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PACES 1 Flashcards

1
Q

Common causes of splenomegaly and investigations

A

Haem- CML, myelofibrosis, hereditary spherocytosis, haemolytic anaemia, ITP
Infective- malaria, visceral leishmaniasis, EBV, IE
Infiltrative- amyloidosis, Felty’s, SLE
Other- portal HTN, splenic vein thrombus, HIV
Investigations- FBC, blood film, thin/thick films, US, CT, LN biopsy

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2
Q

Hereditary spherocytosis- signs, inheritance, investigation, management

A

Signs- Splenomegaly, anaemia, jaundice, cholecystectomy.
Autosomal dominant
Ix- FBC, retics, EMA/osmotic fragility test, direct coombs test (to rule out AIHA)
Mx- folic acid, splenectomy, transfusions

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3
Q

Pulmonary fibrosis- signs, Ix, Mx, spirometry pattern

A

Signs- Clubbing, LTOT, cyanosis, fine creps, CT disease signs
Ix- CXR, HRCT, bloods (ANA, ENA, ANCA), spirometry, obs/ABG
Mx- pirfenidone, nintendanib, steroids, transplant, supportive
Spirometry- restrictive and reduced gas transfer

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4
Q

Causes of upper zone lung fibrosis

A

Coal workers pneumoconiosis, histiocytosis, ank spond, ABPA, radiation, TB, silicosis, sarcoidosis

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5
Q

Causes of lower zone lung fibrosis

A

RA, asbestosis, CT disease, IPF, other (drugs- MTX, nitro, amio)

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6
Q

ADPKD- types, signs, complications, management

A

Type 1 and 2- type 1 more rapidly progressive to ESRF
Signs- uni/bilateral ballotable kidneys, signs of RRT/lines, nephrectomy
Complications- HTN, berry aneurysms, MVP, cystic liver
Management- RRT, transplant, nephrectomy, control HTN (ACEi/ARB), genetic counselling, 5 yearly screening for berry aneurysm, 3L fluid per day, screen family

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7
Q

ABPA- what is it and who gets it? Ix? Mx?

A

Asthmatics, immunocompromised and CF patients- colonise aspergillus fungus in airways and unable to clear it they develop an immune response/hypersensitivity reaction
Ix- aspergillus RAST, IgE, eosinophils, CXR, HRCT
Mx- steroids, itraconazole

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8
Q

EAA/hypersensitivity pneumonitis- pathology, causes, Mx

A

Exposure to allergen causes hypersensitivity reaction- fever, cough, sob, wheeze
Causes- mushroom worker, bird fancier, malt worker, farmers lung
Mx- steroids and avoid trigger

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9
Q

Pneumonectomy- scar, signs, indications

A

Scar- lateral thoracotomy, drain scars
Signs- hemithorax fills with fluid, dull to percuss, no air entry, trachea deviated towards side of surgery, reduced chest expansion
Indications- cancer, TB, PTX, COPD, trauma, aspergilloma, abscess, CF

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10
Q

Lobectomy- scar, signs indications

A

Scar- lateral thoracotomy, drain scars
Signs- may be normal. Hyperexpansion of remaining lobes, reduced air entry over lobectomy area
Indications- cancer, TB, PTX, COPD, trauma, aspergilloma

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11
Q

FEV1 required for lobectomy and pneumonectomy

A

Pneumo >2L
Lobectomy >1.5L

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12
Q

Stigmata of chronic liver disease

A

Dupuytrens contracture, palmar erythema, clubbing, gynaecomastia, jaundice, spider naevi, caput medusae, ascites, hepatomegaly

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13
Q

Tuberous sclerosis- inheritance, complications

A

Autosomal dominant
Angiomyolipoma in kidneys, epilepsy, ash leaf/shagreen patches, hamartomas, cystic lung disease

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14
Q

Causes of CLD

A

ETOH, NAFLD, viral hepatitis, AI hepatitis, PBC, PSC, A1AT deficiency, Wilson’s, HCC, liver mets, haemochromotosis, right heart failure

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15
Q

What monitoring should be offered in CLD

A

6 monthly US and AFP for HCC, yearly OGD for varices

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16
Q

Causes of hepatomegaly

A

Malignancy- HCC, mets
CLD- ETOH, NAFLD, PBC, haemochromotosis
Infective- acute/chronic Hep, abscess, cyst
Infiltrative- amyloid, gauchers, sarcoid
Vascular- budd-chiari
Congestive- CCF, constrictive pericarditis

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17
Q

Budd-Chiari syndrome

A

Hepatic vein occlusion of unknown cause

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18
Q

Wilson’s disease - inheritance, pathology, Ix, complications, Mx

A

Autosomal recessive
Copper accumulation in liver, heart, brain, eyes joints
Ix- high serum cooper, low caeruloplasmin, genetic testing
Parkinsonism, cirrhosis, psychosis, kayser-fleischer rings
Penicillamine, transplant, low copper diet

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19
Q

Causes of hepatosplenomegaly

A

portal HTN
Haem- myelofibrosis, spherocytosis, AIHA, thalassaemia
Infection- malaria, visceral leishmaniasis, EBV, CMV
Infiltrative- sarcoid, amyloid

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20
Q

Thalassaemia- signs, Ix, Mx, complications

A

Signs- frontal bossing, hepato/splenomegaly, pallor, jaundice, cholecystectomy scar
Ix- haemoglobin electrophoresis
Mx- transfusion, folic acid, splenectomy, iron chelation
Complications- iron overload

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21
Q

What characterises bronchiectasis?

A

Abnormal dilation of bronchial walls due to loss of elasticity and muscular tone. Chronic inflammation,
retention of secretions, oedema, scarring and ulceration of bronchial wall. Recurrent infections cause further dilation resulting in a vicious cycle of impaired clearance, infection, and bronchial damage.

