MEDICAL SHORTSEllie Lightman & Tania Wan

The Shorts station10 minutes longExamination or just inspection

DiscussionTopics• Endocrinology• Rheumatology• Dermatology• Ophthalmology• Miscellaneous- eponymous conditions

Two formats:- Get through as many cases as you can- 2-3 cases, examination/inspection & discussion

The Spiel1) Describe what you see or find2) Assimilate findings ‘these are consistent with a

diagnosis of ________’3) ‘I would also like to look for ___________’4) Pathology X can be diagnosed using these

investigations: 5) Treatment options are:

1) Conservative2) Medical 3) Surgical (if applicable)

Endocrinology• Acromegaly

Acromegaly• On inspection, I can see that this gentleman is very tall, with coarse

facial features, prominent periorbital ridges and large, spade-like hands

• O/E: • Hands- warm & sweaty, doughy consistency, marks from blood

glucose testing (diabetes), carpel tunnel (or scar)• Arms- high blood pressure• Face- macroglossia, prognathism, scar- surgery, tattoo- radiotherapy

These findings are consistent with acromegaly• I would also like to:

conduct a full CVS examination looking for cardiomegaly, HTN• History: ask about shoes, rings & hats, ask to see old photos

Acromegaly• Investigations: Glucose tolerance test, then check GH

levels, MRI brain

Treatment:Medical: Somatostatin analogues (octreotide)

Pegvisomant (blocks GH receptor)Dopamine agonists (carbergoline)

Surgical: Transphenoidal or transfrontal excision

Radiotherapy

Your turn

Graves’ DiseaseOn inspection:Exophthalmos, large mass in neck and pt is inappropriately dressed for

the weather.

I would normally proceed to assess the thyroid statusHands: temperature, tremor, heart rate, AFFace: ophthalmoplegia, exophthalmos, lingual thyroidNeck: goitre, mass moves with swallowing but not tongue protrusion,

check for a retrosternal goitre.

History: I would ask about symptoms e.g. palpitations, heat intolerance, diarrhoea

Investigations: TFTs, isotope scanTreatment: medical- carbimazole, PTU, radiothearpy, surgical

SclerosisOn inspection: skin is taut and shiny, characteristic ‘beaking’ of the nose, perioral furrowing and microstomia. I also note telangiectasia around the mouth. Hands: evidence of sclerodactyly and nodules of calcinosis.

On examination: full hand examination examining for temperature (Raynaud’s) and function. I would also like to:conduct a full respiratory examination looking for interstitial fibrosis, cardiovascular disease (evidence of pulmonary hypertension)Full history asking about any swallowing problems (oesophageal dysmotility), SOB (ILD) and ask how the condition affects the patient’s life.

Sclerosis1) Limited systemic (CREST) skin involvement below elbows and knees2) Diffuse systemic sclerosis (visceral involvement)

Investigations: Blood tests- anti-nuclear Ab, anti-centromere Ab (limited), anti Scl-70 (diffuse)Xray hands- calcinosisPulmonary fibrosis- CXR, high-resolution CT thorax, lung function tests (restrictive)Pulmonary hypertension- ECG, ECHORenal: urea & electrolytes, urine microscopy

TreatmentSymptomatic: gloves, handwarmers, CCB, ACE-I, prostcyclin inhibitorsRenal protection- ACE-inhibitors to prevent hypertensive crises

Rheumatology

1) Describe what you see

• 2) These findings are consistent with __________

Presenting a hand examination• Symmetrical deforming polyarthropathy

• With• Ulnar deviation of MCP joints• Swan neck deformity• Bountonnieres deformity• Z thumb• Rheumatoid nodules

• Scars: carpel tunnel release, joint replacement, tendon transfer

• There are no signs of ACTIVE disease • Red, swollen, hot, painful hands

• However function is impaired as shown by• Reduced power grip (squeeze fingers)• Precision grip (buttons/pick up coin)• Key grip• Mention walking aides etc

