station 5 Flashcards
Causes of pyoderma gangrenosum
IBD (UC)
Sarcoidosis
Idiopathic
TB
Haematological malignancies, myeloproliferative disorders
Rheum - RA, ank spond, seronegative arthritis, SLE
Liver - PBC
Ix for non-healing ulcer
Bloods to look for underlying condition - autoimmune screen
Biopsy of the ulcer (pyoderma, Marjolin’s)
Imaging - colonoscopy, CT
Psoriasis
Types / classification
Triggers / exacerbating factors
Key management points
Measuring effect on QOL
Complications
Types: Plaque Pustular (palmar/plantar or generalised) Guttate (post-infection) Flexural Brittle (can be post steroids) Erythrodermic Psoriatic arthropathy (10-30%)
Triggers / exacerbating factors:
NSAIDs, Li, beta blockers
Trauma
Infection
Mx:
Topical - emollient and calcipotriol (vit-D derivative) +/- topical steroid (hydrocortisone)
Can also add dithranol, tar, topical retinoids and salicylic acid (keratinolytic)
Systemic: Phototherapy DMARDs - methotrexate, ciclosporin as first line agents Retinoids Biologics
Disease severity score:
DLQI - max 20 (very bad)
PASI - needed prior to biologics
Complications:
Psychosocial effects
Psoriatic arthropathy
Increased independent cardiovascular risk
Indications for bisphosphonate / bone protection
Those who have been taking steroids for over 3mths, or are likely to, AND
Age over 65
Under 65 but with fragility fracture (NOF)
Under 65 without fragility fracture but T-score <1.5
Drugs that can worsen Raynauds
Beta blockers
Cocaine
Sumatriptan
Key things to ask about if suspect CREST (Hx)
Key things o/e
Other things to examine
Raynauds sx
Oesophageal dysmotility and red flags
Fibrosis - ILD, renovascular disease causing htn
Other autoimmune conditions
O/e: Calcinosis and Raynauds of fingers Sclerodactyly Face - tight shiny skin, telangiectasia Hand function
Other:
Lung for ILD
BP - CREST is RF for malignant htn
Cardiovascular system - pul htn
Difference between Raynaud’s disease and Raynauds syndrome
Disease - colour change seen in fingers occurs in isolation without any associated condition
Syndrome (secondary) - Raynaud’s phenomenon occurs as a result of an associated condition (SLE, CREST)
Crohns disease
Indications for biologics
Fistulating disease
Disease refractory to steroids
Pts not suitable for surgery - eg short bowel, diffuse disease
Crohns disease
Indications for surgery
Emergency - perforation, intractable haemorrhage, failure of medical management of acute flare (obstruction or dilatation)
Elective - abscess, fistula, carcinoma; failure of medical mx, perianal disease (likely complex)
Crohns disease
Acute management of flare
ABCDE assessment, IVF, NBM
Induce remission - oral/IV steroids depending on severity of flare
5-ASA second line, with azathioprine/mercaptopurine or methotrexate if no response to 5-ASA
Inflixiamb third line acutely
Ix:
Obs, bloods, imaging
Mx:
Abx, steroids, analgesia, muscle relaxant
Indications for colonoscopy in context of UC and frequency
5yrly
No active inflammation
L sided colitis only
Crohns colitis in <50% of bowel
3yrly
Mild active inflammation
Polyps
Fhx colorectal malignancy occurring >50yrs
Yrly Mod to severe inflammation Stricture Prev dysplasia PSC or gallbladder involvement Fhx colorectal malignancy <50yrs
RA hx Features of examination Ix Scoring system Mx Complications Poor prognostic factors
