Core cases Flashcards
Osteoperosis
A: Primary (type 1) occurs in postmenopausal women (50-65YO)
Primary (type 2) occurs in women and men over 70YO.
Secondary causes: endocrine (Cushing’s, adrenal insufficiency), corticosteroids, multiple myeloma, renal failure, alcohol, reduced physical activity.
S: asymptomatic until fracture occurs
D: DEXA scan for bone mineral density.
T: Calcium, vitamin D, biphosphonates, oestrogen and calcitonin.
Depression
A: More common in women, high prevalence in low income groups, genetics.
Secondary causes: propanolol, chloroquine (malaria), hypothyroid, Sheehan’s syndrome (hypopituitarism after child birth), Parkinson’s, post-stroke, post-natal (25%), malignancies, adverse life effects (abuse).
D: Two core symptoms for > 2 weeks: low mood, anhedonia, lethargy plus one other symptoms.
T: Lifestyle, CBT, suicide risk assessment.
Fluoxetine in children, In adults citalapram or sertaline.
Anxiety
A: Genetic predisposition, stress, life events.
S: Tension, agitation, feeling of impending doom, insomnia, headaches, vomiting, sweating, palpitations.
D: Clinical
T: Gentle exposure to anxiety-provoking stimuli, CBT, diazepam, paroxetine (SSRI)
Rhematoid Arthritis
A: Systemic autoimmune
Genetic, environmental, hormonal, immunological, infectious. HLA-DR4 found in most.
S: Persistent and symmetrical afffecting MCP, wrist, PIP, knee, MTP, shoulder, ankle, cervical spine, hip, elbow, TMJ joint. Also reumatoid nodules (elbows, lungs), lymphadenopathy.
Joints are inflamed, swollen, tender, stiff, worse in the morning.
Malaise, fatigue, pulmonary fibrosis, vasculitis.
D: Raised ESR and CRP. Joint aspiration shows increased. WCC and protein. Rheumatoid factor.
T: Diet, massage, physiotherapy, NSAIDs.
Steroids used to bride the time until DMARDs are available (Hydroxyquinolone, Sulfasalazine, Methotrexate, Azathioprine, gold salts, Penicillamine.
If DMARDs fail rituximab or adalimimab can be used.
Surgery is last resort.
(not) Lupus
A: Unknown cause, peaks in afro-carribean women 25-35 years.
S: Arthralgia, fever, malaise. Malar “butterly” rash, discoid rash, episcleritis, optic neuritis, retinal infacrts, Raynaud’s phenomenon (reduced blood flow to hands when stressed or cold), sjogren’s, mucosal ulceration.
SOAP BRAIN MD: Serositis (pericarditis/pleurisy), oral ulcers, arthritis (2+ joints), photosensitivty, blood disorders (low neutrophils, lymphocyres and anemia), Renal involvement (proteinuria/casts), antinuclear antibodies, immunological antibodies, neurological (seizures or psychosis), malar rash, discoid rash.
D: Auto-antibody tests: ANA (anti-nuclear antibody), anti-dsDNA, anti-sm (anti-smith - most specific), anti-Ro/La
Renal biopsy.
T: NSAIDs, corticosteroids, immunosupressant (cyclophosphamide, azathoprine)
Alzheimer’s Disease
A: Usually occurs from 6th decade onward, caused by senile plaques, neurofibrillary tangles and beta-amyloid deposition.
S: Short term memory loss over a few years progressing to other domains. Can lead to personality changes, language deficits or apraxia.
D: Mini-mental state exam. Clinical.
T: acetylcholinesterase inhibitors (tacrine, rivastigmine, galantamine and donepezil) or NMDA receptor agonist (memantine)
Epilepsy
A: Excess neuronal firing can be caused from structural (trauma, space-occupying lesion, vascular malformation), metabolic (alcohol, glucose, sodium, oxygen) or infection (HIV syphilis, encephalitis). But is usually idiopathic.
S: Seizures (absence, tonic-clonic or myoclonic).
D: EEG, check for possible causes.
T: Partial focus seizures: lamotigrine then carbamezepine.
General/unclassified seizures: Sodium Valproate.
Refractory: vagal nerve stimulation.
Status epilepticus: IV benozdiazapines, or IV phenytoin/valproate.
Seizure types
Generalised seizures can be:
1. Grand-mal; Unconscious, convulsions, muscle rigidity.
2. Absence; Short LOC, usually no symptoms, often in children. Will just stare blankly.
3. Myoclonic; Sporadic jerks
4. Clonic; Repetitive, rhythmic jerks that usually involve both sides of the body.
5. Tonic; Stiffening of muscles. Can be combined with clonic.
6, Atonic; Sudden and general loss of muscle contraction, collapse.
