Frailty- joints Flashcards
Polymyalgia rheumatica
An inflammatory syndrome of older individuals >50 but normally >70 characterised by pain and sitffness in the proximal muscles of the shoulder, neck and/or pelvic girdle in the absence of any true weakness, might appear limited due to pain
Polymyalgia rheumatica- core manifestations
- Patient aged >50
- Symmetrical shoulder girdle ache >2 weeks
- ESR >40 and or elevated CRP
- Morning stiffness
- Bilateral hip pain or limited range of movement
- Absence of rheumatoid factor and anti CCP
- Rapid response to corticosteroids
- Constitutional symptoms common (in one third)
Polymyalgia rheumatica- medicine
Rapid (24072hr) response to low dose prednisolone (15mg), slowly tapered over months. Require steroids for 1-2 years, bone protection and gastro-protection should be considered, and the steroids should not be stopped abruptly.
May have relapses as the steroid dose is reduced and require it to be increased. DMARDS like methotrexate may be initiated by specialists
Polymyalgia rheumatica- associated conditions
GCA is a large and medium vessel arteritis associated with PMR (15% of patients with PMR) that can lead to irreversible sight loss. Features include headache (usually temporal or occipital), temporal/scalp tenderness, jaw or tongue claudication, visual disturbances and double vison (diplopia). May have absent temporal pulse or thickening of the temporal artery, important to prevent sight loss
Diagnosing GCA
Unlikely if ESR and CRP are normal. Once suspected treatment with high dose steroids are started urgently. Diagnosis can be confirmed with temporal artery ultrasound or biopsy
Psoriatic arthritis- examination findings
- Pitting of nails
- Oncholysis (nail plate separating from nail bed)
- Beau lines (transverse nail ridge), subungual hyperkeratosis, splinter haemorrhages, oil drop sign, salmon patch
- Dactylitis (sausage digits- due to synovitis and flexor tenosynovitis)
- Asymmetrical joint involvement including DIPJ
- Enthesitis: inflammation of tendons
- Uveitis
- Tenosynovitis: inflammation of the myelin sheath
Psoriatic arthritis
A chronic inflammatory joint disease associated with psoriasis- however it can present before, alongside or after the onset of psoriasis.
Affects men and women equally and tends to present between 20-40 and present in 20-30% of those with psoriasis
Spondyloarthropathies
A group of seronegative (RhF negative conditions)
Psoriatic arthritis, ankolysing spondylitis, enteric arthropathy (IBD associated), reactive arthritis and undifferentiated axial spondylarthritis
5 sub types of psoriatic arthritis
There is overlap between them
- Asymmetrical oligoarthritis
- Predominant DIPJ involvement
- Arthritis mutilans: destruction of the whole bone
- ‘Rheumatoid like’ symmetrical polyarthritis
- Axial involvement: usually asymmetrical rather than symmetrical in ankolysing spondylitis
Extra articular features of psoriatic arthritis
Include eye involvement- conjunctivitis or uveitis
Medical treatment of psoriatic arthritis
Similar to RA- remission or goal targeted therapy, can be simple NSAIDs and joint injections but may require esclating to DMARDS like methotrexate or leflunomide. Biologics (usually anti-TNF’s) can be used
Distinguishing psoriatic arthritis from rheumatoid arthritis
- Asymmetrical often oligoarticular joint involvement
- Significant nail pitting/dystrophy
- Involvement of DIPJ in absence of OA
- Dactylitis
- Enthesitis (usually achilles/plantar fascia_
Hx/FHx of psoriasis - Absence of rheumatoid factor/anti-CCP
- X-ray findings can be distinctive with absence of juxta articular osteoporosis, fluffy juxta-articular periosteal new bone and pencil in cup deformity. Where the middle phalanx is narrowed like a pencil and the distal phalanx is eroded centrally like a cup
Reactive arthritis
A sterile inflammatory arthritis that occurs within 1-4 weeks of an infection elsewhere in the body (usually genitourinary or gastrointestinal i.e. chlamydia, Salmonella, Shigella, Yersina although the initial infection can be hard to identify
Reactive arthritis- genes, distribution and course
