marfans/ Ehler Danos patients often on beta blockers?
aortic root dilation.
o BP Rx v important
o Beta-blockers slow down aortic route dilation
Specialities that should be involved for Marfans
Cardio
Opthal
PT/OT
Rheum
Pain Team
Orthotics/podiatrists
Questions to ask Marfans patients
Eye issues
heart problems
Lung collapse
Joint pain - detailed
FHx
Impact on job, life
Genetics marfans
Auto dom
fibrillin gene
chromsome 15
Differentials for hypermobility
Ehler Danos
Marfans
Pseudoxanthoma Elasticum
What Ix for ?Raynauds
Baseline bloods
Auto immune - Ds DNA, ESR, ANA, ENA
Urine dip - protein, blood
ECG - conduction disturbances, Right sided heart strain
+- Echo
CXR +- PFTs
Capillaroscopy
Drug treatment of Raynauds
Nifedipine - Ca2+ channel blocker
phospodiesterase inhibitors eg sildenafil
If incipent gangrene - vasodilators eg prostcyclin
Aspirin, topical GTN
Connective tissue disorders related to Raynauds
Systemic sclerosis
SLE
RA
Polymyositis
Dermatomyositis
Sx to ask about for Raynauds
Rashes/hair loss
Mouth ulcers/dysphagia/Reflux/Malabsorption
Joint pain
Pleurisy/chest pain/SOB
Things to examine in ?Raynauds
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
BP Cut off pregnancy
140/90
Urine dip in pre eclampsia tests
Proteinuria
PCR
What to examine for headache in pregnancy?
Fundoscopy
Eye movements
Visual and sensory inattention
Power/reflexes
Neck stiffness
Differentials for tiredness
Anaemia
Hypothyroid
CKD
T2DM
Adrenal insufficiency
What is secondary hypothyroidism?
Pituitary insufficiency means not enough TRH produced
So not enough TSH
So low/normal TSH and low T3, T4
How long after starting thyroxine do you recheck someones TFTs?
6 weeks
(aim to bring TSH into normal range unless secondary hypothyroidism)
Questions to ask in thyroid hx
Periods
Pregnancy plans
Smoking (Graves eye disease)
Other autoimmune conditions/sx
Eye issues
Thyroid acropatchy
Clubbing
Swellind adn thickening
Overgrown nail plates that lift off the nail bed
Thyroid eye disease
Exopthalmos, proptosis
Red conjunctiva
Pretibial myxedema
Ax with Graves disease
Rx of Graves disease
Carbimazole
Beta blockers (first couple of months for sx)
Radioactive iodine/surgery
STOP SMOKING
Eye disease (mab, steroids, surgery)
Counselling for carbimazole for Graves
- 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
Counselling for thyroid eye disease
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
Counselling for radioiodine
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
Counselling for thyrid surgery
90% chance of cure
risks; laryngeal nerve palsy, removal of parathyroids - low calcium, hypothyroid (lifelong thyroxine)
Tell me about Graves disease
most common cause of thyrotoxicosis
autoimmune, hyper
antibody to TSH receptor
relapsing remitting F>M
tx medically first
Causes of thyrotoxicosis
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
Thyroid antibodies
Anti TPO - Hashimotos/Graves
Anti TSH - Grave
Parkisons examination
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
Parkinsons plus syndromes
Multi systems atrophy - cerebellar signs, postural drop
Lewy body - confusion
Progressive supranuclear palsy - neck/trunk stiffness, vertical limitation
Corticobulbar degeneration
Causes of Parkinsons
PD
Drugs - anti psychotics, metocloperamide
Parkinsons plus
Wilsons
Parkinsons Quadrad
Tremor
Rigidity
Bradykinesia
Postural instability
Parkinsons management
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
Sx of pseudohypoparathyroidisim (low calcium)
Muscle spasms/twitching, cramps
SOB (bronchospasm)
bone pain, abdo pain, headache
low mood, confusion
Seizures
