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MEDICAL SHORTS Ellie Lightman & Tania Wan The Shorts station 10 minutes long Examination or just inspection Discussion Topics • Endocrinology • Rheumatology • Dermatology • Ophthalmology • Miscellaneous- eponymous conditions Two formats: - Get through as many cases as you can - 2-3 cases, examination/inspection & discussion The Spiel 1) Describe what you see or find 2) Assimilate findings ‘these are consistent with a diagnosis of ________’ 3) ‘I would also like to look for ___________’ 4) Pathology X can be diagnosed using these investigations: 5) Treatment options are: 1) 2) 3) Conservative Medical Surgical (if applicable) Endocrinology • Acromegaly Acromegaly • On inspection, I can see that this gentleman is very tall, with coarse • • • • facial features, prominent periorbital ridges and large, spade-like hands O/E: Hands- warm & sweaty, doughy consistency, marks from blood glucose testing (diabetes), carpel tunnel (or scar) Arms- high blood pressure Face- macroglossia, prognathism, scar- surgery, tattoo- radiotherapy These findings are consistent with acromegaly • I would also like to: conduct a full CVS examination looking for cardiomegaly, HTN • History: ask about shoes, rings & hats, ask to see old photos Acromegaly • Investigations: Glucose tolerance test, then check GH levels, MRI brain Treatment: Medical: Surgical: Radiotherapy Somatostatin analogues (octreotide) Pegvisomant (blocks GH receptor) Dopamine agonists (carbergoline) Transphenoidal or transfrontal excision Your turn Graves’ Disease On inspection: Exophthalmos, large mass in neck and pt is inappropriately dressed for the weather. I would normally proceed to assess the thyroid status Hands: temperature, tremor, heart rate, AF Face: ophthalmoplegia, exophthalmos, lingual thyroid Neck: goitre, mass moves with swallowing but not tongue protrusion, check for a retrosternal goitre. History: I would ask about symptoms e.g. palpitations, heat intolerance, diarrhoea Investigations: TFTs, isotope scan Treatment: medical- carbimazole, PTU, radiothearpy, surgical Sclerosis On inspection: skin is taut and shiny, characteristic ‘beaking’ of the nose, perioral furrowing and microstomia. I also note telangiectasia around the mouth. Hands: evidence of sclerodactyly and nodules of calcinosis. On examination: full hand examination examining for temperature (Raynaud’s) and function. I would also like to: conduct a full respiratory examination looking for interstitial fibrosis, cardiovascular disease (evidence of pulmonary hypertension) Full history asking about any swallowing problems (oesophageal dysmotility), SOB (ILD) and ask how the condition affects the patient’s life. Sclerosis 1) Limited systemic (CREST) skin involvement below elbows and knees 2) Diffuse systemic sclerosis (visceral involvement) Investigations: Blood tests- anti-nuclear Ab, anti-centromere Ab (limited), anti Scl-70 (diffuse) Xray hands- calcinosis Pulmonary fibrosis- CXR, high-resolution CT thorax, lung function tests (restrictive) Pulmonary hypertension- ECG, ECHO Renal: urea & electrolytes, urine microscopy Treatment Symptomatic: gloves, handwarmers, CCB, ACE-I, prostcyclin inhibitors Renal protection- ACE-inhibitors to prevent hypertensive crises Rheumatology 1) Describe what you see • 2) These findings are consistent with __________ Presenting a hand examination • Symmetrical deforming polyarthropathy • With • • • • • Ulnar deviation of MCP joints Swan neck deformity Bountonnieres deformity Z thumb Rheumatoid nodules • Scars: carpel tunnel release, joint replacement, tendon transfer • There are no signs of ACTIVE disease • Red, swollen, hot, painful hands • However function is impaired as shown by • Reduced power grip (squeeze fingers) • Precision grip (buttons/pick up coin) • Key grip • Mention walking