2What is this? What condition it associated with? What are the most common causes of this condition?What oesophageal condition is it associated with?Name 3 important investigations
3ANSWERS Iron deficiency anaemia Caused by blood loss (gi bleed, menorrhagia; hookworm in tropics, malabsorption (coeliac disease)Plummer Vinson syndrom (post cricoid web)FBC, ↓serum iron, ↓ferritin, ↑TIBC, FOB, sigmoidoscopy, colonoscopy, barium enemaTx – oral iron
4Describe immediate management A 52 year old diabetic man presented to A and E feeling sick. 1 week previously his GP had treated him for refluxDescribe immediate management
5ANSWER Morphine Oxygen Nitrates (buccal suscard) Aspirin 300mg B-blocker and ACE-I (within 24 hours)Thrombolysis if no contraindications! As presented within 24 hours of ischaemic chest pain with ST elevation of at least 2mm in 2 adjacent chest leadsPRIMARY PCI IF IN COOL TEACHING HOSPITAL
6CONTRAINDICATIONS TO THROMBOLYSIS Internal bleedingProlonged/traumatic CPRAny prev haemorrhagic strokeIschaemic stroke within 1 yearRecent trauma surgery (2 weeks)Intracerebral neoplasm/recent head traumaSuspected aortic dissectionPrev allergic reaction to fibrinolytic
7Report this XrayDescribe 5 changes you should look for on the XRay in this conditionWhat investigations would you do if this was an acute problem?How would you manage?
85 changes in L ventricular failure A alveolar oedema (bat wings)B Kerley B lines (interstitial oedema)C CardiomegalyD Dilated upper lobe vesseldE Pleural EffusionSIGNS: tachycardia, basal creps, pink frothy sputum, PND, orthopnoeaFBC, U+E, cardiac enzymes, ECG (ischaemia, MI, LVH), ABG, BNP (raised in failure) Echo
9Commonest causes of acute LVF? Post MImyocardial ischaemiaMalignant hypertensionaortic stenosis or aortic incompetencemitral incompetencearrythmia
10Management of acute LV failure Sit upGive 100% 02IV access monitor ECG for arrythmias, MI etcDiamorphine mg IV slowlyMetoclopramide 10mg ivFrusemide 40-80mg IV slowlyGive sublingual GTN if systolic BP>100Monitor urine output (catherterise)Repeat ABG and K+ if condition deteriorates
11A 58-year-old afebrile woman presented with a 2-day history of pain and red streaks of her right leg following minor trauma. There were palpable cords beneath the erythematous streaks.How would you manage?
12ANSWER SUPERFICIAL THROMBOPHLEBITIS Treatment includes gentle support by means of a bandage or stocking and elevation of the affected leg.Anti-inflammatory drugs such as ibuprofen 400mg tds.duplex ultrasound scan (DVT risk)
13This 55year old man has returned from a holiday 2 weeks ago with arthralgia, malaise, lymphadenopathy and peripheral neuropathyHe has the following lesion which started as a red macule.What is the diagnosis?How would you treat?
14Erythema chronicum migrans classical immune-mediated skin lesion which occurs at the site of the bite in Lyme disease some weeks after the bite by the tick.(boriella burgdorferi infection)The tick bite leaves a red macule or papule which approximately later expands to produce a hot, painless annular/target lesion.Tx doxycycline
15Lyme diseaseoften the first manifestation of Lyme disease = Lyme borreliosisspirochete Borrelia burgdorferi is transmitted by the bite of the deer tick Ixodes scapularis in the northeastern U.S.systemic borreliosis is a potentially serious disease, causing both acute and chronic symptoms such as fever, malaise, arthralgia, carditis, arthritis, meningitis, neuropathy, ataxia
16TROUSSEAU’s SIGNThis is a recurring thrombophlebitis characterised by successive crops of tender nodules in affected blood vessels. Different veins may be affected simultaneously or randomly.It denotes a thrombotic state and is associated with visceral malignancy, especially of the pancreas and lung.Thrombophlebitis migrans was first recognised by Trousseau in the diagnosis of his own pancreatic cancer.
17What is this?What causes it?What other signs would you look for?
18ANSWERPlummer vinson syndrome (Post cricoid web) Iron deficiency anaemiaKoilonychia, pallor, atrophic mucous membranes, tachycardia if markedTx balloon dilatation and iron supplementsPre-malignant!!!
19This patient presented with weight loss and this crazy skin condition… What is it?Clue: say what you see
20Erythema Gyratum Repens wood-grain" pattern (repens is a plant)wavy, erythematous, urticarial bands with scaleslowly migratebreast, stomach, bladder, prostate, cervix; (occasionally no CA )
21This patient presented with weight loss, a palpable liver. What is this skin condition and with what condition is it associated?
22Necrolytic migratory erythema Glucagonoma - alpha cell tumor of the pancreasis associated with this condition (in more than 70% of patients)abdomen, thighs and buttockspresent with attacks of hyperglycaemia (diabetes mellitus occurs in more than 50% of cases), anaemia, rash and diarrhoea.Also glossitis, angular cheilitis, normocytic anemia90% have liver metastasis at presentation
23This 22yr old woman presents with weight loss and bloody diarrhoea She develops this lesion on her ankleWhat is it?What else is her condition associated with?
24Pyoderma gangrenosumcharacteristic rapidly expanding ulcer with bluish undermined border; often lower extremities; begin as sterile pustules1% to 10% of patients with active ulcerative colitis; often (but not always) parallels diseaseOther disease associations: Crohn’s, chronic active hepatitis, rheumatoid arthritis, HIV infection; acute and chronic granulocytic leukemia (bullous PG)UC associated with uveitis, arthropathy, erythema nodosum, sclerosing cholangitis
25What is this sign?Name 4 causes of this condition
28Cullen’s signyellow blue discolouration of the skin around the umbilicus. It was first reported in ruptured ectopic pregnancy but is more commonly associated with severe, acute pancreatitis.It is caused by pancreatic enzymes that have tracked along the falciform ligament and digested subcutaneous tissues around the umbilicus.
29What is this. What else would you look for What is this? What else would you look for? What investigations would you do? What treatment would you start?
30Tendon xanthomaextensor tendons of fingers, patella, elbows, Achilles tendon (one of the most common sites); diffuse infiltration of tendon by lipidXanthelasma in eyes, corneal arcushypercholesterolemia; Types II and IIILipid profileStatins
32Acanthosis nigricansvelvety thickening and darkening (hyperpigmentation) of the skin, especially on the nape of the neck, axillae and other body foldsunderlying causesobesity; drugs; "malignant" acanthosis nigricans; hereditary, benign ANGLUCOSE INTOLERANCE, INSULIN RESISTANCE
34What is this? With what conditions is it associated?
35Erythema nodosumdeep erythematous painful nodules, symmetrically on the lower legs; female predominance; a hypersensitivity panniculitisfever, chills, malaise, leukocytosisdisease associations: streptococcal infections, drugs (OCPs, sulfonamides, iodides), pregnancy, TB, deep mycoses, acute sarcoidosis, inflammatory bowel disease
36What is this and with what condition is it associated?
37Keratoderma blenorrhagica Keratoderma blenorrhagia is a skin condition associated with Reiter's syndrome.urethritisconjunctivitisa seronegative arthritisIn this disorder there are vesicles which fill in with caseous material.Pustular psoriasis may produce an identical clinical and histological picture.The lesions are found:soles of the hands and feetpenis, causing a circinate balanitisin the mouthIt is treated with 1% hydrocortisone.
38What are these lesions? With what are they associated?
39Erythema multiformeform of cutaneous reaction to an underlying condition. In 50% of cases, a cause can’t be identifiedcommon causes: HERPES VIRUSdrugs (sulfonamides, phenytoin, barbiturates, penicillin, etc.); infections (esp. herpes simplex and Mycoplasma)inflammatory bowel diseaseeruption usually lasts for a week or two, then spontaneously remitsthe "target" lesion is approximately 1cm dull-red macule or papule with a central area of blistering or hemorrhage
41urticaria IDIOPATHIC IS MOST COMMON Drugs (e.g., penicillins, aspirin, NSAIDs, opiates, phenytoin, atropine, metronidazolephenytoinFood stuffs, insect bites, candida infectionssystemic lupus erythematous - in early stages, urticaria may be the only clinical abnormality, with wheals persisting for an unusually long time daysviral hepatitis - may begin with urticariaStill's diseaserheumatic feverhyperthyroidismPrimary lesion is a wheal, a flesh-colored to pink, well circumscribed plaque caused by dermal edema; itchy!Individual lesions last only a few hours, never more than 24 hoursMAJORITY NO CAUSE IS FOUND THEREFORE DO NOT INVESTIGATE!!!