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22
Q

Causes of bronchiectasis

A

Childhood infections: pertussis, TB
Congenital: CF, kartageners
Hypo-immune: CVID, hypogammaglobulinaemia
Hyper-immune: ABPA
Rheum: SLE, IBD, RA, Sjogrens
Idiopathic

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23
Q

Where would you see VATS scars and give some indications

A

2-3 2cm port side scars on thorax
Indications: biopsy, removal of mass, pleurodesis

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24
Q

Signs of pulmonary HTN

A

RV heave, palpable P2, loud P2, TR (PSM), displaced apex beat

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25
Q

Signs of thoracoplasty

A

Posterior thoracotomy scar, tracheal deviation towards affected side, flattening of chest wall, reduced expansion, absent ribs, dull percussion, reduced breath sounds

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26
Q

Types of pleural effusion and causes

A

Transudate: CCF, nephrotic syndrome hypothyroid, Meig’s
Exudate: empyema, parapneumonic, TB, malignancy, SLE, RA, sarcoid, PE
Chylothorax
Haemothorax

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27
Q

HIV- common infections/complications

A

Candida, herpes zoster, PCP, TB, CMV, lymphoma, Kaposi’s sarcoma

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28
Q

Types of jaundice and causes

A
  1. Pre-hepatic: AIHA, sphero/elliptocytosis, Gilbert’s, transfusion incompatibility, SCD, thalassaemia
  2. Hepatic: paracetamol, ETOH, viral hepatitis, EBV, CMV, HCC, NASH, haemochromotosis, Wilson’s
  3. Post-hepatic: gallstones, biliary tract malignancy, PBC, PSC, pancreatitis
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29
Q

What are the clinical and echo markers of severe AS?

A

Clinical: lengthening of murmur, evidence of LV failure, quiet/absent S2, narrow pulse pressure
S4, thrill
Echo: area <1cm2, gradient >40mmHg

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30
Q

Where is a normal apex beat located?

A

5th ICS MCL

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31
Q

Causes of AR

A

Aortic dissection, IE, bicuspid AV, Marfans, syphilis, ank spond, SLE, RA

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32
Q

Indications for surgery in AR

A

Angina, CCF, EF <50%, aortic root diameter >50mm

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33
Q

Signs of an ASD

A

Parasternal heave and palpable thrill, fixed split S2, loud P2, ESM

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34
Q

Signs of Turner syndrome

A

Short stature, shield like chest, wide spaced nipples, webbed neck, high arched palate, coarctation of the aorta

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35
Q

Signs of coarctation of the aorta

A

Radio-radial/radio-femoral delay, thoracotomy scar, ESM over LSE radiating to back

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36
Q

Signs of HCM

A

AF, heaving apex beat, ESM at LSE (with no radiation and louder on valsalva), PSM of MR, signs of CCF

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37
Q

Causes of MR

A

Rheumatic heart disease, IE, IHD, functional MR due to LV dilatation, Marfans, SLE, Ehler’s danlos, chordae rupture post MI, trauma

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38
Q

Signs of mitral stenosis

A

AF, malar flush, elevated JVP, RV heave/palpable S2, opening snap, mid-diastolic rumbling murmur, signs of anticoagulation

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39
Q

Signs and associations of MVP

A

Displaced apex beat, AF, mid-systolic click, with late crescendo-decrescendo murmur
Causes: idiopathic, CT disease (marfans, EDS, SLE), ADPKD, myotonic dystrophy

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40
Q

Causes of pHTN

A
  1. Idiopathic/PAH
  2. Secondary to left heart disease
  3. Secondary to hypoxic lung disease
  4. CTEPH
  5. Other
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41
Q

Signs of TR

A

Distended JVP with giant V waves, RV heave, palpable P2, PSM at LSE, pulsatile hepatomegaly

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42
Q

Signs of PDA

A

wide pulse pressure, eisenmenger’s, continuous machinery murmur in left subclavicular region, palpable thrill, S2 may be obscured by murmur

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43
Q

Features of ToF

A

VSD, PS, over-riding aorta, RVH

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44
Q

Signs and causes of VSD

A

Downs syndrome, parasternal heave and thrill, PSM at LSE (very loud all over precordium)
Causes: congenital, Down’s, ToF, post MI, post surgery

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45
Q

CF- inheritance, signs, complications

A

Autosomal recessive
Short stature, clubbing, lines, bronchiectasis, diabetes
Diabetes, infertility, bronchiectasis, DIOS

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46
Q

4 causes of nephrotic syndrome

A

Minimal change disease, membranous glomerulonephritis, focal segmental glomerulosclerosis, mesangiocapillary glomerulonephritis

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47
Q

PD - signs

A

Asymmetric resting tremor, bradykinesia, show/shuffling/festinant gait, hypomimia, micrographia, autonomic signs, rigidity dysphonia

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48
Q

Types of PD

A

Idiopathic
PSP - vertical gaze palsy
MAS- autonomic and cerebellar symptoms
CBD - alien limb
Vascular - gait predominant
Drug induced
DLB- hallucinations and cognitive impairment

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49
Q

Mx of PD

A

Hold off if symptoms mild due to tolerance
1st levodopa and dopamine dexcarboxylase inhibitor (co-beneldopa, madopar)
COMT inhibitor
MAO-B inhibitor
Dopamine agonist
Amantadine
DBS

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50
Q

Indications for LTOT

A

pO2 <7.3 or pO2 <8 with secondary polycythaemia or right heart failure

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51
Q

Signs of COPD

A

Cyanosis, Co2 retention, LTOT, barrel shaped chest, tar staining, prolonged expiratory phase, cor pulmonale

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52
Q

Autoantibodies in CLD

A

PBC- anti mitochondrial
PSC - anti smooth muscle
AI hepatitis - anti LKM1, anti SM, ANA

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53
Q

NMO- signs, antibodies, how to differentiate

A

Transverse myelitis and optic neuritis (demyelination)
Symptoms more severe than MS but MRI changes less, no OCB
Anti aquaporin 4 ab’s

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54
Q

Signs of lateral medullary syndrome and vessel affected

A

Posterior inferior cerebellar artery
Ipsilateral horners, contralateral hemisensory loss (pain and temp), nystagmus, dysphagia, vertigo

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55
Q

Pyramidal weakness pattern

A

UL’s flexed
LL’s extended
UNILATERAL

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56
Q

Causes of RAPD

A

Optic nerve pathology
CRAO/CRVO, glaucoma, MS, optic neuropathy, tumour, retinal detachment
GCA until proven otherwise in 50+

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57
Q

Causes of cerebellar dysfunction

A

Paraneoplastic
Alcohol
Stroke
Tumour
MS

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58
Q

What is INO

A

Failure of adduction of affected eye with nystagmus on abduction of contralateral eye

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59
Q

TACS vs PACS vs lacunar stroke

A

TACS: contralateral homonomous hemianopia, contralateral hemiplegia, high cortical dysfunction
PACS: 2/3 above
Lacunar: pure hemimotor/sensory loss

