PACEs Flashcards
Aetiology of hypertension
PREDICTION
Primary: 95%
Renal: RAS, GN, APKD, PAN
Endo: Raised T4, Cushing’s, phaeo, acromegaly, Conn’s
Drugs: cocaine, NSAIDs, OCP
Raised ICP
CoA
Toxaemia of pregnancy (PET)
Increased viscosity
Overload with fluid
Neurogenic; DAI, spinal section
Aetiology of PUD
Acute: usually due to drugs (NSAIDs or steroids) or stress
Chronic: drugs, H. pylori, hypercalcaemia, ZE syndrome
CML
Key investigations
Complications
Findings - Signs of anemia, infection, HSM +- lymphadenopathy
Key investigations - Cytogenetic analysis - t(9:22) translocation - forming BCr-ABL fusion protein. Raised myelocyte count. Monitor for blast transformation (AML)
Rx - TKI - imatinib. BMT - curative in younger patients
Cx - AIHA, Infections (due to reduced immunoglobulins), BM Failure/infiltration
Smoking Cessation in history station?
3 As
Ask - enquire as to smoking status
Advise - best way to stop is with support and motivation
Act - provide details of where they can receive help (nhs stop smoking helpline, pharmacy, websites0
Hodkin’s Lymphoma
Classification system
Classification:
Ann Arbor:
1 - One LN group. 2 - >1 but same side of diaphragm. 3 - both sides of diaphraagm. 4 - extranodal inolvement +B for B symptoms
Mitral Stenosis
Aetiology
Murmur
Clinical Features
Dx
Severity Features
Complications (5)
Rx
Complications:
i) Pulmonary HTN, ii) Systemic Emboli - brain, GI, limbs, iii) ortner’s syndrome - RLN palsy, iv) Dysphagia - oesophageal compression, v) Bronchial obstruction
CLL
Complications
Complications - Paraproteinaemia
Causes of amyloidosis (5)
Features of amyloidosis (5)
Congenital - Familial Amyloidosis (AD - transthyretin mutation)
Primary Amyloidosis - AL Amyloid.
Spontaneous, Multiple Myeloma, Waldenstrom’s Macroglobulinaemia
Secondary Amyloidosis - AA Amyloid
Secondary to inflammatory diseases
SLE, RA, Ank Spond, IBD etc.
Dialysis Related - B2 Microglobulin
T2DM - amylin
Features: Renal (proteinuria, nephrotic syndrome, large kidney), Heart (restrictive, arrhythmias), Nerves - peripheral and autonomic neuropathy, carpal tunnel. GIT - macraglossia, malabsorption, hepatomegaly, obstruction. vascular - periorbital prupura
What is EAA
Extrinsic Allergic Alveolitis
- Acute/ Chronic
Acute = T3HS to allergen exposure
Chronic = Granuloma formation + obliterative bronchiolitis
Causes of jaundice
Conjugated
Unconjugated
Conjugated - Usually due to biliary obstruction (Stone, Tumour, Cirrhosis - alcohol, drug, viral, autoimmune/inflammatory)
Unconjugated - pre-hepatic (haemolysis), hepatic (reduced conjugation - CN, GS, hypothyroid, or Reduced uptake of BR- CCF, Drugs - rifa, contrast)
Causes of splenomegaly:
Haematological
Infective
Portal HTN
Connective Tissue
Others
Indications for splenectomy
Haematological - MF, MPS, CML,
Infective- Malaria, TB, EBV,
Portal HTN
Connective Tissue
Others - sarcoid (NCG), Gauchers (LSD), Amyloidosis, Primary immunodeficiency ( CVID)
Indications for splenectomy:
Trauma, Rupture
AIHA, ITP, HS, Hypersplenism (Pancytopenia, reticulocytosis - therefore not bM failure)
Seronegative Spondyloarthropathies/ arthropathies
Spondylo - features
Extra articular
PEAR- Psoriatis, Enteropathy, Ankylosis, Reactive
Spondylo:
Axial arthritis and sacroilitis, Asymmetrical large-joint oligoarthritis or monoarthritis
Enthesitis
Dactylitis
Extra articular: iritis, psoriaform rashes, oral ulcers, AR, IBD
Asthma:
Hx questions
Causes
Hx questions - Precipitants( dust, pollen, smoke, work, atopy? - hayfever, eczema), Diurnal variation, exercise tolerance, Effect on life
Causes - Atopic, Stress, Drug - NSAIDs, Environment - smoking, pollutants, occupation, Infection - post-viral, aspergillosis,
Haematological stains
Sudan Black
Tartate resistent acid phosphatase
Reduced leukocyte alkaline phosphatase
Increased leukocyte ALP
Sudan Black - myeloblasts
Tartate resistent acid phosphatase - Hairy cell leukaemia
Reduced leukocyte alkaline phosphatase - CML, PNH
Increased leukocyte ALP - PV, ET, MF4
Stroke
Causes
Classification -
ACA territory
MCA Territory
PCA territory
Vertibrobasilar
Location of motor symptoms?
Rx
MENDS
Ix SAH
Causes - Haemorrhagic (HTN, bleeding daithesis, thrombolysis, EtOh) Ischaemic - Atherosclerotic, embolic (AF, CAS) watershed, Vasculitis, Anti phospholipid snydrome, thrombophilia
RFs - age, diabetes, htn, smoking alcohol, HChol, PVD, AF, Raised PCT, OCP
Classification - Bamford clinical syndrome, Imaging allows vessel diagnosis, NIHSS/ Bartel - outcome scoring, dragon - prognosis after thrombolysis
ix - CT to exclude bleed but can also demonstrate thrombus in artery immediately and loss of grey white matter differentiation within an hour
DW MRI is the the best to visualise stroke
ACA - frontal and medial cerebrum. Leg effected greater than arm/face, abulia
MCA - lateral/external cerebrum. Face/Arm effected grater than leg. Homonmyous Hemianopia, higher cortical dysfunction (D- aphasia. ND - VS neglect/apraxia)5
PCA - occipital cortext. Mac Sparing HH
VB - Cerebellar, brainstem, occipital cortices. DANISH, HH, CN, Plegias, Sensory Sx
Motor symptoms:
Large artery territories - seizure, Homonymous hemianopia, higher cortical dysfunction
Internal capsule
Brainstem - accompanied by ipsilateral CN sign
Rx- Thrombolysis <4.5 hours, Thrombectomy, “permissive hypertension” to ensure cerebral perfusion. (CT 24hr to ensure no haemorrhagic transformation)
treat sequalae raised ICP if occurs secondary to vasogenic/cytotoxic oedema
Otherwise Aspirin 300 mg 14 days. Clopidogrel lifelong, statin if cholesterol >3.5 but not immediately due to risk of haemorrhagic transfomration
General Mx - Monitoring - Tight Glycaemic contro, BP control but not too agressive due to reduced CPP, regular neuro obs 5
Rx underlying causes - Carotid stenosis, AF, thrombophilia, infection, valve defect etc. Hypercholesterolaemia
Stroke requires a multi-faceted approach to management
MENDS
MDT- neuro, nursing, dietician, SALT, physio, OT, diisability
Eating - swallow screen, ?NGT, malnutrition risk
Neurorehab - physio, speech, cognitive
DVT prophylaxis
Sores - avoid pressure sores (waterlow)
Ix SAH:
CT - 90% positive
