Some Important Cases For Paces

common cases in PACES
DIABETIC
RETINOPATHY
(41) microaneurysms, blot haemorrhages, hard exudates (Background),
circinates of hard exudate near macula, poor acuity (Macular
oedema), cotton wool spots, flame haemmorhages, leashes of new
vessels, photocoagulation scars
(proliferative), vitreous
haemorrhage/scars, retinal detachment (advanced diabetic eye dx).
may be bp, cateract. <
indications
for referral<
all except background, refer background involving macula.
indications
for photocoagulation:
pre-proliferative (cotton wool spots, multiple blots, venous
beeding) or proliferative retinopathy.
<LI> 
RHEUMATOID
ARTHRITIS (31)
symetrical
deforming arthropathy, spindling of fingers. PIP, MCP swelling, DIP
spared, muscle wasting, deformity, pain. nodules at elbow/dorsum
hand, ulnar deviation, nail fold infarcts, arteric lesions. warmth
and swelling sugests active inflam. swan neck, boutonnire
deformity, Z thumb, palmer erythema, anaemia, episcleritis, CVS/RESP
signs. causes
of anaemia:
chronic dx, nsaids, myelosupressive drugs, feltys, assoc pernicious
anemia. treatment:
general (education, excercise, physio - thermal, splinting, diet),
NSAIDs, DMARDs (1st line: methotrexate, sulphasalazine, gold,
penicillamine, (hydroxy)chloroquin, 2nd line: azathioprine,
cyclophosphamide, chlorambucil), corticosteroids (7.5 mg/day with
calcium, bisphophanates), biological agents.
<LI> 
EXOPTHALMOS
(26)
(protrusion
of eye revealing sclera above lower lid on forward gaze). bilateral
asymetrical swelling of medial caruncle, congestion of lateral
canthus, and exopthalmos. look for pretibial myxoedema, thyoid
acropachy. graves
malignant exopthalmos:
may be eu/hypo/hyperthyroid with severe exopthalmos, chemosis,
exposure keratitis, corneal ulceration, painful opthalmoplegia
(lateral, upward and convergent). due to muscle infiltration,
oedema, fibrosis. sight threatening due to optic nerve pressure. Rx:
steroids, tarsoraphy (scar), orbital decompression, radiotherapy.
Causes:
hyperthyroid graves dx, euthyroid graves dx, hypothyroid graves.
asymetrical: cavernous sinus thrombosis, carticocavernous fistula
(pusatile), unilat: retroorbital tumour, orbital celulitis (Hertel
exopthalmometer) Treatment:
lubricant eye drops, avoid smoking, wrap around glasses, optimize
thyroid status. radioiodine may worsen exopthalmos.
<LI> 
ACROMEGALLY
(24) prominent supraobital ridges, large lower jaw, exagerated
wrinkles, full lips, malocclusion/prognathism, interdental spaces,
nose/tongue/ears enlarged, kyphosis, large doughy spade hands, thick
skin, carpal tunnel syndrome, excesive sweating, 1/3 hersuit, husky,
cavernous voice, bitemporal hemianopia. Others: shoe/hat size, bowed
legs, rolling gait, gynaecomatia, gallactorhoea, large/small testes,
acne, greasy skin, skin tags (colonic polyps), acanthosis nigricans,
osteoarthrosis, prox muscle weakness, cardiomegally (bp,
cardiomyopathy), CN3 palsy. Associations:
DM, bp, hyercaliuria, hypercalcemia (if MEN1=pipa=pituitry, islet
cell, parathyroid, adrenal), urolithiasis, hyperTG, diabetes
insipidus, hypopituitrism. Inv:
IGF1, GTT absent GH supression, MRI pituitry, visual fields, old
photos, SXR, ant pit tests (short synACTHen, ITT, TSH, T4,
oestadiol, LH/FSH, testosterone, prolactin). Rx:
trnasphenoidal/transfrontal hypophysectomy, external irradiation,
gold/yttrium implants, bromocriptine (no shrinkage), somatostatin
analogues (shink). cause:99%
pit adenoma, 1% gangliocytoma
<LI> 
CHRONIC
LIVER DISEASE
(21) icterus, pigmentation, clubbing, leuconychia, palmer erythema,
Dupytrens, spider naevi, flapping tremor, scratch marks, purpura,
gynaecomastia, scanty body hair, small testes, hepatomegally,
splenomegally, ascites, ankle oedema, distended abdo veins flow away
+/- cyanosis from pulm-venous shunts. consider transplantation.
causes
alcohol, viral hepatitis, autoimmune CAH, haemochromtosis,
cryptogenic. other: cardiac failure, constrictive pericarditis, Budd
Chiari, 2ry billiary cirrhsis, drugs (methotrexate, mehydopa,
isoniazid, CCl4, amiodarone, aspirin, phenytoin, propylthiouracil,
sulphonamides), Wilsons dx, alpha1antitrypsin def, metabolic
(galactosemia, tyrosinemia, glycogenosis4)
<LI> 
FIBROSING
ALVEOLITIS
(21) sob, clubbing, steroid purpura, reduced symetrical expansion,
fine inspiratory crackles (+/- cyanosis, dullnes lung base, LTOT)
causes
cryptogenic, rheumatoid, conn tissue disorders (systemic sclerosis,
SLE, polymyositis, dermatomyositis, Sjorgens), ankylosing
spondylitis, extrinsic allergic alveolitis, asbestosis, silicosis,
drugs (bleomycin,buslphan, nitrofurantoin, amiodarone), radiation
fibrosis, chemicals (Berylium, mercury), poisons (paraquet), ARDS.
<LI> 
PROSTHETIC
VALVES
(17) Mitral
valve prosthesis
midline sternotomy, S1 prosthetic click, diastolic opening click +/-
mid diastolic flow murmur, pansystolic murmur/failure suggests leak.
Aortic
valve replacement
midline sternotomy, normal S1, systolic opening click, prosthetic S2
+/- systolic flow murmur, early diastolic murmur/collapsing pulse
suggests leak Complictions
thromboemolism, haemorhage, endocarditis, valve leak, dehiscence,
Starr-Edwards ball embolus, valve obstruction (thrombus/fibrosis),
haemolysis.
<LI> 
HEPATOSPLENOMEGALLY
(17) spleen enlarged..cm below costal margin. Liver palpable ... cm
below right costal margin. Check for anemia, lymphadenopathy,
chronic liver disease and renal enlargement. Causes:
myeloproliferative,lymphoproliferative (CLL, lymphoma), liver
cirrhosis with portal hyperension, infections (hepB/C, EBV, CMV),
zoonoses (brucella,weils, toxplasma), megaloblastic anemia, storge
dx (gauchers, glycogen storage), amyloidosis, sarcoidosis,budd
chiari=hep vein thrombosis, infantile PKD. worldwide causes:
malaria, kala azar, schistosomiasis, TB.
Bruit suggests hepatoma.
