Station 5 Flashcards
Rheumatoid arthritis antibodies (2)
Anti-cyclic citrullinated peptide (CCP)
Rheumatoid factor
Criteria to diagnose Psoriatic arthropathy
CASPAR criteria:
Axial or peripheral arthritis
Enthesitis
Psoriasis
Nail dystrophy
Dactylitis
CN 7 palsy symptoms
Slurred speech
Dribble/Dry eye/mouth
Taste
Tinnitus
Pain in face/ear
Bell’s Palsy management
Resolves in up to 6 months
Weaning steroids for 10 days starting at 50mg OD
Eye protection patch + drops
Facial massage leaflet
10% it might happen again
CREST Syndrome
Calcinosis
Raynaud’s phenomenon
Esophageal dysmotility
Sclerodactily
Telangiectasia
Difference between Homocysteinuria and Marfan’s?
Autosomal recessive
No aortic disease
Recurrent DVTs and PEs
Upwards lens dislocation
Causes of Addison’s disease
Autoimmune (with vitiligo, IDDM)
Tuberculosis
HIV/AIDS
Secondary hypoadrenalism - pituitary tumours
Tertiary hypoadrenalism - Steroid medication
Autoimmune adrenalitis antibody
Anti 21-hydroxylase
Causes of hypertension in young patient
1) Cushing – acromegaly – Obesity (metabolic syndrome)
2) Medications induced (STEROIDS)
3) Renal : ADCKD – RAS – GN
4) Suprarenal: Conns – Liddles – pheochromocytoma (remember MEN-2 or neurofibromatosis)
5) Essential HTN
Polycythaemia Rubra Vera exam
Hepatomegaly/hepatosplenomegaly
Venepunctures
Goût
Behçet’s disease
Sheehan syndrome
Addison’s disease - hx and exam
Nausea, vomiting
Salty food craving
Postural symptoms
Tanned skin (due to high ACTH)
Weight loss, fatigue, Impact on life
Autoimmune diseases inc family hx
Hand palmar creases
Postural BP
Addison’s disease
Myasthenia Gravis history and exam
Pseudoxanthoma Elasticum - features mnemonic
Symptoms of Carcinoid Syndrome
Antibodies in Myasthenia Gravis
Anti-acetylcholine receptor (AChR)
Anti-muscle-specific tyrosine kinase (MuSK) antibodies.
Hereditary Haemorrhagic Telangiectasia
Telangiectasia on the lips/tongue/limbs
Bruits from AVMs in lower lungs and liver
BG of anaemia, epistaxis, GI bleed, haematemesis, headaches
Osteogenesis imperfecta
Blue sclerae
Hearing aids
Joint hyper mobility
Scoliosis
Aortic regurgitation
Neurofibromatosis type 1 mnemonic
Café au lait patches
Axillary
Freckles
Eye nodules (Lisch)
Scoliosis & Seizures
Phaemochromocytoma
Optic nerve tumours
Tumour of the kidney (nephroblastoma)
Short stature
Neurofibromatosis type 2 features (5)
Bilateral vestibular schwanomas
Méningiomas
Cataracts
Retinal hamartomas
<6 café au lait spots
Tuberous Sclerosis examination (3) and four associated conditions
Ash-leaf macule
Shagreen patches
Adenoma sebaceum
Epilepsy, learning disability
Benign tumours in brain and kidneys
Cysts on liver/kidney/pancreas
Sporadic or Autosomal dominant TSC1 and TSC2
Polymyositis and Dermatomyositis antibody
Anti-Jo1
Dermatomyositis antibody
Anti-Mi2
MEN 1a syndrome
Parathyroidism
Pituitary adenoma
Pancreatic islet cell tumours
MEN 2a syndrome
Medullary thyroid cancer
Hyperparathyroidism
Phaeochromocytoma
Allport syndrome
Sensorineural deafness
AAA
Haematuria & renal cysts
X-linked dominant disease
Polyarteritis Nodosa
Associated with hepatitis B
Testicular pain
Joint pain
Livedo reticularis
Mononeuritis multiplex
Hypercoagulable state
(Risk factors for PEs)
Drugs (COCP)
Antiphospholipid syndrome
Malignancy
Nephrotic syndrome
Pregnancy
Lymphoproliferative disorders
Polycythaemia rubra vera
Erythema Nodosum
Sarcoidosis (Lofgren syndrome)
Idiopathic / Inflam bowel disease
Group A haemolytic strep
HIV
Tuberculosis
Pregnancy
Drugs (COCOP, abx)
Lofgren syndrome
Sarcoidosis
Bilateral hilar lymphadenopathy
Uveitis
Erythema Nodosum
Fever
Livedo Reticularis
Anti-phospholipid syndrome
SLE
Hepatitis C
Systemic Sclerosis
Calcinosis
Raynaud’s phenomenon
Esophageal dysmotility
Sclerodactyly
Telangiectasia
Arthritis with myopathy
Interstitial lung disease or pulmonary artery hypertension
Seronegative spondarthritides
‘PEAR’:
- Psoriatic arthritis
- Enteropathic arthritis
