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Medical Shorts

Medical Shorts. Ellie Lightman & Tania Wan. The Shorts station. 10 minutes long Examination or just inspection Discussion Topics Endocrinology Rheumatology Dermatology Ophthalmology Miscellaneous- eponymous conditions Two formats: - Get through as many cases as you can

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Medical Shorts

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  1. Medical Shorts Ellie Lightman & Tania Wan

  2. The Shorts station 10 minutes long Examination or just inspection Discussion Topics • Endocrinology • Rheumatology • Dermatology • Ophthalmology • Miscellaneous- eponymous conditions Two formats: - Get through as many cases as you can - 2-3 cases, examination/inspection & discussion

  3. The Spiel • Describe what you see or find • Assimilate findings ‘these are consistent with a diagnosis of ________’ • ‘I would also like to look for ___________’ • Pathology X can be diagnosed using these investigations: • Treatment options are: • Conservative • Medical • Surgical (if applicable)

  4. Endocrinology • Acromegaly

  5. 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

  6. 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

  7. Your turn

  8. Graves’ Disease On inspection: Exophthalmos, large mass in neck and pt is inappropriately dressed for the weather. I would normally proceed to assess the thyroid status Hands: temperature, tremor, heart rate, AF Face: ophthalmoplegia, exophthalmos, lingual thyroid Neck: goitre, mass moves with swallowing but not tongue protrusion, check for a retrosternal goitre. History: I would ask about symptoms e.g. palpitations, heat intolerance, diarrhoea Investigations: TFTs, isotope scan Treatment: medical- carbimazole, PTU, radiothearpy, surgical

  9. Sclerosis On inspection: skin is taut and shiny, characteristic ‘beaking’ of the nose, perioral furrowing and microstomia. I also note telangiectasia around the mouth. Hands: evidence of sclerodactyly and nodules of calcinosis. On examination: full hand examination examining for temperature (Raynaud’s) and function. I would also like to: conduct a full respiratory examination looking for interstitial fibrosis, cardiovascular disease (evidence of pulmonary hypertension) Full history asking about any swallowing problems (oesophageal dysmotility), SOB (ILD) and ask how the condition affects the patient’s life.

  10. Sclerosis 1) Limited systemic (CREST) skin involvement below elbows and knees 2) Diffuse systemic sclerosis (visceral involvement) Investigations: Blood tests- anti-nuclear Ab, anti-centromere Ab (limited), anti Scl-70 (diffuse) Xray hands- calcinosisPulmonary fibrosis- CXR, high-resolution CT thorax, lung function tests (restrictive) Pulmonary hypertension- ECG, ECHO Renal: urea & electrolytes, urine microscopy Treatment Symptomatic: gloves, handwarmers, CCB, ACE-I, prostcyclin inhibitors Renal protection- ACE-inhibitors to prevent hypertensive crises

  11. Rheumatology • Describe what you see • 2) These findings are consistent with __________

  12. 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

  13. Rheumatology • Other manifestations of RA • There are a lot so try to memories 1 or 2 from each system: • Pulmonary • Effusions, fibrosingalveolitus, obliterative bronchiolitis, caplan’s nodules • Eyes • Scleritis • Cardiac • Pericarditis • Renal • Nephroticsydrome • Neuro • Carpel tunnel syndrome • Peripheral neuropathy • Haem • Feltys = RA + splenomegaly + neutropenia

  14. Rheumatology • Can be diagnosed using • RhF • Anti-CCP • Inflammatory markers eg ESR, CRP • FBC often have anaemia of chronic disease • X-ray • Decreased joint space • Soft tissue swelling • Juxta-articular osteopenia (as pannus of inflammation thins it) • Maybe: bony erosions, subluxation

  15. Rheumatology • Treatment options include: • Symptomatic relief: NSAIDs • DMARDs eg methotrexate, sulphasalazine • Step up therapy = Anti-TNF therapy eg infliximab

  16. Rheumatology • Describe what you see • These findings are consistent with __________

  17. Asymmetrical polyarthropathy • With distal interphalangeal joint deformity • Heberdens nodes • Bouchards nodes • Atrophy of hand muscles • Can mention crepitation on movement. Restriction of movement. • Do not talk about active disease – is not inflammatory like RA • However function is impaired as shown by • Reduced power grip (squeeze fingers) • Precision grip (buttons/pick up coin) • Key grip • Mention walking aides etc

  18. Rheumatology • Can be diagnosed using • X ray • Joint space narrowing • Subchondralsclerosis and cysts • Osteophytes

  19. Rheumatology • Treatment options include: • Exercises • reduce weight • Analgesia • intra-articular steroid injections • joint replacement

