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Medicine year 3- EOCP > Frailty- core conditions > Flashcards

Frailty- core conditions Flashcards

1
Q

Septic arthritis

A

Red, hot, swollen joint. Painful and reduced range of movement
Will cause Tachycardia and a fever.
Medical emergency: regard a hot, swollen, acutely painful joint with restriction of movement as septic arthritis until proven otherwise.

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2
Q

Septic arthritis- how pathogens are spread

A
  • Direct injury: injury to a joint with skin break or infected neighbouring bone (infection spreads into joint)
  • Haematogenous: infection in other organs and spreads to joint via blood stream
    Bacterial toxins destroy cartilage and cause progressive joint destruction
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3
Q

Septic arthritis- pathogens

A
  • Gonococcal arthritis: Neisseria gonorrhoea, haematogenous spread from sexually transmitted goncoccal infection
  • Non gonococcal arthritis: staph aureus (most common)- may be direct infection from a wound, can cause rapid joint destruction in days
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4
Q

Septic arthritis- risk factors

A
  • Established joint disease
  • Recent joint injection/sugery
  • Immunosuppression- diabetes, alcoholism
  • IVDU
  • Prosthetic joints
  • UTI, indwelling catheter, recent abdominal surgery
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5
Q

Septic arthritis- investigations

A
  • Bedside: Obs, urine dip, ECG, CXR (for haematogenous spread infection)
  • Bloods: FBC, U&E, LFT, CRP, Lactate, Coag, culture
  • Imaging: X-ray is not diagnostic is useful to see baseline joint condition. May see increased synovial fluid or bone destruction
  • Special- joint aspiration
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6
Q

Septic arthritis- management

A
  • IV abx
  • Analgesia
  • May require joint washout with surgeons
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7
Q

Septic arthritis- Athrocentesis

A
  • Contraindications: overlying skin infection, anti-coagulation, low platelets
  • Aspirate to dryness
  • Look at colour, viscosity and clarity of the joint aspirate
  • Send for: gram stain, WCC, microscopy, culture, polarising microscopy (for crystals)
  • Once done give IV antibiotics, immobilise the joint and analgesia
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8
Q

Aspirate in spetic arthritis:

A

The aspirate will look thick yellow and turbid
It will return as ‘positively birefringent rhomboid shaped crystals under polarised light microscopy’

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9
Q

Different crystals in aspirate

A
  • Positively birefringent rhomboid shaped crystals under polarised light microscopy- calcium pyrophosphate crystals. CPPD or pseudogout.
  • Strongly negative birefringent needle shaped crystals under polarised light microscopy- monosodium urate crystals, Gout
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10
Q

Calcium Pyrophosphate Deposition Disease (CPPD)

A

Crystal deposition in articular cartilage

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11
Q

Causes of CPPD

A
  • Sporadic
  • Secondary causes: Hyperparathyroidism, Haemochromatosis, Hypothyroidism, Diabetes, Low magnesium. Look for secondary causes in younger patients
    Usually effects individuals >50
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12
Q

Presentation of CPPD

A
  • Joint swelling
  • Erythema
  • Pain
  • Oligo or polyarticular symptoms for days or weeks
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13
Q

Acute CPP crystal arhtritis (pseudogout)

A

In the knees or wrists, the crystals stimulate inflammation in the joints

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14
Q

CPPD- aspiration and management

A

Joint aspiration- white chalky fluid, crystals are positively birefringent
Management: NSAID’s, Colchine, Steroids

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15
Q

Gout

A

Monosodium urate deposition in the joints, due to overproduction and under excretion

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16
Q

Gout- risk factors

A
  • Age
  • Male
  • High uric acid levels
  • Diet (purine rich foods – red meat, shellfish)
  • Obesity, diabetes
  • Alcohol use
  • Diuretics (decrease urate excretion)
  • Chemo agents – increased cell turn over
  • Polycythaemia Vera
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17
Q

Gout- presentation

A
  • Acute swollen hot painful joint
  • Usually 1st MTP joint (big toe)
  • Monoarticular
  • May have asymptomatic periods and periodic flare ups
    Chronic disease: Gouty tophi (MSU deposition in the joint)
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18
Q

