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DR Sonam S High Yield Notes For ST 2 5 2nd Edition
DR Sonam S High Yield Notes For ST 2 5 2nd Edition
(MRCP UK)
High yield notes for Paces St 2 & 5
2nd Edition
Complied by Paces network team
www.facebook.com/groups/1638775673089878
© Copyrights with dr Sonam Tshering. All rights reserved
By Dr Sonam Tshering
(MRCP UK)
High yield notes for Paces
St 2 & 5
Complied by Paces network team
www.facebook.com/groups/1638775673089878
© Copyrights with dr Sonam Tshering. All rights
reserved
Acromegaly
Drug history:
Social history
Family history
Personal history-?smoker
Occupational history: ?taxi driver
Physical examination:
Hands- large and doughy (spade like) hand, look for CTS,
sweaty? BM testing marks
Face- prominent supraorbital ridges, enlarged nose and lips,
prognathism, bitemporal hemianopia, visual acuity and
othalmoscopy for optic atrophy, macroglossia, interdental
separation, look for surgical scars (transphenoidal surgery
inside the nose, underside of upper lips,
transcranial(forehead or side of head)
Neck-?goiter
Chest and axilla-gynaecomastia, hyperpigmentation, skin
tags, acanthosis nigricans, hirsuitism
Heart- ?ccf
Check for proximal myopathy
Features of hypopituitarism
Ask to measure BP, dip urine for glycosuria, any old
photographs?
Investigations:
Failure of GH to suppress to <2nmol/l following OGTT.
IGF1
MRI of pituitary
Test anterior pituitary function(TFT, LH, FSH, Testosterone,
short synacthen test, cortisol levels)
Test for complications- fasting blood glucose, measure BP ,
ECG, ECHO, Nerve conduction studies for CTS, sleep studies
for OSA, visual perimetry, colonoscopy
Treatment :
Surgery-transphenoidal hypophysectomy
Radiotherapy
Medical-somatostatin analogues(octreotride and
lancreotide), dopamine agonists, GH receptor
antagonists(pegvisomant)
Active disease
Sweating
HTN
Skin tags
Peripheral oedema
Acute Kidney Injury
DD:
Presenting illness:
Physical examination:
Investigations:
RFT
S.Electrolytes
Urine microscopy
ABG
LFT
ECG(hyperkalaemia)
USG renal tract
Cxr(fliud overload)
Look for the causes
Treatment:
DD for tiredness
Addisons disease
Anaemia( blood loss?
Hypothyroidsm
DM
OSA
DD of postural hypotension:
Addisons disease
DM
Fluid loss
Drugs
parkinsons
Focused history:
Presenting illness:
Tiredness-duration, variation during day, ?effect on quality of
life
Postural hypo-dizzy while standing, any collapse?
Skin changes
Loss of appetite, weight loss
GIT-vomiting,diarrhoea , abdominal pain
Look for causes of addisons( features of TB, cancer
Exclude DDs such as hypothyroidsm, OSA, DM, Anaemia
Other autoimmune diseases(graves,DM, connective tissue
diseases, celiac disease, pernicious anaemia)
Physical examination:
Hands-pigmentation of palmer creases, pulse, ask to
measure lying and standing BP
Face-pallor, oral cavity for pigmentation, ?cushingoid
Neck- any goiter?
Chest-?vitiligo, TB? Loss of hair esp in females
Abdomen: scars for adrenalectomy
Visual field defects(nelsons syndrome)
Addressing concerns :
I think your symptoms are caused by a condition called
addisons disease where your body is not able to produce
enough natural steroids from a gland called adrenal gland
located above kidneys.
we will have to admit you to confirm investigations and also
to exclude other causes such as anaemia, DM. if we start
treatment without confirmation, it will interfere with the
results
the treatment is lifelong replacement of steroids, need to
increase dose in physiological stress
steroid alert card/medic alert bracelet,
investigations:
FBC(lymphocytosis, eosinophilia, anaemia)
S.electrolytes(hyponatraemia, hyperkalaemia)
RBS-Hypoglycemia
Short synacthen test( if after injection of synacthen, cortisol
level increases >550nmol/l, then addisions can be excluded)
9 am cortisol
Adrenal autoantibodies
ACTH (raised in primary hypoadrenalism)
Imaging-CXR(TB), CT adrenal glands
Treatment :
If in adrenal crisis-fluid resuscitation, i/v hydrocortisone
Chronic case:
Glucocorticoid replacement(hydro or prednisolone)
Mineralocorticoid replacement(fludrocortisones for postural
hypotension)
Androgen replacement
Investigations:
Inflammatory markers-ESR, CRP, CBC(anaemia)
HLA B27
RFT and URE(for Amyloidosis)
X ray of LS spine and sacroiliac joint
MRI of LS spine and sacroiliac joint
CXR, Pulmonary function tests, HRCT for Pul fibrosis
ECHO for AR
Extra-articular features:
Anterior uveitis
Apical pul fibrosis
AR, Aortic conduction blocks
Atlanto-axial subluxation
Achilles tendinitis
Amyloidosis, IgA nephropathy
Avascular necrosis of femoral head/osteonecrosis
Causes:
Traumatic, displaced femoral neck fracture, hip dislocation,
Atraumatic- steroid , alcohol abuse,
DIC/coagulopathies/thrombophilias, chemotherapy,
radiation, sickle cell disease, vasculitis, SLE
Investigations:
Treatment:
DD:
Presenting illness:
Investigations:
Treatment:
Anterior uveitis
Treatment of cause:
Behcet’s disease-organ based(MDT approach)
Oral and genital lesions-topical steroids, sucralfate solution.
Colchicine to prevent relapse. for severe mucocutaneous
lesions-systemic steroids and immunosuppressants
(azathioprine
Ocular disease-azathioprine, steroids, interferon alpha
GI lesions-sulfasalazine, steroids, azathioprine
Benign essential Tremor:
DD:
Parkinson’s disease
Thyrotoxicosis
Cerebellar tremor
Alcohol and drug withdrawal tremor
Anxiety disorder
Drugs: salbutamol, theophylline,sodium valproate, lithium,
ciclosporin,tacrolimus
Wilsons disease
Presenting illness:
Tremor- at rest/postural/related to action, which part
affected? Unilateral/bilateral, exacerbating and relieving
factors(?alcohol), effect on hand writing(becomes poorly
legible in BET) and hand functions
DD-Parkinsons disease(unilateral tremor, rigidity,
bradykinesia, micrographia, slurring of speech) ,
cerebellar(action tremor, uncoordinated movements, look for
causes), thyrotoxicosis
Physical examination:
Mainly postural tremor
Exclude parkinson’s disease(rest tremor), thyrotoxicosis,
cerebellar syndrome(action tremor)
Addressing concerns:
Investigations:
TFT
Plasma glucose(hypoglycemia)
Treatment:
B blocker(1st line)
Primidone(2nd line)-anticonvulsant
Physio, occupational and psychological support
DD:
Syncope
Epilepsy
Hypoglycemia
Vertibrobasilar TIA
TIA
Falls
Psychogenic pseudosyncope
Syncope:
1. Reflex syncope
Vasovagal syncope(emotion,fear, pain, orthostatic
stress)
Situational syncope(cough, micturation, post-exercise)
Carotid sinus syncope
2. Cardiac syncope
Arrhythmias-bradycardia and tachycardia(svt, vt)
Structural heart disease-HOCM, valvular heart disease,
IHD
Pulmonary embolism
3. Syncope due to orthostatic hypotension
Primary autonomic failure(MSA,Parkinson’s)
Secondary autonomic failure(DM, amyloidosis)
Drug induced hypotension-vasodilators, diuretics
Volume depletion-diarrhoea, vomiting
Presenting illness: did you lose consciousness? Do you
remember falling?
Physical examination:
Pulse
Ask to measure postural drop of BP
Anaemia
Carotid bruit
Heart
Addressing concerns:
Investigations:
Initial:
Resting ECG, 24 hour ECG
CBC(anemia), Blood glucose, s.electrolytes
Echocardiography
DD:
IBD:
Focused history:
Presenting illness:
Diarrhoea-duration, frequency, blood/mucus
Associated symptoms-abdominal pain, fever
Mouth ulcers, perianal symptoms
Alarm symptoms- features of malignancy(extreme weight
loss, anorexia, anaemia), features of intestinal obstruction,
sepsis(fever, rigors)
Extraintestinal features of IBD-eye redness, joint pain, skin
changes
Addressing concerns:
I think your symptoms are related to a condition called IBD,
which is caused due to overactive immune system leading to
inflammation of bowels
First, we need to exclude bug infection as the cause of your
diarrhea by taking stool samples and start treatment right
away
We need to perform a test from back passage with a tube
with camera in it and take tissues from the bowel for
confirmation , for which I will refer to my bowel consultant
It is usually managed with medications and sometimes
surgery is occasionally needed to remove the affected bowel.
Investigations:
CBC(anaemia), ESR, CRP
S. Albumin
Stool for microscopy and c/s
Sigmoidoscopy/colonoscopy and biopsy
Carpal tunnel syndrome
Presenting illness:
Pregnancy*
Addressing concerns:
Investigations:
Ultrasound scan
NCD
EMG
Look for causes
Treatment:
DD
DD:
IBD
IBS
Infective diarrhoea/small bowel overgrowth
Celiac disease
Thyrotoxicosis
HIV infection
Colorectal cancer
Chronic pancreatitis
Lactose intolerance
Bile salt malabsoption
Carcinoid
Presenting illness:
Treatment:
According to cause
Coeliac disease
Dermatitis herpetiformis
Diarrhoea, abdominal pain, weight loss
Anaemia
DD:
IBD
Infective diarrhoea
Bowel malignancy
Chronic pancreatitis
IBS
Lactose intolerance
Bacterial overgrowth
Focussed history:
Diarrhoea-consistency, frequency , duration, any mucus, any
blood, any tenesmus, exacerbating factors(gluten, lactose),
associated with fever? steatorrhea
Abdominal pain, mouth ulcers,
Alarm symptoms(weight loss, maelaena, haematemesis,
symptoms of lymphoma)
Dermatitis herpetiformis-blistering itchy rash in extensor
surfaces, aggravated with gluten
Malabsorption- bleeding? Osteomalacia(proximal myopathy),
Physical examination:
?cachectic
Koilonychias, anaemia
Rash-pruritic vesicular rash on extensor aspects
Neck-?goiter
Abdomen-normal, to exclude IBD.
