General Practice short Flashcards
Summary of important topics
Ischaemic heart disease
A condition where there is cardiac myocyte damage due to insufficient blood supply. Most commonly caused atherosclerotic plaque build-up in coronary arteries.
Stable angina > unstable angina > NSTEMI > STEMI
RFs for atherosclerosis
Non-modifiable - age, family history, male
Modifiable - obesity, high fat diet, sedentary lifestyle, poor diet, alcohol, smoking, poor sleep, stress, diabetes
Stable angina
A condition where the narrowing of the coronary arteries leads to reduced supply of oxygen, which leads to ischaemia of the myocytes during times of increased demand, e.g. exercise.
RFs same as IHD as part of IHD
Key features: tight chest pain lasting 1 - 5 mins, relieved by rest or GTN spray
Ix: FBC, U+E before starting ACEi, LFTs before statins, ECG, HbA1c, cardiac stress test, gold standard is coronary angiography
Mx: glyceryl trinitrate spray, repeat after 5 mins if ineffective, call ambulance if repeat dose ineffective
Primary prevention:
- Lifestyle changes
- Low-dose aspirin 75mg daily
Secondary prevention: 4As
- Aspirin 75mg
- Atorvastatin 80mg
- ACE inhibitor
- Already on beta blocker (or CCB e.g. amlodipine) for symptom relief
Acute coronary syndrome
A condition caused by atherosclerotic plaque blocking the flow of blood through the coronary arteries.
Unstable angina > NSTEMI > STEMI
ECG and troponin:
- Unstable: both normal/ ECG: ST depression/T wave inversion)
- NSTEMI: ST depression, T-wave inversion and raised troponin
- STEMI: ST elevation, new left bundle branch block, raised troponin
Presentation: crushing chest pain with/without radiation to jaw/arm/neck, sweaty + clamminess, impeding sense of doom, SOB, palpitations, nausea and vomiting
Silent MI (usually diabetics): no chest pain, low-grade fever, sweaty, pale, clammy
Immediate Mx: CPAIN
- Call an ambulance
- Perform ECG
- Aspirin 300mg
- IV morphine for pain
- Nitrate (GTN)
Management of STEMI
If symptom onset within 12 hours:
- Percutaneous coronary intervention (PCI) if available in 2 hrs
- Thrombolysis (e.g. alteplase) if PCI not available within 2 hrs
Management of NSTEMI
BATMAN
B- base decision about angiography and PCI on GRACE score (probability of death 6m after NSTEMI)
A - aspirin 300mg
T - Ticagrelor 180mg STAT
M - morphine
A - antithrombin therapy with fondaparinux
N - nitrate (GTN)
Secondary prevention of ACS
Echo - to asses damage to heart
Cardiac rehabilitation
6As
- Aspirin 75g
- Another antiplatelet e.g. clopidogrel or ticagrelor
- Atorvastatin 80mg
- ACEi
- Atenolol or bisoprolol
- Aldosterone antagonist for HF (i.e. eplerenone)
Atrial fibrillation
Irregularly irregular heart rhythm due to uncoordinated, irregular and rapid atrial contractions which overrides the regular electrical activity released by the sinoatrial node.
