Post on 24-Nov-2015
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This is a list of 70 most common cases in PACES
DIABETICRETINOPATHY(41) microaneurysms, blot haemorrhages,
hard exudates (Background),circinates of hard exudate near macula,
poor acuity (Macularoedema), cotton wool spots, flame haemmorhages,
leashes of newvessels, photocoagulation scars(proliferative),
vitreoushaemorrhage/scars, retinal detachment (advanced diabetic
eye dx).may be bp, cateract. indicationsfor referral:all
except background, refer background involving
macula.indicationsfor photocoagulation:pre-proliferative
(cotton wool spots, multiple blots, venousbeeding) or proliferative
retinopathy.
RHEUMATOIDARTHRITIS (31)symetricaldeforming arthropathy,
spindling of fingers. PIP, MCP swelling, DIPspared, muscle wasting,
deformity, pain. nodules at elbow/dorsumhand, ulnar deviation, nail
fold infarcts, arteric lesions. warmthand swelling sugests active
inflam. swan neck, boutonniredeformity, Z thumb, palmer erythema,
anaemia, episcleritis, CVS/RESPsigns. causesof
anaemia:chronic dx, nsaids, myelosupressive drugs, feltys,
assoc perniciousanemia. 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 withcalcium,
bisphophanates), biological agents.
EXOPTHALMOS(26)(protrusionof eye revealing sclera above
lower lid on forward gaze). bilateralasymetrical swelling of medial
caruncle, congestion of lateralcanthus, and exopthalmos. look for
pretibial myxoedema, thyoidacropachy. gravesmalignant
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 (Hertelexopthalmometer)
Treatment:lubricant eye drops, avoid smoking, wrap around
glasses, optimizethyroid status. radioiodine may worsen
exopthalmos.
ACROMEGALLY(24) prominent supraobital ridges, large lower
jaw, exageratedwrinkles, full lips, malocclusion/prognathism,
interdental spaces,nose/tongue/ears enlarged, kyphosis, large
doughy spade hands, thickskin, carpal tunnel syndrome, excesive
sweating, 1/3 hersuit, husky,cavernous voice, bitemporal
hemianopia. Others: shoe/hat size, bowedlegs, 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, isletcell, parathyroid, adrenal), urolithiasis,
hyperTG, diabetesinsipidus, hypopituitrism. Inv:IGF1, GTT
absent GH supression, MRI pituitry, visual fields, oldphotos, 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), somatostatinanalogues (shink).
cause:99%pit adenoma, 1% gangliocytoma
CHRONICLIVER 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.causesalcohol, viral hepatitis,
autoimmune CAH, haemochromtosis,cryptogenic. other: cardiac
failure, constrictive pericarditis, BuddChiari, 2ry billiary
cirrhsis, drugs (methotrexate, mehydopa,isoniazid, CCl4,
amiodarone, aspirin, phenytoin, propylthiouracil,sulphonamides),
Wilsons dx, alpha1antitrypsin def, metabolic(galactosemia,
tyrosinemia, glycogenosis4)
FIBROSINGALVEOLITIS(21) sob, clubbing, steroid purpura,
reduced symetrical expansion,fine inspiratory crackles (+/-
cyanosis, dullnes lung base, LTOT)causescryptogenic,
rheumatoid, conn tissue disorders (systemic sclerosis,SLE,
polymyositis, dermatomyositis, Sjorgens), ankylosingspondylitis,
extrinsic allergic alveolitis, asbestosis, silicosis,drugs
(bleomycin,buslphan, nitrofurantoin, amiodarone),
radiationfibrosis, chemicals (Berylium, mercury), poisons
(paraquet), ARDS.
PROSTHETICVALVES(17) Mitralvalve prosthesismidline
sternotomy, S1 prosthetic click, diastolic opening click +/-mid
diastolic flow murmur, pansystolic murmur/failure suggests
leak.Aorticvalve replacementmidline sternotomy, normal S1,
systolic opening click, prosthetic S2+/- systolic flow murmur,
early diastolic murmur/collapsing pulsesuggests leak
Complictionsthromboemolism, haemorhage, endocarditis, valve
leak, dehiscence,Starr-Edwards ball embolus, valve obstruction
(thrombus/fibrosis),haemolysis.
