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A PACES > Station 5 > Flashcards

Station 5 Flashcards

1
Q

What is cushings syndrome?
History

A

Hypercorticol

Head
-Rounded face
- Cataracts (steroids)
- Acne
- Visual field defects / headaches (pituitary)
- Oral thrush

Neck
-Buffallo hump
- Acanthosis nigrans

Body
- Central obesity
- Worse diabetic controll - polydipsia …
- Hypertension - headaches
- Increase bodily hair

Limbs
- Proximal myopathy - unable to stand from sitting
- Fragility fractures
- Avascular necrosis of femoral head
- Easy brusing

PMH
COPD / Asthma / bronchiectasis
Malignancy
inflammatory conditions - eg Rhem etc

FH
MEN

Social
Smoking
Diabetes
Function

DH
Steroid use

What is thier CONCERN

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2
Q

Differnet types of cushings and how to differentiate

A

Exogenous
- Secondary to steroid meds

Endogenous
- ACTH dependent -> Pituitary or ectopic neuroendocrine (most commonly small cell Ca / carcinoid)
- ACTH independed -> Adrenal carcinoma

Confirm diagnosis
Screen with

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3
Q

Cushings exam

A

End of bed
- Wheezing
- Central obesity
- Hairloss

Hands
- FIngerprick

Arms
- Bruises
- BP raised

Head
- Visual field defects
- Oral thrush

Neck
- Acanthosis nigrans

Abdo
- Striae
- Scars from adrenal surgery

Legs
- Ask to stand from chair without arms to assess proximal myopathy

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4
Q

Cushings ix

A

Observation chart
- Especially HTN and Tachy (episodic may be concominant phaeo in MEN)
- Finger prick glucose

Urine dip - glucose and protein

Bloods
Confirm diagnosis - overnight dexamethasone test.
ACTH levels
- High Pit / ectopic tumour
- Low Adrenal

Imaging
- CXR for lung Ca
- MRI pituitary
- CT adrenals / chest dependent on likelyhood

ECG - for LVH

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5
Q

What do you have to stop before doing overnight dex supression test? How does it work?

A

HRT
COCP
pred / dex etc

1mg dex at 11pm
Measure cortisol at 9am (should be supressed)

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6
Q

Slightly unclear if cushings from pituitary or not after MRI what test can you do?

A

Inferior petrosal sinus sampling

[Measure ACTH levels in vein draining from pituitary]

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7
Q

How do Ketoconazole / Metyrapone work for cushings

A

reduce baseline cortisol by inhibiting 11b hydroxylase

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7
Q

Management of cushings

A

Conservative
- Patient education
- PT / OT if required
- Slow withdrawal of causative agent

Medical
- Management of HTN / diabetes / bone protection
- Steroid sparing agent eg Azathioprine in crohns
- Ketoconazole / Metyrapone while awaiting definitive surgery ->

Surgery
- Trans-sphenoidal hypophysectomy for pituitary adenoma
Adrenalectomy for adrenal adenoma

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8
Q

Osteoperosis lumbar fracture ix? management?

A

Bloods
- FBC/CRP/ESR - infection / anaemia chornic disease. Myeloma
- Renal function - myeloma and opiate analgesia
- LFTs - ALP mets
- Ca
- Serum electrophoresis / bence jones - myeloma

Imaging
- Lumbar XR
- Likely for DEXA to meausre bone density looking for <-2.5 if she has osteoperosis

Conservative
Physio
Allert button
POC

Medical
Analgesia + constipation counciling
Caclium
Post dexa - bisphosphonate once weekly

Repeat appointment

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9
Q

How do cancers present

A

Local disease
Eg lung Pain / SOB / Cough / haemoptysis

Systemic
- Weight loss, reduced apetite, night sweats
- Paraneoplastic Eg hyperCa, SIADH

Through screening programes eg bowl / breast

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10
Q

History taking basics to jot down structure

A
  • HPC
  • PMH
  • Systems review
  • DH
  • SH
  • FH
  • ICE
  • Summary
  • Plan
  • Examine
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11
Q