Causes: SMITH
Sepsis, MI, ischaemic heart disease, thyrotoxicosis, hypertension
Paroxysmal AF is when the AF is episodic, lasts 30s to 24hrs, needs ambulatory 24-hour ECG
Key features: palpitations, SOB, dizziness/syncope, symptoms of underlying disease
Ix: ECG: absent P waves, narrow QRS complex tachycardia, irregularly irregular ventricular rhythm
Mx: rate control and rhythm control, but most are on bisoprolol, anticoagulation (e.g. apixaban) due to x5 risk of stroke
Chronic heart failure
The inability of the heart to supply enough blood and oxygen to meet the demands of the body
Causes: IHD, valvar heart disease (e.g. aortic stenosis), HTN, AF
HFpEF = EF > 50%
HFrEF = EF < 40%
Key features: exertional SOB, cough with frothy white/pink sputum, pedal oedema, orthopnoea (SOB worse on lying down, how many pillows?), paroxysmal nocturnal dyspnoea
Dx: hx + examination (bi-basal crepitations), N-terminal pro-B type natriuretic peptide (NT-proBNP), ECG, echo
NT-proBNP between 400ng/L - 2000ng/L = specialist and echo within 6 weeks
NT-proBNP > 2000ng/L = specialist and echo within 2 weeks
Medical secondary prevention:
- ACE inhibitor or ARB
- Beta-blocker (e.g. bisoprolol)
- Aldosterone antagonist (e.g. eplerenone or spironolactone) - only if above ineffective
- Loop diuretics (e.g. furosemide) - only if above ineffective
Additional mx: annual flu and pneumococcal vaccine, stop smoking, optimise tx of co-morbidities, cardiac rehab (personalised exercise programmes)
Hypertension
Essential hypertension - 90%
> 140/90mmHg in clinic
135/85mmHg at home
Secondary causes: ROPED: renal disease, obesity, pre-eclampsia, drugs (steroids, alcohol, NSAIDs)
Patients with BP 140/90 - 180/120 need 24-hour ambulatory blood pressure
Stage 1: >135/85 (140/90)
Stage 2: > 160/100 (150/95)
Stage 3: > 180/120
Every new patient is assessed for end-organ damage:
- Urine albumin: creatinine ratio and dipstick for kidney damage
- ECG
- Bloods: HbA1c, U+Es and LFTs
- Fundus examination for hypertensive retinopathy
QRISK score = percentage risk of patient developing stroke or MI in the next 10 years, above 10% = statin
Management for hypertension
A. ACEi (ramipril)
B. Beta-blocker (bisoprolol)
C. Calcium channel blocker (amlodipine)
D. Diuretic (indapamide)
ARB (e.g. candesartan)
Step 1: A, unless > 55 and/or Afro-Caribbean then ARB
Step 2: A + C or A + D or C + D
Step 3: A + C + D
Step 4. A + C + D and
- Serum K less than or equal to 4.5mmol/l = spironolactone (K-sparing)
- Serum K above 4.5mmol/l = beta-blocker
Asthma
A chronic airway disease characterised by hypersensitive smooth muscle in the airways which constrict in response to stimuli and cause inflammation and obstruction in the airways.
Patients often have family or personal history of atopy.
Key features of poorly controlled asthma: diurnal variation, triggered by cold air, exercise, dust etc., sleep disturbance, symptoms between exacerbations
Dx:
- (Quesmed): spirometry (FEV1/FVC of < 0.7) and bronchodilator reversibility , improvement in FEV1 of > 12% is significant
- FeNO = ppb > 40 = positive and supports dx
- Peak flow variability: peak flow diary reading at least twice a day over 2 to 4 weeks, variability > 20% = positive, supports dx
Asthma exacerbations
Key features: cough, tight feeling in chest, SOB, polyphonic wheeze on auscultation
Moderate exacerbation:
- PERF = 50 - 75% of predicted/best
Severe exacerbation:
- PERF = 33 - 50% of predicted/best
- RR > 25
- HR > 110
- Unable to complete sentences
Life-threatening:
92, 33 CHEST
- PERF < 33% of best or predicted
- Cyanosis
- Hypotension/shock
- Exhaustion/confusion/altered consciousness
- Silent chest
- Tachycardia (> 110), tachypnoea (>25)
Treatment for asthma exacerbation
Mild:
- Inhaled SABA (e.g. salbutamol)
- 4 x dose of their inhaled corticosteroid for up to 2 weeks
- Oral prednisolone if high-dose ICS ineffective
- Follow-up within 48 hours
Moderate
- Consider hospital admission
- Nebulised salbutamol
- Steroids (e.g. oral prednisolone or IV hydrocortisone)
Severe: O SHIT ME
O2 to maintain 94 - 98%
Salbutamol IV
Hydrocortisone IV/oral prednisolone
Ipratropium bromide (nebulised)
Theophylline or aminophylline IV
Magnesium sulphate IV
Escalate care
Life-threatening asthma
- Admission to ICU or ITU
- Intubation/ventilation
Treatment ladder for asthma
- SABA (e.g. salbutamol)
- SABA + low-dose ICS (e.g. beclomethasone)
- SABA + low-dose ICS + LTRA
- LABA (salmeterol)
- MART - maintenance and reliever therapy of low-dose ICS and LABA
- Increase to moderate-dose ICS
- Increase to high-dose ICS
- Specialist management (e.g. oral corticosteroids)
Chronic obstructive pulmonary disease (COPD)
Chronic, obstructive airway disease characterised by emphysema (increased mucus production and alveolar damage and dilatation) and bronchitis (chronic cough and sputum production due to inflammation in the bronchi) = decreased surface for gas exchange.