HEPATOSPLENOMEGALLY(17) spleen enlarged..cm below costal
margin. Liver palpable ... cmbelow right costal margin. Check for
anemia, lymphadenopathy,chronic liver disease and renal
enlargement. Causes:myeloproliferative,lymphoproliferative (CLL,
lymphoma), livercirrhosis with portal hyperension, infections
(hepB/C, EBV, CMV),zoonoses (brucella,weils, toxplasma),
megaloblastic anemia, storgedx (gauchers, glycogen storage),
amyloidosis, sarcoidosis,buddchiari=hep vein thrombosis, infantile
PKD. worldwide causes:malaria, kala azar, schistosomiasis, TB.Bruit
suggests hepatoma.
PNEUMONECTOMY(16) chest wall deformity, with flattened L
side associated ith Lthoracotomy scar, L tracheal deviation, L
expansion reduced,percussion dull, breath sounds diminished.
Bronchial breathing Lupper zone due to tracheal deviation.
Llower lobctomydeformity chest, L lower ribs pulled in, L
thoracotomy scar, tracheacentral, apex displaced L, percussion dull
L lower zone, breathsounds diminished. Indicationsfor
pnumonectomy25% non small cell ca (2-6% mort), solitary pulm
nodule of uncertaincause, treatment unresponsive bronchiectasis, TB
in preantibioicera.
RETINITISPIGMENTOSA(16) widespread scattering of black
pigment resembling bonespicules, the macula spared. There is tunnel
vision and nightblindness. Associaions: cateracts, deaf mutism,
mental deficiency.Othercauses of pigmentary
degenerationLaurence Moon Biedl, Refsums dx, hereditary ataxia,
familialnuropathy, neuronal lipidoses (ceroid
lipofuscinosis).
SYSTEMICSCLEROSIS(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.
othersystems:CREST, renal (bp, failure), CVS
(cardiomyopathy, effusion), muscle(myositis, arthritis), intestinal
hypermotility, PBC. Treatment:general (education, exercise,
lubricants), Raynauds (calcium chblockers, 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).
POLYCYSTICKIDNEY DISEASE(14) bilateral flank masses,
bilaterally ballotable, can get abovethem, percussion resonant,
abdominal scarsfrom CAPD/cystaspiration,AV fistula,uremic facies,
hypertension, renaltransplant, parathyroidectomy.
Complications:flank pain, bleeding, uti, nephrolithiasis,
obstrucive uropathy.Otherfeatures:berry aneurysm, mitral
valve prolapse, renal cell carcinoma.Genetics:PKD1 (Ch16,
85%, renal failure), PKD2 (Chr4, 15%), PKD3 rare.
Livercysts:rare in adult AD-PKD, common ininfantile AR-PKD.
Screening:U/S and genetic testing at 20 years (inconclusive
before 20),earlier if FH aneurysm, signs renal dx.
Bilateralrenal enlargement:polycystickidney dx, bilateral
hydronephrosis, amyliodosis, tuberoussclerosis, von Hippel Lindau
disease.
MITRALREGURGITATION(13) pulse regular, JVP not raised, no
ankle/sacral oedem unlesscardiac 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 apexradiates to axilla. MR with pulm bp.
Causes:degenerative, rheumatic heart dx, severe LV
dilatation, MV prolapse,papillairy muscle dysfunction, previous
valvotomy for mitralstenosis, infective endocarditis, annular
calcification,hypertrophic cardiomyopathy, chodrae rupture,
congenital (marfans,erhler danlos, pseudxanthoma elasticum),
endocardial fibrosis.Indicationssurgry: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.
Mitralvave prolapse:post leaflet LSE, ant eaflet over
spine.