- Ankylosing spondylitis
- Reactive arthritis
Autoimmune questions
- morning joint stiffness
- back/pelvic pain
- rash, photosensitivity, nodules, oral ulcers
- dry eyes, dry mouth
- Raynaud’s phenomenon
- dysphagia, heartburn
- lung involvement
- haematuria, bowel habits
Acromegaly symptoms
Headaches
Bitemporal hemianopia
Galactorrhoea, menstrual changes
Increase in hand & shoe size
Change of appearance
Diabetes/polyuria/polydipsia
Excessive sweating
Carpal tunnel syndrome
Acromegaly examination findings
Prognathism
Prominent supraorbital ridge, Large tongue
Bitemporal Hemianopia, CN3 palsy
Tinel & Phallen’s signs for carpal tunnel
Causes of Acromegaly
Pituitary adenoma secreting growth hormone (can be part of MEN1)
Ectopic growth hormone secretion from tumour
Investigations for Acromegaly
IGF1 level
Oral glucose tolerance test for GH supp
Hormone profile
MRI brain +/- body
Management of acromegaly
Transphenoidal surgery
May consider radiotherapy and octreotide
Treatment of complications (OSA, DM, carpal tunnel)
Colonoscopy every three years
Complications of Acromegaly (4)
Hypertension
Diabetes
Sleep apnoea
Heart failure
Causes of hyperthyroidism
Grave’s disease (TSH receptor Ig)
Multinodular goitre
Thyroiditis
Causes of hypothyroidism (3)
Hashimoto’s thyroiditis
Iatrogenic (post-surgery, lithium)
Iodine deficiency
Addison’s disease investigations
Short Synacthen test - synacthen causes rise in ACTH level
Hyponatraema, hyperkalaemia
Renin-aldosterone ratio
Extra-articular manifestations of Rheumatoid arthritis
Scleritis, episcleritis
Pleural effusions / pulm effusion
Pericarditis
Splenomegaly (Felty’s syndrome)
Glomerulonephritis
Methotrexate (3 facts)
Inhibits purine metabolism
Always prescribe folate supplements
Risk of myelosuppression and liver impairment
Ehler-Danlos disease types
Hyper mobile joints type
Velvety skin type
Vascular type
Defect in collagen genes
Polycythaemia rubra Vera symptoms and blood results
Hypertension
DVTs, strokes
High WCC and platelets
Haematocrit >55%
JAK2 mutation
Thyroid exam
Sweaty hands with thyroid acropachy
Irregular pulse
Exophthalmos, peri-orbital swelling
Visual acuity and ocular movements
Neck - observe, goitre, swallowing, percussion sternum, feel lymphadenopathy
Proximal myopathy
Pretibial myxoedema
Symptoms of hyperthyroidism
Sweaty hands & tremor
Tachycardia
Anxiety
Palpitations
Weight loss
Side-effects of Carbimazole
Rash
Agranulocytosis
Hepatitis
Teratogenic
Issues around radio-iodine therapy
4 weeks can’t be around pregnant women or kids
Worsening of eye disease
Avoid pregnancy four months
Eye signs in Grave’s eye disease
Asymptomatic
Lif retraction
Proptosis
Ocular muscle involvement
Corneal involvement
Optic nerve damage
Treat with high dose steroids & ophthalmology & eye drops & stop smoking
Causes of goitre
Idiopathic
Graves’ disease
Iodine deficiency
Pregnancy
Causes of hypothyroidism
Iodine deficiency
Autoimmune thyroiditis
Pituitary failure
Lithium / Amiodarone
Symptoms of hypothyroidism
Depression
Weight gain
Constipation
Differentials loss of peripheral vision
Glaucoma
Retinitis pigmentosa
Retinal artery occlusion (vein is central)
CVA
Chiasmal lesion
Intranuclear ophthalmoplegia
Medial longitudinal fasciculus lesion
Affected eye can’t adduct
Other eye nystagmus on looking that way
Horizontal Diplopia
CN6 palsy
Vertical diplopia
CN 3 or 4 palsy
Ocular exam
Acuity
Fields + extinction
Reflex - accommodation + light
Ophthalmoscopy
Ocular movements inc diplopia
Ankylosing spondylitis symptoms
Pain worse in mornings
Affecting pelvis
Plantar fasciitis, tendinitis, dactyliitis
Red eyes
Scored in Bath
Ank spondylitis exam
ROM neck and spinous processes
Schobers test (5cm above dimples of Venus, 10cm below) —> positive if <5cm expansion
Red eyes
AR murmur
Power/sensation in legs
Extra-articulate features of Ankylosing spondylitis
Atlantoxial dislocation causing cord compression
Anterior uveitis
