PACES Station 5

Question 1

Clinical Features of Acromegaly

Answer 1

Large, sweaty hands
Thickened skin
Prominent supraorbital ridges, enlarged nose and lips
Prognathism
Interdental separation
Macroglossia
Hypertrichosifs
Gynaecomastia
Bitemporal hemianopia (10%)
Carpel tunnel
HTN
Cardiomegaly
Diabetes
Arthropathy
Skin tags and colonic polyps
Headaches, change in ring size/show size

Question 2

Pathophysiology of Acromegaly

Answer 2

Most commonly caused by a growth hormone secreting adenoma of the anterior pituitary. 75% are macro adenomas

Rarer causes include ectopic GH release from carcinoid or small cell tumours

Question 3

Complications of Acromegaly

Answer 3

HTN
Cardiomegaly
Arthritis
IGGT/DM
Visual field defects
Cranial nerve palsies
Tumours: fibroids and colonic polyps with risk of developing into malignancy

Question 4

Investigating possible Acromegaly

Answer 4

Oral glucose tolerance test - should suppress GH
Serum insulin-like growth factor 1
MRI pituitary

Question 5

Management of Acromegaly

Answer 5

Surgical - transphenoidal hypophysectomy with attempt to leave remaining pituitary intact to preserve function

Medical - somatostatin analogues (ocreotide) inhibit GH release. Cause gallstones.
Bromocriptin (Dopamine)agonist

Radiotherapy if surgery contraindicated is an option but also effects other pituitary hormones and visual loss

Question 6

Differential Diagnosis for lump in Neck

Answer 6

Congenital - thyroglossal cyst, branchial anomalies
LNs - bacterial, viral, granulomatous, malignancy
Vascular - aneurysm
Salivary - tumour
Neurogenic - schwannoma, neurofibroma
Thyroid…

Question 7

Management of Thyroid Nodule

Answer 7

1. Functioning or not?
   - serum TSH, if low suggests need scintigraphy to delineate hot nodule or not
   - if TSH normal or high then FNA

Histology may be indeterminate but generally still remove

Question 8

Types of Thyroid Cancer

Answer 8

Papillary carcinoma - most common and most favourable prognosis. Radio iodine /surgical management

Follicular carcinoma

Anaplastic carcinoma - highly aggressive undifferentiated

Medullary thyroid carcinoma - associated with MEN2a (phaeo and primaryPTH), MEN2b (phaeo + marfanoid)

Question 9

Complications of Large Goitre

Answer 9

Dyspnoea and airway obstruction
Dysphagia
Recurrent laryngeal nerve palsy
Horners
Jugular vein compression
Cerebrovascular steal syndrome

Question 10

Clinical Features of Thyrotoxicosis

Answer 10

Goitre (usually non-tender), smooth diffuse in graves
Heat intolerance, sweating, agitation, stress
Weight loss, palpitations
AF
Brisk reflexes
Eyes - proptosis, ophthalmoplegia, lid lag
Specific to graves - proptosis, thyroid acropachy, pretibial myxoedema

Question 11

Investigations of Thyrotoxicosis

Answer 11

TSH/T4
Thyroid autoantibodies
Radioisotope scanning

Question 12

Management of Graves Thyrotoxicosis

Answer 12

Beta blocker - propranolol
Carbiomazole or propylthiouracil
Titrate dose
Stop at 18months (1/3 will remain euthyroid)

IF returns consider:

• repeat course
• radioiodine
• subtotal thyroidectomy

High dose steroids/surgical decompression for severe ophthalmoplegia

Question 13

Progression of Eye Signs in Graves

Answer 13

NOSPECS
No signs
Only lid lag
Soft tissue involvement
Proptosis
Extraoccular muscle involvement
Chemosis
Sight loss due to optic nerve compression/atrophy

Question 14

Common causes of Hyperthyroidism

Answer 14

Graves
Hashimotos (thyrotoxicosis before hypothyroid)
Toxic adenoma
Iodine induced
TSH secreting tumour (rare)
Infective thyroiditis
Post-partum thyroiditis