Biggest cause = smoking
Not reversible with bronchodilators
Key features: cough, wheeze, SOB, sputum production, recurrent chest infections (no clubbing, haemoptysis or chest pain)
Dx: clinical features and spirometry results (FEV1:FVC <0.7) and not bronchodilator reversible
Other Ix: BMI,FBC (anaemia and polycythaemia), sputum culture, ECG + echo (HF) , serum alpha-1 antitrypsin
Management of COPD
Step 1: SABA (salbutamol) and Short-Acting Muscarinic Antagonist (ipratropium bromide)
Then if not ineffective
If no asthma/steroid responsive features:
- Combination of LABA and LAMA
If asthma/steroid responsive:
- Combination of LABA and ICS
Final step = combination of LABA, LAMA and ICS (e.g. trimbow)
Annual flu and pneumococcal vaccinations
Community-acquired pneumonia
Lower-tract respiratory tract infection
Cough, sputum, fever, malaise, haemoptysis, pleuritic chest pain (sharp pain worse on inspiration)
CRB-65 = primary care score whether to send patient to hospital
- Confusion
- Respiratory rate 30 or more
- BP systolic 90 or less, or diastolic 60 or less
- 65 or older
Most common causes =
streptococcus pneumoniae and Haemophilus influenzae
Pseudomonas aeruginosa - in cystic fibrosis
Legionella pneumophila - contaminated aircon
Diagnosis and management of community-acquired pneumonia
CRP levels in primary care to guide management (if CRB-65 1 or less, no admission needed).
Hospital investigations:
- CXR - consolidation
- FBC
- Renal profile
- CRP
More severe:
- Sputum and blood cultures
- Pneumococcal and legionella urinary antigen
Mx: abx according to local guidelines: amoxicillin, doxycycline, clarithromycin
More severe = hospital for IV abx
Gastro-oesophageal reflux disease (GORD)
When acid travels from the stomach via the lower oesophageal sphincter, irritating the oesophageal lining.
Risk factors/precipitating factors: obesity, hiatus hernia (stomach content through the diaphragm), spicy/greasy food, alcohol, NSAIDs
Key features: dyspepsia, heartburn nocturnal cough, hoarse voice, bloating, retrosternal/epigastric pain
Mx:
Conservative: lifestyle changes (e.g. weight loss, reduce alcohol, stop smoking, smaller, lighter meals
Medication review: e.g. stop NSAIDs
Antacids e.g. Gaviscon
PPI e.g. omeprazole
When should you consider referring someone for 2ww direct-access endoscopy?
- Dysphagia at any age! (food getting stuck etc.)
- 55 is cutoff age to do urgent vs routine referral for the below symptoms
- Weight loss
- Anaemia
- Thrombocytopenia
- Treatment resistant dyspepsia
- Nausea and vomiting
- Upper abdominal mass on palpation
Barrett’s oesophagus
When there is metaplasia of the oesophagus from squamous epithelium to columnar epithelium like in the stomach, due to chronic acid reflux.