Addressing concerns:
Your symptoms are suggestive of a condition called celiac
disease. It is the inflammation of lining of gut caused by
allergy to gluten containing foods. However we need to
exclude other inflammatory conditions as well
We will do some blood tests and confirm by taking a piece of
tissue from the small gut with the help of a tube with
camera in it, which is a safe procedure
It responds to exclusion of gluten from the diet. Gluten is
found in anything containing wheat(pasta, bread etc)
Will ask dietician to see you for the diet, GP can prescribe
special prescription diet
Speak to the occupational therapist/employer for different
job in the same company(if pasta chef)
Celiac support groups
Investigations:
CBC-anaemia
Stool RE and culture(to exclude infective dirrhoea)
S.albumin, s.calcium, vit D
Serological tests- IgA Tissue transglutaminase antibodies,
anti-endomysial antibodies, IgA gliadin,reticulin
Upper GI endoscopy and duodenal biopsy
Skin biopsy-immunoflorescence will show IgA deposition in
dermoepidermal junction
Baseline DEXA scan
Management :
Strictly gluten free diet
Correct nutritional deficiencies
Immunosuppresants(prednisolone and azathioprine) if not
responding to diet exclusion
Dapsone for DH
Cushings syndrome
DM
Hypothyroidism
PCOS
Pseudo-cushings
Presenting illness:
Addressing concern:
I think your symptoms may be due to a condition called
cushing’s syndrome. In your case, it is due to the steroids
tablets you have been taking(iatrogenic) in which case I will
get an opinion from the respective consultant regarding
further management or due to overproduction of steroids by
your body(we need to find the underlying cause and treat it)
we need to collect your urine for 24 hours and see the
cortisol(steroid) level in it and some imaging tests as well.
Offer Support groups, physio , occupational therapy
Investigations:
screen with 24 hour urinary free cortisol, overnight
dexamethasone suppression test( to suppress ACTH and
cortisol production , which won’t happen in Cushings)
confirm with-low dose dexamethasone suppression
test(differentiate cushings from pseudocushing), also
midnight cortisol level will be raised
to establish the aetiology:
Suspected ACTH-Independent cushing
syndrome( suppressed ACTH levels)-CT or MRI adrenal
glands
Suspected ACTH-dependent syndrome(high ACTH levels)-
high dose dexamethasone suppression test(partial
suppression in cushings disease, no change in ectopic), CRH
test( no increase in cortisol in ectopic), inferior petrosal
sinus sampling, MRI of pituitary, CT chest(ectopic ACTH)
Causes :
1. ACTH independent
Iatrogenic (steroids)
Adrenal adenoma/carcinoma
Adrenal nodular hyperplasia
2. ACTH dependent:
Cushings disease(pituitary adenoma)
Ectopic ACTH production(lung cancer, carcinoids)
Deep vein thrombosis
DD:
Cellulitis
Compartment syndrome(h/o trauma, on anticoagulants)
Ruptured baker’s cyst(h/o RA)
Presenting illness
Pregnancy? *
Physical examination:
Investigations:
Treatment:
Presenting illness:
Physical examinations:
Investigations:
CK
ANA, anti-Jo 1 antibodies
EMG(Spontaneous fibrillation)
Muscle biopsy, skin lesion biopsy
HRCT, lung function tests-ILD
Malignancy screen
Treatment :
DD
Presenting illness:
polyuria
polydipsia
nocturia
history of trauma
weight loss, fatigue
Drug history
Physical examination:
Dehydration?
Scars in head
Addressing concerns:
Investigations:
Treatment:
Fluid replacement
Desmopressin(drug of choice) in central DI, others are
synthetic vasopressin, chlorpropamide, thiazides, NSAIDs
Diabetic retinopathy:
Diabetic retinopathy
Hypertensive retinopathy
Chronic glaucoma
Cataract
Retinitis pigmentosa
Presenting illness:
Personal-smoker?
Family history
Occupational : driver?
Social history
Pregnancy?
Physical examination:
Visual acuity- drop in vision usu. Suggests maculopathy
Fundoscopy- look in anterior eye for cataracts, retina for
diabetic changes, photocoagulation scars
Check visual fields and eye movements
Ask to check BP, dip urine for glycosuria
Addressing concerns:
I think the reason why your eyesight has deteriorated is
because , diabetes has affected the blood vessels in the
back part of eye called macula, which is important for vision
I will ask eye doctor to see you urgently to confirm the
diagnosis. Meanwhile, I will help your blood glucose level to
keep under control. And it is essential that you stop driving
and inform DVLA until we know how severely your eyesight
has been impaired.
The eye doctor will most likely need to perform a laser
treatment on the blood vessels on the back of your eye. It is
usually painless.
Investigations:
Fasting blood glucose, HbA1c, lipid profile, urine for albumin,
RFT
Eye-fluroscence angiography, OCT, B scan ultrasonography
Treatment :
Good glycemic and hypertensive control-diet, exercise, drugs
Pan-retinal photocoagulation for severe pre-proliferative and
proliferative retinopathy
Focal laser photocoagulation for maculopathy
Novel therapies- intra-vitreal Anti VEGF monoclonal
antibodies, intravitreal corticosteroids
Previous classification :
Background diabetic retinopathy: microaneurysms, dot and
blot haemorrhages, hard exudates(well defined outline,
yellow-white)
Pre-proliferative: background changes plus cotton wool
stops(poorly defined borders), IRMA, venous looping and
beading
Proliferative-neovascularization
Maculopathy(at any stage of retinopathy)-hard exudates
within 500um of macula in a circinate pattern
Advanced diabetic eye disease-RD, vitreous haemorrhage
Dysphagia
DD:
Presenting illness:
Physical examination:
Presenting illness:
Surgical history*
Physical examination:
Addressing concerns:
Investigations:
Genetic testing
ECHO
CBC-anaemia
Treatment:
Causes of seizure:
1. Primary/unprovoked
2. Secondary/provoked seizure
Infection-meningitis, encephalitis, TB cerebral malaria
Neoplastic-primary or metastases
Vascular-stroke,
Trauma
Metabolic-hypoglycemia, hyponatraemia
Drugs-lithium toxicity, benzodiazepine withdrawal,
ciprofloxacin, imipenem, phenothiazines
Alcohol withdrawal
Epileptic syndromes-tuberous sclerosis, sturge-weber
syndrome
History of presenting illness:
Family history?
Alcohol?
Physical examination:
Investigations:
CBC
Electrolytes
Blood sugar
LFTs
Drug levels-lithium, and anti-epileptic levels
ECG to exclude cardiac cause of syncope
MRI brain
EEG-Inter-inctal EEG, ambulatory EEG
Treatment:
Driving:
1. Epilepsy
Group 1- must notify DVLA, Must stop driving. Duration-
5 years(with or without epilepsy medication)
Group 2-must not drive and must notify DVLA. Duration-
10 years(without epilepsy medication)
2. 1 unprovoked epileptic seizure/isolated seizure
st
DD:
Presenting illness:
Exposure history:
Medications- immunosuppressive?
Addressing concerns:
Explain the likely cause of fever
Explain about investigations
Give info about travel clinics, safe sexual practice,
malaria prophylaxis, insect avoidance, food and water
precautions
Obtain help from infectious disease specialist and
microbiologist
Physical examination:
Pulse, temperature
Anemia, jaundice, neck stiffness
lymphadenopathy
skin rashes
lungs
abdomen-hepatosplenomegaly
Investigations:
Treatment:
DD:
Causes:
1. Idiopathic
2. Secondary FSS- trauma, shoulder surgery, DM,
IHD,stroke,hopo and hyperthyroidism, parkinson’s disease,
HTN, drugs(Protease inhibitors, antiretrovirals), malignancy
Presenting illness:
Drug history*
Physical examination:
Limitation of shoulder movement-active and passive
Tenderness at deltoid insertion
Addressing concerns:
Treatment:
Physiotherapy
NSAIDs, oral steroids, intra-articular steroids
Surgery –only in refractory cases
Gout :
Acute –monoarthritis/oligoarthitis
Chronic tophaceous gout
DD of monoarthritis:
Gout
Septic arthritis
Pseudogout
Osteoarthritis
Spondyloarthritis
Tubercular arthritis
Presenting illness:
Joint pain- distribution, severity, more at night?, swelling?
Colour changes? Relieving and aggravating factors, duration,
associated with low grade fever, functional status
Exclude septic arthritis(high grade fever , rigors, foci of
infection),
Risk factors( obesity, cancer, chemotherapy, CKD, alcohol
excess
Exclude seronegative arthritis- bowel changes, urethritis,
psoriasis)
History of trauma
Physical examination:
Joint exam: look for swelling,redness, warmth
Check movement if no pain.
Look for tophi, functional status
Look for causes such as RRT for CKD, Lymphadenopathy etc
Ask to measure BP, dip urine for glycosuria(metabolic
syndrome)
Addressing concerns:
I think your joint pain is due to a condition called gout. It is
deposition of a chemical called uric acid in the joints leading
to inflammation
We will do some blood tests, and draw a fluid from the joint
for confirmation and exclude infection in the joint, which is
crucial as infection can destroy the joint.
We will address your pain with strong painkillers and anti-
inflammatory medications. You may have to take another
medication after few weeks to reduce the frequency of
attacks.
Dietary referral, reduce alcohol
Investigations:
CBC, ESR, CRP
RFT
S.uric acid
Aspiration of synovial fluid for analysis
Blood culture if septic arthritis is suspected
X ray of the joint.
