PACES Active Recall Flashcards
COPD GOLD Stages
COPD MRC Dyspnoea Scale
Causes of Spider Naevi [5]
Pathophysiology: Excess of oestrogen
Normal in childhood
Pregnancy
Oral contraceptive pill
Chronic liver disease
Thyrotoxicosis
Troisier’s Sign
(Virchow’s Node)
Enlarged lymph node at left supraclavicular fossa - Suggestive of gastric adenocarcinoma
Causes of Acanthosis Nigricans [6]
T2DM
Paraneoplastic Syndrome
Thyroid Dysfunction
Acromegaly
Cushing’s Disease
Obesity
Hand Signs in CLD [4]
Leuconychia
Nail Clubbing
Palmar Erythema
Dupuytren’s Contracture
Signs of Portal Hypertension [4]
Splenomegaly
Caput Medusae
Oesophageal Varices
Ascites
Causes of CLD [6]
Common
1. Alcoholic Liver Disease
2. HBV / HCV - Look for tattoos
3. NASH - Usually overweight
Less Common
4. Autoimmune eg AIH, PBC, PSC
5. Metabolic eg Haemochromatosis, Wilson’s, A1-AT Deficiency, Cystic Fibrosis
6. Drugs - Methotrexate, Isoniazid, Amiodarone, Phenytoin
Complications of CLD [7]
Portal Hypertension
UBGIT - Variceal vs Gastric Ulcers
Ascites
SBP
Hepatic Encephalopathy
Hepato-Renal Syndrome
Hepato-Pulmonary Syndrome
Define: Decompensated CLD
Combination of ascites, encephalopathy, hepato-renal syndrome, hepato-pulmonary syndrome in acute setting
Grading of Hepatic Encephalopathy
West-Haven Criteria
Grading of CLD Severity
Child-Pugh Score
Approach to Jaundice
Pre-Hepatic Causes
- Excessive RBC breakdown
- AIHA, Malaria, Sickle Cell Disease
Hepatic Causes
- Hepatocyte Injury
- Viral Hepatitis, Ischaemia, Hypoxia, Paracetamol
Post-Hepatic Causes
- Bile outflow obstruction
- Gallstones, pancreatic head cancer
Pathophysiology of Hepato-Renal Syndrome
Liver dysfunction leads to inadequate hepatic breakdown of vasoactive substances, leading to excessive renal vasoconstriction.
Approach to Ascites
Serum:Ascites Albumin Gradient (SAAG)
- Low SAAG: Albumin is being lost into ascites ie EXUDATE
- High SAAG: Albumin remains in serum ie TRANSUDATE
Transudative Ascites
- CLD with Portal Hypertension
- Heart Failure
- Nephrotic Syndrome
- Budd-Chiari Syndrome
Exudative Ascites
- Malignancy
- Tuberculous Peritonitis
- Ovarian Disease eg Meig Syndrome
Severity Grading of Acute Alcoholic Hepatitis
Main biochemical test is INR, which is a component of both tests scores below
- Maddrey’s Test
- Estimates mortality rate
- Guides use of steroids as treatment - MELD Score
- Estimates 90-day survival rate
Causes of Epigastric Mass [5]
Gastric Carcinoma - Look for Virchow’s Node
Pancreatic Carcinoma - Look for jaundice
Lymphoma
Caudate Lobe of Liver
Causes of RIF Mass [5]
Crohn’s Disease
Caecal Carcinoma
Ovarian Tumour
Renal Transplant
Ileocaecal Mass (Abscess, Appendix)
Causes of LIF Mass [5]
Sigmoid Carcinoma
Diverticular Mass / Abscess
Faecal Loading
Ovarian Tumour
Renal Transplant
Liver Transplant Criteria
King’s College Criteria
Variables differ depending on whether it’s Paracetamol-related liver injury or not
Signs of Chronic Immunosuppression [6]
Increased skin pigmentation
Multiple skin warts
Prematurely-aged skin
Skin malignancies (BCC, SqCC)
Fine tremor (Ciclosporin toxicity)
Gingival hypertrophy
Commonest Causes of ESRF [4]
DM
ADPKD
Chronic Glomerulonephritis
Hypertension (Blacks)
Opportunistic Infections in Renal Transplant [5]
CMV
Pneumocystis Jirovecii
EBV
BK Virus
JC Virus (leading to PMFL)
Abdominal Scars
Abdominal Scars
Abdominal Scars
Abdominal Scars
Abdominal Scars
Abdominal Scars
Abdominal Scars
Abdominal Scars
Abdominal Scars
Abdominal Scars
Thoracic Scars
Thoracic Scars
Thoracic Scars
Thoracic Scars
Thoracic Scars
Thoracic Scars
Indications for Nephrectomy in ADPKD [5]
Persistent pain
Chronic infection
Cyst rupture (leading to haematuria)
Kidney trauma
Make room for transplanted kidney
Causes of Bilateral Asterixis [4]
Metabolic Encephalopathy
Hepatic Failure
Renal Failure
Hypercapnoea
Drug Intoxication (Barbiturates, Phenytoin)
Causes of Bilateral Renal Cysts [5]