42A 32 year old man presents with unilateral leg swelling A 32 year old man presents with unilateral leg swelling. What is your differential diagnosis? How would you investigate and manage this problem?
43Diff diagnosis of unilateral leg swelling Deep vein thrombosisCellulitisRuptured Baker’s cystLymphoedemaFracture
44DVTFigure 2: Well’s Clinical model for predicting pretest probability.Clinical feature ScoreActive cancerParalysis, paresis or recent plaster immobilisation of lower extremities 1Recently bedridden > 3days or previous surgery within 12 weeks requiringregional or general anaesthesiaLocalised tenderness along the distribution of deep venous system 1Swelling of the entire legCalf swelling by more than 3cm compared with asymptomatic leg 1Pitting oedema confined to the symptomatic leg 1Collateral superficial veinsPreviously documented DVTAlternate diagnosis as likely or greater than that of DVT -2
45Well’s criteria SCORE >3 HIGH RISK SCORE 1-2 MODERATE RISK SCORE <1 LOW RISKD-dimer for LOW RISK- good negative predictive valueUSS of deep veins (duplex ideally)Tx clexane (until INR between 2 and 3)Warfarin, support hosiery
47Steven johnsons syndrome severe and sometimes fatal form of erythema multiforme. Bullous ulcerating lesionshigher incidence in children and young adults, and it is twice as common in males than females.seen more often as a response to drugs such as sulphonamide, some sedatives and penicillin or infection or neoplasia
48Differential diagnosis of SJ Behcet's syndromeReiter's syndromesyphilis - primary or secondaryhand, foot and mouth diseasepemphigustoxic epidermal necrolysisKawsasaki diseaseTx refer to specialist care (dermatologist) supportive tx
49USS of legs. Describe what this shows Which is normal?A or B?Management?
50Compression US of legs B is normal – normal compressibility A shows non compressibility – i.e thrombosis in veinTx clexane until warfarin in therapeutic range. Continue warfarin 3-6 monthsIVC filter if worried about PETED stockings
51Jimmy has just enjoyed a snickers bar… he now looks like this… What is happening to poor jimmy?Describe your immediate management
52ANAPHYLAXIS AIRWAY 100% 02 IV adrenaline 1:1000 solution 0.5mL (500mcg) IMRepeat in 5 minutes if no clinical improvementIV access and fluids (colloid if hypotensive)Antihistamine H1-antagonist (chlorphenamine) mg IM/slow IVHydrocortisone mg IM/slow IV (if severe/recurrent/in asthmatics)If bronchospasm does not subside treat as asthma – salbutamol nebs (adjunctive measure)
53Young female presents with weight loss, polyuria and these leg lesions…what is this and what condition is it associated with?
54Necrobiosis lipoidica This is a dermatological condition that is associated with diabetes mellitus in 50% of cases. It occurs in women three times more frequently than in men, usually in young adults or in early adult life.Necrobiosis lipoidica usually affects the skin on the lateral and anterior surfaces of the lower legsThe epidermis is smooth or slightly scaly and atrophic. Delicate vessels may be observed through the surface. Long standing lesions may show ulceration, fibrosis and scarring.if non-ulcerated necrobiosis lipoidica - topical corticosteroidsif ulcerated NL then there may be response to immunomodulating drugs such as cyclosporin and mycophenolate mofetil
56Granuloma annulareGranuloma annulare is a condition which presents with skin lesions that consist of asymptomatic dermal nodules. In children, they are usually on the fingers or toes. This condition is harmless but resolution may take many months.In the adult, this condition is sometimes associated with diabetes.
57What is being tested here What is being tested here? What else would you look for in your examination? How would you investigate and treat?
59Investigating and treating dehydration fluid loss without water replacement - for example, an unconscious patient with fluid lost from diarrhoea, burns, vomiting, sweat, respirationdiabetes insipidusosmotic diuresis - for DKAConn's syndrome - hypokalaemic alkalosisCushing's syndromeincorrect intravenous fluid replacementsome patients with hyperosmolar non-ketoacidotic diabetic coma; this condition may also cause hyponatraemiahypothalamic dysfunction
60Management of severe hypovolaemia Lie patient flat and raise feet to restore BPIV access - Two large cannulae - brown venflonsGive colloid/crytalloid (no evidence either is better)Insert CVP line/arterial line (more accurate assessment of BP)Catheterise and monitor urine output.Monitor Bp, lying and standing, JVP, chest… Pulmonary OEDEMATake blood for group and save, crossmatch.fluid should be run in as fast as possible;patient's response monitored.If the patient remains shocked, group specific or O Negative blood should be given as cross-matching may take up to 45 minutes. If the patient still fails to improve, internal bleeding should be sought.Following stabilisation, fluid infusion may be moderated according to urine production.Give blood to maintain Hb>8g/dl
61HypovolaemiaHaemorrhage – aortic dissection, leaking AAA, splenic ruptureFluid loss - Diarrhoea, vomiting, polyuria,burns3rd space losses- acute pancreatitis, ascitesAdrenal failure
62What is this x ray showing? what condition is this person likely to have?What are the complications of this condition?
63arachnodactylyMARFAN’S SYNDROME (AD) – diff diagnosis homocystinuria -disorder of methionine metabolismOCULARupward lens dislocationretinal detachmentSKELETAL and MUSCLESarachnodactylytall with disproportionately long legs and arms - the span of the arms is greater than the heightpectus excavatumspinal abnormalities - spondylolisthesis, scoliosisSUFEgeneralised joint laxity with predisposition to flat feet or dislocation of patella or shoulderCARDIOVASCULARdilatation of the aorta mayaortic regurg, mitral regurgdissecting aneurysm of the aortaMental development is normal. The average lifespan of an affected individual is 40 to 50 years.
64What is this and with what conditions is it associated?
65Dupuytrens contracture Liver diseaseEpilepsy/ treatment with phenobarbitone or phenytoinPeyronie's disease - penile fibrosisFamily historytraumamyxoedemadiabetes mellitushypercholesterolaemiaAIDS
66What is this called?What conditions is it associated with??
67Alopecia areatalocalised, round bald patches developing suddenly over one or two weeks, without any preceding symptoms. At the edge of the patch, there may be small, broken hairs with a tapering shaft - 'exclamation mark' hairs.autoimmune phenomenonAsssociations: thyroid disorders, vitiligo, diabetes.
68A diabetic patient developed this eruption…what is it? These are small rounded plaques with raised borders lying in a linear fashion over the shins. In late diabetic dermopathy these may present as pigmented scars.
69Diabetic dermopathyThese are small rounded plaques with raised borders lying in a linear fashion over the shins. In late diabetic dermopathy these may present as pigmented scars.
71Peyronie’s diseasethe penis becomes curved due to asymmetrical fibrosis in the fascia surrounding the corpora cavernosa. Curvature towards the affected side is increased during an erection making intercourse difficult and painfulAssoc with dupuytrens contracture and premature atherosclerosis
73Winged scapula Long thoracic nerve injury The long thoracic nerve supplies the serratus anterior muscle. It may be injured as a result of pressure on the shoulder, either from a sudden blow or by prolonged carrying of heavy objects. It is often one of the nerves affected in brachial neuritis and may also be damaged in diabetes mellitus. Winging of the scapula results.
75Henoch schonleinHenoch-Schonlein purpura is a condition characterized by a widespread necrotizing vasculitis of arterioles and small capillaries.children aged 3 to 8 years are affected, boys more than girls,Abdo pain, arthritis (large joints) and glomerulonephritis70% have haematuria and proteinuria, but the glomerulonephritis is often asymptomatic, conferring a good prognosis.The disease is usually self limiting.Bed rest and simple analgesics may be prescribed for arthropathy
76What is this? What aggravates this condition? How do you treat?
77psoriasis Made worse by stress, alcohol, b-blockers, infection Better in sunlightTx emolients, dithranol, Vitamin D analogues, coal tar, keratolyticsPUVAMethotrexate, cyclosporinInfliximab, Etanercept
79erythrodermic psoriasis Life threatening complication of psoriasisPlaques cover over 90% of the body surface.Problems with thermoregulation, septicaemia, dehydration and high output cardiac failure may occur.
80This middle aged man is very unwell and has lost weight He developed these slowly evolving itchy lesionsWhat is the diagnosis?
81Mycosis fungoidesMycosis fungoides is a non-Hodgkin's lymphoma that arises from CD4+ T lymphocytes.It is a cutaneous lymphoma that characteristically affects middle aged males. It usually begins as an eczematous reaction and proceeds to form plaques, tumours and fungating ulcers. Erythroderma may occur which often is highly pruritic.Treatment - topical steroids, topical cytotoxic agents, PUVA or radiotherapy.Prognosis relates to extent and type of skin involvement - average survival in the early stage of this disease is at least years (2)
83Eczema herpeticumwidespread HSV infection superimposed on pre-existing (often mild) atopic eczema.Widespread vesicles and erosions, fever, and malaise occur.treat with intravenous and topical acyclyovirbroad spectrum antibiotics are added in to treat or prevent superinfection.It is necessary to scrupulously care for the skin and carefully monitor fluid and electrolyte balance.Prophylactic oral aciclovir is indicated for recurrent disease.