LP - Xanthocromia at 12 hours/ yellow looking
Liver Disease
Causes of cirrhosis
Cirrhosis scoring systemts
Cx of cirrhosis
Causes of budd chiari syndrome
Liver failure investigations
Signs of liver failure
Causes of portal htn
SAAG
Hepatorenal syndrome Rx
Cx of acute liver failure + rx
General management of LF
Abs in LF
Rx for ascites
Precipitants of hepatic encephalopathy
1st line for cirrhosis - transient elastography
ALT:AST >2 alcohol
Causes - Alcohol, NAFLD, Viral (viral serology), HH, Wilson’s, A1AT, Autoimmune (AIH, PSC, PBC), Ca (mets, primary), Drug (MTX, isoniazid, amiodarone, methyldopa), Vasc - CCF , budd chiari ,
Cirrhosis Scoring:
Childs pugh - ABCDE (Albumin, bilirubin, clotting, distension - ascites, encepholopathy)
MELD - now prefered. bilirubin, clotting,
Cx- portal hyertension (ascites, splenomegaly, varcies, encephalopathy), SBP, decompensation ( Jaundice, enceophalopathy, hypoalmbuminaemia, clotting abnormality, hypoglycaemia), HCC
Causes of budd chiari syndrome - hypercoaguability, local tumour, membranous obstruction (congenital)
Liver failure investigations - FBC, U&E, LFT, Clotting, Glucose, B12, Folate, albumin
Signs of liver failure
-Jaundice, oedema/AScites, enceophalopathy, bruising, varices, fecor hepaticus
FBC: infection, GI bleed, raised MCV (EtOH)
U+Es:
Reduced urea, raised creatinine: hepatorenal syndrome
Urea synthesised in liver: poor test of renal function
LFTs:
AST:ALT >2= EtOH
AST:ALT <1= viraL
Albumin: reduced in chronic liver failure
PT: prolonged in acute liver failure
- *Clotting:** Raised INR
- *Glucose**
ABG: metabolic acidosis
Cause:
Ferritin, a1AT, caeruloplasmin, autoAbs, paracetamol levels
infection - HAV, HBV, HCV, EBV CMV - PCR serology, virology, antibodies
Leptospirosis . Blood urine culture. imaging
Ascites - MC&S, cytology, SAAG, chemistry, AFB
Imaging - US And PV doppler
Transient Elastography
liver biopsy
Causes of portal htn
Pre hepatic - portal vein thrombosis, peritoneal carcinomatosis,
Hepatic- cirrhosis, HCC, schisto, sarcoid
Post hepatic - budd chiari syndrome, nephrotic syndrome , RHF, TR, constrictive pericarditis
TB,
SAAG
<1.1 = Exudative - nephrotic syndrome, malignancy, TB
>1.1 = Portal HTN - Cirrhosis, CCF, Budd chiari,
Hepatorenal syndrome (type 1 - fast and type 2 - slow)
Rx - IV albumin + terlipressin
Dialysis / hepatic transplant
cx of acute liver failure
- bleeding (vit k, FFP, platelets) , sepsis, ascites ( fluid restrict, frusemide, alosteron antag, tap,) , oedema, hypoglycaemia (IV glucose), encephalopathy (lactulose - reduces ammonia production, rifaximin), seizures (lorazepam), cerebral oedema (mannitol)
General Management
Cons - constant follow up, Dietician (must ensure high carb diet), avoidance of alochol and hepatotoxic drugs,
Mx - treat underlying cause, pabrinex (C, B1, B3, B6), diazepam if withdrawing,
NGT- high carbs, thiamine
PPI - against stress ulcers
Monitoring - Fluids - Monitoring of status and output. Avoid using NS due to RAS activation —> go for colloid/ HAS/ 5% dextrose
Daily Bloods
Daily wieghts
ABs
AIH - SMA, SLK, LKM
PBC - AMA
PSC - ANA, ANCA
Ascietes rx
- fluid restrict, frusemide, spiro, therapeutic tap, TIPSS
precipitants of hepatic encephalopathy
HEPATICS - Haemorrhage, Electrolyte- hypokaleamia, hypontaraemia, poisons (diuretics, sedatives), alcohol Tumour HCC, Infection,Constipation,Sugar (low)
Aortic Stenosis
DDx
Causes
Symptoms
Signs
Clinical indicators if severe
Ix
Mx
Indx for VR
Causes: senile calficiation, Congenital - bicuspid valve, supravalvular aortic stenosis (WS), Rheumatic fever
DDx- HOCM (increases with valsava manouvere), MR, Aortic Sclerosis (thickening but no narrowing), CAD
Symptoms:
Triad- dsypnoea, syncope, angina
LVF, Ahhyrthmias, Emboli, Death
Signs:
ESM (loudest at RSE) radiating to carotids
LVF, Soft A2, S4 Heart sound
Slow rising pulse
Severe:
LVF, Soft A2, S4 Heart Sound, NPP
Ix:
CXR - Cardiomeg, postestenotic dilatation, calcified valve ECG - LVH, Echo - thickened, immbole valve cusps. <1 VA, >40 VG, >4 VV. Catheterisation - assess coronaries, valve gradient.
Mx:
Conservative - optimise Rfs
Medical - Reduce preoload - CCB, Ace-i, Reduce afterload - diuretsic, improve myocardial perfusion - beta blockers
Surgical - Baloon valvuloplasty( interim measure) TAVI, Open valve replacement, xenograft/bioprosthesis
Indx for VR:
i) symptomatic ii) LVF EF <60% iii) CABG/ other valve op concurrently
ECG:
Normal: PR, QRS, QT
LVH?
Inferior View - Leads and Artery
Lateral View - Leads and ARtery
Anteroseptal - Leads and Artery
Anterolateral - Leads and ARtery
Posterior - Leads and ARtery
PE
Hypokalaemia
Hyperkalaemia
1st degree HB
Mobitz I
Mobitz II
Complete Heart block
Wellen’s syndrome
LBBB
RBBB
Pericarditis
PR <0.2 ms, QRS <0.12 ms, QT men <430 ms women <450 ms
LVH:
LBBB, complete AV block. - due to septal calcification
(lateral leads) v4-v6 - Tall R, ST depression, t wave inversion
Inferior View - II, III, AVF – RCA
Lateral View - I, AVL, V5, V6 – Left Circ
Anteroseptal - V2- V4 - LAD
Anterolateral - V2-V6 - Left Main Stem (LAD+ L Circ)
Posterior - V1-V3(Deep ST depression with R waves). RCA
PE - S1Q3T3 Classic, Sinus tachy cardia, RAD, RVH
Hypokalaemia - U waves, Absent T wave, prolonged PR, prolonged QT, st depression
Hyperkalaemia - tall t waves, absent p waves, broad qrs, prolonged PR –> sinusoidal
1st degree HB - PR >0.2 ms
Mobitz I - Wenkeback phenomenon, gradual PR prolongation til beat is missed then resets so next PR is shorter
Mobitz II - fixed non conduction of a p wave. Not preceded by PR lengthening or followed by PR shorting
Complete Heart block - P waves and QRS complexes are not related
Wellen’s syndrome - T wave inversion/ hyperkinetic t waves in V2-V3 highly suggestive of imminent LAD occlusion
LBBB - Wide QRS. SRS pattern in V1 and RSR pattern in V6. Wave comes down RV first then spreads to LV.
RBBB - Wide QRS. RSR pattern in V1. SRS pattern in V6.
Pericarditis - Shaddle shaped ST elevation, PR depression, Electrical alternans, Low voltage QRS
Heart Failure - Def
Ix
Medical Management
Causes - myocardial, pressure, arrhyhtmias
Low output
High Ouput HF causes
Causes of RVF
Signs of RVF
Causes of LVF
Criteria for HF diagnosis?