Rheumatology• Other manifestations of RA

There are a lot so try to memories 1 or 2 from each system:

• Pulmonary• Effusions, fibrosing alveolitus, obliterative bronchiolitis, caplan’s

nodules

• Eyes• Scleritis

• Cardiac• Pericarditis

• Renal• Nephrotic sydrome

• Neuro• Carpel tunnel syndrome• Peripheral neuropathy

• Haem• Feltys = RA + splenomegaly + neutropenia

Rheumatology

• Can be diagnosed using

• RhF• Anti-CCP• Inflammatory markers eg ESR, CRP• FBC often have anaemia of chronic disease• X-ray

Decreased joint spaceSoft tissue swellingJuxta-articular osteopenia (as pannus of inflammation thins it)Maybe: bony erosions, subluxation

Rheumatology

- Treatment options include:

- Symptomatic relief: NSAIDs- DMARDs eg methotrexate, sulphasalazine- Step up therapy = Anti-TNF therapy eg infliximab

Rheumatology

1) Describe what you see2) These findings are consistent with __________

Asymmetrical polyarthropathy With distal interphalangeal joint deformityHeberdens nodesBouchards nodesAtrophy of hand muscles

Can mention crepitation on movement. Restriction of movement. Do not talk about active disease – is not inflammatory like RA

However function is impaired as shown byReduced power grip (squeeze fingers)Precision grip (buttons/pick up coin)Key gripMention walking aides etc

Rheumatology

• Can be diagnosed using• X ray

• Joint space narrowing• Subchondral sclerosis and cysts• Osteophytes

Rheumatology

- Treatment options include:

- Exercises- reduce weight- Analgesia- intra-articular steroid injections- joint replacement

Rheumatology

1) Describe what you see

• Question mark posture• Caused by fixed kyphoscoliosis• loss of lumbar lordosis • With extension of cervical spine

2) These findings are consistent withankylosing spondylitis

Rheumatology

• Can be diagnosed using..• Clinical diagnosis• Schober test: 2 points 15 cm apart on the dorsal spine – expand

less than 5cm on maximal forward flexion• Limited chest expansion for age and sex• HLA B27 (90% association)• X-ray (sacroliitis)

• Treatment• Physiotherapy• Analgesia• Anti-TNF

Rheumatology

• Complications = the 5 A’s• Anterior uveitis• Apical lung fibrosis• Aortic regurgitation• Atrioventricular nodal heart block• Arthritis

Dermatology

PsoriasisOn inspection, I can see areas of ‘salmon pink’ plaques covered with ‘silvery-white’ scaling on the extensor surfaces. There are nail changes including: pitting, onycholysis, subungal hyperkeratosis

These findings are consistent with psoriasisI would also like to examine the scalp, naval area

• In my history I would ask about any joint pain, impact of the condition on the patient’s life and their current treatment

Psoriasis• 5 main types:

Classic plaque, pustular, guttate, erythrodermic, palmo-plantar

Treatment1) TopicalCorticosteroids-Vitamin D analogues- calcipotriolDithranol- stains yellow-brownCoal tar

2) Light therapy- UVB, PUVA

3) Systemic- methotrexate, acitretin, ciclosporin, Biologics- etanercept, infliximab

Don’t forget: Counselling & education

Dermatology

EczemaOn inspection there are erythematous patches of skin with lichenification (thickened), on the flexor surfaces of the limbsEvidence of excoriation (scratching)

This is consistent with atopic dermatitis or eczema

Eczema is a primarily a clinical diagnosis. I would like to take a full history asking about any personal or family history of atopy, including allergy, asthma and hayfever and I would enquire about symptoms, predominantly pruritis.

EczemaTypes: Atopic eczema (most common), contact eczema (e.g.nickel)

Treatment:Topical• Emollients, soap substitutes• Topical steroids- hydrocortisone, betamethasone, dermovate• Calcineurin inhibitors – tacrolimus

Systemic ( for severe or unresponsive eczema)• Immunosuppresants: oral steroids, ciclosporin, methotrexate• Phototherapy- UVB or PUVA – psoralen + UVA

Don’t forget- counseling, education, psychological support

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Marfan’s

On inspection/examination, I note this lady is very tall, with long limbs and arachnodactyly (Walker’s/ Steinberg’s sign). She has hyper-mobile joints.