88Neurofibromatosis (2 types) von Recklinhausen's disease, peripheral or type I neurofibromatosis (AD)bilateral acoustic neurofibromatosis, central or type II neurofibromatosisCafé au lait spots commonly seenCOMPLICATIONS:Nerve entrapmentPeripheral nerve tumoursneuropathy
90pemphigoid autoimmune blistering disorder characterized by large, tense, intradermal (subepidermal) blisters on an erythematous base. BLISTERS REMAIN INTACT. If in eyes- blindnessElderly affected, Women > men.it is more common than pemphigustreatments that aim to suppress the inflammatory process, e.g. corticosteroids, antibiotics (e.g. tetracyclines, sulphones)other immunosuppressive treatments aim to suppress the production of the pathogenic antibodies, e.g. high-dose corticosteroids e.g. prednisolone mg per day, azathioprine, methotrexate, cyclophosphamide and cyclosporin
92PEMPHIGUSblisters within the epidermis of both skin and mucous membranes.autoimmune basis?Peak onset is between 60 and 70 years of age. W>MIn comparison, bullous pemphigoid is characterised by blister formation at the level of the basement membrane and not within the epidermis.
93Long standing asymptomatic lump. What is the likely diagnosis?
94Lipoma Treatment is for cosmesis and consists of local excision. Some individuals have multiple subcutaneous lipomata; a biopsy may be required to exclude neurofibromatosis in such patients.The patient with multiple, tender lipomata may have Dercum's disease.A rare complication of lipomata is a liposarcoma.
96Ascending lymphangitis spreading of infection from its focus along regional lymphatic vessels. Commonly, an abscess forms at the regional nodes.commonly due to Streptococcus pyogenes; less often, to Staphylococci. It presents as red blushes and streaks in the skin corresponding to the inflamed lymphatics.Treatment is bed rest with the affected limb elevated.Penicillin V and FlucloxacillinPermanent lymphatic obstruction may develop resulting in a persistent oedema. Repeated attacks cause chronic lymphangitis.
98Erythema chronicum migrans Caused by Borrelia burgdorferi, Lyme disease is common in the northeast United States and in Wisconsin and Minnesota. It is carried by Ixodes spp. of ticks. The rash occurs in 2/3 of those infected, with a solitary lesion characteristic of Stage 1 disease, and multiple lesions characteristic of disseminated Stage 2 disease
102Basal cell carcinomaThis is a locally invasive carcinoma of the basal layer of the epidermis. It almost never metastasizes but it may kill by local invasion.sunlight exposurethe initial lesion is a small pearly-white nodule with visible (telangiectatic) blood vessels; early lesions may bleed and ulcerate and then heal againa red nodule forms which expands to leave a characteristic rolled edge with central ulceration ('rodent ulcer')Tx: surgery, local radiotherapy, cryotherapy, or curretage
103Think maybe he should have come to the doc sooner about this one
105Squamous cell carcinoma Squamous cell carcinoma (SCC) is a malignant tumour of the epidermis in which the cells, if differentiated, show keratin formation.basal cell carcinomakeratocanthomamalignant melanomasolar keratosispyogenic granulomainfected seborrheic wartrapidly expanding painless, ulcerated nodule rolled indurated margin. Often the lesion may have a cauliflower-like appearance with areas of bleeding, ulceration or serous exudation.Metastatic potential – surgery (+radio/chemo if advanced)
106What is this? What types exist and what features are characteristic in this lesion?
107Malignant melanoma superficial spreading (48%) nodular (23%) lentigo maligna (15%)acral lentiginous including periungual (6%)amelanotic melanomaChange in SHAPE, SIZE, COLOUR>5mm diameter, inflammation, bleeding, irritationExcision biopsy (1cm margin for every mm thickness)
108What is happening in this patients arm What is happening in this patients arm? They previosly had a simple ulcer there
111Peutz Jeghers Peutz-Jegher's syndrome (AD) multiple hamartogenous polyps of the gastrointestinal tract - most often in the small bowel but may occur affect any portion of the GI tractmucocutaneous pigmentation - mainly, of the lips, buccal mucosa, genitalia, hands and feetPatients often present with small bowel intussusception before the age of 10 years.The polyps themselves have a very low malignant potential. About 10-20% of patients develop gastrointestinal carcinoma but this is thought to arise from coexistent adenomas.Patients have an increased risk of developing carcinomas of the pancreas, lung, ovary and breast.
113Lichen planus flat-topped shiny violaceous (pink/mauve/purple) typically they are seen on the inner aspects of the elbows, on the wrists, shins and sacral area and genitalsWickhams striae mouth lesionThis is a condition of unknown aetiology characterized by intensely pruritic flat topped papules that are usually seen on the inner aspect of the elbows and wrists. The mucous membranes are often affected.
114What does this chap have? What complications is it associated with?
115Ehlers danlosEhlers-Danlos syndrome (EDS) is a condition where abnormalities of collagen production result in bruising, wide scars, laxity of joints and hyperelasticity of the skin.HerniaMR/ARAortic dissectionpneumothoracesGI bleeds
116This 34 year old wool factory worker presented with this…what is it?
119tylosisTylosis is a congenital hyperkeratosis with pitting of the palms - tylosis palmaris - and of the soles - tylosis plantaris. It is inherited as an autosomal dominant trait.In some cases, it is associated with oesophageal carcinoma.Treatment measures include the use of a keratolytic. Systemic treatment with retinoids may be used
120What is wrong with this chap? How would you diagnose it?
121Kaposis sarcomaKaposi's sarcoma is a multicentric, malignant neoplastic vascular proliferation, characterised by the development of bluish-red nodules on the skin. Sometimes there may be widespread visceral involvement. It may metastasize to lymph nodes.occurs in immunocompromised patients (e.g. HIV positive patients, transplant patients)Diagnosis: skin biopsy
123keratoacanthoma Difficult to distinguish from SCC rapidly growing epidermal tumour that resembles squamous cell carcinoma both clinically and histologically. It is believed to arise from hair follicles.There is little evidence that keratocanthoma has malignant potentialTrauma, viral infection, sun exposure, and chronic exposure to tar, pitch and petroleum have all been implicated as aetiologic agents.Surgical excision is thought to produce less scarring than leaving the lesion to resolve spontaneously.
125Gottrons papulesGottron's papules are scaly, erythematous lesions affecting the dorsum of the hands, knuckles, and extensor surfaces of other small joints. They are characteristic of dermatomyositis.
126What does this patient have? With what is it associated?
127Heliotrope rashPolymyositis and dermatomyositis are systemic connective tissue diseases which are characterised by acute and chronic inflammation of striated muscle.In dermatomyositis there is an accompanying dermatitis. The limb girdle or proximal muscles are most severely affected but their bulk is preserved beyond that expected from their weakness: this is an important sign distinguishing this condition from a limb girdle dystrophy.The aetiology is unknown but there is an association with HLA-B8 and HLA-DR3.Dermatomyositis in males over the age of 60 years may be suggestive of an underlying systemic malignancy.
128This 33 year old woman presented with fever, tachycardia, chills, malaise and this hot tender lesion on her face. What is it? What is tx?
129erysipelasErysipelas is a rapidly spreading Streptococcal infection of the skin and subcutaneous tissue characterized by cellulitis and lymphangitis.Streptococcus pyogenesfever, tachycardia, chills, malaisethe infected area is red, hot, and tender e.g. red shiny plaque on facelocal oedema which produces a raised border that is clinically diagnosticthe cellulitis spreads rapidly to involve uninfected skincareful examination may reveal an abrasion through which the streptococcus organism gained entryan incision within the infected area exudes a thin pusTx: amoxicillin
130What is wrong with this chap? What could have caused it?
131Left CN III palsyTUMOUR, INFECTION, VASCULITIS, DEMYELINATION SAFE ANSWER FOR ALL NERVE LESIONScentral lesions:tumours:due to direct invasion of the third nerve nucleusdue to raised intracranial pressurevascular:caused by a brainstem lesiondemyelinationperipheral causes include:compressive lesions:tumouraneurysm, often the posterior communicating arterybasal meningitisnasopharyngeal carcinomaorbital lesions e.g. Tolosa-Hunt syndromeinfarction:often spares the pupillary reflex, when the condition is termed a "medical third nerve palsy"often caused by diabetes mellitus
132This xray and CT are showing the same sign… what is it?