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60
Q

CI’s to thrombolysis

A

ICH, SoL, seizure at onset, anticoagulation, uncontrolled HTN, LP within 1/52, surgery within 3/12, UGIB within 3/52, stroke within 3/12

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61
Q

Features of dermatomyositis and polymyositis

A

Dermatomyositis: Gottrons papules, heliotrope rash, elevated CK, legs affected more than arms
Polymyositis: progressive, symmetric, proximal weakness

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62
Q

Charcot-Marie-Tooth- signs, inheritance, Ix, Mx

A

5 different types of varying inheritance
Aka hereditary sensory motor neuropathy
Reduced sensation, wasting, weakness.
Pes cavus, inverted champagne bottle legs, footdrop, hammertoe
Ix: NCS
Mx: AFO, PT/OT

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63
Q

Causes of proximal myopathy

A

ETOH, drugs (statins, steroids), dermato/polymyositis, muscular dystrophy, MG/LEMS, Cushings, hypothroid, acromegaly

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64
Q

Causes of ptosis

A

3rd nerve palsy
Myotonic dystrophy
MG
Horner’s
Congenital
Age
SoL

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65
Q

Triad and ab’s in Miller-Fisher

A

Anti gq1b abs
Triad- areflexia, ataxia, ophthalmoplegia

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66
Q

Causes of nystagmus

A

Cerebellar disease, BPPV, posterior stroke, Wernicke’s, MS, stroke, tumour, trauma, drugs

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67
Q

Top reasons for liver transplantation

A

Cirrhosis, acute hepatitis (paracetamol, infectious), HCC

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68
Q

Top reasons for renal transplantation

A

HTN, Diabetes, ADPKD, chronic glomerulonephritis

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69
Q

Haemochromotosis- inheritance, signs, investigations, management

A

HFE gene, autosomal recessive
Diabetes, bronzed, slate-grey, venesection scars, hepatomegaly, signs of CLD, arthralgia, cardiomyopathy
Ferritin >200 females and >300 males, elevated t sats
Regular venesection, desferrioxamine, transplant, family screening, ETOH avoidance

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70
Q

UMN pattern, unilateral weakness

A

Tumour, stroke, hemisection, brain abscess

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71
Q

UMN pattern, bilateral, pure motor

A

Hereditary spastic paraparesis

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72
Q

UMN pattern, bilateral, mixed motor and sensory

A

MS, SCD, syringomyelia, transverse myelitis, Freidrich’s ataxia, cervical spondylosis

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73
Q

LMN pattern, pure motor, bilateral, proximal

A

Statins, steroids, hypothyroid, MG, LEMS, dermato/polymyositis, muscular dystrophy, MND, spinomuscular atrophy

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74
Q

LMN pattern, pure motor, bilateral, distal

A

Myotonic dystrophy, MND, polio

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75
Q

LMN pattern, pure motor, bilateral, asymmetric

A

Mononeuritis multiplex

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76
Q

LMN pattern, mixed motor and sensory, bilateral, proximal

A

CIDP

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77
Q

LMN pattern, mixed motor and sensory, bilateral, distal

A

Charcot-Marie-Tooth, diabetic peripheral neuropathy, alcohol related peripheral neuropathy, GBS, CIDP, paraneoplastic, cauda equina

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78
Q

LMN pattern, mixed motor and sensory, asymmetric

A

Radiculopathy, plexopathy, vasculitis, compression neuropathy, chemo

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79
Q

UMN signs

A

UMN: spasticity, hyperreflexia, clonus, positive Babinski. No fasciculations, mild wasting

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80
Q

LMN signs

A

LMN: flaccid, hyporeflexic / arreflexic, absent Babinski. Severe wasting with fasciculations

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81
Q

Dysphonia vs dysphasia vs dysarthia

A

Dysphasia - language disorder, inability to understand or generate speech
Dysarthia - speech disorder, articulation and pronunciation
Dysphonia - inability to properly formulate sound from the larynx

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82
Q

Causes of brainstem pathology

A

Vascular (ischaemic / haemorrhagic stroke)
Inflammatory (multiple sclerosis, acute disseminated encephalomyelitis)
Brainstem encephalitis (Bickerstaff’s encephalitis)
Central pontine myelinolysis
Trauma
Neoplastic (brainstem gliomas / ependymomas)
Arnold-Chiari malformation
Syringobulbia

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83
Q

Signs and causes of CNIII palsy

A

Ptosis, dilated pupil, down and out eye
Causes: posterior communicating artery aneurysm, DM, GCA, SoL, MS, cavernous sinus thrombosis, surgery, SLE, PAN

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84
Q

Signs and causes of CNVI palsy

A

Esotropia (permanent adduction of affected eye), paralysis of lateral gaze with diplopia
Causes: ischaemia, trauma, MS, SoL, stroke, sarcoid, GCA, raised ICP (false lateralising sign)

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85
Q

Signs and causes of CNVII palsy

A

Weakness of muscles of facial expression (forehead sparing if UMN lesion), hyperacusis
Causes: stroke, SOL, MS, lyme disease, sarcoid, syphilis, Bell’s palsy, Ramsay-Hunt (HSV- ear vesicles)

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86
Q

Signs and causes of cavernous sinus syndrome

A

Signs: painful ophthalmoplegia, orbital congestion, orbital chemosis, periorbital oedema, proptosis, ipsilateral Horner’s syndrome, ipsilateral loss of facial sensation
Causes:
Vascular: carotid artery aneurysm, carotid-cavernous fistulas, cavernous sinus thrombosis
Infections: sinuses
Tumours: nasopharyngeal carcinoma, craniopharyngioma, pituitary adenoma, mets, Inflammatory: sarcoidosis, GPA

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87
Q

Bulbar palsy- what is it, signs, causes

A

Disorder of lower cranial nerves (7-12)
Signs: nasal speech, slurred words, fasciculating and weak tongue, absent jaw jerk, reduced gag reflex, drooling, dysphagia
Causes: MND, myotonic dystrophy, myasthenia gravis, MSA, syringobulbia, poliomyelitis, leptomeningeal disease, radiation damage, nasopharyngeal carcinoma

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88
Q

Signs and causes of Horner’s syndrome

A

Signs: partial ptosis (overcome by upgaze and not fatigable), miosis, anhidrosis
Causes: stroke, syringomyelia, pancoast tumour, thyroid mass, cavernous sinus thrombus, ICA dissection,