<LI> 
PNEUMONECTOMY
(16) chest wall deformity, with flattened L side associated ith L
thoracotomy scar, L tracheal deviation, L expansion reduced,
percussion dull, breath sounds diminished. Bronchial breathing L
upper zone due to tracheal deviation. L
lower lobctomy
deformity chest, L lower ribs pulled in, L thoracotomy scar, trachea
central, apex displaced L, percussion dull L lower zone, breath
sounds diminished. Indications
for pnumonectomy
25% non small cell ca (2-6% mort), solitary pulm nodule of uncertain
cause, treatment unresponsive bronchiectasis, TB in preantibioic
era.
<LI> 
RETINITIS
PIGMENTOSA
(16) widespread scattering of black pigment resembling bone
spicules, the macula spared. There is tunnel vision and night
blindness. Associaions: cateracts, deaf mutism, mental deficiency.
Other
causes of pigmentary degeneration
Laurence Moon Biedl, Refsums dx, hereditary ataxia, familial
nuropathy, neuronal lipidoses (ceroid lipofuscinosis).
<LI> 
SYSTEMIC
SCLEROSIS
(15) middle aged female, skin smooth, shiny, tight fingers and face.
Raynaulds, atrophy of finger tips, telangectasias face,
pigmentation, nodules of calcinosis palpable on some fingers. other:
skin ulcers, vitiligo, Sjorgens, diffuse intersitial fibrosis
(leading cause of death) Rx vasoilators. other
systems:
CREST, renal (bp, failure), CVS (cardiomyopathy, effusion), muscle
(myositis, arthritis), intestinal hypermotility, PBC.
Treatment:
general (education, exercise, lubricants), Raynauds (calcium ch
blockers, ACEi, proscycline, calcitonin GRP), oesophagus (PPI,
prokinetics=cisapride), malabsoption (low residue diet, supplements,
rotational abx), renal (ACEi, steroids), pulm vasc dx
(vasodilators),fibrosis (dpenicillamine, corticosteroids).
<LI> 
POLYCYSTIC
KIDNEY DISEASE
(14) bilateral flank masses, bilaterally ballotable, can get above
them, percussion resonant, abdominal scars
from CAPD/cyst
aspiration,
AV fistula,
uremic facies, hypertension, renal
transplant, parathyroidectomy. Complications:
flank pain, bleeding, uti, nephrolithiasis, obstrucive uropathy.
Other
features:
berry aneurysm, mitral valve prolapse, renal cell carcinoma.
Genetics:
PKD1 (Ch16, 85%, renal failure), PKD2 (Chr4, 15%), PKD3 rare.
Liver
cysts:
rare in adult AD-PKD, common in
infantile AR-PKD. Screening:
U/S and genetic testing at 20 years (inconclusive before 20),
earlier if FH aneurysm, signs renal dx. Bilateral
renal enlargement:
polycystic
kidney dx, bilateral hydronephrosis, amyliodosis, tuberous
sclerosis, von Hippel Lindau disease.
<LI> 
MITRAL
REGURGITATION
(13) pulse regular, JVP not raised, no ankle/sacral oedem unless
cardiac failure, thrusting apex suggestng volume overload in 6 ICS,
ant axilliary lne, possible systolic thrill, left parasternal heave,
Soft S1, S3 suggests severe MR. Loud pansystolic murmur at apex
radiates to axilla. MR with pulm bp. Causes:
degenerative, rheumatic heart dx, severe LV dilatation, MV prolapse,
papillairy muscle dysfunction, previous valvotomy for mitral
stenosis, infective endocarditis, annular calcification,
hypertrophic cardiomyopathy, chodrae rupture, congenital (marfans,
erhler danlos, pseudxanthoma elasticum), endocardial fibrosis.
Indications
surgry:
SOBOE despite ACEI,/diuretics, increased end systolic volume (>
30 ml/m2), serial echo progressive LV dilatation, valvuloplasty +/-
annuloplasty preferable due to dec mort/no anticoagulation.
Mitral
vave prolapse:
post leaflet LSE, ant eaflet over spine.
<LI> 
SPLENOMEGALLY
(13) mass left hypochondrium, cnnot get above it, there is a notch.
It moves diagonally cross abdomen, percussion is dull over left
lower chest and mass. I think this is a spleen enlarged at..cm.
Causes:
v.large:
CML (Ph chr t9;22), myelofibrosis, makaria/kala arar. Large
(4-8cm):myeloproliferaive
(CML, myelofibrosis), lymphoproliferative (lymphoma, CLL), cirrhosis
with portal hypertension. Small
(2-4 cm):
myeloproliferative, lymphoproliferative, cirrhosis with portal
hypertension, infections (EBV, hepatitis,SBE)
<LI> 
NEUROFIBROMATOSIS
(13) multiple (5+) neurofibromas, sessile pedunculated fibromata
some soft others firm, some single others lobulated, some mobile
subcutaneously lumps others nodules along peripheral nerves, cafe au
lait spots,
2/3 axilliary freckling, Lisch nodules=iris harmatomas,
retinal harmatomas, rib nochiing, mental retardation, epilepsy,
renal art stenosis. complications:
kyphoscoliosis, pressure effect (acoustic neuromas CN5-8, cerebellar
signs), CN5 neuroma, spinal nerve root, sarcomatous change, lung
cysts (honeycomb lung), pseudoarthrosis, plexiform neuroma.
Can
also have:
glioma, meningioma, medulloblastoma. Genetics:
aut dominant , NFT1=von Ricklenhausen (chr 17), NFT2 (chr 22)
bilateral acoustic neuroma
<LI> 
BRONCHIECTASIS
(12) underweight, cyanosed, sob, finger clubbing, frequent
productive cough, sputum pot, inspiratory ? heard with unaided
ear, localised crepitations, may be widespread ronchi.. causes:
childhood infections (whooping cough, measels, TB), cystic fibrosis,
bronchial obstruction (foreign body, carcinoma, sarcoid,
lymphadenopathy and fibrosis), hypogammaglobulibemiam, allergic
bronchpulmonary aspergillosis, Marfans,
yellow nail, congenital
(defomity, Kartageners) , smoking related copd (common)
<LI> 
PSORIASIS
(12) (11) Asymetrical arthropathy involving mainly TIP, pitting of
fingernails, onycholysis, some nail plates thickened, hypetkeratosis
under them.Patches of psoriasis over bony prominemces particularly
elbows, knees, trunk, scalp, intragluteal cleft, behind ears, in
navel. Plaques circular, well difined edges, red, silvery scaly
surface. Other
arthropathy:
arthritis mutilans, Rheumatoid-like, oligo/mono artthropathy,
ank
spond
treatment
local
sunlight, uv light, coal tar, dithranol, local steroids,
calipotriol, PUVA (psoralen and uv light). Treatment
systemic:
acitretin (retinoid), antimetabolites (sulphasalazine, methotrexate,
azathioprine, hydroxyurea). Analgesic anti inflam for arthropathy,
intraarticular steroids. Chloroquin contraindicated worsens skin.
Incidence
5% Caucasian, NW europe, USA. Uncommon in Japanese, N American
Indians, Japanese.