Gout- investigations

A
  • X-rays shows tophi
  • Joint aspiration shows negatively birefringent crystals. However, if the clinical diagnosis is clear aspiration is not always needed
  • High urate level
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19
Q

Gout- treatment

A
  • Acute flare: NSAIDs, steroids (oral or injection), colchine, IL1 inhibitors
  • Prevention and management: lifestyle modification, change diet, reduce alcohol, weight loss, Allopurinal/febuxostat. Probenecid
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20
Q

Gout vs Pseudogout

A

Gout: Monosodium urate crystals, needle shaped negative birefringent crystals, may be young largely RF dependent, affects 1st MTP

Pseudogout: Calcium pyrophosphate, Rhomboid positive birefringent crystals, 50+, affects the knee

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21
Q

Crystal arthroplasty management

A
  • Acute: NSAIDs + PPI, Colchine, Corticosteroids oral/IA, Interleukin 1B inhibitor if refractors
  • Chronic: attain normal BMI, stop alcohol, stay hydrated. After an acute attack Allopurinol. Febuostat, Probenecid, Rasburicase (severe/refractors)
  • Chronic CPPD: identify and treat and underlying metabolic abnormalities. NSAIDs and PPI, Colchine, Corticosteroids, Methotrexate, Hydroxylchloroquine
22
Q

Osteoporosis

A
  • Causes swan neck deformity
  • Decrease in bone density
23
Q

Bone remodelling

A
  • Trabecular bone (spongy bone): replaced every 3-4 years
  • Cortical bone (compact bone): replaced every 10 years
  • Bone breakdown: osteoclasts
  • Bone formation: osteoblasts
24
Q

Factors affecting bone remodelling

A
  • Vitamin D: allows calcium absorption from the gut, increasing Ca levels
  • PTH: increases bone reabsorption if Ca is low
  • Calcitonin: stops bone reabsorption if Ca high
  • Exercise: weight baring exercise increases bone formation
  • Hormones: oestrogen and testosterone decrease bone resorption
25
Q

Pathology of osteoporosis

A
  • Thinning of cortical bone
  • Fewer trabecular
  • Bone cells are normal with normal mineralisation
  • There is more bone breakdown with osteoclasts then bone formation with osteoblasts
26
Q

Risk factors for osteoporosis

A
  • Age
  • Low oestrogen: post menopause or early menopause
  • Low serum calcium: after bones have been formed
  • Smoking
  • Alcohol
  • No weight baring exercise
  • Steroids
  • Co-morbidities: Crushings, diabetes, hyperthyroidism
27
Q

Secondary causes of osteoporosis

A
  • Endocrine: Hyperthyroidism, Hyperparathyroidism, Crushings disease, Diabetes mellitus, Hyperprolactinaemia, Early menopause
  • Gastrointestinal: Coeliac disease, IBD, chronic liver disease
  • Rheumatoid arthritis
  • Metabolic: CKD
  • Drug induced: steroids, antiepileptics
28
Q

DEXA scan

A
  • Dual energy x-ray absorptiometry
  • Analyses bone density to diagnose osteoporosis
  • Hip, radius, back
29
Q

FRAX score

A

Evaluates fracture risk, give a 10 year possibility of a fracture. It consider:
* Age
* Sex
* Weight
* Height
* Previous fracture
* If the parent had a fractured hip
* Current smoking
* Corticosteroids
* Rheumatoid arthritis
* Secondary osteoporosis
* Alcohol 3 or more units/day
* Femoral neck BMD (g/cm)

30
Q

NOGG guidelines

A

Based on FRAX score, it gives guidance on how to proceed. The options are to treat, measure BMD with a DEXA scan or lifestyle advice.