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89
Q

Pathology, Signs of Freidrichs ataxia + inheritance

A

Damage to cerebellum, spinal cord and peripheral nerves. Causes mixed UMN/LMN signs
Autosomal recessive
Signs:
Progressive cerebellar ataxia
Hyporeflexia / arreflexia
Distal weakness, initially involving the lower limbs
Dorsal column loss, initially distal
Upgoing plantars
Dysphagia
Reduced visual acuity
Sensorineural hearing loss
Kyphoscoliosis
Pes cavus
Urinary incontinence
Cardiomyopathy
Diabetes mellitus

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90
Q

Signs of spinocerebellar ataxia + inheritance

A

Autosomal dominant
Signs:
Usually presents in third or fourth decade
Progressive cerebellar ataxia
Dysarthria, bulbar palsy
Increased tone
Hyperreflexia
Extensor plantar responses
May have peripheral neuropathy causing fasciculations and wasting

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91
Q

3 types of ataxia

A
  1. Cerebellar
  2. Sensory - loss of proprioception, romberg’s +ve, stomping gait
  3. Vestibular - vertigo, N&V
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92
Q

Describe sensory ataxia, signs and give causes

A

Loss of proprioception, near-normal coordination when the movement is visually observed by the patient, but marked worsening of coordination when the eyes are shut, pseudoathetosis, stomping gait, romberg’s positive
Causes
Peripheral neuropathy- alcohol, diabetes, nutritional deficiency
DCML disruption- tabes dorsalis, SCD, posterior column demyelination

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93
Q

What is pseudoathetosis and what is the cause

A

Sensory ataxia
Random finger movements seen on outstretched hands with eyes closed

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94
Q

Signs and causes of vestibular ataxia

A

Vertigo + nystagmus
BPPV, vestibular neuritis

95
Q

Causes of cerebellar ataxia

A

Paraneoplastic
Alcohol
Tumour
Stroke
Inherited- spinocerebellar, freidrichs
B12 deficiency
MS
Sarcoid
MSA
Lyme disease
Wilsons disease
Ataxic telangiectasia

96
Q

Indications for lung transplant

A

CF
Bronchiectasis
Pulmonary fibrosis
COPD
Pulmonary vascular disease

97
Q

Signs and causes of Brown Sequard

A

Signs: ipsilateral loss of vibration and proprioception, ipsilateral hypertonia, hyper-reflexia, pyramidal weakness, contralateral loss of pain and temperature
Causes: demyelination, trauma, tumour

98
Q

Syringomyelia - signs

A

Cape like distribution of sensory loss, wasting of small muscles of hand

99
Q

CES- signs, causes

A

Signs: sensory level, wasting, weakness, areflexia, bladder/bowel dysfunction
Causes: prolapsed disc, tumour, bony mets, epidural abscess

100
Q

Causes of proximal weakness

A

Alcohol
Statins
Cushings, acromegaly, hypothyroidism
DMD, Becker’s, FSHD
Dermato/polymyositis
MG/LEMS

101
Q

What is S3? Give some causes

A

Additional heart sound heart just after S2. Heard in early-mid diastole, when the ventricles are passively filling. The sound is of blood striking a compliant left ventricles
Causes: LV dysfunction, normal in athletes/kids, MR, VSD (rapid ventricular filling)

102
Q

Causes of wasting of hand muscles

A

Cervical myelopathy
Anterior horn cell disease
Motor neurone disease
C8/T1 radiculopathy
Pancoast’s syndrome
Lower brachial plexopathy
Cervical rib
Mononeuropathy
Charcot-Marie-Tooth disease
Myotonic dystrophy
Inclusion body myositis
Distal spinal muscular atrophy
Disuse atrophy

103
Q

Give some extra-articular features of RA

A

Renal- glomerulonephritis
Eye- scleritis, episcleritis
Lung- fibrosis, effusions
Heart- pericarditis
Splenomegaly
Rheumatoid nodules
Anaemia
Carpal tunnel

104
Q

What criteria are used to diagnose MS?

A

MacDonald’s criteria- lesions disseminated in time and space

105
Q

Signs/symptoms of MS

A

Eyes: optic neuritis, RAPD, INO, nystagmus, red desaturation
Cerebellar signs
Limbs: hypertonia, hyperreflexia, clonus, upgoing plantars, pyramidal weakness
Autonomic dysfunction- catheter

106
Q

Suggest some investigations to be done in MS

A

MRI- peri-ventricular white matter changes seen on FLAIR sequence, gadolinium for determining acuity
LP- paired with serum for OCB
VEP’s
Anti aquaporin4 ab’s to r/o NMO

107
Q

Suggest 3 patterns of MND

A
  1. Limb - asymmetric distal weakness, wasting of small muscles of hand, difficulty in motor tasks
  2. Bulbar - tongue fasciculations, change in speech, drooling, dysphagia, emotional lability
  3. Respiratory - SoB, orthopnoea, OSA
108
Q

What is Hoffmans sign and what is it indicative of

A

Flick the end of the middle finger- positive/pathological is the opposition of index finger and thumb
Indicative of cervical cord compression/myelopathy

109
Q

Describe post-polio syndrome

A

Asymmetric flaccid paraparesis of a single limb
Reflexes usually absent, no UMN signs
Atrophy, fatigue, pain

110
Q

Pathophysiology and signs of MG

A

Ab’s directed against nicotinic acetylcholine receptors at the NMJ
Ocular/ generalised
Fatigable weakness, ptosis, diplopia, dysphagia, dysarthria, proximal weakness, complex ophthalmoplegia, bulbar weakness

111
Q

Specific examination tests and Ix in MG

A

Look for thymectomy scar
Look upward for 20 seconds
Abduct both shoulders then repeatedly ‘flap’ one and test power again- should be weaker once fatigued
Ice pack test, tensilon test
nAChR ab’s, antiMUSK, VGCC’s (LEMS)
Electrophysiology
CT thorax

112
Q

What could trigger a myasthenic crisis and how would you manage it

A

Infection, stress, non-compliance with treatment, dugs (b blockers, CCB’s. lidocaine, abx)
IVIg, PEX, intubation to protect airway

113
Q

Management of MG

A

Pyridostigmine (acetylcholinesterase inhibitor)
Steroids (may need to admit to monitor if giving high doses)
Immunosuppression (azathioprine, mycophenolate)
Thymectomy

114
Q

Inheritance, associated features and signs of myotonic dystrophy

A

Autosomal dominant
Cataracts, diabetes, cardiomyopathy/conduction disease, MVP, low IQ
Myotonic facies, balding, ptosis, cataracts, dysarthria, distal weakness, grip myotonia,

115
Q

How to examine a tremor

A

Observe arms resting, symmetry, speed, nature of tremor
Synkinesis- ask to open and close fist on one hand and see if resting tremor worsens
Outstretch arms and check past pointing

116
Q

Triad of NPH

A

Incontinence
Gait disturbance
Cognitive impairment

117
Q

What is Light’s criteria?

