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Station 5 Flashcards

1
Q

Signs of optic atrophy

A
  • RAPD (constricts when shine light to normal pupil, dilates when shine light on abnormal pupil)

Signs of causes
- Cupping of disc: glaucoma
- Retinitis pigmentosa
- Central retinal artery occlusion: cherry red macula + milky fundus
- Foster-Kennedy syndrome (frontal tumour): optic atrophy in one eye = tumour compression; papilloedema in other eye = raised ICP)

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2
Q

Causes of absent red reflex

A

Red reflex = reflection of light from back of eye
Absent = opacity in ocular media (cornea, lens, aqueous and vitreous humour)
- Cataract
- Vitreous haemorrhage

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3
Q

Acronym for which lobe corresponds to which quadrantopia

A

PITS
- Parietal inferior
- Temporal superior

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4
Q

An important cause of absent pupillary response

A
  • Glass eye!
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5
Q

Causes of sudden vision loss

A

Will always be vascular or trauma
- Vitreous haemorrhage
- Retinal artery occlusion
- Retinal vein occlusion
- Haemorrhagic (‘wet’) age-related macular degeneration
- Stroke

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6
Q

Causes of altitudinal visual field defect (upper/lower visual field loss)

A
  • Branch retinal artery occlusion
  • Anterior ischaemic optic neuropathy
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7
Q

Causes of vitreous haemorrhage

A

Bleeding into vitreous (clear jelly between retina and lens)
- Diabetic retinopathy = most common
- Trauma
- Retinal detachment

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8
Q

Features of vitreous haemorrhage

A
  • Sudden vision loss
  • Cobwebs in vision
  • Absent red reflex
  • Photopsia (bright lights in peripheral vision)
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9
Q

Pathogenesis of diabetic retinopathy

A
  • Vascular occlusion –> VEGF release –> new vessels
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10
Q

Diabetic retinopathy and pregnancy

A
  • Progresses rapidly in pregnancy
  • Diabetic pregnant ladies need to be reviewed once a trimester for retinopathy
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11
Q

Stages of diabetic retinopathy

A

Mild/moderate non-proliferative = background retinopathy:
- Microaneurysms (dots)
- Blot haemorrhages

Severe/very severe non-proliferative = pre-proliferative
- Cotton wool spots (infarcts)
- Venous dilation/beading
- Intraretinal microvascular abnormalities (IRMA) = branching/dilation of existing vessels in retina

Proliferative retinopathy
- New vessels

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12
Q

Treatment for diabetic retinopathy

A
  • Mild/moderate: annual Diabetic Retinopathy Screening Service
  • Pre-proliferative/maculopathy: Ophthalm referral within 3months
  • Proliferate: Ophthalm referral within 2weeks
  • Pan-retinal photocoagulation (lasers applied to 4 quadrants of retina)
  • Do as many sessions until new vessels start to regress
  • Side effects: reduced night vision/visual field loss
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13
Q

Pathogenesis of diabetic maculopathy

A
  • Oedema from leaking capillaries
  • And/or ischaemia due to capillary loss
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14
Q

Features of diabetic maculopathy

A
  • Central vision loss (due to macular oedema)
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15
Q

Indications for laser treatment in diabetic maculopathy

A
  • Retinal thickening within 500μm of fovea (centre of macula)
  • Exudates within 500 μm of the fovea, if associated with adjacent retina thickening
  • Retinal thickening >1 disc area, any part of which is within 1 disc diameter of the fovea

(won’t be expected to detect retinal thickening in exam!)

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16
Q

Features and inheritance mode of retinitis pigmentosa

A
  • Age 10-30, symptoms progress over years–> registered blind by 40s
  • Night vision loss
  • Peripheral vision loss
  • Severe: central vision and colour vision loss

Can be many different modes of inheritance so ask for family history (usually autosomal recessive)

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17
Q

Loss of peripheral vision vs loss of central vision

A

Peripheral vision loss
- Retinitis pigmentosa (constricted fields)
- Glaucoma (constricted)
- Laser photocoagulation (constricted)
- Ischaemic optic neuropathy (unilateral)
- Stroke (homonymous)

Central vision loss
- Diabetic maculopathy
- Age-related macular degeneration
- Optic neuropathy (demyelinating/nutritional)
- Cataract

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18
Q

Syndromes associated with retinitis pigmentosa

A
  • Usher syndrome: sensorineural deafness = most common
  • Alport Syndrome: abnormal glomerular basement membrane–> nephrotic syndrome (defect in collagen)
  • Kearns–Sayre syndrome (mitochondrial disease): progressive ophthalmoplegia, cardiac conduction defect (PACEMAKER)
  • Refsum disease (excess phytanic acid): scaly skin, cerebellar ataxia, peripheral neuropathy, cardiomyopathy
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19
Q

Investigations for retinitis pigmentosa

A
  • Automated perimetry (visual fields)
  • Electroretinogram: reduced amplitude
  • Optical coherence tomography: retinal atrophy
  • Genetic analysis: especially X-linked recessive
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20
Q

Management of retinitis pigmentosa

A
  • Mainly supportive: register as blind to get benefits/reduced TFL costs
  • Luxturna = gene therapy for biallelic RPE65 mutations
  • Vitamin A may slow progression
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21
Q

Mitochondrial inheritance comes from which parent

A
  • Mother as all mitochondrial in embryo come from the egg
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22
Q

Features of optic atrophy

A
  • PAINLESS loss of central vision
  • RAPD
  • 3rd nerve palsy (inflammatory/compressive affects CNIII)
  • INO if MS
  • Speed of progression depends on cause
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23
Q

Causes of optic atrophy

A

Sudden = ischaemic
- Embolic
- Giant Cell Arteritis!!

Subacute = demyelination
- MS
- Neuromyelitis optica

Gradual
- Compressive tumour: optic nerve glioma, frontal meningioma (at anterior cranial fossa), pituitary macroadenoma (compresses optic chiasm)
- Nutritional: B12, alcohol

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24
Q

Investigations for optic atrophy

A
  • Visual-evoked potentials: assess optic nerve function and differentiate from retinal disease (evoked potentials will be delayed and reduced amplitude)
  • Automated perimetry
  • CT brain + orbits with contrast
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25
Q

Management of optic neuropathy

A
  • Steroids in ARTERTIC anterior ischaemic optic neuropathy i.e. GCA (prevents further vascular occlusions)
  • Steroids speed up recovery in optic neuritis but not overall prognosis
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26
Q

Risk factors for thyroid eye disease

A

Autoimmune inflammation of the extra-ocular muscles and
retro-orbital fat
- Autoimmune thyroid disease
- Female middle-aged
- Smoking

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27
Q

Features of thyroid eye diseases

A
  • Lid lag when looking down
  • Proptosis (examine from above)
  • Unilateral progressive vision loss = optic nerve compression
  • Diplopia
  • Signs of thyroid: goitre, thyroid acropatchy, pretibial myxoedema

RED FLAGS
- Optic atrophy due to compression (RAPD, pale disc)
- Corneal exposure during blinking

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28
Q

Investigations for thyroid eye disease

A
  • CT orbits: bone resolution (plan decompression); MRI orbits: soft tissue
  • Thyroid investigations including antibodies
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29
Q

Thyroid disease antibodies

A
  • Anti-TSH receptor = Graves
  • Anti-thyroid peroxidase = Hashimoto’s (and Graves)
  • Anti-thyroglobulin = Hashimoto’s (and Graves)
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30
Q

Management of thyroid eye disease

A

Stable signs
- Artificial tears (methylcellulose eye drops)
- Stop smoking
- Optimise thyroid status
- “Burns out” in 1-5yrs, when can have surgery for cosmetic reasons

Optic nerve compression or corneal exposure = emergency
- Steroids +/- orbital radiotherapy
- Surgical decompression of orbital apex if steroids fail