Joint pain, stiffness, swelling Function Progression Numbness / sensory change Weakness
Systemic sx - Fever, fatigue
O/e: Hands, wrists, elbows Lungs Eyes Carpel tunnel
Ix: Bloods incl RF and CCP Hand and foot XR; wrist XR CXR USS joints if effusion
DAS28 score - aim <3 (>5.1 = high; <2.6 = remission)
Number of tender/swollen joints
Subjective perception of disease activity
ESR
Mx:
Aim to induce and maintain remission
Cons - PT, stop smoking
Med - analgesia, start methotrexate with short bridging course of steroids (methotrexate CI if nodule positive)
Biologics if 2 DMARDs have failed consecutively
Steroids for acute flare
Surgical - joint replacement, tendon reconstruction
Complications:
Disease related - Progression of disease, deformity, loss of function, extra-articular manifestations, megaloblastic anaemia, haemolytic anaemia
Treatment-related - steroids, immunosuppression, GI bleed from NSAIDs, BM suppression from DMARDs
Poor prognostic factors: Seropositive disease (RF, anti-CCP) Poor functional status at presentation Early erosions on XR Extra-articular disease
Extra-articular manifestations of RA
Lung - pleural effusion, ILD Heart - pericarditis Carpel tunnel syndrome Splenomegaly Anaemia of chronic disease Amyloidosis and renal impairment Eyes - scleritis / episcleritis
CXR changes in sarcoidosis
Stage 0 - normal CXR Stage 1 - BHL alone Stage 2 - BHL with pulmonary infiltrates / reticulonodular changes Stage 3 - Pulmonary infiltrates alone Stage 4 - fibrosis
Which skin feature is pahthognomic of sarcoidosis
Lupus pernio - malar rash
Lupus pernio is pathognomic of which condition
Sarcoidosis
Triggers worsening gout
Diet - purine rich
Alcohol
Drugs - thiazides, loop diuretics, aspirin
Renal impairment
Features on examination of Marfans
Increased arm span (arm:height >1.05) Lens dislocation - upward Aortic regurgitation and mitral regurg AAA High arched palate Skin stretch marks Thumb across palm with fingers over Bend thumb to wrist Bend little finger backwards Thumb and little finger around wrist
Tx for Raynauds
Tx underlying cause if present
Cons - stop smoking, gloves
Medical - CCB (nifedipine), PDEi (sildenafil), topical GTN
Features to ask about in presence of Raynauds
Digital ulceration Mouth ulcers Dysphagia, reflux, malabsorption Serositis - pericarditis, pleurisy Eyes Rash Joint pain Alopecia Dyspnoea - ILD, Pul htn
Complications of acromegaly
Compression - bitemporal hemianopia
Diabetes
CV - cardiomyopathy
Increased risk of GI malignancy
Features of acromegaly
G - hypogonadism
T - hypothyroidism
A - hypoadrenalism
Hyperprolactinaemia - galactorrhea DM - polyuria, polydipsia Proximal muscle weakness Carpel tunnel Htn - headache Hypercalcaemia - stones Hx of bowel polyps / malignancy
Focussed examination of acromegaly
Insp - coarse features Bitemporal hemianopia Evidence of carpel tunnel syndrome Hearing aids Fundoscopy to assess papilloedema Proximal weakness
Acromegaly
Ix
Tx
Dx - IGF, OGTT with no suppression of GH
Ix - BP, ECG, MRI head, pituitary function testing, visual field testing, echo (for hypertrophy)
Tx:
1st line - surgery
2nd - medical:
Somatostatin analogues - octreotide
Dopamine agonists - cabergoline, bromocritpine
GH antagonists - pegvisomant
Radiotherapy
