Spot PACES Flashcards
Liver transplant patient
Signs
Revers L shaped scar
possible midline laparotomy
3 main causes int he UK: ALD VIRAL HEPAITITIS NAFLD then PSC / AI etc
Viral Hepatitis:
HCV esp transfusions before 1970 or transfusion abroad
consider HIV acceleration
haemochromatosis:
pigmented
joint replacement
DM pin pricks
ALD:
drain scars
liver biopsy scars
peripheral neuropathy
Autoimmune hep
female
tacrolimus gum hypertrophy
tacrolimus tremor
myotonic dystrophy
frontal balding distal muscle weakness masseter wasting generalised wasting quick fatigue symmetrical distal weakness myotonic grasp - slow relaxation after fists clenched - do on screening!!! Ptosis miosis drowzyness
SLE
:
Differentials = Systemic sclerosis /
young female
20-40
3x more common in africans and asians
11 features:
butterfly mallard rash with or without scarring
discoid rash - same distribution rash - maculopapular with irregular ringed border
photosensitivity with or without alopecia which may scar
oral ulcers
non erosive - non deforming symmetrical arthropathy of small joints - JACCOUDS arthritis:
at rest fingers joints resemble RA joints and boutonniere and swan necks may be seen
THESE FEATURES REVERSE WHEN HANDS ARE CLOSED
IF DESTRUCTIVE ARTHRITIS SEEN THINK ABOUT OVERLAP RA OR PSORIATIC ARTHRITIS
Serositis - pleurites / Pericarditis with effusion / pl eff
Neuro muscular involvement - GBS / seizures / psychotic / transverse myelitis / RARE e.g. new dyspnoea
ANA positive
other abs: antiphons / ds DNA / anti Sm
renal involvement - GN - lupus sclerosing / burnt out histology
Also:
AV or MR with valve replacement due to LIMAN-SACKS ENDOCARDITIS
HTN - GN
FISTULAS / RENAL TRANSPLANT / PD SCAR
COMPRESSION STOCKINGS - PAST DVT
IATROGENIC CUSHINGS FROM LT STEROIDS
NEURO: CN and Peripheral nerve lesions - mononeuritis multiplex
recurrent miscarriage / pre-eclampisa
Pulmonary fibrosis
scarring alopecia
erosive / heavy discoid scarring with granulomas in response to injury
associated antiphospholipid - early onset…
PE
Retinal vein or arterial occlusion early
early MI
non systemic or limited wageners
differential
Eosinophillic non granulomatous - churgh strauss
flattened nasal bridge
septal deviation
inspiratory obstruction
Presentation:
epistaxis isolated
erosion of nasal septum with deviation
Acromegally
pituitary macro adenoma
frontal bossing with increased forehead wrinkle prominent supraorbital brow macroglossia prosognathia - protruding jaw widened spaces between teeth diabetes weight gain increased collar size OA - joint replacement Shovel like hands OSA large feet - look for orthotics
SE:
cardiomyopathy
Ix: CT pituitary Ask: NIV? COPD? re - periwinkles syndrome - osa / hypercapnia / NIV
Sarcoid
Lupus pernio:
It is a chronic raised indurated (hardened) lesion of the skin, often purplish in color. It is seen on the nose, ears, cheeks, lips, and forehead and may be elsewhere
pull fibrosis from methotrexate
Hepatomegally or features of decompensated liver disease
psoriatic arthritis
5 types of psoriatic arthritis 1 symmetrical 2 asymmetrical 3 DIPs (therefore diff from RA) 4 Spondylitis 5 arthropathy mutilans
psoriatic plaques or scars of previous treated psoriasis
nails:
1 PITTING
2. Onychorrhexis: Ridges and splitting in the nail
3 Onycholysis: Separation of the nail from the nail bed - OIL DROP SIGN
4. Splinter hemorrhages: Spots of blood under the nail
5. Subungual hyperkeratosis: Build-up of keratin between the nail and nail bed
FINAL = NAIL PLATE DYSTROPHY
Fingers:
sausage fingers - dactylics
telescoping arthropathy
nail changes
Graves disease
associations:
Coeliac
RA
May also be marfanoid - look for arm breadth long fingers high pallaete lens dislocation - demonstrate with saccades look at my finger over here on left now quickly look at my right fingers and look for bouncing of lens
look for
Exophthalmos specific for GD and may be first sign
look from behind and above
do eye movements - ask about diplopia
ask about acuity re: marfans and lens dislocation
lid lag - not present in graves but present in hyperthyroid thyroidectomy scar appropriately dressed hair loss weight loss guttering tremor thyroid acropatchy
remember as likely treated may now be euthyroid
or HYPOTHYROID if under treated or non compliant
neurofibromatosis
neurofibromas cutaneous in type 1
cafe au lait spots
very few other involvements
Neurofibromatosis type 2
less cutaneous involvement
learning difficulties
more focus on neurofibromas along CNS tracts causing
Sjorgens - not just a milder SLE
secondary to SLE or RA
look for primary diagnosis - SLE / RA other AI
INSPECTION:
ARTIFICAL TEARS OR SALIVA NEARBY?
Dry eyes - xerophthalmia
Dry mouth - xerostoma
Parotid enlargement bilaterally OR SCARS UNDER CHIN FROM GLAND REMOVAL
THIS MAY CAUSE DIFFERENTIAL - PAROTID CANCER / LYMPHOMA / SARCOID / MUMPS
non erosive small joint arthropathy.
fatigue
TEST:
SCHIRMERS TEST - HOOK FILTER PAPER UNDER BOTH EYELIDS FOR 5 MINS AND CLOSE EYES
TEAR SECRETIONS SHOULD MIGRATE >15MM normally
ENA abs = RO / LA positive
RF
ds DNA
if negative - silvery gland biopsy
Charcot Marie Tooth
charcots joints bilaterally
Dermatomyositis
Heliotropic rash - lilac or purple rash over eyes and chest - typically in scarf distribution around the neck
proximal weakness - walking aid
massive hepatosplenomegally
THINK TROPICAL DISEASE OR PT DEMOGRAPHIC
myelofibrosis
malaria
B THAL
HCV - blood transfusion before 1970 / sex etc
Addison’s
hx collapse with hypotension and hypoglycaemia
pigmentation around eyes / creases / scars fatigue recurrent infection hypotension recurrent hypoglycaemia pigmentation in scars
alopecia
female
associated with AI - look for coeliac biscuits
photosensitive secondary to no eye lashes
Vit D deficient due to social withdrawal
STRESS INDUCED OFTEN
alopecia areata - localised
alopecia totalis - 90% hair loss - focus on head
alopecia universalis - no hair anywhere