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31
Q

Causes of bitemporal hemianopia

A

Optic chiasm compression
- Pituitary adenoma = starts from above as compresses inferior chiasmal fibres first
- Craniopharyngioma = starts from below as compresses superior chiasmal fibres first
- Meningioma

Non-chiasmal compression
- Tilted optical discs (nerve enters eye obliquely)
- Nasal retinitis pigmentosa

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32
Q

Symptoms associated with bitemporal hemianopia

A

Pressure effects
- Headache
- Diplopia (pressure on CN III, IV, VI)

Hypopituitarism
GH-secreting tumour
Prolactinoma

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33
Q

Symptoms of hypopituitarism

A
  • Hypothyroid
  • Reduced FSH/LH: reduced libido, erectile dysfunction, reduced menses.
  • Reduced ACTH: tiredness, depression, abdominal pain
  • Reduced GH: dry wrinkly skin, reduced well-being.
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34
Q

Symptoms of prolactinoma

A
  • Men: galactorrhoea, reduced libido, erectile dysfunction
  • Women: galactorrhoea, reduced libido/menses
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35
Q

Investigations for bitemporal hemianopia

A
  • MRI pituitary fossa
  • Endocrine: IGF-1 (high in acromegaly), LS/FSH, ACTH, TFTs
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36
Q

Management of optic chiasm tumour

A
  • Transphenoidal surgery (transfrontal if suprasellar extension)
  • Radiotherapy if residual tumour
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37
Q

Cause of macula sparing homonymous hemianopia (central vision intact)

A
  • Occipital lobe lesion (because macula supplied by PCA and MCA so PCA lesion still means MCA working!)
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38
Q

Features of retinal artery occlusion

A
  • Optic atrophy–> sudden blind
  • Branch retinal artery occlusion = visual field defect opposite to affected quadrant
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39
Q

Causes of retinal artery occlusion

A

Embolic
- Carotid plaque
- Mural thrombus

Arteritis = GCA
- Tender scalp and pulseless temporal arteries

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40
Q

Causes of retinal vein occlusion

A

4 H’s
- HTN
- Hyperglycaemia (diabetes)
- High intraocular pressure (glaucoma)
- Hyperviscosity (myeloma)

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41
Q

Management of retinal vein occlusion

A
  • Usually observe and manage risk factors
  • Macular oedema: intravitreal VEGF inhibitor
  • Neovascularisation: retinal photocoagulation
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42
Q

Pre-pregnancy counselling in diabetic women

A
  • HbA1c <7.0% for 3 months pre-conception
  • Folic acid 5mg (continue until 12 weeks pregnant)
  • Stop ACEi and statins
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43
Q

Management of diabetic foot

A

MDT approach!!!
- “Offloading” pressure: non-removable cast walkers (uninfected/non-ischaemic)
- Debridement of slough/necrotic/callus (TVN)
- non-adherent dressings covered with a layer of gauze (maintain moist environment)
- Fluclox + metronidazole (covers anaerobes)

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44
Q

Different types of neuropathy in diabetes

A
  • Progressive sensory
  • Mononeuritis e.g. cranial nerves
  • Pressure palsies e.g. carpal tunnel syndrome
  • Amyotrophic
  • Autonomic.
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45
Q

Causes of hyperthyroidism

A

2 most common:
- Graves: eye disease and hx of autoimmune
- Toxic multinodular goitre

Also
- Viral thyroiditis: neck pain/recent child-birth
- Drugs: iodine, amiodarone, lithium, contrast
- Gestational

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46
Q

Management of hyperthyroidism

A

Drugs
- Titration: carbimazole 30mg tapered over 8 weeks to 5-10mg
- Block and replace: carbimazole 40mg until T4 low (after 6-8weeks), then add levothyroxine 100mcg
- Each lasts 18months
- 50% relapse rate in Graves
- Also: non-selective beta-blockers (propranolol- avoid in asthma/COPD)

Radio-iodide
- More than 1 dose likely needed
- Complications: long-term hypothyroidism and worsens thyroid eye disease (/can cause thyroid eye disease)
- Can use in mild eye disease with steroid cover afterwards

Surgical = thyroidectomy
- Complications: hypothyroidism, hoarse voice (laryngeal nerve) and parathyroid damage

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47
Q

Important complications of carbimazole

A
  • Rash (10%)
  • Agranulocytosis (0.5%)– stop immediately if mouth ulcers and check neutrophils
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48
Q

Thyroid uptake scan results

A

High uptake = more uptake than surrounding thyroid tissue
- Graves: diffuse
- Toxic multinodular goitre: focal
- Toxic adenoma: focal

Low uptake
- Non-functioning nodules = 10% are malignant (hot nodules never are)
- Thyroiditis
- Drug-induced

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49
Q

Management of toxic multinodular goitre

A
  • Radio-iodide (may cause enlargement briefly first!)
  • Surgery if compressive symptoms (dysphagia/stridor)
    (- Meds don’t work! If not candidate for above, can give low-dose levothyroxine to suppress TSH but not really effective!)
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50
Q

Causes of hypothyroidism

A
  • Autoimmune (Hashimoto’s) = most common in UK
  • Thyroiditis (post-hyperthyroid stage)
  • Iatrogenic: post-ablation/thyroidectomy
  • Drugs: amiodarone/litium/carbimazole!
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51
Q

Implications of pregnancy on hypothyroidism

A
  • Levothyroxine doses increase by 25-50%
  • Check TSH every trimester (aim 0.5–2.0mU/L.)
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52
Q

Features of myxoedema coma

A

Hypothyroid emergency (long-term undiagnosed hypothyroidism or insult e.g. MI)
- Bradycardia
- Hypothermia
- Reduced GCS
- Cardiogenic shock

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53
Q

Important differential diagnosis for hypothyrodism

A
  • Addison’s (can co-exist!
    –> giving levothyroxine in undiagnosed Addison’s may cause Addisonian crisis (enhances cortisol clearance)
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54
Q

Signs of active disease in acromegaly

A
  • Sweating
  • HTN
  • Peripheral oedema
  • Skin tags = skin growth
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55
Q

Important co-existing condition in acromegaly

A

Hypopituitarism
- T4
- LH, FSH and testosterone/oestradiol
- Short Synacthen, cortisol, ACTH

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56
Q

Investigations in acromegaly

A
  • OGTT: growth hormone does not suppress <2nmol/L
  • IGF-1: disease progression
  • MRI pituitary
  • Automated perimetry (visual fields)
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57
Q

Management of acromegaly

A
  • Trans-sphenoidal surgery = 1st line
  • Radiotherapy
  • Drugs
    — somatostatin analogue (octreotide) reduces GH secretion
    — Dopamine agonists (bromocriptine)
    — GH receptor antagonists (Pegvisomant)
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58
Q

Features of each Multiple Endocrine Neoplasia

A
  • MEN1 = 3P = pit, para, panc
  • MEN2a = 2P 1M = PTH, phaeo, medullary cancer
  • MEN2b = 1P 2M = phaeo, marfan’s, medullary cancer
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59
Q

Complications of pituitary surgery

A
  • Diabetes insipidus (may be transient)
  • SIADH (may be transient)
  • Hypopituitarism
  • CSF leak
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60
Q

Investigations for Addison’s Disease

A

Short Synacthen test
- 250mcg tetracotaside
- Check cortisol before, 30mins, 60mins
- Normal: basal cortisol in the reference range, a cortisol rise
of >170nmol above the basal result and/or a peak cortisol > 530nmol/L

ACTH: raised in primary hypoalderstonism
CT adrenals

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61
Q

Management of Addison’s Disease

A
  • Hydrocortisone 20mg AM, 10mg night
  • Fludrocortisone 100mcg (for postural hypotension)
  • DHEA for post-menopausal women with low libido
  • Double dose when unwell
  • Medic alert bracelet
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62
Q