BNP
NYHA Classification of HF
Heart failure - inadequate CO to perfuse the body despite adequate filling pressures
Impaired Systolic function - dilation via starling’s effect –> failure to completely empty ventricle –>
RAS activation due to hypotension –> increase in afterload (peripheral vasoconstriction) / increase in preload–> salt/fluid retention (aldosterone)
Hypertrophied myocardium –> increased metabolic demand –> ischaemia
Ix
NT-Pro-BNP if no history of IHD –> positive then echo
History of IHD –> echo
CXR: A-Alveolar shadowing. B - Kerley Lines, C - Cardiomegaly D - upper lobe diversion E - pleural effusions F- fluid in fissures
Medical Management
Reduce preload - diuretics
Improve myocardial perfusion - Negative chronotropes (beta blockers)/ positive inortroped (digoxin)
Reduce afterload - CCB, ACE-i, hydralazine +nitrate (avoid in AS), aldosterone
Invasive
cardiac resync,
aortic baloon counter pulsation
heart transplant
Causes - myocardial, pressure, arrhyhtmias
myocardial:
IHD, Toxins - EtOH, Chemotherpay, Autoimmune- scleroderma, SLE, RA. infection - HIV, Infiltrative - malignancy, sarcoid, amyloid, HH. genetic- musc dystrophy
pressure:
HTN, Valve disease, restrictive pericarditis, volume
Arrhythmias - tachy / brady
Low output
Pump failure - Impaired systolic /diastolic function / arrhythmias
Excessive - preload (AR, MR, Fluid overload)
Excessive after load (Hypertension, Aortic Stenosis, HOCM)
High output
increased metabolic demand (RVF fails before LVF fails)
AATTPP –> Anaemia, AVM, Thyrotoxicosis , Thiamine Pregnancy, Paget’s
Causes of RVF
LVF, Cor Pulmonale, Tricuspid/pulmonary valve disease
Signs of RVF - Raised JVP, pulsatile hepatomegaly, pitting oedema, ascites
Causes of LVF - IHD, dilated cardiomyopathy, HTN, mitral and aortic valve disease
Signs of LVF - weight loss, muscle wasting, cyanosis, AF, cardiomegaly, S3, Wheeze, basal creps
Framingham Criteria
BNP <100. 96% NPV
NYHA - 1 - 4
1 breathlessness on unaccustomed exercise. 4 breathlessness at rest
Pulmonary HTN
Causes
Causes - Obstructive Airway disease (including OSA), Idiopathic, Sarcoid, Vasculitis, Heart Failure, PE
Diabetes Mellitus
T1DM vs T2DM
Complications:
Neuropathy
Autonomic
Vascular
Mx
T1DM - insulin, monitoring, transplant
T2DM - diet, exercise metformin, SFN, DPP4, GLP1, Acarbose, SGLT2, Insulin, transpl
T1DM - DR3/DR4. Anti - Gad/islet cell. Absent production of insulin.
T2DM - insulin resistance
neuropahy caused by- metabolic (glycosylation, ROS) and ischaemic damage to the vas nevorum
Can be - polyneuropathy (symmetrical), mono/ mono multip, amyotrophy (painful asymmetrical wasting of quads, loss of knee jerk) , autonomic neuropathy
Autonomic:
gastroparesis, urinary retention, postural hypotension, diarrhoea, Sexual dysfunction
Macro - MI, PAD, Stroke
Micro - retinopathy, nephropathy
Mx
MDT
Diet - Standard. Reduce total, refiend carbs, fats etc. Avoid binge drinking.
Hypoglycaemic meds - Biguianides (MFN), SFUs (Glibenclamide etc.), TZD (pioglit), DPP4 i ( Sitagliptin), GLP 1 mims- (Exanatide), SGLT-2 inhib (Dapiglafozin)
Statins - if >40 , T1DM >10 years, T1DM with cx,
Anti - HTN - <130/80. ACE-i best
4 Cs - Control (CBG, Hba1c), Complications (DKA, Honk, RF, Neuropathy, PAD, fundoscopy) , Coping, Competency
CNs Eyes:
II
III
III,IV, VI : Eye movements
V
VII
INO:
III,IV, VI : Eye movements
INO: MLF lesion (MS, stroke etc.) Impaired adduction of ipsilateral eye - i.e. conjugate nerve palsy. convergence is preserved
Neuro
LMN Signs/ Causes
LMN:
Weakness
Paralysis
Loss of reflexes
Causes:
Sinal cord infarction (fracture, dislocation, vasculitis, atheromatous)
Neuro
Ascending
Dorsal Columns
Spinothalamic
Cell bodies for both?
Spinocerebellar
Descending
Pyramidal - Corticospinal
Extrapyrimadal - rubropsinal, tectospinal, vestibulospinal
Dorsal Columns - Fine touch, proprioception, vibration
Spinothalamic - Anterior- crude touch, pressrure lateral - pain temperature
Cell Bodies - DRG
Spinocerebellar - subconscious somatosensory pathway
(posterior, cuneo, rostral, anterior
descending
Pyramidal (voluntary) - Corticospinal, corticobulbar (contralateral UMN for hypoglossal and for facial nerve below eyes. Bicortical representation for facial nerve above eyes)
Extrapyrimadal (involuntary, automatic control) - rubropsinal (hand movements), tectospinal (head in relation to vestibular stimulus), vestibulospinal (posture and balance) , reticulospinal (control of tone)
Hypoglossal nerve:
UMN
LMN
UMN - points away from lesion
LMN - point towards the lesion
Brainstem rule of 4
4 midline structures beginning with M (i) motor tract (corticospinal), medial leminiscus, MLF, motor nuclei)
4 structures to the side beginning with S (spinocerebellar, spinothalamic, sensory trigeminal nucleus, sympathetic pathway)
4 CNs in medulla (9, 10, 11, 12), pons (5, 6, 7, 8), and above the pons (1, 2, 3, 4,) Remember 7 and earlier CNs ahve ipsilateral innervaton
4 midline motor nuclei divine into 12 (but not 1 or 2), 3, 4, 6, 12 (5, 7, 9 and 11 are lateral brainstem structures)
Neuro - Eye reflexes
Explain direct/consensual
Eye receives light input –> pre-tectal nucleus –> then to both ipsilateral (direct) and contralateral (consneusal) edinger-westphal nuclei –> occulomotorn nerve fibres carry AP to the ciliary ganglion which is SNS and causes contraction of sphincter pupillae
Peripheral Neuropathy
Motor
Pattern of weakness in motor neuropathies
Mononeuropathy vs Mononeuritis Multiplex
Diabetic neuoropathy
Motor
Usually distal weakness
If root involvement - proximal weakness (GBS, Botulinum, polio)
Mononeuropathy (single nerve - usually mechanical cause) Mononeuritis Multiplex (multiple nerves - DM and vasculitis)
Diabetic neuoropathy
All modalities effected, absent reflexes. starts at feet and works its ay up
Neuro signs
UMN
LMN
Primary motor problem
Cerebellar Signs
Causes of cerebellar pathology (PASTRIES)
Dissociative sensory loss?
Wallenberg’s?