Question 15

Causes of Hypothyroidism

Answer 15

Primary

• autoimmune (hashimotos)
• iodpathic atrophy
• previous radio iodine
• antithyroid drugs
• infiltrative: sarcoid, systemic sclerosis

Secondary
-hypothalamic, pituitary disease

Question 16

Drugs causing Hypothyroidism

Answer 16

Iodine contrast
Lithium
Sunitinib (tyrosine kinase inhib) used in renal cell carcinoma

Question 17

Features of Cushings

Answer 17

Cushingoid facies
Centripetal obesity
Inter scapular fat pad
Acne vulgaris
Purpuric and petechial rashes
Bruising
Violaceous striae
Proximal myopathy

Question 18

Pathophysiology of Cushings Disease

Answer 18

Hyper secretion of ACTH from pituitary adenoma

Question 19

Causes of Cushings Syndrome

Answer 19

ACTH dependent:

• Cushings disease (pituitary adenoma)
• Ectopic ACTH from SCLC or carcinoid

ACTH independent

• exogenous steroid administration
• adrenocortical adenoma/carcinoma

Question 20

Investigations for cortisol excess

Answer 20

24hr urinary free cortisol (x3)
Midnight salivary/serum cortisol
Dexamethasone suppression test (no ACTH suppression)

Low dose dexamethasone suppression test can help distinguish between bushings and pseudocushings

Consider inferiors petrosal sinus sampling in ACTH dependent Cushings with no clear pituitary source

Check Calcium - hyperPTH in MEN1

Question 21

Complications of Cushings

Answer 21

Diabetes
Osteoporosis
HTN
Cataracts

Question 22

Management of Cushings Syndrome

Answer 22

If adenoma - surgical transphenoidal/adrenalectomy

If adjunct needed then ketoconazole used to inhibit steroid genesis

Question 23

Nelsons Syndrome

Answer 23

Enlargement of a pituitary corticotroph adenoma due to absence of negative feedback from adrenal cortisol following removal of both adrenals.

Also get hyper pigmentation as high ACTM stimulated melanocyte stimulating hormone

May get bitemporal hemianopia

Question 24

What is MEN1?

Answer 24

Autosomal dominant

• Pituitary adenoma (cushings)
• hyperparathyroidism
• pancreatic gastrinoma

Question 25

Clinical Features of Addisons Disease

Answer 25

Widespread pigmentation - buccal mucosa, skin creases and pressure areas Calcification of auricular cartilage No adrenelectomy scars (would be present in Nelsons) Postural hypotension Other autoimmune conditions: vitiligo, T1DM, Pernicious anaemia, RA, SLE, Sj

Question 26

Causes of Primary Adrenal Failure

Answer 26

``` Autoimmune (Addisons) TB Bilateral adrenelectomy Amyloidosis Haemochromatosis HIV Haemorrhagic infarcts - meningococcal Adrenal Mets Congenital Adrenal Hyperplasia ```

Question 27

Diagnostic Tests for Adrenal Insufficiency

Answer 27

9 am serum cortisol | Synacthen test

Question 28

Management of Adrenal Failure

Answer 28

Adrenal crisis - rapid steroid, fluid replacement and reversal of electrolyte abnormalities (low Na, high K)

Question 29

Causes of Pituitary Failure

Answer 29

``` Pituitary mass Previous pituitary surgery/radiotherapy Infiltrative disease Pituitary infarct (Sheehans) Pituitary apoplexy Trauma/ SAH ```

Question 30

Causes of Gynaecomastia

Answer 30

``` Hypogonadism Testicular tumour Chronic Liver Disease CKD Klinefelters Thyrotoxicosis Carcinoma of lung Drugs: digoxin, spironolactone Puberty ```

Question 31

Klinefelters Syndrome

Answer 31

