SLIDESHOW PRACTICE
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
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
A 52 year old diabetic man presented to A and E feeling sick. 1 week
previously his GP had treated him for reflux
• Describe immediate management
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
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
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?
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
Commonest causes of acute LVF?
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•
•
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•
•
Post MI
myocardial ischaemia
Malignant hypertension
aortic stenosis or aortic incompetence
mitral incompetence
arrythmia
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
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?
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)
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?
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
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
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.
What is this?
• What causes
it?
• What other
signs would
you look for?
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!!!
This patient presented with weight
loss and this crazy skin condition…
• What is it?
• Clue: say what
you see
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 )
This patient presented with weight loss,
a palpable liver.
• What is this
skin condition
and with what
condition is it
associated?
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
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?
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
• What is this
sign?
• Name 4
causes of
this
condition
Grey turners
• Acute pancreatitis
•
•
•
•
•
•
•
•
•
•
Gallstones
Ethanol
Trauma
Steroids
Mumps
Autoimmune (PAN)
Scorpion
Hyperlipidaemia
ERCP
Drugs (azathiporine, mercaptourine, diuretics?
What is this?
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.
What is this? What else would you look for? What
investigations would you do? What treatment
would you start?
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
What is this? What is it associated
with?
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
Another example
What is this? With what conditions
is it associated?
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
What is this and with what
condition is it associated?
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.
What are these lesions? With what
are they associated?
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
What is this? What are the
common causes?
urticaria
•
•
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•
•
•
•
•
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•
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!!!
A 32 year old man presents with unilateral leg swelling.
What is your differential diagnosis? How would you
investigate and manage this problem?
Diff diagnosis of unilateral leg
swelling
•
•
•
•
•
Deep vein thrombosis
Cellulitis
Ruptured Baker’s cyst
Lymphoedema
Fracture
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
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
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
Differential diagnosis of SJ
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•
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•
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
USS of legs. Describe what this
shows
• Which is
normal?
• A or B?
• Management
?
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
Jimmy has just enjoyed a snickers bar… he now looks like
this…
• What is happening
to poor jimmy?
• Describe your
immediate
management
ANAPHYLAXIS
•
•
•
AIRWAY
100% 02
IV adrenaline 1:1000 solution
0.5mL (500mcg) IM
•
Repeat in 5 minutes if no clinical improvement
•
IV access and fluids (colloid if hypotensive)
•
Antihistamine H1-antagonist (chlorphenamine) 10-20 mg IM/slow IV
•
Hydrocortisone 100-500mg IM/slow IV (if severe/recurrent/in asthmatics)
•
If bronchospasm does not subside treat as asthma – salbutamol nebs
(adjunctive measure)
Young female presents with weight loss, polyuria and these
leg lesions…what is this and what condition is it associated
with?
Necrobiosis lipoidica
• This is a dermatological condition that is associated with diabetes
mellitus in 50% of cases. It occurs in women three times more
frequently than in men, usually in young adults or in early adult life.
• Necrobiosis lipoidica usually affects the skin on the lateral and
anterior surfaces of the lower legs
• The epidermis is smooth or slightly scaly and atrophic. Delicate
vessels may be observed through the surface. Long standing
lesions may show ulceration, fibrosis and scarring.
• if non-ulcerated necrobiosis lipoidica - topical corticosteroids
• if ulcerated NL then there may be response to immunomodulating
drugs such as cyclosporin and mycophenolate mofetil
What is this? With what is it
associated?
Granuloma annulare
• Granuloma annulare is a condition which
presents with skin lesions that consist of
asymptomatic dermal nodules. In children,
they are usually on the fingers or toes.
This condition is harmless but resolution
may take many months.
• In the adult, this condition is sometimes
associated with diabetes.
What is being tested here?
What else would you look for in your examination?
How would you investigate and treat?
Dehydration
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reduced tissue turgor
thirst
dry mucous membranes
sunken eyes
Prolonged capillary refil
tachycardia
dark urine
hypotension (late sign in young- preterminal)
low urine output (<600 ml/day or 30 ml/hr)
Investigating and treating
dehydration
•
fluid loss without water replacement - for example, an unconscious patient
with fluid lost from diarrhoea, burns, vomiting, sweat, respiration
•
diabetes insipidus
•
osmotic diuresis - for DKA
•
Conn's syndrome - hypokalaemic alkalosis
•
Cushing's syndrome
•
incorrect intravenous fluid replacement
•
some patients with hyperosmolar non-ketoacidotic diabetic coma; this
condition may also cause hyponatraemia
•
hypothalamic dysfunction
Management of severe
hypovolaemia
•
•
•
Lie patient flat and raise feet to restore BP
IV access - Two large cannulae - brown venflons
Give colloid/crytalloid (no evidence either is better)
•
Insert CVP line/arterial line (more accurate assessment of BP)
•
•
Catheterise and monitor urine output.
Monitor Bp, lying and standing, JVP, chest… Pulmonary OEDEMA
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•
•
•
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Take blood for group and save, crossmatch.
fluid should be run in as fast as possible;
patient's response monitored.
If the patient remains shocked, group specific or O Negative blood should be given as
cross-matching may take up to 45 minutes. If the patient still fails to improve, internal
bleeding should be sought.
Following stabilisation, fluid infusion may be moderated according to urine production.
•
Give blood to maintain Hb>8g/dl
Hypovolaemia
• Haemorrhage – aortic dissection, leaking AAA,
splenic rupture
• Fluid loss - Diarrhoea, vomiting, polyuria,burns
• 3rd space losses- acute pancreatitis, ascites
• Adrenal failure
What is this x ray showing?
• what condition is
this person likely to
have?
• What are the
complications of
this condition?
arachnodactyly
•
MARFAN’S SYNDROME (AD) – diff diagnosis homocystinuria -disorder of methionine metabolism
•
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OCULAR
upward lens dislocation
retinal detachment
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SKELETAL and MUSCLES
arachnodactyly
tall with disproportionately long legs and arms - the span of the arms is greater than the height
pectus excavatum
spinal abnormalities - spondylolisthesis, scoliosis
SUFE
generalised joint laxity with predisposition to flat feet or dislocation of patella or shoulder
•
•
•
•
CARDIOVASCULAR
dilatation of the aorta may
aortic regurg, mitral regurg
dissecting aneurysm of the aorta
•
Mental development is normal. The average lifespan of an affected individual is 40 to 50 years.
What is this and with what
conditions is it associated?
Dupuytrens contracture
• Liver disease
• Epilepsy/ treatment with phenobarbitone or phenytoin
•
•
•
•
•
•
•
Peyronie's disease - penile fibrosis
Family history
trauma
myxoedema
diabetes mellitus
hypercholesterolaemia
AIDS
What is this called?
• What
conditions is it
associated
with??
Alopecia areata
• localised, round bald patches developing
suddenly over one or two weeks, without any
preceding symptoms. At the edge of the patch,
there may be small, broken hairs with a tapering
shaft - 'exclamation mark' hairs.
• autoimmune phenomenon
• Asssociations: thyroid disorders, vitiligo,
diabetes.
A diabetic patient developed this
eruption…what is it?
These are small rounded plaques with raised borders lying in a
linear fashion over the shins. In late diabetic dermopathy these
may present as pigmented scars.
Diabetic dermopathy
• These are small rounded plaques with
raised borders lying in a linear fashion
over the shins. In late diabetic dermopathy
these may present as pigmented scars.
What is wrong
with these chaps?
Peyronie’s disease
• the penis becomes curved due to
asymmetrical fibrosis in the fascia
surrounding the corpora cavernosa.
Curvature towards the affected side is
increased during an erection making
intercourse difficult and painful
• Assoc with dupuytrens contracture and
premature atherosclerosis
• What is wrong with
this chap?
Winged scapula
• Long thoracic nerve injury
• The long thoracic nerve supplies the serratus
anterior muscle. It may be injured as a result of
pressure on the shoulder, either from a sudden
blow or by prolonged carrying of heavy objects.
It is often one of the nerves affected in brachial
neuritis and may also be damaged in diabetes
mellitus. Winging of the scapula results.
Henoch schonlein
• Henoch-Schonlein purpura is a condition characterized
by a widespread necrotizing vasculitis of arterioles and
small capillaries.
• children aged 3 to 8 years are affected, boys more than
girls,
• Abdo pain, arthritis (large joints) and glomerulonephritis
• 70% have haematuria and proteinuria, but the
glomerulonephritis is often asymptomatic, conferring a
good prognosis.
• The disease is usually self limiting.
• Bed rest and simple analgesics may be prescribed
for arthropathy
What is this? What aggravates this
condition? How do you treat?
psoriasis
• Made worse by stress, alcohol, b-blockers, infection
• Better in sunlight
• Tx emolients, dithranol, Vitamin D analogues, coal tar,
keratolytics
• PUVA
• Methotrexate, cyclosporin
• Infliximab, Etanercept
erythrodermic psoriasis
• Life threatening complication of psoriasis
• Plaques cover over 90% of the body
surface.
• Problems with thermoregulation,
septicaemia, dehydration and high output
cardiac failure may occur.
This middle aged man is very
unwell and has lost weight
• He developed these
slowly evolving itchy
lesions
• What is the
diagnosis?
Mycosis fungoides
• Mycosis fungoides is a non-Hodgkin's lymphoma that arises from
CD4+ T lymphocytes.