Chest pain causes

A
  1. Cardiac
  2. PE
  3. PTX
  4. Pneumonia
  5. MSK
  6. Gastro / gall bladder
  7. Anxiety
  8. Dissection
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12
Q

and writing in types of tremor

A

Parkinsons - small
Cerebella - messy
essential - messy

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13
Q

Tremor differentials

A

Essential

Parkinsons
Parkinsons plus. PSP, MSA, CBD, demetia lewy

Drug induced
- Dont forget OTC Metoclopramide / promethazine

Thyroid

Phaeo

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14
Q

How is alcohol related to tremor

A

Alcohol -> cerebellar disease
Withdrawal -> tremor especially in morn
Improves essential

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15
Q

2 syndromes with ciliary dyskinesia

A

Primary ciliary dyskinesia
Kartageners

both get chronic sinusitis and infertility

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16
Q

Heart defects associated dextrocardia

A

Transposition of great arteries
VSD
pulmonary stenosis

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17
Q

Present VSD

A

This young patient has a loud pan systolic murmur

The pulse is regular and the fingernails are clubbed

There is a prominent apex beat.

There is a loud P2 and raised JVP which would be suggestive of Eisenmenger’s syndrome

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18
Q

What is Eisenmenger’s? Causes?

A

Occurs with L-> R shunt
Rise in pulm artery pressure to that of L sided circulation
-> reversal of shunt
-> cyanosis

Causes
- congenital VSD/ASD/PDA/Fallots
- Pulmonary hypertension

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19
Q

How might murmur change with size of VSD

A

Small - loud pansystolic
Large - softer murmur with loud P2 (pulm HTN) + early diastolic pulm regurg

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20
Q

Causes of VSD

A

Congenital - 1/500 Births
Eg With down / turners / tetralogy / pda

Aquired
- Post MI with septal rupture

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21
Q

Fallots bits

A

Pulm stenosis
VSD
Overriding aorta
RVH

22
Q

What is fibromuscular dysplasia ? Symotoms? Diagnosis?
Treatment?

A

Condition where some large arteries have abnormal cells in wall -> string of beads appearance
Most commonly Renal and Carotid arteries (GI and all others can be involved)

Usually occurs in some women

Symptoms
- Headaches, neck pain, pulsitile tinnitus,
- May cause TIA
- Renal artery -> HTN, flank pain, Renal Bruis
- Intestine / liver /spleen - pain and weight loss
- Extremities - discomfort on exercise

Complications
- As above
- Aneurysms / Dissection of artery
- SCAD

Diagnosis
Angiography / CT / US

Treatement
- STOP smoking
- Consider antiplatelet for stroke prevention
- Anthypertensive
- Angioplasty / stenting
- Surgery for high risk arteries

23
Q

Main 2 issues with peutz jegher?
Cause?
Complications

A

Colonic polyps
Melanotic macular patches in mouth, arms and genetalia

Autosomal Dominant Mutation in STK11 gene (tumor supressor)

Complcations
- Polyp large enoigh to obstruct
- Polpt ulcerate and bleed -> IDA
- Cancer many places - Colon, pancreas, uterine, breast, lung, testis

Exam of macules
Colonoscopy
Genetic testing for STK11

24
Q

Heredetary haemorhagic telangectasia is? Where do you get them?
Diagnosis? Management?

A

Osler webber rendu

Autosomal Dominant causing Telangectasias in many places which can bleed especially
- nasal recurrent epistaxis - 95%
- GI melena 25%
- pulm arteriovenous malformation (SOB) 15% -> SOB, cyanosis, polycythemia, stroke

Diagnosis
FBC anaemia
Feceal occult blood
Angiography
Genetic testing

Management
- Symotomatic eg iron / blood
- Telangectasia - laser
- Emobili - antiplatelets
- Pulm AVNs - surgical

3 words / 3 people

25
Q

Facial findings of hypothyroid

A

Peaches and cream complexion
Loss of outer 1/3 eyebrow hair

26
Q

Anaemia definition

A

In men aged over 15 years — Hb below 130 g/L.

In non-pregnant women aged over 15 years — Hb below 120 g/L.

In children aged 12–14 years — Hb below 120 g/L.