Dx of Neuropathy
UMN (primary motor cortex to anterior horn cell)
- Spasticity (hypertonia), Pyramidal pattern of weakness (Extensors in UL, flexors in LL), hyperreflexia, upgoing plantars, no wasting
LMN (Anterior horn cells to NMJ)
-flaccid (hypotonia), hyporeflexia, downgoing plantars, wasting, fasciculations
Motor
Symmetrical, reflexes may still be present, no sensory disturbance, fatiguability (MG)
Cerebellar Signs
Dysdiadochokineisa, Dysmetria, Ataxia, Nystagmus, Intention Tremor, Staccato speech, hypotonia
Causes of cerebellar pathology
Paraneoplastic, Alcohol, Sclerosis (MS), Tumour (CPA), Rare (MSA, Friedrich’s, AT), Iatrogenic (phenytoin), Endo (hypothyroidism), Stroke (vertebrobasilar
Dissociative sensory loss
Suggest of cervical lesion (syringomyelia) - ST- loss of pain and temp but no loss of DCLM -proprioception or vibration
Wallenberg’s
PICA/ AICA insult
DANVAH - Dysphagia, Ataxia (IL), Nystagmus (IL), Vertigo, Anasthesia (IL facial numbness, CL pain loss), Horner’s
Neuropathy - EMG can help with diagnosis distinguish between axonal loss/ demyelination
Neuro Signs
CPA Syndrome
Beck’s Syndrome
Spasticity vs Rigidity
Hallmark of cord lesion/compression
Hall marks of spinal stenosis
Neuropathy vs Myopathy
CPA Syndrome causes - VSchwann, Meningioma, Mets, AStrocytoma
Sx - CN 5,6,7,8 (IL), DANISH
Beck’s Syndrome - Anterior Spinal Artery Syndrome (AAA repair). Lesions effect- Corticospinal tract, Spinothalamic Tract but not DCLM (this is not in anterior spinal artery distribution)
Spasticity (clasp knife) - Extremity is weak, resistance is greater in flexion than extension. Velocity dependent (faster the more spastic)
Rigidity - equal resistance throughout and in all planes of movement,
Cord Lesion - LMN + pain at level, UMN below, Look for reflex, sensory and motor level
Spinal stenosis - aching pain in buttocks, parasthaesia/numbness, relieved by leaning forwards, worse on walking up hills, spinal claudication. negative SLR (cf disc prolapse)
neuropathy vs myopathy - Neuropathy = distal weakness, Myopathy = proximal weakness, rest pain/tenderness = inflammatory myopathy, firm muscles = pseudohypertrophy in muscular dystrophies, fasciculatons = anterior horn/root disease, Fatiguabuility = MG/LEMS
Causes of weakness
Cerebral
Cord
Anterior horn
Roots
Periperhal Nerve
NMJ
Muscle
Cererbral - VINIT N= any SOL I = usually demyelination
Cord - V= beck;s , I = MS, transverse myelitis, Devic’s. Trauma
Anterior Horn - I= Polio, I= GBS, progressive muscular atrophy
Roots/ Plexus - Compression - Sponydlosis, Cauda equina, Carcinoma. Inflammation - Neuritis, Parsonage turner radiation
Nerve - Mononeuropathy - Compression/.trauma Polyneuropahty - GBS, CMT, CIDP
NMJ - MG, LEMS, Botulism
Muscle - Dystrophies (proximal, symettrical loss), Myositis, Disuse (RA), Toxins - Steroids, electrolytes, Endo - hypothyroidism
Causes of mixed U/LLMN signs
ALS (Anterior horn and PMC)
Friedrich’s Ataxia (ataxia, cardiomyopathy, absent reflexes, DM, FRATAXIN)
SACD (B12)
Taboparesis (syphyllis)
Causes of Hand wasting
Cord - Syringomyelia
Anterior Horn- MND , Polio
Roots - Spondylosis, Neurofibroma
Plexus - Compression - rib, pancoast’s. Trauma -Klumpke’s
Nerves - Compressive, Mononeuritis- DM, Generalised - CMT
Muscles - Disuse (RA), Myotonic Dystrophy, Volkman ischaemic contracture
Romberg’s +ve
Romberg’s -ve
Positive = Vestibular (CPA, labyrinthitis) or proprioceptive (DCML - SACD. Peripheral nerves - Senosry neuropathy - Alcohol, DM, uraemia, b12)
Negative = cerebellar (infarct, aclohol etc. etc.)
Medicine stuff
Postural hypotension causes- STANDUP
Causes of VERTIGO - IMBALANCE
Conductive causes of hearing loss - WIDENING
SNHL - DDIVINITY
Postural Hypotension
Salt (Hypovolaemia, addison’s), Toxins - hypotension inducing, TCas, Anti psychotics, L DOPA. Autonomic neuropathy - DM, GBS, Parkinson’s, Dialysis, Unwell, Pooling (venous)
VERTIGO
I- inf,injury M - menieres’s, peri lymph B- BPV A- minoglycosides, furosemia L- ymph A- rterial N- erve C- entral E - pilepsy
Conductive hearing loss
W - wax,FB, I- infection, cholesteatoma D- Drum perf, Extra - otosclerosis, Neoplasia (NPC), Injury - barotrauma, Granulomatous- Wegener’s, Sarcoid
SNHL
Developmental (alports, waaardenberg, NIE, TORCH), degenerative , infection (meningitis, measles, mumps), vascular (stroke, ischaemia of internal auditory artery), inflammatory (vasculitis, sarcoidosis), neoplastic (CPA), injury , toxins (gent, frus, aspirin)
Definitions:
Tremor - RAPID
Myoclonus
Dystonia
Chorea
Atheteosis
hemiballismus
Tardive Syndromes:
Dyskinesia, Dystonia, Akathisia
Tremor- Regular, Rhythmic osccilation
RAPID -Resting (4-6, worse with distraction), Action/postural (6-12, worse with outstretched hand. Either Benign essential tremor or caused by sympathetic excess), intention (worse at end stage of movement, cerebellar), Dystonic (variable)
Myoclonus - sudden involuntary jerk
Dystonia - prolonged muscular contraction
Chorea - non-rhythmic, purposeless, jerky, flitting movements (huntinton’s, RF, L- DOPA, WIlson’s)
Athetosis - slow, sinous, writhing movements (CP, kernicterus)
hemiballismus - large aplitude flinging chorea, (STN lesion)
Tardive Syndromes: (anti dopaminergics)
Dyskinesia - lip smacking etc., Dystonia (prolonged muscular contraction), Akathisia (restlessness)
Types of aphasia
ALl domains of speech effected
Limited comprehension
Comprehend well but can’t express (look frstrated)
Can’t repat things
struggle with nouns and verbs
Global - ALl domains of speech effected
Wernicke’s - Limited comprehension (temporal)
Brocha’s - Comprehend well but can’t express (look frstrated) (parietal)
Conductive - Can’t repat things (angulate)
Anomic aphasia - struggle with nouns and verbs
Definitions
Epilepsy
Multiple Sclerosis
Spondylosis
Spinal Stenosis
Polyneuropathy
Muscular Dystrophy
Syrinx
Epilepsy - Tendency to recurrenty spontaneous , intermittent, abnormal electrical actiity in part of the brain manifesting as seizures
Multiple Sclerosis - Chronic inflammatory condition of CNS involving demyelination white matter plaques that are disseminated in space and time
Spondylosis - Degenerative process due to trauma and aging. Can cause - myelopathy (central - UMN) radiculopathy (lateral - LMN)
Spinal Stenosis - Generalised narrowing of the spinal canal. Degenerative osteoarthritic process
Polyneuropathy - Generalised symmetrical and widely distributed disorders of peripheral and cranial nerves. Distal weakness and senosry loss in a glove and stocking distribution
muscular Dystrophy - Group of conditions causes progressive degeneration and weakness of specific muscle groups. (effect proteins involved in muscle function i.e. dystrophin)
Syrinx - fluid filled tubular cavity in the central canal of spinal cord
Parkinsonism - prove it
Signs / Symptoms
Causes
Pathology in PD
Ix in PD
Proving someone has parkinson’s? - Glabellar tap (blinking doesn’t disappear), Synkinesis - tone (tremor) can be worsened on distraction
Signs - Tremor, BRadykinesia (slow initiation of movement), Rigidity, Festenating gait, Postural instability, micrographia, mask like face, dementia, autonomic instability, loss of arm swing,, monotonous voice, sleep disorders (insomnia, EDS, rem sleep disorder), depression
Causes - Parkinson’s Disease, Parkinson’s Plus (PSP - postural inst, vertical gaze palsy, dementia, MSA - autonomic, cerebellar, CBD - aphasia, apraxia, akinetic regidity, alien limb, LBD - fluctuating cognition, visual hallucinations ), Iatrogenic (Neuroleptics, Metoclopramide), Infection (syphillis, HIV, CJD), Trauma (dementia Puglistica), Genetic (wilson’s)
Pathology in PD - Loss of Da Neurones in pars compacta of SN. beta amyloid plaques. NFT. Braak staging
ix in PD - largely clinical UK Parkinsons Society Brain Bank Diagnostic Criteria, Structural imaging MRI to rule out Park + Syndromes, DaT Scan
Mx of PD -
MDT approach - Nurse, Neurologist, OT, PT, depression, disability (unified parkinsone disease rating scale)
L DOPA (w/ Dopa Decarb Inh. Lose response in <5 years). MOAi, Do Analog, COMT inhib, DBS, SSRIs (depression),
Apomorphine - Rapidly acting dopamine agonist. SC rescue pen
Features of autonomic Dysfunction
Hyper - salivation, hydrosis
Constipation
urinary - frequency , urgency, nocturia
Erectile dysfunction
Postural hypotension
Multiple Sclerosis
Def.