Management of Addisonian Crisis

A
  • IV hydrocortisone: 100mg STAT –> 50mg QDS
  • IV fluids
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63
Q

Types of Polyglandular Autoimmune Syndromes

A

Type 1 (AIRE mutation)
- Addison’s
- Hypoparathyroid
- Mild immune deficiency (candida)

Type 2
- Addison’s
- T1DM
- Thyroid disease

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64
Q

Nelson’s Syndrome

A
  • Bilateral adrenalectomy –> lots of ACTH (negative feedback) –> rapid enlargement pituitary microadenoma –> compress optic chiasm
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65
Q

Investigations for Cushing’s Syndrome

A
  • Pregnancy test!!!
  • Low-dose dexamethasone suppression test (1mg at midnight –> 0900 cortisol >50nmol/L is Cushing’s): normal in pseudo-Cushing’s
  • Midnight salivary cortisol
  • 24hr urine cortisol (ideally 3x)

If positive:
- ACTH: inappropriately normal/elevated in pituitary and ectopic Cushing’s
- High-dose dexamethasone suppression test (2mg QDS for 2 days – measure cortisol at 0hrs and 48hrs)- suppressed is pituitary Cushing’s, not suppressed is ectopic ACTH
- Adrenal CT: may find incidentaloma
- MRI pituitary
- Bilateral inferior petrosal sinus sampling (if nothing seen on MRI pituitary)

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66
Q

Management of Cushing’s Syndrome

A
  • Metyrapone while await definitive treatment (blocks 11b-hydroxylase = involved in steroid metabolism)

Pituitary Cushing’s
- Transphenoidal resection +/- radiotherapy

Adrenal Cushing’s
- Adrenalectomy
- Ketoconazole/metyrapone

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67
Q

Differentiate pseudo-Cushing’s from Cushing’s

A

Low-dose dexamethasone suppression test then CRH test
- Cortisol not increased in pseudo-Cushing’s but is increased in Cushing’s (as dexamethasone suppresses ACTH greater in pseudo-Cushing’s vs Cushing’s)

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68
Q

Causes of Cushing’s

A

Pituitary adenoma

Adrenal
- Adenoma
- Hyperplasia
- Carcinoma

Ectopic
- Small cell lung cancer

Exogenous
- Steroids

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69
Q

Cause of Klinefelter’s Syndrome

A
  • 47 XXY (could also be XXXY or XYY)
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70
Q

Features of Klinefelter’s Syndrome

A
  • Infertility (leading cause in men!)
  • Gynaecomastia + breast tenderness
  • Hypogonadism: erectile dysfunction, low body hair, small testes, fatigue
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71
Q

Causes of male infertility

A
  • Klinefelter’s
  • Kallman’s: can’t smell
  • Haemachromatosis: joint pain, tanning, diabetes
  • Fragile X: low IQ
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72
Q

Investigations for Klinefelter’s

A
  • High FH/LSH, low testosterone
  • Karyotype (XXY)
  • Bone mineral density
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73
Q

Management of Klinefelter’s

A
  • IM testosterone every 3 months (does not help with fertility!)
  • Fertility assistance
  • Cosmetic surgery for gynaecomastia
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74
Q

Diagnostic criteria in PCOS

A

Rotterdam criteria = 2 of:
- Amenorrhoea (no period in 3months if usually regular, or 6months if usually irregular)
- Hyperandrogenism (acne, hirsutism, male-pattern baldness)
- Polycystic ovaries seen on USS

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75
Q

Differential diagnosis for PCOS

A
  • Congenital adrenal hyperplasia (high 17-hydroxyprogesterone)
  • Androgen-secreting tumour (very high testosterone)
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76
Q

Cause of Turner Syndrome

A
  • 45X (missing X chromosome in girl)
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77
Q

Complications of Turner Syndrome

A

Cardio
- Bicuspid aortic valve
- Aortic dissection
- HTN

Renal
- Horseshoe kidney

Gastro
- Coeliac
- Angiodysplasia

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78
Q

Management of Turner Syndrome

A
  • Growth: recombinant growth hormone until growth <2cm/year
  • Pubertal delay: low-dose oestrogen + cyclical progesterone
  • Once cyclical periods induced: ovarian HRT (oestrogen + progestogen)
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79
Q

Features of Noonan Syndrome

A

Like Turner Syndrome but autosomal dominant so can occur in men
- NOT infertile
- Webbed neck
- Short
- Pectus excavatum
- Hypertelorism (long distance between eyes)
- Congenital heart defects: pulmonary stenosis, HOCM, tetralogy of Fallot

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80
Q

Investigations for arterial ulcer

A
  • Ankle-brachial pressure index (0.9-1.2 is normal, <0.5 is severe arterial disease)
  • Doppler ultrasound
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81
Q

Management of venous ulcer

A
  • 4-layer compression bandaging (if no PVD)
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82
Q

Management of arterial ulcer

A
  • Angioplasty
  • Amputation
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83
Q

Complications of diabetic retinopathy

A
  • Vitreous haemorrhage
  • Traction retinal detachment
  • Neovascular glaucoma (due to rubeosis iridis = new vessels on iris)
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84
Q

Causes of cataract

A

Congenital
- Turner syndrome
- Myotonic dystrophy
- Rubella

Acquired
- Old
- Steroids
- Diabetes

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85
Q

Signs specific to Graves eye disease

A
  • Proptosis
  • Exposure keratitis
  • Chemosis (redness)
  • Ophthalmoplegia
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86
Q

Progression of eye signs in Graves Disease

A

NO SPECS
- No signs
- Only lid lag/retraction
- Soft tissue involvement (periorbital oedema)
- Proptosis
- Extraocular muscle involvement
- Chemosis
- Sight loss (optic nerve compression/atrophy)

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87
Q

Condition to be careful when prescribing levothyroxine

A
  • IHD (levothyroxine may worsen angina)
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88
Q

Complications of hypothyrodism

A

Cardiac
- Pericardial effusion (rub)
- CCF (oedema)

Neurological
- Proximal myopathy
- Carpal tunnel
- Ataxia

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89
Q

Why get pigmentation in Addison’s

A
  • Cleavage of POMC gives ACTH and MSH (melanocyte-stimulating hormone)
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90
Q

Uses of Wood’s light (UV)

A
  • Depigmentated = bright white
  • Fungi (dermatophytes) = green
  • Corynebacterium (erythrasma) = coral pink
  • Porphyria = urine turns red
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91
Q

Papule vs nodule

A
  • Papule: raised dome-shaped <0.5cm (lichen planus)
  • Nodule: dome-shaped >0.5cm (acne vulgaris)
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92
Q

Vesicle vs bulla

A
  • Vesicle: circumscribed cavity containing fluid <0.5cm (HSV)
  • Bulla: >0.5cm (bullous pemphigoid)
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93
Q

Erosion vs ulcer

A
  • Erosion: lose part of epidermis (pemphigus vulgaris)
  • Ulcer: extends into dermis and below (venous ulcer)
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94
Q

Management of cutaneous lupus

A
  • Strong suncream
  • Stop smoking
  • Discoid lupus: topical steroids (clobetasol)
  • Oral steroids and steroid-sparing agents
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95
Q

Differential for malar rash

A
  • Lupus
  • Seborrheic dermatitis: scaly
  • Rosacea: telangiectasia, papules/pustules–> worsened by heat, spicy food, alcohol
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96
Q

Differential for photosensitive rash

A
  • Lupus
  • Drug-induced: tetracyclines/quinolones, NSAIDs, diuretics
  • Polymorphous light eruption: very itchy- starts 2days after sun and fades within a week
  • Actinic dermatitis: sun-exacerbated eczema
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97
Q

Differential for discoid patches

A
  • Discoid lupus
  • Discoid eczema: not photosensitive, no scarring
  • Psoriasis
  • Tinea corporis: scaling/erythema at margins, central clearing
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98
Q

