Adult Health: Medicine Flashcards
Rheumatology
18, female, healthy, pain in MCP, PIP, no redness. Ab ANCA 1;160, mono What initial treatment?
A. Methotrexate
B. sulfasalazine
C. hydroxychloroquine
D. prednisolone
E. paracetamol
C. hydroxychloroquine. Might also supplement with NSAIDs, best modality.
Joints involved for SLE: MCP, PIP, wrist & knees.
For this patient, highly likely its due to SLE (young, healthy, woman, Positive I assume ANA, not ANCA due to titre results.)
Management for SLE
- Control disease activity.
- Hydroxychloroquine is effective treatment for SLE, especially for rash and arthritis.
○ Protective effect in reducing damage accrual in longterm
- NSAIDs or low-dose steroids for mild symptoms. Moderate-to-high steroids for more severe manifestations.
Values for ANA (antinuclear antibodies are positive for 1:160 titres and higher)
Normal ANCA values differ (0 - 0.22 units/mL) ANCA is antineutrophil cystoplasmic antibody.
**Case studies from RACGP: **
To evaluate what is severe/not severe/mild!
Case study 1
A medical student, aged 24 years, presented with a 3-month history of fatigue and arthralgia. She has occasional mouth ulcers and alopecia. She has a photosensitive rash on her face. Investigation results:
ANA 640 homogenous, positive anti-Ro, ESR 30, lymphopenia, low C3
Normal urinary sediment and negative for protein.
She was diagnosed with SLE, and treated with NSAIDs as required and hydroxychloroquine.
Case study 2
A 35-year-old mother of two, presented with 6-month history of fatigue, lethargy and arthralgia. She has had intermittent episodes of chest pain with one presentation to emergency department without a specific cause found. She has now noticed increased swelling in her legs with puffy eyes. Investigation results:
Urinary protein to creatinine ratio 0.38 (normal 0.02), MSU showed glomerular red cells, ESR 40, albumin 32
ANA 1280 homogenous, positive anti-dsDNA and anti-Sm, low C3 and C4.
She was diagnosed with SLE, with renal biopsy showing Class IV lupus nephritis. She was treated with pulsed steroids and commenced on mycophenolate.
Case study 3
A sales executive, aged 48 years, presented with a prolonged episode of chest pain and was found to have acute coronary syndrome when she presented to emergency department. She was a non-smoker and had no relevant family history. Her background history included two episodes of pericarditis in her twenties, intermittent arthralgia and occasionally a low platelet count was noted. She also had two previous miscarriages. Investigation results:
ANA 320 homogenous, positive anti-dsDNA, ESR 25, low neutrophil and platelet counts, low C3/4, normal urine sediment and no proteinuria
Coronary angiogram found an irregular LAD with greater than 70% stenosis in the mid portion which was treated with thrombolysis, and a stent was inserted.
She was diagnosed with SLE, but current presentation was probably not due to active disease. She was started on hydroxychloroquine. In the next few months, she had an exacerbation of joint pain and was found to have synovitis at her wrists. Methotrexate was added to control her symptoms.
ANCA positive disease:
1) Granulomatosis with polyangiitis (GPA or Wegener granulomatosis)
2) Eosinophilic Granulomatosis with polyangiitis (EGPA or Churg-Strauss syndrome)
3) Microscopic Polyangiitis (MPA)
4) Drug-induced vasculitis
5) Renal limited vasculitis
Cardiology
75old pt feature of aortic stenosis, EF of left vent. 35%, all indication for operation. What to do
A. open valve replacement
B. percutaneous valve dilatation
B. Open Valve Replacement.
Technically, TAVI should be the answer based on the STEM but either way the aortic valve should be replaced unless there is a contraindication to surgery.
Diagnosis of aortic stenosis: ANGINA + DYSPNEA + BLACKOUTS –> AORTIC STENOSIS
Normally, AS is asymptomatic until condition becomes more moderate. [SOB, reduced exercise tolerance, angina, syncope]
Elderly can present with non specific symptoms [fatigue, inability to underatke activities daily living]
- Most common valvular disease in elderly
- PHYSICAL EXAMINATION: ESM at RUSE radiates to carotids, have a slow to rise carotid pulse, single or paradoxical split of second heart sounds.