Pre-malignant condition and high risk of developing oesophageal adenocarcinoma
Tx: endoscopic monitor for progression to cancer, PPIs, endoscopic ablation of abnormal epithelium
Irritable bowel syndrome
Functional bowel disorder caused by a disturbance in the gut-brain axis
Key features: IBS
I - intestinal discomfort (abdominal pain related to the bowels, bloating)
B - bowel habit abnormalities (more/less frequent)
S - Stool abnormalities (watery, loose, hard or associated with mucus
Triggers: anxiety/depression, stress, sleep deprivation, illness, caffeine, alcohol
Dx: exclude serious pathology first
- FBC (anaemia)
- Coeliac serology - anti-TTG, anti-EMA
- Faecal calprotectin
- Inflammatory markers
- CA125
Diagnostic criteria
At least 6m abdo pain or discomfort AND at least one:
- Pain/discomfort relieved by opening bowels
- Bowel abnormalities (more/frequent)
- Stool abnormalities (hard, watery, mucus)
AND at least two of:
- Straining, urgent need to empty bowels or incomplete emptying
- Bloating
- Worse after eating
- Passing mucus
Mx: explanation and reassurance, hydration, adjust fibre intake, reduce stress, low FODMAP diet (dietician-guided)
Medical: loperamide (diarrhoea), bulking form laxatives (e.g. ispaghula husk), anti-spasmodic e.g. hyoscine butylbromide, peppermint oil
IBD
Crohn’s: NESTS
- No mucus or blood in stool (or less likely)
- Entire GI tract affected
- Smoking is risk factor
- Terminal ileum most affected and Transmural (full thickness) inflammation
- Skip lesions
Ulcerative colitis: CLOSE UP
- Continuous inflammation
- Limited to colon and rectum
- Only superficial mucus
- Smoking is protective
- Excrete blood and mucus
- Use aminosalicylates
- Primary sclerosing cholangitis
Dx: 1st line: faecal calprotectin, anti-TTG, stool microscopy and culture. Gold standard: colonoscopy and multiple intestinal biopsies
IBD treatment
- Acute (inducing remission during exacerbation)
- Maintaining remission
Acute:
UC: 1st line is aminosalicylate (e.g. oral/rectal mesalazine), 2nd line is oral or rectal prednisolone
If severe = IV steroids in hospital
Crohns: steroids 1st line
Maintaining remission
UC: mesalazine (aminosalicylate)
Crohn’s: azathioprine/mercaptopurine
Conditions associated with IBD
Erythema nodosum - tender, red nodules on shins
Enteropathic arthritis (inflammatory arthritis)
Primary sclerosing cholangitis
Red eye conditions (e.g. anterior uveitis)
Gallstones (cholelithiasis)
Can be asymptomatic, but can cause cholecystitis, cholangitis and pancreatitis
4F - female, fat, fair, forty
Key features: biliary colic (severe RUQ/epigastric if gallstones blocking neck of gallbladder
- After high-fat meals
- Lasts 30 mins to 8hrs
Ix: 1st line is USS: presence of gallstones in gallbladder, ducts or dilatation of the duct
Thickened gallbladder wall and fluid/sludge = acute cholecystitis
Liver function tests and their meanings
- Raised bilirubin, pale stools, dark urine = obstructive
- Alkaline phosphatase - raised in biliary obstruction if accompanied by biliary colic
- Alanine aminotransferase (ALT) + Aspartate aminotransferase (AST) - raised in intrahepatic damage
ALP markedly raised, ALT and AST mildly raised = cholestasis “obstructive picture”
Mx: asymptomatic = conservative, symptomatic = laparoscopic cholecystectomy
Management of cholecystitis
Inflammation of gallbladder and key complication of cholelithiasis
Fever, N+V, tachycardia, tachypnoea, Murphy’s sign (pressure on RUQ stops inhalation due to pain)
- Emergency hospital admission
- IV fluids
- Nil by mouth
- Antibiotics
Endoscopic retrograde cholangiopancreatography (ERCP) - inserting endoscopy into the common bile duct to the sphincter of Oddi = removal of gallbladders in the common bile duct
Surgery = cholecystectomy
Appendicitis
Inflammation of appendix
Peak incidence: 10 - 20 years old
Food and bacteria become trapped at the opening of the appendix = infection, inflammation, gangrene, rupture = peritonitis
Key features: central abdo pain that moves to RIF within 24hrs, fever, nausea and vomiting, guarding, rebound tenderness, Rovsing’s sign (pressure on LIF causes pain in RF)
Dx: history and examination, CT scan when other pathology possible, USS in females to exclude ectopic and ovarian pathologies
Mx: emergency admission under surgical team for appendectomy (usually laparoscopic)
Pyelonephritis