133Porcelain gallbladder Porcelain gallbladder is a calcification of the gallbladder believed to be brought on by excessive gallstones but more studies are necessary to determine the exact cause.Porcelain gallbladder often results in a diagnosis of gallbladder cancer. The association with the two is uncertain; gallbladder cancer is rare, but is almost always found with porcelain gallbladder. The prognosis is poor, in that the gallbladder is usually asymptomatic until the cancer has spread.
134A 53-year-old man presented with low-grade fever and abdominal pain A 53-year-old man presented with low-grade fever and abdominal pain. A tender, erythematous umbilical 3-cm mass is shown.
135Strangulated umbilical hernia In a strangulated hernia, the blood supply of the contents of the hernia, e.g. bowel or omentum, is cut off. It is commonest at the neck of the sac. The region becomes ischaemic and subsequently gangrenous. Gangrene can lead to perforation of the bowel with ensuing peritonitis.When a loop of gut is strangulated, there will also be intestinal obstruction.
136This 23 year old woman is complaining of rectal pain This 23 year old woman is complaining of rectal pain. She denies any other symptoms
137What is this xray showing? Patient presented with an acute abdomen with the sudden onset of severe upper abdominal pain, nausea and vomiting.
139Describe how you would investigate and manage this patient A 50-year-old man presented with a 2-day history of atraumatic right middle finger swelling, redness, and pain. There was tenderness and swelling of the proximal interphalangeal joint. ESR was elevated. The leukocyte count normal.Describe how you would investigate and manage this patient
140Septic arthritis URGENT ADMISSION!!! ASPIRATE!!!! blood cultures full blood count for leucocytosiserythrocyte sedimentation rateC-reactive proteinaspiration of synovial fluid - usually purulent with a neutrophil count above 50,000 per mm3, and low glucose concentrationanti-streptolysin O titreTx flucloxacillin and amoxicillin empirically!
141A 65-year-old woman presented to the emergency department because a friend was concerned that the patient was having a stroke. The patient was asymptomatic other than complaints of a pestering nonproductive cough. What is wrong?
142Subconjuntival haemorrhage This presents as a bright red patch under the conjunctiva following rupture of a small conjunctival vessel.It may arise spontaneously, following slight trauma, or as a result of local congestion due to coughing or sneezing.In head injury, blood from a fracture at the base of the skull may travel through the floor of the orbit and into the subconjunctival space. The condition is usually unilateral.Recurrent or bilateral subconjunctival haemorrhage suggests hypertension or blood dyscrasias.
143A 28-year-old woman complained of a foreign-body sensation, pain and redness of the outer lower quadrant of her left eye of 2-day's duration.
144episcleritis unilateral in two-thirds of cases. It is benign and self-limited.30% are associated with general medical conditions such as collagen disease, herpes zoster, gout and syphilis.There are two types - simple and nodular. Simple episcleritis is characterized by a very acute onset. It is mild, sectoral, recurrent and resolves rapidly. The nodular form presents as a localised, raised mobile area of inflammation near the limbus. The nodules may be single or multiple and usually recur.About 15% of patients develop a mild iritis. Episcleritis is distinguished from conjunctivitis by the localised response and the lack of palpebral conjunctival involvement.oral non-steroidal anti-inflammatory drug (NSAID).
145A 2- year-old girl presented with fever, erythema, and swelling of the left upper eyelid. There were no visual symptoms or proptosis.
146periorbital cellulitis The findings shown are suggestive of acute periorbital cellulitis, or more accurately, preseptal cellulitis, an infection confined to the soft tissues of the eyelid. Bacteriology of preseptal cellulitis includes those bacteria that cause sinusitis (Haemophilus influenzae, Streptococcus pneumoniae, Moraxella catarrhalis, S pyogenes); skin flora from trauma (Staphylococcus aureus and group A Streptococcus); and idiopathic (H influenzae type B, S pneumoniae). (L.S.)
147A 20-year-old man presented with a brief loss of consciousness following a fall from standing height. He had a brief lucid interval then became progressively less responsive. This is his CT scan
148Extradural haematomaThe characteristic appearance of a CT of an extradural haemorrhage is of a biconvex, lozenge shaped area of increased density.Spread is limited by the adhesion of the dura to the skull. A midline shift with compression of the ipsilateral ventricle may be apparent.
149A 25-year-old man was brought to the emergency department after having been hit in the left lateral chest with a jet ski. He was short of breath and hypotensive.
150Tension pneumothoraxShould not have obtained an Xray… emergency situation
151A 37-year-old homeless man presented to the emergency department with a 3-week history of neck pain that had started after a motor vehicle accident
152Subluxation of c1 on c2Cervical subluxation is a flexion injury. There is no bony damage but the soft tissues are extensively damaged and the posterior ligaments torn. The affected vertebra hinges forward on the one below, opening up the interspinous space posteriorly then falls back again.Radiologically there may be an increased gap between the spines of affected vertebra, but the film often appears normal - flexion radiology may be required to demonstrate the instability.Treatment is usually a collar for six weeks. However, if there is persistent instability a posterior spinal fusion may be required.
154Bell’s palsyIt is a lower motor neurone palsy usually diagnosed by exclusion. Typically, presentation is with facial distortion, loss of taste, hyperacusis and a watery eye.Bell's palsy was previously considered as an idiopthic lower motor neurone nerve palsy but there has been increasing evidence to suggest that the main cause of Bell's palsy is latent herpes viruses (herpes simplex virus type 1 and herpes zoster virus), which are reactivated from cranial nerve ganglia
162Trochlear CN IV palsy Diplopia abnormal head posture - head tilted towards the normal side, face rotated towards the normal side, and the chin is depressed. The affected eye is higher than its fellow.positive head tilt test - affected eye moves higher when the head is tilted towards the affected sideCNIV is thinnest and has the longest intracranial course damaged easily by stroke and trauma
163What is wrong with these miserable looking folk?
164Myasthenia gravisMyasthenia gravis is an acquired autoimmune disorder characterised by weakness, typically of the periocular, facial, bulbar, and girdle muscles.Associated with serum IgG antibodies to acetylcholine receptors in the postsynaptic membrane of the neuromuscular junction.Classically, the muscles are easily fatigued.It affects 5 people in everyNon-thymoma cases have a peak incidence at years and again, at years of age; those associated with thymoma have a peak incidence at years of age.
165Diff diagnosisLambert-Eaton syndrome - muscles are not fatiguable - contraction leads to increased strength - reflexes are diminishedcongenital myastheniabotulismmotor neurone disease (MND) - note that eye is very rarely involved in MND
166Myasthenia gravis Exacerbated by: exercise, barbituates, steroids improvement in strength after administering a short-acting anticholinesterase drug, for example, edrophonium chloride.acetylcholine receptor antibodiesManagementoral anticholinesterase medication, e.g. pyridostigmine or neostigmine (symptomatic improvement).if there is life-threatening or respiratory weakness developing in treated patients, then this usually requires immediate control of the airway, treatment of any underlying infection, and a course of plasma exchangethymectomy - required if there is a thymoma because of the risk of local infiltration. Also occasionally undertaken in other non-thymoma patients with myastheniaimmunosuppression with corticosteroids +/- cytotoxic agents is also highly effective in inducing remission of disease and may be necessary preliminary to surgery in patients with severe disease.plasma exchange
167Lambert eatonLambert-Eaton myasthenia is a presynaptic myasthenic syndrome characterised by impaired release of acetycholine from nerve terminals.60% of patients have small cell lung carcinoma.Electromyography shows increased evoked potentials after repeated galvanic stimulation (the opposite occurs in myasthenia gravis). Symptoms improve with exercise
169Right sided horners syndrome slight ptosispupillary miosis:due to paralysis of the sympathetically innervated Muller's muscle which normally dilates the pupilanhydrosis over the foreheadPancoasts tumour, carotid body tumour infection, vasculitis, demyelinating disease MS
170What is wrong with this chap What is wrong with this chap? Ignore the white thing I don’t know what that is
171hydrocephalus Communicating hydrocephalus obstruction to CSF flow from outside the ventricular system, usually in the subarachnoid space. All the ventricles show a generalised dilatation on a CT scan. It is safe to perform a lumbar punctureNon-communicating hydrocephalusobstruction to CSF flow within the ventricular system. Fluid accumulates proximal to the site of the blockage causing dilation.
172Management of hydrocephalus The cause of hydrocephalus should be eliminated if possible - e.g. colloid cysts of the 3rd ventricle, intraventricular meningioma, other obstructive causes.Otherwise, relieve pressure by shunting, or if the patient is rapidly deteriorating, by draining the ventricle directly.Endoscopic third ventriculostomy has become a more recent, and important, treatment option for occlusive hydrocephalus associated with aqueductal stenosis or space-occupying lesions of or around the posterior third ventricle and upper brainstem (1,2):this procedure appears to be more successful in adults than in young childrenit is efficacious in both previously shunted and non shunted patientcomplication and mortality rates compare favorably with those for shuntshas also been increasingly used as an alternative treatment option for shunt complicationsLumbar puncture may be used to relieve pressure in an acute communicating hydrocephalus.
