This is a list of 70 most common cases in PACES

DIABETICRETINOPATHY(41) microaneurysms, blot haemorrhages, hard exudates (Background),circinates of hard exudate near macula, poor acuity (Macularoedema), cotton wool spots, flame haemmorhages, leashes of newvessels, photocoagulation scars(proliferative), vitreoushaemorrhage/scars, retinal detachment (advanced diabetic eye dx).may be bp, cateract. indicationsfor referral:all except background, refer background involving macula.indicationsfor photocoagulation:pre-proliferative (cotton wool spots, multiple blots, venousbeeding) or proliferative retinopathy.
RHEUMATOIDARTHRITIS (31)symetricaldeforming arthropathy, spindling of fingers. PIP, MCP swelling, DIPspared, muscle wasting, deformity, pain. nodules at elbow/dorsumhand, ulnar deviation, nail fold infarcts, arteric lesions. warmthand swelling sugests active inflam. swan neck, boutonniredeformity, Z thumb, palmer erythema, anaemia, episcleritis, CVS/RESPsigns. causesof anaemia:chronic dx, nsaids, myelosupressive drugs, feltys, assoc perniciousanemia. treatment:general (education, excercise, physio - thermal, splinting, diet),NSAIDs, DMARDs (1st line: methotrexate, sulphasalazine, gold,penicillamine, (hydroxy)chloroquin, 2nd line: azathioprine,cyclophosphamide, chlorambucil), corticosteroids (7.5 mg/day withcalcium, bisphophanates), biological agents.
EXOPTHALMOS(26)(protrusionof eye revealing sclera above lower lid on forward gaze). bilateralasymetrical swelling of medial caruncle, congestion of lateralcanthus, and exopthalmos. look for pretibial myxoedema, thyoidacropachy. gravesmalignant exopthalmos:may be eu/hypo/hyperthyroid with severe exopthalmos, chemosis,exposure keratitis, corneal ulceration, painful opthalmoplegia(lateral, upward and convergent). due to muscle infiltration,oedema, fibrosis. sight threatening due to optic nerve pressure. Rx:steroids, tarsoraphy (scar), orbital decompression, radiotherapy.Causes:hyperthyroid graves dx, euthyroid graves dx, hypothyroid graves.asymetrical: cavernous sinus thrombosis, carticocavernous fistula(pusatile), unilat: retroorbital tumour, orbital celulitis (Hertelexopthalmometer) Treatment:lubricant eye drops, avoid smoking, wrap around glasses, optimizethyroid status. radioiodine may worsen exopthalmos.
ACROMEGALLY(24) prominent supraobital ridges, large lower jaw, exageratedwrinkles, full lips, malocclusion/prognathism, interdental spaces,nose/tongue/ears enlarged, kyphosis, large doughy spade hands, thickskin, carpal tunnel syndrome, excesive sweating, 1/3 hersuit, husky,cavernous voice, bitemporal hemianopia. Others: shoe/hat size, bowedlegs, rolling gait, gynaecomatia, gallactorhoea, large/small testes,acne, greasy skin, skin tags (colonic polyps), acanthosis nigricans,osteoarthrosis, prox muscle weakness, cardiomegally (bp,cardiomyopathy), CN3 palsy. Associations:DM, bp, hyercaliuria, hypercalcemia (if MEN1=pipa=pituitry, isletcell, parathyroid, adrenal), urolithiasis, hyperTG, diabetesinsipidus, hypopituitrism. Inv:IGF1, GTT absent GH supression, MRI pituitry, visual fields, oldphotos, SXR, ant pit tests (short synACTHen, ITT, TSH, T4,oestadiol, LH/FSH, testosterone, prolactin). Rx:trnasphenoidal/transfrontal hypophysectomy, external irradiation,gold/yttrium implants, bromocriptine (no shrinkage), somatostatinanalogues (shink). cause:99%pit adenoma, 1% gangliocytoma
