A 72 year old ex-engineer has a 12 month history of increasing breathlessness, with mild wheeze and a cough. He smokes 40/day, since the age of 18.
| Name three potential differentials at this point. What main features would you expect from the history for each of these?
- Chronic Obstructive Pulmonary Disease- Productive cough without blood. Worsened at extremes of temperature.
- Lung Cancer- Weight loss, blood in sputum, lethargy
- Pulmonary Fibrosis- Industrial history with exposure to asbestos. Worsening dyspnoea, but otherwise asymptomatic
- Heart Failure- Chest pains, Fatigue, Orthopnea
He describes a productive cough with no blood in it, worst last winter. He denies any asbestos exposure, saying he worked outdoors mainly.
|What signs would you expect on examination
|Hyperinflation (barrel chest), reduced expansion, resonant or ↑ percussion, wheeze, ↑ JVP, ↓ Breath sounds.
You decide he may have COPD
|What investigations would you do next? What would these show?
- Full Blood Count- May show Polycythaemia (Raised Haematocrit)
- Chest X-Ray
- Flattened Hemidiaphragms
- Dilated pulmonary arteries
- O2 Sats- may be "normal low" 88-92%
- ABG shows reduced oxygen, and possibly Respiratory Acidosis
- Spirometry in the long term environment, to delineate from restrictive lung disease, and measure disease progress.
- ECG to exclude cardiac cause.
He shows most of these signs, and you decide on a diagnosis of COPD.
|How would you manage this patient initially?
- Short Acting β-2 Agonist (SABA) PRN or Short Acting Muscarinic Antagonist (SAMA) PRN
- Refer to Pulmonary Rehabilitation Team
- Offer smoking cessation advice
- Consider Oxygen Therapy
A 62 year old lady presents with a 2 month history of increasing pain in her hip, now stopping her from walking to the shops.
|Name as many questions to clarify her presentation as you can.
- How did it start? How has it changed? Does it move anywhere?
- Do you have any stiffness in the joints?
- Any instability?
- How far can you walk? Can you dress yourself without difficulty?
- What has it prevented you doing? Shopping, cleaning, cooking, socialising? (bonus CIDR point)
- What age did you reach the menopause?
- Do you smoke?
- Do you have any medical history that's relevant? Joint replacement, cancer.
After your rigorous interrogation, she reveals the following:
I don't have much difficulty with it except towards the end of the day, or after I've been sat for a while- then I feel really stiff and it hurts to move, but once I get going, it's bearable. I can walk to the shops 200m away, but getting dressed in the morning is difficult. I reached the change aged 51, I've never smoked, and I've never been in hospital before!
|What is your working diagnosis? What tests would you do to confirm this?
- Bloods - ESR & CRP can be normal or raised, seronegative (Rheumatoid factor -ve)
- X-rays - only abnormal if advanced:
- Joint space narrowing
- Subchondral sclerosis
- Subchondral cysts
- MRI - early cartilage changes
- Arthroscopy - early fissuring and surface erosion of cartilage
|Detail the management options for Osteoarthritis
- Physiotherapy & weight loss
- Pain control
- Intra-articular steroid injections
- Joint replacement
A 22 year old man collapses to the ground in Newcastle City Centre. He is seen to be moving by passers by, but as the ambulance arrives, he stops, but seems confused, slurring his speech.
|Name some differential diagnoses for his collapse
- Vasovagal syncope
His friends describe him seeming dazed before he fell, and seeing stiffening and jerking limbs.
|What type of epilepsy could this be?
|Partial becoming generalised tonic clonic
|Name as many potential causes as you can
- Previous head injury leading to cortical scarring
- Infective (SLE, sarcoid, meningits, encephalitis)
- Space Occupying Lesion
- Alcohol/ Benzodiazepine withdrawal
- Medication- Tramadol, Theophyline, Cocaine
|Describe the potential management options
- Do nothing, and see if there's another seizure
- Specialist referral
- Sodium Valproate
49 year old lady presents with sudden onset weakness in her left arm. She describes no other symptoms, but mentions seeing her GP 6 months previously with double vision, and has a history of low mood.
|Name 3 differential diagnoses. What are the salient features of the history for each of these?
- Multiple Sclerosis- Multiple, self-resolving episodes of any sensory or motor changes. Sometimes attacks are worsened by heat.
- Stroke- Clear sensory or motor change, either unilaterally or bilaterally. Facial drooping, speech problems. All lasting>24hrs.
- Brachial Plexus injury- Clear trauma, with neuropathic pain (doesn't explain double vision)
You perform an examination, and find internuclear ophthamoplegia, and brisk reflexes on the left hand arm.
|Which of the above is most likely? What tests would you do to exclude the others?
|Multiple Sclerosis- Clinical diagnosis, but:
- Lumbar Puncture- Oligoclonal bands of IgG distinct from the blood indicate CNS inflammation.
- Evoked Potentials- in the case of visual loss
|What criteria would be used to assist you in diagnosis?
|McDonald Criteria (See Multiple Sclerosis)
|What are the management options?
Note, these are for attack onset MS, the secondary progressive is more difficult, and primary progressive often doesn't respond to therapies.
It is possible to just leave a relapse to run its course, rather than trial medication (and the associated side effects). Steroids such as methylprednisalone are useful for fresh inflammation, however.
Disease Modifying Therapies
- Interferon β, copaxome. Injected at home by patient. Reduces relapse rate by ~1/3
- Natalizumab- Monoclonal Antibody. Anti-VLA-4 "teflon coats" the white blood cells, so they cannot adhere to the blood vessels and sneak through to cause inflammation. 81% reduction in relapse rate, 2/3 reduction in disability. Be wary of reactivation of JC virus in these immunosuppressed patients.
A 55 year old man presents with a red, scaly rash across his elbows. On inspection, the border is well defined.
|What disease could this be?
| Chronic Plaque Psoriasis
|What are the potential causes?
|Some genetic link
|What are the potential treatments?
- Coal tar
CIDR has a lot of FoCP's core conditions, so try those quizzes too (link below)