STATION 5 Flashcards
1
Q
Management of Charcot’s foot
A
- Non- surgical
Protective splint
weight bearing braces
orthosis
cast - surgical
open reduction and internal fixation andfusion
later stages:
Realingment osteoyomy and fusion
2
Q
What are the side effect of cyclosporine?
A
gum hypertrophy
hypertension
increase risk of malginanacy e.g NHL
3
Q
A
ascites
astertix
jaundice
encelopathy
Vacular
varices
caput maduses
4
Q
what are variant syndrome for liver transplantaion?
A
- diuretics resistant ascites
- hepto-renal syndrome
- chronic heptaic encephalopathy
- hepato-pulumonary syndrome
- recurrent cholangitis
5
Q
Investigation and management of acute stroke
A
- CT head - exclude haemorrhage
- thromoblysis if within the window
mechanincal pneumatic compression
SALT
PT - manage spascity
Secondary/long term
- lifesyle manangement
weight loss, reduce salt and alcohol intake - BP, diabetes control
6
Q
what are the examination finding of retinitis pigimentosa
A
Reduced visual acuity
fundoscopy: waxy pallor of the optic skin and pigmentation of the retina in bony spicule pattern.
7
Q
what are the differential diagnosis of bilateral visual loss
A
Acute - migraine
Chronic -
1. glaucoma
2. cataract
3. diabetic retinopathy and maculopathy
4. idiopathic intracranial hypertension
5. Vitamin A defcieincy
8
Q
inheritance associated with retinitis pigmentosa ?
A
Autosomomal
recessive
x link
approx 30% de novo mutation
9
Q
syndromic association of reitinits pigmentosa
A
- usher syndrome - retinitis pigmentosa and sensory neural deafness
- refsum syndrome - progressive muscle wasting , weakness and ataxia
10
Q
causes of acute monoarticular pain and swelling
A
Trauma
Infective arthritis
Inflammation - (crystal arthiritis - gout, psuedo gout, reactive arthritis, sarcoidosis )
Heamarthrosis - bleeding disorder
Degenerative - Flare of OA
11
Q
investigation for reactive arthriritis
A
Blood test - FBC, LFT, Serum creatinine and urice acid
BC
Synovial fluid analysis and culture - cell count, Gram stain and culture and polarising microscopy for crystals
USS
urine PCR for gonococuss and chlamydia
HIV, syphillis and hep B
12
Q
what are the symptoms and signs of hypothyroidism
A
- lethargy
- muscle weakness
- fatigue
- cold intolerance
- mood
- postural hypotension
- menorrhagia
- myxoedema
13
Q
what are the clinical sigs of hypothyroidims
A
- bradycardia
- cerebellar dysfunction
- slow relaxing deep tendon reflex
- peripheral neuropathy - (Maybe associated with pernicious anemia )
14
Q
causes of hypothyroidism
A
- Hashimoto’s
- iatrogenic-thyroidectomy, radio-iodine therapy
- drugs- amiodrarone, carbimazole,propythiouracil,lithium.
- de quervain
- post partum
15
Q
investigation for thyroids
A
- TFT
- antityroglobulin and thyroid perioxidase antibodies
- 9am cortisol
- lipid profile - hypercholestrolaemia i hypothyroid
- fbc -macrocystic anameia
- u+e
7.ck
thyroid uss
16
Q
what cardiac condition is assos with osteogenesis imperfecta?
A
aortic regurg
biscuspid aortic valve
17
Q
clinical finding of osetogenesis imperfecta
A
blue sclera
short stature
spinal scoliosis
conductive deafness
joint hypermobility and skin hyperlaxity
18
Q
Ix and treatment of osteogenesis imperfecta
A
- bone profile - vitamin d and calcium
- DEXA scan - get xray of the jaw and dental check up before starting
19
Q
A
J1. oint instability and dislocations due to hypermobility.
2. Skin fragility, bruising, and delayed wound healing.
3. Vascular issues (e.g., arterial rupture, aneurysms) in vascular EDS (vEDS).
4. Osteoarthritis from repeated joint injuries.
5. Cardiovascular problems, including mitral valve prolapse and aortic dissection.
6. Muscle strains and tendon ruptures due to fragile connective tissue.
20
Q
what are the complications of meningitis?
A
- Permanent neruological e.g sequale e.g deafness
- long term memory loss
21
Q
what are the symptoms of hypothyroidism?
A
weight gain
depression
cold intolerance
constipation
proximal muscle weakness
mennorahagia
22
Q
what are the physical findings of hypothyroidism ?