CHRONICLIVER DISEASE(21) icterus, pigmentation, clubbing, leuconychia, palmer erythema,Dupytrens, spider naevi, flapping tremor, scratch marks, purpura,gynaecomastia, scanty body hair, small testes, hepatomegally,splenomegally, ascites, ankle oedema, distended abdo veins flow away+/- cyanosis from pulm-venous shunts. consider transplantation.causesalcohol, viral hepatitis, autoimmune CAH, haemochromtosis,cryptogenic. other: cardiac failure, constrictive pericarditis, BuddChiari, 2ry billiary cirrhsis, drugs (methotrexate, mehydopa,isoniazid, CCl4, amiodarone, aspirin, phenytoin, propylthiouracil,sulphonamides), Wilsons dx, alpha1antitrypsin def, metabolic(galactosemia, tyrosinemia, glycogenosis4)
FIBROSINGALVEOLITIS(21) sob, clubbing, steroid purpura, reduced symetrical expansion,fine inspiratory crackles (+/- cyanosis, dullnes lung base, LTOT)causescryptogenic, rheumatoid, conn tissue disorders (systemic sclerosis,SLE, polymyositis, dermatomyositis, Sjorgens), ankylosingspondylitis, extrinsic allergic alveolitis, asbestosis, silicosis,drugs (bleomycin,buslphan, nitrofurantoin, amiodarone), radiationfibrosis, chemicals (Berylium, mercury), poisons (paraquet), ARDS.
PROSTHETICVALVES(17) Mitralvalve prosthesismidline sternotomy, S1 prosthetic click, diastolic opening click +/-mid diastolic flow murmur, pansystolic murmur/failure suggests leak.Aorticvalve replacementmidline sternotomy, normal S1, systolic opening click, prosthetic S2+/- systolic flow murmur, early diastolic murmur/collapsing pulsesuggests leak Complictionsthromboemolism, haemorhage, endocarditis, valve leak, dehiscence,Starr-Edwards ball embolus, valve obstruction (thrombus/fibrosis),haemolysis.
HEPATOSPLENOMEGALLY(17) spleen enlarged..cm below costal margin. Liver palpable ... cmbelow right costal margin. Check for anemia, lymphadenopathy,chronic liver disease and renal enlargement. Causes:myeloproliferative,lymphoproliferative (CLL, lymphoma), livercirrhosis with portal hyperension, infections (hepB/C, EBV, CMV),zoonoses (brucella,weils, toxplasma), megaloblastic anemia, storgedx (gauchers, glycogen storage), amyloidosis, sarcoidosis,buddchiari=hep vein thrombosis, infantile PKD. worldwide causes:malaria, kala azar, schistosomiasis, TB.Bruit suggests hepatoma.
PNEUMONECTOMY(16) chest wall deformity, with flattened L side associated ith Lthoracotomy scar, L tracheal deviation, L expansion reduced,percussion dull, breath sounds diminished. Bronchial breathing Lupper zone due to tracheal deviation. Llower lobctomydeformity chest, L lower ribs pulled in, L thoracotomy scar, tracheacentral, apex displaced L, percussion dull L lower zone, breathsounds diminished. Indicationsfor pnumonectomy25% non small cell ca (2-6% mort), solitary pulm nodule of uncertaincause, treatment unresponsive bronchiectasis, TB in preantibioicera.
RETINITISPIGMENTOSA(16) widespread scattering of black pigment resembling bonespicules, the macula spared. There is tunnel vision and nightblindness. Associaions: cateracts, deaf mutism, mental deficiency.Othercauses of pigmentary degenerationLaurence Moon Biedl, Refsums dx, hereditary ataxia, familialnuropathy, neuronal lipidoses (ceroid lipofuscinosis).