173NPHNormal pressure hydrocephalus is a form of communicating hydrocephalus in which the intracranial pressure, as measured by lumbar puncture, is normal or intermittently raised.Failure to reabsorb CSF is compensated by reduced production.gait apraxiaprogressive dementia with memory losssphincter disturbance resulting in incontinence
174What has happened here? What are the risk factors for this?
175L Middle cerebral artery ischaemic stroke Hypodense (dark) area on CTNo midline shiftNon-modifiable risk factorsincreasing agemale genderAfro-Caribbean descentpositive family history of strokeModifiable Risk factors for strokesmokingdiabetes mellitusdiet:high salt intakehigh fat intakelow potassium intakelow vitamin intakeexcess alcohol intakemorbid obesitylow physical exerciselow body temperaturecholesterol
177Haemorrhagic strokeNote the high-density haemorrhage within the low density of the oedematous, infarcted region in the right hemisphere. Haemorrhage is evident from its onset on CT scanning.
178What is this??What factors predispose to this condition?How would you manage?
179Subdural haemorrhageThe characteristic picture of a CT scan of a subdural haemorrhage is one of a biconcave, concentric shaped, area of increased density spreading around the surface of the cerebral hemisphere. The contralateral ventricle may dilate owing to obstruction at the foramen of Munro.After days, the subdural haematoma becomes isodense with brain. Later it becomes relatively hypodense.
180Subdural haematomaSubdural haemorrhages result from rupture of cortical bridging veins. These connect the venous system of the brain to the large intradural venous sinuses and lie relatively unprotected in the subdural space.any factor that stretches the bridging veins:cerebral atrophy, e.g. elderlylow CSF pressure after shunting, for example for long- standing hydrocephalus or a fistulaalcoholismcoagulation disorder or anticoagulation therapypatients in whom conscious level is depressed:evacuate haematoma through 2-3 burr holes, and irrigate cavity with salinenursing in the head down position is recommended to prevent recollectionpatients in whom conscious level is not depressed:consider conservative measures - steroid treatment over several weeks
182Multiple myelomaa malignant neoplasm of plasma cells that arises in the bone marrow. Presentation is with anaemia, bone pain, skeletal destruction, pathologic fractures, or Bence Jones proteinuria.M (monoclonal) band on serum electrophoresisTx- cytotoxic chemo and supportive ,measures
183What is wrong with these chaps? What features are common?
184Parkinson’s disease tremor bradykinesia rigidity impaired postural reflexesshuffling gaitexpressionless, unblinking facePill-rolling tremorslurred monotonous speechsmall handwritingincreased salivation and dribblingAli actually has parkonsonsim due to dopamine depletion within the basal ganglia (boxing knocked it all out)
186Myotonic dystrophy characterised by myotonia and muscular atrophy. Inheritance is AD. The incidence is 5 per with onset between 15 and 40 years, although it may present as early as birth. The causal gene is on chromosome 19.The disease is slowly progressive and is characterised by cataract formation, hypogonadism, frontal balding and cardiac disorders.There is weakness, wasting and myotonia of involved muscles. Wasting of the stenocleidomastoids produces the classical swan-necked appearance
187Loss of lower limb refelxes and extensor plantar response noted in this 15 year old boy…
188Friedreich's ataxiamost common inherited ataxia. prevalence of 1 ininheritance is arprogressive gait and limb ataxia, loss of proprioception, pyramidal weakness and dysarthria.Extra-neurological involvement includes:hypertrophic cardiomyopathy in most patientsdiabetes mellitus in 10%pes cavus and kyphoscoliosisOnset is usually during adolescence.
189What is wrong with this 14 yr old boy ? He has foot drop and reduced reflexes
190Charcot marie toothAD condition characterised by slowly progressive sensorimotor neuropathy. It is the most commonly inherited peripheral neuropathy in the UK.type I:a demyelinating sensorimotor neuropathyearly onset, typically in the first decadepresentation with walking difficulties and pes cavusassociated deformities include eqinovarus foot and kyphoscoliosiswasting occurs:distally before proximallyin the legs before the armsdistal wasting may produce the classical inverted champagne bottle deformitythere is generalised areflexiathere may be cerebellar ataxia of the armsrespiratory muscles may be weaknerve conduction is slowed to less than 38 m/secperipheral nerves may be palpably thickened
191This girls leg is wasted, weak, with absent knee and ankle reflexes What is your differential diagnosis?
192polioPoliomyelitis is a notifiable infectious viral illness affecting the central nervous system.Poliomyelitis is an acute illness that follows invasion through the gastrointestinal tract by one of the three serotypes of polio virus (serotypes 1, 2 and 3)LMN lesionSensation is unaffected by this condition. When a badly- paralysed limb is picked up it has a floppy feel which, in the presence of normal sensation, is characteristic of the residual paralysis from poliomyelitis.
194What is this?What conditions is it associated with?
195Berry aneurysm adult polycystic kidney disease Ehlers-Danlos syndrome coarctation of the aortamostly remain asymptomatic throughout lifevary in size, most symptomatic aneurysms are >1 cmoften occur at vessel bifurcationscause 80% of subarachnoid haemorrhagesIf >1cm clip them prophylacticallyIf <1cm leave them (risk of surgery>risk of bleed)
197Optic atrophy Full moon Featureless disc retinal lesions: optic nerve: central retinal artery or vein occlusionretinitis pigmentosatobacco / nutritional - end result of tobacco amblyopiaoptic nerve:chronic glaucoma - most common of all causesischaemic optic neuropathysecondary to papilloedema or papillitissecondary to optic neuritis or retrobulbar neuritistrauma - severing, avulsion, contusion, surgeryfamilial - Leber's disease, Friedreich's ataxiapressure on optic nerve:tumour - glioma, meningiomaPaget's diseaseaneurysm of the anterior circle of Willischiasmal compression:pituitary tumour, craniopharyngioma, suprasellar meningioma, aneurysm, stroke
199Acute glaucoma cupping Tx of acute closed angle glaucomareduction of intra-ocular pressure by reducing aqueous secretion – acetazolamidepupillary constriction - topical pilocarpine or thymoxamine, an alpha receptor antagonistsurgical or laser iridectomy - once the attack has been controlled - rarely surgery may be undertaken as an emergency procedure if medical management fails
209Tuberous sclerosiscongenital disease characterised by hamartomatous lesions in the skin, nervous system and internal organs, principally heart and kidney.Triad ofadenoma sebaceum:actually an angiofibroma with passive involvement of sebaceous glandsepilepsymental retardation
212Osler weber renduHereditary haemorrhagic telangiectasia is a rare AD condition where multiple small telangiectases occur on the skin and mucous membranes, most commonly on the lips and the tongue. Lesions are also often scattered over the pulps of fingers.Epistaxis is the most common complaint.When telangiectases are present in the gastrointestinal tract they may cause chronic blood loss with iron deficiency anaemia. Occasionally there may be torrential bleeding.Arteriovenous malformations may occur in the:liverlungs, causing:clubbingmurmursparadoxical emboli
214Scurvy Gingival haemorrhage Vitamin C deficiency anaemia, spongy gums, a tendency to mucocutaneous haemorrhages, and brawny induration of calf and leg muscles, poor wound healingTx Vitamin C mg/day orally.
216Gingival hyperplasia acute leukaemia – typically AML Drugs: scurvy phenytoinnifedipinecyclosporinscurvypregnancygingivitis
217What is wrong with this patient and what is your immediate management 55yr old man was started on ACE-I for his hypertension 2 weeks ago. His blood pressure is now higher than 2 weeks ago and his creatinine is raised
218Renal artery stenosis STOP ACE-I ! This condition may result in secondary hypertension and secondary hyperaldosteronism. Other possible features include:coexistant cerebrovascular, cardiovascular or peripheral vascular diseasedeterioration of renal function following treatment with ACE inhibitorabdominal bruit; signs of coexistant vascular disease e.g. carotid or femoral bruit; absent peripheral pulsesTx - balloon dilatation
219This patient presented with tiredness and weight loss This patient presented with tiredness and weight loss. ON examination his tongue has this appearance and he has proteinuria, oedema and hepatosplenomegaly
220Macroglossia in amyloidosis In amyloidosis, there is extracellular deposition of fibrillar protein. This may be in a localized deposition or widely distributed throughout the body.Amyloid fibrils stain with Congo red and show apple green birefringence in polarized light.Cytotoxic and immunosuppressive drugs have been used to treat amyloidosis, but often with poor results. Improvement may be attained by treatment of an underlying cause.