A

Exudate = Pleural protein: serum protein > 0.5
Pleural LDH : serum LDH >0.6

118
Q

Give some causes of clubbing

A

Resp: cancer, bronchiectasis, fibrosis, mesothelioma, TB
Cardio: IE, cyanotic congenital heart disease
GI: IBD, CLD, coeliac disease

119
Q

Differential diagnoses of neck lump

A
  1. Congenital e.g. branchial/thyroglossal cyst
  2. Lymphadenopathy - reactive, neoplastic, inflammatory
  3. Thyroid mass e.g. goitre, carcinoma, nodule
  4. Lipoma
  5. Salivary gland neoplasm
120
Q

How to examine a neck lump

A

Hand- tremor, sweaty
Pulse ?AF
Face- eyes, pallor, eye movements
Neck- palpate nodes, palpate mass, ask to stick tongue out and swallow
Extra: heart sounds, splenomegaly

121
Q

HHT - inheritance, presentations, complications

A

Autosomal dominant vascular disorder
Characterised by mucocutaneous bleeding and AVM’s
Epistaxis, GI bleeding, SAH, haemoptysis
Mucocutaneous telangiectasia

122
Q

Marfans syndrome- signs/complications

A

Scoliosis
Pectus deformity
Arachnodactyly
Micrognathia
High arched palate
Hypermobility
Lens dislocation
Myopia
Aortic aneurysm/dissection
MVP, MR/AR
Pneumothorax

123
Q

Marfans- inheritance and genetics

A

Autosomal dominant
Defect in Fibrillin-1 gene

124
Q

Management of Marfans

A

Lifelong b-blockers to protect aorta
Regular echo surveillance
Genetic counselling
Regular ophthalmology input
Aortic surgery if diameter >50mm or >45mm with FHx aortic dissection

125
Q

Clinical features of non-proliferative diabetic retinopathy

A

No neovascularization
Microaneurysms
Soft exudates (cotton wool spots)
Hard exudates – lipid deposition
Haemorrhages (dot or blot)
Venous beading

126
Q

Clinical features of proliferative diabetic retinopathy

A

Neovascularisation from disc/retinal vessels

127
Q

What are the 4 stages of diabetic retinopathy, give complications

A

Mild, mod, severe non-proliferative
Proliferative
Vitreous haemorrhage
Retinal detachment
Macula oedema

128
Q

Risk factors for diabetic retinopathy

A

Longer duration of diabetes, hyperglycaemia, pregnancy, hypertension and nephropathy.

129
Q

CRVO- presentation, risk factors, fundoscopy appearance, management

A

Sudden onset, painless visual loss
RF’s: age, diabetes, HTN, smoking, hypercoaguable, obesity, glaucoma
Signs: RAPD, diffuse retinal haemorrhage, dilated tortuous veins, macula oedema, cotton wool spots
Mx: refer ophtal, VEGF, laser

130
Q

CRAO- presentation, risk factors, fundoscopy appearance, management

A

Sudden onset painless visual loss/disturbance
RF’s; hypercoaguability, AF, carotid artery stenosis, GCA, PAN, SLE, polycythaemia, Waldenstroms
Signs: RAPD, pale oedematous retina with cherry red spot at macula
Mx: treat cause, ocular massage, intra-aterial thrombolytics

131
Q

Retinitis pigmentosa associations

A

Primary RP, mitochondrial disorders (Kearns-sayre), Freidrich’s ataxia

132
Q

RP- presentation, fundoscopy signs, other associated signs

A

Loss of peripheral vision/tunnel vision ‘bumping into things’
Peripheral bone spicule pigmentation with relative macula sparing
Waxy pallor of the optic disc
Attenuation of retinal blood vessels

PPM, proximal myopathy, ataxia

133
Q

What are the types of scleroderma

A

Limited scleroderma
Systemic sclerosis (limited and diffuse cutaneous)

134
Q

What is the difference between limited and diffuse systemic sclerosis and which ab’s are found in each?

A

Limited cutaneous = skin changes distal to elbows and knees, and face. Aka CREST syndrome. Anti-centromere ab’s
Diffuse cutaneous = skin changes proximal to elbow/knees. Renal, GI, lung and cardiac involvement. Anti-SCl-70 ab’s

135
Q

Risk factors for gout

A

Male
High alcohol/ red meat diet
Diuretics
Ciclosporin
CKD
HTN
TLS
Myeloproliferative disorders

136
Q

Gout: investigations and management

A

Ix: joint aspiration (negatively birefringent crystals)
Acutely: NSAID’s, colchicine, steroids
Chronic: allopurinol/febuxostat (if 2 or more attacks per year)

137
Q

Features of ankylosing spondylitis

A

Back pain- worse in morning, better with exercise, better with NSAID’s
Sacroiliitis

138
Q

Features of ankylosing spondylitis

A

Back pain- worse in morning, better with exercise, better with NSAID’s
Sacroiliitis
Achilles enthesitis
Aortic regurgitation
Apical pulmonary fibrosis
Atlanto-axial subluxation
Anterior uveitis

139
Q

Ix/Mx of ankylosing spondylitis

A

Schober test- measure 10cm up 5cm down from dimples of venus, area should increase by >5cm on felxion
HLA-B27
X-rays
Echo
Not DMARD’s
Long term NSAID’s
Maybe rituximab

140
Q

Triggers/links to psoriasis

A

Trauma- Koebner’s phenomenon
Drugs- b-blocker, NSAID’s, lithium, antimalarials
HIV