- If degenerative AS: murmur would radiate to apex instead with high pitched quality. Gallavardin phenomenon.
- Degenerative AS: calcium deposition on aortic valve leaflets + progressive narrowing of valve orifice + subsequent reduction of CO
- Symptomatic, sever AS -> poor prognosis
- In elderly, TAVI (transcatheter aortic valve implantation) is recommended for severe AS
○ Other treatment: SAVR (surgical aortic valve replacement) or palliative care
Diagnostic: Transthoracic Echocardiography (TTE)
If mild AS, 2-yearly serial TTE –> reduced to yearly TTE for moderate AS. Severe AS -> valve intervention
Pharmacology
Waldenstorm macroglobenemia patient came with rigors and fever and right lower lobar pneumonia admitted and started ampicillin and after 2days following papulo vesicular rash developed. What is the most appropriate management?
A. prednisolone
B. immunoglobulin
C. stop ampicillin
D. ACYCLOVIR
D. Acyclovir.
Likely the vesicular rash / papulovesicular rash is more to Herpes Zoster.
If it is due to ampicillin, rash would look more maculopapular
**Explanation** Pt got vasicular rash Waldenstorm macroglobenmia is immuncompromise condition Herpes zoster more common In this condition antiviral should be given Waldenstrom's macroglobulinemia (WM) involves excessive production of a particular protein called immunoglobulin M (IgM). Although the most common symptoms of WM include tiredness, weakness, weight loss, and bleeding of the nose or gums, some patients may develop skin rashes. Such rashes may develop from direct infiltration of the skin by cancerous blood cells (lymphoplasmacytoid B-cells). In these cases, patients can develop non- specific reddish-brown to purple patches or plaques (flat-topped, raised patches) on their skin. Because people with WM have impaired immunity, they are at higher risk for certain types of infections. A common infection associated with rash that may affect patients with WM is shingles (caused by reactivation of the chicken pox virus). Shingles, or herpes zoster, is characterized by the appearance of clustered blisters, usually confined to a single area of the body, which can be itchy or painful. The best treatment for shingles, antiviral medications, is most effective if it is started early in the disease course. Unfortunately, shingles may leave patients with long-lasting discomfort at the site of involvement, even if the original rash has subsided. Some medications, both topical and oral, may be helpful in alleviating this discomfort.
Pharmacology
After administration of Cefazolin, a young patient developed allergic reaction in the skin (picture of multiple red rash on the back). Regarding management of this patient in the future with cephalosporin, which is correct?
A. Cephalosporin other than cefazolin
B. No cephalosporin
C. Neither penicillin and neither cephalsoporin
D. Doxycycline
E. Ceftriaxone
C. Neither penicillin and neither cephalosporin.
https://www.medscape.com/viewarticle/576939?form=fpf on pennicillin safe in patient allergic to cephalsoprins
Cross-reactivity may be greater between first-generation cephalosporins and penicillins than between second-, third-, or fourth generation cephalosporins and penicillins.
Cephalosporin-allergic patients may have cross-reactivity with determinants of the penicillins, with different cephalosporins, or may react to just a single cephalosporin.
Pharmacology
Patient for cellulitis, treated with cefazolin. Then picture given after 3 days of treatment, macular drug reaction on trunk. Asking the Cefazolin stopped, which one not good for patient for future?
A. All cephalosporins
B. All penicillin and cephalosporins
C. Just cefazolin
D. Clindamycin
B. All penicillin and cephalosporins.
Same reason as previously.
Cross-reactivity may be greater between first-generation cephalosporins and penicillins than between second-, third-, or fourth generation cephalosporins and penicillins.
Cephalosporin-allergic patients may have cross-reactivity with determinants of the penicillins, with different cephalosporins, or may react to just a single cephalosporin.
1st Gen: Cefalexin/Cefazolin
2nd Gen: Cefuroxime
3rd Gen: Cefotaxim/Ceftriaxone
All these antibiotics does not protect against LAME (Listeria, Atypicals -mycoplasma chlamydia-, MRSA, Enterococcus)
Only 5th Gen can do MRSA: Ceftopiprole.
