Station 5 Top ten:

1. Rheumatoid arthritis 2. Systemic sclerosis 3. Hemianopia 4. Acromegaly 5. Ankylosing spondylitis 6. HIV related problems 7. Diabetic retinopathy 8. Neck lump 9. Retinitis pigmentosa 10. Thyroid eye disease

Endocrine

1. Acromegaly 2. Goitre 3. Hyperthyroidism 4. Hypothyroidism 5. Thyroid eye disease 6. Cushings syndrome 7. Addisons disease 8. Polycystic ovarian syndrome 9. Pseudohypoparathyroidism

Eyes

1. Hemianopia 2. Diabetic retinopathy 3. Retinitis pigmentosa 4. Papilloedema 5. Choroiditis 6. Hypertensive retinopathy 7. Glaucoma 8. Retinal artery occlusion 9. Optic atrophy 10. Retinal vein occlusion 11. Horners syndrome

Locomotor

1. Rheumatoid hands 2. Systemic sclerosis

3. Ankylosing spondylitis 4. Pagets disease 5. Psoriatic arthropathy 6. Marfans syndrome 7. Systemic lupus erythematosus 8. Osteoarthrosis 9. Swollen knee 10. Gout

Skin

1. HIV-related problems 2. Psoriasis 3. Hereditary haemorrhagic telangectasia 4. Systemic sclerosis 5. Neurofibromatosis 6. Peutz-Jeghers syndrome 7. Lichen planus 8. Tuberous sclerosis 9. Pseudoxanthoma elasticum 10. Erythema nodosum 11. Pyoderma gangrenosum 12. Raynauds phenomenon 13. Sturge-Weber syndrome 14. Vitiligo 15. Acanthosis nigricans 16. Keratoderma blenorrhagica 17. Henoch-Schonlein purpura 18. Alopecia areata 19. Erythema multiforme 20. Pemphigus

ENDOCRINE Thyroid stations: Hx presentation:

Neck lump Eye problems diplopia Heat/Cold intolerance Tremor Weight change Diarrhoea, constipation Palpitations Oligomenorrhoea

Examination

Hands acropachy, tremor, sweaty Pulse tachy/ AF Eyes position, chemosis, ophthalmoplegia Neck exam incl swallowing, LNs, retrosternal goitre and bruit Reflexes Proximal myopathy Pretibial myxoedema

What is Graves disease? Autoimmune Dx with TSHR-Abs which hyperstimulate the thyroid and also bind to soft tissues in the orbit, leading to a hyperthyroid state and thyroid eye disease. It is the most common cause of hyperthyroidism. Is it more common in women (5x). The antibodies can also direct. It presents with symptoms of hyperthyroidism such as weight loss, anxiety, tremor, heat intolerance or tachycardia, neck swelling from a diffusely enlarged mildly tender goitre, and Graves eye disease, with proptosis, exophthalmos, chemosis and complex ophthalmoplegia. What is the treatment for Graves disease? Symptoms can be initially controlled with beta-blockade. I would consider an urgent ophthalmology opinion if there was any visual loss, ophthalmoplegia or inability to close the eyes, and eye lubricants, steroids, tarsorrhaphy or orbital irradiation or decompression. Treatment for Graves is through anti-thyroid medications such as carbimazole or propylthiouracil, radioactive iodine therapy, or partial or complete thyroidectomy. All treatments have their downsides; antithyroid drugs cause rash, myopathy, alopecia, agranulocytosis and aplastic anaemia and liver problems, radioactive iodine is contraindicated in pregnancy, iodine allergy, radiation risk (incontinent), solitary nodules and in eye disease which it may worsen, surgery has complications such as vocal cord paralysis and hypoparathyroidism.

Other causes of exophthalmos? Bilateral Graves Dx, cavernous sinus thrombosis, caroto-cavernous fistula (pulsating globe) Unilateral orbital tumour or cellulitis What are other causes for hyperthyroidism

Graves Toxic solitary nodule Toxic multinodular goitre Overtreatment with thyroxine Iodine toxicity Post partum thyroiditis XS TSH secretion from pituitary function Amiodarone therapy

Ix for hypothyroidism?

TFTs High TSH, low T4 May be anaemic and hyponatraemic May have raised CK and cholesterol ECG small complex, bradycardia, heart block

Ix hyperthyroidism

TFTs TSHR-Abs

Treatment of hypothyroidism? Replacement with L-thyroxine lifelong. (Complications if too rapid IHD with MI, Angina, heart failure) What complications of hypothyroidism do you know?

Cardiac heart failure, pericarditis/effusion, HTN, IHD, bradycardia, Neuro psychosis, pseudodementia, myxoedema coma, carpal tunnel syndrome,

peripheral neuropathy, cerebellar signs

Hashimotos thyroiditis Association with Addisons, Graves, Pernicious anaemia, vitiligo, Rheum arthritis, DM, hypoparathyroidism, UC, SLE Ix for multinodular goitre?

TFTs US goitre Radioisotope scan hot or cold (cold may be malignant) FNA of cold nodules If affecting local structures CT or MRI Stridor flow/volume loops

Solitary thyroid nodule?