``` Tall Gynaecomastia Other features of hypogonadism including small, firm testes Autoimmune disease Mitral valve prolapse Varicose veins ``` Genetics: XXY or mosaicism XXY:XY

Question 32

Turners Syndrome

Answer 32

XO ``` Short stature, square chest Widely spaced nipples Webbed neck Nail dysplasia High arch palate Short fourth metacarpals Numerous naevi Wide carrying angle ``` Associated: Coarctation, DM, renal malformations, cataracts, ptosis

Question 33

Physiological Actions of Parathyroid Hormone

Answer 33

Stimulated by low Calcium Bone: increase bone resorption Kidneys: stimulates calcium reabsorption and inhibits phosphate (unlike vitD which promotes uptake of both) Stimulates vitD synthesis

Question 34

Clinical Features of RA

Answer 34

``` Symmetrical deforming polyarthropathy Involves PIPs and MCPs Palmar subluxation and ulnar deviation Swan neck, boutonnieres and Z deformity Rheumatoid nodules (firm, non-tender) May be vasculitic nail fold infarcts/pupura Risk of nerve entrapments ``` Then: MSK, ears, eyes, c-spine, lungs, heart, spleen, kidneys

Question 35

Diagnostic Criteria for RA

Answer 35

``` ACR - at least 4 of the following: -morning stiffness >1hr -symmetrical joint involvement -arthritis in >3 joints involves small joints of hand -postive RF -rheumatoid nodules -radiographic evidence ```

Question 36

Rheumatoid Factor

Answer 36

IgM against Fc of IgG. Present in 75% of RA and occurs in other autoimmune connective tissue disease e.g. SLE. Suggests more aggressive joint disease than seronegative disease and extra-articular manifestations more common AntiCCP also a poor prognostic marker

Question 37

Possible causes of anaemia in RA

Answer 37

``` Anaemia of chronic disease Iron deficiency -GI loss due to NSAIDs Folate deficiency - methotrexate Pernicious anaemia BM suppression - gold, methotrexate, sulphasalazine Feltys Anaemia of renal disease ```

Question 38

Eye involvement in RA

Answer 38

``` Episcleritis (painless) Scleritis (painful) Cataracts - steroids Sjogrens Extraoccular muscle tenosynovitis ```

Question 39

Renal disease in RA

Answer 39

Membranous glomerulonephritis - gold Mesangioproliferative glomerulonephritis Acute tubulointerstitial nephritis - NSAIDs Renal amyloidosis

Question 40

Principles of Management of RA

Answer 40

MDT General: education, physio, OT, bone protection, pneumovax Analgesia DMARDS Biologicals - antiTNF (infliximab/adaluminab) Corticosteroids

Question 41

DMARDS in RA

Answer 41

Sulphasalazine - risk of nausea, rash neutropenia - 3 monthly FBC, LFT Methotrexate - need baseline CXR and monitor LFT, FBC Leflunomide- risk of HTN, neutropenia Azathioprine - check TPMT prior to starting (predicts BM toxicity) Ciclosporin - causes HTN and renal impairment

Question 42

Clinical Features of Psoriatic Arthropathy

Answer 42

Nails - pitting, onycholysis, transverse ridging Psoriatic plaques Koebners phenomenon - plaques over sites of trauma Other things to examine: - MSK association with gout - CVS: Aortitis and AR - Resp: apical lung fibrosis - Eyes: conjunctivitis, uveitis

Question 43

Patterns of Psoriative Arthropathy

Answer 43

Asymmetrical, oligoarthritis involving DIP Symmetrical polyarthritis involving PIP and MCP (rheumatoid pattern) DIP arthritis Arthritis mutilans - aggressive deforming disease with bone resorption leading to telescoping Spondylitis/sacroilitis - asymmetrical unlike AnkSpond

Question 44

Enthesitis

Answer 44

Inflammation of tendon insertion

Question 45

Dactylitis

Answer 45

Inflammation of tendon sheath leading to sausage like swollen fingers

Question 46

Management of Psoriatic arthropathy

Answer 46

MDT... Analgesia Corticosteroids DMARDs - methotrexate, sulfasalazine, cyclosporin