<LI> 
OSLER
WEBER RENDU
(11) (heridatary haemmorhagic telangectasias) Telangectasias on
face, around mouth, on lips, tongue, buccal and nasal mucosa and
fingers. Anemia but no features of systemic sclerosis
.complications:
GI haemorhhage, epistaxis, hemoptysis 2ry to pulm AV aneurysms,
conjunctival telagactesias (bloody tears), retinal
detachment/haemorrhage, cirrhosis (telangectasias/transfusion),
massive intrahepatic shunting Treatment:
chronic oral Fe therapy, oestrogens to induce squamous metaplasia of
nasal mucosa, low dose finbrinolytic agents (aminocaproic acid),
pulse dye laser NOT cautery. Genetics:
Autosomal dominant, several gene defects possible.. non contractile
capillaries cause prologed bleeding.

<LI> 
PLEURAL
EFFUSION
(10) Pulse regular, JVP normal, trachea usually central,expansion
normal, percussion stony dull at R/L base, diminished TVF, VR and
diminished breath sounds. May be bronchial breathing over effusion.
Causes
Exudate
(>30 g/l,
LDH >200) bronchial carcinoma, secondary
malignancy, PE with infarction, pneumonia, TB, mesothelioma,
rheumatoid arthritis, SLE, lymphoma. Transudate (<30 g/l) cardiac
failure, nephrotic syndrome, cirrhosis. Other
causes of dullness at lung bases raised
hemidiaphragm, basal collapse, collapse/consolidation totally
occluding distal airways, pleural thickening. (TB, asbestos,
empeyema) Pleural
bx:
Abram's needle for tb/malignancy place in normal saline.
Thoracoscopy for either diagnosis and pleurodesis
<LI> 
PERIPHERAL
NEUROPATHY
(9) impaired light touch, vibration, joint position and pinprick in
a stocking +/- glove distribution. causes:
DM, carcinomatous neuropathy, vitB12 def, vit B def (alcoholics,
poor nutrition, dialysis), drugs (isoniazid, vincristine,
nitrofurantoin, gold, ethanbutol, phenytoin, hydralazine,
metronidazole, amiodarone, chloramphenicol, cyclosporin),
idiopathic, leprosy, other (guillin barre, PAN, amyloidosis, AIDS),
rare (myxoedema, acromegaly, sarcoidosis, uremia, Lyme dx, tetanus,
botulism, paraprotein, hereditary ataxia, Refsum's dx, arsenic
posoning, POEM syndrome) Motor
causes:
carcinomatous, lead, porphyria, diptheria, Charcot Marrie Tooth.
<LI> 
MIXED
AORTIC VALVE DISEASE
(9) Predominant
AS
Regular slow rising pulse (possibly bisferens). JVP not elevated.
Apex palpable 1 cm left of MCL, forcefull sustained heave (pressure
overload). Systolic thrill apex, aortic area and carotid. Harsh
ejection systolic murmur aortic area radiating to neck, soft A2,
early diastolic murmur LSE loudest on leaning forward, in
inspiration. BP low with low pulse pressure. Predominant
AR
regular pulse, large volume and collapsing (possibly bisferens). JVP
not raised. Apex in ant ax line 6ICS
thrusting (volume overload).
Harsh systolic murmur aortic area radiating to neck, early diastolic
murmur LSE loudest on leaning forward, in inspiration. BP.
Management:
Cardiac cath is gold standard, gradient on echo is unreliable in
severe AR. Best treatment AV repair, surgery indicated
for stenotic
symptoms, lv compromise in regurgitation. Ex testing can be used
except for severe AS.

<LI> 
MIXED
MITRAL VALVE DISEASE
(9) Predominant
MS
malar flush, left thoracotomy scar. Pulse irregularly irregular, JVP
not raised. Tapping Apex, not displaced. Left parasternal heave.
Loud S1, pansystolic murmur radiating axilla, loud P2, opening snap,
mid dialstolic rumbling localised to apex. Predominant
MR with pulm hypertension
left thoracotomy scar, pulse irregular. Apex thrusting (volume
pverload), apex 6 IC ant ax line, soft S1loud pansystolic murmur LSE
and or apex. Loud P3, in left lateral posn mid diastolic low rumble
followed by opening snap.
Management:
Cardiac catheter study gold standard.
<LI> 
TRANSPLANTED
KIDNEY
(9) Usually
assoc APKD. Fullness in flanks, swelling under scar RIF. Bilateral
flank masses bimanually ballotable (or 1 mass and 1 nephrectomy
scar). Palpable rounded mass under the scar in RIF feels like
kidney. Diseases
leading to transplantation:
DM nephropathy, hypertensive renal dx, glomerulonephritis.
Difficult
to transplant:
HUS (recurrence possible, esp if on cyclosporin), sickle cell
(increased crisis), systemic sclerosis (chornic vasular/gi
problems), focal glomerulosclerosis (recurrence in graft common),
oxalosis (severe recurrence of stone dx), cystinosis and Farby's dx
(continued dx activity). 5,
10 yr outcome:
HLA identicle living (88, 73), other living (74, 56), HLA matched
cadaver (70, 56).
<LI> GRAVES
DISEASE
(9) M:5F,
hyperthyroid
graves usually
female, thin, sweaty palms, fine tremor of outstretched hands,
tachycardia, fidgety and nervous, small diffuse
goitre with bruit,
exophalmos (?chemosis, opthalmoplegia, lateral tasoraphy), lid lag.
Euthyroid
Graves:
exopthalmos,
thyroid acropachy, pretibial myxoedema, pulse regular with normal
rate, palms not sweaty, no hand tremor, no lid lag. Previous
thyroidectomy scar.
Hypothyroid
Graves:
exopthalmos,
goitre, thyroidectomy scar, pretibial myxoedema, thyroid acropachy,
hypothyroid facies, hoarse voice, slow pulse, slowly reacting
reflexes.. It is likely that she has hyperthyroidism treated in the
past (?thyroidectomy or radioactive iodine) now on inadequate
throxine replacement alternatively Graves occasionally develops
autoimmune hypthyroidism. Ask
some questions:
heat
intolerence, weight loss, increased apetite, diarhhoea, exertional
dyspnoea, fatiguability, can't keep still,
irritability, nervousness, menstrual symptoms., other
signs:
fever, systolic hypertension, vasodilation, flow murmur, proximal
myopathy, hyperactive reflexes, childhood choreoathetosis, fine thin
hair with temporal recession, onycholysis (Plummer's nails esp
4th
finger), palmer erythema, spider naevi, minimal hepatosplenomegally,
axillary lymph nodes, osteoperosis, regardless of thyroid statud
pulse may be regular or irregular. Graves can occur without eye
signs and in elderly males. Graves
exopthalmos due
to retrorbital fat, enlarged intraorbital muscles, lymphocytic
infiltration inc water and mucopolysacharide. Can develop without
hyperthyroidism , course not linked to thyroid status. Pretib
mxyoedema
develops usually after hyperthyroidosm treated esp with radioiodine.