Pathology
Subtypes
Signs/ Symptoms
Ix
Mx
HLA DRB1 associated condition. Chronic inflammatory condition of the CNS characterised by demyelinated white matter plaques desseminated in space and time
DDx - MS, Devic, Sarcoid, SOL
Pathology - CD4 mediated destruction of of oligodendrocytes –> demyelination. Later in disease process formation of islands of T Cells which secrete cytokines that lead to a diffuse atrophic process.
Subtypes - Relapsing remitting, Primary progressive, Secondary progressive, Progressive relapsing
Signs/ Symptoms - lhermitte’s sign, Uhthoff’s phenomenon, parasthaesia, redued vibration sense, optic neuritis, INO, RAPD, diplopia, ataxia, cerebellar signs, spastic paresis, GI - swallowing disorder, constipation, erectile dysfunction, urinary retention/incontinence,
McDonald Criteria
Ix - LP (IgG oligoclonal bands), MRI (gad enhancing, T2 hyperintense plaque), Anti-AQP4/NMO (Devic Syndrome), Anti-MBP, Delayed evoked potentials
Mx -
MDT - Nurse, Nueorlogy, PT, OT, Disability assessment
Acute attack - high dose methylpred
DMARDs - Flinglimod, Glatiremer Acetate, PEG-Ifn, Natalazumab (Anti_VLA a4), Alemtuzumab (Anti- CD52)
Sx mx - Spasticity - baclofen, dantrolene. Urinary symptoms - oxybutynin, Depresion - SSRIs, Fatigue - midafonil + amantadine, Pain -amitryptilline, ED - Sildenafil, Tremor - clonazepam
Spondylosis
Pathology
Rx
Spinal canal stenosis mx
pathology
- Degeneraive condition efecting spine. Osteophyte formation may also in volve lumbar disc prolapse. Can involve myelopathy or radiculopathy
Conservative - rest, analgesia, physio
Medical - Transforminal steroid joint injection
Surgical - Discectomy/ Laminectomy
Spinal canal stenosis
Conservative - corsets, analgesia, physio
medical -analgesics, epidural injections
Surgical- decompresson
Polyneuropathy
Definition
Features of sensory,motor autonomic neuropathies
Main causes of sensory, motor, autonomic neuropathies
Testing autonomic function
Talk about GBS
Metabolic Causes
Inflammatory Causes
inherited Causes
Vasculitic Causes
Drug Causes
Infectious Causes
Toxic Causes
Other causes
Polyneuropathy - Generalised symmetrical and widely distributed disorders of peripheral and cranial nerves. Distal weakness and senosry loss in a glove and stocking distribution
Features senosry:
Glove and stocking distribution (length dependent), loss of reflexes, Charcot’s joints, painful neuropathie in alcoholic/diabetic, proprioceptive loss (B12 - large fiber loss), loss of pain/temperature sensation ( painful dysthesia)
Features motor:
Weakness, clumsiness, LMN signs, CN - diplopia, dysarthria, dysphagia, Resipiratory invovlement
Features Autonomic:
Horner’s, Anhydrosis, Postural instability, Urinary retention, constipation, gastroparesis, ED/ Ejaculatory failure
Tests - Standing/sitting BP, ECG >10bpm variation with respiration
Main causes:
Sensory - Etoh, B12, DM, Paraproteinaemias (CRF, Cancer), Vasculitis
Motor - GBS, Pb, CMT, Botulinism, Paraneoplastic
Autonomic Neuropathy - DM, HIV, SLE, GBS/LEMS
GBS (anti ganglioside antibodies, raised protein on LP) ( Ix - Cjej, Mycplas, CMV) - AIDP (demyelinating) , ADAM (axonal loss) , Miller Fisher (opthalmaplegia, ataxia, areflexia)
- Ascending flaccid paralysis. Proximal > distal. LMN signs
Mx - Supprotive (autonomic - inotropes, respiratory, VTE proph) , Rx infection, IVIG/ PLEX, Novel SC IVIG for CIDP
Metabolic ( mostly axonal - reduced amplitute EMG)
- Uraemic, DM, Hypothyroid, B1 deficiency, B12 deficiecny
Inflammatory Causes
- GBS, CIDP, Sarcoidosis
Inherited Causes
- CMT - HSMN1 (demyelinating) + 2 (PMP22)
- Friedrich’s Ataxia (sensory) (FRATAXIN)
- Refsum’s Syndrome
vasculitis
- small vessel vasculitidies (PAN, Cryoglobulinaemia, RA, Wegener’s)
Drugs
- Vincristine, Isoniazide, Phenytoin, Alcohol
Infection
- Leprosy, Syphyllis, Lyme, HIV,
Toxic
- Lead,
Other
- amyloid, paraproteinaemias
MND Def
Ix
Features
Mx
Causes of bulbar palsy/pseudobulbar palsy
Myotonic Dystro
Def -
Features
Rx
Acquired myopathies
Def - Group of inherited motor neuropathies involving demyelination of axons. No sensory or occular involvement
Associated with SOD1, C9ORF mutations and FTLD
Types - Progressive Muscular Atrophy (best), Progressive Bulbar Palsy (worst), Primary Latertal Sclerosis, Amyotrophic Lateral Sclerosis
Ix - MRI - exclude plaques/ cord lesions
LP - exclude inflammation
EMG - reduced velocity
Revised El Escorial Diagnostic Criteria
Features-
mixed UMN/LMN
Bulbar involvement indicated bad prognosis
FTLD
mx - MDT approach
Nurse, neurologist, PT, OT, orthoptist
Symptomatic treatment - dysphagia (NG, PEG), Resp fail (NIV), Spasticity (bacl, botul), Drooling (amitrypt)
Riluzole - Glutamate antagonist. Improve life expectancy >3ms
Bulbar Palsy - MND, GBS, MG, CPMyelinoly.
Psuedobulbar - Stroke, MS, MND, CPMyelin.