Question 47

Adverse effects of antiTNF alpha

Answer 47

``` Serious infection e.g. TB Haematological malignancy Nausea Hypersensitivity Worsens heart failure ```

Question 48

Contraindications for antiTNF alpha

Answer 48

``` Pregnancy/breastfeeding Active bacterial infection Active TB (need 2 month therapy before initiating) Septic arthritis CCF Demyelinating disease ```

Question 49

Clinical Features of Ankylosing Spondylitis

Answer 49

``` Severe kyphosis with protuberant abdomen Decreased cervical movement Decreased spinal movement Reduced chest expansion Schobers test positive - 10 above, 5 below dimples of venus should increase by 5cm ``` Extra bits: anterior uveitis, aortic regard, apical fibrosis, AV block (check pacemaker)

Question 50

Definition of Ankylosing Spondylitis

Answer 50

Symptomatic sacroilitis for > 3 months with morning stiffness and improvement with exercise, worsening with rest

Question 51

Systemic Manifestations of Ankylosing Spondylitis

Answer 51

``` Eyes: anterior uveitis Aortic regurg AV block Apical fibrosis Atlantoaxial subluxation Achilles tendonitis Amyloidosis ```

Question 52

Diagnosing Ank Spond

Answer 52

Clinical hx Raised inflammatory markers evidence of sacroilitis on XR/MRI

Question 53

Management of Ank Spond

Answer 53

``` MDT... Education Physio/OT Analgesia Corticosteroids DMARDs - gold, penicillamine (methotrexate and sulphasalazine help peripheral disease but not spine) Biologicals such as adalimumab ```

Question 54

Clinical Features of Gout

Answer 54

Asymmetrical joint deformity and swelling Tophi, hands, feet, ears Olecranon bursa

Question 55

Differential Diagnosis for single inflamed joint

Answer 55

``` Gout/pseudogout Septic arthritis Spondyloarthritis OA Lyme disease/stills disease ```

Question 56

Pathophysiology of Gout

Answer 56

Uric acid produced by breakdown of purines in liver by enzyme xanthine oxidase - eliminated by kidneys and GI tract Causes: - reduced excretion: HTN, CKD, drugs (ACEi, aspirin, thiazides) - Increased purine production: diet, lymphoproliferative disorders, secondary polycythaemia, glycogen storage disease

Question 57

Management of Gout

Answer 57

Acute: rest, rehydrate, NSAIDs, colchicine Recurrent: lifestyle advise, allopurinol

Question 58

What is pseudogout

Answer 58

Crystal arthropathy of calcium pyrophosphate deposition - postivitely bifringent crystals in polarised light Chondrocalcinosis on radiograph Occurs in haemochromatosis, hypothyroidism and CKD

Question 59

Classification of Systemic Sclerosis

Answer 59

Diffuse: involvement of skin, trunk and extremities, early involvement of lung, kidney, gut and heart Limited: skin only at extremities and face, late lung involvement including pHTN, renal crisis is rare

Question 60

Diagnostic Criteria for Systemic Sclerosis

Answer 60

1 major or 2+ minor Major - skin involvement Minor - sclerodactyl, finger pulp atrophy, bilateral pulmonary fibrosis

Question 61

Organ involvement in systemic sclerosis

Answer 61

Skin - raynauds, sclerodactyly, pulp atrophy, calcinosis, nail dystrophy, ulceration, telangiectasia, vitiligo MSK - arthritis, myositis, myopathy, intraairticular calcification GI - dysphagia, GORD, intestinal hypo motility leading to bacterial overgrowth and malabsorption Renal - malignant HTN, glomerulonephritis, renal crises Resp - ILD, pleural effusions CVS - restrictive cardiomyopathy, pericarditis, pulmonary HTN

