Station 2: Assymptomatic hypertension

Presenting complaints:

Elevated BP


HOPC:

- whether any previous BP readings recorded before, home BP
- symptoms of uncontrolled HTN: headache, giddiness, chest pain, SOB, BOV, ankle oedema, sweating, tremors, weight change, urinary problem (ie: haematuria, oliguria)
- symptoms or history of anxiety disorders (TRO white coat HTN)
- questions to rule out secondary HTN:

•   Thyroid disorder: palpitation, weight change, heat/cold intolerance, nervousness, neck lumps
•   Cushing's : weight gain, acne, back ache, hyperpigmentation
•   Conn's: weakness, palpitation
•   Phaeochromocytoma: palpitation, flushing, headache
•   Acromegaly: headache, visual field defect, increase ring or shoe size
•   Hyperparathyroidsm: weakness, constipation

- caffeine intake 

- snoring, gasping at night, daytime somnolence (for OSA)

- check patient's weight and height ? obese

- in female patient, check LNMP TRO pregnancy

Past medical/surgical history: 

• past history of heart disease, renal disease or endocrine problems
• history of other cardiovascular risk factors:  DM or HLD

Family history:

- FHX of HTN, heart disease or premature CVD, renal disease or endocrine problems


Medications/drug allergies:

- use of steroid (for treatment of other chronic illness (ie: asthma), TCM or anabolic steroid)
- use of OCP
- use of NSAIDS


Social history:

- alcohol history
- smoking status
- dietary history
- exercise or fitness level (? sedentary lifestyle)
- work history
- relationship/marital issue
- ? any stressor recently


Address ICE:

- patient's idea, concern and expectation


Physical examinations:

- check BP (ensure cuff size not too small), measure BP on both upper limb and compare to lower limb
- calculate patient's BMI
- check pulse for radial-radial or radio-femoral delay
- eyes: fundoscopy for papilloedema, flame haemorrhage, hard exudate, AV-nipping, silver wiring
- neck: for goitre
- full cardiovascular and peripheral vascular examination for bruits, murmur, assess for signs of heart failure (raised JVP, bibasal creps, LL oedema)
- check abdomen for palpable ballotable kidney, renal bruits


Investigations:

- at least need separate BP  reading in clinic  or ABPM before confirming the diagnosis of HTN
- renal panel including eGFR, micoalbuminuria, 24-hour UTP, urinalysis for blood, protein and presence of casts
- serum calcium, uric acid
- TFT
- IGF-I
- fasting lipids and glucose, OGTT
- ECG: LVH
- ECG: notching of ribs (for coarctation of aorta)
- plasma renin and aldosterone
- 24 hours urinary cathecolamine and metanephrine
- 8am serum cortisol, 24 hours urinary free cortisol
- 2Decho
- US kidneys

The end

Station 1: Pulmonary fibrosis

Clinical findings:

- breathless, oxygen support ie LTOT
- cyanosis
- bilateral clubbing
- purpura, moon fancies (from steroid)
- lung: symmetrical reduced expansion, dullness on percussion, fine inspiratory crackles
- look out for underlying aetiology:

• RA: symmetrical deforming polyarthropathy, rheumatoid nodule
• SLE: malas rash, alopecia
• polymyositis, dermatomyositis: tender muscle, proximal muscle weakness, heliotrope rashes gottron papules
• ankylosing spondylitis: stooped ? mark posture
• scleroderma: tight shiny face, sclerodactyly, telangiectasia

- assess for complications:

• pulmonary HTN: palpable P2,  left parasternal heave
• cardiac failure: raised JVP, LL oedema, bibasal crepitations

Aetiolgy:

1. Idiopathic - most common is UIP
2. Autoimmune causes: as above, acute causes like pulmonary vasculitis (Churg- Strauss, wegeners)
3. Sarcoidosis
4. Extrinsic allergic alveolitis
5. Drug induced: bleomycin, nitrofurantoin, amiodarone, MTX, cyclophosphamide
6. Radiation fibrosis
7. Occupational/environmetal exposure: asbestosis, silica, coal, beryllium
8. Allergic bronchopulmonary aspergillosis ( ABPA)

Investigation:

- FBC, renal panel, LFT, inflammatory markers,  serum calcium, ACE, ABG
- CXR: bilateral reticulonodular and interstitial shadowing
- ECG: RVH
- HRCT: traction bronchiectasis, basal honey combing, ground class changes
- Lung function test; restrictive defect, reduced lung volume, impaired diffusion capacity
-  serology: ANA, ENA profile, C3/C4, RF and anti- CCP, ANCA (c- ANCA for WG, p- ANCA for  churg- strauss)
- serum precipitins
- Histology
- BAL, VATS
- 2d echo, cardiac cath: for pulmonary hypertension
- 6 minute walk test (to assess functional status)