Focal/partial seizures can be:
- Simple; maintain awareness. May be motor (jerking, rigidity, spasms, head turning), sensory (unusual sensations affecting the vision/hearting etc) or psychological (memory or emotional disturbance).
- Complex; unaware. Lip-smacking, chewing, fidgeting or walking movements that are involuntary.
- Partial with secondary generalisation; starts out unaware but deteriorates to unaware.
Septic Arthritis
A: Joint invaded from pathogens, usually via the blood but also trauma. Usually staph aureus, but there are many others. (H Influenza in children) (Neisseria Gonorrhoea in sexually active).
S: Fever, joint pain, erythema, warmth, decreased movement. Can be any joint but is usually the knee. Hip is commonest in infants.
D: Increased WCC and CRP. Joint aspiration shows cloudy synovial fluid, and blood cultures are taken.
T: IV antibiotics.
Ankylosing spondylitis
A: Genetic and environmental, there is a strong association with HLA-B27. Causing inflammation of the entheses.
S: Low back pain and stiffness, onset younger than 40YO, for more than 3 months. Worse in the morning or with inactivity. Better on exercise. Peripheral enthesitis, hip and shoulders can become involved. Also get iritis.
D: Schober’s test for spinal range of motion. Blood test for HLA-B27, raised ESR and CRP. XR.
T: Long term NSAIDS. DMARDs then biologics (see RA)
Reactive arthritis (Reiter’s syndrome)
A: Develops 2-6 weeks after infection, usually GI or GU.
Associated with HLA-B27, more commonly young males.
S: Joint swelling, papules on penis arms and feet. Classic triad: Urethritis, conjuncitivits, arthritis (can’t see, can’t pee can’t bend their knee). Also fever and malaise.
D: Raised ESR, CRP, WCC. May swab patient for infections.
T: Rest, NSAIDs, steroids, antibiotics if infected.
Gout
A: Caused by monosodium urate monohydrate crystals from faulty uric acid metabolism.
(hyperuricemia) is caused by: thiazide diuretics, purine intake in diet (alcohol, red meat), lead, inherited enzyme deficiency, dehydration, aspirin.
S: Acute: monoarthritis, painful, swollen, hot, erythematous joint for 7-14 days. Often in the metatarsal-phalangeal of big toe. But ankle, wrist and knee may be affected.
Chronic: Gout tophi on hands, pinna, polyarthritis.
D: Bloods show increased uric acid levels. Joint aspiration shows gout crystals (needle shaped).
T: Acute: NSAIDs or cholchicine. Corticosteroids.
Prophylaxis: allopurinol or febuxostat to reduce uric acid levels.
Pseudogout
A: Caused by calcium pyrophosphate crystals.
Primary or secondary to hyperparathyroidism, haemochromatosis, hypothyroidism, hypophosphataemia, Wilson’s disease.
S: Acute: monoarthritis, painful, swollen, hot, erythematous joint for 7-14 days. Most commonly shoulders, knees and wrist.
Chronic: Gout tophi on hands, pinna, polyarthritis.
D: Joint aspiration, CPP crystals are typically rod-shaped.
T: Acute: NSAIDs or cholchicine. Corticosteroids.
Prophylaxis: allopurinol or febuxostat to reduce uric acid levels.
Myasthenia Gravis
A: Autoimmune related neuromuscular disorder. Peak age at 30, females more common.
S: Ptosis, opthalmoplegia, dysphagia, dysarthria, facial weakness, limb and respiratory muscle weakness that is worse with exercise.
D: Tensilon test (edrophonium given to produce an improvement in symptoms). Acetylcholine receptor antibodies, anti-MUSK antibodies.
Single Fibre electromyelography is the most sensitive test.
T: Corticosteroids and acetylcholine esterase inhibitors (Pyridastigmine)). IV immunoglobulins, plasma exchange and intubation if severe. Thyomas may need surgical removal. P
Lewy Body Dementia
A: Onset of cognitive symptoms is within one year of parkinsonism. cognitive symptoms from PD take place a few years after parkinsonism.
S: Memory impairment, apathy, delusions, hallucinations, Parkinsonism features of rigidity and bradykinesia but less of resting tremors. Frequent falls are common. May get autonomic features such as dry skin, postural hypotension or sexual dysfunction.
D: MRI/CT to rule out other causes. Dopamine transporter scan. But no diagnostic tests yet.
T: Levodopa may help parkinsonism, cholinesterase inhibitors (Donepezil) for cognitive symptoms and quetiapine for psychosis.