Question 62

Antibodies in Systemic Sclerosis

Answer 62

Limited - ANA, RF, antiCentromere | Diffuse - anti Scl 70, anti RNA pol

Question 63

Management of Systemic Sclerosis

Answer 63

General: education, PT/OT, analgesia, MDT Raynauds: smoking cessation, hand warmers, vasodilators (calcium antagonists, ACEi, prostacyclin), sympathectomy GI: low residue diet, nutritional supplements, Abx, PPI for reflux, pro kinetics Renal: ACEi Rs: vasodilator therapy for pHTN, antifibrotis therapy - D penicillamine, interferon gamma

Question 64

Clinical features of psoriasis

Answer 64

Erythematous plaques with silvery white scales on extensor surfaces, behind ears and scalp Asymmetric arthropathy and nail changes Koebner phenomenon Auspitz sign - visible bleeding points over plaques from enlarged dermal capillaries and intense scratching CVS - aortic regard Rs - apical lung fibrosis Eye - uveitis

Question 65

Pathophysiology of Psoriasis

Answer 65

Inflammatory skin condition Receive abnormal epidermal proliferation T cell mediated Associated with HLA-B13, B17 and Cw6, also susceptibility gene on chr 6 Genetics and environmental factors involved

Question 66

Exacerbating factors in Psoriasis

Answer 66

``` Trauma Sunburn Stress Alcohol Smoking Beta haemolytic strep - guttate psoriasis Drugs - lithium, beta blockers, Acei, antimalarials Withdrawal of steroids HIV ```

Question 67

Cardinal histopathological features of psoriasis

Answer 67

``` Acanthuses (skin thickening) Parakeraotisis Absence of granular cell layer Polymorphonuclear abscess of munro Dilated capillary loops in upper epidermis ```

Question 68

Variants of Psorias

Answer 68

``` Chronic plaque psoriasis Pustular psoriasis Guttate psoriasis Palmoplantal psoriasis Erythrodermic psoriasis ```

Question 69

What skin conditions demonstrate Koebners phenomenon?

Answer 69

``` Psoriasis Lichen planus Vitiligo Viral warts Pemphigus Pemphigoid Molloscum contagiosum ```

Question 70

Management of psoriasis

Answer 70

General: patient education, avoid exacerbating factors Topical: emollients, steroids, UVB, tar, dithranol Systemic: methotrexate, azathioprine, cyclosporin, tacrolimus, retinoids

Question 71

Clinical Features of Neurofibromatosis

Answer 71

Neurofibromas along course of peripheral nerves > 6 Axillary freckling Cafe au last spots >6 HTN - secondary to renal artery stenosis Acoustic neuroma ? hearing aid Eyes - cataracts, optic glioma, lisch nodules (hamartomata on iris) on slit lamp Pulmonary fibrosis, pneumothorax Heart - cardiomyopathy MSK: Kyphoscoliosis, bowing of legs, rib notching, charcot joints Kidney - RAS Phaeochromocytomas

Question 72

Genetics of Neurofibromatosis

Answer 72

NF1 (peripheral) - AD, chr 17, tumour suppressor gene (neurofibromin normally binds and inhibits Ras) NF2 (central) AD chr 22 also tumour suppressor gene

Question 73

Clinical features of HHT

Answer 73

Telangiectasis of face, mouth, lips, tongue, buccal mucosa NO features of Systemic sclerosis Conjunctival pallor (iron deficiency anaemia) Resp: AVMs, may be clubbed as a result CVS: high output cardiac failure GI: iron def anaemia, hepatosplenomegaly, portal HTN Eyes - retinal haemorrhage Neuro: SAH, central vascular lesions, ischaemic stroke - paradoxical emboli from pulmonary AVM

Question 74

What are telangiectasia?