Tx complications - DM, htn, carpel tunnel
Ddx of acutely painful knee
Reactive arthritis RA Psoriatic arthritis Gout / pseudogout Septic arthritis
Htn and hypo-K
Ddx
Ix
Mx
Ddx:
Hyperaldosteronism - Conns, Cushings, renal artery stenosis
Liddles syndrome - pseudohyperaldosteronism - tx with amiloride for direct ENaC antagonism
Ix:
Screening - renin:aldosterone ratio, having stopped anti-htn drugs and diuretics
Confirmation - saline suppression test - aldosterone doesn’t fall with saline load
Imaging - CT/MRI adrenals looking for adenoma or bilateral adrenal hyperplasia
To distinguish one side from the other - adrenal vein sampling for raised aldosterone
Mx:
Medical - spironolactone and eplerenone
If glucocorticoid suppressible - steroids (1-3%)
Surgical - resection of adenoma or adrenalectomy
Ix for suspected Cushings
Mx
Ix:
24hr urine cortisol
Low dose dexamethasone suppression test - cortisol should suppress. If not -> Cushing’s disease or ectopic ACTH release
If no suppression, high dose dex suppression test. If cortisol suppresses -> pituitary adenoma secreting ACTH, if no suppression -> ectopic source of ACTH
Imaging of pituitary
Mx:
MDT - PT
Medical - bone protection, ketoconazole/metyrapone (inhibit cortisol synthesis)
Surgical - resection of source (pituitary, lung, adrenal)
Bilateral adrenalectomy if refractory disease with ectopic ACTH
Can consider radiotherapy
Back/neck pain and stiffness
Hx:
Examination
Ix
Mx
Scoring system
Hx: Duration and worsening Triggers Occupation and function FLAWS Sx of caudal equina Neurology Sciatic pain Associated features of any spond - heart (AR, AV node block), lung (ILD), Achilles tendonitis, amyloid (CTS), eyes (ant uveitis) Enthesitis - plantar fasciitis Red flags - night pain
Questions / concerns
O/e:
Neck/back - look, feel, move.
Flexion, lateral flexion, extension and rotation at neck and back
Sacroiliac pain
Other features - Schobers test, wall test (wall-occiput)
Ix: Bloods incl HLA-B27 XR - neck/back, CXR, sacroiliac joints Echo Spirometry MRI
Mx:
MDT - PT, OT, rheumatology (consider DMARDs)
Analgesia
Bone changes - squaring of the vertebrae, syndesmophytes, sacroiliitis
BASDAI (Bath ank spond disease activity index) - >4/10 -> active disease
Prolactinoma
Classification
Micro vs macro
Mx:
1st line - medical - cabergoline
If compression causing bitemporal hemianopia - surgery is 1st line
Replacement of pituitary hormones if necessary
Osteogenesis imperfecta
Problem with collagen type 1
Mainly AD inheritance, some AR
Type 1 commonest -
Type 2 - lethal
Type 3 - progressive
Type 4-8 also
Hx:
Fractures and surgery
FHx
O/e: Bowing of bones Evidence of fractures Blue sclera Hearing aids
Ix:
Genetic analysis
Monitor with echo for aortic root dilatation
Mx:
MDT
Bone protection
Acute back pain
Hx
Examination
Red flags - rule out cord compression, caudal equina and possible malignant cause
How to distinguish between a squint an an ocular nerve palsy
Cover the other eye
A squint will correct
A nerve palsy (eg CNIII) will not
Rules of driving and diabetes
When must the DVLA be informed
Pt must inform DVLA if:
At risk of hypoglycaemia
Visual impairment or have required laser treatment
Neuropathy requiring eg automatic car or hand controls
On insulin
Pt must not drive if:
Hypo requiring third party help
