RRHHEEUUMMAATTOOLLOOGGYY MMCCQQSS

Q. APPROACH TO A PATIENT WITH CT DISEASE?? (ORAL) 1) Clinically history-exam(articular & extra)

2) Auto Ab detection.

3) ESR-CRP.

4) Radiology.

ESR USED FOR FOLLOW UP & NOT THE DIAGNOSIS / CAUSES OF HIGH ESR???

1RY SCLEROSING CHOLANGITIS ANCA +VE

SLE

ARTHRITIS M/C presentation(not the skin)

DRUGS CAUSING SLE add: phenothiazines-OCP-grisiofulvein

M/C CARDIAC pericarditis

BLOOD pancytopenia

PSYCHOSIS IN SLE disease itself or steroid therapy.

LUPUS NEPHRITIS biopsy reveals??? silver wire.

ANA IS THE MOST SENSITIVE BUT…..anti DNA is the most specific

P.17: OTHER INDICATIONS OF PULSE STEROIDS.

POLYMYOSITIS

Associated with HLA B8 & HLA D3

Should exclude before diagnosing Duchenne & Baker. (untreatable)

VASCULITIS PAN use pulse steroidin case of RPGN(add to TTT)

TAKAYASAU'S bruit over left subclavian & CCA

DD OF ARTHRITIS

1) COLLAGEN D. SLE- sero-ve- OA- Rh. fever – HSP - still's – Kawasaki – RA.

2) METABOLIC gout & pseudogout

3) INFECTIONS viral-TB-septic-lyme disease???

4) LYME: CA Boriella Burgdorfi(spirochetes)-

MOT tics after safari or camping

Cl./P M-P rash / Arthralgia bilateral – symmetrical - knee joint.

TTT doxycycline & amoxicillin.

5) REACTIVE 6) MISCELLANEOUS: malignancy-sickle cell-hemophilia-chondro malacia -trauma-

hemarthrosis

RHEUMATOID more extra articular with RF +ve patients.

PSORIATIC ARTHRITIS erythmato-squamus rash on extensor aspects of limbs.

KCS ass. with pernicious anaemia.

PPHHYYSSIIOOTTHHEERRAAPPYY IINN OOFF AASS??????

1) NECK orthosis.

2) CHEST breathing exercise.

3) LUMBAR & SACROILIAC swimming.

4) KYPHOSIS orthosis. (thoracolumbar jacket)

AS: associated with bilateral fibrocavitary diseases in lung(case of AS + progressive dyspnea)

SCLERODERMA

CAUSES OF CYANOSIS??? IPF(central)- Raynauds (peripheral)

CLUBBING & PSEUDO-CLUBBING.

M/C OF DEATH Cardiac causes.

INVEST. add NAIL FOLD CAPILLOROSCOPE(early diagnosis of Raynauds)

TTT Most. Imp. Is to warn the patient to wear gloves & socks in cold weather

USES OF COLICHICINE 1) GOUT & PSEUDOGOUT

2) BEHCET

3) FMF

4) LIVER???

5) SCLERODERMA

6) PSEUDO-PSEUDO GOUT

CHONDRO-CALCINOSIS:

Common in patients with PREVIOUS HISTORY OF OA (PREVIOUS JOINT DISEASE)

ADD COLICHICINE in TTT for prophylaxis

PSUDO-PSEUDO-GOUT:

CAUSES MILWAUKEE SHOULDER(destruction & Hgic effusion)

CCC. in ESRD

OSTEO-ARTHRITIS:

Affects the whole joint. (MCQ)

1st event matrix loss. (MCQ)

SEPTIC ARTHROPATHY:

Joint aspirate Glucose & proteins in

Common in Osteoarthritis.

M/C site hip.

OSTEOPOROSIS:

CAUSES ADD Malignancy-coeliac enteropathy-anorexia nervosa-pregrancy

1ST SYMPTOM FRACTURE(very important-MCQ)

INVEST. DEXA SCAN: > 2.5 SD IS DIAGNOSTIC 2 TYPES:

a) Z-score compare to normal person of the same age

b) T-score compare to normal young adult

It's measured in grams hydroxyl appetite/cm2

TTT. SERM (RALOXIFIEN) IS A NON- CARCINOGENIC HRT.

GGIITT MMCCQQss DISEASES OF SALIVARY GLANDS:

Anorexia ; bulemia nervosa lead to salivary gland Swelling due to purgatives

Xerostomia: oral breathing, polyuria ; polydepsia

OTHER OESPH DISEASES: 1) CAUSTIC OESP INJURY: KOH, delay endoscopy, never induce emesis, precancerous

2) PLUMMER VINSON:

middle age female.

dysphagia, iron; vit B12 def anaemia, splenomegaly in a

precancerous

3) ZENKER'S DIVERTICULUM:

Etiology protrusion of post pharynreal wall (cricopharyngeus ms non-relaxing)

C/O double phase swallowing.

Aspiration not related to swallowin.g(MCQ)

Invest avoid endoscopy(dangerous)(MCQ)

TTT diverticulectomy-myotomy

BISMUTH black stools ; masks melena.