• It is a cutaneous lymphoma that characteristically affects middle
aged males. It usually begins as an eczematous reaction and
proceeds to form plaques, tumours and fungating ulcers.
Erythroderma may occur which often is highly pruritic.
• Treatment - topical steroids, topical cytotoxic agents, PUVA or
radiotherapy.
• Prognosis relates to extent and type of skin involvement - average
survival in the early stage of this disease is at least 10-15 years (2)
What has this young chap
developed?
Eczema herpeticum
• widespread HSV infection superimposed on pre-existing
(often mild) atopic eczema.
• Widespread vesicles and erosions, fever, and malaise
occur.
• treat with intravenous and topical acyclyovir
• broad spectrum antibiotics are added in to treat or
prevent superinfection.
• It is necessary to scrupulously care for the skin and
carefully monitor fluid and electrolyte balance.
• Prophylactic oral aciclovir is indicated for recurrent
disease.
Eczema herpeticum again
What has this 72 year old man
developed? What would you advise?
Chronic venous insufficiency
• Wear thick socks
• Avoid bruising
• Raise legs up as often as possible
• Compression bandaging for ulcer
• Tx dermatitis, infection
What is this?
• What are the
main
complications?
Neurofibromatosis (2 types)
• von Recklinhausen's disease, peripheral or type I
neurofibromatosis (AD)
• bilateral acoustic neurofibromatosis, central or type II
neurofibromatosis
• Café au lait spots commonly seen
• COMPLICATIONS:
– Nerve entrapment
– Peripheral nerve tumours
– neuropathy
What is this?
pemphigoid
•
•
autoimmune blistering disorder
characterized by large, tense, intradermal (subepidermal) blisters on an
erythematous base. BLISTERS REMAIN INTACT. If in eyes- blindness
•
Elderly affected, Women > men.
•
it is more common than pemphigus
•
treatments that aim to suppress the inflammatory process, e.g.
corticosteroids, antibiotics (e.g. tetracyclines, sulphones)
•
other immunosuppressive treatments aim to suppress the production of the
pathogenic antibodies, e.g. high-dose corticosteroids e.g. prednisolone 3060 mg per day, azathioprine, methotrexate, cyclophosphamide and
cyclosporin
What is this?
PEMPHIGUS
• blisters within the epidermis of both skin
and mucous membranes.
• autoimmune basis?
• Peak onset is between 60 and 70 years of
age. W>M
• In comparison, bullous pemphigoid is
characterised by blister formation at the
level of the basement membrane and not
within the epidermis.
Long standing asymptomatic lump.
What is the likely diagnosis?
Lipoma
• Treatment is for cosmesis and consists of local
excision.
• Some individuals have multiple subcutaneous
lipomata; a biopsy may be required to exclude
neurofibromatosis in such patients.
• The patient with multiple, tender lipomata may
have Dercum's disease.
• A rare complication of lipomata is a liposarcoma.
What is shown at the arrow?
Ascending lymphangitis
• spreading of infection from its focus along regional
lymphatic vessels. Commonly, an abscess forms at the
regional nodes.
• commonly due to Streptococcus pyogenes; less often, to
Staphylococci. It presents as red blushes and streaks in
the skin corresponding to the inflamed lymphatics.
• Treatment is bed rest with the affected limb elevated.
• Penicillin V and Flucloxacillin
• Permanent lymphatic obstruction may develop resulting
in a persistent oedema. Repeated attacks cause chronic
lymphangitis.
What is this? It started life as a red
macule.
Erythema chronicum migrans
• Caused by Borrelia burgdorferi, Lyme
disease is common in the northeast United
States and in Wisconsin and Minnesota. It
is carried by Ixodes spp. of ticks. The rash
occurs in 2/3 of those infected, with a
solitary lesion characteristic of Stage 1
disease, and multiple lesions characteristic
of disseminated Stage 2 disease
What is this associated with?
Vitiligo is associated with
•
•
•
•
Hypothyroidism
Addison’s disease
diabetes mellitus
pernicious anaemia
• Tx camouflage cream
What does this 72 year old chap
have?
Basal cell carcinoma
• This is a locally invasive carcinoma of the basal layer of the
epidermis. It almost never metastasizes but it may kill by local
invasion.
• sunlight exposure
• the initial lesion is a small pearly-white nodule with visible
(telangiectatic) blood vessels; early lesions may bleed and ulcerate
and then heal again
• a red nodule forms which expands to leave a characteristic rolled
edge with central ulceration ('rodent ulcer')
• Tx: surgery, local radiotherapy, cryotherapy, or curretage
• Think maybe he
should have come to
the doc sooner about
this one
What is this?
Squamous cell carcinoma
• Squamous cell carcinoma (SCC) is a malignant tumour of the
epidermis in which the cells, if differentiated, show keratin formation.
•
•
•
•
•
•
basal cell carcinoma
keratocanthoma
malignant melanoma
solar keratosis
pyogenic granuloma
infected seborrheic wart
• rapidly expanding painless, ulcerated nodule rolled indurated
margin. Often the lesion may have a cauliflower-like appearance
with areas of bleeding, ulceration or serous exudation.
• Metastatic potential – surgery (+radio/chemo if advanced)
What is this? What types exist and what
features are characteristic in this lesion?
Malignant melanoma
•
•
•
•
•
superficial spreading (48%)
nodular (23%)
lentigo maligna (15%)
acral lentiginous including periungual (6%)
amelanotic melanoma
• Change in SHAPE, SIZE, COLOUR
• >5mm diameter, inflammation, bleeding, irritation
• Excision biopsy (1cm margin for every mm thickness)
What is happening in this patients arm?
They previosly had a simple ulcer there
Marjolin’s ulcer (arm)
• cancer
What is this condition?
Peutz Jeghers
•
Peutz-Jegher's syndrome (AD)
•
multiple hamartogenous polyps of the gastrointestinal tract - most often in
the small bowel but may occur affect any portion of the GI tract
mucocutaneous pigmentation - mainly, of the lips, buccal mucosa, genitalia,
hands and feet
•
•
Patients often present with small bowel intussusception before the age of 10
years.
•
The polyps themselves have a very low malignant potential. About 10-20%
of patients develop gastrointestinal carcinoma but this is thought to arise
from coexistent adenomas.
•
Patients have an increased risk of developing carcinomas of the pancreas,
lung, ovary and breast.
What are these lesions?
Lichen planus
• flat-topped
• shiny
• violaceous (pink/mauve/purple)
• typically they are seen on the inner aspects of the
elbows, on the wrists, shins and sacral area and genitals
• Wickhams striae mouth lesion
• This is a condition of unknown aetiology characterized
by intensely pruritic flat topped papules that are usually
seen on the inner aspect of the elbows and wrists. The
mucous membranes are often affected.
What does this chap have? What
complications is it associated with?
Ehlers danlos
• Ehlers-Danlos syndrome (EDS) is a condition
where abnormalities of collagen production
result in bruising, wide scars, laxity of joints and
hyperelasticity of the skin.
•
•
•
•
•
Hernia
MR/AR
Aortic dissection
pneumothoraces
GI bleeds
This 34 year old wool factory worker
presented with this…what is it?
Cutaneous anthrax
• Anthrax sheep wool
What is this?
tylosis
• Tylosis is a congenital hyperkeratosis with
pitting of the palms - tylosis palmaris - and
of the soles - tylosis plantaris. It is
inherited as an autosomal dominant trait.
• In some cases, it is associated with
oesophageal carcinoma.
• Treatment measures include the use of a
keratolytic. Systemic treatment with
retinoids may be used
What is wrong with this chap? How
would you diagnose it?
Kaposis sarcoma
• Kaposi's sarcoma is a multicentric, malignant
neoplastic vascular proliferation, characterised
by the development of bluish-red nodules on the
skin. Sometimes there may be widespread
visceral involvement. It may metastasize to
lymph nodes.
• occurs in immunocompromised patients (e.g.
HIV positive patients, transplant patients)
• Diagnosis: skin biopsy
What is this?
keratoacanthoma
• Difficult to distinguish from SCC
• rapidly growing epidermal tumour that resembles squamous cell
carcinoma both clinically and histologically. It is believed to arise
from hair follicles.
• There is little evidence that keratocanthoma has malignant potential
• Trauma, viral infection, sun exposure, and chronic exposure to tar,
pitch and petroleum have all been implicated as aetiologic agents.
• Surgical excision is thought to produce less scarring than leaving
the lesion to resolve spontaneously.
What are these? What are they
associated with?
Gottrons papules
• Gottron's papules are scaly, erythematous
lesions affecting the dorsum of the hands,
knuckles, and extensor surfaces of other
small joints. They are characteristic of
dermatomyositis.
What does this patient have? With
what is it associated?
Heliotrope rash
• Polymyositis and dermatomyositis are systemic connective tissue
diseases which are characterised by acute and chronic inflammation
of striated muscle.
• In dermatomyositis there is an accompanying dermatitis. The limb
girdle or proximal muscles are most severely affected but their bulk
is preserved beyond that expected from their weakness: this is an
important sign distinguishing this condition from a limb girdle
dystrophy.
• The aetiology is unknown but there is an association with HLA-B8
and HLA-DR3.
• Dermatomyositis in males over the age of 60 years may be
suggestive of an underlying systemic malignancy.