In pregnant women — Hb below 110 g/L throughout pregnancy.

27
Q

Mechanisms of anaemia

A

Production issues
- Myelofibrosis
- Marrow infiltration eg Ca / infection
- B12 / Folate / iron
- Renal anaemia (epo)
- Thalassaemia

Increased destruction
- Sickle cell
- Spherocytosis
- Haemolysis from valves
- Hypersplenism

Increased plasma volume
- Post resus
- Pregnancy

Blood loss

Anaemia of chronic disease

28
Q

Microcytic anaemia causes

A

Caused by impaired haemoglobin synthesis

Anaemia of chronic disease
Iron deficiency
Thalassaemia
Acute - lead posoning
Sideroblastic anaemia

29
Q

How to differentiate Normocytic anaemia cause

A

[RBCs lost / less produced]
WBC and reticulocyte count

30
Q

Macrocytic anaemia causes? investigations to differentiate?

A

Decreased DNA synthesis / decreased cell division

Megaloblastic (impaired DNA synthesis) - Delayed maturation which results in fewer large cells
- Vit b12/folate
- Chemotherapy drugs which interupt dna synthesis
- Anti folate drugs - methotrexate, phenytoin, trimethoprim

Non megaloblastic
- Alcohol use
- liver disease
- Hypothyroid
- haemolysis
- Myeloma
- Myelodysplasia

31
Q

Signs of anaemia

A

All
- pallor
- Hyperdynamic circulation - tachycardia, systolic flow murmur (+/- hypotension)
- Peripheral / pulm oedema due to high output cardiac failure

Iron deficiency
- Koilonycia, Angular stomatitis

b12 deficiency
- Jaundice
- Peripheral neuropathy + hyperreflexic knee jerks, absent ankle reflex
- Glossitis
- Cognitive imparement

Haemolysis
- Jaundice
- Cardiac surgery
- Splenectomy surgery

Crohns - apthous ulceration
Telangectasia - HHT
Mucosal lesions - peutz jegur

Abdo scars / masses

Anaemia of chronic disease - Rashes / joint pathology

32
Q

How to interpret iron studies

A

Low ferritin
- Iron deficiency

Normal ferritin does not exclude
- Ferritin increases with age / inflammation/infeciton

Iron levels
Iron levels
Total iron binding capacity
-> Transferrin (carrier of iron)

Transferrin saturations = iron level / total iron binding capacity
- normal 20-50%
- Low suggests iron deficiency
- normal in anaemia suggests anaemia of chronic disease
- High hereditary haemochromatosis

33
Q

History points for causes of iron defiency anaemia

A

General symptoms
- Fatigue, weight loss, exercise tollerance

Dietary restrictions

Meds
- Anticoagulants
- OTC analgesia - NSAIDS

Blood loss
- Donation
- Menstural
- Malena
- Epistaxis
- Haematuria

Malabasorbtion
- Diarrhoea
- Ulcers in mouth
- Weight loss / fevers

PMH
- IBD
- coeliac
- Surgery
- Pregancy

34
Q

IDA investigations

A

Bloods for specific cause
- Iron / b12 / folate
- Coeliac - anti-TTG / anti-endomysial

The poo itself
- Stool culture
- Feacal Calprotectin
- Parasite screen

Visualise the bowel
- OGD / colonoscopy

woman
- Gynae review if needed

If epistaxis / haemoptysis
- Chest CT to look for pulmonary artery venous malformations (HHT)

35
Q

Differentals of B12 deficiency?
apart from Ix of these what other Ix?

A

Diet - especially vegans

Drugs
- Metformin
- PPIs

Decreased Absorbtion
- Crohns
- Coeliac
- Pancreatic insufficiency
- Pernicious anaemia
- Hy pylori
- Surgery

  • Diphyllobothrium latum - fish tapeworm

Additional Ix
- Neuro signs - MRI of spine
- Visual evoke potentials if optic atrophy suspected

DDDD

36
Q

Bloods to suggest anaemia of chronic disease? Pathophysiology

A

Usually normocytic / microcytic
Elevation of inflammatory markers
Low serum iron
Normal / reduced serum iron binding capacity

Inflammatory cytokines (eg IL-6) increase Hepcidin (produced in liver) which blocks the release of iron from macrophages, hepatocytes, and enterocytes

37
Q

IDA how long do you give iron for

A

3 months after normalisation of anaemia and microcytosis
-> replace marrow and liver stores

38
Q

Why is b12 given as injection?