She has a high arched palate and I can see (upwards) lens dislocation. Chest- pectus excavatum/carinatum defomity of the chest, scars from pneumothorax, midline sternotomy scar.

Otherwise- aortic incompetence: collapsing pulse, early diastolic murmur, radio-radial delay

These findings are consistent with Marfan’s.

Marfan’sAutosomal dominant, defect in fibrillin-1 gene (Chr 15)Diagnosis is clinical

ManagementConservative: Annual echocardiogram to monitor aortic valve/root

Medical: beta blockers- reduce aortic root dilatation

Surgical: aortic valve repair

Ophthalmology

1) Describe what you see2) These findings are consistent with

Ophthalmology • Diabetic retinopathy

• Back ground retinopathy• Microaneuryms• Blots haemorrhages• Hard exudes

• Preproliferative• Cotton wool spots• Flame haemorrhages• Venous beading and looping

• Proliferative• Neovascularisation – can cause vitreous haemorrhage, tractional retinal detachment and neovascular gluacoma• Look out for pan-retinal photocoagulation scars

• Diabetic maculopathy

• ‘macular oedema or hard exudates within one disc space of the fovea’

Ophthalmology

• Can be diagnosed using…..

• Slit lamp examination• Random/fasting glucose test

Ophthalmology

- Treatment options include:- Tight glycaemic control- Treat other RF: hypertension, high cholesterol, smoking

cessation

- Pan-retinal photocoagulation – if have maculopathy/proliferative/preproliferative retinopathy

Ophthalmology

1) Describe what you see2) These findings are consistent with __________

Simplified hypertensive retinopathy

Grade 1: Silver wiring = increased reflectance from thickened arterioles

Grade 2: arteriovenous nipping = narrowing of veins as arterioles cross them

Grade 3 :cotton wool spots and flame haemorrhages

Grade 4: papilloedema = blurry indistinct margin, engorged veins running down ontoRetina, loss of venous pulsation

There may also be hard exudates (macularStar)

Ophthalmology

• Can be diagnosed using….• Clinical diagnosis• BP!

• Treatment options include:• For grade 3+ use oral anti hypertenisves and monitor BP

Ophthalmology

1) Describe what you see2) These findings are consistent with __________

Ophthalmology

1) Describe what you see1) Peripheral bone spicule pigmentation – follows the veins and

spares the macula2) Optic atrophy – due to neuronal loss

• 2) These findings are consistent with __________• Retinitis pigmentosa

NB is associated with night vision loss and tunnel vision

Ophthalmology

• Can be diagnosed using….• Clinical diagnosis

• Treatment options include:• No treatment although vitamin A may slow disease progression

Miscellaneous

1) Describe what you see

Miscellaneous 1) Describe what you see

1) Cutaneous neurofibromas (2+)2) Café au lait patches (6+, over 15mm diameter in adults)3) Axillary freckling4) Lisch nodules = melanocytic hamartomas of the iris

2) These findings are consistent with __________neurofibromatosis (type 1)

Clinical diagnosisSymptomatic treatment – surgery if neurofibromas compress

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Facial nerve palsyMost often caused by Bell’s palsy (idopathic-75%)Unilateral paralysis of facial muscles

Make sure to look behind the ears to distinguish from Ramsay Hunt Syndrome- HZV reactivation in geniculate nucleus of the facial nerve (look for immunosuppression)

Perform relevant cranial nerve examination- look for facial muscle weakness, hyperacusis (paralysis of stapedius), Bell’s phenomenon

Bell’s PalsyManagementConservative- eye care: drops, tape

Medical: aciclovir (HSV), short course of prednisolone

Reassurance: Usually complete recovery in a few weeks

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