aides etc Rheumatology • Other manifestations of RA There are a lot so try to memories 1 or 2 from each system: • Pulmonary • Effusions, fibrosing alveolitus, obliterative bronchiolitis, caplan’s nodules • Eyes • Scleritis • Cardiac • Pericarditis • Renal • Nephrotic sydrome • Neuro • Carpel tunnel syndrome • Peripheral neuropathy • Haem • Feltys = RA + splenomegaly + neutropenia Rheumatology • Can be diagnosed using • RhF • Anti-CCP • Inflammatory markers eg ESR, CRP • FBC often have anaemia of chronic disease • X-ray Decreased joint space Soft tissue swelling Juxta-articular osteopenia (as pannus of inflammation thins it) Maybe: bony erosions, subluxation Rheumatology - Treatment options include: - Symptomatic relief: NSAIDs - DMARDs eg methotrexate, sulphasalazine - Step up therapy = Anti-TNF therapy eg infliximab Rheumatology 1) Describe what you see 2) These findings are consistent with __________ Asymmetrical polyarthropathy With distal interphalangeal joint deformity Heberdens nodes Bouchards nodes Atrophy of hand muscles Can mention crepitation on movement. Restriction of movement. Do not talk about active disease – is not inflammatory like RA However function is impaired as shown by Reduced power grip (squeeze fingers) Precision grip (buttons/pick up coin) Key grip Mention walking aides etc Rheumatology • Can be diagnosed using • X ray • Joint space narrowing • Subchondral sclerosis and cysts • Osteophytes Rheumatology - Treatment options include: - Exercises - reduce weight - Analgesia - intra-articular steroid injections - joint replacement Rheumatology 1) Describe what you see • Question mark posture • Caused by fixed kyphoscoliosis • loss of lumbar lordosis • With extension of cervical spine 2) These findings are consistent with ankylosing spondylitis Rheumatology • Can be diagnosed using.. • Clinical diagnosis • Schober test: 2 points 15 cm apart on the dorsal spine – expand less than 5cm on maximal forward flexion • Limited chest expansion for age and sex • HLA B27 (90% association) • X-ray (sacroliitis) • Treatment • Physiotherapy • Analgesia • Anti-TNF Rheumatology • Complications = the 5 A’s • Anterior uveitis • Apical lung fibrosis • Aortic regurgitation • Atrioventricular nodal heart block • Arthritis Dermatology Psoriasis On inspection, I can see areas of ‘salmon pink’ plaques covered with ‘silvery-white’ scaling on the extensor surfaces. There are nail changes including: pitting, onycholysis, subungal hyperkeratosis These findings are consistent with psoriasis I would also like to examine the scalp, naval area • In my history I would ask about any joint pain, impact of the condition on the patient’s life and their current treatment Psoriasis • 5 main types: Classic plaque, pustular, guttate, erythrodermic, palmo-plantar Treatment 1) Topical CorticosteroidsVitamin D analogues- calcipotriol Dithranol- stains yellow-brown Coal tar 2) Light therapy- UVB, PUVA 3) Systemic- methotrexate, acitretin, ciclosporin, Biologics- etanercept, infliximab Don’t forget: Counselling & education Dermatology Eczema On inspection there are erythematous patches of skin with lichenification (thickened), on the flexor surfaces of the limbs Evidence of excoriation (scratching) This is consistent with atopic dermatitis or eczema Eczema is a primarily a clinical diagnosis. I would like to take a full history asking about any personal or family history of atopy, including allergy, asthma and hayfever and I would enquire about symptoms, predominantly pruritis. Eczema Types: Atopic eczema (most common), contact eczema (e.g.nickel) Treatment: Topical • Emollients, soap substitutes • Topical steroids- hydrocortisone, betamethasone, dermovate • Calcineurin inhibitors – tacrolimus Systemic ( for severe or unresponsive eczema) • Immunosuppresants: oral steroids, ciclosporin, methotrexate • Phototherapy- UVB