Treatment :
Acute – NSAIDs, Colchicine, steroids
Chronic/recurrent- allopurinol , febuxostat, probenecid
Dietary changes, reduce risk factors
Physiotherapy, occupational therapy
Palpitations
Diplopia
Anxiety and sweating
DD:
Thyrotoxicosis
Pheochromocytoma
Anxiety disorder
Cardiac causes of palpitations
Presenting illness:
Palpitations
Sweating, heart intolerance, weight loss despite good
appetite, irritability, diarrhoea, oiligomenorrhoea( also ask
features of hypothyroidsm)
Eye changes-double vision, dry eyes
Proximal myopathy
Phreochromocytoma(intermittent symptoms of headache,
flushing, palpitaitons)
Alarm symptoms-cardiac disease? Chest pain, SOB
Physical examination:
Hands- tremor, tachycardia/AF
Eyes- exopthalmos(visible lower sclera), lid lag, lid retraction,
conjunctival chemosis, complex opthalmoplegia(eye
movement exam)
Neck exam-diffuse neck swelling, bruit?
Proximal myopathy?
Pretibial myxoedema
Investigations:
TFT
ECG
TSH receptor stimulating antibodies, anti-thyroid peroxidase
antibodies
Radioisotope uptake scan
Usg neck
Treatment:
Anti-thyroid medications
B-blockers
Radio-iodine therapy
surgery
Haemoptysis:
DD:
Pulmonary embolism*
Infection-pneumonia, TB*, lung abcess, bronchiectasis,
bronichitis, aspergillosis
Bronchial malignancy*, metastases
Cardiac-mitral stenosis, Acute LVF
Vasculitis-wegener’s , goodpasture’s, HHT
Bleeding disorders, anticoagulants
Presenting illness:
Haemoptysis- onset, frequency, amount, colour-fresh blood,
pink(Pul oedema and MS), Brown/rusty(indicates
mucopurulent sputum)
Associated symptoms- to exclude DD.
Features of malignancy , tuberculosis and pulmonary
embolism
Rash , arthralgia, myalgia, epistaxis, rhinosinusitis(wegener’s
Ask about DVT(leading to PE)
Personal-smoker*
Occupational-exposure to asbestos
Investigations:
CBC,ESR, CRP
CXR
Sputum for c/s, AFB stain, Malignant cell
LFT, RFT, Electrolytes
Clotting profile
D-Dimer, CT pulmonary angiogram
CT chest
Bronchoscopy
Echo if MS, LVF
Auto-antibody screen-ANCA, anti –GBM antibodies
Urine analysis(GN-Wegener’s, good pasture)
Headache:
DD
1. Primary headaches
Migraine
Tension- type headache
Trigeminal autonomic cephalgias(TAC)- cluster headache,
paroxysmal hemicranias, short lasting unilateral
neuralgiform headache attacks with conjunctival injection
and tearing (SUNCT), hemicrania continua
Other primary headaches- primary cough headache, primary
exercise headache, primary headache associated with sexual
activity, primary thunder clap headache, primary stabbing
headache etc…..
2. Secondary headaches
Headache attributed to trauma/injury to head and neck
Due to cranial or cervical vascular disorder
Non vascular intracranial disorder
Due to substance or its withdrawal
Due to infection
Due to disorders of ENT
Due to psychiatric disorder
Migraine:
Cluster headache:
Paroxysmal hemicranias:
SUNCT:
Physical examination
Treatment:
DD
Presenting illness:
Physical examination:
Skin survery- non blanching palpable purpuric rash esp. on
extensor aspects of lower limbs and buttocks
Joints- swelling?
Check pedal oedema(nephrotic syn)
Ask to measure BP, dip urine for haematuria
Addressing concerns:
I think the cause of your symptoms and rash may be due to
a condition called HSP. It is caused by inflammation of small
blood vessels.
We will do some blood tests and urine tests and refer to skin
doctor for skin biopsy. Sometimes, it can affect kidneys as
well, we need to ensure that it is not affected as well and
needs follow up for the same reason.
I will give painkillers and NSAIDs for your joint pain and the
condition should resolve by its own. Rarely, we may have to
give steroids for this condition.
Investigations:
FBC, CRP, ESR
Urine dipstick and microspopy
RFT
Coagulation profile
Abdominal imaging if severe abdominal pain
Skin biopsy( IgA and C3 deposition seen under
immunoflorescence), renal biopsy(IGA nephropathy)
Management :
Spontaneous resolution
Analgesics(NSAIDs may be avoided in active phase of
disease )
Immunosuppressive therapy on severe renal involvement
Follow up to see renal involvement
Hep C with skin rash
Dermatologic manifestations:
Cryoglobulinemia-leukocytoclastic vasculitis-palpable
purpura in the legs, livido reticularis, urticaria. Ask about
pain,pruritus, raynaud’s phenomenon
Erythema nodusum
Erythema multiforme
Presenting illness:
Physical examination:
Rash
Stigmata of CLD
Tattoos, injection marks
Addressing concerns:
Investigations:
Anti-HCV antibody
HCV RNA
Skin biopsy
Investigations to see liver involment-LFT, USG HBS, a-
fetoprotein
Treatment :
DAA-interferon, ribavirin
Biological agents-rituximab
Hereditary hemorrhagic telangiectasia/ Osler-Weber-
Rendu-Syndrome
Presenting illness:
Physical examination:
Pallor
Telangiectasias of face, lips, tongue,oral cavity
Bruit in the lung?
?stroke
Addressing concerns:
I think your symptoms are due to a condition called HHT,
where blood vessels bleed without any warning and it can
make you anaemic leading to tiredness
I will have to check your blood to see how anaemic you are
and refer for further tests to see any abnormal blood vessels
in different organs or not( CT angiogram)
The treatment involves treating the anaemia with iron
tablets, or blood transfusion and also trying to stop the blood
vessels from bleeding
This is an inherited condition, I will refer to geneticist if you
are thinking of having children.
Treatment:
Oral or i/v iron
BT
To reduce bleed-tranexamic acid, aminocaproic acid,
estrogen therapy, cauterization, laser, AVMs-embolisation,
surgical resection
Genetic counselling
Hoarseness of voice
DD:
Hypothyroidism*, Goiter
Laryngeal malignancy*
Acute laryngitis(mostly viral)
chronic laryngitis( fungal- steroid inhaler use)
Reflux laryngitis-GERD*
Vocal fold-polyp, nodule, cyst
Bilateral vocal cord paralysis
Overuse of voice(singer)
Hypertension
DD:
1. Primary
2. Secondary
Endocrine-primary hyperaldosteronism(conn’s
syndrome), cushing syndrome, pheochromocytoma,
thyroid dysfunction, acromegaly, congenital adrenal
hyperplasia
Renal- renal artery stenosis, PKD, CKD, GN
Vascular-coartation of aorta, vasculitis, connective
tissue disease(SLE, scleroderma)
OSA
Drugs-cocaine, amphetamines
Pregnancy induced pre-eclampsia/eclampsia
Presenting illness:
Recreational-cocaine, amphetamine
Family history*
Personal-alcohol, smoking
Menstrual history
Physical examination:
Investigations:
Baseline lab work up and also to see target organ damage
Urine microscopy
RFT
S.Electrolytes
Lipid profile
Blood glucose
ECG
To look for causes:
Coartation of aorta- CXR, CT angiography, echo
Conn syndrome-
1. screening tests-hypokalaemia, bicarbonate
level(metabolic alkalosis), plasma aldosterone to rennin
activity ratio(ARR) when greater than 20-25 is highly
suggestive, kaliuresis(urinary K excretion more than 30
mmol/day
2. confirmatory- urinary aldosterone level,s.aldosterone
level , salt loading test
3. CT scan adrenal gland
Renovascular HTN-doppler flow USG , CT/MR angiography
Treatment:
Life style modification
Treatment of HTN and its cause
Treat target organ damage
Hypopituitarism
Presenting illness:
Physical examinations:
Pallor
Skin-dry , pale and wrinkled
Pulse-bradycardia(hypothyroidism)
Check eyes-pallor, eye movements, Visual fields
Look for axillary, facial hair
Gynaecomastia?(mostly found in primary hypogonadism due
to elevated LH levels but can be found in hypopituitarism
with hormone replacement therapy)
Ask to measure Postural drop of BP, palpate testes for
testicular atrophy
Investigations:
CBC-anaemia?
TSH, T4
Morning cortisol and ACTH
Testosterone, oestradiol, LH, FSH
Prolactin
GH levels
Water deprivation test and vasopressin stimulation test
MRI pituitary
Glucocorticoids
Thyroxine
Testosterone, HCG injection(if fertility is desired), estrogen
replacement
GH- if symptomatic
Treatment of cause such as pituitary tumour by surgery.
Hypothyroidism
DD:
Hypothyroidism
1. Primary hypothyroidism
*prior treatment for hyperthyroidism-previous thyroid
surgery, radioiodine therapy, excessive use of carbimazole
*iodine deficiency
*autoimmune disease-hashomoto’s thyroiditis,
*post partum thyroiditis
*subacute/D-quervain’s thyroiditis
*drugs-amiodarone, lithium
Cushing’s syndrome
Addisions disease
Type 2 DM
Presenting illness:
Lethargy
GIT-constipation, weight gain
Metabolic-cold intolerance, menorrhagia
N/S-fatigue, depression, cognitive impairment, psychosis
Hoarse of voice
Neck lump
Coarsening of hands
Elevated BMI
Hand-pulse(bradycardia), dry skin, nail changes(onycholysis,
ridging), carpal tunnel syndrome
Face-periorbital puffiness, xanthelesma
Neck-goiter, thyroidectomy scars
Proximal myopathy
Lower limbs- non pitting oedema, Slow relaxing tendon
reflexes
Look at eyes for grave’s disease
Look for autoimmune diseases-vitilgo, pernicious anemia, DM
Ask for postural drop of BP(to exclude coexisting addisons)
Look for carpal tunnel syndrome, cerebellar features
Addressing concerns :
Investigations:
TFT-TSH, T4 , t3
Anti-TPO(Thyroid peroxidase antibodies) , anti-thyroglobulin
antibodies….Hashomoto’s
FBC-macrocytic anaemia
Lipid profile
9 am cortisol
USG of neck
Treatment:
Levothyroxine replacement
Ichthyosis
Types:
Presenting illness:
Drug history*
Family history*
Sexual history
Physical examination:
Addressing concerns:
Investigations:
Skin biopsy
Genetic testing
CBC with PBF
TFT
Autoimmune screen-ANA, anti-dsDNA(SLE), anti-centromere
antibodies(SS)
Tests for sarcoidosis
Treatment:
Presenting illness:
Obese female
Increased ICP- non-specific headache ,nausea and vomiting
Papilloedema-leading to secondary progressive optic
atrophy-visual loss
Diplopia-on lateral gaze(false localizing sign-6 th nerve palsy)
tinnitus
Exclude DD—migraine, tension, ICSOL
Personal-smoker?