A

Most common mechanisms of deficiency are dsorders of luminal absorbtion

If vegan diet is cause can just give oraly

39
Q

Folate and borderline b12 what do you need to do?

A

Replace both - ideally b12 first

If just replace folate there is a risk of worsening b12 deficiency -> subacute degeneration of cord

40
Q

Haemolysis investigations? Key infections causing?
Ix for cause?

A

Blood film - fragmentation
Reticulocyte count
LDH
DAT
Haptoglobin

Infection screen
- Mycoplasma
- Malaria
- Parvovirus
- EBV

Specific causes
- Haemoglobinopathy screen
- G6PD screen
- Osmotic fragility test - spherocytosis / eliptocytosis
- Flow cytometry for CD55 and CD59 - Paroxysmal nocturnal haemaglobinaemia

41
Q

Aaemia and raised white cell count / platelets causes

A

WCC
- Infection / inflammation
- Leukaemia
- Malignancy
- Steroids

Thrombocytosis
- Blood loss
- Iron deficiency
- Myeloproliferatice

42
Q

Eczema differentials

A

Scabies - especially if intense itching after showers

tinea pedis if starting between toes and spreading

Irritant contact dermatitis - if localised to a particular area

Sebberhoeic dermatitis - if affecting head

43
Q

Eczema common triggers

A

House dust mites

Pet fur

Pollen

Food - eg cows milk/eggs/nuts

Detergents

Stress

44
Q

Lifestyle advice eczema ? Other treatment?

A

Avoid triggers eg pets / dust

Dont use non perescription shower gel

Don’t overwash - can dry out skin

Cotton clothes

Treatment
- Plenty emollents
- Use prescription soaps eg dermol 500
- Topical corticosteroids for defined period of time (less potent over eyes / face / flexures)
- Antihistamines
- Topical Abx if infection

45
Q

Immunosupressant / Biologic for eczema

A

Azathioprine
Cyclosporine
Methotrexate
Mycophenolate mofetil

Dupilumab

46
Q

Topical steroids side effects?

A

Telangectasia
Atrophy
Striae
If eyelids -> glaucoma / cataracts

47
Q

Causes of puritis

A

Skin
- Eczema
- Dermatitis herpetiformis
- Scabies
- Fungal
- Lichen planus

Systemic
- Cholestasis
- Uraemia
- Lymphoma
- Polycythaemia
- Drug reactions

48
Q

Causes of non bacterial meningitis

A

Viral Eg HSV
Lime disease
Fungal
Protozoal eg malaria
Malignant
Paraneoplastic

49
Q

How would you approach meningitis management

A

Focused A-E with obersvations

Bedside
- Glucose

Bloods
Inflam markers, lactate

If no localising signs or evidence of raised ICP -> LP otherwise

Administer broad spectrum antibiotics according to local guideline

Organise Urgent CTB followed by LP
LP looking at opening pressure, Protein, glucose, lactate, Cell counts, gram stain, culutre, viral / bacterial PCR

50
Q

Complications of meningitis

A
  • Death
  • Permanent neurological issues eg cognitive, deafness, blindness
51
Q

Management of migraine

A

Acute symptom management
- Start with paracetamol and NSAID
- Consider triptans
- Antiemetic

Prophylaxis if recurrent or debilitating
- Lifestyle - hydration, sleep, exercise, stress and other triggers eg chocolate
- Propranolol / topimarate

52
Q

Important Qs in Headache to rule out

A
  • Meningism - neckstiffness, photophobia
  • Infective symptoms - eg rash, Immunosuppression, fevers
  • Evidence raised icp
    -Nausea and vomiting focal neurology, Posture, coughing
  • GCA - jaw claudication, scalp tenderness, visual loss
53
Q
A

A PACES (10 decks)

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