TTT OF ACUTE HEMATEMESIS ; MELENA packed RBC's ; Colloid transf. (repeated MCQ)

VARIANTS OF ACUTE GASTRITIS eosinophilic-allergic-lymphocytic-granulomatous-

reactive (gastric antral telangectasia)In investigations: blood urea only without creatinine.

PYLORIC STENOSIS

urinary pH < 5.

metabolic alkalosis tetany, dehydration ; pre-RF

MMAALLAABBSSOORRPPTTIIOONN:: GIARDIA ccc. by IgA.

HYPOTHYROIDISM malabsorption

GLUTEN:

a) Milk intolerance.

b) Other investigations T3-T4 ; BS.

c) Causes Cancer oesphagus.

d) causes of subtotal villous atrophy: Whipple - gastrinoma -hypo- globulin - tropical sprue.

TROPICAL SPRUE milk intolerance + steatorrhea + Fat sol. Vitamins. ADEK.

BLIND LOOP steatorrhea + Fat sol Vitamins. ADEK.

WHIPPLE HLA B27

INVEST. OF MALABSORPTION:

a) FECAL FAT gold standard(1st step)

b) BIOPSY most definitive.

c) DON'T FORGET PT; INR ( vit K)

TUMORS IN GIT (MCQ)

1) CANCER OESOPH. gluten enteropathy is 1 of the causes

2) CANCER STOMACH Menetrier $ is a RF. (repeated MCQ)

LARGE MUCOSAL FOLDS IN STOMACH (MCQ LAST YEAR ; LANGE)

PROTEIN LOSING ENTEROPATHY.

3) GASTRINOMA liver metastasis is a common.

4) VIPOMAS SECRETORY DIARRHEA doesn't resolve by fasting

5) M/C 1RY MALIG. TUMOR OF SI adenocarcinoma bleeding / rectum iron def.

6) 1RY INTESTINAL LYMPHOMA ttt by ABS in early stages…. occurs on top of Coeliac D.-Crohn's- HIV.

7) TUMORS OF THE DISTAL PART OF SI lipoma ; cacinoid

8) CANCER COLON: M/C GIT carcinoma palpable per rectum

9) CARCINOID:

M/C ENDOCRINAL TUMORS OF GIT.

SITE appendix.

Intestinal ischemia is common - Granuloma in liver

1ST LINE OF INVEST. (HIAA)

1ST LINE OF TTT Octreotide.( Acromegaly-insulinoma-ruptured varices)

10) FAMILIAL Polyposis: no clubbing / Intussusceptions / Dysentry.

11) TUMORS IN BILIARY SYSTEMS

1) CHOLANGIOSARCOMA:

Cause GB stones; ulcerative colitis.

Cl./P abd. Pain; obst jaundice -ALP > 3X

TTT palliative

2) CARCINOMA OF THE GB:

Adenocarcinoma

Usually uncurable at presentation-obst. Jaundice

INFLAMMATORY BOWEL DISEASE 1) ULCERATIVE COLITIS:

2ry milk intolerance.

Sulphasalazine DOESN"T RISK FOR CANCER OR PREVENT INTESTINAL OBST.

2) CROHN'S: 2ry milk intolerance or subacute intestinal obstruction-Strictures.

3) COMPLICATIONS OF IBD:

a) toxic megacolon can occur in crohn's

b) mouth ulcer “Aphthus Ulcer”

c) in crohn's biliary ; renal stones are common

d) CBC Megaloblastic An???VIT B12 def. (T. ileum affection)

DIVERTICULITIS:

# NSAIDS.

Complications paralytic ileus ; septicemia-abscess

TTT 1st line is DIETRY FIBERS. (MCQ)

PSEUDO-MEMBRANOUS COLITIS

CAUSES CLINDAMYCIN ; CEPHALO SP.

INVEST. CL. DIFICILE TOXIN IN STOOL

TTT. VANCOMYCINE + MDTRONIDAZOLE.

GALL BLADDER: 1) CBD diameter should be < 8mm-

2) M/C GB stones cholesterol.

3) IMAGING

a) PLAIN X-RAY usually radiolucent.

b) US most imp.….. size of stone ; intra-hepatic biliary dilatation indication to:

c) ERCP extrahepatic biliary obstn

TTT OF ACUTE CHOLYSYSTITIS AMPICILLIN ISN'T USED NOW

1RY SCLEROSING CHOLANGITIS MAINLY INTRAHEPATIC(MCQ)

PANCREAS CYSTIC FIBROSIS:-sever steatorrhea-glaucose intolerance-peptic ulcer-the pathology is:

widespread obstn in pancreatic ductules

ACUTE PANCREATITIS:

a) M. avium is a cause in HIV patients.

b) Prayer's postion

c) on auscultation: bowel sounds(paralytic ileus)

CHRONIC PANCREATITIS:

NO OF s. AMYLASE. (only in acute)_

Stones aren't a cause??????? (not sure of this….found in LANGE)

RENAL FAILURE false in amylase. (MCQ)

PANCREATIC DIVISM chronic pancreatitis

INTESTINAL TB mainly ileocaecal - perianal fistulas-granulomatous hepatitis-pain without alternation in bowel habits

MALIGNANT ASCITIS sister Mary Joseph nodules in umbilicus.