This 33 year old woman presented with fever, tachycardia,
chills, malaise and this hot tender lesion on her face. What
is it? What is tx?
erysipelas
•
Erysipelas is a rapidly spreading Streptococcal infection of the skin and
subcutaneous tissue characterized by cellulitis and lymphangitis.
•
Streptococcus pyogenes
•
•
•
•
•
•
fever, tachycardia, chills, malaise
the infected area is red, hot, and tender e.g. red shiny plaque on face
local oedema which produces a raised border that is clinically diagnostic
the cellulitis spreads rapidly to involve uninfected skin
careful examination may reveal an abrasion through which the
streptococcus organism gained entry
an incision within the infected area exudes a thin pus
•
Tx: amoxicillin
What is wrong with this chap?
What could have caused it?
Left CN III palsy
•
TUMOUR, INFECTION, VASCULITIS, DEMYELINATION SAFE ANSWER FOR ALL
NERVE LESIONS
•
central lesions:
–
tumours:
•
•
–
–
–
•
due to direct invasion of the third nerve nucleus
due to raised intracranial pressure
vascular:
caused by a brainstem lesion
demyelination
peripheral causes include:
–
compressive lesions:
•
•
•
•
•
–
–
tumour
aneurysm, often the posterior communicating artery
basal meningitis
nasopharyngeal carcinoma
orbital lesions e.g. Tolosa-Hunt syndrome
infarction:
often spares the pupillary reflex, when the condition is termed a "medical third nerve palsy"
•
often caused by diabetes mellitus
This xray and CT are showing the
same sign… what is it?
Porcelain gallbladder
• Porcelain gallbladder is a calcification of the
gallbladder believed to be brought on by
excessive gallstones but more studies are
necessary to determine the exact cause.
• Porcelain gallbladder often results in a diagnosis
of gallbladder cancer. The association with the
two is uncertain; gallbladder cancer is rare, but
is almost always found with porcelain
gallbladder. The prognosis is poor, in that the
gallbladder is usually asymptomatic until the
cancer has spread.
A 53-year-old man presented with low-grade fever and abdominal pain.
A tender, erythematous umbilical 3-cm mass is shown.
Strangulated umbilical hernia
• In a strangulated hernia, the blood supply of the
contents of the hernia, e.g. bowel or omentum, is
cut off. It is commonest at the neck of the sac.
The region becomes ischaemic and
subsequently gangrenous. Gangrene can lead
to perforation of the bowel with ensuing
peritonitis.
• When a loop of gut is strangulated, there will
also be intestinal obstruction.
• This 23 year old
woman is
complaining of
rectal pain. She
denies any other
symptoms
• What is this xray
showing?
• Patient presented
with an acute
abdomen with the
sudden onset of
severe upper
abdominal pain,
nausea and
vomiting.
Gallstone pancreatitis
A 50-year-old man presented with a 2-day history of atraumatic right middle
finger swelling, redness, and pain. There was tenderness and swelling of the
proximal interphalangeal joint. ESR was elevated. The leukocyte count normal.
• Describe how you
would investigate
and manage this
patient
Septic arthritis
• URGENT ADMISSION!!!
• ASPIRATE!!!!
•
•
•
•
•
blood cultures
full blood count for leucocytosis
erythrocyte sedimentation rate
C-reactive protein
aspiration of synovial fluid - usually purulent with a neutrophil count
above 50,000 per mm3, and low glucose concentration
• anti-streptolysin O titre
• Tx flucloxacillin and amoxicillin empirically!
A 65-year-old woman presented to the emergency department because a friend
was concerned that the patient was having a stroke. The patient was
asymptomatic other than complaints of a pestering nonproductive cough. What
is wrong?
Subconjuntival haemorrhage
• This presents as a bright red patch under the conjunctiva
following rupture of a small conjunctival vessel.
• It may arise spontaneously, following slight trauma, or as
a result of local congestion due to coughing or sneezing.
• In head injury, blood from a fracture at the base of the
skull may travel through the floor of the orbit and into the
subconjunctival space. The condition is usually
unilateral.
• Recurrent or bilateral subconjunctival haemorrhage
suggests hypertension or blood dyscrasias.
A 28-year-old woman complained of a foreign-body
sensation, pain and redness of the outer lower quadrant of
her left eye of 2-day's duration.
episcleritis
• unilateral in two-thirds of cases.
• It is benign and self-limited.
• 30% are associated with general medical conditions such as
collagen disease, herpes zoster, gout and syphilis.
• There are two types - simple and nodular. Simple episcleritis is
characterized by a very acute onset. It is mild, sectoral, recurrent
and resolves rapidly. The nodular form presents as a localised,
raised mobile area of inflammation near the limbus. The nodules
may be single or multiple and usually recur.
• About 15% of patients develop a mild iritis. Episcleritis is
distinguished from conjunctivitis by the localised response and the
lack of palpebral conjunctival involvement.
• oral non-steroidal anti-inflammatory drug (NSAID).
A 2- year-old girl presented with fever, erythema,
and swelling of the left upper eyelid. There were
no visual symptoms or proptosis.
periorbital cellulitis
• The findings shown are suggestive of acute
periorbital cellulitis, or more accurately, preseptal
cellulitis, an infection confined to the soft tissues
of the eyelid. Bacteriology of preseptal cellulitis
includes those bacteria that cause sinusitis
(Haemophilus influenzae, Streptococcus
pneumoniae, Moraxella catarrhalis, S
pyogenes); skin flora from trauma
(Staphylococcus aureus and group A
Streptococcus); and idiopathic (H influenzae
type B, S pneumoniae). (L.S.)
A 20-year-old man presented with a brief loss of consciousness
following a fall from standing height. He had a brief lucid interval then
became progressively less responsive. This is his CT scan
Extradural haematoma
• The characteristic appearance of a CT of
an extradural haemorrhage is of a
biconvex, lozenge shaped area of
increased density.
• Spread is limited by the adhesion of the
dura to the skull. A midline shift with
compression of the ipsilateral ventricle
may be apparent.
A 25-year-old man was brought to the emergency
department after having been hit in the left lateral chest
with a jet ski. He was short of breath and hypotensive.
Tension pneumothorax
• Should not have obtained an Xray…
emergency situation
A 37-year-old homeless man presented to the emergency
department with a 3-week history of neck pain that had
started after a motor vehicle accident
Subluxation of c1 on c2
• Cervical subluxation is a flexion injury. There is no bony
damage but the soft tissues are extensively damaged
and the posterior ligaments torn. The affected vertebra
hinges forward on the one below, opening up the
interspinous space posteriorly then falls back again.
• Radiologically there may be an increased gap between
the spines of affected vertebra, but the film often
appears normal - flexion radiology may be required to
demonstrate the instability.
• Treatment is usually a collar for six weeks. However, if
there is persistent instability a posterior spinal fusion
may be required.
What is wrong with this girl…be
specific!
Bell’s palsy
• It is a lower motor neurone palsy usually
diagnosed by exclusion. Typically, presentation
is with facial distortion, loss of taste, hyperacusis
and a watery eye.
• Bell's palsy was previously considered as an
idiopthic lower motor neurone nerve palsy but
there has been increasing evidence to suggest
that the main cause of Bell's palsy is latent
herpes viruses (herpes simplex virus type 1 and
herpes zoster virus), which are reactivated from
cranial nerve ganglia
Patient is asked to look left
Right VI nerve palsy
•
•
•
•
•
Tumour
Trauma
Demyelination
Ischaemia (stroke)
Raised intracranial pressure
• FALSE LOCALISING SIGN
Left CN 9 palsy
• Uvula deviates away from the affected
side
Left CN 12 palsy
• Tongue deviates towards side of lesion
• What is wrong with
this lil lady?
Trochlear CN IV palsy
• Diplopia
• abnormal head posture - head tilted towards the normal
side, face rotated towards the normal side, and the chin
is depressed. The affected eye is higher than its fellow.
• positive head tilt test - affected eye moves higher when
the head is tilted towards the affected side
• CNIV is thinnest and has the longest intracranial course
damaged easily by stroke and trauma
What is wrong with these miserable
looking folk?
Myasthenia gravis
• Myasthenia gravis is an acquired autoimmune disorder
characterised by weakness, typically of the periocular, facial, bulbar,
and girdle muscles.
• Associated with serum IgG antibodies to acetylcholine receptors in
the postsynaptic membrane of the neuromuscular junction.
• Classically, the muscles are easily fatigued.
• It affects 5 people in every 100 000.
• Non-thymoma cases have a peak incidence at 10-30 years and
again, at 60-70 years of age; those associated with thymoma have a
peak incidence at 40-50 years of age.
Diff diagnosis
• Lambert-Eaton syndrome - muscles are
not fatiguable - contraction leads to
increased strength - reflexes are
diminished
• congenital myasthenia
• botulism
• motor neurone disease (MND) - note that
eye is very rarely involved in MND
Myasthenia gravis
•
Exacerbated by: exercise, barbituates, steroids
•
improvement in strength after administering a short-acting anticholinesterase drug,
for example, edrophonium chloride.
