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SLIDESHOW PRACTICE by wuyunyi

VIEWS: 30 PAGES: 426

									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?
•   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
•   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
•   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
•   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

•   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

•   OCULAR
•   upward lens dislocation
•   retinal detachment

•   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 30-
    60 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                            Non-modifiable risk factors
     smoking
     diabetes mellitus            increasing age
     diet:                        male gender
           high salt intake       Afro-Caribbean descent
           high fat intake        positive family history of stroke
           low potassium intake
           low vitamin intake
     excess alcohol intake
     morbid obesity
     low physical exercise
     low body temperature
     cholesterol
       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 badly-
  paralysed 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 follow-
  through 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             • EXUDATE
• Protein<3g/100ml       • Protein>3g/100ml

  – Cardiac failure        –   Malignancy
  – Constrictive           –   Pyogenic Infection
    pericarditis
                           –   Tb
  – Nephrotic syndrome
                           –   Pancreatitis
  – Cirrhosis
                           –   Lymphoma
  – Ovarian tumours –
                           –   Myxoedmea
    meig’s syndrome
 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 re-
  entrant 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 AV-
  blocking 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
•   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

								
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