  20. Rheumatology • Describe what you see • Question mark posture • Caused by fixed kyphoscoliosis • loss of lumbar lordosis • With extension of cervical spine 2) These findings are consistent with ankylosing spondylitis

  21. 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

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

  23. Dermatology

  24. Psoriasis On inspection, I can see areas of ‘salmon pink’ plaques covered with ‘silvery-white’ scaling on the extensor surfaces. There are nail changes including: pitting, onycholysis, subungal hyperkeratosis These findings are consistent with psoriasis I would also like to examine the scalp, naval area • In my history I would ask about any joint pain, impact of the condition on the patient’s life and their current treatment

  25. Psoriasis • 5 main types: Classic plaque, pustular, guttate, erythrodermic, palmo-plantar Treatment 1) Topical Corticosteroids- Vitamin D analogues- calcipotriol Dithranol- stains yellow-brown Coal tar 2) Light therapy- UVB, PUVA 3) Systemic- methotrexate, acitretin, ciclosporin, Biologics- etanercept, infliximab Don’t forget: Counselling & education

  26. Dermatology

  27. Eczema On inspection there are erythematous patches of skin with lichenification(thickened), on the flexor surfaces of the limbs Evidence of excoriation (scratching) This is consistent with atopic dermatitis or eczema Eczema is a primarily a clinical diagnosis. I would like to take a full history asking about any personal or family history of atopy, including allergy, asthma and hayfever and I would enquire about symptoms, predominantly pruritis.

  28. Eczema Types: Atopic eczema (most common), contact eczema (e.g.nickel) Treatment: Topical • Emollients, soap substitutes • Topical steroids- hydrocortisone, betamethasone, dermovate • Calcineurin inhibitors – tacrolimus Systemic( for severe or unresponsive eczema) • Immunosuppresants: oral steroids, ciclosporin, methotrexate • Phototherapy- UVB or PUVA – psoralen + UVA Don’t forget- counseling, education, psychological support

  29. 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- pectusexcavatum/carinatumdefomity 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.

  30. Marfan’s Autosomal dominant, defect in fibrillin-1 gene (Chr 15) Diagnosis is clinical Management Conservative: Annual echocardiogram to monitor aortic valve/root Medical: beta blockers- reduce aortic root dilatation Surgical: aortic valve repair

  31. Ophthalmology • Describe what you see • These findings are consistent with

  32. 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 neovasculargluacoma • Look out for pan-retinal photocoagulation scars

  33. Diabetic maculopathy • ‘macular oedema or hard exudates within one disc space of the fovea’

  34. Ophthalmology • Can be diagnosed using….. • Slit lamp examination • Random/fasting glucose test

  35. Ophthalmology • Treatment options include: • Tight glycaemic control • Treat other RF: hypertension, high cholesterol, smoking cessation • Pan-retinal photocoagulation – if have maculopathy/proliferative/preproliferative retinopathy

  36. Ophthalmology • Describe what you see • These findings are consistent with __________

  37. Simplified hypertensive retinopathy Grade 1: Silver wiring = increased reflectance from thickened arterioles Grade 2: arteriovenous nipping = narrowing of veins as arterioles cross them Grade 3 :cotton wool spots and flame haemorrhages Grade 4: papilloedema = blurry indistinct margin, engorged veins running down onto Retina, loss of venous pulsation There may also be hard exudates (macular Star)

  38. Ophthalmology • Can be diagnosed using…. • Clinical diagnosis • BP! • Treatment options include: • For grade 3+ use oral anti hypertenisves and monitor BP

  39. Ophthalmology • Describe what you see • These findings are consistent with __________

  40. Ophthalmology • Describe what you see • Peripheral bone spicule pigmentation – follows the veins and spares the macula • Optic atrophy – due to neuronal loss • 2) These findings are consistent with __________ • Retinitis pigmentosa NB is associated with night vision loss and tunnel vision

  41. Ophthalmology • Can be diagnosed using…. • Clinical diagnosis • Treatment options include: • No treatment although vitamin A may slow disease progression

  42. Miscellaneous • Describe what you see

  43. Miscellaneous • Describe what you see • Cutaneous neurofibromas(2+) • Café au lait patches (6+, over 15mm diameter in adults) • Axillary freckling • Lisch nodules = melanocytic hamartomas of the iris 2) These findings are consistent with __________ neurofibromatosis (type 1) Clinical diagnosis Symptomatic treatment – surgery if neurofibromas compress

  44. da

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