•
acetylcholine receptor antibodies
•
Management
–
–
–
–
–
oral anticholinesterase medication, e.g. pyridostigmine or neostigmine (symptomatic
improvement).
if there is life-threatening or respiratory weakness developing in treated patients, then this
usually requires immediate control of the airway, treatment of any underlying infection, and a
course of plasma exchange
thymectomy - required if there is a thymoma because of the risk of local infiltration. Also
occasionally undertaken in other non-thymoma patients with myasthenia
immunosuppression with corticosteroids +/- cytotoxic agents is also highly effective in
inducing remission of disease and may be necessary preliminary to surgery in patients with
severe disease.
plasma exchange
Lambert eaton
• Lambert-Eaton myasthenia is a presynaptic
myasthenic syndrome characterised by impaired
release of acetycholine from nerve terminals.
• 60% of patients have small cell lung carcinoma.
• Electromyography shows increased evoked
potentials after repeated galvanic stimulation
(the opposite occurs in myasthenia gravis).
Symptoms improve with exercise
Right sided horners syndrome
• slight ptosis
• pupillary miosis:
– due to paralysis of the sympathetically innervated
Muller's muscle which normally dilates the pupil
• anhydrosis over the forehead
• Pancoasts tumour, carotid body tumour
infection, vasculitis, demyelinating disease MS
What is wrong with this chap? Ignore
the white thing I don’t know what that is
hydrocephalus
• Communicating hydrocephalus
– obstruction to CSF flow from outside the ventricular
system, usually in the subarachnoid space. All the
ventricles show a generalised dilatation on a CT scan.
It is safe to perform a lumbar puncture
• Non-communicating hydrocephalus
– obstruction to CSF flow within the ventricular system.
Fluid accumulates proximal to the site of the blockage
causing dilation.
Management of hydrocephalus
– The cause of hydrocephalus should be eliminated if possible - e.g.
colloid cysts of the 3rd ventricle, intraventricular meningioma, other
obstructive causes.
– Otherwise, relieve pressure by shunting, or if the patient is rapidly
deteriorating, by draining the ventricle directly.
– Endoscopic third ventriculostomy has become a more recent, and
important, treatment option for occlusive hydrocephalus associated with
aqueductal stenosis or space-occupying lesions of or around the
posterior third ventricle and upper brainstem (1,2):
– this procedure appears to be more successful in adults than in young
children
– it is efficacious in both previously shunted and non shunted patient
– complication and mortality rates compare favorably with those for
shunts
– has also been increasingly used as an alternative treatment option for
shunt complications
– Lumbar puncture may be used to relieve pressure in an acute
communicating hydrocephalus.
NPH
• Normal pressure hydrocephalus is a form of
communicating hydrocephalus in which the
intracranial pressure, as measured by lumbar
puncture, is normal or intermittently raised.
• Failure to reabsorb CSF is compensated by
reduced production.
• gait apraxia
• progressive dementia with memory loss
• sphincter disturbance resulting in incontinence
What has happened here? What
are the risk factors for this?
L Middle cerebral artery ischaemic
stroke
• Hypodense (dark) area on CT
• No midline shift
Modifiable Risk factors for
stroke
smoking
diabetes mellitus
diet:
high salt intake
high fat intake
low potassium intake
low vitamin intake
excess alcohol intake
morbid obesity
low physical exercise
low body temperature
cholesterol
Non-modifiable risk factors
increasing age
male gender
Afro-Caribbean descent
positive family history of stroke
Haemorrhagic stroke
• Note the high-density haemorrhage within
the low density of the oedematous,
infarcted region in the right hemisphere.
Haemorrhage is evident from its onset on
CT scanning.
• What is this??
• What factors
predispose to this
condition?
• How would you
manage?
Subdural haemorrhage
• The characteristic picture of a CT scan of a
subdural haemorrhage is one of a biconcave,
concentric shaped, area of increased density
spreading around the surface of the cerebral
hemisphere. The contralateral ventricle may
dilate owing to obstruction at the foramen of
Munro.
• After 10-20 days, the subdural haematoma
becomes isodense with brain. Later it becomes
relatively hypodense.
Subdural haematoma
•
Subdural haemorrhages result from rupture of cortical bridging veins. These
connect the venous system of the brain to the large intradural venous
sinuses and lie relatively unprotected in the subdural space.
•
any factor that stretches the bridging veins:
– cerebral atrophy, e.g. elderly
– low CSF pressure after shunting, for example for long- standing hydrocephalus
or a fistula
•
•
alcoholism
coagulation disorder or anticoagulation therapy
•
patients in whom conscious level is depressed:
– evacuate haematoma through 2-3 burr holes, and irrigate cavity with saline
– nursing in the head down position is recommended to prevent recollection
•
patients in whom conscious level is not depressed:
– consider conservative measures - steroid treatment over several weeks
How do you diagnose and treat this
condition?
Multiple myeloma
• a malignant neoplasm of plasma cells that arises
in the bone marrow. Presentation is with
anaemia, bone pain, skeletal destruction,
pathologic fractures, or Bence Jones proteinuria.
• M (monoclonal) band on serum electrophoresis
• Tx- cytotoxic chemo and supportive ,measures
What is wrong with these chaps? What features are common?
Parkinson’s disease
•
•
•
•
tremor
bradykinesia
rigidity
impaired postural reflexes
•
•
•
•
•
•
shuffling gait
expressionless, unblinking face
Pill-rolling tremor
slurred monotonous speech
small handwriting
increased salivation and dribbling
• Ali actually has parkonsonsim due to dopamine depletion within the
basal ganglia (boxing knocked it all out)
• What is wrong with
this chap?
Myotonic dystrophy
• characterised by myotonia and muscular atrophy.
• Inheritance is AD. The incidence is 5 per 100 000 with
onset between 15 and 40 years, although it may present
as early as birth. The causal gene is on chromosome 19.
• The disease is slowly progressive and is characterised
by cataract formation, hypogonadism, frontal balding and
cardiac disorders.
• There is weakness, wasting and myotonia of involved
muscles. Wasting of the stenocleidomastoids produces
the classical swan-necked appearance
Loss of lower limb refelxes and extensor plantar
response noted in this 15 year old boy…
Friedreich's ataxia
• most common inherited ataxia. prevalence of 1 in 50000.
• inheritance is ar
• progressive gait and limb ataxia, loss of proprioception,
pyramidal weakness and dysarthria.
• Extra-neurological involvement includes:
– hypertrophic cardiomyopathy in most patients
– diabetes mellitus in 10%
• pes cavus and kyphoscoliosis
• Onset is usually during adolescence.
What is wrong
with this 14 yr
old boy ?
• He has foot drop
and reduced
reflexes
Charcot marie tooth
•
AD condition characterised by slowly progressive sensorimotor neuropathy.
It is the most commonly inherited peripheral neuropathy in the UK.
•
type I:
–
–
–
–
–
a demyelinating sensorimotor neuropathy
early onset, typically in the first decade
presentation with walking difficulties and pes cavus
associated deformities include eqinovarus foot and kyphoscoliosis
wasting occurs:
• distally before proximally
• in the legs before the arms
– distal wasting may produce the classical inverted champagne bottle deformity
•
there is generalised areflexia
–
–
–
–
there may be cerebellar ataxia of the arms
respiratory muscles may be weak
nerve conduction is slowed to less than 38 m/sec
peripheral nerves may be palpably thickened
• This girls leg is
wasted, weak, with
absent knee and
ankle reflexes
• What is your
differential
diagnosis?
polio
• Poliomyelitis is a notifiable infectious viral illness
affecting the central nervous system.
• Poliomyelitis is an acute illness that follows invasion
through the gastrointestinal tract by one of the three
serotypes of polio virus (serotypes 1, 2 and 3)
• LMN lesion
Sensation is unaffected by this condition. When a badlyparalysed limb is picked up it has a floppy feel which, in
the presence of normal sensation, is characteristic of the
residual paralysis from poliomyelitis.
differential
•
•
•
•
Polio
Trauma
Botulism
paraneoplastic
• What is this?
• What conditions
is it associated
with?
Berry aneurysm
• adult polycystic kidney disease
• Ehlers-Danlos syndrome
• coarctation of the aorta
•
•
•
•
mostly remain asymptomatic throughout life
vary in size, most symptomatic aneurysms are >1 cm
often occur at vessel bifurcations
cause 80% of subarachnoid haemorrhages
• If >1cm clip them prophylactically
• If <1cm leave them (risk of surgery>risk of bleed)
Optic atrophy
•
•
Full moon
Featureless disc
•
retinal lesions:
–
–
–
•
central retinal artery or vein occlusion
retinitis pigmentosa
tobacco / nutritional - end result of tobacco amblyopia
optic nerve:
–
–
–
–
–
–
–
chronic glaucoma - most common of all causes
ischaemic optic neuropathy
secondary to papilloedema or papillitis
secondary to optic neuritis or retrobulbar neuritis
trauma - severing, avulsion, contusion, surgery
familial - Leber's disease, Friedreich's ataxia
pressure on optic nerve:
•
•
•
•
tumour - glioma, meningioma
Paget's disease
aneurysm of the anterior circle of Willis
chiasmal compression:
–
pituitary tumour, craniopharyngioma, suprasellar meningioma, aneurysm, stroke
Acute glaucoma cupping
Tx of acute closed angle glaucoma
• reduction of intra-ocular pressure by reducing aqueous
secretion – acetazolamide
• pupillary constriction - topical pilocarpine or
thymoxamine, an alpha receptor antagonist
• surgical or laser iridectomy - once the attack has been
controlled - rarely surgery may be undertaken as an
emergency procedure if medical management fails
papilloedema
• intracranial space-occupying lesions – tumours, cerebral abscesses;
subdural haematoma
• hydrocephalus e.g. subarachnoid haemorrhage, meningitis, head
injury
• venous sinus thrombosis
• benign intracranial hypertension
• malignant hypertension
• central retinal venous occlusion, ischaemic optic neuropathy, optic
neuritis
• chronic carbon dioxide retention
Pan retinal photocoagulation
• Treatment of diabetic nephropathy
maculopathy
• Reduced vision
What would this patient complain of?