- Strong association with being HLA-B27 positive which is present in 60-80% of cases,
- An asymmetrical peripheral oligoarthritis (often knees) and sometimes axial involvement
- Approximately 50% have a self limiting course of 3-5 months, 30% have recurrent episodes and 10-20% develop a chronic course needing immunosuppressive therapy
Reiters syndrome
The triad of conjunctivitis, nongonococcal urethritis and arthritis (cant see, cant pee, cant climb a tree)
Associated symptoms of reactive arthritis
- Cant pee: urethritis, prostatis, haemorrhagic cystitis, salphingitis, circinate balanitis
- Cant see: sterile conjuncitivitis, anterior uveitis
- Cant climb a tree: Asymmetric oligoarthritis, Enthesitis, Sacroilitis, Dactylitis
- Other: Keratoderma blennorrhagicum, Hyperkeratotic nails, painless oral ulcers, rarely IgA nephropathy and cardiac features
Investigations into reactive arthritis
Will show elevated CRP, ESR and negative antibodies- HLAB27 status may be determined as it is associated with poorer prognosis, but has limited diagostic utility. Cultures at this stage will most likely be negative with no organisms in the joint cavity. Management is mostly NSAIDs and steroids, although some go on to require DMARDS
Cauda equina syndrome
Emergency compression of the lumbar sacral nerve roots at the end of the spinal cord (around L1/L2) when they fan out and leave the spinal column. Will require emergency MRI and operative management to prevent persistent disability
Superficial spreading melanoma
Common in the lower limbs, in young and middle ages adults. Related to intermittent high intensity UV exposure. 70% of all melanoma
The three other types of malignant melanomas
Lentigo maligna melanoma: common on the face, in the elderly population, related to long term cummulative sun exposure
Nodular melanoma: common on the trunk, in young and middle aged adults, related to intermittent high intensity UV exposure
Acral lentiginous melanoma: common on the palms, soles and nail beds, in elderly population, no clear relation with UV exposure
What are some skin infections and what are they commonly caused by
Cellulitis - strep pyogenes and staph aureus
Erysipelas - Group A strep (strep pyogenes)
Impetigo - staph aureus, group A strep
Furuncle - staph aureus
Meningococcal rash - neisseria meningitis
Chancre - treponema pallidum
Definition of infection and sepsis
Infection- caused by pathogenic microorganisms such as bacteria, viruses, parasites, prions or fungi. The diseases can be spread directly or indirectly
Definition of infection and sepsis
Infection- caused by pathogenic microorganisms such as bacteria, viruses, parasites, prions or fungi. The diseases can be spread directly or indirectly
Sepsis- characterised by life-threatening organ dysfunction due to a dysregulated host response to infection
Septic shock
Patients with septic shock can be clinically identified by a vasopressor requirement to maintain a mean arterial pressure of 65 mm Hg or greater and serum lactate level greater than 2 mmol/L (>18 mg/dL) in the absence of hypovolemia
Criteria to identify sepsis
- SIRS
- qSOFA
- Can also use EWS when assessing patients
SIRS criteria
2 or more of the following criteria:
- Temp >38 or <36
- Pulse >90 BPM
- RR >20/min or PCO2 <32mmHg
- WBC >12,000 cells/mm or <4,000 cells/mm or >10% immature (band) forms
QSOFA criteria
- Altered mental status GCS <15
- Tachypnoea RR >22
- Hypotension SBP <100mmHg
2 or 3 points means you are at high risk of poor outcome
Red flags for sepsis
- Supplemental O2 requirement
- Purpuric rash
- HR >130
- > 2 lactate
- RR >25
- Systolic BP <90
- V or less on APVU
Sepsis 6
Give 3
- Fluids
- Oxygen
- Antibiotics
Take 3
- Blood cultures
- Lactate
- Urine (fluid balance)
Sepsis 6
Give 3
- Fluids- normally saline, 0.5ml/kg/hour
- Oxygen- aim for >94% unless COPD
- Antibiotics
Take 3
- Blood cultures
- Lactate
- Urine (fluid balance)
Antibiotics for sepsis
Mostly Tazocin as a broad spectrum antibiotics
- Adults under 65: Cefuroxime and Metronidazole
- Adults over 65: Piperacillin-tazobectam
- Penicillin allergy under 65: Cefuroxime
- Immediate penicillin allergy: Tericlopanin and ciprofloxacin and Metronidazole
