GP RA/OA, Thyroid, IBD/IBS, Skin Flashcards
OA risk factors
Age, female
Obesity
Previous Fractures / joint damage
Pathology of OA
Loss of articulation cartilage
-> cartillangeous growths which calcify -> osteophytes
Features of OA
Worse on movement, relieved by rest
Mostly hands, feet and weight bearing (hips, knees, spine)
Crepitus
Bouchard . Herberdens nodes
Ix in OA
FBC and ESR -> normal RF negative ACPA X-ray - Loss of joint space, Osteophytes, Subchondral sclerosis and Cyst formation MRI - early cartilage changes
Management of OA
Patient education
Weight loss -> especially if weight bearing joints
Strengthening exercises
Bracing devices / joint support / walking stick
Good footwear
Medication
Paracetamol / NSAIDs
Intraarticular corticosteroid injections
Surgical
Hip / knee replacement
RA RF?
Smoking
Female
Family Hx
HLA -DR4
Pathology of RA
Autoimmune symetical inflammation of joints
- > synovium grows forming mass called ‘Pannus’
- > pannus damages articulate cartilage and subchondral bone -> bony erosions
Features of RA
Insidious onset pain
Early morning stiffness which eases
Proximal joints of hands and feet (progresses to wrists, elbow, shoulder, spine, knees…)
Swelling of joints
Z shaped thumb
Boutonnière deformity / swan neck
Non articular manifestations of RA (Name 4)
Systemic - fever, fatigue, weight loss
Eyes - sjogrens
Neuro - carpal tunnel, cord compression, mononeuritis multiplex
Haem - Lymphadenopathy, thrombocytosis, anaemia, Fetty syndrome
Pulm - pleural effusion, fibrosis, rheumatoid nodules
Vessels - raynauds, pericardial effusion
Vasculitis - ulcers
R.A Ix?
Peripheral symmetrical polyarthritis worse in morning
Bloods - Raised CRP/ESR, normochromic normocytic anaemia, thrombocytosis
Autoantibodies - ACPA [key], RF (less specific)
X-ray - soft tissue swelling
-later joint narrowing, erosions of joint margins, cysts, porous is of bone
Synovial fluid - sterile
Mx of RA
NSAIDs
Corticosteroids - oral / injection
Disease modifying antirheumatic drugs - Methotrexate / sulfasalazine
Biological DMARD - TNFa inhibitors (entanercept/infliximab)
-IL-1 receptor blocker ….
Side effects of methotrexate
Kills babies - stop 3months prior to conception
Mouth ulcers, diarrhoea
Liver/pulmonary fibrosis
Renal impairment
Causes of hypothyroidism
Autoimmune thyroiditits - antibodies to TSH receptor -> goitre (hashimotos) / atrophy
Post partum thyroiditis
Iatrogenic - Thyroidectomy, radioactive iodine
Drug induced - carbimazole, lithium, amiodarone, interferon
Iodine deficiency
Congenital hypothyroidism
Sx / signs of hypothyroid
Sx
Tiredness, weight gain, cold intolerance, goitre
Depression, poor memory
Dry skin/hair
Arthralgia, weakness, reduced libido, constipation
Signs Mental slowness Dry thin hair Bradycardia Dry skin Slow-relaxing reflexes
Ix in hypothyroid
Serum free t4 - low
Thyroid autoantibodies
Anaemia, hyponatraemia
Mx of hypothyroid
Levothyroxine - assessed after 6 weeks
Annual measurement of TSH
What is a myoedema coma? Ix? Mx?
Severe hypothyroidism -> coma and confusion
-hypothermia, cardiac failure, hypoglycaemia, hyponatraemia
Ix
TSH, T4 and cortisol
FBC,U+E, glucose, cultures
ECG monitoring
Mx T3 Oxygen Gradual rewamrmig Hydrocortisone Glucose Supportive
Causes of hyperthyroidism
Graves - IgG antibodies -> stimulate TSH receptor
Toxic multinodular goitre
Post partum thyroiditis
De Quervain -> transient due to inflammation of gland with infection
Sx and signs of hyperthyroid
Sx Weight loss Irritability, sweating, palpitations Heat intolerance Tremor Oligomenorrhea Eye complaints Loss of libido
Signs Tremor Hyperkinesis Tachycardia / AF Warm vasodilator peripheries Exopthalmos (only graves) Lid lag Goitre Bruit
Ix in hyperthyroid ? How to differentiate graves from toxic multinodular goitre?
Serum TSH - low
Serum free t3/4 - raised
TSH receptor autoantibodies
Ultrasound - differentiate graves and toxic multinodular goitre
[±exopthalmos]
Mx of hyperthyroid
Drugs - carbimazole [risk of agranulocytosis]
Radioactive iodine
Surgery
What happens thyroid crisis? Cause? Mx?