Retinitis pigmentosa
• Night blindness
• peripheral visual loss
• pigmentary retinopathy
• Seen in Laurence-Moon-Biedl syndrome
Tuberous sclerosis
• congenital disease characterised by hamartomatous
lesions in the skin, nervous system and internal organs,
principally heart and kidney.
• Triad of
• adenoma sebaceum:
– actually an angiofibroma with passive involvement of sebaceous
glands
• epilepsy
• mental retardation
What is this? With what is it
associated?
Same again…
Osler weber rendu
•
Hereditary haemorrhagic telangiectasia is a rare AD condition where
multiple small telangiectases occur on the skin and mucous membranes,
most commonly on the lips and the tongue. Lesions are also often scattered
over the pulps of fingers.
•
Epistaxis is the most common complaint.
•
When telangiectases are present in the gastrointestinal tract they may
cause chronic blood loss with iron deficiency anaemia. Occasionally there
may be torrential bleeding.
•
•
•
Arteriovenous malformations may occur in the:
liver
lungs, causing:
– clubbing
– murmurs
– paradoxical emboli
Scurvy
• Gingival haemorrhage
• Vitamin C deficiency
• anaemia, spongy gums, a tendency to
mucocutaneous haemorrhages, and
brawny induration of calf and leg muscles,
poor wound healing
• Tx Vitamin C - 100-200 mg/day orally.
What is this? What causes it?
Gingival hyperplasia
• acute leukaemia – typically AML
• Drugs:
– phenytoin
– nifedipine
– cyclosporin
• scurvy
• pregnancy
• gingivitis
What is wrong with this patient and what is
your immediate management
• 55yr old man was
started on ACE-I
for his
hypertension 2
weeks ago. His
blood pressure is
now higher than 2
weeks ago and his
creatinine is
raised
Renal artery stenosis
• STOP ACE-I !
• This condition may result in secondary hypertension and
secondary hyperaldosteronism. Other possible features
include:
• coexistant cerebrovascular, cardiovascular or peripheral
vascular disease
• deterioration of renal function following treatment with
ACE inhibitor
• abdominal bruit; signs of coexistant vascular disease
e.g. carotid or femoral bruit; absent peripheral pulses
• Tx - balloon dilatation
• This patient presented
with tiredness and
weight loss. ON
examination his
tongue has this
appearance and he
has proteinuria,
oedema and
hepatosplenomegaly
Macroglossia in amyloidosis
• In amyloidosis, there is extracellular deposition of fibrillar
protein. This may be in a localized deposition or widely
distributed throughout the body.
• Amyloid fibrils stain with Congo red and show apple
green birefringence in polarized light.
• Cytotoxic and immunosuppressive drugs have been
used to treat amyloidosis, but often with poor results.
Improvement may be attained by treatment of an
underlying cause.
What is wrong with this patient?
HEPATOMEGALY
• MASSIVE
•
•
•
•
•
Secondary metastasis
HCC
alcoholic liver disease with fatty infiltration (more likely to have shriveled
liver)
myeloproliferative disease
malaria
• MODERATE
•
•
•
right heart failure
haemochromatosis
haematological disease:
– chronic myeloid leukaemia
– lymphoma
•
fatty liver - secondary to diabetes, toxins
• MILD
•
•
hepatitis
biliary obstruction
Hepatosplenomegaly
• infection:
– acute viral hepatitis
– infectious mononucleosis
– cytomegalovirus
• haematological disease:
–
–
–
–
–
–
leukaemia
myeloproliferative disease
lymphoma
pernicious anaemia
sickle cell anaemia
thalassaemia
• chronic liver disease and portal hypertension:
– chronic active hepatitis
• amyloidosis
• acromegaly
• systemic lupus erythematosus
What is this condition and how
would you treat?
• Ca and PO4
are normal
• Alk Phos is
raised
Paget’s
• It is characterised by excessive and
disorganised bone resorption and
formation.
• Analgesia
• Bisphosphonates
• Surgery for fractures/ joint replacement
• What is the likely
cause of this boy’s
enlarged abdomen
who presented with
fever, chills and
sweating?
Splenomegaly
• MASSIVE SPLENOMEGALY :
– chronic myeloid leukaemia
– myelofibrosis
– primary lymphoma of the spleen
– malaria
– kala-azar (visceral form of leishmaniasis )
• MODERATE SPLENOMEGALY
• portal hypertension:
– splenic/portal vein thrombosis
– hepatic cirrhosis
– Budd-Chiari syndrome
• lymphocytic leukaemias
• thalassaemias
What emergency surgery was
performed here?
Liver transplant
• Possible indications in an adult include:
• fulminant or subacute liver failure:
– paracetamol poisoning
– viral hepatitis
• end-stage liver cirrhosis:
– alcoholic liver disease
– chronic active hepatitis
– primary biliary cirrhosis
caput Medusae
• It is a sign of severe portal hypertension
with portal-systemic shunting through the
umbilical veins
• It is a sign of severe portal hypertension
with portal-systemic shunting through the
umbilical veins
What is this and how many are we
allowed?
Spider naevi
• None are normal for a man
• Less than 5 in women
• They are found in the distribution of the superior vena
cava i.e. on the arms, neck, and chest wall.
• cirrhosis - most frequently, alcoholic
• oestrogen excess - usually in association with chronic
liver disease; part of normal hepatic function is the
inactivation of oestrogens
• hyperthyroidism
• rheumatoid arthritis - rarely
87 year old man presented with abdominal
pain and a 4 wk history of constipation
• What features
would you expect
on examination?
• How would you
treat this man?
Sigmoid volvulus - 'bent inner-tube'
- inverted U - sign
• marked abdominal distension
• sudden onset of colicky pain
• absolute constipation and no passage flatus for at least 24 hours
• abdomen is distended and tympanic
• left ilac fossa tenderness
• rectal examination reveals a capacious, empty rectum
• Tx immediate management: sigmoidoscopy and air insufflation
• there is a gush of liquid faeces and flatus as the obstruction is
relieved
• High fibre diet and review medication
Caecal volvulus
• A caecal volvulus occurs when there is twisting of the
bowel at the caecum and resultant intestinal obstruction.
• Distention of the caecum ensues to the extent that the
volvulus can be felt as a palpable mass. The patient may
have vomiting, abdominal pain and constipation.
• The classical radiological appearance is the 'comma'
sign - there is a gas-filled ileum and caecum.
• Treatment is by decompression and resection, or fixing
of the caecum to the posterior abdominal wall.
What does this xray show?
• With what
conditions is it
associated?
Ulcerative colitis
• primary sclerosing cholangitis
• Cholangiocarcinoma
• sacro-iliitis and ankylosing spondylitis
•
•
•
•
•
pyoderma gangrenosum, erythema nodosum
anterior uveitis
episcleritis
Increased risk colon cancer
Toxic megacolon
What does this colonoscopy show?
crohns
• What is this
close up of a
barium enema
showing?
• What disease
has caused this?
String Sign
• Crohns disease
• Small-bowel followthrough study
demonstrates the string
sign in the terminal ileum.
•
pseudodiverticula of the
antimesenteric wall of the
terminal ileum, secondary
to greater distensibility of
this less-involved
segment of the wall
What is this? How would you treat?
• Small bowel obstruction with fluid levels
• Drip and suck
pneumoperitoneum
What does this xray show?
• A 23yr old man
presented to A and
E with fever,
abdominal
distension and
tenderness
• On examination he
was tachycardic and
had postural
hypotension
Toxic megacolon
• life-threatening complication of inflammatory or infectious
colitis.
• segmental, non-obstructive dilatation of the colon to
greater than 6 cm diameter
• systemic toxicity
• Xray
– dilatation of the lumen from 6-15 cm
– the most common sites of dilatation are the right and transverse
colons
– there is thickening of the colonic wall with disruption of the
normal haustral pattern
– there may be multiple air-fluid levels
Diverticular disease
• Management – high fibre diet,
antispasmodics, laxatives
• Complications: peritonitis, fistula
formation, persistent haemorrhage,
pericolic abscess formation, intestinal
obstruction, and repeated episodes of
diverticulitis that are resistant to medical
therapy.
What sign is shown? What is the
most likely cause?
• Apple core sign
• Stricture most likely due to colon cancer
What is wrong with this patient?
Dextrocardia/Situs Inverus
• Kartagener's syndrome
• bronchiectasis (also seen in Xray)
• sinusitis
• dextrocardia
• It is associated with a defect in cilia function and now is
termed as synonymous with primary ciliary dyskinesia.
• The situs inversus is thought to be a developmental
consequence of failure of ciliary action in the formation of
the gastrointestinal tract and other stuctures.
What is the diagnosis?
• This patient presented
with gradual onset,
intermittent dysphagia.