or PUVA – psoralen + UVA Don’t forget- counseling, education, psychological support Marfan’s On inspection/examination, I note this lady is very tall, with long limbs and arachnodactyly (Walker’s/ Steinberg’s sign). She has hyper-mobile joints. She has a high arched palate and I can see (upwards) lens dislocation. Chest- pectus excavatum/carinatum defomity of the chest, scars from pneumothorax, midline sternotomy scar. Otherwise- aortic incompetence: collapsing pulse, early diastolic murmur, radioradial delay These findings are consistent with Marfan’s. Marfan’s Autosomal dominant, defect in fibrillin-1 gene (Chr 15) Diagnosis is clinical Management Conservative: Annual echocardiogram to monitor aortic valve/root Medical: beta blockers- reduce aortic root dilatation Surgical: aortic valve repair Ophthalmology 1) Describe what you see 2) These findings are consistent with Ophthalmology • Diabetic retinopathy • Back ground retinopathy • Microaneuryms • Blots haemorrhages • Hard exudes • Preproliferative • Cotton wool spots • Flame haemorrhages • Venous beading and looping • Proliferative • Neovascularisation – can cause vitreous haemorrhage, tractional retinal detachment and neovascular gluacoma • Look out for pan-retinal photocoagulation scars • Diabetic maculopathy • ‘macular oedema or hard exudates within one disc space of the fovea’ Ophthalmology • Can be diagnosed using….. • Slit lamp examination • Random/fasting glucose test Ophthalmology - Treatment options include: - Tight glycaemic control - Treat other RF: hypertension, high cholesterol, smoking cessation - Pan-retinal photocoagulation – if have maculopathy/proliferative/preproliferative retinopathy Ophthalmology 1) Describe what you see 2) These findings are consistent with __________ Simplified hypertensive retinopathy Grade 1: Silver wiring = increased reflectance from thickened arterioles Grade 2: arteriovenous nipping = narrowing of veins as arterioles cross them Grade 3 :cotton wool spots and flame haemorrhages Grade 4: papilloedema = blurry indistinct margin, engorged veins running down onto Retina, loss of venous pulsation There may also be hard exudates (macular Star) Ophthalmology • Can be diagnosed using…. • Clinical diagnosis • BP! • Treatment options include: • For grade 3+ use oral anti hypertenisves and monitor BP Ophthalmology 1) Describe what you see 2) These findings are consistent with __________ Ophthalmology 1) Describe what you see 1) Peripheral bone spicule pigmentation – follows the veins and spares the macula 2) Optic atrophy – due to neuronal loss • 2) These findings are consistent with __________ • Retinitis pigmentosa NB is associated with night vision loss and tunnel vision Ophthalmology • Can be diagnosed using…. • Clinical diagnosis • Treatment options include: • No treatment although vitamin A may slow disease progression Miscellaneous 1) Describe what you see Miscellaneous 1) Describe what you see 1) Cutaneous neurofibromas (2+) 2) Café au lait patches (6+, over 15mm diameter in adults) 3) Axillary freckling 4) Lisch nodules = melanocytic hamartomas of the iris 2) These findings are consistent with __________ neurofibromatosis (type 1) Clinical diagnosis Symptomatic treatment – surgery if neurofibromas compress da Facial nerve palsy Most often caused by Bell’s palsy (idopathic-75%) Unilateral paralysis of facial muscles Make sure to look behind the ears to distinguish from Ramsay Hunt Syndrome- HZV reactivation in geniculate nucleus of the facial nerve (look for immunosuppression) Perform relevant cranial nerve examination- look for facial muscle weakness, hyperacusis (paralysis of stapedius), Bell’s phenomenon Bell’s Palsy Management Conservative- eye care: drops, tape Medical: aciclovir (HSV), short course of prednisolone Reassurance: Usually complete recovery in a few weeks Resources