Physical examination:
Addressing concerns :
The brain and the spinal cord are bathed by a clear watery
fluid called CSF within the skull.
IIH is raised pressure within the skull which puts pressure on
the brain. The exact cause is not known. The raised pressure
will give pressure to back of the eye where the nerve
responsible for vision called optic nerve is situated. It gets
swollen and if not treated, might lead to blindness.
I will give medications to relieve your headache and ask eye
doctor to see you and refer to brain doctor.
Investigations:
MRI/CT Brain(to rule out intracranial lesion)
LP
Bed side USG-measure diameter of optic nerve sheath
Detailed ophthalmic assessment(formal perimetry, OCT)
Treatment:
DD:
kallman’s syndrome
other causes of primary hypogonadism
DD of tall stature:
klinefelter
familial
marfan’s
homocystinuria
Presenting illness:
Social history?*
Physical exam:
Tall stature
Gynaecomastia
Paucity of facial and axillary hair
Auscultate precordium for mitral valve prolapsed
Ask to palpate testes-small and firm
Investigations:
Treatment :
Causes:
Presenting illness:
Pulse, BP
Anaemia
Abdomen-?mass, features of IBD
Perform DRE
Investigations:
Treatment:
sarcoidosis
lyme disease
myasthenia gravis,
myotonic dystrophy-frontal balding, myotonic facies,
myotonic grip, percussion myotonia,
fascioscapulohumeral dystrophy-winging of scapula,
proximal myopathy with wasting
bilateral bells palsy
GBS
Presenting illness:
Physical examination:
Examine 7th CN, 5TH CN, 8TH CN, look for vesicles in ear and
oral cavity, look for scars in mastoid and parotid region, look
for hemiparesis
Ask about taste sensation and lacrimation
Addressing concerns:
Investigations:
Treatment:
Prognosis:
Causes:
Presenting illness:
Personal-alcohol , smoking
Physical examination
Investigations:
Treatment:
Tall stature
H/O Spontaneous pneumothorax
Chest pain, palpitations, sob(AR)
Presenting illness:
Pneumothorax-when? Frequency? How treated?
Syncope,chest pain, sob, palpitations( aortic dissection, AR)
Eye- vision problem?
Joints-hypermobility?
Joint pain/back pain?
Learning difficulties, epilepsy, developmental
delay(homocystinuria)
Physical examination:
Tall with disproportionately long limbs compared to trunk
Hands- thumb sign(steinberg sign)), wrist sign,
arachnodactyly, joint hyperextensibility of joints
Kyphoscoliosis
Eyes-lens displaced upward, heterochromia? Blue sclera?
Myopia, RD, Iridodenesis(inspect closely)
Mouth-high arched palate, crowding of teeth
Heart- AR? MVP?
Lungs-pectus excavatum or carinatum, chest drain scars, ?
pneumothorax?
Pes planus
Addressing concerns:
Your symptoms may be due to a condition called marfan
syndrome . it is inherited condition affecting muscles, joints
and sometimes can affect heart and eyes.
We will do tests to exclude problem with the heart and refer
to eye doctor for assessment for any eye problem
Treatment is symptomatic with treatment of underlying
condition associated with it
Support groups
Treatment:
Genetic counseling
Cardiac- lifelong B-blockade, elective aortic root replacement
when diameter is >50mm or if dilatation is occurring at
>5mm/year or if there is family history of dissection
Opthalmological follow up
Physio and occupational therapy
MEN type 1 syndrome
Presenting illness:
Family history*
Physical examination:
Visual acuity, visual field defects, fundoscopy
Parathyroidectomy scar in neck, thymectomy scar
Ask to measure BP
Addressing concerns:
MEN type 1 syndrome is a rare hereditary disorder that
causes tumours in the glands that produces hormones, such
as parathyroids, pancreas and pituitary. It produces
excessive hormones that can lead to disease.
However the tumours are usually non-cancerous(benign)
Although it can’t be cured, regular testing is needed to
detect problems
Will refer to gland doctor, bowel doctor, and surgeons……
Genetic counselling
Investigations:
Treatment:
Presenting illness:
Physical examination:
Pulse, BP
Neck mass/thyroid nodule, neck scar
Fundoscopy-hypertensive retinopathy
Addressing concerns:
Treatment:
Hereditary pheochromocytomas:
MEN 2 syndrome
Von-Hippel-Lindau Syndrome
Neurofibromatosis
Tuberous sclerosis
Meralgia paraesthetica
Causes:
Clinical features
Investigations:
Management :
Conservative initially
General :
Medical :
Presenting illness:
Drug history*
Personal-smoker, alcohol?
Physical examination
Addressing concerns:
Investigations:
Medical:
cholinesterase inhibitors-pyridostigmine
immunosuppresants-steroids, azathioprine, cyclosporine,
MMF
I/V IG
Plasmapheresis
DD:
Diabetic dermopathy
Cutaneous sarcoidosis
Granuloma annulare
Presenting illness:
Drug history
Physical examination:
Addressing concerns:
Investigations:
Treatment:
Presenting illness
Physical examination:
Skin-neurofibromas, café-au-lait spots, axillary freckling,
scars from previous surgery, plexiform neuromas
Arm- ask for blood pressure
Investigations:
Clinical diagnosis
2 or more:
Treatment:
DD:
COPD
Asthma
Narcolepsy
Central sleep apnea syndrome( due to stroke and heart
failure…no airway collapse)
Presenting illness:
Drug history-sedatives?
Smoker?
Alcohol?
Driver?
Physical examination:
Obese
Dyspneic or sleepy at rest, on oxygen therapy , CPAP
machine nearby
Face-facial plethora, central cyanosis, conjuctival
congestion(secondary polycythaemia), macroglossia,
tonsillar enlargement?
Neck-ask to measure neck circumference(>17 inch in men
and >15 inch in women)
JVP
Examine Respiratory system
Look for signs of Pulmonary HTN, CCF
Ask to measure BP, dip urine for glucose
Addressing concerns:
Investigations:
DD
3. Gradual loss
Presenting illness
Drug history-ethambutol?
Personal-tobacco?
Family history*
Physical examinations:
Visual acuity- reduced
Light reflex- RAPD may be there
Fundoscopy-optic disc may look total pallor, temporal pallor,
cupping(glaucoma)
Colour vision
Visual fields
Eye movement-INO in MS, Nystagmus
Look for causes- such as cerebellar signs if MS
Addressing concerns:
Investigations:
Presenting illness:
Physical examination:
Short stature as opposed to Marfan’s, kyphoscoliosis
Face- blue sclera, hearing aids?, dentinogenesis imperfecta,
Locomotor-evidence of previous multiple fractures, bowing of
long bones, joint hypermobility,
Heart-AR/surgical scars
Skin-hyperlaxity
Addressing concerns:
I think your fractures and the problem with the eyes are
connected and may be due to a condition called
osteogenesis imperfecta. It is a condition where there is
rapid formation and destruction of bone leading to weakened
bone.
We need to do some tests to confirm it and tests to see the
thickness of your bone.
Treatment involves preventing fractures by giving
medications to strengthen the bone
It is inherited condition, and will refer to geneticist as there
will be implication if you want to have children in the future
Treatment:
Patient edu and genetic counselling
Calcium, vit D, bisphosphonates
Orthopaedic interventions for fracture, hearing aids
Physio, occupational therapy
Pagets disease
Osteomalacia
metastases
Presenting illness:
Bony pain
Fractures
Increasing hat size
Hearing loss
Alarm symptoms-high output cardiac failure, cord
compression
Features of OA and gout associated with it
Physical examination:
Collapsing pulse(hyperdynamic)
Enlargement of the skull-frontal bossing, enlarged maxilla
Deformities of long bones- bowing of tibia, previous fractures
Kyphosis
Hearing aid?(CN 8TH nerve), other CN nerves may be affected
Exclude osteomalacia- proximal myopathy
Heart –CCF?
Addressing concerns:
Pagets disease –due to high turnover of the bones
We will do x rays and blood test(ALP), also check vit D and
calcium levels as it can cause similar symptoms
We will address your pain with analgesia
Investigiations:
ALP(raised), calcium and phosphorus levels are often normal
VIT D(normal)
Imaging- x ray and bone scintigraphy/isotope bone
scan(areas of increased uptake in pagetic bone)
Treatment:
Medical-NSAIDs, Bisphosphonates, cal and vit D supplements
Physio, occupational therapy
Orthopaedic interventions
Palpitations:
DD:
*cardiac
AF
SVT( A.flutter, AV nodal reentrant tachycardia-rapid and
regular pounding in the neck),
Atrial/ventricular extrasystoles(typically a missed beat
followed by strong beat, improves on exercise)
Ventricular arrhythmias-VT(presyncope/syncope)
Causes of AF(Rheumatic heart diease, IHD, HTN,
Thyrotoxicosis,
(rapid and regular palpitations are due to sinus tachycardia,
SVT, VT,,,,, Irregular palpitations-AF and extrasystoles)
*Non cardiac:
Thyrotoxicosis,
anaemia
Panic attacks, anxiety disorder,
drugs
AF:
Focused history:
Palpitations-regular/irregular, nature of onset , duration, how
fast, have you counted your pulse?, how frequently? Ask to
tap the rhythm, any triggers such as caffeine, alcohol,
exercise(precipitates VT)?, how does it terminate?(SVT
terminate by holding breath/straining-valsalva, extra systoles
terminate with exercise), associated symptoms such as
chest pain, SOB, collapse? Presyncope? Anxiety?(perioral
and finger tip paraesthesias.