A
hypothermia,
bradycardia
diastolic dysfunction
cognitive impairment
coarse facies
lateral eyebrow thining
goiter
dry or coarse
horse voice
delayed relaxation
non- pitting oedema
23
Q
what are the causes of hypothyroidism
A
- Primary or TSH indepedent
A- Thyroiditis - Hashimotos, postpartum, subacute, drug induced , radiation, infectious
B- Iodine related
C- Iatrogenic - throidectomy, ablation, medication, radiation
D. Infiltrative - - hemochromatosis, amyloidosis, sarcoidosis, reidel thyrodidits - Central - TSH depended
Pituitary dysfunction
Hypothalamic dysfunction
24
Q
investigation for suspected failing transplant
A
- bloods including tacrolimus level
- USS or CT
- Biopsy
25
How would you localise a level of myelopathy ?
sensory level
UMN Lesion below the level
LMN at the lesion
26
how would you manage acute IBD
A. Bedside
1.observation : BP, HR and Temp - signs of sepsis
2. Stool MC&S - infective cause
3. Bloods - Anaemia. electrolyte disturbance, and inflam markers and LFT
Treatment
Analagesia
IV fluids
Hydrocortiosone
VTE prophylaxis
27
what are the indications of surgical intervention for IBD
1. refractory to medical management
2. fistulating disease
3. Dilatation
28
what investigations would you request for a young stroke?
1. FBC, U&E, LFT
2. Autoimmune screen - dsDNA, ANA,ENA
3. Coagulation- antiphospholipid antibodies
4. ECG - paroxysmal arrhytmia
5. ECHO +/- bubble contrast
6. Carotid Doppler
7. CT MRI
29
how would you treat TIA
Aspirin until a review in the clinic - change to clopidogrel
conservative - Alcohol, smoking, weight loss,
Modify and optimise HTN, DM
Stop driving for a month
30
what are the complications of antiphospholipid syndrome
Recurrent VTE and DVT
multiple miscarriages
Livedo reticularis
Thrombocytopenia
31
what condition could cause obstructive picture in a transplanted lung ?
bronchiolitis obliterans
Involve transplant team early - perform bronchoscopy or biopsy
32
Examination findings of Parkinson's Disease
Pin rolling tremor
Cogwheel rigidity
Bradykinesia
postural instability
mask-like face
33
what are the differential ddx of Parkinson's
1. Idiopathic
2. Drug-induced Parkinsonism - metoclopromide
3. Wilson disease
4. Parkison's + - supranuclear palsy, multisystem atrophy, lewy body disease
4. normal pressure hydrocephalus
34
what are the associated features or conditions associated with spinal bifida
1. Arnold-Chiari malformation -brain tissue extending into the spinal canal
2. hydrocephalus
3. Bladder and Bowel Dysfunction - Neuropathic bladder,incontinence or recurrent UTI
4. syrinx
5. leg spasciity
35
questions to assess thyroid status
weight and appetite
bowel habit
preference for heat or cold
menstrual cycle
Sleep
tremors
palpitations
Is there any pain, swelling or redness in your eye ?
seeing double?
able to close eyes fully ?
swelling in front of the neck ? yes - check pressure sx - changes /horseness to voice, difficulty swallowing ?
36
what question to ask to screen for proximal neuropathy
Do you have difficulty raising your arm or rising from a seated position ?
37
what do you check for in hyperthyroid examination
Proptosis
LID RETRACTION and LID LAG
close eye fully
Visual acuity
eye movement for opthalmolpegia
examine sweelinf of the neck
test power in proximal limb
inspect shins for evidence of pretibial myoxedem
38
investigation
FBC, LFT, CK
Thyroid panel - TSH, T4
antiboidies - TSH receptor and thyroid peroxidase
USS
RAI
CT or MRI of the orbit to assess for eye disease
39
what are the features of Cushing syndrome?