FUNCTIONAL GIT DISORDERS somatoform disorders(MCQ)

LLIIVVEERR MMCCQQSS HHIISSTTOOLLOOGGYY && LLIIVVEERR IINNVVEESSTT..

HEPATIC ARTERY SUPPLIES 25% of the cardiac output ; 50% of the total hepatic O2 supply

ALT early diagnostic / but AST early prognostic

1ST TEST LIVER DISEASE TRANSAMINASES

P.8: GT only liver enzyme affected by enzyme inducers(MCQ)

IGG chronic hepatitis while IgA alcoholics ; liver cirrhosis

VVIIRRAALL HHEEPPAATTIITTIISS

IGA responsible for the be - bridging in liver cirrhosis(CLINICAL PATHOLOGY)

HAV the highest cholestasis

HBV usually in the prodroma there's polyarthritis

CARRIER no enzyme elevation

CHRONIC HEPATITIS enzymes.

PROLONGED JAUNDICE Gilbert-relapse: SGPT

HSV, YELLOW FEVER sever necrosis + liver enzymes

MONONUCLEOSIS DISEASES?? IMN-CMV-TOXOPLASMOSIS-EBV…..

JAUNDICE Chronic hepatitis(direct) ... AIHA. (indirect)

CCIIRRRRHHOOSSIISS

CHRONIC ACTIVE HEPATITIS INTERFACE HEPATITIS(MCQ)

H. HAEMOCHROMATOSIS HLA A3(MCQ)

WILSON causes FANCONI $

MALLORY HYALINE WILSON – PBC -alcoholic-NASH

1RY BILIARY CIRRHOSIS mainly intrahepatic.

HEPATIC ENCEPHALOPATHY

CHRONIC LIVER DISEASE WORSE THAN ACUTE…WHY??? Due to affection of:

ASTROCYTES(ischemia)_OLIGODENTROCYTES(decreases the nerve conduction)

BUT IN ACUTE no pathological changes

1ST AID Enema + FLAGYL

DD OF ENCEPHALOPATHY hypoglycemic coma (remember DD of DELIRIUM???)

…SO THE 1ST AID IV Dextrose 10%

FULMINATE HEPATITIS

Acute fatty liver of pregnancy - REYE's –TETRACYCLINE.

all cause mitochondrial damage(MCQ)

THERE"S NO HSM – ascitis - low albumin(ACUTE)(MCQ)

PORTAL HTN:

IN POST-SINUSOIDAL ADD 1) IVC obstn (in BEHCET)...

2) Cardiac causes???TVD-RVF-constrictive pericarditis

PATIENT WITH LCF…BLEEDING??

1) Bleeding tendency. (due to low coagulation factors)

2) Peptic ulcer.

3) Rupture varices.

BA SWALLOW SHOWS worm like filling defects

COMPLICATIONS add hepatorenal $

HCC HEPATIC BRUIT MAAMON's sign

ONLY CURATIVE TTT Transplantation.

SURGICAL RESECTION IF good GC - (no decompensation)

FATTY LIVER PEM(MAINLY KWO)

M/C CAUSE OF NASH DM(repeated MCQ)

INVESTIGATIONS CT is better than Sonar

JJAAUUNNDDIICCEE:: I. BILIRUBIN Causes constipation-neonatal jaundice-cholestasis…

INTRA-HEPATIC add 1ry biliary cirrhosis(MCQ)

EXTRA-HEPATIC add cystic fibrosis

GILBERT defect in Z-Y receptors(MCQ)

JAUNDICE + LEUCOCYTOSIS SBP (the 1st to think of)

DDRRUUGG IINNDDUUCCEEDD

ENZYME phentoin-carbamazepine-rifampicine_i

ENZYME (-) barbatirates

ZONE 3 the most affected.

OCP ON LIVER cholestasis(stones)-adenoma-budd chiari-

DRUGS CAUSING FIBROSIS ;CIRRHOSIS methotrexate-

VIT A-GRANULOMAS allopurinol-amiodarone-acetaaminophen is toxic through it's active

metabolite >>> antidote ... N-acetyl cystein(MCQ)

OTHERS ADD TO POSTOPERATIVE JAUNDICE: accidental ligation of bile duct-synthetic valve-infection.

BUDD-CHIARI all liver is congested except >>> caudate lobe

TRANSPLANTATION Add to indications: cryptogenic cirrhosis - HCC- intrapulmonary

shunts-1ry ; 2ry biliary cirrhosis, cholangiosarcoma(MCQ)

add to# disseminated malignancy

PREGNANCY ALP-clotting factors(budd chiari)-stones(Lecture)

ADD TO EMERGENCIES acute fulminating hepatitis