Look for causes-features of thyrotoxicosis, rheumatic heart
disease,pheochromocytoma(headaches, flusing, sweating)
Alarm symptoms-angina, syncope, stroke signs, CCF
Past medical history:
Rheumatic heart disease, IHD, HTN, hyperthyroidism,
stoke/TIA, DM, Vascular disease( CHADS2-VAS)
Medication history:
Thyroxine? Salbutamol? Recreational drugs-cocaine,
amphetamine?
Drugs that prolong QT segment may precipitate polymorphic
VT( Macrolides, quinidine , amiodarone, ssri, TCA)
Physical examinations:
Pulse-irregularly irregular
Ask to measure BP
Eyes and face-thyroid eye signs, malar rash
Neck-goiter, carotid bruits
Heart-any murmur?
Lung bases-fine crepts for heart failure
Addressing concerns:
I think the cause of your palpitation is an irregular heart
beat called atrial fibrillation. The cause is often not found but
we will look for underlying problems if any and treat them
The fact that you complain of chest pain and sob may mean
a reduced blood supply to your heart
We will need to confirm with ECG and investigate further
with ultrasound scan of your heart(echo), may need 24 hour
measurement of your heart rhythm, and dye test to see
blood supply in your heart.
We can treat AF by getting the heart back to normal rhythm
or try stopping beating it fast. We may have to use blood
thinning agents as AF is a risk factor for formation of blood
clots esp in heart.
Investigations:
Resting ECG, 24 hr ECG monitoring(holter monitor)
Echocardiogram
Coronary angiogram, stress echo, myocardial perfusion scan
Implantable loop recorders, electrophysiological studies
CBC-anaemia
TFT
S.electrolytes
Treatment :
Paroxysmal AF:
Rhythm control strategy is preferred: best achieved by DC
cardioversion following several weeks of anticoagulation,
and followed by B-blockers/amiodarone
Rate control-B-blockers, calcium channel
blockers(verapemil),amiodarone, digoxin(ABCD)
DD:
ICSOL-tumour , haemorrhage
IIH( OCP, Tetracycline)-female, obese,hypothyroidism
Malignant hypertension
Excessive CSF production-choroid plexus papilloma
Decreased CSF resorption-meningitis, SAH, Venous sinus
thrombosis
CO and lead poisoning
Graves opthalmopathy(usu unilateral)
Presenting illness:
Physical examination:
Eye exam- visual acuity(usu. Normal), fields-tunnel vision if
severe, eye movement( 6th nerve palsy), fundoscopy-
papilloedema
ask for BP and urine dipstick(accelerated HTN)
fundoscopic findings- venous engorgement and tortuosity
with loss of venous pulsation, optic discs appears blurred
and hyperemic, haemorrhages, exudates, cotton wool spots
around the disc.
Investigations:
CT or MRI brain
Lumber puncture
Treatment :
Based on underlying cause:
Idiopathic intracranial hypertension:
life style changes-losing weight, stopping precipitant drugs
medical-diuretics , carbonic anhydrase inhibitors, steriods
interventional-serial lumber puncture, lumboperitoneal
shunts, optic nerve sheath fenestration
Paroxysmal Nocturnal Haemoglobinuria
DD:
Aplastic anaemia
Haemolytic anemias
Paroxysmal cold haemoglobulinemia
Presenting illness:
Physical examination:
Anaemia/pallor
Skin ecchymoses
Fever?
Abdomen-hepatomegaly, ascites(Budd-Chiari syndrome),
absent bowel sounds(bowel necrosis)
Papilledema in presence of cerebral vein thrombosis
Tender skin nodules
Addressing concerns:
Investigations:
Treatment:
Complications:
Thrombosis
Complications of pancytopenia-infections, anaemia
Leukaemic transformation
Pemphigus
DD:
Bullous pemphigoid
pemphigus
Dermatitis herpetiformis
Drug eruption
Herpes gestationis
Liner IgA disease
impetigo
Presenting illness:
Mucous membrane lesions develop initially by months (50%)
-mouth lesions/vaginal
Cutaneous blisters- tensed (pemphigoid) or flaccid? Pain?
Distribution? Itchy?
Alarm symptoms- features of secondary infection/septic
shock
Drug allergies
Physical examination:
See the location of rash, see inside mouth
Skin blisters are flaccid blister filled with clear fluid located
on normal skin or erythematous base and easily broken
down, leaving red denuded skin and crusted erosions
Nikolsky sign(not to be performed in exam)
Ask to look at TPR chart
Addressing concerns:
Investigations:
Treatment :
General-nutrition, hydration, emollients for skin, barrier
nursing, treat secondary infection
Specific-immunosuppressants, IV IG, Bilogic therapies
Peripheral neuropathy: mixed /sensory neuropathy
DM
Alcohol
Drug induced
Nutritional-vit B12 deficiency
Hypothyroidism
Vasculitis
Infection-HIV, leprosy
CMTD
Presenting illness:
Personal-alcohol*
Family history*
Physical examination-Lower limbs exam, look for charcot
arthopathy in DM
Addressing concerns:
Investigations:
NCS to confirm it
Look for causes- CBC, fasting blood glucose, LFT, gamma
GGT, TFT, VIT b12, B1 assays, infection screen, vasculitis
screen
Stem: history of itching for 10 months. Ankle joints pain (on and
off). Father died of blood cancer.
DD:
Presenting illness:
Personal-smoker?
Family history*
Physical examination:
Evidence of venesection
Plethoric face
Polycythaemia/injected conjunctival vessels
Splenomegaly/hepatosplenomegaly
Ask to measure BP
Addressing concerns:
Investigations:
Pulse oximetry to measure arterial oxygen saturation(to rule
out hypoxia as a secondary cause of erythrocytosis)
CBC,,,increased three cell lines, Increased Hb, increased
haematocrit
Red blood cell mass
JAK2 mutation and serum erythropoietin level( positive JAK2
mutation and low Epo level confirms diagnosis)
Bone marrow biopsy(not usually necessary)
S.uric acid
USG abdomen to look for hepatosplenomegaly
Treatment:
Complications
DD:
Presenting illness:
Physical examination:
Test for proximal myopathy
Tone, reflexes and sensory may be normal on limb exam
Look for causes- thyroid(hand signs, eye signs, neck, deep
tendon reflex), Myositits(rash,gottron’s papules), MG(partial
ptosis, complex opthalmoplegia, fatiguability, facial muscle
weakness), Cushing’s syndrome
Investigations:
CBC, ESR(PMR)
TFT
VIT D levels
LFT(Alcohol)
Urinalysis- myoglobulinemia
RFT
S.electolytes
PTH level
Muscle biopsy, anti-Ro, anti La antibodies , anti RNP
antibodies -Myositis
EMG- MG, Myositis
Genetic testing-muscular dystrophies
Physical examination-
Addressing concerns:
DD:
Psoriasis
Eczema
Discoid lupus
Presenting illness
Rash-nature, distribution, scaly? Precipitating factors
(alcohol, streptococcal throat infection, stress, drugs,
sunlight), itchy?
Joint pain?
Physical examination:
Rash- well circumscribed erythematous plaque with silvery
white scales in extensor surfaces, scalp
Nails-pitting, ridging, onycholysis, subungual hyperkeratosis
Joints-asymmetrical arthritis?
Addressing concerns
Your itchy rash is due to a condition called psoriasis
I will give some emollients and creams containing steroids
and vit D. if that doesn’t improve, I will refer to skin doctor
for further treatment.
Support groups
Investigations:
It is a clinical diagnosis, if in doubt, skin biopsy
Treatment:
General – avoid precipitating factors, emollients,
antihistamines
Topical therapy- steroids, Vit
analogues(calcipotriol),retinoids(tazarotene), coal tar,
dithranol
Systemic therapy- retinoids(acitretin), MTX and other
immunosuppresants, biologics
PUVA therapy
Variants of psoriasis:
Chronic plaque
Pustular
Guttate
Erythrodermic
Palmoplanter
Psoriatic arthropathy:
DD
Rheumatoid arthritis
Seronegative arthropathy(enteropathic, reactive, ankylosing
spondylitis)
Presenting illness:
Joint pain- pattern/which joints? , swelling? Stiffness and its
duration? More at rest or activity? Functional status
Skin rash, bowel symptoms, urinary symptoms, back
pain/neck pain
Nail changes
Extra-articular- apical pulmonary fibrosis, anterior uveitis,
Achilles tendinitis
Physical examination:
Pattern of joint involvement: asymmetrical oligoarthritis,
symmetrical rheumatoid like pattern, DIP arthopathy,
spondylitis, arthritis mutilans
Nail changes?
Finger-dactylitis
Skin-psoriasis
Lungs-apical fibrosis,
Heart –AR?