141
Q

Management of psoriasis

A

Emollients
Topical steroids
Topical vitamin D
Topical tacrolimus
Phototherapy

142
Q

Features and management of psoriatic arthritis

A

Features: psoriatic skin changes, OA/RA/arthritis mutilans, enthesitis, dactylitis, spondyloarthritis
Seronegative
Mx: MTX, sulfasalzine, leflunomide, ciclosporin

143
Q

Complications of RA

A

Anaemia of chronic disease
Cushing’s from steroids
Accelerated cardiovascular disease
Felty’s syndrome
Osteoporosis

144
Q

Management of RA

A

Steroids – exogenous Cushing’s, osteoporosis, cataracts, weight gain
Methotrexate – pulmonary fibrosis
Sulphasalazine – rash
Hydroxychloroquine – retinitis
Biologics – opportunistic infections

145
Q

Triad in MEN1

A

Pituitary adenoma
Parathyroid adenoma
Pancreatic tumour (insulinoma, Zollinger-Ellison, VIPoma)

146
Q

Symptoms of pituitary adenoma

A

Visual field defects- bitemporal hemianopia
Headaches
Diplopia
Hormone deficiencies (compression of non-functioning adenomas)
Decreased libido / fertility (hypogonadotropic hypogonadism)
Cold intolerance, lethargy (hypothyroidism)
Lethargy, postural dizziness (hypoadrenalism)
Hormone excess (functioning pituitary adenoma)
Acromegaly
Cushing’s disease
Galactorrhoea, amenorrhoea, erectile dysfunction (prolactinoma)

147
Q

What hormones are released by the pituitary gland?

A

Anterior: TSH, LH/FSH, GH, prolactin, ACTH
Posterior: oxytocin, ADH

148
Q

Signs/symptoms of Cushing’s

A

Central adiposity, neck fat pad
Striae
Moon face
HTN
Hyperglycaemia
Cataracts
Proximal myopathy
Acne
Hursutism

149
Q

Causes of Cushing’s

A

Iatrogenic glucocorticoids
ACTH secreting pituitary adenoma
Adrenal tumour
SCLC/carcinoid tumour

150
Q

Investigations for Cushing’s

A

24 hour urine cortisol
Overnight dexamethasone suppression test
MRI pituitary
CT adrenals

151
Q

Causes of hypothyroidism

A

Iodine deficiency
AI disease (Hasimoto’s– anti TPO ab’s)
Thyroidectomy, radio-iodine, radiotherapy
Amiodarine, lithium
Secondary hypothyroidism e.g. pituitary tumour

152
Q

Causes of hyperthyroidism

A

Excess levothyroxine
Grave’s disease (TSH receptor ab’s)
De Quervains thyroiditis
Post-partum thyroiditis
Toxic adenoma
Multinodular goitre
Lithium
Amiodarone

153
Q

Sx/presentation of acromegaly

A

Headaches
Visual disturbance
Sweating
Carpal tunnel
Diabetes
HTN
Change in appearance
OSA
Macroglossia, teeth separation
Colonic polyps

154
Q

Ix for acromegaly

A

IGF1
OGTT (failure to suppress GH is +ve)
MRI head
Complications: HbA1c, BP, echo, colonoscopy, TSH/ACTH/LH/FSH/prolactin, sleep study

155
Q

Management of acromegaly

A

Trans-sphenoidal resection of adenoma
Octreotide/lanreotide (somatostatin analogue)
Pegvosimant (GH receptor antagonist)

156
Q

How do you manage a TIA?

A

Historically ABCD2 score used
If symptoms within last week, refer for assessment within 24 hours. If symptoms > 1 week ago refer for Ix within a week.
CT head
Aspirin 300mg then 75mg OD
Statin
Not drive for 1 month
Lifestyle mods inc stopping smoking
TIA clinic- carotid dopplers, MRI

157
Q

DVLA advice for group 1 licence for; TIA, stroke, MI, seizure

A
  1. TIA: not drive for 4 weeks, don’t ned to tell DVLA
  2. Stroke: not drive for 4 weeks, do not need to tell DVLA unless significant remining disability may need reassessment
  3. If PCI then 1 week ban, if no PCI then 4 weeks. Don’t need to tell DVLA
  4. Stop driving for 6 months awaiting further Ix, then after further assessment may be able to restart after 6 months/1 year seizure free. Need to tell DVLA
158
Q

DVLA advice for group 2 licence for; TIA, stroke, MI, seizure

A
  1. TIA/stroke: stop driving 1 year
  2. MI: 6 weeks then ETT
  3. Seizure: 5 years
159
Q

Main points for DVLA advice in diabetes Group 1 vs 2

A

Group 1: no restrictions unless disabling hypos or insulin >3 months, then need to inform DVLA
Group 2: no restrictions if diet alone, if on any meds/insulin will need to inform DVLA and satisfy further requirements e.g. hypo awareness

160
Q

When do you refer for RRT?

A

Refer to renal at CKD4-5 (eGFR <30), or if rapidly progressive CKD3. Aim to refer a year before RRT needed

161
Q

Risks of splenectomy and how to mitiagte these

A

Risks: susceptible to infection (particularly encapsulated eg pneumococcus, haemophilus), thrombocytosis post-op.
Mitigation: aim to give all vaccinations >2 weeks pre-surgery, Pen V, education, medic alert bracelet

162
Q

Causes of TR

A

Ebstein’s anomaly, pHTN, PS, MS, RV dilatation, carcinoid, IE, rheumatic heart disease

163
Q

How do you develop Eisenmenger’s

A

Chronic left to right shunt results in pulmonary arterial hypertension. Pressure in the right heart eventually equalises then exceeds left heart and shunt reverses

164
Q

Inheritanceof HCM

A

Autosomal dominant, or de novo

165
Q

Considerations in genetic testing

A
  1. Give cooling off period after consent to change mind
  2. Warn about negative effects e.g. implication for insurance, implication on other family members
  3. May find things we can’t do anything about
  4. May find things of uncertain significance
166
Q

How often should diabetics be screened for retinopathy?