Investigations:
thyrotrophin receptor Abs, even radioiodine uptake with exception
of nodules,
new bone formation (acropachy) on xray = soap bubbles,
coarse spicules cf
HPOA(=linear new bone formation). Organ
specific autoimmune dx
thyroid, pernicious anemia, atrophic gastritis, DM, Addisons,
hypoparathyroidism, premature ovarian failure, renal tubular
acidosis, fibrosing alveolitis, chronic active hepatitis, primary
biliary cirrhosis. Female propenderence assoc premature hair
greying, alopecia areata, vitiligo. Autoimmune
thyroiditis also assoc
with Sjorgens, myasthenia gravis, systemic sclerosis, mixed conn
tissue dx, cranial arteritis, polymyalgia rheumatica. Autoimmune
thyroid dx's:
Grave's, Hashimotos thyroiditis, atrophic myxoedema, usually FH of
other 2. all 3 fall under hashitoxicosis.
<LI> RHEUMATOID
LUNG
(8) possibly cyanosis and dyspnoea. Fine inspiratory crackles aka
crepitations on auscultation both bases. In view of rheumatoid
changes in the hands the likely diagnosis is fibrosing alveolitis
associated wirg rheumatoid disease. Comments:
Develops overtly in 2% RA, subclinical in 50%, poor prognosis,
progessing to honeycomb CXR, bronchiectasis, chronic cough,
progressive dyspnoea. PFT reduced diffusion capacity and compliance,
restrictive pattern. Gold can induce same interstitial lung dx but
reverses on discontinuing drug. Pulm
Rheumatoid dx:
pleural
disease
(exudate, Rh F +ve, low glucose, WCC <5), intrapulmonary
nodules
(can become infected/cavitate/haemoptysis/rupture ->
pneumothorax, massive confluent nodules in assoc with
pneumoconiosis=Caplan syndrome), obliterative bronchiolitis
(classucally dyspnoea, high pitched wheeze=squawk, hyperinflation),
pulmonary arteritis, apical fibrobulous dx.
<LI> MIXED
MITRAL AND AORTIC DISEASE
(8) If 1 murmur found LOOK FOR 2ND MURMUR e.g .Mixed
aortic and mitral valve disease
Left
thoracotomy scar, malar flush, pulse irregularly irregular, slow
rising, jvp not elevated, apex is heaving/lifting, etc in the abt ax
line, parasternal heave, systolic thrill at apex, aortic area and
neck. S1 loud, harsh ejection systolic murmuraortic area radiating
to neck, pansystolic murmur LLSE radiating to apex and axilla, early
diastoli mumur just audible in aortic area and down LSE with patient
sitting forward in expiration and opening snap followed by mid
diastolic rumbing murmur localised to apex. Which
lesion is dominant?
Slow rising pulse suggests AS is the dominant aortic valve lesion,
it is not possible to determine major mitral valve lesion. Further
investigation with echo leading to TOE +/- cardiac catheterisation
with LV angiography would be required to assess heamodynamic
signifance of each lesion.
<LI> MYOTONIC
DYSTROPHY
(8) Myopathic facies (drooping mouth, long lean, lifeless, sad,
sleepy expression), male frontal balding, ptosis (may be
unilateral), wasting of
facial muscles (temporalis, masseter,
sternomastoid, shoulder girdle, quadreiceps. When making a fist
unable to open it quickly especially repeatively. Worsen in cold and
excitement, difficulty opening eyes after firm closure. When shaking
hands difficulty releasing grip (feature of myotonia).
dimples/depressions induced by percussion fill slowly (percussion
myotonia of tongue/thenar eminence). Genetics:
Aut dom, expanded trinucleotine repeats Chr 19 myotonin protein
kinas gene, shows anticipation (ancestors presenile cateracts),
diagnosis by genetic test, M>F. Other
features:
cardiomyopathy, intellect/personality deterioration, slurred speech
combined with tongue/pharyngeal myotonia, testicula atrophy,
diabetes mellitus (end organ unresponsiveness to insulin).
myotonia
congenita (Rhomsens's dx)
myotonia without other features of dyotonic dystrophy. Normal
refkexes, possible Herculean appearance ?involuntary isometric
exercise. Aut dom/recessive ion channelopathies.
<LI> CHRONIC
OBSTRUCTIVE PULMONARY DISEASE
(8)
Emphysema
thin man pink puffer appearance, nicotine staining of
fingers. Tachypnoeic at rest, lip pursing, prolonged expiration,
suprasternal notch to cricoid distance reduced suggesting
hyperinflation (normally >3 finger breaths). Chest hyperinflated,
expansion mainly verticle, tracheal tug. Accessory muscles
respiration, indrawing of lower ribs on inspiration
due to
flattened diaphragm. Percussion hypersonant obliterating cardiac and
hepatic dullness, breath sounds quiet in classical emphyema, wheezes
are often heard if associated bronchial dx. SOMETIMES decreased
breath sounds over the upper/middle/lower zoneof R/L lung raises
possibility of emphysematous bulla. Chronic
Bronchitis
male smoker, foggy city, dust/fumes, frequent respiratory infection,
classical blue bloater. Nicotine staining, stocky,
centrally cyanosed, suffused conjuntivae. Hyperinflated ches
evidenced by use of accessory muscles on inspiration and tracheal
tug, pulse 80 bpm, venous pressure not elevated (ankle oedema,
hepatomegally if cor pulmanal present), trachea central,
suprasternal notch to cricoid distance reduced. Expansion equal but
reduced to 2 cm, percussion note resonant, auscultation: expiratory
phase prolonged, widespread expiratory ronchi (and may be coarse
crepitations). Forced expiratory time 8 seconds, no flapping tremor
(unless severe hypercapnoea in which case fundi
papilloedema). Possibly cor pulmanale if ankle oedema.
Definitions:
Emphysema = pathological diagnosis, chronic bronchitis = cough
productive of sputum on 3 months of the year in 2 consequtive years.
COPD = obstructive spirometry. Causes
of empysema:
smoking (assoc with chronic bronchitis mixed centrilobular and
panacinar), alpha1atitrypsin deficiency (young, lower zone,
panacinar ?iceterus, hepatomegally), coal dust (centrilobular
emphysema simple coal dust pneumoconiosis only minor
abnormalities of gas exchange), Macloed's syndrome (Swyer-James rare
unilateral emphysema following childhood bronchiolitis and
subsequent impaired alveolar growth.
<LI> CARCINOMA
BRONCHUS
(0,8) LOOK FOR RADIOTHERAPY TATOES
Carcinoma
bronchus with pleural effusion:
Clubbing, nicotine staining, hard lymph node in R/L supraclaviculare
fossa, pulse regular, JVP not elevated, trachea central, chest
expansion normal, persussion stony dull at R/L base, tactile
fremitus, vocal resonance and breath sounds all diminished over area
of dullness. Carcinoma
of bronchus with radiation therapy:
cachectic, radiation burn R/L upper chest, clubbing, noctine
staining, pulse regular, JVP nor elevated, no lymph nodes. Trachea
deviated to R/L, expansion diminished R/L upper chest, TVF and
resonance increased over upper chest, dull percussion note, area of
bronchial breathing. Likely radiotherapy for carcinoma bronchus
causing collapse and consolidation of /L upper lung. Pancoast's
syndrome:
radiation burn to chest, lymph nodes palpable in R/L axilla, trachea
central, chest signs normal, wasting of small muscles of R/L hand,
sensory loss +/- pain over T1 dermatome (can be C8-T2), R/L Horner's
syndrome (ptosis, myosis, anhydrosis, enopthalmos). This is
pancoast's syndrome due to apical carcinoma involving the lower
brachial plexus and cervical sympathetic nerves.
