SLIDESHOW PRACTICE

1. SLIDESHOW PRACTICE

2. What 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

3. ANSWERS • 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 enema • Tx – oral iron

4. A 52 year old diabetic manpresented to A and E feeling sick. 1 week previously his GP had treated him for reflux • Describe immediate management

5. ANSWER • 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 leads • PRIMARY PCI IF IN COOL TEACHING HOSPITAL

6. CONTRAINDICATIONS TO THROMBOLYSIS • Internal bleeding • Prolonged/traumatic CPR • Any prev haemorrhagic stroke • Ischaemic stroke within 1 year • Recent trauma surgery (2 weeks) • Intracerebral neoplasm/recent head trauma • Suspected aortic dissection • Prev allergic reaction to fibrinolytic

7. Report this Xray • Describe 5 changes you should look for on the XRay in this condition • What investigations would you do if this was an acute problem? • How would you manage?

8. 5 changes in L ventricular failure • A alveolar oedema (bat wings) • B Kerley B lines (interstitial oedema) • C Cardiomegaly • D Dilated upper lobe vesseld • E Pleural Effusion • SIGNS: tachycardia, basal creps, pink frothy sputum, PND, orthopnoea • FBC, U+E, cardiac enzymes, ECG (ischaemia, MI, LVH), ABG, BNP (raised in failure) Echo

9. Commonest causes of acute LVF? • Post MI • myocardial ischaemia • Malignant hypertension • aortic stenosis or aortic incompetence • mitral incompetence • arrythmia

10. Management of acute LV failure • Sit up • Give 100% 02 • IV access monitor ECG for arrythmias, MI etc • Diamorphine 2.5-5 mg IV slowly • Metoclopramide 10mg iv • Frusemide 40-80mg IV slowly • Give sublingual GTN if systolic BP>100 • Monitor urine output (catherterise) • Repeat ABG and K+ if condition deteriorates

11. A 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?

12. ANSWER • 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)

13. This 55year old man has returned from a holiday 2 weeks ago with arthralgia, malaise, lymphadenopathy and peripheral neuropathy • He has the following lesion which started as a red macule. • What is the diagnosis? • How would you treat?

14. Erythema 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

15. Lyme disease • often the first manifestation of Lyme disease = Lyme borreliosis • spirochete 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

16. TROUSSEAU’s SIGN • This 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.

17. What is this? • What causes it? • What other signs would you look for?

18. ANSWER • Plummer vinson syndrome (Post cricoid web) Iron deficiency anaemia • Koilonychia, pallor, atrophic mucous membranes, tachycardia if marked • Tx balloon dilatation and iron supplements • Pre-malignant!!!

19. This patient presented with weight loss and this crazy skin condition… • What is it? • Clue: say what you see

20. Erythema Gyratum Repens • wood-grain" pattern (repens is a plant) • wavy, erythematous, urticarial bands with scale • slowly migrate • breast, stomach, bladder, prostate, cervix; (occasionally no CA )

21. This patient presented with weight loss, a palpable liver. • What is this skin condition and with what condition is it associated?

22. Necrolytic migratory erythema • Glucagonoma - alpha cell tumor of the pancreas • is associated with this condition (in more than 70% of patients) • abdomen, thighs and buttocks • present with attacks of hyperglycaemia (diabetes mellitus occurs in more than 50% of cases), anaemia, rash and diarrhoea. • Also glossitis, angular cheilitis, normocytic anemia • 90% have liver metastasis at presentation

23. This 22yr old woman presents with weight loss and bloody diarrhoea • She develops this lesion on her ankle • What is it? • What else is her condition associated with?

24. Pyoderma gangrenosum • characteristic rapidly expanding ulcer with bluish undermined border; often lower extremities; begin as sterile pustules • 1% to 10% of patients with active ulcerative colitis; often (but not always) parallels disease • Other 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

25. What is this sign? • Name 4 causes of this condition

26. Grey turners • Acute pancreatitis • Gallstones • Ethanol • Trauma • Steroids • Mumps • Autoimmune (PAN) • Scorpion • Hyperlipidaemia • ERCP • Drugs (azathiporine, mercaptourine, diuretics?