SYSTEMICSCLEROSIS(15) middle aged female, skin smooth, shiny, tight fingers and face.Raynaulds, atrophy of finger tips, telangectasias face,pigmentation, nodules of calcinosis palpable on some fingers. other:skin ulcers, vitiligo, Sjorgens, diffuse intersitial fibrosis(leading cause of death) Rx vasoilators. othersystems:CREST, renal (bp, failure), CVS (cardiomyopathy, effusion), muscle(myositis, arthritis), intestinal hypermotility, PBC. Treatment:general (education, exercise, lubricants), Raynauds (calcium chblockers, ACEi, proscycline, calcitonin GRP), oesophagus (PPI,prokinetics=cisapride), malabsoption (low residue diet, supplements,rotational abx), renal (ACEi, steroids), pulm vasc dx(vasodilators),fibrosis (dpenicillamine, corticosteroids).
POLYCYSTICKIDNEY DISEASE(14) bilateral flank masses, bilaterally ballotable, can get abovethem, percussion resonant, abdominal scarsfrom CAPD/cystaspiration,AV fistula,uremic facies, hypertension, renaltransplant, parathyroidectomy. Complications:flank pain, bleeding, uti, nephrolithiasis, obstrucive uropathy.Otherfeatures:berry aneurysm, mitral valve prolapse, renal cell carcinoma.Genetics:PKD1 (Ch16, 85%, renal failure), PKD2 (Chr4, 15%), PKD3 rare. Livercysts:rare in adult AD-PKD, common ininfantile AR-PKD. Screening:U/S and genetic testing at 20 years (inconclusive before 20),earlier if FH aneurysm, signs renal dx. Bilateralrenal enlargement:polycystickidney dx, bilateral hydronephrosis, amyliodosis, tuberoussclerosis, von Hippel Lindau disease.
MITRALREGURGITATION(13) pulse regular, JVP not raised, no ankle/sacral oedem unlesscardiac failure, thrusting apex suggestng volume overload in 6 ICS,ant axilliary lne, possible systolic thrill, left parasternal heave,Soft S1, S3 suggests severe MR. Loud pansystolic murmur at apexradiates to axilla. MR with pulm bp. Causes:degenerative, rheumatic heart dx, severe LV dilatation, MV prolapse,papillairy muscle dysfunction, previous valvotomy for mitralstenosis, infective endocarditis, annular calcification,hypertrophic cardiomyopathy, chodrae rupture, congenital (marfans,erhler danlos, pseudxanthoma elasticum), endocardial fibrosis.Indicationssurgry:SOBOE despite ACEI,/diuretics, increased end systolic volume (>30 ml/m2), serial echo progressive LV dilatation, valvuloplasty +/-annuloplasty preferable due to dec mort/no anticoagulation. Mitralvave prolapse:post leaflet LSE, ant eaflet over spine.
SPLENOMEGALLY(13) mass left hypochondrium, cnnot get above it, there is a notch.It moves diagonally cross abdomen, percussion is dull over leftlower chest and mass. I think this is a spleen enlarged at..cm.Causes:v.large:CML (Ph chr t9;22), myelofibrosis, makaria/kala arar. Large(4-8cm):myeloproliferaive(CML, myelofibrosis), lymphoproliferative (lymphoma, CLL), cirrhosiswith portal hypertension. Small(2-4 cm):myeloproliferative, lymphoproliferative, cirrhosis with portalhypertension, infections (EBV, hepatitis,SBE)
NEUROFIBROMATOSIS(13) multiple (5+) neurofibromas, sessile pedunculated fibromatasome soft others firm, some single others lobulated, some mobilesubcutaneously lumps others nodules along peripheral nerves, cafe aulait spots,2/3 axilliary freckling, Lisch nodules=iris harmatomas,retinal harmatomas, rib nochiing, mental retardation, epilepsy,renal art stenosis. complications:kyphoscoliosis, pressure effect (acoustic neuromas CN5-8, cerebellarsigns), CN5 neuroma, spinal nerve root, sarcomatous change, lungcysts (honeycomb lung), pseudoarthrosis, plexiform neuroma.Canalso have:glioma, meningioma, medulloblastoma. Genetics:aut dominant , NFT1=von Ricklenhausen (chr 17), NFT2 (chr 22)bilateral acoustic neuroma
BRONCHIECTASIS(12) underweight, cyanosed, sob, finger clubbing, frequentproductive cough, sputum pot, inspiratory ? heard with unaidedear, localised crepitations, may be widespread ronchi.. causes:childhood infections (whooping cough, measels, TB), cystic fibrosis,bronchial obstruction (foreign body, carcinoma, sarcoid,lymphadenopathy and fibrosis), hypogammaglobulibemiam, allergicbronchpulmonary aspergillosis, Marfans,yellow nail, congenital(defomity, Kartageners) , smoking related copd (common)