Inflammation of kidney due to bacterial infection, affects renal pelvis and parenchyma)
RFs: female, vesicoureteric reflux, structural urological abnormalities, pregnancy, diabetes
Causes: E.coli (same as lower UTI), klebsiella pneumoniae
Key features: dysuria, suprapubic discomfort and increased frequency + triad of: fever, loin pain/back pain, nausea/vomiting
Dx: urine dipstick (blood, nitrites, leukocytes) midstream urine (MSU) for microscopy, culture and sensitivities, bloods (raised CRP + raised WCC)
Mx: refer to hospital if sepsis or not safe to manage in community
Antibiotics: 7 - 10 days
- Cefalexin
- Co-amoxiclav (sensitivities known)
- Trimethoprim (sensitivities known)
- Ciprofloxacin (keep lowered seizure threshold in mind)
Systematically unwell patients need sepsis six pathway - 3 tests, 3 treatments
Tests: blood culture, blood lactate, urine output
Treatments: O2 to maintain 94 - 98%, empirical broad-spec abx, IV fluids
Eczema (atopic eczema - a type of dermatitis)
Chronic atopic skin condition, caused by defects in the skin barrier = inflammation
Triggers: cold weather, certain foods, stress, washing powders
Key features:
- Starts in infancy
- Erythematous, weeping/crusted (exudative) and vesicular patches and lesions.
- Flexor surfaces (inside elbows/knees), neck and face
Mx: flares and maintenance
Maintenance: artificial skin barrier with emollients, as greasy as tolerated and as often as possible
Acute: thicker emollients, topical steroids, wet wraps, tx infections (staphylococcus aureus or eczema herpeticum - HSV infection)
Topical steroid ladder: thins skin, which can worsen eczema and infections long-term
- Mild: hydrocortisone 0.5, 1 and 2.5%
- Moderate: eumovate (clobetasone butyrate)
- Potent: betnovate (betamethasone 0.1%)
- Vert potent: dermovate
Psoriasis + psoriatic arthritis
Chronic autoimmune condition, caused by rapid regeneration of new skin cells - uncontrolled keratinocyte proliferation, leading to hyperkeratosis and parakeratosis
Triggers: skin trauma (Koebner phenomenon), infection (strep throat, HIV), drugs: BALI (beta-blockers, anti-malarial, lithium, NSAIDs), withdrawal of steroids, stress, alcohol + smoking, cold/dry weather
RFs: family history, obesity, smoking
Key features: dry, flaky, scaly, lightly erythematous skin lesions, raised and rough - commonly on extensor surfaces (although could be on flexor surfaces)
Types of psoriasis
Plaque psoriasis - most common, symmetrical plaques on extensor surfaces . Itchy, well-defined circular to oval bright pink/red raised lesions with white/silvery scales. Nail changes: pitting, onycholysis (peeling of nails away from nailbed)
Guttate psoriasis - small, raised papules on trunk and limbs after streptococcal throat infection
Inverse (flexural) - smooth, erythematous plaques without scales in flexures and skin folds
Pustular psoriasis - multiple petechiae on palms and soles
Generalised/erythrodermic psoriasis - severe, rare form with systematic symptoms
Management of psoriasis
Topical:
- Emollient to reduce scale and itch
- 1st line: potent topical corticosteroids (e.g. betnovate) + topical vitamin D (one AM and one PM, try for 4 weeks)
- 2nd line: repeat one (4 weeks) or topical vit D ( 12 weeks)
- 3rd line: topical dithranol, coal tar
Phototherapy:
- Narrowband UVB
Systemic:
1st line: Methotrexate (shared care protocol - initiated by secondary care, continued by primary care), give folic acid
DON’T GIVE TRIMETHOPRIM WITH METHOTREXATE
Take methotrexate once a week
Blood tests for patients on methotrexate
- FBC, U+Es and LFTs every 2 weeks until dose is stable, then monthly for 3 months then at least 3 monthly afterwards
Psoriatic arthritis
Inflammatory arthritis associated with psoriasis
Different types: asymmetrical oligoarthritis and symmetrical polyarthritis
Key features: affects DIP joints and axial skeleton, whereas rheumatoid arthritis does not
Signs: psoriatic plaques, nail pitting, onycholysis, dactylitis (inflammation of entire finger)
Screening: Psoriasis Epidemiological Screening Tool (PEST)
X-ray changes:
- Periostitis - inflammation of periosteum (thickened, irregular outline of bone)
- Ankylosis (fusion of bones at the joint
Osteolysis (destruction of bone)
Dactylitis (inflammation of whole digit)
Classic “pencil-in-cup” appearance due to erosion of bone at the joint
Mx: MDT between dermatologists and rheumatologists.