Lobectomy:
R/L thoracotomy scar, trachea deviated R/L/ R/L chest expansion
diminished, percussion resonant, breath sounds harsher. R/L
lobectomy for removal of tumour, resistant lung abscess or localised
bronchiectasis. Complications
:
local
effects:
SVC obstruction (?oeema face/upper extremities, suffusion eyes,
fixed engorgement of neck veins, dilataio superficial veins),
stridor (SVC obstruction, dysphagia). Metastases
and their effects (pain,
?hepatomegally, neurological signs). Non
metastatic effects:
HPOA wrists/ankles, peripheral neuropathy, cerebellar degeneration,
encephalopathy, priximal myopathy, polymyosistis, dermatomyositis,
Eaton Lambert syndrome), SIADH, ectopic ACTH, PTH,PTHrP, carcinoid),
gynaecomastia (?HCG secreting tumour?), thrombophlebitia migrans,
non bacterual thrombotic endocarditis, anemia (usually normoblastic,
occasionally leucoerythroblastic), pruritis, Herpes zoster,
acanthosis nigricans, arythema gyratum repens (irregular wavy bands
with marginal desquamation on trunk, neck and extremities).
<LI> HYPERTENSIVE
RETINOPATHY
(0, 8) Narrow retinal arterioles (normal AV ratio 1:1), may be
tortuous, varying calibre, increased light reflex (copper/silver
wiring), AV nipping (all occur in aging, arteriosclerosis,
hypertension). Flame haemmorhages and blot haemorrhage , cotton wool
exudates (this constitutes grade 3 retinopathy and a diagnosis of
malignant (accelerated) hypertension even without papilloedema),
there is papilloedema (cerebral oedema or malignant hypertension
haemorrhages and exudates not necessary). This is grade 4
retinopathy. Causes
of hypertension: essential
(94%), renal (4% - ?RAS, acute nephritis, PKD), endocrine 1%
(cushing's, conn's, phaechromocytoma, acromegaly, hyperPTH,
hypothyroidism, OCP), miscellaneous <1% (caorctation,
polycythemia, acute porphyria, pre-eclampsia). cerebral
tumour or raised ICP
from any cause can cause 2ry hypertension (Cushing's reflex). If
phaeochromocytoma
screen for MEN2 and von Hippel-Lindau in patient
AND families.
<LI> AORTIC
STENOSIS
(7) Aortic
stenosis:
Pulse regular, small volume and slow rising, JVP not raised (unless
cardiac failure), apex 1cm left of MCL 5ICS (i.e. Apex Normal or
Slightly displaced unless cardiac failure) with forcefull sustained
heave (pressure overload). Sysolic thrill aortic area, carotids +/-
apices. Harsh ejection systolic murmur aortic area radiating to
neck., soft A2 (or absent). Associated ejection click if valve
bicuspid). Blood pressure low normal with decreased pulse pressure. 
Murmur
quietens as dx progresse/cardiac failure. Look careflully for MS as
both conditions obscure eachother. (MS missed AS severity
unerestimated) need echo. Aortic
sclerosis:

normal pulse, apex undiplaced, barely palpable, no thrills, ejection
systolic murmur not harsh or loud, only radiates faintly to neck. A2
normal +/- ejection click. This is aortic sclerosis (assoc with 50%
inc death CVS risk, no significant gradient on echo).
Causes:
1. Rheumatic heart disease (often associated mitral valve dx or
aortic regurg), 2. Bicuspid aortic valve (M 60's), 3. Degenerative
calicification (in elderly, stenosis usually mild), 4. Congenital
(worsen during childhood and adolescence due to calification).
Indications
for surgery:
symptoms, pressure gradient 50-60 mmHg lower if EF low, may need
simultaneous CABG, , consider valvotomy in young. Beta blockers as
temporising measure. Av block in calcific aortic stenosis/post
aortic valve operation/pacemaker insertion..Other
causes of short systolic murmur:
prolapsed mitral valve, trivial MR, hypertrophic cardiomyopathy.
<LI> OCCULAR
PALSY
(3, 7)
6th
nerve palsy:
convjivergent strabismus, impairment lateral movement R/L eye,
diplopia worse on looking R/L. (outermost image comes from affected
eye). Causes
mononeuritis
multiplex, demyleinating dx,
raised ICP false localising sign due
to long course, neoplasm (assoc ipsilateral facial palsy if pontine
tumour, myasthenia gravis, vascular lesions, compression by aneurysm
(ectatic basilar artery uncommon), subacute meningitis
(carcinomatous, lymphomatous, fungal (AIDS), TB, meningovascular
syphilis)
3rd
nerve palsy.:
ptosis, lifting lids reveals divergent strabismus, dilated pupil,
eye fixed in down and out position (and there is angulated
dipliopia. This is complete (NB often partial) causes
unruptured
aneurysm of Post comm art (or int carotid) artery painful,
mononeuritis multiplex, vascular lesion (contralateral hemiplegia =
Webers synddrome, opthalmoplegia predominant=vascular if
ptosis/pupil changes prominent extriinsic compression), 4. midbrain
demyelinating lesion (intranuclear opthalmoplegia commoner),
myasthenia gravis, other (sabacute meningitis, opthalmoplegic
migraine, paraseller neoplasm, sphenoidal wing meningioma,
carcinomatous lesions skull base)
nerve palsy adducted
eye cannoot look downwards causing one above the other
diplopia, angulated diplopia on looking down and out, worse on
reading or going down stairs, SKEW deviation (sometimes also seen in
brainstem lesions). Cavernous
sinus (Sup orb fiss)
total
or subtotal opthalmoplegia often painful, sensory loss in CN5i
(absent corneal reflex) due to tumor compressing 3, 4, 5, 6 as
travel from cavernous sinus to SOF. Causes
of Mononeuritis multiplex:
DM, PAN, Churg Strauss, Rheumatoid, SLE, Wegeners, sarcoidosis,
carcinoma, amyloidosis, leprosy, Sjorgens, Lyme dx). Other
causes ocular palsy1. intranuclear opthalmoplegia
(abduction
impaired bilaterally, normal adduction or vice versa, no strabismus,
ataxic nystagmus distguishes from bilat CN6 palsy), 2.
Exopthalmic
opthalmoplegia (upward and outward gaze most often reduced), 3.