1. HTN
2. DM
3. proximal myopathy
4. Osteopenia
Avascual necrosis of the bone
Redistrubution of the fat to upper half of the body and face (moon facies ), fat in the supraclavicular and dorsocervixal regions
Thining of skin
Acne and Hiurtism
Cataract andglaucoma
40
what investigation should request for cushingoid
Fasting blood glucose and HbA1C
Lipid panels
Serum Vitamin D
Bone density scan
41
How do you investigate for suspected endogenous cushing's
1. Screening test
a) 24 hour urinary free cortisol measurement
b) Low dose dexamethasone suppression test
c) Late night salivary cortisol
if 2/3 abnormal
2. Measure ACTH
If ACTH low - Adrenal CT
If ACTH is increase - pituitary or ectopic
Proceed to do HIgh dose dexamthasone supreesion test
1- If serum cortisol suppressed - MRI brain
2. Serum cortisol not suppressed - ectopic - CT/PET
42
what are the extra-articular features of RA
Eyes: episcleritis, scleritis, scelromalacia, Keratoconjunctivitis sicca
Cardiac: constrictive pericarditis, pericardial effusions
Lungs - fibrosis, methotraxate-related fibrosis , fibrosis alvolitis (obstructive Lung disease )
Kidneys: nephrotic syndrome ( membranous nephropathy , renal amyloidosis
Felty syndrome: Slenomegaly. RA, neutropenia
43
what are the possible causes of Anaemia in RA
Anaemia of chronic disease
Iron deficiency anaemia as a result of PUD from NSAIDs
Bone marrow suppression
Autoimmune haemolytic anaemia
Spenomegaly
44
what are the radiological features you might in RA
1. Soft tissue swelling
2. Loss of joint space with potential subluxation
3. Periarticular osteopenia and joint erosion
45
Diagnostic criteria of RA
1. Morning stiffness >1 hour
2. Swelling of 3 or more joints
3. Swelling of MCP, PIP, wrist joint
4. Subcutaneous RA
5. Presence of IgM Rheumatoid factor
6. Radiographic erosions/ Periarticular osteopenia
46
what would you find in hand examination of someone with RA
1. Symmetrical deforming arthropathy
2. Rheumatoid nodules
Palmer subluxation and ulnar drif
Swan -neck - rupture of lateral slip of extensor expansion
Boutonenier - rupture of central slip
Z shape deformitites
Swelling and subluxation of ulnar styloid
47
How is disease actiivity measured in RA
DAS28
5.1> Active disease
48
what are the causes of weakness related to the brain
1. Stroke
2. Tumor
3. Brain abscess
4. MS
5.ADEM
49
Causes of weakness related to the spinal cord
1. Spinal cord compression from disc herniation
2. Trauma
3. Infection
4. Vascular disease
5. Vitamin B12 Deficiency
6. MS
7. Transverse myelitis
8. Hereditary
50
what are the complications of acromegaly?
Hypertension
DM
Proximal Myopathy
Carpal tunnel syndrome
Congestive cardiac failure
OSA
OA
Colon cancer
51
what examination would you perform in Acromegaly
BP
Visual Fields
Proximal Myopathy - stand with arms crossed
Carpel tunnel
52
what investigations would you do in Acromegaly?
IGF-1
OGTT
fasting blood glucose and serum calcium and PTH (think of MEN )
MRI head
Colonoscopy
pitutiatry panel -TSH, ACTH, Prolactin FSH, LH
53
Management of acromegaly
Transpheoidal recetion
Radiothrapy
octreotide -somastostatin receptor agonist
dopamine agonist
pegvisonant
54
what examination would you do in TIA
CV exam- Pulse, BP. Auscultation
Neurological exam
- pronator drfit
-visual field
-CN VII weakness
- CN V and upper limb sensation
55
Investigation for HTN
1. Evidence of end-organ damage - Fundoscopy, LVH on ECG, renal impairment, cardiac failure
2. Ix for underlying course
a. Urinalysis and urine ACR
b. U&E - low K, high bicarbonate (Conn's)
c. Aldosterone/renin ratio - High ARR >30 - conn. Low ARR - 2dry cause
d. Plasma +/- urinary metanephrines
56
what are the causes of optic disc swelling
1. Pailloedema - raised IC pressure - SOL, Intracranial pressure, carverbous sinus thrombosis.
2. Optic Neuritis: MS, reduced visial acuity, central scomtoma, pain on eye movement. Unilateral
3. Accelerated phase hypertension
4. Central retinal vein occlusion - large number of haemorrahges
5. Anterior ischaemic optic neuropathy - pale disc, reduced colour vision/loss of vision. Ass with pain on chewing and scalp tenderness. Non-artetitic- painless visual loss
57
what are the complications of Eisenmenger's syndrome ?
1. Chronic hypoxaemia - polycythaemia - dizziness, headache, visual problems.
2. IDA due to polycythaemia
3. Paradoxical emboli
58
Management of Eisenmenger's syndrome
Pulmonary vasodilator therapy - PDE% inhibiotr, espprostenol
Anti-coagulation
Supportive - Immunisation,
Correction is CI
Heart and lung transplant
59
Differential diagnosis for Ataxia
MS
Vestibular ataxia
Stroke
Drug/ alcohol
Friedriech ataxia
60
causes of thunderclap headache
SAH
Meningitis
Intracranial hypertension
Central venous thrombosis
Malignant hypertension
61
what are the precipitating factors for DKA/HHS
4I
Insulin forgotten
Infection
Infartion
Injury
62
what are the ddx for syncope
Cardiac: brady or tach, obstructive cardiac lesion : AS, MS, HOCM, PH
Neuro : Episley, vertbrobasilar insufficiancy, EtOH, diabetes (hypo)
Orthostatic (postural ) hypotension - vasodilator drugs
vasovagal: stress, cough, micturation, defeaction
63
Investigations for non- provoked VTE/PE
EXAMINE CERVIAL LYMPHADENOPATHY
Baseline bloods: check calcium, LFT,
Exclude nephrotic syndrome
CT AB - depending on hx and Ix
follow up -
64
Investigations for fever of unknown origin
(Septic screen)
1. Blood culture - including thick and thin film
2. Urine and CSF
3. Serology: EBV, CMV, HIV testing
4. Molecular PCR: HIV for confirmation
Procalcitonin - high specificity for bacterial infection
CRP, ESR, autoantibodies, immunoglobulin and complement levels
CK
US abomen - collection
Cross section imaging: CTAP, MRI, PET - vaculities
65
ddx for bilateral lower leg swelling ?