Hyperpyrexia, tachycardia, extreme restlessness
-> delirium, coma and death
Infection, stress, surgery/radioactive iodine treatment
Large doses of carbimazole, propranolol, and potassium iodide
Hydrocortisone - blocks conversion of t4->t3
Graves eye features
Lid retraction, lid lag
Exophthalmos - protruding eyeball
Opthalmoplegia - limited movements
HLA in coeliac? What causes it?
Typical histology?
HLA-DQ2 , DQ8
Gliardin (gluten)
Villous atrophy and crypt hyperplasia
Features of coeliac
Presents in infancy - diet change
Or adults in 5th decade
Anaemia, nutritional deficiency,
Ix in coeliac
Serum antibodies - IgA tTG (tissue transglutaminase), IgA EMA
Distal duodenal biopsy - crypt hyperplasia and villous atrophy
Blood count - anaemia
DEXA scan - increased risk of osteoporosis in older
Small bowel radiology - if complication such as lymphoma suspected
Mx in coeliac? Complications?
Lifelong gluten free diet
Correct vitamin deficiency
Increased risk of T cell lymphoma, small bowel / oesophageal ca
HLA in IBD
HLA B27
Some differences between UC and Crohns
Crohns
Any part of GI
Discontinuous involvement (skip lesions)
Deep ulcers
Microscopic - Transmural inflammation, granulomas in 50%
UC Only colon Begins in rectum and spreads proximally Continuous involvement Bleeds easily Microscopic - no granuloma, goblet cell depletion, crypt abscesses
Clinical feaures of Crohns
Abdo pain
Weight loss
Terminal ileum -> right iliac fossa and mimic appendicitis
Diarrhoea, bleeding, pain
Clinical features of UC
Diarrhoea with blood and mucus
Often relapses and remissions
Extra GI manifestations of IBD
Eyes - conjunctivitis
Joints - arthralgia
Skin - erythema nodosum, ulcers
Hepatobiliary - fatty liver, hepatitis, gall stones, cirrhosis
Renal - stones
Venous thrombosis
Ix in IBD
Bloods - anaemia
Imaging - colonoscopy, abdo X-ray, USS, small bowel imaging
Mx of Crohns
Oral 5-ASA (aminosalicylic acid)
Steroids - Prednisolone
->methotrexate if resistant
Azathioprine
Metronidazole - antibacterial and immunosuppressive
Anti TNFa - infliximab
When would you offer surgery in IBD
Failure of medical therapy Stricture Abscess Cancer Fissures
Mx of UC
Mild - aminosalicylic acid -> prednisolone
Severe - prednisolone
Systemic features - hydrocortisone, infliximab, cyclosporin
Maintain remission - aminosalicylic acid, azathioprine
Ix/ Mx of acute severe UC ? Monitor?
Admit
FBC,CRP, liver, U+E
Blood cultures
Abdo X-ray -> look for dilation and mucosal islands
Stool cultures
IV hydrocortisone
Correct U+E / fluid
LMW heparin -> VTE risk
If no response ->. Cyclosporin and infliximab
Monitor
Stool chart
Vital signs
Bloods / abdo X-ray if needed
Ix / features in CKD
EGFR
Proteinuria / haematuria
Anaemia -> Reduced erythropoetin by kidney
-blood loss, dietary deficiencies
Bone disease - eg osteoporosis
Neuro [almost all] - Peripheral neuropathy / weakness / parathesia
-autonomic dysfunction
Cardiovascular - MI, HF, stroke
Mx of CKD
Renoprotection - Blood pressure - ACE, CCB, diuretic
CV risk - Statins, smoking, diabetic control
Complication mx
Hyperkalaemia - dietary restriction
Ca/phosphate- dietary, calcium carbonate
-Vit D for calcium
Anaemia - iron
Acidosis / infections
Renal replacement therapy in CKD
Dialysis
Haemo -
Peritoneal
Transplant
Anne Mx
Washing with acne soaps, discourage picking
1- topical benzoyl peroxide / retinoids
2- oral antibiotics
3-oral retinoids
Psoriasis features
Plaques over extensor surfaces - elbows, knees
What is guttate psoriasis ?
Often in children / young adults
Eruption of small oval plaques on trunk 2 weeks after strep throat
Mx of psoriaiss
Topical
- Emollients
- Vit D analogues - calcitrol
- Corticosteroids
Phototherapy
Systemic
- Retinoic acid
- immunosuppression - methotrexate / cyclosporin
- TNFa blockers - infliximab
Rheumatoid X-ray
Symmetrical in small joints of hands and feet
SOLES
Subluxation Osteopenia (periarticular) Loss of joint space Bony Erosions Soft tissue Swelling
Joint spared in RA
Distal phalange