Single larger nodule in multinodular goitre Thyroid adenoma Toxic ademoma Thyroid cyst Thyroid cancer

o Papillary commonest, young pts, good prognosis o Follicular elderly, can spread haematologically o Anaplastic elderly, aggressive, local invasion, poor prognosis o Medullary young, rare, secrete calcitonin or ACTH o Lymphoma young

Acromegaly Hx

Change in hand size Change in shoe size Non-fitting dentures Change in facial features Systemic features Tunnel vision/Visual probs Diabetes Hypertension Pains in hands at night or writing - CTS

Ex Hands

Hands large and wide and doughy Carpal tunnel release scars or thenar eminence wasting and median nerve sensory

loss Sweaty

Face

Supraorbital ridges Jaw - prognathism Large Ears and nose Acne Macroglossia Deep voice

Eyes

VISUAL FIELDS Body

Kyphosis Acanthosis nigricans Skin tags

Say you would:

Check BP Cardio Ex Urine dip for glucose and BM

Ix

IGF1 - raised GH levels after OGTT no suppression in acromegaly MRI of sella Turcica

Screen for hypopituitarism Prolactin, Testosterone, LH, FSH Visual perimetry CALCIUM for MEN1 Echo BP Diabetes Consider bowel investigations as at higher risk of colonic polyps

What is MEN1?

Rare , AD, MEN1 gene Pancreatic tumours Pituitary tumours Parathyroid hyperplasia/adenomata

What is MEN 2a?

RET gene Medullary thyroid carcinoma Phaeochromocytoma Parathyroid hyperplasia

What is MEN 2b? MEN2a plus:

Marfanoid body habitus Mucosal neuromata

Causes of macroglossia

Amyloidosis Hypothyroidism Downs syndrome

Management?

Surgical if possible trans-sphenoidal or transfrontal hypophysectomy Radiation / Bromocriptine / Octreotide

Post-operative complications?

Meningitis Diabetes insipidus Panhypopituitarism

What are the causes of acathosis nigricans?

Acromegaly Obesity T2DM Gastrointestinal malignancy

Cushings Hx:

Steroid use what is the reason for steroids??? Wt gain Hirsutisn Easy bruising Acne Proximal weakness (up stairs, etc) Menstrual disturbance Loss of libido Depression Back pain

On examination:

Moon-like facies Buffalo hump Hirsutism Plethora Candida Striae Obesity Bruising Proximal myopathy Spinal tenderness

If on steroids examine appropriate system Also:

BP Dip urine glucose CBG Visual fields Fundus optic atrophy or papilloedema, HTN of DM retinopathy

What are the causes of these features?

Iatrogenic steroid use Pituitary adenoma Cushings Disease Adrenal adenoma Adrena carcinoma Ectopic ACTH production from Small cell lung Ca or Medullary Thyroid Ca

Investigations?

24 hour free urinary cortisol Plasma ACTH/Cortisol

Overnight dexametasone suppression test CXR? Malignancy AXR adrenal calcification US/CT/MR adrenal imaging

Treatment for Cushings disease?

Trans-sphenoidal microadenomectomy Radiotherapy Bilateral adrenalectomy

EYES Diabetic retinopathy Hx

Visual changes Hx DM Ask about:

o Diagnosis o Control o Treatment o MI, Stroke, Nerve probs, Eye probs, Kidney probs, ulcers

Clues: CBG meter, white stick, Insulin, Ophthalmoscopy Ex

Hands for CBG marks Pulse Acuity PERLA Ophthalmoscopy Eye movement Leg ulceration Peripheral pulses

Offer:

Peripheral neuropathy Postural blood pressure

What is non-proliferative retinopathy (Background and pre-proliferative)?

Micro-aneurysms Hard exudates Dot and blot haemorrhages Cotton wool spots

How to distinguish HTN and DM retinopathy?

Difficult DM always has microaneurym formation

Management

Good glycaemic control Screening Ophthalmology referral (urgent if loss of vision or proliferative changes) Photocoagulation (reduces angiogenesis)

Other eye probs in diabetes? Cataracts Central retinal artery and vein occlusions Vitreous haemorrhage Isolated Cranial nerve palsy Retinopathy

Hypertensive retinopathy Grade 1: Silver wiring Grade 2: AV nipping Grade 3: Cotton wool spots and flame haemorrhages Grade 4: Papilloedema

Retinitis pigmentosa Hx

Tunnel vision Night blindness Hearing loss? Balance probs Heart probs

Ex Acuity Fields EOMs Ophthalmoscopy widespread scattering of black pigments sparing the macula

?Hearing loss Usher syndrome ?Obesity and polydactyly Laurence-Moon Syn ? Cerebellar ataxia, deafness, peripheral neuropathy, cardiomyopathy Refsums

Dx ?Ophthalmoplegia, bilateral ptosis and ICD (heart block) Kearns Sayre

syndrome Ataxia Freidrichs Abetalipoproteinaemia

What is it? Genetic disease with rod-cone dystrophy which leads to apoptosis and visual loss. Individuals usually are born with normal vision, only developing symptoms in early adulthood or middle age. Loss