• He also has had
recurrent chest
infections
Achalasia
•neuromuscular failure of relaxation at the lower end of the oesophagus
with progressive dilatation, tortuosity, incoordination of peristalsis and
often hypertrophy of the oesophagus above.
• MANAGEMENT
• intrasphincteric injection of
botulinum toxin
• endoscopic hydrostatic or
pneumatic dilatation
• Heller's operation cardiomyotomy - success rate of
about 90% in those who do not
respond to dilatation
• What is this
upper GI
endoscopy
showing?
• What appearance
would it have on
barium swallow?
• Oesophageal candidiasis
• Furry oesophagus on swallow
• This patient
presented with
retrosternal chest
pain
• What is the
diagnosis?
Corkscrew Oesophagus
• Altered motility of the oesophagus
(sometimes loosely referred to as
"spasm") can be a cause of chest pain.
• The rare condition of diffuse oesophageal
spasm (seen radiologically as a
"corkscrew oesophagus") is associated
with pain,
What is wrong with this 55 yr old publican who has
long standing recurrent abdominal pain and weight
loss
Chronic pancreatitis
•
Plain film with extensive calcification in
duct system of a patient with chronic
pancreatitis secondary to alcohol
• Apparently this is a
“leather bottle
stomach”
• This is it out of the
• Body
• Caused by gastric
cancer
Oesophageal varices
Peutz jeghers
• multiple hamartogenous polyps of the
gastrointestinal tract - most often in the
small bowel but may occur affect any
portion of the GI tract
• mucocutaneous pigmentation - mainly, of
the lips, buccal mucosa, genitalia, hands
and feet
Oral hairy leukoplakia
• This is a lesion on the tongue that may be
seen in immunocompromised patients.It
appears to be the result of a proliferation
of Epstein-Barr virus, possibly associated
with Papilloma virus in the superficial
layers of the squamous epithelium of the
tongue.
What is this upper GI endoscopy of
dueodenum showing?
How else would you investigate this?
Coeliac disease
• Endoscopic still of duodenum of patient with
coeliac disease showing scalloping of folds
•
•
•
•
ENDOMYSIAL ANTIBODIES
ENDOSCOPY AND JEJUNAL BIOPSY
Bloods – anaemia, iron, folate, PT prolonged
DEXA- looking for damage due to low Ca
• Tx gluten free diet, vit + calcium + iron
supplements, pneumococcus vaccine
• Biopsy of small bowel showing coeliac
disease manifested by blunting of villi,
crypt hyperplasia, and lymphocyte
infiltration of crypts,
This man has a 2 month history of weight loss. He
is itchy, has no pain and has a palpable gall
bladder
Head of pancreas Ca
• Presents with painless obstructive jaundice, weight loss
and anorexia
• Gallbladder is palpable (Courvoisiers Law)
• painless jaundice + palpable gallbladder is not
gallstones!!!!
• US/CT for diagnosis (CT for staging)
• Tx Whipples (pancreatoduodenectomy)
• Chemo
• Most present with metastatic disease with crap
prognosis (6months mean survival)
Sclerosing cholangitis
• Beads on a string
• Associated with UC
Acute otitis media
• common causes are URTI (viral or bacterial)
• clinical features
–
–
–
–
–
–
ear pain
ear rubbing
cloudy white/yellow eardrum (pus in middle ear)
bulging eardrum
distinctly immobile eardrum
distinctly red eardrum
• 80% recover in around three days without antibiotics
• complications are rare
• Tx paracetamol and Inbuprofen (watchful waiting)
Glue ear
• Secretory otitis media, or `glue ear', is the most frequent
cause of hearing problems in children.
• accumulation of serous or viscous fluid within the middle
ear
• pain
• conductive hearing loss
• dull / dark blue/ grey appearance of tympanic membrane
• Rinne's test negative; Weber's test - sound heard
loudest in the deafer ear.
Grommets
• The function of a grommet is to ventilate the
middle ear, rather than drain it. Grommets thus
replace the function of the blocked eustachian
tube in glue ear and improve hearing.
• use of grommets in glue ear (otitis media with
effusion) offer only small benefits
• potentially adverse effects on the tympanic
membrane are common after grommet insertion
– ears treated with grommets had an additional risk for
tympanosclerosis one to five years later
This 5 year old boy presented with
fever, malaise, sore throat and otalgia
• What is the
differential
diagnosis?
• How would
you manage
this condition?
Acute tonsilitis
• Differential –
• rest
• soluble paracetamol held in the mouth and then
swallowed eases the discomfort (1)
• the patient must be encouraged to drink to prevent
dehydration
• antibiotics are unnecessary for most patients with sore
throat as it is a self-limiting condition, which resolves by
one week in 85% of people, whether it is due to
streptococcal infection or not
The Centor criteria
•
•
•
•
tonsillar exudate
tender anterior cervical lymph nodes
absence of cough
history of fever
• Then treat with antibiotics as it could be
Group A beta-haemolytic streptococcus
infection (erythromycin as amoxicillin will
cause rash in infectious mononucleosis)
Torsion of testis
The patient is a five year old boy who
presented with a febrile urinary tract
infection (UTI).
• His CT and US are shown. What is
diagnosis?
Acute pyelonephritis
• On CT, an edematous left kidney is seen
with multiple large areas of decreased
enhancement in the periphery
• Ultrasound images reveal an enlarged left
kidney with heterogeneous echo texture
as well as several discrete areas of
hyopechogenicity
• Staghorn calculi
nephrocalcinosis
Right hydronephrosis
Chronic pancreatitis
gallstones
• Note that no contrast was necessary to
acquire this image; sequence depicts fluid
which is either stagnant or flowing slowly.
What sign is being shown?
• What other features
are likely to be
present?
• would you treat this
problem?
Trousseau’s sign
• Paraesthesia, tetany, psychosis, convulsions, long QT interval
• Chvostek’s sign (tapping on facial nerve causes twitch
• mild tetany - oral calcium supplements
• severe tetany - intravenous calcium gluconate, 10 ml (2.32 mmol)
calcium gluconate 10% IV over 10 minutes.
•
• vitamin D - either if primary disease is due to vitamin D or, to ensure
adequate absorption of calcium.
– calciferol for simple vitamin D deficiency
– alfacalcidol or calcitriol if in renal failure - offer no advantage over
calciferol for simple deficiency
This 38 yr old woman with asthma has presented
with a purpuric rash and haematuria, proteinuria
and raised BP
• What is
the
diagnosis
?
Churg Strauss
•
The six classification criteria
•
•
•
•
•
•
asthma
peripheral blood eosinophilia
neuropathy
pulmonary infiltrates
paranasal sinus involvement
biopsy showing vasculitis with extravascular eosinophils
•
Laboratory diagnosis is based on tissue biopsy and the antineutrophil cytoplasmic
antibody (ANCA) test. About 25% of patients have cANCA and about 50% have
pANCA
•
This syndrome is also characterised by elevated levels of IgE.
•
•
Glomerulonephritis is a result of the vascultits
Tx high dose corticoteroids
This 50 year old man who enjoys a drink and smokes 10
cigs per day presents with epigastric pain and weight loss.
What is being shown here and how would you investigate?
Virchow’s node
• Gastric cancer
• endoscopy and biopsy: investigation of choice
• barium meal; suspicious findings:
–
–
–
–
–
–
space occupying mass
rigidity of adjacent gastric wall
greater curve ulcer
an ulcer with irregular borders and disruption of normal mucosal folds
contracted, non-distensible stomach - linitis plastica
fundic tumours are difficult to evaluate because of poor filling
• chest x-ray, liver enzymes, and liver ultrasound for evidence of
metastases
• anaemia in as much as 50% of all cases
• faecal occult blood test positive in the vast majority of subjects
This 70 year old man presented with a few weeks
history of difficulty swallowing and weight loss
• What other
investigations would
you perform?
• What is his prognosis?
• What would you do for
him in terms of
swallowing difficulty?
Oesophageal carcinoma
• Adenocarcinoma (lower 1/3)
• Apple core sign
• CT staging should be performed
• 5 year survival 10% (asymptomatic until late
stage)
• Oesophageal stenting (palliative)
Risk factors for Oe cancer
•
•
•
•
•
•
•
•
AGE
Diet (far eastern diet)
Smoking
Acid reflux
Barret’s oesophagus (30-40X)
Achalasia
Tylosis
Plummer-vinson (fe deficiency oesophageal
web) also called paterson-kelly-brown
• What is this
upper GI
endoscopy
showing?
• What symptoms
will this 70 yr old
man be
experiencing?
Oesophageal Ca
•
•
•
•
•
•
•
Dysphagia
Vomiting/ food regurg
Chest pain
Odynophagia
Wt loss/ anorexia
Haematemesis
Hoarse voice/ coughing/ aspiration of
saliva into lung
• What is being
shown here?
• Hiatus hernia with pneumoperitoneum
• SLIDING
– Sphincter at bottom of oesophagus and top of
stomach slides through hiatus in diaphragm. May
slide up and down
• ROLLING
– Part of stomach protrudes up through a hole in the
diaphragm next to the oesohagus… can become
strangulate. Less common
This 34 yr old male patient presented with
malaise, weight loss, apthous ulcers and this
intensely itchy skin rash
Dermatitis herpetiformis
• Dermatitis herpetiformis is an intensely itching subepidermal
vesicular blistering condition that usually develops in the 3rd or 4th
decade. Men>women.