1. cardaic failure
2. Liver failure
3. Nephrotic syndrome
4. fluid overload
5. Inferior vena cava obstruction (intra abdominal malignancy )
66
what investigations would you do in neprotic syndrome
Urinalysis and uACR
Reanl function
LFT
BFTS
FBC and coagulation
Lipids
Ix for the underlying cause
- autoimmune serology - ANA, complement, anti-phosholipase A2 receptor (PLA2R) membranous nephropathy )
Infections - HIV, HBV, HCV
CXR - fluid overload
Renal tract USS
HbA1C
67
MAnagement of nephrotic syndrome
1. loop diurectic d
2. anticoagulation if serum albumin is <20g/l
3. treat primary cause
4. ACE inhibitors
68
what is nephrotic syndrome and common cause ?
Hypoalibumniaemia + proteinuria (>3g/day or uACR >250mg/mmol)
Assosiciated with hypercholesterolemia
Increased thrombotic risk
Increased susceptibility to encapsulated bacterial infection
common cause:
1. Primary - membranous nephropathy, FSGS, minimal change disease and IgA nephropathy
2. secondary glomerular lesion
- Diabetic nephropathy
- amyloidosis
-SLE
-RA
Drung - NAIDS, gold, heroin
Infections : - HIV, HBV, HCV, MAlaraia
69
what symptoms should you check for in Liver disease
Jaundice,
Weight loss
Abdominal pain
Abdominal swelling
fever
Anorexia
Pruritis
Drowsiness, daytime somnolence, cognitive problem
Change in bowel habit - malena
Dark urine
medication
Alcohol
Viral infection
Travekla nd sexual hx
tattos and accupuntcutre
70
Investigations for liver disease
Blood: FBC, clotting, Calcium, U+E, INR
CXR - Effusion, mets
ISS of liver - dilated ducts, gall stones, mass lesions
Special
Hepattiis serology
Paracetamol levels
MRCP+/- ERCP - diagnostic and therapeutic
OCD varcies
CT abdomen
Ascitic tap
If encephalopatjic investigate for for reversible causes - dehyration, infection, GI bleed, constipation
71
what are the causes of erthema nodosum?
skin - tender, smooth, shiny nodules on the shins
SAD CLOTH
S= sarcoidosis
A= Autoimmune disease - SLE, IBD
D- Drugs e.g sulfonamides, oral contraceptives, penicillin, phyntoid
C = Cryptococcus and other fungal infections
L = Lymphoma
O = Other bacterial infections: Tuberculosis (TB) and Yersinia are notable examp
T- TB
S- Streptococcal Infection
72
Complications of Acromegaly
Acanthosis nigricans
BP
Carpel tunnel syndrome
Diabetes Mellitus
Enlarged organs
Field defect
Gatrointestinal malignancy - (colon carcinoma ), goitre
Heart Failure, hirsute, hypopituitary
IGF-1
Joint arthropathy
Kyphyosis
Lactation (galactorrhoea)
Myopathy
73
How do you investigate for the cause of complications of acromegaly
1. CXR - cardiomegaly
2. ECG: Ischaemia (DM and hypertension )
3. Pituitary Function Test: TSH, ACTH, PRL and test
4. Glucose: DM
5. Visual perimetry
6. OSA
74
Management of Aromegaly
Surgery: Trans-sphenoidal approach - (Post complication - DI, Panhypopituitarism,meningitis )
Medical therapy: Somatostatin analogues - (octreotide ) domapine agonist (cabergoline )
GH receptor antagonist ( pegvisomant- SC) block GH action
Radiotherapy
Follow up -
Annal GH, prolactin, ECG, Visula fields and MRI head
75
Causes of acanthosis nigricans
Obesity
T@DN
Acrogmegaly
Cushing syndrome
Ehtinicity - inidan subcortinent
Malignancy - gastric carcinoma and lymphoma
76
causes of macroglossia
Acromegaly
Amyloiodosis
Hypothyroidism
Down syndrome
77
how do manage hyperthyroidism
b-blocker for sx relief
Block and replace
Titrate dose and monitor thyroxine
Opthalmopathy - steroids
Stop at 18 months and assess
if return - repeat block and replace
Radoiodine
Subtotal thyroidectomy