Management:

- multi-disciplinary approach (respi. rheumato, cardio, physio, OT)
- pharmacological:

• Oral steroid
• Immunosuppressant: cyclosporin, MMF, Azathioprine
• Anti-fibrinolytic: Pirphenidone, Nintedanib (inhibit VEGF)
• treatment of pulmonary HTN: prostanoids (Epoprostenol, Ilioprost), endothelin antagonist (Bosentan), phosphodiestarase-inhibitors (Sildenafil, Taladafil)

- vaccination (pneumococcal, flu)

- LTOT

- pulmonary rehab

- lung transplant 

The end

Station 2: Joint pain

Presenting complaint:

- joint pain

HOPC:

- which joint? symmetrical versus assymetrical? small joint versus large joint (ie: spine)

- duration acute versus chronic, if acute try to establish timeline (how often is the joint flare), duration of each attack

- aggravating or relieving factors ? is it worse with activity or rest

- morning stiffness if presence, duration of EMS

- associated features including swelling, redness, restriction in range of movement, change in sensation, change in color of the joint

- systemic features: fever, loss of appetite, loss of weight, lethargy

- other features suggestive of diagnosis:

• RA: EMS, deformity, presence of nodule at the elbow, any SOB or cough (? ILD), red painful eye (uveitis)
• systemic sclerosis: skin itch and tightening, ulcer at the digits, change in color (? Raynaud's   phenomenon), difficulty swallowing, reflux, change in bowel habit
•  sjogren: sicca symptoms
• SLE: any photosensitivity rashes, hair loss, chest pain (pericarditis), SOB (pleuritis)
• gout: sudden onset, precipitating factors (high purine foods)
• psoriasis: skin rashes (silvery plaques with scaling), family history of psoriasis
• reactive arthritis (Reiter's syndrome): rashes on the feet and sole (keratoderma blenorrhagica), penile discharge, urinary symptoms (uretritis), conjunctivitis, if present need to take further     sexual history
• enteropathic (IBD-related arthropathy): change in bowel habit, mouth ulcer
• anykylosing spondylitis: spine involvement, SI joint pain with EMS, better with activity

- recent trauma or injury

Past medical history:

- of gout, autoimmune illness
- malignancy

Medications, drug allergies:

- use of analgesia ie: NSAIDS
- active medications (ie: HCTZ than can precipitate gout, procainamide or hydralazine can cause drug-induced lupus)

Family history:

- of autoimmune illness- RA, ankylosing spondylitis
- of psoriasis

Social history:

-  occupation -> repetitive strain injury or trauma
- smoking and alcohol history
- how is patient coping at home and work? Any social support
- assess daily ADL and functional status

ICE:

- check patient's ideation, concern and expectation and how the pain impact on their life


The end

Station 5: Acromegaly

General inspection:

- face: prominent supraorbital ridges, large lower jaw, overbiting of frontal tooth (prognathism), increase interdental space, exaggerated facial wrinkles, coarse facial features with increased soft tissue size (ie: nose, ear, lips), macroglossia (** ask patient for old photo**)
- large foot, OA signs of the joint
- sign of hirsuitsm
- voice- husky and cavernous


Hands:

- large, doughy, spade-shaped, thickened skin
- sweaty palm
- assess for carpal tunnel syndrome (tinel's and phalen's, decreased sensation at the medial nerve distribution) or previous scar


Armpit:

- check for skin tag
- acanthosis nigrican


Eye:

- bitemporal hemianopia


Other features:

- DM
- HTN
- hyperTG
- DI
- hypercalcaemia with hypercalciuria
- hypopituitarism

Symptoms:

- excessive sweating
- increase shoe, ring, denture size
- headache
- paraesthesia of the hands and feet
- visual field impairment
- arthralgia
- hypogonadism (amenorrhoea or loss of libido)
- present with DM or difficult to control HTN in clinic


Investigation:

- OGTT  with GH, lack of suppression of GH
- IGF- I
- MRI of pituitary
- test for pituitary hormone function (LH, FSH, oestradiol/testerosterone), ACTH (by using synacthen test), TFT, prolactin
- metabolic screen: fasting glucose, lipid panels, urine dipstick
- screen for malignancy:colono ( due to high risk of colonic polyp)
- visual field testing

Treatment:

Surgery:
1. Trans-sphenoidal (preferred) versus transfrontal (for larger tumour) hypophysectomy

Medical:
1. Dopamine agonist: cabergoline, bromocriptine
2. Somatostatin analogue: octreotide, lanreotide
3. GH receptor antagonist: pegvisamont