Hypoglycaemic unawareness
Found behind the wheel having a hypo
For commercial or HGV licence:
Good control for past 12mths, at necessary times of the day
Can provide evidence of 3mths of good control with no hypos
Deranged LFTs
Causes
Ix
Mx
x
Bowels loose
Causes
Ix
Mx
x
Sjogrens
ix
tx
Ix:
Bloods incl anti-Ro and -La
Salivary gland biopsy
Tx:
hydroxychloroquine is first line DMARD
Optic atrophy
Causes
Hx and o/e
Causes: Congential RP Mitochondrial disorders - Leber's Friedrichs ataxia
Acquired MS Drugs Neurosyphilis Glaucoma, SOL, Pagets Dietary deficiency - B12 Retinal artery occlusion Inflammatory cause - sarcoid
Hx: Progressive visual loss, typically colour Bilateral Vascular risk factors Other neurology - MS Eye infection / trauma Headache - SOL
PMH - glaucoma
O/e: RAPD and INO - MS Acuity Pale, well demarcated disc Fields - chiasmal lesions Enlarged blind spot Colour vision - Ishihara
Signs of the cause - retinitis pigmentosa, cupped disc (glaucoma), central retinal artery occlusion
Other signs - cerebellar signs -> MS; scoliosis and yes caves -> Friedrichs
Argyll Robertson pupil (accommodates but doesn’t react) -> neurosyphilis
Frontal bossing of skull - Pagets
Usher syndrome
2 facts
Retinitis pigmentosa and sensineural deafness
Commonest cause of deaf/blindness in the UK
Retinitis pigmentosa
Some conditions
Inheritance
Mx
Conditions - Usher syndrome (deafness), Bardet-Biedl syndrome (polydactyly), Refsums, Alports, Kearns Sayre (mitochondrial inheritance - ophthalmoplegia, ataxia, dysphagia and cardiac conduction defects)
Inheritance
AD, AR or X-linked
Sporadic mutations can occur in approx 30% of cases
Can be syndromic or not
Mx:
MDT
OT and support services
Referral to ophthalmologist
Causes of bilateral carpel tunnel syndrome
Narrowing of tunnel - RA, OA, PsA
Fluid - Renal failure / dialysis, hypothyroid, pregnancy
Infiltration - vasculitis, amyloidosis
DM
Involvement of limited sclerosis
Skin below elbow
CREST as part of limited sclerosis
Lung involvement - pul htn
Involvement of diffuse sclerosis
Diffuse skin and organ involvement
Cardiac - fibrosis, pericarditis
Lung (not as common as limited sclerosis)
GI - malabsorption
Liver
Renal - can have acute renal crisis - ARF and htn
Diabetes
Hx
O/e
Diagnosis and progression Medication Hypos Control Other vascular risk factors - smoking, htn, obesity, cholesterol Foot care - regular chiropodist input Eye screening Sx of peripheral neuropathy - burning, parasthesia Sx of claudication
O/e: Retinopathy Neuropathy Charcots joints Feet - ulcers and callus Foot pulses Neuro exam ABPI
Thyroid problem
Sx of hyper and hypo-thyroidism Eye sx and visual change Recent URTI (thyroiditis) Drugs which can interact with the thyroid - amiodaraone, Li Current medications FLAWS
Phaeochromocytoma
What conditions can be associated
Ix
Mx
MEN2A and MEN2B
Von hippel Lindau
NF1
10% bilateral, 10% malignant
Ix:
24hr urinary Catecholamines and metanephrines
Imaging
MIGB scan
Look for associated conditions - PTHrP from MEN2a medullary thyroid tumour, posterior fossa MRI for haemangioblastomas (VHL), neurofibromas (NF1)
Mx:
Alpha (phenoxybenzamine) then beta block (propranolol) after 2-3 days
Surgery
IV fluids post op due to sudden loss of vasoconstriction
Visual change
Hx
Examination
Mx
Hx:
Onset and progression.