Myotonic Dystrophy
Def- AD Cl Channelopathy –> causes tonic muscle spasms (percussion myotonia)
- Expressionless faces, Ptsosis ,dysarthria, Dysphagia, slow relaxation of hand , wasting wekaness of distal muscles, cataracts, cardiomyoptahy, dm
Rx - phenytoin for myotonia, avoid GA
Acquired myopathies
- usually related to systemic disease (Cushing, Hypothyroid, hyper/hypocalcaemia)
Inclusion body myositis (dysphagia, distal + prox muscles), Dermatomyositis, polymyositis
Proving patient has disorder
Marfan’s
Parkinson’s
Myasthaenia
Myotonic Dystrophy
NF1
Tuberous Sclerosis
Behcet’s
Sjogren’s
Acromegaly
Thyroid
HHT
Marfan’s - Arachnodact, arm spain >height, Downward lens dislocation, high arched palate
Cx - Ruptured AA, pneumothorax, hernias
Mx - Bbs slow dilation of aortic root, Regular reveiw with ortho, ophth, cardio5
Parkinson’s - Gait, glabellar tap, synkinesis- tone/tremor worse with distraction
Myasthaenia - ptosis and eye drooping on upward gaze, voice tires counting to 50, fatiguability (test strength, chicken flap, re-test strength), hold breath count down (used to evaluate acute disease severity), myasthenic snarl, Tensilon test (edrophonium - power will improve. Only small improvement in LEMS). EMG - decreased response to train of impulses. Drugs worsening MG - Beta blockers, lithium, macrolide, tetracyclines
Myotonic Dystrophy - percussion myotonia, can’t stop you from blowing out there cheeks
NF1 - CAFE NOIR
Cafe au lait, ax freck, neurofibroma, retinal hamartoma, neoplasm, orthopaedic, reduced IQ, renal (RAS)
TS
Adenoma Sebaceum, Subgunfual Fibroma, Retinal hamartoma, Ash leaf depigmented patch, Shagreen patch
- Epilepsy, developmnetal delay, lyphangiomyomas - lung, liver kidney, rhabdomyoma - heart, glioma- brain
Behcet’s
Skin pathergy needle prick test (develop ulcer at site of needle)
Sjogren’s
Schirmer’s Tear Test
Acromegaly
Hands - boggy sweaty, spade like, thenar wasting, thenar wasting
Face - prominent supraorbital ridge, cuti verticis gyrata, prognathis, macroglossia, widely spaced teeth
Proximal weakness
GTT, IGF1, Glucose, MRI, Visual fields
Thyroid
Active vs inactive - Active signs: Sweaty hands, Tichycardia, AF, Lid Lag, Brisk reflexes, Tremor
Grave’s - Pretibial, Opthalmoplegia, Exopthalmus, THyroid acropachy
HHT (OWD syndrome. AD )
Typical oromucocutaneous telangiectasia –> epistaxis 5
AV malformations in viscera, Pulmonary HTN
GI polyps
more neuro sx
1. Ipsilateral spast paresis inferiot to lesion, 2. ips lat. loss of proprioception and vibration. 3. contralateral loss of pain and temp
- *1. Bilateral spastic paresis
2. Bilateral loss of proprioception and vibration sensation
3. Bilateral limb ataxia** - *1. Bilateral spastic paresis
2. Bilateral loss of pain and temperature sensation** - *1. Flacid paresis (typically affecting the intrinsic hand muscles)
2. Loss of pain and temperature sensation**
1. Loss of proprioception and vibration sensation
Painless
Early sphincter/erectile dysfunction
Bilateral motor and sensory distrbance below lesion
Brown- Sequard
- Ipsilateral spast paresis inferiot to lesion, 2. ips lat. loss of proprioception and vibration. 3. contralateral loss of pain and temp
Friedrich’s Ataxia (+cerebellar signs) / SACD (B12) - ST tracts spared
- Bilateral spastic paresis
- Bilateral loss of proprioception and vibration sensation
- Bilateral limb ataxia
Anterior SPinal artery Occlusion
- Bilateral spastic paresis
- Bilateral loss of pain and temperature sensation
Syringomyelia (arnold ch mal, masses, spina bif, 2o - trauma, myelitis etc.)
- Flacid paresis (typically affecting the intrinsic hand muscles) (ventral horns not Corticospinal tract), UMN signs in legs
- Loss of pain and temperature sensation
dissociated sensory loss - absent pain/tem preserved touch, propr, vibration. Horner’s syndrome
Tabes Dorsalis (neurosyphillis)
- Loss of proprioception and vibration sensation
intrinsic cord disease
Painless
Early sphincter/erectile dysfunction
Bilateral motor and sensory distrbance below lesion
Anatomy mnemonics
Lumbar Plexus
Sacral Plexus
Brachial Plexus
Subclavian Artery
External carotid artery
Facial Nerve
Nerves passing through orbital fissure
Lumbar Plexus - I Twice get laid on fridays (T12- L4)
Ilioinguinal, Iliohypogastric, Genitofemoral, lateral cutaneous nerve of thigh, obturator femoral
Sacral Plexus ( descend near psoas and exit via the greater/infeior sciatic foramen or obturator foramen) - Main branches- some irish sailors pestor polly
Superior gluteal, inferior gluteal, sciatic, posterir cutaneous nerve of thigh, pudendal nerve
Brachial Plexus - MARMU (C4-T1)
Musculocut, axillary, radial, median ulnar,
Subclavian Artery - Indeed very tired individuals sip, strong cofee served daily done at last
Internal thoracic, vertebral, thyrocervical, inferior thyroid, superficial cervical, supra scapular, costocervical, superior intercostal, deep cervical, dorsal scapular, axillary
external carotid artery - Some anatomists like fucking others prefer s and m
Superior thyroid, ascending pharyngeal, lingual, facial, occipital , posterior aurcular, maxillary, superficial temporal
Facial Nerve - two zulus buggered my cat
temporal, zygomatic, bucallis, mandibular, cervical
Orbital fissure - live frankly to see absolutely no insult
Lacrimal ,frontal, trochlea, Superior CN III, abducens ,Nasociliary, Inferior CN III
Borders:
What is the deep inguinal ring
Borders of the inguinal canal
What is the femoral ring
Borders of the femoral canal
Femoral Triangle
hesselbach’s triangle
Inferior Lumbar Triangle
Superior Lumbar Triangle
Borders of the adductor canal
Anterior Neck triangle
Psoterior neck triangle
Submandibular triangle
Deep Inguinal ring - oval shaped opening in the transersalis fascia
Inguinal Canal -
Floor - inguinal ligament, lacunar ligament medially.
Roof - Arching fibres of internal oblique and transversus abdominus
Anteriorly - External oblique aponeurosis (and internal oblique). Superficial ring allows exits here
Posteriorly - Conjoint tendon medially and fascia transversalis. Deep ring permits entry through the fascia transversalis here)
Femoral ring - Beginning if femoral canal.
Anterior - inguinal ligament
Posterior - pectinal ligmanet
Medially - lacunar ligament
Laterally - Femoral vein
Borders of femoral canal - Continuous with the femoral ring so same borders
Contains lymph node of cloquet + other lymphatic structures
Femoral Triangle -
Superiorly - Inguinal ligament
Sartorius - Medially
Adductor Longus - Laterally
Hesselbach’s triangle - Defect through which direct inguinal hernias often occurs
Inferiorly - Inguinal ligament
Medially - Lateral border of rectus abdominus
Lateraly - Inferior epigastric artery / vein
Inferior Lumbar Triangle
Inferiorly - Iliac Crest
Postero-Medially - Latissumus Dorsi
Antero-Laterally - External Oblique
Superior Lumbar Triangle
Superiorly - 12th rib
Medially - Quadratus Lumborum
Laterally - Internal Oblique
Roof - External Oblique
Floor - Transveralis fascia
Borders of the adductor canal
Anterio-medial - Sartorius
Antero-lateral - Vastus Medialis
Posterior - Adductor longus+ Magnus
Anterior neck triangle -
Midline
Medial border SCM,
Mandible
Posterior neck triangle
lateral border of SCM
clavicel
trapezius
Cutaneous Innervation of leg
Lateral
Medial
Sole
(Postero - )
Lateral - Sural nerve L5/S1
Medial - Saphenous nerve / L4
Sole of the foot - largely branches of tibial nerve, small lateral area supplied by sural nerve, small medial area supplied by the saphenous nerve (at the foot arch)
Rheumatological Bloods
HLA?