Cataracts
Kidney stones
Causes of low calcium
pseudo/hypoparathyroidism
CKD
Vit D deficiency
Pancreatitis
Autoimmune - thyroid, addisons, vitiligo
Blood transfusion
Wilsons, haemochromatosis, DM
Drugs - bisphosphonates, chemo
Examination for hypocalcaemia/hypoparathyroidism
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
Pseudohypoparathyroidism
Sx of hyperparathyroidism
Osteoporosis
Kidney stones
Polyuria
Abdo pain
Fatigue
Depression/confusion
Bone/joint pain
Frequent illness
Nausa/vom/loss of appetite
Explain primary hyperparahtyroidism
Adenoma is most common cause
Paathyroid hyperplasia
Malignancy
Too much PTH causes high calcium
Explain secondary hyperparathyroidism
LOW CALCIUM so PTH increases to try and compensate
Causes; severe hypocalcaemia, severe vit D deficiency, CKD
Explain tertiary hyperparathyroidism
Had secondary for so long, even once calcium is treated PTH remains high
Ix for hyperparathyroidism
DEXA
24 urine calcium
USS/XR kidneys
USS/radioactive parathyroid scan
Management of hyperparathyroidism
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
Questions to ask in Cushings
Acne, weight, hair, face, skin changes
thirst, polyuria
Periods, erections, mood
Headaches, visual change, abdo pain, lung ca sx
BP
inc creams, nasal spray
What is Cushing
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
Causes of pseudo Cushings
ETOH
Obesity
Pregnancy
How would you Ix ?Cushings
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
Treatment of Cushings
Transphenoidal hypophysectomy
If surgery fails - carbegoline
+- pituitary irridation
Cardiac causes of clubbing
Infective endocarditis
Cyanotic congential heart disease
Atrial myxoma
Respiratory causes of clubbing
Lung ca (not small cell)
CF
Bronchiectasis
Lung abcess
Empyema
PF
NOT COPD
Gastrointestinal causes of clubbing
IBD
Malabsoprtion
Cirrhosis
GI Lymphoma
Other causes of clubbing
thryotoxicosis
Hereditary
Features of clubbing
Loss of Lovibonds angle/Schamroth window
1st satge - periungual erythema and softening of nail bed
Bublous swelling of terminal phalanx
later hyper extension
Butterfly rash lupus
+- discoid
mouth ulcers
scarring alopecia
nail infarcts
Jaccouds arthropathy (looks like RA)
Discoid lupus
photosensitive
Ax conditions/sx for lupus
Raynauds
Sjorgens
Pleuritis/pericarditis
Arthritis
Specific questions for lupus
Pregnancy
Photosensitive
Respiratory effects of SLE
Pleural effusion
Pleural rub
Fibrosing alveolitis
Neurology effects of SLE
Focal neuro (Finger nose, pronator drift)
Chorea
Ataxia
Renal effects of SLE
HTN
Haematuria
Frothy urine/proteinuria/edema
Ix for ?SLE
DsDNA, ANA
High ESR normal CRP
Elevated immunoglobulins
Reduced complement
U+Es, urine microscopy
Management of SLE
Mild disease - topical steroids, hydroxychloroquinine
Mod - pred, azothiaprine
Severe - MMF, Methylpred, cyclophosphamide, azothiaprine
Side effects
Haematological
Haemorrhagic cysitis
Infertility
Tetratogenicity
Osteoporosis definition
BMD >2.5 SD below the mean average at hip
Endo causes of osteoporosis
Hypogonadism
Hyperthyroid
Hyperprolactinaemia
Cushing
Diabetes
Gastro causes of Osteoporosis
Coeliac
IBD
Chronic liver disease
Pancreatitis
Malabsorption
Management of osteoporosis
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
Coeliac Ix
HL DQ2/DQ8
Anti TTG, IgA
Duodenal/jejunal biopsy
Modified March criteria
DEXA
Complications of coeliac
Enteropathy Associated T cell lymphoma
GI malignancy
Dermatitis herpetiformis
Osteopaenia/porosis
Hyposlenism
Lactose intolerance, bacterial overgrowth, panceatic insuffiency
Koebner phenomenom
Vitiligo worse at trauma sites
How is vitiligo diagnosed?