SPLENOMEGALLY(13) mass left hypochondrium, cnnot get above
it, there is a notch.It moves diagonally cross abdomen, percussion
is dull over leftlower 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), cirrhosiswith portal
hypertension. Small(2-4 cm):myeloproliferative,
lymphoproliferative, cirrhosis with portalhypertension, infections
(EBV, hepatitis,SBE)
NEUROFIBROMATOSIS(13) multiple (5+) neurofibromas, sessile
pedunculated fibromatasome soft others firm, some single others
lobulated, some mobilesubcutaneously lumps others nodules along
peripheral nerves, cafe aulait 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, cerebellarsigns), CN5 neuroma, spinal nerve root,
sarcomatous change, lungcysts (honeycomb lung), pseudoarthrosis,
plexiform neuroma.Canalso have:glioma, meningioma,
medulloblastoma. Genetics:aut dominant , NFT1=von
Ricklenhausen (chr 17), NFT2 (chr 22)bilateral acoustic
neuroma
BRONCHIECTASIS(12) underweight, cyanosed, sob, finger
clubbing, frequentproductive cough, sputum pot, inspiratory ? heard
with unaidedear, 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,
allergicbronchpulmonary aspergillosis, Marfans,yellow nail,
congenital(defomity, Kartageners) , smoking related copd
(common)
PSORIASIS(12) (11) Asymetrical arthropathy involving mainly
TIP, pitting offingernails, onycholysis, some nail plates
thickened, hypetkeratosisunder them.Patches of psoriasis over bony
prominemces particularlyelbows, knees, trunk, scalp, intragluteal
cleft, behind ears, innavel. Plaques circular, well difined edges,
red, silvery scalysurface. Otherarthropathy:arthritis
mutilans, Rheumatoid-like, oligo/mono
artthropathy,ankspondtreatmentlocalsunlight, uv light, coal
tar, dithranol, local steroids,calipotriol, PUVA (psoralen and uv
light). Treatmentsystemic:acitretin (retinoid),
antimetabolites (sulphasalazine, methotrexate,azathioprine,
hydroxyurea). Analgesic anti inflam for arthropathy,intraarticular
steroids. Chloroquin contraindicated worsens
skin.Incidence5% Caucasian, NW europe, USA. Uncommon in
Japanese, N AmericanIndians, Japanese.
OSLERWEBER RENDU(11) (heridatary haemmorhagic
telangectasias) Telangectasias onface, around mouth, on lips,
tongue, buccal and nasal mucosa andfingers. Anemia but no features
of systemic sclerosis.complications:GI haemorhhage,
epistaxis, hemoptysis 2ry to pulm AV aneurysms,conjunctival
telagactesias (bloody tears), retinaldetachment/haemorrhage,
cirrhosis (telangectasias/transfusion),massive intrahepatic
shunting Treatment:chronic oral Fe therapy, oestrogens to
induce squamous metaplasia ofnasal mucosa, low dose finbrinolytic
agents (aminocaproic acid),pulse dye laser NOT cautery.
Genetics:Autosomal dominant, several gene defects possible..
non contractilecapillaries cause prologed bleeding.
PLEURALEFFUSION(10) Pulse regular, JVP normal, trachea
usually central,expansionnormal, percussion stony dull at R/L base,
diminished TVF, VR anddiminished breath sounds. May be bronchial
breathing over effusion.CausesExudate(>30 g/l,LDH
>200) bronchial carcinoma, secondarymalignancy, PE with
infarction, pneumonia, TB, mesothelioma,rheumatoid arthritis, SLE,
lymphoma. Transudate (3 finger breaths). Chest
hyperinflated,expansion mainly verticle, tracheal tug. Accessory
musclesrespiration, indrawing of lower ribs on inspirationdue
toflattened diaphragm. Percussion hypersonant obliterating cardiac
andhepatic dullness, breath sounds quiet in classical emphyema,
wheezesare often heard if associated bronchial dx. SOMETIMES
decreasedbreath sounds over the upper/middle/lower zoneof R/L lung
raisespossibility of emphysematous bulla.