• intensely pruritic, vesicular rash chiefly affecting the extensor
surfaces of shoulders, buttocks, knees, forehead and scalp, sparing
the mucosae. Small blisters are rarely seen since they are rapidly
excoriated, leaving raw papules. Vesicles are frequently grouped, as
those of the true herpes virus, hence the name 'herpetiformis.‘
• About 90% of patients with dermatitis herpetiformis will have coeliac
disease
• Tx - dapsone, in doses of 25-100 mg/day for itching
• Gluten free diet
• Topical steroids
How would you exanine this
patient?
Determining if indirect or direct
inguinal hernia
• Only true way to know is at surgery
• Reduce hernia
• Place finger over internal ring with 2
fingers
• When standing if no protrusion hernia is
likely indirect. If protrusion present is
direct.
How would you examine this
patient?
DO NOT EXAMINE
• ANAL FISSURES ARE EXTREMELY
PAINFUL!!!
• There is a prominent skin tag present also
in this photo
What is the diangosis? How would
you treat?
Prolapsed internal haemorrhoids
• CONSERVATIVE TX
–
–
–
–
ensuring the perineum is dried and washed after defaecation:
digital replacement of prolapsed haemorrhoids:
local anaesthetic creams and ointments
treatment aimed at reducing spasm of the internal anal sphincter:
• nitroglycerine ointments:
– glyceryl trinitrate 0.2-0.3% (unlicensed)
• botulinum toxin injection
• SURGICAL TX
– sclerotherapy
– rubber band ligation
– photocoagulation
– cryotherapy
• HAEMORRHOIDECTOMY
• LORD’S STRETCH!!!! ANAL DILATATION UNDER GA
HOW WOULD YOU TREAT THIS?
HYDROCOELE
•
Tx childhood hydrocoeles only if they persist after 1 yrs old. The procedure
is as for an inguinal hernia - open the sac, inspect the testis for
abnormalities, ligate and divide the patent processus vaginalis.
•
In adults, primary hydrocoeles may be treated:
•
conservatively - reassure the patient and provide a scrotal support.
•
by aspiration - use a sterile needle and syringe. Clear, pale yellow fluid
should be drained; fluid that is bloodstained suggests trauma or other
underlying pathology. Following aspiration, the testis should be palpable. A
sclerosant such as phenol may then be injected to stop fluid from
reaccumulating, otherwise, periodic aspiration may be necessary. A
hydrocoele should not be tapped if there is any suspicion of tumour - in the
case of a tumour, aspiration may result in spread of malignant cells.
•
by operation - if the diagnosis is in doubt, the hydrocoele is large, or fluid
repeatedly reaccumulates after drainage. Once the fluid has been removed,
the testis is examined for abnormalities.
Neuropathic ulcer (diabetes pt)
What is this?
• How would the
patient who has had
this removed have
been investigated
initially?
Ruptured appendix
•
Acute appendicitis is usually a clinical diagnosis
•
•
•
•
•
full blood count - leukocytosis is generally present
urea and electrolytes - assessment of dehydration
pregnancy test
serum amylase - if pancreatitis suspected
abdominal radiology - helpful to distinguish:
–
–
–
–
–
volvulus
intussusception
renal stones (90%)
gallstones (10%)
localised ileus
•
Generally, urine analysis is unhelpful in differentiating appendicitis from a urinary tract
infection.
•
There is no place for barium enema in the diagnosis of appendicitis. Occasionally,
ultrasound and CT scanning are used to investigate suspected appendicitis where the
story is atypical. US exclude gynae pathology (ovarian cyst)
Diff diagnosis of acute appendicitis
•
•
•
•
Ectopic pregnancy
Salpingitis
Period pains
Cystitis
•
•
•
•
•
Cholecystitis
Diverticulitis
Perforated ulcer
Meckel’s diverticulum
Crohn’s disease
• What is this
a sign of?
Duodenal atresia
• investigated by:
• electrolyte and acid-base status measures, e.g.
U&E's, blood gases, with subsequent correction
of abnormalities
• plain abdominal X-ray: this may show a 'double
bubble' sign of duodenal obstruction
• barium study may show stenosis
• Treatment involves surgical correction via a
duodenojejunostomy with resection of the atretic
section.
A 34 year old vagrant is treated following a
second variceal bleed… what is shown
here?
TIPS
• TRANSJUGULAR INTRAHEPATIC PORTO-SYSTEMIC
SHUNT
• the treatment of acute oesophageal variceal bleeds
which fail to respond to drugs or sclerotherapy
• the prevention of variceal bleeds
• angioplasty balloons and metallic stents are used to
enlarge and maintain the porto-systemic shunt
What is wrong with this chap? How would
you investigate? What are common causes?
ASCITES
•
•
•
•
NOTE DRAIN SITES!!!
Shifting dullness
ultrasound
diagnostic paracentesis in which 30 to 50 ml of fluid is withdrawn.
• This will enable identification of:
–
–
–
–
–
–
–
protein content: albumin and total protein
malignant cells
bacteria
white blood cells
Glucose
TB culture
amylase
CAUSES OF ASCITES
• TRANSUDATE
• Protein<3g/100ml
– Cardiac failure
– Constrictive
pericarditis
– Nephrotic syndrome
– Cirrhosis
– Ovarian tumours –
meig’s syndrome
• EXUDATE
• Protein>3g/100ml
–
–
–
–
–
–
Malignancy
Pyogenic Infection
Tb
Pancreatitis
Lymphoma
Myxoedmea
MANAGEMENT OF ASCITES
• TENSE ASCITES
– therapeutic paracentesis of 4-6 litres
– plasma volume expansion with albumin (6g/litre of ascitic fluid removed)
• NON-TENSE ASCITES
– bed-rest, reduced salt intake, and spironolactone (50-100 mg per day).
A fall in weight of approximately 0.5 kg per day should be aimed for.
– spironolactone is gradually increased to 300 mg per day and then, if
necessary, frusemide is added, but only once the spironolactone has
reached its maximum dose.
– loop diuretics may precipitate the hepatorenal syndrome
– If a patient has malignant ascites then large doses of frusemide may be
required to control ascites.
– A Le Veen shunt (peritoneo-venous) may be useful in refractory cases.
• What is wrong with
this baby?
• How would you
treat?
kwashiokor
• Classically hair colour change, hepatomegaly,
pitting oedema, bleating cry when picked up
• Tx electrolyte imbalance, hypoglycaemia,
vitamin deficiency. May need warming if
hypothermic.
• 80-100kcal/kg/day – care not to overload pt
• What is wrong with
this baby?
Marasmus
• Marasmus is failure to grow associated with emaciation and fair
appetite. It may be defined in terms of weight, for example less than
60% of that expected for age.
• Marasmus generally occurs in infants up to one year. In the
developed world it is found in infants who are born undernourished
or are recovering from a severe chronic illness, especially those
affecting the bowel.
• In developing countries this condition commonly is associated with
failure of lactation due to poor nutrition of the mother.
• Note that marasmus is an adaptive response to poor nutrition.
• A 77 year old man
presents with his 4th
episode of rectal
bleeding. The blood is
a mixture of fresh
blood and clots. The
bleeding was severe
enough to require a 4
unit blood transfusion.
Barium enema was
normal. Colonscopy
showed this lesion
Angiodysplasia
• Colonic angiodysplasia is a common cause of acute or chronic
rectal bleeding and iron deficiency anaemia.
• Angiodysplasias are tiny - 1-5 mm in diameter - hamartomatous
capillary lesions in the colonic wall which produce bleeding out of
proportion to their size. They are believed to be acquired, possibly
as a result of tension on the veins where they pass through the
muscularis.
• colonscopy: may visualise lesion
• Treatment:
• electrical coagulation via the colonoscope
• resection of segment of colon if the above is unsuccessful
This baby presented with severe diarrhoea, alopecia, FTT
and a rash over the mucocutaneous junction. This started
soon after he stopped breastfeeding
.
acrodermatitis enteropathica
• autosomal recessive disorder
characterized by periorificial and acral
dermatitis, alopecia, and diarrhoea
• Sharply demarcated, brightly
erythematous periorificial plaque
• Caused by Zinc deficiency
• Tx zinc
• This boy
presented with this
rash, diarrhoea
and confusion
• What is wrong?
Pellagra
• caused by deficiency of niacin
• classically characterised by four D's:
–
–
–
–
photosensitive dermatitis
diarrhoea
dementia
Death
• monotonous maize diet (maize is low in tryptophan)
• a very low protein diet
• conditions producing considerable loss of protein e.g.
nephrotic syndrome
• What is wrong with this
man with wrist drop and
marked wasting of the
lower extremities?
Beriberi
• severe prolonged deficiency of vitamin B1 (thiamine)
• Beriberi was discovered in the seventeenth century in
Java by the Dutch physician Jacobius Bonitus. The
name means "sheep" in the local language; this
describes the characteristic gait of patients.
• Today, beriberi is confined to the poorest parts of Asia
where little else is eaten except polished rice.
• Prevention of beriberi requires:
• a more varied diet, including legumes and pulses
• thiamine supplementation of rice
Scoliosis
• Image in a 27-year-old tennis player with a
history of cystic fibrosis and only minimal
symptoms exhibits bronchial wall
thickening, bilateral small nodular
opacities, and scoliosis.
bronchiectasis
Barrel chest
• Emphysema
• Sorry I think that man might actually be
dead
• What is this?