Differential for scarring alopecia

A
  • Discoid lupus
  • Lichen planus: itchy, violaceous, on wrists, not photosensitive
  • Tinea capitis: children, scaling
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99
Q

Management of psoriasis

A

1st line = Topical
- Frequent emollients
- Vitamin D (calcipotriol)
- Topical steroids in flares
- Coal tar (stains skin brown)

2nd line = UVA phototherapy + psoralen (makes skin sensitive to UVA)
- 6 weeks at a time
- Side effects: blistering, erythema, CANCER

3rd = Systemic
- Retinoids (acitretin = teratogenic, dry lips)
- Methotrexate
- Biologics: adalimumab (anti-TNFa)

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100
Q

Triggers for psoriasis

A
  • Trauma (Koebner phenomenon)
  • Infections: beta-haemolytic strep
  • Drugs: beta-blockers, NSAIDs, antimalarials
  • Cold weather
  • Smoking/alcohol
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101
Q

How to quantify skin condition’s effect on patient’s life

A
  • Dermatology Life Quality Index
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102
Q

Most common areas for vitiligo

A

Hyperpigmented areas
- Face
- Dorsum
- Nipples
- Axilla
- Anus/genitals

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103
Q

Management of vitiligo

A

Conservative
- Psychological support
- Skin camouflage (make-up)

Medical
- Topical steroids
- Phototherapy if more widespread
- Depigmentation (bleaching): monobenzone cream

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104
Q

Pathogenesis of vitiligo

A
  • No melanocytes–> no melanin (unclear why exactly)
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105
Q

Conditions associated with pyoderma gangrenosum

A
  • IBD (UC)
  • Rheumatoid arthritis
  • Haem: acute and chronic myeloid leukaemia
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106
Q

Management of pyoderma gangrenosum

A

MDT approach!
- Bed rest/compression bandages
- Topical steroids, or prednisolone if large ulcers
- Steroid-sparing agents (ciclosporin, infliximab)

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107
Q

Skin changes in diabetes

A
  • Infection
  • Ulcers: neuropathic/arterial
  • Necrobiosis lipoidica: on shins
  • Diabetic dermopathy: brown scaly patches on shins
  • Granuloma annulare
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108
Q

Diagnostic criteria for Haemorrhagic Hereditary Telangiectasia

A
  • Epistaxis
  • Telangiectasia at multiple sites
  • Organ AVMs (brain, lungs, liver)
  • 1st-degree relative with HHT

3 criteria = definite; 2 = suspected

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109
Q

Mode of inheritance for Haemorrhagic Hereditary Telangiectasia

A
  • Autosomal dominant due to mutations in endoglin ( ENG) on chromosome 9 and activin receptor-like kinase 1 ( ACVRL1) on chromosome 12
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110
Q

Cause of porphyria cutanea tarda

A
  • Lack enzyme uroporphyrinogen decarboxylase (UROD)–> accumulation of porphyrins in the skin
  • Usually sporadic but can be autosomal dominant
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111
Q

Triggers for porphyria cutanea tarda

A
  • Alcohol: reduced UROD activity
  • Oestrogens (COCP)
  • Liver disease: increased iron in liver reduces UROD activity
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112
Q

Differential for porphyria cutanea tarda

A
  • Epidermolysis bullosa: mechanically induced bullae
  • Epidermolysis bullosa acquisita: autoimmune, blisters on skin and mucous membranes (unlike porphyria)
  • Pseudoporphyria: CKD and drugs (NSAIDs, doxycycline, diuretics)
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113
Q

Investigations for porphyria cutanea tarda

A
  • Urine fluoresces red under Wood’s light
  • 24hr urine: uroporphyrins
  • Liver screen + AFP if diagnosis made
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114
Q

Management of porphyria cutanea tarda

A
  • Phlebotomy to reduce hepatic iron
  • Low-dose hydroxychloroquine if phlebotomy does not work
  • Remove triggers (alcohol)
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115
Q

Causes of Koebner phenomenon

A
  • Psoriasis
  • Vitiligo
  • Lichen planus
116
Q

Triad of features in Henoch-Schonlein Purpura

A
  • Purpuric rash (legs/buttocks)
  • Abdo pain
  • Arthritis
117
Q

Triggers for Henoch-Schonlein Purpura

A
  • Infection: parvovirus B19, streptococcus, HSV
  • Drugs: penicillin, minocycline, phenytoin
118
Q

Cause of Henoch-Schonlein Purpura

A
  • IgA vasculitis with C3 deposition
119
Q

Complication of Henoch-Schonlein Purpura

A
  • IgA nephropathy: proteinuria and haematuria
  • HTN
120
Q

Management of Henoch-Schonlein Purpura

A
  • 90% resolve by themselves
  • Steroids may help arthritis
121
Q

Glass eye and ascites

A
  • Ocular melanoma!
122
Q

Different types of malignant melanoma

A
  • Superficial spreading = 80%
  • Lentigo maligna = face/scalp in elderly
  • Acral lentiginous = palms/soles + subgungal
  • Nodular = invade early
  • Amelanotic
123
Q

Prognostic marker in malignant melanoma

A
  • Breslow thickness = how far tumour invades into dermis
  • > 4mm = 50% 5-year survival
124
Q

Signs of severe asthma exacerbation which requires admission if persists after initial treatment

A
  • PEFR 33–50 %best of predicted
  • Respiratory rate > 25/min
  • Heart rate > 110/min
  • Inability to complete sentences in 1 breath
125
Q

Management of migraine

A

Acute
1. Aspirin 900mg (max 4g per day) - paracetamol if pregnant
2. Oral triptan (not if IHD)

Chronic
- Propranolol/topiramate (not if pregnant)

126
Q

Treatment of cluster headache

A
  • Subcut/nasal triptans
  • 100% O2
  • Prophylaxis: verapamil 80mg TDS (ECG at baseline and 10 days –> can increase to 960mg OD)
127
Q

NICE thresholds for HTN management

A

Clinic BP
- 140/90 to 179/119: do ambulatory monitoring
- >180/120: treat immediately if end-organ damage

Ambulatory BP
- 135/85 to 149/95: treat if 60-80 with end organ damage/co-morbidities/QRISK >10 (if <60, treat regardless)

128
Q

NICE guidelines for HTN management

A
  • Diabetes/<55yrs: ACEi then CCB then thiazide-like
  • > 55yrs or black: CCB then ACEi then thiazide-like
129
Q

Variceal bleed- acute management

A

Initial
- Terlipressin (vasopressin agonist)
- Ceftriaxone
- OGD: band ligation = oesophageal, cyanoacrylate injection = gastic

Continued bleeding after OGD
- Balloon tamponade ±transjugular intrahepatic porto-systemic shunt (TIPS)

130
Q

Non-variceal bleeding- acute management

A

Initial
- IV PPI
- OGD: adrenaline injection + cauterization

Continued bleeding after OGD
- Selective arterial embolization
- Surgery

131
Q

Variceal bleeding- chronic management

A
  • Non-selective beta-blocker (propranolol)
132
Q

Scoring systems for upper GI bleed

A
  • Rockall = mortality
  • Blatchford = who need intervention
133
Q

Features of upper GI bleed who can be discharged from A&E

A
  • Age <60
  • SBP > 100mmHg
  • Pulse <100/min
  • No significant comorbidity (especially heart/liver disease)
  • No witnessed blood loss
134
Q

Definition of sepsis

A
  • Life-threatening organ dysfunction caused by a dysregulated host response to infection (SOFA score ≥2)

(SOFA score based on GCS, CVD, resp, coagulation, liver, renal function)

135
Q

Definition of septic shock

A
  • Need vasopressors to keep MAP 65 and lactate >2 despite IV fluids (40% mortality)
136
Q