ChronicBronchitismale smoker, foggy city, dust/fumes,
frequent respiratory infection,classical blue bloater. Nicotine
staining, stocky,centrally cyanosed, suffused conjuntivae.
Hyperinflated chesevidenced by use of accessory muscles on
inspiration and trachealtug, pulse 80 bpm, venous pressure not
elevated (ankle oedema,hepatomegally if cor pulmanal present),
trachea central,suprasternal notch to cricoid distance reduced.
Expansion equal butreduced to 2 cm, percussion note resonant,
auscultation: expiratoryphase prolonged, widespread expiratory
ronchi (and may be coarsecrepitations). 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 = coughproductive of sputum on 3 months of the year in 2
consequtive years.COPD = obstructive spirometry. Causesof
empysema:smoking (assoc with chronic bronchitis mixed
centrilobular andpanacinar), alpha1atitrypsin deficiency (young,
lower zone,panacinar ?iceterus, hepatomegally), coal dust
(centrilobularemphysema simple coal dust pneumoconiosis only
minorabnormalities of gas exchange), Macloed's syndrome
(Swyer-James rareunilateral emphysema following childhood
bronchiolitis andsubsequent impaired alveolar growth.
CARCINOMABRONCHUS(0,8) LOOK FOR RADIOTHERAPY
TATOESCarcinomabronchus with pleural effusion:Clubbing,
nicotine staining, hard lymph node in R/L supraclavicularefossa,
pulse regular, JVP not elevated, trachea central, chestexpansion
normal, persussion stony dull at R/L base, tactilefremitus, vocal
resonance and breath sounds all diminished over areaof dullness.
Carcinomaof bronchus with radiation
therapy:cachectic, radiation burn R/L upper chest,
clubbing, noctinestaining, pulse regular, JVP nor elevated, no
lymph nodes. Tracheadeviated to R/L, expansion diminished R/L upper
chest, TVF andresonance increased over upper chest, dull percussion
note, area ofbronchial breathing. Likely radiotherapy for carcinoma
bronchuscausing collapse and consolidation of /L upper lung.
Pancoast'ssyndrome:radiation burn to chest, lymph nodes
palpable in R/L axilla, tracheacentral, chest signs normal, wasting
of small muscles of R/L hand,sensory loss +/- pain over T1
dermatome (can be C8-T2), R/L Horner'ssyndrome (ptosis, myosis,
anhydrosis, enopthalmos). This ispancoast's syndrome due to apical
carcinoma involving the lowerbrachial plexus and cervical
sympathetic nerves. Lobectomy:R/L thoracotomy scar, trachea
deviated R/L/ R/L chest expansiondiminished, percussion resonant,
breath sounds harsher. R/Llobectomy for removal of tumour,
resistant lung abscess or localisedbronchiectasis.
Complications:localeffects:SVC obstruction
(?oeema face/upper extremities, suffusion eyes,fixed engorgement of
neck veins, dilataio superficial veins),stridor (SVC obstruction,
dysphagia). Metastasesand their effects
(pain,?hepatomegally, neurological signs). Nonmetastatic
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 bandswith marginal desquamation on trunk,
neck and extremities).
HYPERTENSIVERETINOPATHY(0, 8) Narrow retinal arterioles
(normal AV ratio 1:1), may betortuous, varying calibre, increased
light reflex (copper/silverwiring), AV nipping (all occur in aging,
arteriosclerosis,hypertension). Flame haemmorhages and blot
haemorrhage , cotton woolexudates (this constitutes grade 3
retinopathy and a diagnosis ofmalignant (accelerated) hypertension
even without papilloedema),there is papilloedema (cerebral oedema
or malignant hypertension haemorrhages and exudates not necessary).
This is grade 4retinopathy. Causesof hypertension:
essential(94%), renal (4% - ?RAS, acute nephritis, PKD),
endocrine 1%(cushing's, conn's, phaechromocytoma, acromegaly,
hyperPTH,hypothyroidism, OCP), miscellaneous