• What is it showing?
Flow volume loop
• Showing severe airflow limitation
• This is a normal one
Hyperinflated lung
• COPD
Report this xray of a 47-year-old smoker who presented after just a few
hours of rigors and productive cough. What other investigations would
you carry out and how would you manage?
consolidation in the right upper lobe
• Consistant with a pneumonia
• Investigate:
– FBC (WCC raised, particularly neutrophils)
– U+Es
– Sputum and blood culture
– Pulse oximetry and ABG
– Serology for atypicals
– RBS – diabetes is risk factor for infection
Assessing severity
• CURB-65
–
–
–
–
–
Confusion
Urea>7mmol/l
Resp rate>30
BP systolic<90 or diastolic<60
Age>65
• Score
– 0-1 home Tx
– 2 consider hospital supervised Tx (in or outpt)
– 3 or more in patinet Tx and assess for ICU
MANAGEMENT
What is this ECG of a 23 year old man with
episodes of tachycardia showing? How would you
manage?
Wolf Parkinson White
• The two complications of WPW are the development of an AV reentrant tachycardia or atrial fibrillation.
• An AV re-entrant tachycardia is managed as for any other
supraventricular tachycardia (see linked item)
• Atrial fibrillation secondary to WPW should not be treated with AVblocking drugs such as verapamil and digoxin. The simplest method
of terminating atrial fibrillation is cardioversion. If drugs are to be
used then they must slow conduction in the accessory pathway e.g.
intravenous sotalol, flecainide, amiodarone. These drugs will slow
the ventricular response and will often result in restoration of sinus
rhythm.
• For prevention of atrial fibrillation drugs such as oral sotalol and
amiodarone are effective.
This 69 year old man was admitted to hospital 5
years earlier with palpitations and blackouts. He
was discharged on a new medication.
• What has
happened to
him?
• What other
problems are
associated?
Amiodarone side effects
•
•
•
•
•
•
•
•
•
•
•
•
The side-effects are time and dose related.
Minor side effects of amiodarone include corneal microdeposits.
Moderate side effects include:
photosensitivity
skin discolouration
abnormal thyroid function, and abnormal TFTs
nausea
nightmares
sleep disturbance
Serious side effects include:
peripheral neuropathy
disturbed hepatic function:
– acute hepatitis and jaundice are particularly associated with intravenous
administration
– chronic toxicity may cause fibrosis or cirrhosis
•
•
amiodarone lung
amiodarone has some proarrhythmic potential
This is the ECG of a 70yr old man with exercise
intolerance. What is shown…how would you
manage?
Complete heart block
• Acute inferior block:
• give atropine to reduce vagal effect
• temporary pacing required for profound bradycardia
• Acute anterior block:
• start temporary pacing early
• may need a permanent pacemaker
• Chronic block:
• permanent pacing
An 57 year old lady with
palpitations.
Atrial flutter with 2:1 AV conduction
• The sawtooth waveform of atrial flutter can
usually be seen in the inferior leads II, III
and aVF if one looks closely. Sometimes
the rapid atrial rate can be seen in V1.
• Suspect atrial flutter with 2:1 block when
you see a rate of about 150 bpm.
68 year old lady on digoxin
complaining of lethargy.
What is wrong? What is your
immediate management?
Management of VF
• Give 1 shock at 360
• IMMEDIATELY RESUME CPR 30:2 FOR
2 MINS
• ASSESS RHYTHM
• Restrictive lung disease. Chest radiograph
of a 67-year-old man diagnosed with
idiopathic pulmonary fibrosis, based on
open lung biopsy findings. Extensive
bilateral reticulonodular opacities are seen
in both lower lobes.
• Restrictive lung disease. A CT scan image
from a 59-year-old woman shows
advanced pulmonary fibrosis. Extensive
honeycombing and traction bronchiectasis
are present.
• Chest radiograph in a 60-year-old dairy
farmer who had an 8-year history of
intermittent dyspnea shows bilateral
reticulonodular interstitial infiltration
secondary to subacute hypersensitivity
pneumonitis
Bilateral hilar lymphadenopathy
• DIFF DIAGNOSIS
• Sarcoidosis (commonest cause in UK)
• tuberculosis
• lymphoma - almost never shows the striking
symmetry of the BHL
• carcinoma
• fungi
• hypogammaglobulinaemia
• berrylliosis
• This 55yr
old pipe
lagger
developed
left sided
chest pain,
finger
clubbing
and weight
loss
Lid lag
• Graves disease
Pretibial myxoedema
• Graves disease
bronchiectasis
Pseudohypoparathyroidism
• End organ resistance to PTH
• Small metacarpals
• Pseudopseudohypoparatyhroidism – is
when have physical abnormality but no
end organ resistance to PTH
• What are the
indications for this?
• What are the
complicatons?
• Where is the semi
permeable membrane?
• Where is the dialysate?
Dialysis
• Acute renal failure
–
–
–
–
Persistent hyperkalaemia
Severe metabolic acidosis
Pulmonary oedema
Encephalopathy or pericarditis (20 to uraemia)
• End stage (established) renal failure
• eGFR<15ml/min
Complications or RRT
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•
•
•
•
Hypotension/ hypertension
Anaphylaxis
hyperkalaemia - from poor dietary compliance
amyloidosis –
infection - Gram positive bacteria are common. There is an increased
incidence of hepatitis C
•
malnutrition - causes include:
–
–
–
–
•
•
•
•
loss of amino acids and peptides in the dialysate
sodium restriction and poor palatability of diet
dialysis induced hypercatabolism
social and psychological factors
aluminium intoxication - from inadequate filtration of incoming water supply this is now rare
Vascular access- thrombosis, stenosis, bleeding, ischaemia
Anaemia
Renal osteodystrophy
• What is this?
• What would it feel
like?
• What could have
caused this (rarely)
Varicocoele
• Feels like a bag of worms
• Dull dragging ache at end of day
• Commoner on left side
• Rarely renal carcinoma can compress L
testicular vein and cause a L sided
varicocoele
SAH
• Subarachnoid haemorrhage accounts for
about 6% of cerebrovascular disease with
an annual incidence of about 1 per 10,000.
It is bleeding from intracranial vessels in
the subarachnoid space. Occasionally, the
arachnoid layer gives way and a subdural
haematoma develops.
• Seen here as white area in the centre
syringomyelia
• Cavitation of central segment of spinal cord
• DISSOCIATED SENSORY LOSS (spinothalamic
damage- lose pain and temp but retain light
touch, proprioception and vibration)
• WEAKNESS, WASTING, LOSS OF REFLEXES
(anterior horn cell damage)
• Consider surgery for tx
Bulbar Palsy
• LMN lesion
• Apparently
showing same
thing
• In a homosexual
man with weight
loss and
recurrent
infections
CMV retinitis
• Cytomegalovirus (CMV) retinitis occurs in immunocompromised
patients.
• 'pizza pie' fundus:
– retinal spots which are the result of superficial retinal infarction
– also flame shaped haemorrhages
• associated with a low CD4 count
• Asymptomatic or sudden (and untreatable) visual loss
• Other manifestations of cytomegalovirus infection in these patients
includes encephalitis, pneumonitis, and diffuse gastro-intestinal
involvement.
• Treat with ganciclovir (or foscarnet in cases of reduced sensitivity to
ganciclovir).
Roth spots
• These are superficial retinal
haemorrhages with red edges but pale or
white centres. These may be seen in a
variety of conditions including infective
endocarditis. They are not pathognomonic
of any particular disease.
• Also seen in leukaemia
Loosers zones
• Osteomalacia
• This is a pseudofracture seen in osteomalacia. On x-ray,
it appears as a thin, translucent band, about 2 mm in
width, which runs perpendicular to the surface of the
bone extending from the cortex inwards.
• incomplete stress fractures which heal with callus lacking
in calcium
• pubic rami, the necks of the humeri and femora and at
the axillary edge of the scapulae
• Oral kaposi’s sarcoma
• Wickham’s striae
• Lichen planus
• The oral lesions have a radiating velvet, white or gray
appearance, most commonly in a reticulated pattern.
This represents the "lace-like" network of linear
subepithelial fibrosis found in these lesions. The buccal
and glossal mucosas are most commonly affected,
however, lesions can also be found in the palate and
gingiva (erosive gingivitis).
Central retinal artery occlusion
• The retina has become milky because of
infarction. Tissue necrosis makes the tissue lose
its normal transparency.
• Cherry-red spot
• The red-orange color of the fovea appears in
stark contrast to the surrounding milky retinal
edema. Called a "cherry-red spot," it results from
the fact that the fovea contains only the
photoreceptor layer, which is spared because it
is nourished by the choroidal circulation rather
than the retinal circulation.
Central retinal vein occlusion
• The patient presents with painless loss of vision,
often mixed with sparkles, that may be sudden
or evolve over hours to days.
• Systemic hypertension is the most common
cause; hyperviscous and hypercoagulable states
must also be considered.
• Numerous haemorrhages seen – splattered with
blood
thalassaemia
What is
shown on
left?
What else is
needed for
the diagnosis
of this
condition?
Serum electrophoresis
• Monoclonal IgG kappa monoclonal band
• Multiple myeloma
• Control sample ran on left
• Increased plasma cells on bone marrow biopsy
• CRAB