Differential diagnosis for peripheral vascular disease in legs

A
  • Sciatica/cauda equina
  • Anterior tibial compartment syndrome
  • Osteoarthritis
137
Q

What is Leriche’s syndrome

A

Blockage of AAA as it goes into common iliac
- Bilateral leg pain
- Absent pulses
- Aorto-iliac bruit
- Impotence

138
Q

Investigations for unprovoked DVT

A
  • Cancer if signs/symptoms of cancer
  • Antiphospholipid (must be off anticoagulant)
  • Thrombophilia if also has 1st-degree relative with VTE (must be off anticoagulant): antithrombin, Protein C/S, Factor V Leiden
139
Q

Duration of treatment for DVT

A
  • Usually 3 months but may be longer if unprovoked
140
Q

Contraindications for DOAC

A
  • Moderate/severe chronic liver Disease (Child-Pugh class B or C)
  • Creatinine clearance <15
  • GI ulcer or varices
  • Brain tumour with bleeding risk
  • Arteriovenous malformations
  • Weight <50kg or >120kg (warfarin to check if therapeutic)
141
Q

Treatment of DVT if pregnant

A
  • LMWH
142
Q

CP450 inhibitors = increased warfarin

A

ASS-ZOLES
- Antibiotics (cipro, erythromycin, isoniazid)
- SSRIs
- Sodium valproate
- ZOLES (fluconazole, omeprazole)

143
Q

CP450 inducers = reduced warfarin

A

SCARS
- Smoking
- Chronic alcohol
- Anti-epileptics (phenytoin, carbamazepine)
- Rifampicin
- St John’s wort

144
Q

Diagnostic criteria for rheumatoid arthritis

A

ACR/EULAR criteria (RA scores 6+)
A. Joint involvement:
- 2–10 large joints (1)
- 1–3 small joints (2)
- 4–10 small joints (3)
- > 10 joints (5)
B. Serology:
- Low + ve RF or anti-CCP antibody (2)
- High + ve RF or anti-CCP antibody (3)
C. Acute phase response, i.e. abnormal CRP or ESR (1)
D. Duration >6 weeks (1)

145
Q

Which joint is spared in rheumatoid arthritis

A
  • DIP
146
Q

Extra-articular complications in rheumatoid arthritis

A

Haematology
- Felty Syndrome (RA + splenomegaly + neutropenia)
- Anaemia (check for pallor)

Skin
- Pyoderma gangrenosum
- Nodules

Eyes
- Scleritis/episcleritis

Cardiac
- Pericarditis/myocarditis
- Valve regurgitation
- Accelerated atherosclerosis

Respiratory
- Lower zone fibrosis
- Effusions
- Nodules
- Bronchiolitis obliterans
- Caplan Syndrome

Neurology
- Peripheral neuropathy
- Compressive neuropathy

147
Q

Types of compressive neuropathy in rheumatoid arthritis

A
  • Cervical myelopathy (atlanto-axial subluxation): spastic paraparesis, UMN signs, ± scar from previous surgery
  • Ulnar neuropathy (elbow involvement).
  • Carpal tunnel syndrome (wrist involvement).
148
Q

X-ray features of rheumatoid arthritis

A
  • Periarticular osteopaenia
  • Erosions
  • Joint space narrowing
  • Deformity
149
Q

Commonest ILD radiological subtype in rheumatoid arthritis

A
  • NSIP (RA is inflammatory condition)
150
Q

Management of rheumatoid arthritis

A

Conservative
- MDT approach (OT, physio)

Medical
- 1st = methotrexate and folic acid (5mg weekly), with short-course steroids while takes effect (also sulfasalazine/leflunomide)
- 2nd = biologics (infliximab, adalimumab)

Surgical if
- Not responding to medical
- Nerve compression (Carpal tunnel)
- Imminent tendon rupture

151
Q

Management of rheumatoid arthritis flare

A
  • Intra-articular methylpred if localised
  • 2-4 week reducing regimen pred (starting at 20mg)
  • NSAIDs with PPI cover
152
Q

Blood tests before starting DMARD in rheumatoid arthritis

A
  • FBC
  • LFTs
  • Hep B and C
153
Q

Monitoring needed while on DMARD for rheumatoid arthritis

A
  • 6-monthly clinical reviews: check for TB/fibrosis
  • Regular bloods (FBC/LFTs/U&Es)- initially every 2 weeks
154
Q

Side effects of methotrexate

A
  • Hepatitis
  • Alveolitis
  • Stomatitis
  • Toxicity: bone marrow suppression –> pancytopaenia–> opportunistic infections
155
Q

Treatment for methotrexate toxicity

A
  • FOLINIC acid
156
Q

X-ray differences between rheumatoid arthritis and osteoarthritis

A
  • RA: juxta-articular osteopenia, erosions, symmetry, deformity.
  • OA: sclerosis, osteophytes.
  • Both: bone cysts, joint space narrowing.
157
Q

Management of psoriatic arthritis

A
  • Methotrexate (also leflunomide)
  • Avoid prednisolone as skin can flare when withdraw
  • Anti-TNFa (infliximab) for severe
158
Q

Forms of psoriatic arthritis

A
  • DIP involved (like OA)
  • Large joint mono/oligoarthritis- with massive effusions
  • Seronegative (similar to RA)
  • Sacroiliitis (like ank spond)
  • Arthritis mutilans (very severe)
159
Q

Features suggestive psoriatic arthritis vs rheumatoid

A
  • Asymmetry
  • Nail changes (POSH)
  • Dactylitis (inflammation of entire digit = sausage digit)
  • Negative CCP
  • Family history of psoriasis
160
Q

HLA associations in psoriatic arthritis

A
  • B38/B39 = peripheral distal arthritis.
  • DR4 = rheumatoid
  • B27 = sacroiliitis
161
Q

Features in ACR diagnostic criteria for SLE

A

ANA >1:80 = a must

Then need score of 10 based on following domains:
- Renal
- Mucocutaneous
- Haem
- Constitutional
- Neuropsychiatry

162
Q

Skin features in SLE

A
  • Malar rash
  • Discoid
  • Alopecia
  • Mouth ulcers
  • Vasculitic rash (palms usually)
163
Q

Systemic manifestations of SLE

A
  • Cardio: Libman-Sacks endocarditis (AR/MR)
  • Resp: fibrosis/effusions
  • Renal: hypertension
  • Neuro: cranial nerve lesion, transverse myelitis
164
Q

Investigations for SLE

A
  • Immune tests: ANA, dsDNA, C3/4
  • CXR: fibrosis/effusion
  • Echo
  • Skin and renal biopsy: Ig and C3 deposition
165
Q

Management of SLE

A
  • 1st line = hydroxychloroquine (check vision before as causes retinal toxicity)
  • Also other immunosuppressants
  • Statin as high CVD risk
  • Rituximab (anti CD20)
  • IV immunoglobulin and plasmapheresis in severe flares not responding to steroids
166
Q

Investigations to show if SLE is active

A
  • Urine: red cell casts
  • ESR
  • C3 and C4 fall
  • Anti-dsDNA rise
167
Q

Side effects of cyclophosphamide

A

HITI
- Haemorrhagic cystitis (reduced as now take mesna before and after each infusion)
- Infection: reactivation of latent and bone marrow suppression (10 days after infusion)
- Teratogenic
- Infertility

168
Q

Special test in Sjogren’s Disease

A
  • Schirmer’s = 5mm filter paper placed in lower eyelid–> patient closes eye–> expect moisture to migrate 15mm in 5mins
169
Q

Investigations in Sjogren’s Disease

A
  • Anti Ro and La
  • Schirmer’s test
  • Salivary gland biopsy
170
Q

Cause of Sjogren’s Disease

A
  • Usually secondary to other connective tissue disease (SLE/RA)
171
Q

Limited vs diffuse cutaneous systemic sclerosis

A
  • Limited (slow) = distal to knees and elbows, facial involvement, but the trunk is spared
  • Diffuse (rapid) = proximal to the elbows and knees; organ involvement
  • Note: CREST is subtype of limited (scleroderma should not extend beyond the MCPs)
172
Q

Causes of secondary Raynaud’s

A
  • Systemic sclerosis (v. unlikely to be this if no Raynaud’s!)
  • SLE
  • Sjogren’s
  • Dermatomyositis
  • Mixed connective tissue disease (SLE/scleroderma/polymyositis)

so when see Raynaud’s patient, don’t just assume it is systemic sclerosis and need to ask questions to exclude the others!