Myasthenia gravis (?ptosis, variable strabismus, facial weakness,
snarling smile, proximal muscle weakness, weak nasal voice, WORSENS
ON REPITITION, FATIGUABILITY test eye movements wuth eyes held 1
position between movements, count to 50 may superficially
resemble 3rd
of 6th
nerve palsy.,4. Cavernous sunus syndrome, 5. 4th
n palsy, 6. Ocular myopathy
<LI> MITRAL
STENOSIS (7)
Malar flush, left thoracotomy scar, irregularly irregular pulse in
rate and volume OR sinus
rythm small volume pulse. JVP not raised,
no ankle or sacral oedema (unless in heart failure). Tapping cardiac
impulse (S1), apex indisplaced, left parasternal heave, loud S1,
loud P2, opening snap, mid-diastolic low rumbling murmur (with
presystolic accentuation if NSR), localised to the apex heard
loudest in left lateral position, diagnosis is mitrak stenosis with
previous valvotomy. There are signs of pulmonary hypertension.
Opening snap: nearer S2 = tighter stenosis, absent=calcified mitral
valve, s1 will be soft) Other
signs:
giant v waves (tricuspid incompitence), Graham Steele murmur (rare
2ry pulmary incompetence. Brief high pitched early diastolic whiff).
Indications
for surgery/ valvuloplasty:symptoms
limiting normal activity, pulmonary iedena without cause, recurrent
emboli (anticoagulate most MS's even if sinus rhythm), pulm oedema
in pregnancy (emergency valvotomy), deterioration due to AF
unresponsive to med rx), haemoptysis. valvotomy
criteria:
mobile valve: louds S1, opening snap absence of calcium in submitral
apparatus on TOE, absence of MR. Esp in young female desiring later
pregnancy.
MS accentuated by exercise.
<LI> GOITRE
(7)
1) multinodlar
goitre:
multinodular goitre, R/L lobe more enlrged cf L/R. No lymph nodes,
no retrosternal extension, no bruit, clinically euthyroid (check
pulse, palms, tremor lid lag, tendon reflexes). Diagnosis in middle
aged/elderlyy patient is likely to be simple multinodular goitre
which
is due to relative
iodine deficiency in suscetible person. Multinodular suggests
longstanding. If no recent change asymptomatic observe 6-12 months
otherwise FNAC.. Diffuse
goitre
firm, diffusely enlarged goitre, without retrosternal extension
(check for bruit, feel pulse to assess thyroid status)
Causes
of diffuse goitre:
1. simple goitre (euthyroid, no bruit, relative iodine deficiency,
esp females ?puberty, pregnancy), 2. treated Grave's dx
(?exopthalmos +/- bruit, eu or hypothyroid), 3. hyperthyroid Graves
(?bruit, tachycardia, exopthalmos, tremor, sweating, 3. Hashimito's
dx (usually micronodular, symetrical, ?hypthyroid facies,
bradycardia, jerks, 4. de Quervain's viral throiditis (tender,
contitutional upset, absent radioiodine uptake , inc T4, supressed
TSH), 5. goitrogens (e.g. Lithium, iodine xs, phenylbutazoned,
para-aminosalysilic acid), 6. dyshormonogenesis (6 congenital enzyme
defects all rare) solitary
thyroid nodule
check for lymphadenopathy. Causes
solitary nodule:
1. palpable nodule in multinodular goitre, 2. thyroid adenoma
(variable radioiodine uptake), 3. toxic adenoma (hot nodule, tacy,
sweaty palms, lid lag), 4. thyroid cysts, 5. thyroid carcinoma
(?hard, lymph nodes, recent change, cold on scan). check TFT's,
FNAC, radioiodine scan (cold = possible malignancy), possible
subtotal lobectomy. thyroid
carcinoma:
1. papilliary carcinoma (commonest, children/middle aged. Regional
lymph node spread, often resectable, good prognosis, often TSH
dependent so responds to thyroxine. 2. follicular carconimoa
(2nd
commonest, later life, blood borne mets, rx surgery, supressive
thyroxine, fair prognosis, take up/respond to radioiodine therapy.
3. anaplastic carcinoma (elderly, highly malignant), 4. medullary ca
(rare, young adults, secretes calcitonin, sometimes ACTH, usually
good prognosis), 5. usually previous Hashimoto's, large rapidly
expanding mass. MEN2a
(sipple's)
med ca thyroid, phaeochromocytoma, parathyroid hyperlasia (50%)
MEN
2b(aka
3)
med ca thyroid , phaeochromocyto,a, nuro abnormalties (mucosal
neuromas, marfanoid, pigmentation, proximal myopathy, megacolon,
intestinal ganglioneuromatosis. Both aut dom, RET oncogene, genetic
screening prophylactic thyroidectomy or annual calcitonin
check, urine catecholamines, serum calcium)
<LI> DIABETIC
FOOT/CHARCOT JOINT
(7) Diabetic
foot 
ulcer on sole R/L foot (most commonly under head of 1st metatarsal),
2 toes previously amputated. Thick callous over pressure points of
feet, normal concavity of transverse arch at head of metatarsals is
lost. Loss of sensation to light touch, vibration and pinprick in
glove and stocking distribution. Feet cold, foot pulses not
palpable, loss of hair lower legs which are shiny. Peripheral
neuropathy, neuropathic ulcer, evidence periph vasc dx, it is likely
underlying
diabetes (?fundi). Charcot
joint:
relevent above plus ankle joint greatly deformed and swollen, loud
crepitus accompanying movement which is of abnormal range.
Charcot
joint (neuropathic arthropathy gross osteoarthrosis and new
bone formation from repeated minor trauma without normal protective
pain response causing
painless joint destruction). Contributing
factors to DM foot:
injury, neuropathy (calluses), small vessel dx, large vessel dx
(ischemia, gangrene), inc susceptibility to infection,
maldistributed pressure and foot deformity. causes
of neuropathic ulcers:
tabes dorsalis, leprosy, porphyria, amyloidosis,
progressive
sensory neuropathy
(familial, cryptogenic), rare late manifestation
of Charcot-Marie-Tooth dx Causes
of Charcot joint:
DM, tabes dorsalis, syringomyelia, leprosy (worldwide), other (yaws,
progressive sensory neuropathy, hereditory neuropathy,
neurofibromatosis)
<LI> OLD
TUBERCULOSIS
(6) Thoracoplasty:
Trachea
deviated R/L. R/L upper chest shows deformity with decreased
expansion, dull percussion note. Bronchial breathing and
crepitations. Apex beat may be displaced to R/L. Thoracotomy scar
posteriorly with evidence of rib resections. This patient has
had
R/L thoracoplasty for Rx of TB in pre-chemotherapy era.
Apical
TB
trachea deviated R/L. Diminished expansion, crackles at R/L apex
suggesting R/L apical fibrosis. Old TB is
likely cause. Phrenic
crush:
Expansion diminished on R/L, dullness, reduced/absent breath sounds
at R/L base. R/L supraclavicular scar (+/- crepitations). Patient
has had phrenic crush for TB before the days of chemotherapy.