Imaging
LOSS
LESS (O)
Normal joint space, periarticular erosions, soft tissue swellings
chondrocalcinosis
FBC, Haematinics, ESR, CRP, Us and Es, Serum Urate, Bone profile
Autoimmune - ANA, RhF, Anti - CCP, Anti DsDNA
Urine Chlamydia PCR
Blood Culture
HLA - DR4/ DR1
Imaging:
CXR - RA, SLE, Sarcoid, TB, Vasculitis (wegener’s)
US/MRI - tenosynovitis, enthesitis, Septic arthritis/ osteomyelitis
LOSS - OA
LESS (O) - RA
Normal joint space, periarticular erosions, soft tissue swellings - Gout
chondrocalcinosis - Pseudogout
Which nerve root?
Hip flexion and adduction
Knee extension, Hip adduction, Knee jerk reflex
Foot inversion and dorsiflexion, Knee extension, Knee jerk
Hallux dorsiflexion, Foot inversion, Foot dorsiflexion, Knee flexion, Hip extension, Hip abduction
Foot eversion, Foot and toe plantar flexion, Knee flexion, Ankle jerk
L2 - Hip flexion and adduction
L3 - Knee extension, Hip adduction, Knee jerk reflex
L4 - Foot inversion and dorsiflexion, Knee extension, Knee jerk
L5 - Hallux dorsiflexion, Foot inversion, Foot dorsiflexion, Knee flexion, Hip extension, Hip abduction
S1 - Foot eversion, Foot and toe plantar flexion, Knee flexion, Ankle jerk
Back Pain
Ix
Mx
Ix - Only if red flags. FBC, CRP, ESR, Bone Profile, Serum electrophoresis, Urine dip for bence jones, PSA, U&Es
Imaging - MRI is most detailed
Mx-
Conservative:
Max 2d bed rest
Keep active, how to lift/stoop
PT
Psychosocial issues re. chronic pain and disability. Warmth
Medical:
Analgesia: paracetamol +/- NSAIDs +/- codeine
Muscle relaxant: low dose diazepam ST
Facet joint injectoins
Surgical:
Decompression
Prolapse surgery e.g. microdiscectomy
More Definitions
OA
RA
Examples of trinucleotide repeat disorders
Gout
Pseudogout
Seronegative arthropathies
Ank Spond
Relapsing polychondritis
Bechet’s
Raynaud’s
Polymyositis Dermatomyositis
SLE
Wegener’s
OA - chronic degenerative condition where there is a progressive loss of hyaline cartilage
RA - Chronic systemic inflammatory disease characterised by a systemic , deforming, peripheral polyarthritis
Trinucleotide repeat’s - Huntingtin’s, Freidrich’s ataxia (no anticipation), Fragile X, Myotonic Dystrophy
Gout - is an inflammatory, erosive joint disorder characterised by the presence of monosodium5 urate crystals within the joint space.
Pseudogout - an inflammatory, erosive joint disorder characterised by the presence of calcium pyrophopshate crystals within the joint space.
Seronegative arthropathies - Inflammatory arthropathies effecting spine and peripheral joints in the absence of RhF and associated with HLA- B27
Ank Spond - Chronic disease of unknown aetiology associated with spondylosing, inflammation and thickening of the spinal joints alongside systemic manifestations
Relapsing Polychondirits - Is a rare, relapsing autoimmune disorder causing inflammatory destruction of cartilage (ear, nose larynx)
Behcet;s - is an autoimmune connective tissue disease leading to a small vessel vasculitis, mucositis as well as occular and other systemic manfiestations (cardiac neuro)
Raynaud’s - Peripheral digit ischaemia precipitated by cold or emotion
Polymyositis Dermatomyositis - Acquired autoimmune condition leading to inflammation of the striated muscles and skin with some other systemic involvement
SLE - Multisystem autoimmune disorder where various antibodies form immune complexes, which deposit in various organs
Wegener’s - Granulomatosis With polyangitis. Necrotising Granulomatous inflammatiion and small vessel vasculitis with a prediliction for skin, kidneys and respiratory tract
Management of OA
Management of RA
Management of paget’s
OA
Conservative:
Reduce weight
Alter activities: increase rest, reduce sport
Physio: muscle strengthening
Walking aids, supportive footwear, home mods
Medical:
Analgesia:
Paracetamol and or topical NSAIDs e.g. topical diclofenac (rather than oral NSAIDs)
If insufficient control consider addition of opioid analgesics e.g. tramodol.
NB antiplatelet, coRx with PPI if NSAIDs
Joint injection: LA and steorids
Surgical:
Arthroscopic washout: esp knee, remove foreign bodies and trim cartilage
Arthroplasty: replacement or excision
Osteotomy: small area of bone cut out
Arthrodesis: last resort of pain management.
Novel techniques:
microfracture-> fibro-cartilage formation
Autologous chondrocyte implantation
RA
Conservative: Physio, OT, PT
Medical: Methotrexate +DMARD (initally oral steroids). 2 failed DMARDS –> biologics. Infliximab, Adalamimumab, Etanercept, Rituximab
Mx of CV risk
Surgical - prosthesis , ulna stylectomy
Paget’s
Cons - hearing aids, OT, PT, surveillance for malignancy, HF
Medical- bisphosphonates, Mx of high output HF
Features of RA - ANTI CCP Or RF
Features of SLE - SOAP BRAIN MD
Features of Anti-Phospholipid Syndrome. CLOTS
Features of Ankylosing Spondylitis. 7 As
Features of RA - ANTI CCP Or RF
Arthritis (swan neck, boutonnieres, Z thumb, ulnar deviation, dorsal subluxation of ulnar stylid), nodules, tenosynovitis (de quervians - EPL/APL and atlanto - axial subluxation), Immune (AIHA, Vasculitis, Amyloid), cardiac (IHD, pericarditis), Carpal tunnel, Pulmonary - nodules, lower zone fibrosis, effusion, Ophthalmic - Sjogren’s, Conjuctivitis, keratitis, scleritis, epislcleritis, Raynaud’s, Felty’s
>1 hr morning stiffness, exercise helps
SLE - SOAP BRAIN MD Anti DsDNA, Anti Smith, Anti -ro, Anti - LA, ANA. Complement - C3 C4
Serositis (pleuritis, pericarditis) , Arthritis, Oral Ulcers, Peripheral Neuropathy Blood Involement, renal involvement, ANA, Immune (AIHA, vasculitis, , Neurology (seizures, psychosis), Malar Rash, Discoid Rash
Monitoring - ESR, DsDNA, C3/C4
Nb Rashes are photosensitive
APLS–> Anticardiolipin. Lupus ANticoagulant
CLOTT -> Clotting abnormality - long APTT, Livedo reticularis, Obstetric problems, Thrombocytopenia, Thrombosis - Venous and arterial
Anyklosing Spondylitits - Anylosis of SI joints, Ossification of the spinous ligaments, spondylitis of the vertebrae, fusion of the anterior and posterior spinal segments. Squaring of the vertebral bodies. Ankylosis of costovertebral joints. HLAB27
Kyphosis, Restrictive spirometry pattern
Apical fibrosis, Anterior Uveitis, AV Node Block, Aortic Regurgitation, Amyloidosis, apical fibrosis, achilles tendonitis
How many bursae are ther in the knee
What’s the pathology in baker’s cyst
Three:
Infra patellar
Pre patellar
Supra patellar - but you only milk the supra patellar when you do tap and sweep. This is hte only one that communicates with the capsule
Baker’s Cyst - fluid accumulation in the semi-membranous bursa
ACL Repair - what tendons are used
Semitendinosis + gracilis - wrapped together to increase tensile strength pinned into the medial tibia plateau
Fistula Examination (Renal)
Inspect- scar, size, any previous scars, skin changes, any signs of steal phenomona, ask about any hand pain, needle marks should be well spaced in a rope ladder like fashion