Addressing concerns:
Investigations:
Clinical diagnosis
Pyoderma gangrenosum
Malignant ulcer
Infective-tubercular
Venous ulcer/arterial ulcer
Neuropathic ulcer
Vasculitis
Trauma
Presenting illness
Physical examination:
Ulcer- edge (purplish, necrotic, overhanging), floor-may be
purulent, surrounding erythema, tender
Abdomen-IBD
Lymph nodes(lymphoma)
Addressing concerns:
Investigations:
CBC
Wound swab for gram stain and C/S
Skin biopsy
Bowel-endoscopy and biopsy
Treatment:
Presenting illness-
Physical examination:
Addressing concerns:
FBC, RFT
TFT
ESR
RF
Anti-centromere antibodies, anti-scl70 antibodies
ANA, Anti dsDNA
CXR-cervical rib
Treatment:
DD:
Enteropathic arthritis
Psoriatic arthritis
Ankylosing arthritis
Septic arthritis
Presenting illness:
Family history
Occupational history
Sexual history*
Travel history*
Addressing concerns:
Treatment:
Medical- NSAIDs, steroids(systemic , intraarticular),
tetracycline if Chlamydia is positive, DMARDs,
physiotherapy
Retinal vein occlusion
Presenting illness
Physical examination:
Visual acuity
Papillary reflex-normal or RAPD
Visual field
Fundoscopy- tortuosity and dilatation of all branches of
central retinal veins, widespread dot/blot/flame shaped
haemorrhages in all quadrants , optic disc and macular
edema may be present, cotton wool spots may be present.
Look for risk factors-plethoric face(PCRV), dm
Ask to measure BP
Investigations:
Fluorescein angiography
OCT
Look for risk factors: FBC, ESR, blood glucose,lipid profile,
plasma protein electrophoresis
Treatment:
Risk factors
AGE(old age)
DM, HTN, hyperlipidaemia,smoking
glaucoma,
myeloproliferative disorders(polycythaemia, MM,
waldenstrom macroglobulinemia)
acquired hypercoagulable states(APS)
Inherited hypercoagulable states(protein C deficiency,
protein S deficiency, antithrombin deficiency, Activated
protein c resistance
Inflammatory diseases- bechcet’s syndrome, sarcoidosis
Retinitis pigmentosa
Presenting illness:
Physical examination:
EYE
1. visual acuity-impaired if it involves macula
2. fields: peripheral vision loss/constriction of visual field
3. eye movement-opthalmoplegia in KS syndrome
4. fundoscopy-peripheral spiculated black pigments in both
retinas, pale optic disc/optic atrophy, attenuated retinal
vessels
5. Look for cataract(50%)
Any hearing aids? Polydactyly? DM?
Addressing concerns
Genetic testing
Electroretinogram (objective measure of rod and cone
function)
Treatment :
Genetic counseling
Supportive-visual aids
Rheumatoid arthritis
DD:
Physical examination:
Joints- symmetrical deforming polyarthopathy affecting
MCPs, PIPs and classically sparing DIPs
Deformities- swan neck(flexion of DIP), boutonniere’s
deformities, Z deformity of thumb, ulnar deviation of
fingers, subluxation at MCPs
Palmer erythema, wasting of small muscles of hand
Look for rheumatoid nodules
Check for hand function
Eyes
Lungs
Abdomen-splenomegaly in felty’s syn
Check BP, urine dipstick for GN
Addressing concerns:
Investigations:
CBC(neutropenia, anaemia)
ESR
CRP
RF
Anti-CCP
X-ray of hands
RFT, urine dipstick
CXR
DX: RA, active or not? Functional status, ? look for mixed
connective tissue diseases, look for systemic manifestations
Treatment:
Details:
DD to think of:
Presenting illness-
Establish nature of back pain(onset-gradual or rapid,
severity(disturbs sleep or not, daily activities?), exacerbating
and relieving factors, radiation, what precipitated? Any
trauma?
Physical examination:
Ask for pain and feel for the spine
Examine lower limbs for tone, power, reflexes and check
sensation if time and also indicate the need to check
perianal tone and sensation
Look at observation chart
Indicates the need to look for signs of endocarditis( heart
murmur?)
Addressing concerns:
It is not likely a case of another fracture (but would do x ray
to exclude it). It is likely the part of adjacent vertebral bones
known as disc might be infected with a bug, and probably
the bug entered from the cut injury travelling in the blood
stream (due to incomplete antibiotic course) and finally
reaching the vertebra where the bone was previously broken
(as broken bones act as a favourable place for bugs to grow).
Because of the infection, you are feeling generally unwell.
Clinical judgement:
Immediate management- admit in hospital, asses for signs of
sepsis syndrome, fluid balance
Commence empirical antibiotic after taking blood sample for
culture( i/v flucloxacillin)
Immediate tests- CBC, Blood culture, urea and electrolytes,
CRP, x ray spine and MR spine looking for evidence of
discitis/cord compression
The need to discuss with the senior/consultant and liaison
with microbiologist and surgeon
Recognizes the abnormal bone(previous bone fracture as
nidus for infection)
Physical signs:
Pyrexia( from the info)
Excludes septic shock
Identifies spinal tenderness and excludes cord compression
Probable diagnosis:
Infective discitis presumed secondary to bacteremia
following incompletely treated soft tissue infection
Others:
Osteoporotic fracture
Sheehan’s syndrome
Presenting illness:
Physical examination:
Pallor
Pulse-brady(Hypothyroidism)
Postural drop of BP
Skin-dry, wrinkled
Eye movements and visual fields
Reduced axillary hair
Addressing concerns:
Investigations:
TSH, T4
S.Electrolytes(hyponatraemia, normal K)
S.cortisol, ACTH
LH, FSH, S.estradiol
GH levels
Prolactin levels
Insulin tolerance test ( induces hypoglycemia and as a result
leading to increased cortisol levels in normal person, in this
case, the cortisol level will not rise)
MRI of pituitary-?emty sella
DD:
Focused history:
Shortness of breath: onset, frequency, on exertion or at rest,
functional status(MRC dyspnea scale), orthopnea, PND,
exacerbating(activity) and relieving factors(rest, GTN),
Associated symptoms- chest pain, palpitations,
Ankle swelling
To exclude DD( respiratory symptoms cough, wheeze,
sputum production, haemoptysis, chest pain,fever, chest
trauma(pneumothorax)
Personal history
Family history
Social , occupational history
Physical examination:
Dyspnea at rest
Pulse, ask to measure BP
Cyanosis
JVP
Precordium exam
Lungs-fine crepts
Pedal oedema
Addressing concerns:
I think the cause of your shortness of breath and swollen
ankles is heart failure. It means that your heart muscle is not
effectively pumping as it should, so fluid collects in lungs and
peripheries
I would like to obtain Heart tracing(ECG) and confirm with
ultrasound of heart(echo), also some blood tests to exclude
anaemia
We can start treatment right away and one of which is water
tablets to remove fluid collection and other tablets as well
Investigations:
ECG
ECHO
CBC(anaemia), s.electrolytes, TFT, BNP
Cxr
Treatment :
General-no added salt, restricted fluid intake, influenza
vaccination, cardiac rehab
Medical- diuretics, ACEi or ARB, B-blockers, spironolactone,
digoxin,
Interventional/surgical-ICD, CRT, CABG, Heart transplant
Manage risk factors-smoking, hyperlipedemia, DM
Sickle cell anaemia
Clinical features
Signs:
Hypoxemia
Dehydration
Cold temperature(vasoconstriction)
Investigations:
Treatment:
Pharmacological
Non-pharmacological
DD of rash on face
SLE
Dermatomyositis
Eczema
Rosacea
Mitral stenosis
Carcinoid syndrome
Presenting illness:
Facial rash- photosensitive
Hair loss(alopecia)
Mouth ulcers
Lungs-Pleurisy and effusion
Heart-Pericarditis/myocarditis/endocarditis
Easy bruising(thrombocytopenia)
Renal involvement –reduced urine output, ankle and facial
swelling, high blood pressure
MSK-arthritis, raynaud’s phenomenon
CNS-psychosis, seizures, depression, weakness/paraesthesia
DD: MS(palpitations, sob, chest pain), acne rosacea(pustules,
flushing), carcinoid(flushing, diarrhoea, wheeze)
Features of mixed connective tissue disorder
Investigations:
CBC-pancytopenia?
ESR(Raised in active disease), CRP
Urine dipstick
RFT
Immunology- ANA, anti-dsDNA antibody, anti-smith antibody,
anti-Ro and anti La antibodies, anti-RNP antibody(mixed
CTD), anti-phospholipid antibodies(anti-cardiolipin antibodies
and lupus anticoagulant), C3 AND C4 decreased in active
disease
Organ based:
1. Kidney- kidney biopsy
2. Lngs-CXR, CT chest
3. Heart-ECG, echo
4. CNS-MRI brain(neuropsychiatric manifestations)
5. Skin-skin biopsy
1. General measures
Patient education and counselling
Avoid excessive sunlight-sunscreens, hats
Removal of offending drug
Physio and occupational therapy
Management of cardiovascular risk factors
2. Medical
Analgesics, NSAIDs for arthritis (may worsen renal
involvement )
Hydroxychloroquine, topical steroids for Skin disease
In severe systemic disease-systemic steroids,
cyclophosphamide, azathioprine, MMF, monoclonal
antibodies(rituximab), IV Ig
Autologous stem cell transplantation(for severe disease)
RRT for end stage RF due to lupus nephritis
Drug induced lupus:
Class I-normal
Presenting illness:
Past medical history: HTN, CKD, PUL fibrosis, PUL HTN, IHD,
autoimmune diseases (thyroid disorders)
Drug history:
Personal-smoker?
Physical examination:
Support groups
Investigations:
DD
Presenting illness:
Asymptomatic (10%)
Constitutional symptoms-headache, malaise, arthralgias,
fever, weight loss
CVS-HTN, CCF, AR, Pericarditis, MI, raynaud’s phenomenon,
claudication
N/S-headache, stroke, TIA,seizures, visual disturbance
Skin lesions-erythema nodosum
Physical examination:
Peripheral pulses-decreased pulsation in brachial
arteries(one or both arm)
Blood pressure-difference of at least 10mmhg of systolic BP
between arms*
Neck-carotid bruit*, subclavian bruit, neck scars for previous
surgery
Abdomen-renal bruit
Heart- AR*, CCF, pulmonary hypertension
Fundoscopy for hypertensive changes
Addressing concerns:
Investigations:
DD:
TIA/stroke
Temporal lobe seizure
Hypoglycemia
Migraine variant
Dementia
Presenting illness:
Paroxysmal, transient loss of memory function verified by a
witness. Remote memory is preserved (remember who you
are, recognize the people you know well). Striking loss of
memory for recent events(can’t remember where you are or
how you got there) and impaired ability to retain new
information(registration of information is intact)
Anxious and agitated, may repeatedly ask questions
concerning the events.