31
Q

Osteoporosis treatment

A
  • Conservative: quit smoking, reduced alcohol, regular exercise, Balanced diet
  • Medical: Bisphosphonates (oral alendronic acid, IV zoledronate), Teripartide, Denosumab. Calcium and vitamin D replacement
  • Surgical: bony fractures
32
Q

When to do a FRAX score

A
  • Do FRAX score in women >65 and men >75
    OR
  • In women <65 and men <75 with risk factors
33
Q

When to offer a DEXA scan

A
  • Offer DEXA scan without initial FRAX score to anyone >50 with history of fragility fracture
  • Consider starting treatment without DEXA scan in people with a vertebral fracture
  • For patients with risk factors for osteoporosis do a FRAX score first. High risk patient should have DEXA
34
Q

The 4 ethical principles

A
  • Beneficience- doing good
  • Non-maleficence: do no harm
  • Justice: ensuring fairness
  • Autonomy: patient is able to choose freely
35
Q

You should suspect arrhythmias in

A
  • Patients with syncope especially if: there is no warning, it occurs when lying or sitting, a cardiac history or abnormal ECG
  • Patients with falls: where there is significant injury, a cardiac history or abnormal ECG
36
Q

Investigations into arrhythmias

A
  • A standard ECG
  • 24 hour heart rate monitor
  • Devices for monitoring over 1-4 weeks
  • An implantable device i.e. Reveal

Common osteoporotic fractures: Neck of femur, pelvis, humerus, radius/ulna, vertebra

37
Q

Benign Paroxysmal Positional Vertigo

A

The most common cause of vertigo
When the calcium carbonate crystals become dislodged from the gel in the urticle and migrate into the semi circular canals

38
Q

BPPV- risk factors

A
  • Most commonly occurs 50-70
  • Women are more affected then men
39
Q

BPPV- symptoms

A
  • Vertigo- tends to last a minute, temporary sensation
  • Doesn’t affect hearing or cause tinnitus- different from menieres disease
  • Imbalance between attacks
40
Q

BPPV- diagnosis and treatment

A
  • Canalithiasis- the calcium carbonate crystals move freely through the semi circular canals
  • Cupulothiasis- gets caught within the nerves of the semi circular canal
  • Dix-hallpike manoeuvre: Causes torsional nystagmus in posterior canal BPPV which is the most common type.
    Treated with the epley mannoeuvre
41
Q

Acne- four factors involved

A
  • Increased sebum production
  • Hypercornification of the pilosebaceous duct (blackhead/comedone)
  • Abnormality of microbial flora- Propionibacterium acnes
  • Inflammation
42
Q

Types of acne

A

Open comedone, closed comedone, papules, pustules, cysts, scars

43
Q

Topical treatment for acne

A
  • Benzoyl peroxide- can be bought OTC
  • Topical retinoids- useful for comedones
  • Topical antibacterials- Clindamycin and Erythromcyin
44
Q

Oral therapies for acne

A
  • Oral antibiptics: Teracyclines (Oxytetracycline, doxycyckine, Limecycline, Erythromycin
  • Hormonal treatment (some OCP)
  • Isotretinoin
45
Q

Psoriasis- chronic plaque psoriasis

A
  • 85-90%
  • Well defined patches of redness with a thick silver scale
  • Typically on extensor surfaces like elbows and knees
46
Q

Causes of psoriasis

A
  • Intense proliferation and abnormal keratinocytes proliferation, triggered by an active cellular immune system
  • Role for T cells, dendritic cells and cytokines
  • Genetic factors
  • Type 1 psoriasis (young onset) most strongly associated with CW0602 (PSORS1)
  • Environmental triggers i.e. trauma, infection, drugs, EtOH
47
Q

Psoriasis histology

A
  • Psoriatic epidermis contains scattered neutrophils
  • Neutrophil microabcesses can form
  • Psoriasis may be pustular
48
Q

Types of psoriasis

A
  • Guttate psoriasis
  • Erythrodermic psoriasis
  • Scalp psoriasis
  • Flexural psoriasis
49
Q

Features of psoriasis

A

Nail pitting, onycholysis

50
Q

Treatment for psoriasis

A
  • First line treatment of Psoriasis: Calcipotriol, Tar, Dithranol (anthralin) for chronic plaque psoriasis, topical steroids
  • Photo: PUVA, UVB
  • Systemic: biologics, ciclosporin, methotrexate, retinoids
  • The systemic treatment is more toxic then first line

Medicine year 3- EOCP (27 decks)

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