230Liver transplant Possible indications in an adult include: fulminant or subacute liver failure:paracetamol poisoningviral hepatitisend-stage liver cirrhosis:alcoholic liver diseasechronic active hepatitisprimary biliary cirrhosis
234Spider naevi None are normal for a man Less than 5 in women They are found in the distribution of the superior vena cava i.e. on the arms, neck, and chest wall.cirrhosis - most frequently, alcoholicoestrogen excess - usually in association with chronic liver disease; part of normal hepatic function is the inactivation of oestrogenshyperthyroidismrheumatoid arthritis - rarely
23587 year old man presented with abdominal pain and a 4 wk history of constipation What features would you expect on examination?How would you treat this man?
236Sigmoid volvulus - 'bent inner-tube' - inverted U - sign marked abdominal distensionsudden onset of colicky painabsolute constipation and no passage flatus for at least 24 hoursabdomen is distended and tympanicleft ilac fossa tendernessrectal examination reveals a capacious, empty rectumTx immediate management: sigmoidoscopy and air insufflationthere is a gush of liquid faeces and flatus as the obstruction is relievedHigh fibre diet and review medication
238Caecal volvulusA caecal volvulus occurs when there is twisting of the bowel at the caecum and resultant intestinal obstruction.Distention of the caecum ensues to the extent that the volvulus can be felt as a palpable mass. The patient may have vomiting, abdominal pain and constipation.The classical radiological appearance is the 'comma' sign - there is a gas-filled ileum and caecum.Treatment is by decompression and resection, or fixing of the caecum to the posterior abdominal wall.
239What does this xray show? With what conditions is it associated?
243What is this close up of a barium enema showing? What disease has caused this?
244String Sign Crohns disease Small-bowel follow-through study demonstrates the string sign in the terminal ileum.pseudodiverticula of the antimesenteric wall of the terminal ileum, secondary to greater distensibility of this less-involved segment of the wall
249What does this xray show? A 23yr old man presented to A and E with fever, abdominal distension and tendernessOn examination he was tachycardic and had postural hypotension
250Toxic megacolonlife-threatening complication of inflammatory or infectious colitis.segmental, non-obstructive dilatation of the colon to greater than 6 cm diametersystemic toxicityXraydilatation of the lumen from 6-15 cmthe most common sites of dilatation are the right and transverse colonsthere is thickening of the colonic wall with disruption of the normal haustral patternthere may be multiple air-fluid levels
252Diverticular diseaseManagement – high fibre diet, antispasmodics, laxativesComplications: peritonitis, fistula formation, persistent haemorrhage, pericolic abscess formation, intestinal obstruction, and repeated episodes of diverticulitis that are resistant to medical therapy.
253What sign is shown? What is the most likely cause?
254Apple core signStricture most likely due to colon cancer
256Dextrocardia/Situs Inverus Kartagener's syndromebronchiectasis (also seen in Xray)sinusitisdextrocardiaIt is associated with a defect in cilia function and now is termed as synonymous with primary ciliary dyskinesia.The situs inversus is thought to be a developmental consequence of failure of ciliary action in the formation of the gastrointestinal tract and other stuctures.
257What is the diagnosis?This patient presented with gradual onset, intermittent dysphagia.He also has had recurrent chest infections
258Achalasia MANAGEMENT intrasphincteric injection of botulinum toxin neuromuscular failure of relaxation at the lower end of the oesophagus with progressive dilatation, tortuosity, incoordination of peristalsis and often hypertrophy of the oesophagus above.MANAGEMENTintrasphincteric injection of botulinum toxinendoscopic hydrostatic or pneumatic dilatationHeller's operation - cardiomyotomy - success rate of about 90% in those who do not respond to dilatation
259What is this upper GI endoscopy showing? What appearance would it have on barium swallow?
260Oesophageal candidiasis Furry oesophagus on swallow
261This patient presented with retrosternal chest pain What is the diagnosis?
262Corkscrew OesophagusAltered motility of the oesophagus (sometimes loosely referred to as "spasm") can be a cause of chest pain.The rare condition of diffuse oesophageal spasm (seen radiologically as a "corkscrew oesophagus") is associated with pain,
263What is wrong with this 55 yr old publican who has long standing recurrent abdominal pain and weight loss
264Chronic pancreatitisPlain film with extensive calcification in duct system of a patient with chronic pancreatitis secondary to alcohol
270Peutz jeghersmultiple hamartogenous polyps of the gastrointestinal tract - most often in the small bowel but may occur affect any portion of the GI tractmucocutaneous pigmentation - mainly, of the lips, buccal mucosa, genitalia, hands and feet
272Oral hairy leukoplakia This is a lesion on the tongue that may be seen in immunocompromised patients.It appears to be the result of a proliferation of Epstein-Barr virus, possibly associated with Papilloma virus in the superficial layers of the squamous epithelium of the tongue.
273What is this upper GI endoscopy of dueodenum showing What is this upper GI endoscopy of dueodenum showing? How else would you investigate this?
274Coeliac diseaseEndoscopic still of duodenum of patient with coeliac disease showing scalloping of foldsENDOMYSIAL ANTIBODIESENDOSCOPY AND JEJUNAL BIOPSYBloods – anaemia, iron, folate, PT prolongedDEXA- looking for damage due to low CaTx gluten free diet, vit + calcium + iron supplements, pneumococcus vaccine
276Biopsy of small bowel showing coeliac disease manifested by blunting of villi, crypt hyperplasia, and lymphocyte infiltration of crypts,
277This man has a 2 month history of weight loss This man has a 2 month history of weight loss. He is itchy, has no pain and has a palpable gall bladder
278Head of pancreas CaPresents with painless obstructive jaundice, weight loss and anorexiaGallbladder is palpable (Courvoisiers Law)painless jaundice + palpable gallbladder is not gallstones!!!!US/CT for diagnosis (CT for staging)Tx Whipples (pancreatoduodenectomy)ChemoMost present with metastatic disease with crap prognosis (6months mean survival)
282Acute otitis media common causes are URTI (viral or bacterial) clinical featuresear painear rubbingcloudy white/yellow eardrum (pus in middle ear)bulging eardrumdistinctly immobile eardrumdistinctly red eardrum80% recover in around three days without antibioticscomplications are rareTx paracetamol and Inbuprofen (watchful waiting)
284Glue earSecretory otitis media, or `glue ear', is the most frequent cause of hearing problems in children.accumulation of serous or viscous fluid within the middle earpainconductive hearing lossdull / dark blue/ grey appearance of tympanic membraneRinne's test negative; Weber's test - sound heard loudest in the deafer ear.
286GrommetsThe function of a grommet is to ventilate the middle ear, rather than drain it. Grommets thus replace the function of the blocked eustachian tube in glue ear and improve hearing.use of grommets in glue ear (otitis media with effusion) offer only small benefitspotentially adverse effects on the tympanic membrane are common after grommet insertionears treated with grommets had an additional risk for tympanosclerosis one to five years later
287This 5 year old boy presented with fever, malaise, sore throat and otalgia What is the differential diagnosis?How would you manage this condition?
288Acute tonsilitis Differential – rest soluble paracetamol held in the mouth and then swallowed eases the discomfort (1)the patient must be encouraged to drink to prevent dehydrationantibiotics are unnecessary for most patients with sore throat as it is a self-limiting condition, which resolves by one week in 85% of people, whether it is due to streptococcal infection or not
289The Centor criteria tonsillar exudate tender anterior cervical lymph nodesabsence of coughhistory of feverThen treat with antibiotics as it could be Group A beta-haemolytic streptococcus infection (erythromycin as amoxicillin will cause rash in infectious mononucleosis)
293The patient is a five year old boy who presented with a febrile urinary tract infection (UTI). His CT and US are shown. What is diagnosis?
294Acute pyelonephritisOn CT, an edematous left kidney is seen with multiple large areas of decreased enhancement in the peripheryUltrasound images reveal an enlarged left kidney with heterogeneous echo texture as well as several discrete areas of hyopechogenicity
306What sign is being shown? What other features are likely to be present?would you treat this problem?
307Trousseau’s signParaesthesia, tetany, psychosis, convulsions, long QT intervalChvostek’s sign (tapping on facial nerve causes twitchmild tetany - oral calcium supplementssevere tetany - intravenous calcium gluconate, 10 ml (2.32 mmol) calcium gluconate 10% IV over 10 minutes.vitamin D - either if primary disease is due to vitamin D or, to ensure adequate absorption of calcium.calciferol for simple vitamin D deficiencyalfacalcidol or calcitriol if in renal failure - offer no advantage over calciferol for simple deficiency
308This 38 yr old woman with asthma has presented with a purpuric rash and haematuria, proteinuria and raised BPWhat is the diagnosis?
