Frailty- core conditions Flashcards
Septic arthritis
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.
Septic arthritis- how pathogens are spread
- 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
Septic arthritis- pathogens
- 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
Septic arthritis- risk factors
- Established joint disease
- Recent joint injection/sugery
- Immunosuppression- diabetes, alcoholism
- IVDU
- Prosthetic joints
- UTI, indwelling catheter, recent abdominal surgery
Septic arthritis- investigations
- 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
Septic arthritis- management
- IV abx
- Analgesia
- May require joint washout with surgeons
Septic arthritis- Athrocentesis
- 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
Aspirate in spetic arthritis:
The aspirate will look thick yellow and turbid
It will return as ‘positively birefringent rhomboid shaped crystals under polarised light microscopy’
Different crystals in aspirate
- 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
Calcium Pyrophosphate Deposition Disease (CPPD)
Crystal deposition in articular cartilage
Causes of CPPD
- Sporadic
- Secondary causes: Hyperparathyroidism, Haemochromatosis, Hypothyroidism, Diabetes, Low magnesium. Look for secondary causes in younger patients
Usually effects individuals >50
Presentation of CPPD
- Joint swelling
- Erythema
- Pain
- Oligo or polyarticular symptoms for days or weeks
Acute CPP crystal arhtritis (pseudogout)
In the knees or wrists, the crystals stimulate inflammation in the joints
CPPD- aspiration and management
Joint aspiration- white chalky fluid, crystals are positively birefringent
Management: NSAID’s, Colchine, Steroids
Gout
Monosodium urate deposition in the joints, due to overproduction and under excretion
Gout- risk factors
- 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
Gout- presentation
- 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)
Gout- investigations
- 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
Gout- treatment
- Acute flare: NSAIDs, steroids (oral or injection), colchine, IL1 inhibitors
- Prevention and management: lifestyle modification, change diet, reduce alcohol, weight loss, Allopurinal/febuxostat. Probenecid
Gout vs Pseudogout
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
Crystal arthroplasty management
- 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
Osteoporosis
- Causes swan neck deformity
- Decrease in bone density
Bone remodelling
- Trabecular bone (spongy bone): replaced every 3-4 years
- Cortical bone (compact bone): replaced every 10 years
- Bone breakdown: osteoclasts
- Bone formation: osteoblasts
Factors affecting bone remodelling
- 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
Pathology of osteoporosis
- 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
Risk factors for osteoporosis
- 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
Secondary causes of osteoporosis
- 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
DEXA scan
- Dual energy x-ray absorptiometry
- Analyses bone density to diagnose osteoporosis
- Hip, radius, back
FRAX score
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)
NOGG guidelines
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.
Osteoporosis treatment
- 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
When to do a FRAX score
- Do FRAX score in women >65 and men >75
OR - In women <65 and men <75 with risk factors
When to offer a DEXA scan
- 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
The 4 ethical principles
- Beneficience- doing good
- Non-maleficence: do no harm
- Justice: ensuring fairness
- Autonomy: patient is able to choose freely
You should suspect arrhythmias in
- 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
Investigations into arrhythmias
- 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
Benign Paroxysmal Positional Vertigo
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
BPPV- risk factors
- Most commonly occurs 50-70
- Women are more affected then men
BPPV- symptoms
- Vertigo- tends to last a minute, temporary sensation
- Doesn’t affect hearing or cause tinnitus- different from menieres disease
- Imbalance between attacks
BPPV- diagnosis and treatment
- 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
Acne- four factors involved
- Increased sebum production
- Hypercornification of the pilosebaceous duct (blackhead/comedone)
- Abnormality of microbial flora- Propionibacterium acnes
- Inflammation
Types of acne
Open comedone, closed comedone, papules, pustules, cysts, scars
Topical treatment for acne
- Benzoyl peroxide- can be bought OTC
- Topical retinoids- useful for comedones
- Topical antibacterials- Clindamycin and Erythromcyin
Oral therapies for acne
- Oral antibiptics: Teracyclines (Oxytetracycline, doxycyckine, Limecycline, Erythromycin
- Hormonal treatment (some OCP)
- Isotretinoin
Psoriasis- chronic plaque psoriasis
- 85-90%
- Well defined patches of redness with a thick silver scale
- Typically on extensor surfaces like elbows and knees
Causes of psoriasis
- 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
Psoriasis histology
- Psoriatic epidermis contains scattered neutrophils
- Neutrophil microabcesses can form
- Psoriasis may be pustular
Types of psoriasis
- Guttate psoriasis
- Erythrodermic psoriasis
- Scalp psoriasis
- Flexural psoriasis
Features of psoriasis
Nail pitting, onycholysis
Treatment for psoriasis
- 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