<LI> HEMIPLEGIA
(6) R/L UMN facial weakness, R/L arm and leg weak (without wasting),
increased tone, hyperreflexia. R/L plantar is extensor, abdominal
reflex diminisghed on R/L side. This is R/L hemiplegia. May be also
R/L hemisensory loss, visual field testing may reveal R/L homonymous
hemianopia. causes:-CVA
(thrombosis, haemorrhage
- check bp, embolism AF, murmurs,
bruits), Brain tomour (?insidious onset, papiklloedema, headache,
?evidence of 1ry e.g. Clubbing). posterior
circulation
nystagmus, ocular palsy, dysphagia, cerebellar signs. Parietal
lobe signs:
agnosia (inattention) e.g. tactile (astereognosis=cant recognise by
feel),
visual, auditory (only recognises voice if can see/touch),
autotopognosia (parts of own body), apraxia (cannot execute despite
normal power/coord) e.g. dressing apraxia (usually r
parietooccipital|), gait apraxia, trunk, facial movements.( Corpus
collosum, parietal, premotor) Constructional apraxia (hepatic
encephalopathy), dyslexia (reading), dysgraphia (writing),
dyscalculia (calculating) post parietal lobe.
<LI> CEREBELLAR
SYNDROME
(6) unilateral
cerebellar lesion:
Nystagmus to R/L, ataxia with eyes open evidenced by rapid
alternating movements (dysdiadokinesia). Finger-nose test impaired
on R/L.with past-pointing, intention tremor (increased on
approaching target), heel-shin tetst impaired on R/L, gait ataxic
with tendency to fall R/L. Ataxic dysarthria with explosive staccato
speech. Patient has a R/L cerebellar lesion. Other cerebellar sugns:
ipsilateral hypotonia, reduced power, pedular jerks, skew deviation
eyes, pendular arm drift rebound. Cerebellar
vermis lesion:
widebased cerebellar ataxia and robergism same eyes open and closed
(cf sensory ataxia which is wirse eyes closed). Little or no
abnormality in limbs when tested on bed. Causes:
1. mutiple sclerosis (?internuclear opthalmoplegia, optic neuritis,
atrophy, etc), 2. brainstem vascular lesion, 3. posterior fossa SOL
(papilloedema e.g. tumor, abscess e.g. 2Ry to otitis media), 4.
paraneoplastic cerebellar syndrome (clubbing, cachexia, 5. alcoholic
cerebellar degeneration (nutritional), Freidrich's ataxia
(?scoliosis, pes cavus, pyrimadal and dorsal colum signs, absent
ankle jerks). Other causes of cerebellar ataxia: hypothyroidism
(?facies, pulse, reflexes), anticonvulsant toxicity (esp phenytoin
nystagmus), ataxia telangactasia (recessive progressive ataxia,
choreoathetosis, ocular apraxia, telangectasia conjunctivae, face,
skin, low IgA infections, lymphoreticular malignancy).
<LI> TOPHACEOUS
GOUT (6)
Asymetrical swelling small joints of hands and feet, tophi formation
in perarticular tissues. Occasional severe deformity. Tophi on helix
of ear and some of the tendon sheaths (esp ulnar surface forearm,
olecranon bursa, achiles tendon and pressure points).
treatment:
avoid aspirin causes uric acid retention unless v high doses. Rx
1st
line NSAIDs (except if CRF, GI ulcer, severe heart failure),
colchicine (SE: nausea, diarrhoea, abdo pain), 2nd
line: intrarticular/systemic steroids. Allopurinol or uricosuric
(probenecid, sulphinpyrazone) drugs started 2-3 weeks after acute
episode (otherwise prolong acute attack, trigger further episides).
Indictations
for prophylaxis
if: recurrent, tophi, chronic arthritis, renal dx, young with
hyperuricemia FH renal/heart dx, normo-uricaemia
not achieved by
lifestyle i.e. wt loss, decease alcohol, food and high
purines). Significance
of tophi Tophus
proportional severity and duration. Paradoxically tophi indicate dec
frequency, severity cf non tophacouus. Large tophi may have area of
necrosis exuding pasty/chalky monosodium urate crystals. Sinuses
possible.Complications:
renal dx, carpal tunnel syndrome. Associations:
obesity, hyperlipidemia, hypertension these cause an association
with DM and IHD.causes
of 2ry uricemia:
drugs (esp thiazides, also ethanbutol, nicotinic acid, cyclosporin),
myeloproliferative and lymphoproliferative disorders (cell tunover
preformed purines), chronic renal failure, alcoholism, obesity.
<LI> RASH
OF UNCERTAIN CAUSE (6)
Rash
description routine.
Visual survey, distribution, surrounding skin (scratch marks,
radiotherapy field marks, paper thin skin). Adequate exposure.
Monomorphic or pleomorphic. 6 features. 1. colour (erythema,
pigment), 2. size, 3. shape (oval, circular, annulaar), 4. surface
(scaling or eroded), 5. character (papule,
macule, vesicle, etc),
6. secondary features (lichenification, crusting, etc).
Discussion:
DD, how you would differentiate, mention drug hx. Emolients, abx for
infection. Consider biopsy.
Dermatology terms:
macule=flat
curcumscribed, not raised, papule=raised, circumscribed, <1cm,
nodule=larger papules, weals=circumscibed elevations itchy, tingly,
vesicles=small well defined fluid collections (bullae=large
vesicles), scales, crusts , scars, pustules (contain puss),

 
ulcers
have: shape, edge, floor, base and secretion.
<LI> HYPOTHYROIDISM
(6)
myxoedema
Overweight, myxoedematous facies (thickened and coarse facial
features, periorbital puffiness and pallor). Skin rough, dry and
inelastic with distinct yellowish tint (carotenemia), generalised
non pitting swelling subcutaneous tissues, hoarse voice, croaking,
hard of hearing, slow movements, thinning of hair which is dry and
brittle, may be loss of outer third of eyebrow (not reliable). Slow
pulse (give rate), no palpable goitre, relaxation of ankle jerks
(and other reflexes) is delayed and slow. Patient has
myxoedema
(look for assoc autoimmune dx). Other symptoms: CNS disorders:
peripheral neuropathy, cerebellar ataxia, pseudodementia, drop
attacks, epipepsy. myxoedema=accumulation hyaluronic acid binding
water in dermis Hasimoto's
thyroiditis.
as above + symmetrical firm, fine micornodular goitre, likely
diagnosis is Hasimotos thyroiditis (assoc autoimmine dx).
Hypothyroid
Grave's dx
as above + exopthalmos, patient likely to have Grave's dx treated
with radioiodine or thyroidectomy (scar) and is now hypthyroid
(occasionally Grave's sponteously progresses to hypothroidism).
ask
patient some questions:
deafness and hoarse voice, cold intolerence, tiredness and
depression, constipation (occasionally presents to surgeons), angina
unmasked once rx started, menhorhagia (middle aged), 1ry/2ry
amennorhea (younger).
Other
feature:
anemia (normochromic Fe deficient due to atrophic gastritis,
magaloblastic pernicious anemia, mild form in siimple
hypothyroidism), carpal tunnel, preipheral cyanosis (+/- malar
flush), Raynaud's phenomenon, hypertension, accident prone,
hypothermia, Hoffman's syndrome (pain, ache, swellin muscles after
exertion and myotonia), pychosis (myxoedema madness), hypothyroid
coma. Assoc
autoimmune dx:
pernicious anemia (?spleen, SACDC), Addisons dx (?buccal + scar
pigmentation), vitiligo, Rheumatoid arthritis (?hands, nodules),
Sjorgens (?dry eyes and mouth), ulcerative colitis, idiopathoc
(presumed autoimmune ?CAH with icterus etc), SLE (?rash), haemolytic
anemia, diabetes mellitus (?fundi), Grave's dx, hypoparathyroidism,
premature ovarian failure. Comments:
should check B12, fasting sugar. Autoimmune thyroiditis presents as
case 1 or 2.