Aortic regurgitation, arrhythmias
Fibrosis
IgA nephropathy
Ankylosing spondylitis tests
Renal function
HLA-B27
XR lumbar spine and pelvic joints
ECG for cardiac problem
CXR for fibrosis
Acromegaly complications
Diabetes
Hypertension
Carpal tunnel syndrome
Hypogonadism
OSA
Recital bleeding from polyps or kidney stones
Acromegaly examination
Visual fields
Face - prom supraorbital ridge, prognathism, macroglossia
Carpal tunnel syndrome
Proximal myopathy
Neck circumference if OSA
Acromegaly investigations
IGF-1 level
Oral glucose tolerance test (paradoxical rise)
MRI pituitary fossa
Formal visual fields
Hormone screen (ACTH, cortisol, TSH, LH, FSH, prolactin) + calcium for MEN1
Cushing’s examination
Fingerprick glucose marks
Carpals tunnel
Facial plethora with hirsutism
Buffalo hump
Proximal myopathy
Cushing syndrome causes
Steroid use
Pituitary adenoma secreting ACTH
Small cell lung cancer secreting ACTH
Adrenal adenoma/carcinoma
Treatment of Cushing syndrome
Surgery
Octreotide, somatostatin
Optimise lifestyle
Definition of osteoporosis
Bone density more than 2.5 standard deviation below the mean value for an adult the same gender and race
Investigations that confirm Cushing syndrome
24h urinary cortisol
Low dose dex supp test
Investigations that identify cause of Cushing syndrome
9am ACTH level
High dose dex supp —> of low urinary cortisol then pituitary adenoma
MRI pituitary fossa or CT CAP
Pyoderma gangrenosum
Painful red/black ulcers
IBD
Autoimmune
Haematological malignancy
Hep C
limited systemic sclerosis antibody
Anti centromère antibody
Diffuse systemic sclerosis antibody and features
Anti-Scl70
Renal crisis
Interstitial lung disease
Pulmonary artery hypertension
Right heart failure
Dermatomyositis exam
Gottron’s papules
Heliotropic rash on face
ILD, pulm hypertension
Reflux
Cardiac arrhythmias & myositis
Cancer association
Anti-Jo1
Headache examination
Visual fields
Fundoscopy
Cranial nerves 3-4-6 and CN 7
Temporal tenderness
Nuchal rigidity
Power in arms/legs
Reactive arthritis
Associated with salmonella, campylobacter, chlamydia
Triad: conjunctivitis + arthritis + urethritis
Can cause dactylitis
AIDS-defining illnesses:
CD4 <200
PCP or mycobacterium avium
Oesophageal candidiasis
Chronic diarrhoea (from CMV)
Kaposi syndrome
Marfan syndrome cause & manifestations
Autosomal dominant from fibrillin gene mutation (chrom 15)
Hugh arched palate
Longer arm span than tall height
Upward lens dislocation, blue sclera
Aortic root dilatation/regurgitation/MVP
Hypermobility with arachnodactily
Spontaneous pneumothorax, emphysema, Bronchiectasis
Raynaud’s phenomenon associations (esp if has a digital ulcer)
Scleroderma
SLE
Rheumatoid arthritis
Dermatomyositis
Polymyositis
Everything autosomal dominent except for:
Recessive:
Wilson’s disease (ATP7B gene)
Friedrich’s ataxia (frataxin gene)
Hereditary Haemochromatosis (HFE gene)
Symptoms of Haemochromatosis
Arthralgia with synovitis
Diabetes
Cardiomyopathy
Bronze skin
Raised ferritin and transferrin
Screening of relatives
Extra-articulas features of Ankylosing spondylitis
Anterior uveitis
Aortitis
Aortic regurgitation
Apical pulmonary fibrosis
Amyloidosis causing glomerulonephritis
Achilles tendon enthesitis
Cause of Marfan syndrome
Autosomal dominant mutation causing a defect in Fibrillin-1
Differential diagnoses acromegaly
Craniopharyngeoma
Hypothyroidism
Pituitary function tests
9am cortisol
LH, FSH, testostérone, oestradiol
Thyroid function tests
Prolactin
Plasma and urinary sodium
Characteristics of Raynaud’s phenomenon not seen in Raynaud’s disease (3)
- Asymmetrical
- dilated nail fold capillaries due to co-existing autoimmune disorder
- digital ulcers
Exacerbating factors for Raynaud’s phenomenon (3)
Cold
Drugs (bisoprolol, COCP)
Vibrating tools
Drugs that cause drug-induced lupus (4)
Phenytoin
Isoniazid
Procainamide
Infliximab
Differentials for vitiligo (2)
Pityriasis versicolor
Albinism