Radiotherapy:
1. Stereotactic radiosurgery
2. Conventional radiotheraphy

The end

Station 2: Ascites

Presenting complaints:

- abdominal swelling

HOPC:

- duration: acute versus gradual
- associated features: pain
- site: localized or generalized
- other symptoms:
  - jaundice
  - hamatemesis
  - per rectal bleeding/malaena
  - stool ? pale coloured stool
  - urine  ? dark -coloured urine, frothy urine, oliguria
  - any change in bowel habit
  - systemic symptoms: lethargy, loss of appetite, weight change
  -  cardiac symptoms: SOB/chest pain/ orthopnae/PND or LL oedema
  - heat or cold intolerance
  - fever
  - any lumps in the body

- screening for risk factor: alcohol, h/o hepatitis B and C in the past, medication  (ie: traditional medication)
 
Past medical history:

- h/o liver, renal, cardiac or thyroid disorder
- h/o malignancy
- h/o blood clots in the past ie: DVT/PE, use of OCP
- CV risk factor: DM, HTN, HLD
- is patient on dialysis support?
- previous abdominal surgery

Medication and drug allergies


Social history:

- alcohol history
- h/o illicit drug use
- sexual history
- travel history
- not to forget about occupation, relationship status, family history and smoking history


ICE:
- ask about patient Idea, Concern and Expectation


Differential diagnosis:

1. Cirrhosis with/without portal HTN  (from alcoholic liver disease, chronic hepatitis, autoimmune hepatitis, haemochromatosis, PBC, PSC, NASH, Wilson's diease, crytogenic) * transudate
2. Systemic causes including cardiac (CCF, constrictive pericarditis), renal (ESRF, nephrotic syndrome), hypothyroidsmn, malabsorption * transudate
3.  Intra-abdominal malignancy (ie: liver, ovarian, colon cancer, metastatic) *exudate
4. Chronic pancreatitis *exudate
5. Infective causes: TB peritonitis *exudate
6. If tender and subacute consider Budd-chiari syndrome from malignancy * exudate

** transudate, total protein< 30g/L and exudate > 30g/L

Investigation:

1. Blood test
- FBC, renal panel, LFT including albumin coagulation studies, inflammatory marker (CRP, procal), amylase and lipase, TFT, coagulation profile
- work-up for hepatitis including Hep B, C serology, AFP
- ascitic tap to send for FEME, cell count, ascites fluid albumin, C/S, cytology, AFB smear and C/S, amylase

2. Scan
- US abdomen
- pan-CT
- 2Decho

Management:

1. Not all ascites need to be tap, sometime done for therapeutic purposes with (in transudate) or without albumin cover (exudate)
2. strict I/O charting, daily weight
3. Low Na diet
4. Fluid restriction
5. Diuretic, spironolactone
6. Antibiotic if fever, abdominal pain (risk of spontaneous bacterial peritonitis) - usually with IV Rocephine + flagyl after full septic work-up
7. Treat or optimize underlying causes, alcohol cessation

The end

Neuro examination: Parkinson's disease

PARKINSON'S DISEASE

Pathology:
degeneration of dopaminergic neuron at the nigrostriatal pathway

3 cardinal features:  bradykinesia with rigidity and/or resting tremor

Features in Neurological Examination:

1. General inspection:

-> mask-like facies ('hypomimia') with reduced eye blinking rate, drooling of saliva

-> pill-rolling tremor

2. Assess gait 

-> parkinson patient has difficulty in initiating gait, but when they start walking, their gait tend to shuffle with lack of arm swing with festinating gait (and stooped posture) as if they try to find their centre of gravity, and when they made a turn, it's usually done in small steps like statue (turn 'en bloc')

3. Tone for rigidity

-> at the elbow-> lead-pipe rigidity, at the wrist-> cog-wheel rigidity 

-> in patient that are on medication, the rigidity may not be easily be demonstrated so you may need to bring out by assessing tone in one side of one limb and the other side, ask patient to move their hands up and down and pat their hand on the thigh 

4. Assess for tremor

-> by asking the patient to put their hands on the thigh with the thumb up to the ceiling. If the tremor, not presence, try to distract patient by asking them to close their eyes and count number backward, this will help to bring out the tremor. Make a note whether this is symmetrical or asymmetrical. Idiopathic will be asymetrical/unilateral while parkinsonism from other cause will be symmetrical

5. Assess for bradykinesia (slowing with decrement)

-> assess by asking the patient to tap the thumb with each finger, there will decremental of the amplitude and frequency of succession tap. Same can be demonstrated on lower limb by using heel tap

6. Assess the speech

-> monotonous, low volume

7. Assess the function

-> ie: assess the handwriting for micrographia, by asking patient to button and unbutton cloth

8. Assess for Parkinson plus features

-> vertical gaze palsy in PSP, horizontal gaze palsy in MSA

-> assess for cerebellar features 

At the end of the examination, say you want to take full history of the patient including occupational history, family history and drug history as well as full neurological and cognitive assessment.  You also want to check the standing and lying BP (to check for autonomic involvement such as in MSA).