27. What is this?

28. Cullen’s sign • yellow 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.

29. What is this? What else would you look for? What investigations would you do? What treatment would you start?

30. Tendon xanthoma • extensor tendons of fingers, patella, elbows, Achilles tendon (one of the most common sites); diffuse infiltration of tendon by lipid • Xanthelasma in eyes, corneal arcus • hypercholesterolemia; Types II and III • Lipid profile • Statins

31. What is this? What is it associated with?

32. Acanthosis nigricans • velvety thickening and darkening (hyperpigmentation) of the skin, especially on the nape of the neck, axillae and other body folds • underlying causes • obesity; drugs; "malignant" acanthosis nigricans; hereditary, benign AN • GLUCOSE INTOLERANCE, INSULIN RESISTANCE

33. Another example

34. What is this? With what conditions is it associated?

35. Erythema nodosum • deep erythematous painful nodules, symmetrically on the lower legs; female predominance; a hypersensitivity panniculitis • fever, chills, malaise, leukocytosis • disease associations: streptococcal infections, drugs (OCPs, sulfonamides, iodides), pregnancy, TB, deep mycoses, acute sarcoidosis, inflammatory bowel disease

36. What is this and with what condition is it associated?

37. Keratoderma blenorrhagica • Keratoderma blenorrhagia is a skin condition associated with Reiter's syndrome. • urethritis • conjunctivitis • a seronegative arthritis • In 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 feet • penis, causing a circinate balanitis • in the mouth • It is treated with 1% hydrocortisone.

38. What are these lesions? With what are they associated?

39. Erythema multiforme • form of cutaneous reaction to an underlying condition. In 50% of cases, a cause can’t be identified • common causes: HERPES VIRUS • drugs (sulfonamides, phenytoin, barbiturates, penicillin, etc.); infections (esp. herpes simplex and Mycoplasma) • inflammatory bowel disease • eruption usually lasts for a week or two, then spontaneously remits • the "target" lesion is approximately 1cm dull-red macule or papule with a central area of blistering or hemorrhage

40. What is this? What are the common causes?

41. urticaria • IDIOPATHIC IS MOST COMMON • Drugs (e.g., penicillins, aspirin, NSAIDs, opiates, phenytoin, atropine, metronidazole • phenytoin • Food stuffs, insect bites, candida infections • systemic lupus erythematous - in early stages, urticaria may be the only clinical abnormality, with wheals persisting for an unusually long time - 2-4 days • viral hepatitis - may begin with urticaria • Still's disease • rheumatic fever • hyperthyroidism • Primary 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 hours • MAJORITY NO CAUSE IS FOUND THEREFORE DO NOT INVESTIGATE!!!

42. A 32 year old man presents with unilateral leg swelling. What is your differential diagnosis? How would you investigate and manage this problem?

43. Diff diagnosis of unilateral leg swelling • Deep vein thrombosis • Cellulitis • Ruptured Baker’s cyst • Lymphoedema • Fracture

44. DVT Figure 2: Well’s Clinical model for predicting pretest probability. Clinical feature Score Active cancer 1 Paralysis, paresis or recent plaster immobilisation of lower extremities 1 Recently bedridden > 3days or previous surgery within 12 weeks requiring regional or general anaesthesia 1 Localised tenderness along the distribution of deep venous system 1 Swelling of the entire leg 1 Calf swelling by more than 3cm compared with asymptomatic leg 1 Pitting oedema confined to the symptomatic leg 1 Collateral superficial veins 1 Previously documented DVT 1 Alternate diagnosis as likely or greater than that of DVT -2

45. Well’s criteria • SCORE >3 HIGH RISK • SCORE 1-2 MODERATE RISK • SCORE <1 LOW RISK • D-dimer for LOW RISK- good negative predictive value • USS of deep veins (duplex ideally) • Tx clexane (until INR between 2 and 3) • Warfarin, support hosiery

47. Steven johnsons syndrome • severe and sometimes fatal form of erythema multiforme. Bullous ulcerating lesions • higher 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

48. Differential diagnosis of SJ • Behcet's syndrome • Reiter's syndrome • syphilis - primary or secondary • hand, foot and mouth disease • pemphigus • toxic epidermal necrolysis • Kawsasaki disease • Tx refer to specialist care (dermatologist) supportive tx

49. USS of legs. Describe what this shows • Which is normal? • A or B? • Management?

50. Compression US of legs • B is normal – normal compressibility • A shows non compressibility – i.e thrombosis in vein • Tx clexane until warfarin in therapeutic range. Continue warfarin 3-6 months • IVC filter if worried about PE • TED stockings