Answer 74

Enduring dilation of small blood vessels, capillary or venules (venules in HHT)

Question 75

What is HHT

Answer 75

Autosomal dominant condition, multiple genes associated on different chromosomes Telangiectasia effect multiple organs

Question 76

Management of HHT

Answer 76

``` Anaemia - iron sups, transfusion Skin - cosmetic/laser ablation Epistaxis - cauterise, laser ablation PAVM - embolisation, surgical resection/ligation GI - photocoag therapy, ```

Question 77

Clinical Features of Dermatomyositis

Answer 77

Heliotrope rash around eyes Violaceous scaly papule over knuckles, elbows, knees - Gottron papule Erythema + Poikiloderma in photosensitive distribution Proximal muscle weakness and tenderness Associated ILD, dysphagia, arthritis

Question 78

Drugs causing dermatomyositis like skin changes

Answer 78

Hydroxyurea Penicillamine Statin Quinidine

Question 79

Investigations in Dermatomyositis

Answer 79

raised CK EMG - spontaneous fibrillation Muscle biopsy - necrosis, phagocytosis of muscle fibres

Question 80

Causes of Purpura

Answer 80

Platelet defect - idiopathic, CLD Capillary defect - age, steroids, vasculitis, ehlers-danlos, HHT, scurvy Coag defect - warfarin, vWF, DIC, amyloidosis

Question 81

Lichen Planus

Answer 81

Flat topped, violaceous polygonal papule on fleecers surfaces Fine white striae - wickhams - on surface of lesions Koebners phenomenon Scalp involvement with scarring alopecia Lace like white lines on buccal mucosa Dystrophic nails Associated drugs - ACEi, beta blockers, NSAIDs, antimalarials Hep C association

Question 82

Underlying causes of Erythema nodosum

Answer 82

``` Streptococcal throat infection TB Sarcoidosis IBD Behcets Drugs - OCP, penicillin, tetracyclines, sulphonamides ```

Question 83

Clinical Features of SLE

Answer 83

Erythematous, maculopapular rash in butterfly distribution, sparing nasolabial folds with scaling and follicular plugging May have vasculitis lesions, livedo, photosensitivity, alopecia Symmetrical non-erosive polyarthritis Hands - palmar erythema, arthritis, raynauds, dermatomyositis Nails - splinter haemorrhages, nail-fold capillaries, periungal infarcts Mouth - ulcers Scalp - scarring alopecia Rs - ILD, pleural effusions, CVS - pericarditis, pHTN CNS - hemiparesis, mononeuritis multiplex Renal - HTN, oedema, Haem - splenomegaly, lymphadenopathy Eyes - sjogrens, retinal infarcts

Question 84

Diagnostic Criteria for SLE

Answer 84

``` 4 of the following: -malar rash -discoid rash -photosensitivity -oral ulcers -arthritis -serositis -renal involvement -neurological involvement -haematologial involvement ANA positive ```

Question 85

Causes of Drug Induced Lupus

Answer 85

``` Procainamide Hydralazine Quinidine Chlorpromazine Methyldoxpa Phenytoin Carbamazepine OCP ```

Question 86

Differentiating SLE with drug induced lupus

Answer 86

SLE - more females, renal and CNS involvement more common, positive antidsDNA Drug induced - equal male to female, rare renal and CNS involvement, positive anti-histone

Question 87

Autoantibodies of SLE

Answer 87

``` ANA in 95% antihistone in drug induced antidsDNA - high specificity for SLE Anti-ro, antiLa antiphospholipid ```

Question 88

Management of SLE

Answer 88

Non-pharm - avoid over exposure - avoid high dose OCP - remove offending drugs - smoking cessation Pharm - NSAIDs - antimalarials - hydroxychloroquine - corticosteroids - cytotoxics: azathioprine, mycophenalate, cyclosporin

Question 89

Clinical Features of Tuberous Sclerosis

Answer 89

Salmon papule and nodules over face in butterfly distribution - adenoma sebaceous Periungal fibroma - smooth, firm nodules adjacent to nails Shagreen patches - irregular, green-brown patches over lumbosacral region Ash leaf macules - hypopigmented areas over trunk and buttocks Cafe au last spots Eyes - angiofibromata of eye lid, retinal hamartomata Oral - bifid uvula, high arch palate Resp - pneumothorax, cysts Abdo - hepatic and renal hamartoma Neural - focal deficit depending on location of tubers

Question 90

Genetics of Tuberous sclerosis

Answer 90

Autosomal dominante - 2 loci identified Chr 9 and Chr 16 (hamertin and tuberin tumour suppressor genes) 65% spontaneous

Question 91

Pemphigus vulgaris

Answer 91