Symptoms lasts typically less than 24 hours
Precipitants-stress, pain, exertion, sexual intercourse
Exclude DD
Any head injury
Annual Recurrence (4-5%)
Drug history-sedatives
Alcohol*, smoker*
Physical examination:
Addressing concerns:
Investigations:
Electrolytes, RBS
MRI/CT scan to rule out stroke
EEG to rule out seizure
ECG
Treatment:
reassurance
Transient ischaemic attack
DD of TIA:
Migraine
Focal epilepsy
TGA
Hypoglycemia
MS
DD of amaurosis fugax:
Central retinal vein or branch occlusion
Diabetic maculopathy
GCA
Vitreous haemorrhage
hypoglycemia
Presenting illness:
Addressing concerns:
Investigations:
Treatment:
1% if score 0-3
4% if score 4-5
8% if score 6-7
Tuberous sclerosis
Presenting illness
Drug history-anti-epileptics
Physical examination:
Treatment:
Rapamycin(immunosuppressant)
Treatment of organ based involvement:
Antileptic medications, surgery
Turner syndrome
DD:
Presenting illness:
Short stature
Limbs-wide carrying angle/cubitus valgus at elbow, short
fourth and fifth metacarpal/metatarsal bones,
lymphoedema(puffiness over fingers and toes)
Face-high arch palate, inner canthal folds, ptosis, cataracts
Ear- hearing loss (ottitis media and otosclerosis), anomalous
auricles
Neck-short neck, webbed posterior neck, low posterior hair
line*, goiter?
Chest-shield chest with widely spaced nipples, pectus
excavatum may be present
Heart- biscuspid aortic valve, coartation of aorta(?repaired)
Skin-excessive pigmented naevi
Ask to measure BP
Addressing concerns:
Investigations:
Karyotyping -45XO karyotype in peripheral blood
lymphocytes
Exclude organ involvement:
1. Heart- ECHO
2. Endocrine-blood glucose, TFT, Low plasma estradiol with
raised LH, FSH(Hypergonadotrophic hypogonadism), vit D
levels/bone prolife(risk of osteoporosis)
3. Renal- USG(horseshoe kidneys)
HRT
Recombinant growth hormone to increase height
Genetic counseling
Pregnancy-specialist fertility clinic input, very few may
conceive but will have major risk of severe congenital
anomalies
Treatment of associated conditions
Prophylactic gonadectomy in case of mosaicism as there is
chance of gonadoblastoma
Psychological therapy
Uncomplicated MI 5 weeks ago, now presents with fatigue:
Patient Information:
DD to think of:
Anaemia(GI bleed)
CCF
Postural hypotension
Fatigue due to b-blocker(if given)
Dehydration secondary to AKI by ACE inhibitor
Electrolyte imbalance
Physical examination:
Check pulse, offer to examine lying and standing BP
Check anemia
Listen to heart and lung bases
Asks for/look at observation charts
Patient Information:
DD to think of:
Anaemia(GI bleed)
CCF
Postural hypotension
Fatigue due to b-blocker(if given)
Dehydration secondary to AKI by ACE inhibitor
Electrolyte imbalance
Physical examination:
Check pulse, offer to examine lying and standing BP
Check anemia
Listen to heart and lung bases
Asks for/look at observation charts
DD of hypopigmentation:
Vitiligo
Pityriasis versicolor
Leprosy
Post inflammatory-chemical exposure
Morphea
Discoid lupus
Tuberous sclerosis(ash leaf macules)
Presenting illness:
Family history*
Physical examinations:
Addressing concerns:
Investigations:
FBC(anaemia)
LFT(PBC)
Blood glucose
TFT
9 am cortisol (addison’s disease)
Treatment :
Presenting illness:
Smoker? Alcohol?
Physical examination:
Xanthelesma(eye)
Tuberous xanthomas-firm, painless red –yellow nodules,
usually in extensor surfaces such as knee, elbow and
buttocks (pressure areas)
Tendinous xanthomas-nodules related to tendons and
ligaments(Achilles tendon mostly)
Eruptive xanthomas-crops of small red to yellow papules,
itchy
Look for features of atherosclerosis(unequal and weak pulse,
Features CCF due to MI)
Addressing concerns:
Investigations:
Family history*
Investigations:
Acute porphyrias-AIP
Dd:
Addisions
Heriditary angioedema
Angioedema
Types:
Hereditary –
1. Type 1-low C1 Inhibitor
2. type 2-C1 inhibitor doesn’t function properly
3. with Normal C1 Inhibitor(formerly Type 3)
Acquired –Type 1 and type 2
Idiopathic
Allergic
ACE-inhibitor induced
Non-histaminergic
Presenting illness:
Addressing concerns:
Investigations:
Treatment:
ABCD approach:
Three phases
Presenting illness
Pets
Occupational history*
Physical exam
Plan of action
It is inflammation of the small blood vessels
The exact cause is not known, likely due to overactive
immune system targeting healthy blood vessels
Will do blood tests and refer to different doctors depending
on the organ involvement
Treatment is to dampen down inflammation initially with
steroids and based on organ damage
Investigations
SPECIFIC
p-ANCA
biopsy-skin , lung, kidney
Steroids
Rituximab, cyclophosphamide,azathioprine, MTX
Treatment of asthma
Confusion:
Causes of confusion:
Elderly
1. Infections-UTI, RTI
2. Electrolyte imbalance
3. Polypharmacy/recent change in medications
4. Stroke/subdural haematoma
5. Metabolic disturbance-hepatic, uraemic encephalopathy
6. Hypo or hyperglycemia
7. Cerebral metastases, tumours
8. Alcohol withdrawal syn
Young
1. Recreational drug use and withdrawal
2. Alcohol withdrawal syn
3. Meningitis
4. Infections as above
5. Metabolic disturbances
Presenting illness:
*diuretics-hyponatraemia-confusion
Social *
Plan of action:
Investigations:
CBC, CRP, ESR
Blood glucose
S.electrolytes
RFT
LFT
Urine microscopy and c/s
ECG
Urine toxicology screen
TFT
Blood culture
CXR
CT scan of head if needed
Treatment:
Presenting illness
Family history*
Plan of action:
Malabsorption:
Pancreatic enzyme supplements
Fat soluble vitamins
Hypersensitivity pneumonitis /Extrinsic allergic alveolitis
Forms:
DD:
Pneumonia
Asthma
Pulmonary fibrosis
Presenting illness:
Acute:
subacute
chronic
Occupational history**
Pets**
Hobbies*
Addressing concerns:
Investigations:
Treatment:
DD:
PUD
Gastritis
Gastric malignancy
Pancreatitis
Cholilithiasis/cholecystitis
IHD
Esophagitis, barret’s esophagus
achalasia
Functional dyspepsia
Presenting illness:
Plan of action:
GERD is a condition where the acid from the stomach leaks
up into the gullet (esophagus). It usually occurs due to the
weakened ring of muscles at the bottom of gullet
Your symptoms are consistent with GERD and there are no
danger symptoms such as unexplained weight loss and
difficulty swallowing which would need further tests.
So, I will prescribe you some medications to lower down the
acid level in your tummy for 4-8 weeks and review the
response. You also need to change your lifestyle-need to lose
weight, avoid smoking, alcohol, avoid large meals, and avoid
immediately sleeping after meals and need to elevate the
head end while sleeping.
If it doesn’t respond to the medication and lifestyle
changes..Will refer to bowel doctor for further tests such as
breath tests and endoscopy tests
Investigations:
Endoscopy- to look for complications of reflux such as
esophagitis, , strictures, barret’s esophagus) and to see
anatomy(hiatal herinia, strictures, masses)
Manometry-determine lower esophageal sphincter pressure
Ambulatory 24 hour PH studies/testing
Test for H pylori-carbon-13 urea breath test/ stool antigen
test(keep 2 weeks wash out period of PPI)
Treatment:
1. General-lifestyle modifications
Losing weight
Avoid alcohol, smoking, citrus fruits, tomato based products
Avoiding large meals
Waiting 3 hours after a meal before lying down
Elevating the head of bed by 8 inches
2. Pharmacologic- trial of PPI initially
3. Surgery-laparoscopic fundoplication, sleeve gastrectomy
Giant cell arteritis/temporal arteritis and PMR
Presenting illness:
Physical examination
Pulse
Measure bp in both arms
Visual acuity, visual field, fundoscopy- mainly anterior
ischaemic optic neuropathy(optic disc may be chalky white
and oedematous), also central and branch retinal artery
occlusion
Scalp tenderness
Proximal myopathy
Auscultate carotid artery for bruit
Addressing concerns:
Investigations:
ESR, CRP
CBC-mild normocytic normochromic anaemia
Colour duplex USG of temporal artery-wall oedema
Temporal artery biopsy
Screening of large vessel aneurysm with CT scan
Treatment:
DD:
Septic arthritis
Crystal arthritis
OA
Gout
Presenting illness:
Drug history-warfarin
Investigations:
Treatment:
UTI
Renal stone
Renal tract malignancy
GN-IgA nephropathy, post-infectious GN, Alport syndrome,
sickle cell nephropathy
PKD
Pulmonary-renal syndromes-goodpasture syndrome,
wegener’s syndrome, microscopic polyangitis
Other VasculItis-PAN, HSP
Connective tissue diseases- SLE, Slceroderma
Radio/chemotherapy
Drugs-anticoagulants
Bleeding disorders
Presenting illness:
Physical examination
Puffy face?