173
Q

Systemic manifestations of systemic sclerosis

A

GI
- Oesophageal dysmotility
- Small/large bowel involved in 50% = malabsorption and bacterial overgrowth (–> 3 D’s = dysphagia/dyspepsia/diarrhoea)

Respiratory = leading cause of death in systemic sclerosis
- ILD (NSIP)
- Pulmonary HTN (palpable P2, parasternal have = RVH, heart failure)

Sclerodermic renal crisis
- Sudden severe HTN –> CCF, rapid renal failure, microangiopathic haemolytic anaemia

174
Q

Antibodies in systemic sclerosis

A
  • ANA (90% of all patients)
  • Anti-topoisomerase = diffuse
  • Anti-centromere = limited
175
Q

Management of systemic sclerosis

A

No treatment affects disease progression…

  • Raynaud’s: nifepidine and sildenafil (iloprost infusion if gangrene)- also heated gloves!
  • Gut dysmotility: erythromycin (pro-kinetic)
  • Renal crisis: ACEi
176
Q

Colour changes in Raynaud’s

A
  • White (vasoconstriction) –> blue (cyanosis) –> red (blood rushes back- painful)
177
Q

Most common arthritis in men over 40

A
  • Gouty arthritis
178
Q

Stages of gouty arthritis

A
  • Asymptomatic hyperuricaemia
  • Acute gouty arthritis
  • Intercritical gout (interval between attacks)
  • Chronic tophaceous gout.
179
Q

Commonest places for gout

A
  • Hallux (big toe)– “podagra” is gout involving big toe
  • Arch of foot
  • Ankle
180
Q

Triggers for gout

A
  • Alcohol
  • Shellfish/oily food/legumes (lentils/chickpeas)
  • Dehydration
  • Infection
  • Trauma
181
Q

Medical conditions that predispose to gout

A
  • CKD
  • Hypothyroidism
  • Diabetes
  • Polycythaemia rubra vera
  • Myeloproliferative/lymphoproliferative
182
Q

Drugs that increase urate levels

A
  • Thiazides
  • Low-dose aspirin
  • Pyrazinamide/ethambutol
  • Ciclosporin
  • Levodopa
183
Q

Features of gout on XR

A
  • Punched out erosions (“mouse bites”)
  • No juxta-articular osteopaenia = differentiates from other inflammatory arthritis
  • Joint space loss in late disease
184
Q

Management of acute gout

A
  • High-dose naproxen with PPI cover (continue 2 days after end of attack)
  • Colchicine (contraindicated in blood disorder + severe renal/liver failure)
  • Pred 30mg for 5 days
185
Q

Indications for allopurinol in gout

A
  • > 3 flares a year
  • CKD stage 3+
  • Gouty arthritis
  • Tophi
  • On diuretics
186
Q

Management of chronic gout (including urate targets)

A

Allopurinol (febuxostat is 2nd line)
- 2 weeks after acute gout
- Aim for urate <360micromol/L (or <300 if gouty tophi)
- Cover with colchicine initially

187
Q

Mechanism of allopurinol

A
  • Inhibits xanthine oxidase that catalyses the conversion of hypoxanthine to xanthine, and xanthine in turn to uric acid.
188
Q

Important interactions in gout medications

A

Allopurinol
- Azathioprine (allopurinol increases effect = bone marrow suppression)
- Warfarin (allopurinol increases effect)

Colchicine
- Statins (colchicine increases effect = myopathy)
- Ciclosporin (increased nephrotoxic effect)

189
Q

Causes of acute hot joint

A
  • Septic
  • Gout/pseudogout (wrist/knee)
  • Palindromic rheumatism
  • Polyarticular condition (reactive arthritis, psoriatic arthritis)
  • Avascular necrosis (steroids/sickle cell)
  • Bleeding (haemophilia)
190
Q

Causes of reactive arthritis

A
  • STD: Chlamydia
  • Gastroenteritis: Campylobacter, Salmonella, Shigella, or Streptococcus
191
Q

Contraindications to joint aspirate

A
  • Prosthetic joint (done in Theatre)
  • Overlying cellulitis
  • Overlying psoriasis (increases risk of septic arthritis)
192
Q

Gout vs pseudogout crystals

A
  • Gout: negatively birefringent needles
  • Pseudogout: positively birefringent rods
193
Q

Features of polymyalgia rheumatica

A
  • Proximal myalgia affecting shoulders and pelvic girdle
  • Sudden onset (wake up with symptoms!)
  • Stiffness worse in morning/after rest
  • Can’t lift hands above head = classic!
194
Q

Age and ethnicity for Giant Cell Arteritis

A
  • Over 50 always!
  • Northern European
195
Q

Differentials for polymyalgia rheumatica

A
  • Myositis: muscle weakness, Gottron’s papules/heliotrope rash/lung fibrosis
  • Glenohumeral osteoarthritis: globally restricted shoulder movements +/- crepitus
  • Rotator cuff tear: painful arc on abduction
  • Rheumatoid arthritis: synovitis
196
Q

Management of Giant Cell Arteritis

A
  • Prednisolone 60mg
  • Pulsed methylprednisolone if visual symptoms
  • Consider alendronic acid/DEXA
197
Q

Extra-articular manifestations of ankylosing spondylitis

A

4 A’s
- Aortic regurgitation
- Anterior uveitis
- Achilles tendonitis
- Apical fibrosis

198
Q

Differential for ankylosing spondylitis

A
  • Psoriatic sacroiliitis
  • IBD-associated spondyloarthropathy
  • Paget’s
  • Hyperparathyroidism
  • Mets
199
Q

Severity grading system for ankylosing spondylitis

A
  • BASDAI (Bath Ankylosing Spondylitis Disease Activity Index)–> 4+ is active disease
200
Q

X-ray features of ankylosing spondylitis

A
  • Sacroiliitis (sclerotic/erosions)
  • Syndesmophytes (bony outgrowth from spinal ligament)
  • Bamboo spine
201
Q

Management of ankylosing spondylitis

A
  1. NSAIDs and physio
  2. Anti-TNFa (if not respond to 2 NSAIDs)

Intrarticular hydrocortisone for enthesitis

202
Q

Complications of Paget’s Disease

A
  • Skeletal: fracture
  • Cardiac: angina, high-output cardiac failure
  • Neurology: deafness (auditory nerve entrapment), cerebral ischaemia due to steal syndrome (increased bone metabolism)
  • Metabolic: hypercalcaemia (with immbolisation/fracture)
  • Oncology: osteogenic sarcoma
203
Q

X-ray features of Paget’s Disease

A
  • Osteoclastic and/or osteoblastic lesions
  • Trabecular thickening of inner pelvis
204
Q

Management of Paget’s Disease

A
  • Bisphosphonates if symptomatic: risedronate for 2months or STAT IV zolendronic acid
205
Q

Bisphosphonate side effects

A
  • Oesophagitis/ulcer
  • Osteonecrosis of jaw
  • Systemic symptoms: myalgia, flu-like
206
Q