How does CKD increase the risk of osteoporosis
Causes increased phosphate which increases parathyroid hormone production. Also reduces vitamin D activation
What should you prescribe with a bisphosphonate
A PPI
Bisphonates can affect jaw health and cause gastric ulcers
What antibiotic do you give in sepsis
Tazocin- for a minimum of 7 days
What oxygen sats are you aiming for in sepsis
> 94%- use a 15L nonrebreathe mask then titrate down
Fluid rescusitation- sepsis
Give saline unless they have hypernatremia- 0.5ml/kg/hour
Sepsis: blood cultures and antibiotics
Try and get blood cultures before Abx but dont delay Abx for cultures
Symptoms associated with dementia
- Memory loss
- Disorientation
- Changes in patterns of behaviour and personality traits
- Visual perception problems and loss of fine motor skills
Delirium
Between 2 to 5 days, often worse at night
Main causes: infection, fall, broken bone, surgery, polypharmacy, old age, cognitive impairment, hospital stays
Hyperactive delirium
- Pulling hair out, trying to get out of bed
- Vivid hallucinations
- Paranoid: wont take medication, eat or drink
- Fluctuating course
Delirium symptoms
- Psychomotor disturbances, picking at clothes
- Acute disturbance in cognition
- Acute mental status change
- Inattention
Hypoactive delirium
- Withdrawn/drowsy
- More common, harder to detect
- Higher risk of mortality
Risks of delirium
- Falls
- Pressure sores
- Increases length of hospital stays: increased risk of infection
- Developing cognitive impairement
- 1 in 5 die
Treatment for delirium
Haloperidol
Quetiapine: if they have lewy body disease and parkinsons
When to do a dementia screen
> 65, fractures, serious illlness, dementia
Hyperkalaemia: ECG changes
Stage 1: peaked T waves, P wave widens and flattens, PR segment lengthens, P waves disappear
Stage 2: Prolonged QRS interval and development of sine rhythm, can cause conduction blocks
Stage 3: Sine rhythm, wide bizarre QRS. Causes asystole, VF, PEA with bizarre wide complex rhythm
Description of eczema
Widespread erythematous ill-defined scaly rash
Predominantly affects flexure regions
Crusting
Lichenification
Description of psoriasis
Widespread erythematous rash characterised by scaly well defined plaques
30% of chronic plaque psoriasis is associated with psoriatic arthritis
Treatment for acne
Washes: salicyclic acid, chorhexidine
Topical: benzoyl peroxide, retinoids
Acne: exacerbating factors
- Medications: steroids, antiepileptics and EGRF inhibitors
- Topical skin products (including shaving products) or cosmetics
- High glycaemic index foods and dairy
Characteristics of severe, inflammatory acne
- Papules: small (<1cm), elevated, solid inflammatory lesions that appear erythematous.
- Pustules: small, well-circumscribed, erythematous epidermal lesions filled with pus (“pimple”).
- Nodules: similar to papules, but >1cm.
- Cysts: firm, encapsulated lesions containing fluid or fluid-like material.
Signs of inflammatory acne lesions after they have healed
- Scarring: there are many different types of acne scarring including ice pick, box, saucer, anetoderma, atrophic, hypertrophic and keloidal scarring.
- Pigmented macules: small spots <1cm in diameter, altered in colour, but not usually raised, these fade with time.
- Keloid scarring: shiny, rubbery nodules of fibrous scar tissue, which may be larger than the original lesion.
Topical therapies for acne
- Salicyclic acid: removes keratin plugs, unblocking pores
- Benzoyl peroxide: has antibacterial effects
- Topical retinoids: inhibits sebum production
Systemic therapies for acne
- Anti-androgenic options: oral contraceptive pill and spironolactone (contraindicated in pregnancy)
- Antibiotics: tetracyclines and erythromycin, have anti-inflammatory properties
- Isotretinion: systemic retinoid which inhibits sebum production
Isotretinoin
- Used to treat moderate to severe acne
- Used if acne is persistent, treatment resistent, cystic or scarring
- Side effects: mucosal dryness, dry skin and sensitivity to sun exposure
- Regularly monitor LFT’s and cholesterol
- Teratogenic and contraindicated in pregnancy