Unilateral or bilateral
Pain - GCA, glaucoma, uveitis
Associated sx - haloes around objects, flashing lights (glaucoma, RP, retinal detachment)
Reduced night vision
Reduced peripheral vision (pituitary, pan-retinal photocoagulation, glaucoma)
Distortion of vision eg straight lines - macular pathology
RF - drugs that are toxic - ethambutol (TB), methanol
O/e:
Assess associated signs of RP eg hearing aids
Acuity, fields, neglect, reflexes, fundscopy, colour vision
Ix: Colour vision testing and perimetry Retinal photos for progress Fundal angiogram - fluorescin Genetic analysis
Mx: No treatment for underlying cause Refer to ophthalmologist. OT Inform DVLA - need acuity 6/10 to drive Support groups
Signs of severe C. diff colitis
Fever >38.5 WCC >15 CRP >150 Toxic megacolon - Bowel >7cm dilated AKI / dry Raised lactate Diffue / severe abode pain
Causes of weight loss
Diet in Upper GI malignancy Lower GI malignancy Lung malignancy Thyroid Addisons DM Psych TB IBD Coeliac
Causes of dysphagia
Neuromuscular problem - MND, dystrophy, MS
SOL
Pharyngeal pouch
Webbing
Narrowing of oesophagus - stricture
Oesophageal dysmotiltiy - Achalasia, corkscrew oesophagus, limited sclerosis
Oesophagitis - candida
Rockall score
Parameters
What does it predict
Predicts mortality
Pre and post endoscopy
Pre - Age, grade of shock (BP > or < 100 systolic), co-morbidities
Blatchford score
Parameters
What does it predict
Predicts need for intervention
0 -> outpatient investigation
Urea, Hb, systolic BP, HR, co-morbidities (liver and heart disease) and presentation (malaena, syncope)
Causes of thrombocytopaenia
ITP Infection - EBV, CMV HUS/TTP/DIC Splenic sequestration - malaria, extravascular haemolysis Drugs - HIT, Bone marrow - myelodysplastic syndrome, pancytopaenia, parvovirus, HIV, hep C, rubella B12/folate deficiency Malignancy - lymphoma SLE Plt aggregation Pregnancy - HELLP
Features of neurofibromatosis type 1
Inheritance and chr
Complications
Associated features
AD, chr 17
Cafe au lait spots (>5)
Neurofibromas
Lisch nodules (eyes)
Axillary freckling
Complications
Pressure effects of the neurofibromas - acoustic neuroma, spinal root compression, hydrocephalus
Malignant change
Intracranial tumours - glioma, meningiomata, medulloblastoma
Associated features Pul htn and fibrosis scoliosis Phaeo / MEN2A Fibromuscualr hyperplasia causing renal artery stenosis and htn
Features of neurofibromatosis type 2
Bilateral acoustic neuromas and intracranial tumours
Tuberous sclerosis
Features
Mx
AD but 80% sporadic new mutations
TSC1 (hamartin - chr 9) or TSC2 (tuberin - chr 16)
Hamartomas in kidiney, skin, brain, eye and heart
Ash leaf macules Shagreen patch Periungual fibromata Adenoma sebaceum 80% have epilepsy
Associated with lung cysts, polycystic kidneys and renal angiomyolipomas, retinal hamartomas and cardiac rhabdomyomas
Mx:
Topical sirolimus
Screen for malignancy
How is lichen planus treated
What infection is it associated with
Steroids - intralesional or oral
Hep C
ABCD scoring criteria
Age >60 BP >140/90 CF - weakness = 2; speech diet = 1 Duration - >1hr = 2; <1hr = 1 DM
Criteria for admission for TIA ix
ABCD score 4 or above Crescendo TIA (more than 2 events in prev 7 days) Persistent neurology or fluctuating sx Chronic or paroxysmal AF Anticoagulated Prosthetic valve Young <50 with neck pain
Causes of headache and unilateral weakness in the young
Hemiplegic migraine Carotid or vertebral artery dissection TIA with underlying cause - APLS, SLE, Sjogrens, vasculitis, endocarditis Venous sinus thrombosis GCA
How can a carotid artery dissection present
Headache / neck pain TIA sx Amaurosis fugal Horners Focal weakness Neck swelling, tinnitus and bruit
Further assessment of someone presenting with parkinsonism
Vascular risk factors
Autonomic sx - postural hypotension, urinary function, constipation
Cerebellar features
Supranuclear features
Cognitive assessment and hallucinations - LBD
Review drugs - neuroleptic and antiemetics