<LI> OPTIC
ATROPHY (6)
Disc pale, clearly delineated, pupil reacts consensually to light
but not directly. Field testing with head of hat pin reveals central
scotoma. Well defined disc edge suggests not 2ry to papilloedema
(yellow grey disc blurred margins). V early optic neruritis direct
pupil reflex sluggish not absent check Marcus Gunn
phenomenon (diret reflex, then rapidly alternate pupil and will
slowly dilate). Causes:
1. mutiple sclerosis (temporal pallor only ?nystagmus, scanning
speech, cerebellar ataxia, etc), 2. compression of optic nerve by a)
tumour (pituitry ?bitemporal heminaopsia)) b) aneurysm. 3. Glaucoma
(?pathological cupping), 4. Optic atrophy in DM assoc with DID-MOAD
(Diabetes insipidus, DM, deafness rare recessive inheritence), 5.
Other causes:
ischemic optic atrophy (abrupt visual loss in elderly
+/- pain; thrombosis or embolus of post ciliary art; temporal
arteritis), Lebers optic atrophy (6M:1F), retinal artery occlusion,
toxic ambylopia (lead, methyl alcohol, arsenic, insecticides,
quinine), nutritional ambylopia (famine, etc, tobacco-alcohol
ambylopia, B12 deficiency, DM), Freidrichs ataxia, tabes dorsalis,
Pagets dx , consecutive optic atrophy (2ry to ganglion cell
destruction)
<LI> AORTIC
REGURGITATION (5)
Regular pulse, large volume, collapsing in character. JVP not
raised, vigourous arterial pulsations in neck (Corrigan's sign),
apex thrusting (volume overload) in ant axilliary line, 6 ICS, high
pitched early diastolic murmur audible down LSE and aortic area,
louder on expiration, sitting forward. Wide pulse pressure e.g.
250-300/30-50). Look for cause: high arched palate, aryl robertson
pupils, arthropathy/ank spond, if none then Rheumatic/IE likely.
Other
signs:
de Mussett sign (head nods), Quinkes signs (visible cap pulsation),
Duroziez's sign (fem art auscultated
when compressed distally,
diastolic murmur = retrograde flow). Austin flint murmur=severe
aortic incompetence (regurgitant jet interefes with mitral valve).
Causes:
Rheumatic fever, Infective endocarditis, longstanding hypertension
(aortic dilatation, aneurysm), Marfans syndrome (tall extermities,
arachnodactyly, high arched pakate), Ank spond (male, fixed
kyphosis, question mark), Rheumatoid arthritis, coarctation of aorta
(inn assoc with biscupid aortic valve),
associated with
mermemranous VSD, syphilitic aortitis (argyll robertson pupils, asc
aortic anerysm), Hurlers syndrome.
Indication surgery:
aim to replace valve before serious LV dysfunction occurs. Serial
echoes, radionuclear angiography, mild/moderate dx: ACEinhibitors,
calcium antagonists decrease rate of deterioration. Replace valve
urgently for infective endocarditis.
<LI> HEPATOMEGALLY
(5) Liver palpable at x cm below right costal margin (?icterus,
ascites, signs of cirrhosis esp gynaecomastia, pigmentation, lymph
nodes). Common
causes:
cirrhosis usually alcohol (?spide naevi, gynaecomastia,
etc.), secondary carcinoma (?hard nobly, cachexia, evidence of
primary), congestive cardiac failure (?raised JVP, ankle oedema,
S3/murmur, tender pulsatille liver wiith giant v waves in tricuspid
incompetence) Causes
of hard, nobbly hepatomegally
Malignancy 1ry or 2ry, polycstic kidneydx (?kidneys?),
macronodular cirrhosis (after hep B with widespread necrosis),
hydatid cysts (eosinophylia, rupture -> anaphylaxis), syphilitic
gummas (late benign syphilis usually hepatosplenomeggaly and anemia,
rapid response to penicillin). Other
causes of
hepatomegally:
infection (hep A/B, glandular fever, Weils dx), primary tumours
(hepatoma, adenoma), lymphoproliferative (?lymph nodes), PBC
(?middle aged female, scratch marks, xanthelasma), haemochromatosis
(male, slate grey), sarcoidosis (?erythema nodosum, lupus pernio,
chest signs), amyloidosis (?rheumatoid artritis or other chronic
dx), hydatid cyst (?welsh connection Nb patients name),
amoebic abscess (?tropical connection ?name ?appeaance), budd chiari
syndrome (?icterus, ascites, tenser hepatomegally), Reidels lobe,
emphysema (apparent hepatomegally).
<LI> CHARCOT
MARIE TOOTH DISEASE
(5) Distal wasting of lower limbs, relatively preserved thighs. Pes
cavus, clawing of toes, weakness of extensors of toes and feet.
Ankle jerks are absent, plantars no response. Only slight distal
sensory sensoty loss, lateral popliteal ?and ulnar nerves palpable
(in some families only), steppage gait due to bilateral foot drop.
May be wasting of small muscles of hand.
Commentry:
Variable inheritance. deformity>>disability. Rarely: Talipes
eqionovarus, toe retraction, fasciculation. Mainly motor nerves,
also dorsal roots/columns, pyramidal tracts slightly effected.
Condition becomes arrested in midlife. FH: formes fruste (minor
changes e,g, pes cavus, absent ankle jerks only). Inverted champagne
botle legs is more neuromythology.There is slow progression up the
limbs.
<LI> MOTOR
NEURONE DISEASE
(5) Weakness, wasting, fasciculation of hand, arms, shoulder, but
upper
limb reflexes are exagerated (Progressive muscular atrophy
minimal pyramidal signs can be inc, dec, absent). There is upper
motor neurone spastic weakness with exagerated reflexes in the legs.
(amyptrophic lateral sclerosis). Ankle clonus, bilateral extensor
plantars, may have indistinct nasal speech, fasciculating tongue and
palatal paralysis (progressive bulbar palsy). There are no sensory
signs. Other
causes of fasciculations:
cervical spondylosis, syringomyelia (dissoc sensory loss), Charcot
Marie Tooth (champagne bottles, pes cavus, palpable nerves), acute
stages of poliomyelitis rarely in old polio, neuralgic amyotrophy
(eg. Following viral infection), thyrotoxic myopathy, syphilitic
amyotrophy, chronic symetrical spinal muscular atrophy, after
exercise in fit adults, benign giant fasciculations. DD
of MND:
cervical cord compression (Cx MRI), syphilitic myopathy,
occasionally old polio, spinal muscular atrophy juvenile onset type
3 (Kugelberg Welander dx) survival motor neurone gene defect.
<LI> ULNAR
PALSY
(5) Generalised muscle wasting of hands (dorsal guttering, loss
hypothenar eminence), weakness sparing the t

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