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ALL ABOUT THYROID IN MRCP PACES

ALL ABOUT THYROID IN MRCP PACES


Based on the instruction given, you may decide on where you going to start your examination first. For example, if the instruction given, 'to assess thyroid status', you can start at the peripheries than onto the thyroid gland. Or if the instruction given, ' to examine the patient's neck', then you may want to start at the neck first and then go onto peripheral when you have extra time.


1. GENERAL INSPECTION
Basic step is ALWAYS your general inspection, inform the patient that you want to stand at the edge of the bed to have a general look first:
-> patient may appeared anxious, fidgeting, myxedema facies (dull, puffy, sparse hair with loss of 1/3 of eyebrow)
-> if you shake patient hands, the palms are warm and sweaty in hyperthyroid patient
-> brief look at the eye and neck , you may noticed exopthalmos or large goitre


2. HANDS
If you start from peripheries, begin with the hands for:
-> sweaty and warm palm
-> check for the pulse for bounding tachycardic and sometime irregular (in AF) pulse
-> nail clubbing ('thyroid acrophachy')
-> stretch the arm to look for tremor
-> Tinels and phalen's test for carpal tunnel syndrome
->  +- Pemberton's sign: ask patient to raise the arms above their head and look for suffusion of face (signs of retrosternal goitre)


3. EYES
-> check for lid lag, lid retraction
-> proptosis
-> corneal involvement with conjunctivae chemosis and redness
-> EOM - assess for diplopia which often due is complex opthalmoplegia  from swelling of intra-ocular muscle


4. NECK
-> check for goitre (assess for size, texture- is it smooth or nodular, is it a solitary of multiple nodule) or thyroidectomy scar
-> check mobility with swallowing (versus with sticking out tongue to differentiate from thyroglossal cyst)
-> palpate for cervical LN
-> listen for bruits
-> check for retrosternal extension


5. LIMBS
-> test power to look for proximal myopathy
-> brisk or slow deep tendon reflxes
-> pretibial myxoedema (waxy, non-pitting oedema with hyperpigmentation and induration due to to stimulation of fibroblast and large amounts of glycosoaminoglycan)


Investigation:

-> Thyroid function test (including T3, T4 and TSH)
-> thyroid antibodies (TSH receptor Ab, Tg Ab, thyroid peroxidase)
-> US thyroid for goitre
-> Radio-isotope scan, if 'cold nodule' -> FNAC
-> CT/MRI neck for retrosternal extension
-> CT scan of orbit, Hertel's exopthalmometer  for eye involvement
-> Serum calcitonin (MEN-2)


Causes of hyperthyroidsm:

1. Graves disease
2. Toxic adenoma
3. Multi-nodular goitre
4. Viral/post-partum thyroiditis
5. Iodide-induced
6. Iatrogenic- over replacement of thyroxine in hypothyroid patient


Causes of hypothyroidsm:

1. Hashimoto thyroiditis
2. Recovery from thyroiditis
3. Iodide- deficient
4. Iatrogenic- over-treatment from anti-thyroid meds in hyperthyroid patient


Management of thyroid patient:

-> Anti-thyroid medication (Carbimazole, PTU). Carbimazole is preferred as once/daily dosing, PTU is preferred as safer in pregnancy but thrice/daily dosing). Risks of agranulocystosis, hepatitis, rashes including Steven Johnson Syndrome. Inform patient, if  develop fever, sore throat, so seek treatment immediately in view of risk of neutropenia.
-> Beta -blockers (ie: Propranolol to help with palpitation and aid to reduce T4-T3 conversion)
-> thyroxine replacement for hypothyroid patient (lower dose in elderly and patient with known heart disease)
-> for hyperthyroid patient, aim for treatment with anti-thyroid medication for 18 months and monitor for relapse. In patient with frequent relapse, other treatment to consider include RAI  (may worsened thyroid eye disease, in mild eye disease, oral steroid should be use as prophylaxis) and thyroidectomy


Management of thyroid opthalmopathy:

-> stop smoking
-> mild: eye drops, elevate the head at night, diuretic to reduce oedema, tinted glass for protection
-> moderate: tarsorraphy surgery, prism put in front of spectacle to help with diplopia
-> severe: treated immediately with high dose steroids, orbital irradiation and plasma exchange as adjunct, if there is no improvement within 72-96 hrs, to consider orbital nerve decompression by surgical removal of the floor and medial wall of the orbit


The end