Risk score for unstable angina/NSTEMI

A
  • TIMI (>3 is high risk for mortality)
207
Q

Bacterial vs viral lumbar puncture results

A
  • Bacterial: high protein, low glucose, high neutrophils, see microbe
  • Viral: normal protein, normal glucose, mononuclear cells (lymphocytes/monocytes)
208
Q

Diagnostic criteria for DVT

A
  • > 3cm increase in calf swelling (10cm below tibial tuberosity)
209
Q

DVLA rules for syncope

A
  • Unclear cause: 6 month driving ban
  • Treated cause: 4 weeks
  • Syncope due to seizures: seizure-free for 1 year
210
Q

Side effect of hydroxychloroquine

A
  • Retinopathy
211
Q

Side effect of sulphasalazine

A
  • Bone marrow suppression
  • Rash
212
Q

Side effect of azathioprine

A
  • Bone narrow suppression
213
Q

What is Jaccoud’s athropathy

A
  • Tendon contractures –> mimics rheumatoid arthritis
  • Associated with SLE, rheumatic fever, Sjogren’s
214
Q

Features of reactive arthritis

A
  • Can’t see: conjunctivitis
  • Can’t pee: urethritis
  • Can’t climb a tree: asymmetrical lower limb oligoarthritis (esp knee)

Also:
- Keratoderma blennorrhagia (plaques on soles)
- Circinate balanitis (penile ulcers)

215
Q

Features of amyloidosis

A
  • Very high JVP (high right heart pressures)
  • Ankle oedema
  • Periorbital purpura
  • Macroglossia
  • Constitutional symptoms
216
Q

Diagnosis of amyloidosis

A
  • Congo red stain: apple-green birefringence
  • Serum immunofixation (shows monoclonal protein)
  • Immunoglobulin free light chain assay
217
Q

Management of amyloidosis (primary)

A
  • Mephalan (chemotherapy) –> stem cell transplant
218
Q

Features of hypertensive retinopathy

A

1: Silver wiring (arteriole walls sclerosed)
2: +Arteriovenous nipping (arteriole crosses venule, compressing it)
3: +Cotton wool spots and flame haemorrhages
4: +Papilloedema
SAF was a Cool Person

219
Q

Fundoscopy features of retinitis pigmentosa

A
  • Peripheral pigmentation in retina
  • Narrowing of retinal vessels
  • Pale optic disc (neuronal loss)
220
Q

Fundoscopy features of retinal artery occlusion

A
  • Cherry red spot (macula gets blood supply from choroid)
  • Pale retina
  • Attenuated vessels
221
Q

Fundoscopy features of retinal vein occlusion

A
  • Flame haemorrhages
  • Swollen optic disc
  • Dilated tortuous veins
  • Cotton wool spots (microinfarcts)
222
Q

Aspects of an ulcer which need to be described

A
  • Shape
  • Edge
  • Base
  • Floor
  • Secretions
223
Q

Examination for rheumatoid arthritis

A

Look
- Place hands on white pillow
- Wrist –> MCP –> DIP –> PIP

Feel

Move
- Fist
- Stopping traffic
- Fingers pointing down
- Prayer sign
- Finger abduction
- Hold paper between fingers while examiner tries to pull the paper out
- Grip and pincer strength
- Undo a button/play the piano
- Sensation
- Write something
- Pallor/inside mouth

224
Q

Mechanism of methotrexate in rheumatoid arthritis

A
  • Inhibits T and B cells
  • Inhibits purine synthesis (hence need folic acid)
225
Q

Causes of anaemia in rheumatoid arthritis

A
  • Anaemic of chronic disease
  • GI bleeding (NSAIDs)
  • Bone marrow suppression (DMARDs)
  • Megaloblastic anaemic
  • Haemolytic anaemia
226
Q

Cause of Ehlers-Danlos

A
  • Genetic mutation (autosomal dominant)–> reduced collagen
227
Q

Investigations in Raynaud’s

A
  • Autoimmune screen (ANA, ENA, dsDNA, complement, ESR)
  • Urine dip (protein/haematuria)
  • ECG to check right heart strain/conduction abnormality– so also listen to heart for loud P2 and feel for RV heave (pulmonary HTN due to diffuse systemic sclerosis)
  • CXR (fibrosis)
228
Q

Definition of gestational HTN

A
  • BP >140/90 after 20 weeks gestation (before 20 weeks gestation is “pre-existing HTN”)
229
Q

Types of pre-eclampsia

A
  • Early-onset = before 34 weeks (causes IUGR)
  • Late-onset = after 34 weeks (no IUGR)
230
Q

Definition of severe pre-eclampsia

A
  • BP >160/110
  • Symptoms
  • Biochem/haem derangement
231
Q

Symptoms/signs of pre-eclampsia

A
  • Worst headache ever!
  • Epigastric pain (bleed in liver due to coagulopathy)
  • Sudden oedema affecting fingers/sacrum
  • Brisk reflexes (CNS irritability)
  • Ankle clonus
232
Q

Complications of pre-eclampsia

A
  • Eclampsia = grand mal seizures (LOC and tonic-clonic)
  • Stroke
  • AKI
  • HELLP (Haemolysis, Elevated Liver enzymes, Low Platelets)
  • IUGR/foetal death
233
Q

Investigations for pre-eclampsia

A
  • 2+ proteinuria
  • Urine protein/creatinine ratio >30mg/mmol
  • Monitor foetus
234
Q

Management of pre-eclampsia

A
  • Labetalol (nifedipine if asthmatic)
  • Aspirin 75mg from 12 weeks gestation if high-risk for pre-eclampsia
  • Deliver by 36 weeks
235
Q

Management of eclampsia seizure

A
  • IV magnesium
236
Q

When to check d-dimer in DVT

A
  • If Wells Score is 1 or less
  • If Wells Score is 2+ but USS normal or cannot do USS within 4hrs
237
Q

Important blood tests in acutely painful knee

A
  • HLA-B27 (+ve in 50% of reactive arthritis)
  • Urate
  • Anti-CCP/rheumatoid factor
238
Q

Complications of acromegaly

A
  • Cardiac: cardiomyopathy/IHD
  • Diabetes
  • HTN
  • OSA
239
Q

Important complication of trans-sphenoidal surgery in acromegaly

A

Hypopituitarism
- T4
- LH, FSH and testosterone/oestradiol
- Short Synacthen, cortisol, ACTH

240
Q

Drug causes of hyperthyroidism

A
  • Iodine
  • Amiodarone
  • Lithium
  • Contrast
241
Q

Nail changes in psoriasis

A

POSH
- Pitting
- Onycholysis
- Subungal hyperkeratosis

242
Q

Psoriasis variants

A
  • Guttate
  • Flexural: intertriginous areas
  • Pustular: palms/soles
  • Erythrodermic
243
Q

Bullous pemphigoid vs pemphigus vulgaris

A

Bullous pemphigoid
- Deep = doesn’t rupture
- Doesn’t affect mucosal

Pemphigus vulgaris
- Superficial = ruptures
- Mucosal involvement

244
Q

Features of high-risk proliferative retinopathy

A
  • New vessels on/adjacent to disc > 1/4 of the area of the disc in size
  • OR any new vessels causing vitreous haemorrhage

–> Needs pan-retinal laser coagulation within 2 weeks

245
Q

Features of Turner Syndrome

A
  • Webbed neck
  • No secondary sexual characteristics (pubes)
  • Cubitus valgus
  • Widely-spaced nipples
  • Shortened 4th/5th metacarpals
  • Nail dysplasia
246
Q

Counselling needed before radio-iodide

A
  • Up to 4 weeks away from children/pregnant women (bad for teachers!)
  • Away from confined spaces/same bed as someone for a few days
  • No pregnancy for 4 months
  • Can worsen eye disease
  • May set off alarms in airports!
247
Q

Other causes for goitre (apart from thyroid conditions)