309Churg Strauss The six classification criteria asthma peripheral blood eosinophilianeuropathypulmonary infiltratesparanasal sinus involvementbiopsy showing vasculitis with extravascular eosinophilsLaboratory diagnosis is based on tissue biopsy and the antineutrophil cytoplasmic antibody (ANCA) test. About 25% of patients have cANCA and about 50% have pANCAThis syndrome is also characterised by elevated levels of IgE.Glomerulonephritis is a result of the vascultitsTx high dose corticoteroids
310This 50 year old man who enjoys a drink and smokes 10 cigs per day presents with epigastric pain and weight loss. What is being shown here and how would you investigate?
311Virchow’s node Gastric cancer endoscopy and biopsy: investigation of choicebarium meal; suspicious findings:space occupying massrigidity of adjacent gastric wallgreater curve ulceran ulcer with irregular borders and disruption of normal mucosal foldscontracted, non-distensible stomach - linitis plasticafundic tumours are difficult to evaluate because of poor fillingchest x-ray, liver enzymes, and liver ultrasound for evidence of metastasesanaemia in as much as 50% of all casesfaecal occult blood test positive in the vast majority of subjects
312This 70 year old man presented with a few weeks history of difficulty swallowing and weight loss What other investigations would you perform?What is his prognosis?What would you do for him in terms of swallowing difficulty?
313Oesophageal carcinoma Adenocarcinoma (lower 1/3)Apple core signCT staging should be performed5 year survival 10% (asymptomatic until late stage)Oesophageal stenting (palliative)
314Risk factors for Oe cancer AGEDiet (far eastern diet)SmokingAcid refluxBarret’s oesophagus (30-40X)AchalasiaTylosisPlummer-vinson (fe deficiency oesophageal web) also called paterson-kelly-brown
315What is this upper GI endoscopy showing? What symptoms will this 70 yr old man be experiencing?
316Oesophageal Ca Dysphagia Vomiting/ food regurg Chest pain Odynophagia Wt loss/ anorexiaHaematemesisHoarse voice/ coughing/ aspiration of saliva into lung
318Hiatus hernia with pneumoperitoneum SLIDING Sphincter at bottom of oesophagus and top of stomach slides through hiatus in diaphragm. May slide up and downROLLINGPart of stomach protrudes up through a hole in the diaphragm next to the oesohagus… can become strangulate. Less common
319This 34 yr old male patient presented with malaise, weight loss, apthous ulcers and this intensely itchy skin rash
320Dermatitis herpetiformis Dermatitis herpetiformis is an intensely itching subepidermal vesicular blistering condition that usually develops in the 3rd or 4th decade. Men>women.intensely pruritic, vesicular rash chiefly affecting the extensor surfaces of shoulders, buttocks, knees, forehead and scalp, sparing the mucosae. Small blisters are rarely seen since they are rapidly excoriated, leaving raw papules. Vesicles are frequently grouped, as those of the true herpes virus, hence the name 'herpetiformis.‘About 90% of patients with dermatitis herpetiformis will have coeliac diseaseTx - dapsone, in doses of mg/day for itchingGluten free dietTopical steroids
322Determining if indirect or direct inguinal hernia Only true way to know is at surgeryReduce herniaPlace finger over internal ring with 2 fingersWhen standing if no protrusion hernia is likely indirect. If protrusion present is direct.
326Prolapsed internal haemorrhoids CONSERVATIVE TXensuring the perineum is dried and washed after defaecation:digital replacement of prolapsed haemorrhoids:local anaesthetic creams and ointmentstreatment aimed at reducing spasm of the internal anal sphincter:nitroglycerine ointments:glyceryl trinitrate % (unlicensed)botulinum toxin injectionSURGICAL TXsclerotherapyrubber band ligationphotocoagulationcryotherapyHAEMORRHOIDECTOMYLORD’S STRETCH!!!! ANAL DILATATION UNDER GA
328HYDROCOELETx childhood hydrocoeles only if they persist after 1 yrs old. The procedure is as for an inguinal hernia - open the sac, inspect the testis for abnormalities, ligate and divide the patent processus vaginalis.In adults, primary hydrocoeles may be treated:conservatively - reassure the patient and provide a scrotal support.by aspiration - use a sterile needle and syringe. Clear, pale yellow fluid should be drained; fluid that is bloodstained suggests trauma or other underlying pathology. Following aspiration, the testis should be palpable. A sclerosant such as phenol may then be injected to stop fluid from reaccumulating, otherwise, periodic aspiration may be necessary. A hydrocoele should not be tapped if there is any suspicion of tumour - in the case of a tumour, aspiration may result in spread of malignant cells.by operation - if the diagnosis is in doubt, the hydrocoele is large, or fluid repeatedly reaccumulates after drainage. Once the fluid has been removed, the testis is examined for abnormalities.
331What is this?How would the patient who has had this removed have been investigated initially?
332Ruptured appendix Acute appendicitis is usually a clinical diagnosis full blood count - leukocytosis is generally presenturea and electrolytes - assessment of dehydrationpregnancy testserum amylase - if pancreatitis suspectedabdominal radiology - helpful to distinguish:volvulusintussusceptionrenal stones (90%)gallstones (10%)localised ileusGenerally, urine analysis is unhelpful in differentiating appendicitis from a urinary tract infection.There is no place for barium enema in the diagnosis of appendicitis. Occasionally, ultrasound and CT scanning are used to investigate suspected appendicitis where the story is atypical. US exclude gynae pathology (ovarian cyst)
335Duodenal atresia investigated by: electrolyte and acid-base status measures, e.g. U&E's, blood gases, with subsequent correction of abnormalitiesplain abdominal X-ray: this may show a 'double bubble' sign of duodenal obstructionbarium study may show stenosisTreatment involves surgical correction via a duodenojejunostomy with resection of the atretic section.
336A 34 year old vagrant is treated following a second variceal bleed… what is shown here?
337TIPS TRANSJUGULAR INTRAHEPATIC PORTO-SYSTEMIC SHUNT the treatment of acute oesophageal variceal bleeds which fail to respond to drugs or sclerotherapythe prevention of variceal bleedsangioplasty balloons and metallic stents are used to enlarge and maintain the porto-systemic shunt
338What is wrong with this chap. How would you investigate What is wrong with this chap? How would you investigate? What are common causes?
339ASCITES NOTE DRAIN SITES!!! Shifting dullness ultrasound diagnostic paracentesis in which 30 to 50 ml of fluid is withdrawn.This will enable identification of:protein content: albumin and total proteinmalignant cellsbacteriawhite blood cellsGlucoseTB cultureamylase
341MANAGEMENT OF ASCITES TENSE ASCITES NON-TENSE ASCITES therapeutic paracentesis of 4-6 litresplasma volume expansion with albumin (6g/litre of ascitic fluid removed)NON-TENSE ASCITESbed-rest, reduced salt intake, and spironolactone ( mg per day). A fall in weight of approximately 0.5 kg per day should be aimed for.spironolactone is gradually increased to 300 mg per day and then, if necessary, frusemide is added, but only once the spironolactone has reached its maximum dose.loop diuretics may precipitate the hepatorenal syndromeIf a patient has malignant ascites then large doses of frusemide may be required to control ascites.A Le Veen shunt (peritoneo-venous) may be useful in refractory cases.
342What is wrong with this baby? How would you treat?
343kwashiokorClassically hair colour change, hepatomegaly, pitting oedema, bleating cry when picked upTx electrolyte imbalance, hypoglycaemia, vitamin deficiency. May need warming if hypothermic.80-100kcal/kg/day – care not to overload pt
345MarasmusMarasmus is failure to grow associated with emaciation and fair appetite. It may be defined in terms of weight, for example less than 60% of that expected for age.Marasmus generally occurs in infants up to one year. In the developed world it is found in infants who are born undernourished or are recovering from a severe chronic illness, especially those affecting the bowel.In developing countries this condition commonly is associated with failure of lactation due to poor nutrition of the mother.Note that marasmus is an adaptive response to poor nutrition.
346A 77 year old man presents with his 4th episode of rectal bleeding A 77 year old man presents with his 4th episode of rectal bleeding. The blood is a mixture of fresh blood and clots. The bleeding was severe enough to require a 4 unit blood transfusion. Barium enema was normal. Colonscopy showed this lesion
347AngiodysplasiaColonic angiodysplasia is a common cause of acute or chronic rectal bleeding and iron deficiency anaemia.Angiodysplasias are tiny mm in diameter - hamartomatous capillary lesions in the colonic wall which produce bleeding out of proportion to their size. They are believed to be acquired, possibly as a result of tension on the veins where they pass through the muscularis.colonscopy: may visualise lesionTreatment:electrical coagulation via the colonoscoperesection of segment of colon if the above is unsuccessful
348This baby presented with severe diarrhoea, alopecia, FTT and a rash over the mucocutaneous junction. This started soon after he stopped breastfeeding.