Clinical diagnosis
Can look under wood lamp
Management of vitiligo
Steroid creams
Cacineurin inhibitors eg tacrolimus ointment
Phototherapy
Sun protection
Skin protection
Make up/camouflage
Gouty tophi
Rheumatoid nodules
Rheumatoid lung
(Type, tx)
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
Bugs causing reactive arthritis
Diarrhoea - salmonella, streptococcus, campylobacter
Chlamydia
Gonoccoal - more commonly septic joint
Bloods to Ix ?Rheumatoid
RF Anti CCP HLA B27
Score for Ank Spond
BASAI Bath Ank Spond Activity Index 4 out of 10 = severe disease
Schobers
10cm measured up from L5 Should increase by >5cm
Occiput wall test ank spond
2cm or less is normal
How do you diagnose osteogenesis imperfecta?
Clinical features
FHx
Genetic testing
Management of osteogenesis imperfecta
(Acute fractures/prevention of future fractures)
MDT - PT/OT/podiatry/orthotics
Analgesia
Bisphosphonates
ENT and cardio FU
Management of fractures
Exercise, idet, not smoking
Genetic screening
Features of osteogenesis imperfecta
Hypermobile
Blue sclera
Hearing aids
Short stature
Affects type 1 collagen
Multiple fractures as a child
Aortic dilatation
Differentials for osteogenesis imperfecta
Ehler Danos
Marfans
Pseudoxanthoma Elasticum
Vit D deficiency
Osteomalacia
Rickets
Non accidental injury
Types of osteogenesis imperfecta
Type 1 - mild
Type 2 - Dx in utero w fractures, death in first year of life
Mainly auto dom (although some types are recessive)
Describe subacute combined degeneration of the cord
Affects dorsal and lateral columns
Sensory loss, weakness, ataxia, gait issues, parathesia
Can lead to spastic parapesis
Caused by B12 deficiency
Types of meningitis
- viral meningitis
- meningitis caused by protozoa, fungal and tuberculosis (TB)
- lyme meningitis
- paraneoplastic meningitis
- malarial meningitis.
- bacteria
Acute management of suspected meningitis
- cultures and baseline bloods
- LP - protein, glucose, virology, microscopy, culture, cell count
- CT to exclude raised ICP first if concerned
- broad spec ABx
Retinitis pigmentosa
- bone spicule pattern
- pigmentation of retina
- waxy pallor
Management of retinitis pigmentosa
Opthlmogy
Genetic testing
Ax syndromes retinitis pigmentosa
o Usher syndrome ( + sensorineural deafness)
o Bardet–Biedl syndrome
o Kearns–Sayre syndrome
o Refsum’s disease
o Alström’s disease.
- Alports
Inheritance of retinitis pigmentosa
Auto dom
Auto recesive
X linked
How do you Ix acromegaly?
Check IGF 1 level
Then OGTT - acromegaly shows failure to suppress groh hormone
MRI pituitary
Systemic features acromegaly
DM
HTN
IHD/cardiomyopathy
Bitemporal hemianopia
Tx of acromegaly
transphenoidal surgery
2nd line - dopamine agonists eg bromocriptine, somastatin (GH inihibitor) ananlogues eg ocreotide
3rd line pituitary radiatherapy
Can cause hypopituitarism
Differentials of an acute joint
Reactive artritis - STI
Gout
Pseudo gout
IBD
Psoriasis
Infection
Causes of Gout
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
X Ray features of Gout
soft tissue swelling
punched out mouse bite erosions
overhanging edges
calcification
Joint space preserved until late
Managemnt of gout
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
Ulnar Nerve Palsy
Wasting of small muscles
Clawing of 4th and 5th fingers
Causes of carpal tunnel syndrome
Fluid retention - pregnancy, obesity, menopause
SOL - ganglion, osteophytes, fracture
DM, smoking, hypothyroid
Presentation of carpal tunnel syndrome
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
What tests can you do for carpal tunnel?
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
Ix/Rx carpal tunnel
EMG
NCS
USS
Splinting, physio, analgeesia
Steroids
Open/endoscopic surgery
When does pre eclampsia occur
After 20 weeks