A
  • Iodine deficiency
  • Pregnancy
  • Puberty
248
Q

Differences in the types of amiodarone-induced hyperthyroidism

A

Type 1
- Due to high iodine content of amiodarone
- In pre-existing thyroid condition (latent Graves/multinodular thyroid)
- 3 months onset
- Treatment: high-dose carbimazole

Type 2
- Destruction of thyroid–> release of T4
- In healthy people
- 30 months onset
- Treatment: steroids

249
Q

Investigations for male infertility

A
  • Morning testosterone
  • Sex hormone binding globulin (high as binds to testosterone = less active free testosterone)
  • FH/LSH (high in primary testicular failure)
  • Semen analysis
  • Pituitary scan if above investigations normal
250
Q

Causes of female infertility

A

Hypothalamic-pituitary: hypopituitarism, Kallman (hypogonadism), anorexia (amenorrhoea)
- Low FSH/LH

Hypothalamic-pituitary-ovarian dysfunction: PCOS, hyperprolactinaemia
- Normal FSH/LH

Ovarian failure: premature ovarian insufficiency
- High FSH, low oestrogen

Others: uterine, tubal disorder, genetics (Turner’s)

251
Q

Investigations for female infertility

A
  • Mid-luteal progesterone (cycle length - 7): should be high as ovulation creates corpus luteum which makes progesterone
  • Testosterone (PCOS)
  • Prolactin
  • FSH/LH
  • Ultrasound
252
Q

Investigations in C1 esterase inhibitor deficiency

A
  • Low C4, normal C3
  • Low C1q
253
Q

Important social history question in palpitations

A
  • Caffeine intake!
254
Q

Important question to ask in joint pain (especially if young)

A
  • Joint hypermobility (if yes, ask about pneumothorax)
255
Q

Two arachnodactyly signs

A
  • Thumb and pinky can overlap around wrist
  • Thumbnail folded across palm protrudes beyond ulnar
256
Q

Investigations for Marfans and its complications

A
  • Genetic testing (autosomal dominant mutation FBN1 gene)
  • Echo (cardiomyopathy)
  • Ophthalm referral (lens dislocation)
  • MRI spine (dural ectasia)
  • Pelvic XR: acetabular protrusion (femur head protrudes into pelvis)
257
Q

Types of Ehlers-Danlos

A
  • Hypermobile
  • Classic
  • Vascular
  • Kyphoscoliosis
258
Q

Important drug classes you need to ask about in haematemesis/PR bleeding

A
  • NSAIDs
  • Anticoagulants
259
Q

Key investigation in acute intermittent porphyria

A
  • Urine porphobilinogen (high)
260
Q

Management of acute intermittent porphyria

A
  • High carb diet with IV dextrose
  • Haem arginate
  • Haematology referral
261
Q

Beta-blocker commonly used in thyrotoxicosis

A
  • Propranolol (non-cardioselective)
262
Q

Drugs which cause optic neuropathy

A
  • Ethambutol
  • Amiodarone
  • Linezolid
  • Ciprofloxacin
  • Sildenafil
263
Q

Other causes of pigmented retina (apart from retinitis pigmentosa)

A
  • Infectious: rubella, syphilis, toxoplasmosis
  • Drugs: hydroxychloroquine
  • Angioid streaks in pseudoxanthoma elasticum
264
Q

Management of Hereditary Haemorrhagic Telangiectasia

A
  • Treat iron-deficiency anaemia!
  • Nasal humidification/spray (keep it moist)
  • Cauterisation and laser therapy
  • Screening for AVMs
265
Q

CASPAR diagnostic criteria for psoriatic arthritis

A
  • Current psoriasis (2 points)
  • Psoriatic nail changes
  • Dactylitis
  • Negative rheumatoid factor
  • Juxta-articular new bone formation

Need to score ≥ 3 points

266
Q

Examination findings in Paget’s Disease

A
  • Frontal bossing
  • Bowing and warmth of arms and legs
  • Hearing loss (CN 8 - otosclerosis)
  • Heart failure
267
Q

Pathogenesis of Paget’s Disease, including stages

A
  • Accelerated bone turnover and abnormal bone remodelling –> deformity and enlargement of bones (axial skeleton especially)
  • Osteolytic phase –> mixed phase (osteoblastic and osteoclastic) –> burnt out quiescent osteosclerotic phase.
268
Q

Causes of tunnel vision

A

Retinal
- Retinitis pigmentosa

Optic nerve
- Glaucoma

269
Q

Mechanism behind panretinal laser photocoagulation

A
  • Burn peripheral vessels –> directs blood towards ischaemic vessels in centre –> less VEGF
270
Q

Differential for RAPD (apart from optic nerve issue)

A
  • Massive retinal detachment
271
Q

Normal optic cup:disc ratio (as a %)

A
  • 30%
272
Q

4 types of spondyloarthropathy

A
  • Ank spond
  • Psoriatic
  • IBD
  • Reactive arthritis
273
Q

Skin signs for dermatomyositis

A
  • Gottron’s papules
  • Heliotrope rash
  • V-neck sign
274
Q

Why might rheumatoid cause painful walking

A
  • Subluxation (partial dislocation) of toe joints –> joint sticks out into sole –> keep on walking on this joint, causing painful callus
275
Q

Importance of hyperpigmentation in Addison’s

A
  • Shows Primary (as increased ACTH), not Secondary
276
Q

Differential for Port Wine Stain

A
  • Sturge-Weber: seizures, low IQ, brain angiomas
  • Klippel-Trénaunay syndrome: increased vessels one side, increased limb size on one side
277
Q

Causes of skin hyperpigmentation

A
  • Primary Addison’s
  • Haemochromatosis
  • Drugs: amiodarone, chemotherapy
  • Paraneoplastic secreting ACTH
278
Q

Erythematous maculopapular rash with scarring alopecia

A
  • Discoid lupus
279
Q

Conditions which trigger pseudogout

A
  • Haemachromatosis
  • Acromegaly
  • Hyperparathyroidism
  • Hypothyroidism
  • Wilson’s
280
Q

Criteria for referring rheumatoid arthritis to surgeons

A
  • Not responding to medical
  • Nerve compression (Carpal tunnel)
  • Imminent tendon rupture
281
Q

Features of Ehlers-Danlos

A

Skin/joints
- Fragile hyper-extendable skin (bruises)
- Joint dislocations

Cardiac
- Mitral valve prolapse (pansystolic with ejection click)

Abdo
- AAA rupture (may have scar!)
- Bowel perforation

282
Q

Hearing loss differential

A
  • Paget’s (hypercalcaemia, increased hat size, easy fractures, heart failure symptoms)
  • Acoustic neuromas
  • Drug-induced (furosemide, aminoglycosides)

Remember to do Rinne/Weber’s and otoscopy!

283
Q

Phaeochromocytoma management

A
  • Alpha blockade (phenoxybenzamine - can cause reflex tachy by increasing noradrenaline release)
  • Then Beta blockade (metoprolol- to treat tachy)
  • IV fluids
  • High salt diet on 3rd day after alpha blockade ( counteract catecholamine-induced volume contraction and orthostasis, which can be associated with alpha-adrenergic blockade)
  • IV phentolamine –> sodium nitroprusside infusion for hypertensive crisis
284
Q

Phaeochromocytoma management

A
  • Alpha blockade (phenoxybenzamine - can cause reflex tachy by increasing noradrenaline release)
  • Then Beta blockade (metoprolol- to treat tachy)
  • IV fluids
  • High salt diet on 3rd day after alpha blockade ( counteract catecholamine-induced volume contraction and orthostasis, which can be associated with alpha-adrenergic blockade)
  • IV phentolamine –> sodium nitroprusside infusion for hypertensive crisis
285
Q

Why do alpha blockade before beta blockade in phaeochromocytoma

A

Because beta blockade first may lead to unopposed alpha stimulation –> vasoconstriction and hypertensive crisis

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