ADPKD
Multiple simple cysts
Tuberous Sclerosis
von Hippel Lindau Syndrome
Trisomies (Patau, Edward, Down)
Causes of Single Palpable Kidney [4]
ADPKD
Hydronephrosis
Renal Hypertrophy
Renal Cell Carcinoma
Causes of Bilateral Palpable Kidneys [6]
ADPKD
Multiple simple cysts
Tuberous Sclerosis
von Hippel Lindau Syndrome
Trisomies (Patau, Edward, Down)
Amyloidosis
Extra-Renal Manifestations of ADPKD [4]
Cerebral Aneurysms (Stroke, CN III Palsy)
Liver Cysts [Common]
Pancreatic, Splenic Cysts [Less Common]
MVP, AR [Increased incidence but unclear association]
Aortic Stenosis Prognosis
Prognosis is based on presenting complaint
Chest Pain: Median survival of 5 years
Breathlessness: Median survival of 3 years
Syncope: Median survival of 18 months
Causes of Aortic Stenosis [3]
- Calcific degeneration
- Congenital (bicuspid valve)
- Rheumatic disease
Aortic Stenosis Markers of Severity [2]
- Aortic valve area (in relation to body surface area)
- Mean valve gradient
Indications for Aortic Stenosis Surgery
- Symptomatic AS
- MVP >40 (Severe Grade)
+ Any of the following:
A. LV dysfunction (EF < 45%)
B. Abnormal response to exercise
C. Ventricular tachycardia
D. LVH > 15mm
E. Valve area < 0.6 (Severe Grade) - Going for CABG anyway
Types of Transplant Rejection [4]
Classic Immunosuppression Side-Effects [6]
- All - Increased infection, skin malignancies
- Prednisolone - Cushingoid Syndrome
- Cyclosporine - Gum hypertrophy
- Tacrolimus - Tremor
- MMF - Nausea and vomiting
- Azathioprine - Bone marrow suppression
Contraindications to Renal Transplant [3]
- Active malignancy (must be cancer-free for 2 years)
- Active infection
- Advanced atheromatous disease (relative contraindication)
B Symptoms of Non-Hodgkin’s Lymphoma [3]
- Fever > 38.0
- Weight loss of >10% body weight over 6 months
- Drenching night sweats
Causes of Massive Splenomegaly [2]
Spleen enlarges to >20cm
1. CML
2. Myelofibrosis
Causes of Mild Splenomegaly [5]
- Lymphoma
- CLL
- Liver cirrhosis with portal hypertension
- Infections - Malaria, leishmaniasis, schistomiasis
- Felty’s Syndrome (Splenomegaly, rheumatoid arthritis, neutropaenia)
Causes of Hepatosplenomegaly [7]
Causes of Hepatosplenomegaly [7]
Common Causes
1. Infections
- Malaria, Leishmaniasis
- Myeloproliferative Disorders
- CML, Myelofibrosis
- Associated with anaemia - Lymphoproliferative Disorders
- Lymphadenopathy
- Constitutional symptoms - Portal Hypertension
- Look for other CLD signs
Uncommon Causes
5. Wilson’s Disease
- Kayser-Fleisher Rings
- Parkinsonism features
- Haemochromatosis
- Look for venesection marks - Rare Causes
- Gaucher’s Disease
- Niemann-Pick Disease
UMN Signs [6]
- Spastic paresis
- Hyperreflexia
- Hypertonia
- No muscle wasting
- No fasciculations
- Positive Babinski (Upgoing plantars)
LMN Signs [6]
- Flaccid paralysis
- Hyporeflexia
- Hypotonia
- Muscle wasting
- Fasciculations
- Negative Babinski (Downgoing plantars)
Spot Diagnosis
- LMN signs
- Hyporeflexia
- Hypotonia
- Muscle wasting (particularly distally, leading to inverted champagne bottle shape of legs) - Distal weakness
- Distal sensory loss in glove-and-stocking distribution
- Bilateral pes cavus
- Bilateral foot drop
Charcot-Marie-Tooth Disease
Bronchiectasis Investigations
7 Labs
2 Radio
Labs
1. FBC (Neutrophilia)
2. Serum IgG, IgM, IgA (Hypoglammaglobulinaemia)
3. A1AT Levels
4. Aspergillus Precipitins, Serum IgE (ABPA)
5. Autoantibodies (CTD)
6. CF Sweat Test
7. Sputum AFB + TB PCR
Radiology
1. CXR
2. HRCT Thorax
- Classic Signs: Tram tracks, signet ring
- Reid Classification
Lung Upper Lobe Fibrosis
“CHARTS”
Coal Miner’s Pneumoconiosis
Histiocytosis
Ankylosing Spondylitis
Radiation
Tuberculosis
Sarcoidosis, Silicosis
Lung Lower Lobe Fibrosis
“CAIRO”
Connective Tissue Disease (eg Scleroderma, SLE)
Asbetosis
Idiopathic Pulmonary Fibrosis
Rheumatoid Arthritis
Others: Medications (Amiodarone, Methotrexate, Chemotherapy)