A

Yearly, more frequently in pregnancy

167
Q

Stages/features of hypertensive retinopathy (CACO)

A

Stage 1 - copper and silver wiring, meaning an increased light reflex of the vessels
Stage 2 - AV nipping
Stage 3 - Cotton wool spots and flame haemorrhages
Stage 4 - optic disc swelling

Stage 3 or 4 should be considered a medical emergency and the patient urgently assessed for other end organ damage (LVH, proteinuria, encephalopathy), a possible underlying secondary cause (via the physical exam and initial investigations) and initiated on treatment

168
Q

Questions to ask in a history of change in vision

A

Chronicity
Uni/bilateral
All/part of vision
Ability to see colour
Painful/painless
General health- any muscular symptoms, headaches
History of eye problems
PMH/DH/FH

169
Q

Causes of optic disc swelling

A

Raised ICP- IIH, SOL, intracranial infection, venous sinus thrombosis
Optic neuritis
Ischaemic optic neuropathy- diabetes, HTN, GCA
Hypertensive retinopathy

170
Q

Management of COPD

A

Non-pharm: pulmonary rehab, smoking cessation, vaccinations, dietician
Pharm: inhalers (SABA, SAMA, LABA, LAMA, ICS), nebulisers, oral steroids, oral theophylline, LTOT, carbocisteine
Also rescue pack
Surgery: bullectomy, volume reduction, transplant

171
Q

What are some complications of diabetes

A

Retinopathy
Nephropathy
Neuropathy
Autonomic dysfunction e.g. gastric paresis
CVD
Neuropathic pain
Erectile dysfunction

172
Q

HbA1c levels for diagnosis/targets

A

<42 normal
42-47 pre-diabetes
48+ - diabetes
If known diabetes, target <48

173
Q

Alternatives to HbA1c and reasons for using

A

Total glycated haemoglobin, fructosamine estimation
Haemoglobinopathies, post-transfusion

174
Q

Gestational diabetes- screening, management, post-partum check

A

If risk factors then OGTT at 24-28 weeks
If prev GD then OGTT ASAP
Initially trial diet/lifestyle change for 2 weeks with home BM monitoring. If not improved commence metforming then insulin
If fasting glucose >7 commence insulin immediately
Post-partum 6 week fasting glucose

175
Q

Causes of secondary hypertension

A

Renal: PKD, glomerulonephritis
Endocrine: hyperthyroid, Cushing’s, Conn’s, acromegaly, phaeochromocytoma
CVS: co-arctation of the aorta, RAS
Iatrogenic: steroids, OCP, mirabegron
OSA

176
Q

Risk factors for osteoporosis

A

Early menopause
Steroids/Cushing’s
RA
Hyperthyroidism
Female
FHx
Smoking
ETOH

177
Q

Causes of foot drop

A

Congenital: CMT
Traumatic: L4/5, sciatic nerve, common peroneal nerve injuries, disc prolapse, pressure from cast
Diabetes, ETOH,
Inflammatory: PAN, RA, churg strauss
Infective: HIV, Lymes, leprosy
Muscular: MG, MND

178
Q

Pathophysiology and causes of Horner’s syndrome

A

Disruption in sympathetic nerve supply to the eye- could be 1st order (brain to c spine), 2nd order (spinal cord to neck) or 3rd order (neck into face)
Causes:
Congenital
FON: stroke, SOL, wallenbergs, syringomyelia, trauma, MS
SON: pancoast tumour, trauma
TON: cavernous sinus thrombus, carotid artery dissection

179
Q

Causes of a spastic paraparesis

A

Hereditary spastic paraparesis
CP
MND
MS
Freidrich’s ataxia

180
Q

Causes of flaccid paralysis

A

Trauma
Spinal abscess/epidural haematoma
Poliomyelitis
GBS
MG
Porphyria
Hypokalaemia
Cord compression
Spinal stroke
Acute transverse myelitis
Lyme disease

181
Q

Inheritance and complications of Huntington’s disease

A

Autosomal dominant
Chorea, athetosis, hemiballismus, cognitive impairment, psychiatric complications, rigidity, aspiration pneumonia, seizures, dysarthria, ataxia

182
Q

DDx of chorea

A

Inherited: Huntington’s disease, Wilson’s disease.
Vascular: Stroke, polycythaemia rubra vera.
Immune mediated: Sydenham’s chorea, SLE, anti-phospholipid syndrome.
Hormonal: Pregnancy (chorea gravidarum), OCP use, hyperthyroidism.
Toxic: Anti-psychotics, dopaminergics in Parkinsonian patients, anti-epileptics.
Infectious: HIV, Lymes.
Paraneoplastic.

183
Q

Management of MND

A

Riluzole
PEG feeding
NIV
Palliative care input
PT/OT

184
Q

FSHD - inheritance, signs/features

A

Autosomal dominant
Bilateral ptosis, wasting of facial muscles, hearing aids, PPM, foot drop, winged scapula, proximal weakness, hearing aids

185
Q

Causes of mixed UMN/LMN symptoms

A

MND
Freidrich’s ataxia
Syringomyelia
Dual pathology

186
Q

CT findings in ILD

A

Groundglass changes
Traction bronchiectasis
Honeycombing
Reticular markings

187
Q

CT findings in bronchiectasis

A

Dilated airways
Signet ring sign
Bronchial wall thickening
Air trapping
Tram track sign

188
Q

Give some symptoms of HIV seroconversion

A

Fever, fatigue, myalgia/arthralgia/ lymphadenopathy, malaise, rash, headache

189
Q

Give some examples of AIDS defining illness/CD4 count threshold

A

CD4 count <200
PCP, TB
Candida
Kaposi’s sarcoma
Invasive cervical cancer
CMV
Cryptococcal meningitis
PML
Cerebral toxoplasmosis

190
Q

Indications for antiretroviral therapy in HIV

A

CD4 count <500
In setting of opportunistic infection

191
Q

What are the 4 ethical principles

A
  1. Beneficence - do good
  2. Non-maleficence - do no harm
  3. Autonomy- individuals with capacity have the right to make their own decision
  4. Justice - act in BI of wider community e.g. fair allocation of resource
192
Q

What principles are considered when making a deicison for osmeone who lacks capcacity

A

Act in their best interests
Choose the least restrictive option
Consider their prior/family wishes
Take all steps to ensure lack capacity

193
Q

What is an ADRT?