PSORIASIS(12) (11) Asymetrical arthropathy involving mainly TIP, pitting offingernails, onycholysis, some nail plates thickened, hypetkeratosisunder them.Patches of psoriasis over bony prominemces particularlyelbows, knees, trunk, scalp, intragluteal cleft, behind ears, innavel. Plaques circular, well difined edges, red, silvery scalysurface. Otherarthropathy:arthritis mutilans, Rheumatoid-like, oligo/mono artthropathy,ankspondtreatmentlocalsunlight, uv light, coal tar, dithranol, local steroids,calipotriol, PUVA (psoralen and uv light). Treatmentsystemic:acitretin (retinoid), antimetabolites (sulphasalazine, methotrexate,azathioprine, hydroxyurea). Analgesic anti inflam for arthropathy,intraarticular steroids. Chloroquin contraindicated worsens skin.Incidence5% Caucasian, NW europe, USA. Uncommon in Japanese, N AmericanIndians, Japanese.
OSLERWEBER RENDU(11) (heridatary haemmorhagic telangectasias) Telangectasias onface, around mouth, on lips, tongue, buccal and nasal mucosa andfingers. Anemia but no features of systemic sclerosis.complications:GI haemorhhage, epistaxis, hemoptysis 2ry to pulm AV aneurysms,conjunctival telagactesias (bloody tears), retinaldetachment/haemorrhage, cirrhosis (telangectasias/transfusion),massive intrahepatic shunting Treatment:chronic oral Fe therapy, oestrogens to induce squamous metaplasia ofnasal mucosa, low dose finbrinolytic agents (aminocaproic acid),pulse dye laser NOT cautery. Genetics:Autosomal dominant, several gene defects possible.. non contractilecapillaries cause prologed bleeding.

PLEURALEFFUSION(10) Pulse regular, JVP normal, trachea usually central,expansionnormal, percussion stony dull at R/L base, diminished TVF, VR anddiminished breath sounds. May be bronchial breathing over effusion.CausesExudate(>30 g/l,LDH >200) bronchial carcinoma, secondarymalignancy, PE with infarction, pneumonia, TB, mesothelioma,rheumatoid arthritis, SLE, lymphoma. Transudate (3 finger breaths). Chest hyperinflated,expansion mainly verticle, tracheal tug. Accessory musclesrespiration, indrawing of lower ribs on inspirationdue toflattened diaphragm. Percussion hypersonant obliterating cardiac andhepatic dullness, breath sounds quiet in classical emphyema, wheezesare often heard if associated bronchial dx. SOMETIMES decreasedbreath sounds over the upper/middle/lower zoneof R/L lung raisespossibility of emphysematous bulla. ChronicBronchitismale smoker, foggy city, dust/fumes, frequent respiratory infection,classical blue bloater. Nicotine staining, stocky,centrally cyanosed, suffused conjuntivae. Hyperinflated chesevidenced by use of accessory muscles on inspiration and trachealtug, pulse 80 bpm, venous pressure not elevated (ankle oedema,hepatomegally if cor pulmanal present), trachea central,suprasternal notch to cricoid distance reduced. Expansion equal butreduced to 2 cm, percussion note resonant, auscultation: expiratoryphase prolonged, widespread expiratory ronchi (and may be coarsecrepitations). Forced expiratory time 8 seconds, no flapping tremor(unless severe hypercapnoea in which case fundi papilloedema). Possibly cor pulmanale if ankle oedema. Definitions:Emphysema = pathological diagnosis, chronic bronchitis = coughproductive of sputum on 3 months of the year in 2 consequtive years.COPD = obstructive spirometry. Causesof empysema:smoking (assoc with chronic bronchitis mixed centrilobular andpanacinar), alpha1atitrypsin deficiency (young, lower zone,panacinar ?iceterus, hepatomegally), coal dust (centrilobularemphysema simple coal dust pneumoconiosis only minorabnormalities of gas exchange), Macloed's syndrome (Swyer-James rareunilateral emphysema following childhood bronchiolitis andsubsequent impaired alveolar growth.