``` Flaccid blisters with clear fluid Fragile Involved buccal mucosa\ Blisters just above basal cell layer IgG autoantibodies against desmogleins ``` Drugs implicated: penicillamine, benzylpenicillin, ACEi Treat with barrier nursing, corticosteroids, avoid dehydration

Question 92

Pemphigoid

Answer 92

Tense blisters IgG against hemidesmosomes in basement membrane Mucosal involvement rare Treat with steroids/steroid sparing agents

Question 93

Pseudoxanthoma elasticum

Answer 93

folds of loose skin in neck, popliteal fossa, axilla and groin Plucked chicken appearance Due to abnormal mineralisation and calcification of elastic fibres Associated with: - aortic regurg - mitral regurgitation - mitral valve prolapse - peripheral vascular disease - restrictive cardiomyopathy - renovascular disease - HTN - angioid streaks

Question 94

Causes of Angioid Streaks

Answer 94

Irregular red-brown lines radiating from optic disc ``` Ehlers danlos Pseudoxanthoma elasticum marfans sickle cell disease lead poisoning ```

Question 95

Ehlers Danlos Syndrome

Answer 95

11 different forms, some AD some AR Collage defect Features: skin - broad nasal bridge, wide eyes, thin hyper extensible skin, impaired wound healing MSK -kyphoscoliosis, hyper extensible joints, hallus valgus, pes planes GI: diverticula, diaphragmatic hernia, megacolon CVS - MVP, AR, aneurysms, dissections

Question 96

Causes of Blue sclerae

Answer 96

``` Pseudoxanthoma Marfans OI Ehlers Danlos Alkaptonuria ```

Question 97

Causes of Acanthosis Nigricans

Answer 97

``` Obesity Diabetes/insulin resistance Cushings Acromegaly Thyroid disease PCOS Familial Malignancy - adenocarcinoma of GI tract ```

Question 98

Pretibila myxodema

Answer 98

Firm, non pitting pink/purply brown plaques on anterolateral aspect of lower legs peau d'orange texture

Question 99

Diabetic Retinopathy

Answer 99

Background: blot haemorrhages, hard exudate Preprolifeative: large blot haemorrhages, cotton wool spots, venous dilatations/beading Proliferative: leashes of new vessels with evidence of photocoag scars

Question 100

Eye problems in Diabetes

Answer 100

``` Cataracts Glaucoma Mononeuritis multiplex Infections Diabetic retinopathy (25%) ```

Question 101

Pathophysiology of Diabetic Retinopathy

Answer 101

Hyperglycaemia's structural and physiological effect on retinal capillaries Increased sorbitol results in increased vessel permeability and weakness Retinal ischaemia (small vessel disease) triggers VEGF Production of vasoprolierative factors e.g. VEGF leads to new vessel formation

Question 102

Indications to refer to Opthalmology

Answer 102

Non-proliferative with macular involvement Pre-proliferative Proliferative - urgent

Question 103

Complications of laser photocoag

Answer 103

Vitreous haemorrhage Visual field constriction Headaches Retinal vein occlusions

Question 104

Hypertensive retinopathy

Answer 104

1 - Arteriolar narrowing 2 - AV nipping 3 - micro aneurysms, blot haemorrhages, flame haemorrhage, exudates 4 - papilloedema

Question 105

Retinitis Pigmentosa

Answer 105

Black-brown pigmentation resembling bone spicules Constricted visual fields Night blindness Photopsia - flashes of light Associated with alports syndrome, bardett-biedel (polydactyly)