Palpate - hum and a thrill (vein)
Comment on how far the trhill is palpable from the fistula site –> if the thrill is not palpable proximally can indicate thrombosis
-> if thrill is not palpable proximally but the fistula is pulsatile –> then that is a sign of proximal thrombosis
–> look for evidence of multiple central venous scars –> central venous scarring = higher risk of throbosis
Nystagmus
Central
Peripheral
Central - Vertical nystagmus
Peripheral - Horizontal nystagmus
Nail Changes in Psoriasis
Subunglual Hyperkeratosis
Pitting
onycholysis
Interstitial Lung Disease: - dyspnoea, dry cough, exercise intolerance, weight loss, exposures? reduced chestp expan, fine inspiratory crackles
Environmental Causes
Drug Causes
Hypersensitivity Causes
Infectious Causes
Systemic Causes
Causes of pulmonary fibrosis by location
Apical (A PENT)
Basal ( STAIR)
Environmental Causes
Pneumoconiosis - Silicosis, Asbestosis
Drug Causes
Nitro, Metho, Amiod, Sulfasalaz, Bleomycin
Hypersensitivity Causes
EAA- Malt worker, Farm worker, Bird fancier
Infectious Causes
TB, Viral, Aspergillos
Systemic Causes
Sarcoid, Sclerosis, Dermatomyositis, SLE, RA, Ankylosing spondylitis
Idiopathic Pulmonary Fibrosis
Apical - ABPA, Pneumoconiosis -silicosis, coal. EAA, Negative seroarthropathy - Ank spond, TB
Basal - Sarcoid. Toxins - . -Asbestosis. Idiopathic. Rheumatoid - sjogren, SLE, scleroderma
Mx of CF
General
MDT: physician, GP, physio, dietician, specialist nurse
Chest:
PT: postural drainage, forced expiratory techniques
Abx: acute infections and prophylaxis
Mucolytis: DNAse
Bronchodilators
Vaccinations
GI:
Pancreatic enzyme replacement: Creon
ADEK supplements
Insulin
Ursodeoxycholic acid for impaired hepatic function to stimulate bile secretion
Advanced lung disease:
O2
Diuretics
NIV
Heart/lung transplant
Other:
Rx of complications e.g. DM
Fertility and genetic counselling
DEXA osteoporosis screen
Skin signs of dermatomyositis
Lung involement poly/derm
Gottron’s papules
Shawl sign - mac pac rash on back
Mechanic’s hands
Heliotropic rash
Nailford erythema
Subcut calcification
Retinopathy
Poly - Pulmonary HTN
Derm - Pulmonary fibrosis
Sarcoidosis
Occular - ant uveitis, conjunctiitis, iritis, episcleritis
Lungs - BHL, PF
Cardio - restricitve cardiomyopathy
Neuro - neurosarcoidosis
Renal - sarcoidosis
Cutaneous - Lupus pernio, Granuloma, ERythema nodosum
Joint - polyarthralgia
Other - parotitid, lacrimal, submand gland enlargement
Causes of clubbing
Respiratory causes
Cardiac Causes
GI Causes
Other Causes
Clubbing - boggy nail bed, loss of concave angle with nailbed, drumstick nail, Increased cruvature in transverse/longitudinal planes
Resp - Carcinoma, Fibrosis, Suppartive lung diseases
Cardiac - Infective endocarditis, Cyanotic Heart Disease, Atrial Myxoma
GI - Cirrhosis, GI Lymphoma, IBD, Coeliac
Other - Sarcoid, Thyroid acropachy, familial, Unilateral - upper limb AVM/ aneurysm
Resp Signs
Consolidation
Bronchiectasis
ILD
Pleural effusion
Consolidation - Reduced expansion, increase TVF, ?dull percussion, Bronchial breathing, Reduced air entry, crackles
Bronchiectasis - Coarse inspiratory crackles that change when patient coughs, purulent sputum, clubbing, wheeze + systemic signs for other disease (splenomegaly in Immunodefieicnt causes / Situs inversus in Kartagener’s)
ILD - Dyspnoea, dry cough, restrictive spirometry, clubbing, reduced chest expansion, fine inspiratory crackles, reduced air entry,
Pleural effusion - Dyspnoea, pleuritic chest pain, dull percussion, reduced breath sounds, reduced TVF, tracheal deviation.
Resp Defs
Pneumonia
Empyema
Bronchiectasis
Cystic Fibrosis
Aspergilloma (mycetoma)
EAA
Sarcoidosis
Pulmonary HTN
Cor Pulmonale
Asthma
Pneumothorax
Pneumonia - An infective or inflammatory process leading to consolidation of part or parts of the lung
Emyema - Pus in the pleural space
Bronchiectasis - chronic respiratory condition in which there is dilatation of the bronchioles leading to accumulation of mucus, secretion and microbes –> airway damage and infection
Cystic Fibrosis - AR condition affecting CTFR gene leading to reduced luminal Cl secretion / Na resorption and Reduced NaCl resorption in sweat (hence sweat test salty), Faecal elastase, Neonatal immunoreactive trypsinogen
- Pancreas, GI, Male genital tract, sinus, Lung
Aspergillosis/ Mycetoma - Collection of fungus within a pre-existing cavity
Extrinsic Allergic Alveolitis - Can be either an acute or chronic hypersensitivity reaction to various environmental allergens (aspergillus clavatus, farmer’s lung, pidgeon fancier’s lung) . Acute - T3HS . Chronic - Granuloma and fibrosis
Sarcoidosis - Multisystem granulomatous disease of unknown cause
Pulmonary HTN - PA Pressure >25 mmHg
Cor Pulmonale - RHF due to chronic PHTN
Asthma - episodic, reversible airway obstruction due to bronchiole hypersensitivity to allergens
Pneumothorax - accumulation of air in pleural space with secondary lung collapse
Pleural Effusions
Light’s Criteria
Transudate Causes
Exudate Causes
When are pleural effusions visible on CXR
Empyema vs Pleural effusion on CXR
How to tap
What to send for
Light’s Criteria -
Used when pleural fluid pH between 7.25-7.35
LDH >20
Fluid:Serum LDH Ratio: >0.6
Fluid:serum protein ratio: >0.5
Gravity: >1.016
= Exudate
rTransudate - HF, LF, RF, Dressler Syndrome, trauma, asbestos, yellow nail
Exudate - Empyema, infection, malignancy, PE, TB, RA, SLE, Lymphoma, oesophageal rupture ( raised amylase)
Visible on X ray - >250 ml
Empyema - Wide angle with chest wall, asymmetrical/unilateral, bi convex angle with the wall (whereas effusions or concave (sloping) )
Tap - percuss upper border and then go one to two intercostal spaces below. Infiltrate with LA down to pleura Larger catheter for haemothorax.
Send for - MC&S, Biochem, Cytology, Immunology
Causes of bronchiectasis
Primary
Secondary
Ix for bronchiectasis
Mx
Primary - Idiopathic , CF, PCD (Kartag.) Young’s syndrome, Yellow Nail syndrome, \
Secondary -
Post infectious: Pneumonia, TB, ABPA, UC
Bronchial obstruction: Malginancy, FB,
Immunodeficiency - Brutons, CVID, IGa def
Sputum: MC&s, Bloods - Search for underlying cause,
CXR - Tram lining, Signet rings, increased bronchovascular markings
, Spirometry - obstructive,
HRCT - dilated thickened airways, pooling of mucus
CF - Sweat test
Abdo exam - situs inversus
Mx -
Conser - Chest physio, clerance techniques, stop smoking
Med - Bronchodilators, Mucolytics - carbocysteine, Ab prophylaxis, vacccinations. CF - Dornase alfa, ABPA - steroids
Exacerbations - cipro
Surg - Localised disease
DDx of pulmonary oedema
Transudative
Increased caillary hydrostatic pressure - CCF, Overload, RF
Reduced oncotic pressure - Hypoalbuminaemia, Beri Beri, Nephrotic Syndrome, Cirrhosis, Protein losing states
Raised interstitial pressure - Reduced lymph drainage
Exudative
Increased capillary permeability - ARDS