CARCINOMABRONCHUS(0,8) LOOK FOR RADIOTHERAPY TATOESCarcinomabronchus with pleural effusion:Clubbing, nicotine staining, hard lymph node in R/L supraclavicularefossa, pulse regular, JVP not elevated, trachea central, chestexpansion normal, persussion stony dull at R/L base, tactilefremitus, vocal resonance and breath sounds all diminished over areaof dullness. Carcinomaof bronchus with radiation therapy:cachectic, radiation burn R/L upper chest, clubbing, noctinestaining, pulse regular, JVP nor elevated, no lymph nodes. Tracheadeviated to R/L, expansion diminished R/L upper chest, TVF andresonance increased over upper chest, dull percussion note, area ofbronchial breathing. Likely radiotherapy for carcinoma bronchuscausing collapse and consolidation of /L upper lung. Pancoast'ssyndrome:radiation burn to chest, lymph nodes palpable in R/L axilla, tracheacentral, chest signs normal, wasting of small muscles of R/L hand,sensory loss +/- pain over T1 dermatome (can be C8-T2), R/L Horner'ssyndrome (ptosis, myosis, anhydrosis, enopthalmos). This ispancoast's syndrome due to apical carcinoma involving the lowerbrachial plexus and cervical sympathetic nerves. Lobectomy:R/L thoracotomy scar, trachea deviated R/L/ R/L chest expansiondiminished, percussion resonant, breath sounds harsher. R/Llobectomy for removal of tumour, resistant lung abscess or localisedbronchiectasis. Complications:localeffects:SVC obstruction (?oeema face/upper extremities, suffusion eyes,fixed engorgement of neck veins, dilataio superficial veins),stridor (SVC obstruction, dysphagia). Metastasesand their effects (pain,?hepatomegally, neurological signs). Nonmetastatic effects:HPOA wrists/ankles, peripheral neuropathy, cerebellar degeneration,encephalopathy, priximal myopathy, polymyosistis, dermatomyositis,Eaton Lambert syndrome), SIADH, ectopic ACTH, PTH,PTHrP, carcinoid),gynaecomastia (?HCG secreting tumour?), thrombophlebitia migrans,non bacterual thrombotic endocarditis, anemia (usually normoblastic,occasionally leucoerythroblastic), pruritis, Herpes zoster,acanthosis nigricans, arythema gyratum repens (irregular wavy bandswith marginal desquamation on trunk, neck and extremities).
HYPERTENSIVERETINOPATHY(0, 8) Narrow retinal arterioles (normal AV ratio 1:1), may betortuous, varying calibre, increased light reflex (copper/silverwiring), AV nipping (all occur in aging, arteriosclerosis,hypertension). Flame haemmorhages and blot haemorrhage , cotton woolexudates (this constitutes grade 3 retinopathy and a diagnosis ofmalignant (accelerated) hypertension even without papilloedema),there is papilloedema (cerebral oedema or malignant hypertension haemorrhages and exudates not necessary). This is grade 4retinopathy. Causesof hypertension: essential(94%), renal (4% - ?RAS, acute nephritis, PKD), endocrine 1%(cushing's, conn's, phaechromocytoma, acromegaly, hyperPTH,hypothyroidism, OCP), miscellaneous