Tx combination of NSAIDs, steroids, DMARDs (e.g. methotrexate), anti-TNF medications
Measles
Morbillivirus, not up to date with immunisations
Urgently notifiable within 24 hours
Key features: preceding sore throat, cough, conjunctivitis, coryza, high fever > 40
Maculopapular rash 2-5 days after - a “pot of paint” distribution - from head spreading down to trunk and limbs, Koplik spots pathognomonic for measles.
Dx: oral fluid sample for measles RNA and IgG and IgM antibodies specific to measles
Mx: supportive, absence from school until 4 days after rash development
Complications: AOM, pneumonia, blindness, subacute sclerosing panencephalitis
Rubella - urgently notifiable within 24 hours
Rubella virus, not up to date with immunisation
Prodrome: coryza, fever, sore throat
Macular, pale-pink rash 1 - 2 days after, starts behind ears with post-auricular lymphadenopathy and spreads to face and trunk, limb-sparing
Dx: rubella-specific IgM serology
Mx: supportive, stay off school 5 days after rash develops
If unvaccinated pregnant woman, must isolate and if suspected or confirmed rubella - urgent referral to obstetrics
Congenital rubella syndrome before 20 weeks - cataracts, deafness and heart defects e.g. patent ductus arteriosus
Parvovirus B19
Slapped cheek/fifth disease
Prodrome of fever, coryza and diarrhoea
Then 1- 2 weeks later, reticular, erythematous rash across whole body, bright-red cheeks, perioral sparing
Dx: clinical
Mx: supportive, children can go back to school once rash appears as no longer infectious
Complications: foetal hydrops (oedema) and aplastic crisis in sickle cell disease
Scarlet fever - urgently notifiable 24 hours
Only bacterial cause of childhood exanthem, associated with tonsilitis
Streptococcus pyogenes
Prodrome: fever, sore throat, headache
Then 1 - 2 days later, widespread, macular, erythematous rash that starts on chest, rough “sand-paper” texture, peri-oral sparing, lymphadenopathy, strawberry tongue
Mx: phenoxymethylpenicillin (pen V) for 10 days, absence from school until 1st dose of abx
Complications: post-streptococcal glomerulonephritis, rheumatic fever
Glandular fever
Infectious mononucleosis - Epstein Barr virus
Often presents as a widespread, maculopapular rash after being prescribed amoxicillin for suspected tonsilitis
Key features: fever, sore throat, fatigue, hepato/splenomegaly
Dx: clinical, but can give positive heterophil antibodies
Mx: supportive, go back to work or school once feeling better
Chickenpox
Varicella zoster virus - highly contagious, intubation period of up to 21 days
Prodrome of fever, malaise, appetite loss
Then 1 - 2 days later, a very itchy, vesicular rash! Starts on chest or face and then spreads to the whole body for 2 - 5 days
No longer infectious when all lesions have crusted over and can go back to school
Mx: supportive with hygiene measures, oatmeal baths and calamine lotion
Complications: secondary bacterial infection due to scratching, pneumonia (mostly in adults), encephalitis, shingles
Kawasaki’s disease
Prolonged, high-grade fever of more than 5 days and CREAM
C- conjunctivitis
R - rash
E - erythema of the palms and soles and desquamation
A - adenopathy (cervical - unilateral and non-tender)
M- mucosal inflammation (e.g. strawberry tongue)
Ix: echo, ECG
Mx: high-dose aspirin and IV immunoglobulins
Monitor with echo as risk of coronary aneurysms
Impetigo
Common, superficial, highly contagious bacterial skin condition, pustular or bullous lesions that can appear anywhere on the body.