A

A legal document instructing doctors that a patient does not want artificial life support should he become terminally ill
Can also say other treatments you would not want e.g. artificial feeding, NIV etc

194
Q

Section 135/136

A

Police use section 135 to remove someone from a public place and take them to a place of safety, here the section 136 is used to detain them awaiting further MHA assessment

195
Q

Section 5(4) vs section 5(2)

A

5(4) allows nurses to detain you for 6 hours in hospital, but NOT in the ED
5(2) allows a doctor to detain you in hospital for 72 hours for MHA assessment

196
Q

Features of section 2

A

Detained for 28 days for further assessment of mental health disorder

197
Q

Features of section 3

A

Detained for up to 6 months for treatment of a mental health disorder

198
Q

Give some examples of notifiable diseases

A

TB, mumps, measles. rubella, meningitis, campylobacter, p;loio, brucellosis, cholera, SARS, scarlet fever, whooping cough, HUS, enteric fever

199
Q

What must you ensure when you break confidentiality

A

You are doing so with legal backing
You tell the patient
You reveal the minimum information needed

200
Q

When can you break confidentiality

A

When required by law or justified in the public interest
- Ordered by a judge
- Notification of infectious disease
- Risk to national security
- Can tell patients at risk of serious communicable disease if original patient will not and cannot be persuaded to do so e.g. HIV

201
Q

Sx/signs of GCA

A

Headache, throbbing
Jaw claudication
Scalp tenderness
Proximal weakness of PMR
Systemic fever, myalgia
RAPD, pale optic disc
Absent temporal artery pulsation

202
Q

Ix/Mx of GCA

A

Ix: FBC, U&E, LFT, CRP, ESR, PV
Mx: steroids immediately- 40mg if uncomplicated, 60mg if complicated. Refer ophthalmology- IV methyl pred if visual loss. Temporal artery biopsy

203
Q

Causes of central vision loss (CCHOM)

A

Macular disease- diabetic maculopathy, ARMD
CRVO
Hypertensive retinopathy
Cataract
Optic neuritis

204
Q

Causes of peripheral visual loss (CCRISG)

A

RP
Glaucoma
CRAO
Ischaemic optic neuropathy
Stroke
Chiasmal lesion

205
Q

Causes of acute loss of vision

A

Stroke
Retinal vascular occlusion
GCA

206
Q

Causes of gradual loss of vision

A

Nerve compression eg tumour
Inherited
Degenerative
Toxic
Nutritional

207
Q

Causes of binocular diplopia

A

3/4/6 CN palsy
INO
MG
Thyroid eye disease

208
Q

Antibody tests in thyroid disease

A

anti TPO ab’s - Hashimoto’s +/- Graves
Thyroid receptor ab’s - Grave’s

209
Q

Signs in thyroid eye disease

A

Upper lid retraction
Proptosis
Corneal involvement
Sight loss

210
Q

Screening test in UL exam

A

Observe at rest- tremor, ask to count from 10-1
Arms out- rebound
Pronator drift and pseudoathetosis
Winging of scapula
Myotonia
Past pointing
Arms behind head- proximal myopathy and scars

211
Q

Spasticity vs rigidity

A

Spasticity is velocity dependent and pyramidal
Rigidity is not velocity dependent and extra pyramidal

212
Q

Causes of issues at anterior horn cell

A

Polio, SMA, ALS

213
Q

How to demonstrate visual/spatial neglect and how this helps localise lesion

A

Cortical problem
Give bilateral simultaneous stimulation eg flap both hands and they will only see one

214
Q

Features of NF1

A

Cafe au lait patches >6
Neurofibromas
Scoliosis
Axillary freckling
Leisch nodules- melanin in Iris
Optic glioma
ADHD/ LD
Epilepsy
HTN
Phaeochromocytoma

215
Q

Location of lesion in inferior and superior VF defect

A

PITS
parietal- inferior defect
Temporal- superior defect

216
Q

How to examine eyes

A

Observe
Pupils and accommodation
Red reflex
Fundoscopy
Visual fields
Eye movements

217
Q

Describe the surgical sieve

A

Vascular
Infective
Trauma
Autoimmune
Metabolic
Idiopathic
Neoplastic
Congenital
Degenerative
Endocrine

218
Q

Process of diabetic foot exam

A
  1. Observe- hair loss, ulcers, callous formation, Charcot joint, arches, amputation, scars, inspect footwear
  2. Gait- stomping, broad stance, high steppage
  3. Palliation- heat, pulses
  4. Sensation- cotton wool, vibration, joint position sense
219
Q

Inheritance and chromosome in NF1 and 2

A

Autosomal dominant
Chromosome 17
Chromosome 22

220
Q

Features of NF2

A

Bilateral sensorineural deafness from bilateral acoustic neuroma
Skin changes uncommon

221
Q

How to perform rheum/hand exam

A

Inspect hands: nail changes, scars, deforming polyarthropathy, rashes, bruising, raynauds, calcinosis, tophi, wasting
Inspect elbows
Inspect neck and scalp
Palpate- temperature, pulses, sensation, effusions, nodules
Movement/function- make a fist, oppose fingers and thumbs, prayer/reverse prayer sign, elbow extension

222
Q

Effect of SUN on rheum conditions

A

Worse: lupus, dermatomyositis
Better: psoriasis
No change: sarcoid

223
Q

Scalp involvement in rheum conditions

A

Scalp involved: psoriasis, lupus
Not involved: sarcoid, dermatomyositis

224
Q

Which rheum conditions cause scarring

A

Sarcoid and discoid lupus
Psoriasis does not scar

225
Q

Questions to ask in rheum history

A

When were you diagnosed- if <16 then JIA
Which joints affected
Ever had a rash
Current treatments- include infusions
Previous treatments trialled

226
Q

What does the presence of nodules in RA mean

A

They are seropositive

227
Q

Histological features of UC

A

Continuous inflamed mucosa
Crypt abscesses
Mucosal only

228
Q

Extra-intestinal features of UC

A

Iritis, uveitis, episcleritis
Erythema nodosum
Pyoderma gangrenosum
Ank spond
Osteoporosis
PSC
Anaemia
VTE

229
Q

Histological findings in Crohn’s

A

Transmural inflammation
Skip lesions
Fistulas

230
Q

Escalation of treatment for UC

A

Steroids
5ASA
Azathioprine
Biologics eg inflixmab
Surgery

231
Q

Define pulmonary hypertension

A

PAP >25mmHg at rest

232
Q

MS- management and efficacy

A

Beta interferon
Glatiramer
Decrease relapses on RRMS but do not alter disease progression
Also fingolimod, natalizumab

233
Q

Causes of SIADH

A

Drugs- ssri’s, carbamazepine, amitriptyline
Brain injury
Infections
Hypothyroid
Sclc

PACES (2 decks)

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