349acrodermatitis enteropathica autosomal recessive disorder characterized by periorificial and acral dermatitis, alopecia, and diarrhoeaSharply demarcated, brightly erythematous periorificial plaqueCaused by Zinc deficiencyTx zinc
350This boy presented with this rash, diarrhoea and confusion What is wrong?
351Pellagra caused by deficiency of niacin classically characterised by four D's:photosensitive dermatitisdiarrhoeadementiaDeathmonotonous maize diet (maize is low in tryptophan)a very low protein dietconditions producing considerable loss of protein e.g. nephrotic syndrome
352What is wrong with this man with wrist drop and marked wasting of the lower extremities?
353Beriberi severe prolonged deficiency of vitamin B1 (thiamine) Beriberi was discovered in the seventeenth century in Java by the Dutch physician Jacobius Bonitus. The name means "sheep" in the local language; this describes the characteristic gait of patients.Today, beriberi is confined to the poorest parts of Asia where little else is eaten except polished rice.Prevention of beriberi requires:a more varied diet, including legumes and pulsesthiamine supplementation of rice
364Report this xray of a 47-year-old smoker who presented after just a few hours of rigors and productive cough. What other investigations would you carry out and how would you manage?
365consolidation in the right upper lobe Consistant with a pneumoniaInvestigate:FBC (WCC raised, particularly neutrophils)U+EsSputum and blood culturePulse oximetry and ABGSerology for atypicalsRBS – diabetes is risk factor for infection
366Assessing severity CURB-65 Score Confusion Urea>7mmol/l Resp rate>30BP systolic<90 or diastolic<60Age>65Score0-1 home Tx2 consider hospital supervised Tx (in or outpt)3 or more in patinet Tx and assess for ICU
368What is this ECG of a 23 year old man with episodes of tachycardia showing? How would you manage?
369Wolf Parkinson WhiteThe two complications of WPW are the development of an AV re-entrant tachycardia or atrial fibrillation.An AV re-entrant tachycardia is managed as for any other supraventricular tachycardia (see linked item)Atrial fibrillation secondary to WPW should not be treated with AV-blocking drugs such as verapamil and digoxin. The simplest method of terminating atrial fibrillation is cardioversion. If drugs are to be used then they must slow conduction in the accessory pathway e.g. intravenous sotalol, flecainide, amiodarone. These drugs will slow the ventricular response and will often result in restoration of sinus rhythm.For prevention of atrial fibrillation drugs such as oral sotalol and amiodarone are effective.
370What has happened to him? This 69 year old man was admitted to hospital 5 years earlier with palpitations and blackouts. He was discharged on a new medication.What has happened to him?What other problems are associated?
371Amiodarone side effects The side-effects are time and dose related.Minor side effects of amiodarone include corneal microdeposits.Moderate side effects include:photosensitivityskin discolourationabnormal thyroid function, and abnormal TFTsnauseanightmaressleep disturbanceSerious side effects include:peripheral neuropathydisturbed hepatic function:acute hepatitis and jaundice are particularly associated with intravenous administrationchronic toxicity may cause fibrosis or cirrhosisamiodarone lungamiodarone has some proarrhythmic potential
372This is the ECG of a 70yr old man with exercise intolerance This is the ECG of a 70yr old man with exercise intolerance. What is shown…how would you manage?
373Complete heart block Acute inferior block: give atropine to reduce vagal effecttemporary pacing required for profound bradycardiaAcute anterior block:start temporary pacing earlymay need a permanent pacemakerChronic block:permanent pacing
375Atrial flutter with 2:1 AV conduction The sawtooth waveform of atrial flutter can usually be seen in the inferior leads II, III and aVF if one looks closely. Sometimes the rapid atrial rate can be seen in V1.Suspect atrial flutter with 2:1 block when you see a rate of about 150 bpm.
37668 year old lady on digoxin complaining of lethargy.
377What is wrong? What is your immediate management?
378Management of VF Give 1 shock at 360 IMMEDIATELY RESUME CPR 30:2 FOR 2 MINSASSESS RHYTHM
381Restrictive lung disease Restrictive lung disease. Chest radiograph of a 67-year-old man diagnosed with idiopathic pulmonary fibrosis, based on open lung biopsy findings. Extensive bilateral reticulonodular opacities are seen in both lower lobes.
385Chest radiograph in a 60-year-old dairy farmer who had an 8-year history of intermittent dyspnea shows bilateral reticulonodular interstitial infiltration secondary to subacute hypersensitivity pneumonitis
387Bilateral hilar lymphadenopathy DIFF DIAGNOSISSarcoidosis (commonest cause in UK)tuberculosislymphoma - almost never shows the striking symmetry of the BHLcarcinomafungihypogammaglobulinaemiaberrylliosis
397Pseudohypoparathyroidism End organ resistance to PTHSmall metacarpalsPseudopseudohypoparatyhroidism – is when have physical abnormality but no end organ resistance to PTH
398What are the indications for this? What are the complicatons?Where is the semi permeable membrane?Where is the dialysate?
399Dialysis Acute renal failure End stage (established) renal failure Persistent hyperkalaemiaSevere metabolic acidosisPulmonary oedemaEncephalopathy or pericarditis (20 to uraemia)End stage (established) renal failureeGFR<15ml/min
400Complications or RRT Hypotension/ hypertension Anaphylaxis hyperkalaemia - from poor dietary complianceamyloidosis –infection - Gram positive bacteria are common. There is an increased incidence of hepatitis Cmalnutrition - causes include:loss of amino acids and peptides in the dialysatesodium restriction and poor palatability of dietdialysis induced hypercatabolismsocial and psychological factorsaluminium intoxication - from inadequate filtration of incoming water supply - this is now rareVascular access- thrombosis, stenosis, bleeding, ischaemiaAnaemiaRenal osteodystrophy
401What is this?What would it feel like?What could have caused this (rarely)
402Varicocoele Feels like a bag of worms Dull dragging ache at end of day Commoner on left sideRarely renal carcinoma can compress L testicular vein and cause a L sided varicocoele
404SAHSubarachnoid haemorrhage accounts for about 6% of cerebrovascular disease with an annual incidence of about 1 per 10,000. It is bleeding from intracranial vessels in the subarachnoid space. Occasionally, the arachnoid layer gives way and a subdural haematoma develops.Seen here as white area in the centre
406syringomyelia Cavitation of central segment of spinal cord DISSOCIATED SENSORY LOSS (spinothalamic damage- lose pain and temp but retain light touch, proprioception and vibration)WEAKNESS, WASTING, LOSS OF REFLEXES (anterior horn cell damage)Consider surgery for tx
409Apparently showing same thing In a homosexual man with weight loss and recurrent infections
410CMV retinitisCytomegalovirus (CMV) retinitis occurs in immunocompromised patients.'pizza pie' fundus:retinal spots which are the result of superficial retinal infarctionalso flame shaped haemorrhagesassociated with a low CD4 countAsymptomatic or sudden (and untreatable) visual lossOther manifestations of cytomegalovirus infection in these patients includes encephalitis, pneumonitis, and diffuse gastro-intestinal involvement.Treat with ganciclovir (or foscarnet in cases of reduced sensitivity to ganciclovir).
412Roth spotsThese are superficial retinal haemorrhages with red edges but pale or white centres. These may be seen in a variety of conditions including infective endocarditis. They are not pathognomonic of any particular disease.Also seen in leukaemia
414Loosers zones Osteomalacia This is a pseudofracture seen in osteomalacia. On x-ray, it appears as a thin, translucent band, about 2 mm in width, which runs perpendicular to the surface of the bone extending from the cortex inwards.incomplete stress fractures which heal with callus lacking in calciumpubic rami, the necks of the humeri and femora and at the axillary edge of the scapulae
418Wickham’s striaeLichen planusThe oral lesions have a radiating velvet, white or gray appearance, most commonly in a reticulated pattern. This represents the "lace-like" network of linear subepithelial fibrosis found in these lesions. The buccal and glossal mucosas are most commonly affected, however, lesions can also be found in the palate and gingiva (erosive gingivitis).
420Central retinal artery occlusion The retina has become milky because of infarction. Tissue necrosis makes the tissue lose its normal transparency.Cherry-red spotThe red-orange color of the fovea appears in stark contrast to the surrounding milky retinal edema. Called a "cherry-red spot," it results from the fact that the fovea contains only the photoreceptor layer, which is spared because it is nourished by the choroidal circulation rather than the retinal circulation.
422Central retinal vein occlusion The patient presents with painless loss of vision, often mixed with sparkles, that may be sudden or evolve over hours to days.Systemic hypertension is the most common cause; hyperviscous and hypercoagulable states must also be considered.Numerous haemorrhages seen – splattered with blood