RFs: children, eczema, crowded environments, direct contact with infected person, poor hygiene
Non-bullous - pustules or vesicles, dries into honey-coloured crusted lesions
Bullous - bullae (blister > 1cm), ruptures and oozes pus, might be associated with fever, malaise, lymphadenopathy
Dx: clinical history and examination, swabs of weeping lesions can confirm cause and abx sensitivities
Mx:
Conservative: hygiene measures, wash affected areas with soap, wash hands, cover affected areas, stay off work or school until blisters are healed
Hydrocortisone cream 1% if not on face
Fusidic acid cream if on face
If widespread or bullous then oral flucloxacillin/clarithromycin
Rheumatoid arthritis
Chronic inflammation affecting the joint, inflammatory arthritis
Symmetrical polyarthritis - multiple small joints: MCP, PIP, wrist, MTP
Large joints: ankles, hips, knees, shoulders
RFs: female, middle age (>40), obesity, smoking, HLA-DR4
Key features: worse in morning, stiffness/pain > 30 mins, worse with rest and improves with activity
Dx: Rheumatoid factor (positive in 70%), anti-cyclic citrullinated peptide antibodies (positive in 80%), CRP and ESR, X-ray of affected joints
Mx: refer to rheumatology, NSAIDs and baseline bloods while waiting. DMARDs e.g. methotrexate
Osteoarthritis
Wear and tear of the synovial joint
RF: obesity, increased age, occupation that put stress on joints, family history, female, injury
Imbalance between cartilage damage and chondrocyte response = structural problems
Hips, knees, DIPs, carpometacarpal (base of thumb), lumbar spine, cervical spine
X-ray changes: LOSS
Loss of joint space
Osteophytes (new bony spurs)
Subchondral sclerosis
Subchondral cysts
Key features: pain/stiffness that is worse on activity and end of the day, bulky/bony enlargement, crepitus on movement, joint effusions, referred pain e.g. hip OA presenting as LBP
Hand signs: Bouchard’s nodes (PIP), Heberden’s nodes (DIP), squaring of CMC joint
Dx: clinical Dx if > 45 with typical OA symptoms and no morning stiffness (or < 30 mins)
Mx: therapeutic exercises, weight loss, occupational therapy e.g. walking aids
Topical NSAIDs for knee, oral NSAIDS + PPI for gastroprotection, intra-articular steroid injections for short-relief, joint replacement if severe
Osteoporosis
Imbalance between osteoblast (bone remodelling) and osteoclast (bone breakdown) causing bone reabsorption to exceed remodelling = reduced tubercular bone density, increased risk of fragility and fractures.
RFs: FIGHT ME! SHATTERED
Female, Menopausal, Steroids, Hyperthyroidism/Hypothyroidism, Alcohol/smoking, low Testosterone, Thin (low BMI), Erosive disease (e.g. IBD), Renal/liver failure, Early Menopause, DMT1 or malabsorption
Investigations for osteoporosis
Bone mineral density measured using DEXA scan, T-score used to make a diagnosis
T-score is the number of standard deviations the patient is away from the BMD of a healthy young adult
> -1 is normal
Between -2.5 to -1 is osteopenia
< -2.5 is osteoporosis
Management of osteoporosis
- Weight loss and regular exercise
- Stop smoking and reduce alcohol
- Adcal D3
- 1st line medical tx: bisphosphonates e.g. alendronic acid (alendronate 70mg once weekly), interferes with osteoclast attachment to bone
Take on empty stomach, full glass of water, stand up or sit up for 30 mins after to reduce reflux and erosion of oesophagus
Side effects: reflux, oesophageal erosion, osteonecrosis of the jaw