Causes of an isolated CN VI palsy
SOL- cavernous sinus and superior orbital fissure, MCA aneurysm
Raised ICP
MS
Stroke / TIA - microvascular and thromboembolic
Any cause of mononeuritis multiplex - DM, CTD/vasculitis, sarcoid, amyloidosis
GBS - Miller Fisher variant (ataxia, ophthalmoplegia and areflexia)
Infection - lyme, TB, viral
GCA
Cerebral lymphoma
Wernickes encephalopathy
Neurological cause - myositis affecting muscle, NMJ problem, nerve/nucleus problem
How to diagnose MS
McDonald Criteria
Two lesions separated in time and space, visible on contrast enhanced MR
How to tx MS
MDT - neurologist, PT/OT, SALT, dietician
Symptomatic Anticholinergics for overactive bladder +/- intermittent self catheterisation Baclofen and botox for spasticity Neuropathic pain relief Erectile dysfunction tx Antidepressants
Disease modifying
Beta-interferon
Glatiramer, fingolimod, natalizumab
Features of complicated malaria
Parasite count >2% Features of cerebral malaria - Decreased GCS Features of haemolysis - Hb <80 Hypoglycaemia ARDS DIC / coagulopathy Shock BP<90mmHg Renal impairment (AKI) Metabolic acidosis
Complications of malaria
AKI and metabolic acidosis ARDS Acute liver impairment Haemoglobinuria -> Blackwater fever Cerebral malaria -> seizures Splenic rupture Superimposed sepsis (usually GN) DIC Shock Hypoglycaemia
Causes of erythema nodosum
Sarcoidosis IBD - Crohns Drugs - penicillin, OCP Malignancy - haematological Rheumatic fever bacterial infection - strep, mycoplasma TB
Associations of sturge weber syndrome
temporal lobe epilepsy Glaucoma Strabismus optic atrophy SOL
Inclusion body myositis - features
Later onset (>50), distal myopathy with decreased reflexes
Slow onset weakness
Can causes foot drop
No muscle tenderness
Ix of suspected polymyositis
CK ANA (Jo1 in dermatomyositis) CRP/ESR MRI of involved muscle Muscle biopsy EMG
Whole body for CT for underlying malignancy (lung, ovarian and breast commonest)
Mx of polymyositis / dermatomyositis
MDT
Encourage physical activity to maintain strength - OT/PT
Skin manifestations - Sunblock, topical antipruritics, topical corticosteroids +/- tacrolimus and hydroxychloroquine
Steroids - High dose prednisolone, tapering down;
DMARDs and steroid sparing agents
IV Ig if refractory
Indication for biologic therapy in RA
Failure of 2 consecutive DMARDs, including methotrexate AND has two DAS28 scores >5.1, at least a month apart
What is the management of RA
Assess disease severity by DAS score
Acute flares are treated with steroids
Chronic disease mx: Cons, medical, surgical
Cons - PT and exercise; analgesia
Medical - DMARD - First line is methotrexate (CI if nodules present - worsens disease), sulfasalazine, hydroxychloroquine
Second line - biologic therapy - infliximab, rituximab
Usually in combination with methotrexate
What patterns can psoriatic arthritis take
DIP joint disease associated with onycholysis
Rheumatoid pattern - Small joint polyarthropathy
Large joint oligoarthritis
Spondyloarthritis / sacroileitis
Arthritis mutilans
Features of dermatomyositis on examination
Rash over bony prominences - extensor surfaces of phlanges, elbows
Mechanics hands - dry cracked skin
Nailfold erythema and periungual telangiectasia
Heliotrope rash at the eyes
Skin - photosensitive rash in sun-exposed areas
Raynauds
Alopecia
Weakness +/- tenderness of muscles - proximal weakness
Complications of dermatomyositis
Underlying malignancy - GI, breast, prostate, ovarian
ILD
Myocarditis
Arthralgia
Causes of nephrotic syndrome
DM GN - MCD, membranous, FSGS Amyloidosis Myeloma TIN - NSAIDs SLE / lupus nephritis Rhabdomyolysis HIV and Hep B/C
What are the criteria for an HGV licence in someone on insulin
No hypos within the past 12mths Under a diabetes consultant Can prove 3mths of blood sugar control Never had a hypo at the wheel Never needed third party assistance
Radiological changes seen in RA
Loss of joint space
Soft tissue swelling
Periarticular osteoporosis
Articular erosions