Measure BP
Abdomen- PKD
Features of SLE, Scleroderma, vasculitis
Plan of action:
Investigations:
Presenting illness:
Investigations:
S.calcium
S.albumin to calculate total corrected calcium level
PTH level
Investigations for malignancy
Treatment
ABC
Hydration
Loop diuretics
Bisphosphonates
Patients with malignancy may require chemo, radio and
surgery
Hypogammaglobulinemia(Common variable
immunodeficiency)
IgA deficiency
X-linked agamamglobulinemia/Bruton’s
DD:
Cystic fibrosis
AIDS, lymphoproliferative disorders(secondary
immunodeficiency)
Presenting illness:
Addressing concerns:
hypogammaglobulinemia –is a condition due to deficiency of
antibody..that can fight infections.
Referral to immunologist
MDT approach
Avoid life vaccines
CVID-can be autosomal recessive
Investigations:
BASIC and to see manifestations of disease
CBC with differential, ESR, CRP
Sputum for gram stain/c/s, AFB
Stool RE
S. albumin, s.calcium, vit D, clotting profile (malabsorption)
CXR
Anti-HIV
HRCT, Lung function tests
Specific:
Levels of serum immunoglobulin-total IgG, IgA, IgM
Common variable immunodeficiency-IgG levels less than 2
SD below the mean, also low levels of IgA and Ig M
Selective IgA deficiency
Hyper-IgM syndrome-IgM markedly increased, others are
decreased
Flow cytometric analysis-Peripheral blood lymphocyte
phenotyping- absent or less B-lymohocytes
Checking antibodies to vaccines the child
received..antibodies will be absent(antibody response to
immunization)
Absence of antibodies to blood group A and B antigens
Complement levels
Serum electrophoresis
Treatment:
Replacement of Ig G(i/v or S/C) for primary
immunodeficiency
Treatment of secondary hypogammaglobulinemia –according
to underlying cause
Stem cell transplantation for severe combined
immunodeficiency
Treatment of infections-lungs and GI
Avoid life vaccines
Lithium toxicity
Tremors for last 20 years back due to salbutamol inhaler but changed its character
in two weeks. Mainly intentional (while holding objects). Started on lithium for mood
change 6 months back. On lisinopril, HCT, metformin. Has been suffering from
traveller’s diarrhoea.
Notes:
Acute-mainly GI
Acute on chronic-both GI and neurological involvement
Chronic-only neurological manifestations.
Chronic :
CNS- tremor, seizures, altered mental status, coma. SILENT syndrome-
syndrome of irreversible lithium effectuated neurotoxicity(cognitive
impairment, cerebellar dysfunction,peripheral neuropathy)
Renal toxicity-nephrogenic DI, neprhotic syn, chronic TIN, renal tubular
acidosis
Endocrine-hypothyroidism
Aplastic anaemia
Management:
Prognosis:
DD
Presenting illness
MSK
1. bone pain(most common) mostly in lumbar spine
2. pathologic fractures-mostly vertebral
spinal cord compression-back pain, weakness and numbness
in extremities
bleeding-thrombocytopenia
infections-due to leucopenia
Aaemia-weakness
hypercalcemia-confusion, somnolence, bone pain,
constipation, polyuria, thirst
hyperviscosity-malaise, fever, paresthesia, sluggish
mentation,headache, sensory loss, blurring of vision,
epistaxis, stroke, MI
N/S-Carpal tunnel syndrome, peripheral neuropathies
Renal failure
Amyloidosis
Soft tissue masses-plasmacytomas
Cryoglobulinemia, raynauds phenomenon
Plan of action
Investigations
CBC(pancytopenia)
Peripheral blood film-Rouleau formation
ESR, CRP
Total protein, albumin, globulin
S.calcium and electrolytes
RFT
ALP
24 hour urine for quantification of Bence Jones protein,
protein, creatinine clearance
Serum protein electrophoresis
Urine protein electrophoresis-to identify bence jones protein
B2 microglobulin is a prognosticator in MM
Serum viscosity
Skeletal survey-plain x rays(osteolytic lesions), MRI, PET scan
Bone marrow studies-more than 10% plasma cells
Treatment
1. Transplant candidates
Induction therapy followed by autologous stem cell
transplant
Induction therapy, bortezomib based (bortezomib,
cyclophosphamide, dexamethasone or bortezomib,
doxurobicin, dexamethasone, or bortezomib, lenalidomide,
dexa)
2. Non transplant candidates
Bortezomib, melphalan, prednisolone,,,, lenalidomide,
doxurobicin, vincristine
Complications:
Bone fracture
Spinal cord compression
Renal failure
Infections , bleeding , anaemia
Hyperviscosity-stroke, MI
Amyloidosis
Isolated
Associated with 3 syndromes- MEN 2, Von-Hippel-Lindau
syndrome, NF type 1
DD:
Anxiety disorder
Insulinoma-hypoglycemia
Hyperthyroidism
Paroxysmal SVT
Presenting illness:
Personal-smoking, alcohol
Plan of action:
Investigations:
Specific:
Plasma metanephrine
24 urinary collection for catecholamines and metanephrines
Imaging-abdominal CT scan, MRI, scintigraphy, PET scan
ECG
RFT, Urine for albumin
Blood glucose
Fundoscopy
Treatment:
Three types
Type II: usually inherited in autosomal dominant pattern. Occurs in 3 rd or 4th decade
of life
Investigations:
Treatment:
Presenting illness
Family history*
Alcohol history*
History of hepatitis
Plan of action:
Investigations:
Treatment:
Presenting illness:
asymptomatic
Jaundice, pruritus, fatigue,right upper quadrant pain
Might present as acute hepatitis
Bacterial cholangitis-recurrent febrile episodes
CLD-Ascites, variceal bleeding, hepatic encephalopathy
IBD-mostly ulcerative colitis, also chron’s disease
Physical examination:
Stigmata of CLD
Features of IBD
Plan of action:
PSC is a disease of the bile ducts, which carry the digestive
liquid bile from the liver to your small instestine
In PSC, inflammation causes scars within the bile ducts,
leading to narrow bile duct and damaging liver
It is commonly associated with bowel condition called IBD
Will do blood tests to check the liver function and then refer
to liver specialist for further investigations and management
Investigations
LFT-raised ALP, gamma glutamyl transpeptidase,
aminotransferases and bilirubin
PT, INR, S.Albumin
USG HBS
ERCP* OR MRCP*(preferred)
Liver Biopsy-staging and prognosis, shows onion skin
fibrosis/periductal fibrosis
Percutaneous Transhepatic cholangiography if ERCP fails
UGIE for varices
Treatment
Immunosuppresants-steroids
Bile salts-ursodeoxycholic acid
Cholestyramine for itching
Liver transplantation
Replacement of vit A, D, E, K
Sarcoidosis
DD
Tuberculosis
NHL
Presenting illness
Aymptomatic
Fever, anorexia, arthralgia, fatigue
Lungs-cough, chest pain, sob on exertion
Lofgren’s syndrome-fever, polyarthralgias, bilateral hilar
lymphadenopathy
Eye-uveitis
Heart-heart block, sudden death,arrhythmias,
Skin-erythema nodusum , lupus pernio,
Lumps and bumps-lymphadenopathy
NS-Hypothalamic pituitary sarcoidosis-DI and hypoginadism,
cranial nerve palsies, lymphocytic meningitis
Plan of action
Investigations:
Treatment:
Symptomatic therapy with NSAIDs
Steroid and steroid sparing agent(MTX, Azathioprine),
infliximab
Surgery-lung transplantation(stage 1v sarcoidosis)
Indications of steroid:
Staging of sarcoidosis:
Causes:
Adhesions-post surgery, tuberculosis
Stricture of small bowel-chron’s , tuberculosis
Bowel malignancy
hernias
Presenting illness:
Recurrent vomiting
Recurrent crampy abdominal pain
Abdominal distension
Visible/palpable bowel loops
Gargling noises
constipation
Features of Tuberculosis?
Plan of action:
Seems like your bowels have difficulty moving the
contents due to narrowing and bends in the bowel
because of adhesions. It can happen following abdominal
surgery
Will do some blood tests and obtain x-ray, usg scan and
special scan called CT scan after drinking some contrast
liquid to see the affected bowel
Will get an opinion from surgical team
Treatment is laxatives, anti-sickness medication, pain
relievers
But if the bout of SABO is bad, need to rest bowel
completely without taking anything from mouth
Surgery is usually not helpful as obstruction can be at
multiple levels , but obviously will get an opinion from the
surgeon.
Give tips about diet-low fiber diet, eat small servings, 5/6
times a day, softer foods, drink fluids,
Investigations:
CBC
RFT, S.electrolytes
RBS
LFT
IMAGING- plain x ray, USG, contrast CT scan abdomen
Diagnostic laparoscopy
Laxatives-lactulose, laxido
Anti-emetics
Pain relievers-
Short course of steroids
Conservative:
Small vessel
1. Wegener’s granunomatosis/granunomatosis with
polyangitis
2. Churg-strauss syndrome
3. Microscopic polyangitis
Medium vessel- PAN, Kawasaki disease
Large vessel-Giant cell arteritis, Takayasu’s arteritis
Variable vessel-Behcet’s disease
Associated with connective tissue disease-SLE, RA
Cryoglobulinemia
Wegener’s granulomatosis:
Presenting illness:
Drug history
Plan of action:
Investigations:
Polyarteritis nodusa
Lungs are usually spared
ANCA is usually negative
Rx is steroids
Von-Hippel-Lindau(VHL) disease
*autosomal dominant
Presenting features
Pheochromocytomas
Eye-retinal haemangiomas/haemangioblastoma, retinal
detachment, vision loss
CNS(brain and spinal cord)-haemangioblastoma-usually arise
from cerebellum
Kidney-renal cysts, renal cell carcinoma(common cause
of mortality)
ear-endolymphatic sac tumours of middle ear-hearing loss,
tinnitus, vertigo
pancreas-cysts, pancreatic cancer
ovarian cyst in women, epididymal cyst in men
Surgical history-nephrectomy
Family history*
Plan of action:
Investigations:
Screening/follow up
Yearly eye examination
Yearly physical exam
Yearly 24 urine test to screen for elevated catecholamines
Yearly abdominal USG In teenage, CT abdomen in adulthood
MRI of brain and spinal cord 2 yearly