Autoimmune symetical inflammation of joints - >synovium grows forming mass called ‘Pannus’ - >pannus damages articulate cartilage and subchondral bone -> bony erosions

GP RA/OA, Thyroid, IBD/IBS, Skin Flashcards by Hamish Reed-Embleton

OA risk factors

Age, female
Obesity
Previous Fractures / joint damage

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Pathology of OA

Loss of articulation cartilage

-> cartillangeous growths which calcify -> osteophytes

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Features of OA

Worse on movement, relieved by rest
Mostly hands, feet and weight bearing (hips, knees, spine)
Crepitus
Bouchard . Herberdens nodes

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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

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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

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RA RF?

Smoking
Female
Family Hx
HLA -DR4

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Pathology of RA

Autoimmune symetical inflammation of joints

> synovium grows forming mass called ‘Pannus’
> pannus damages articulate cartilage and subchondral bone -> bony erosions

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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

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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

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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

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Mx of RA

NSAIDs

Corticosteroids - oral / injection

Disease modifying antirheumatic drugs - Methotrexate / sulfasalazine

Biological DMARD - TNFa inhibitors (entanercept/infliximab)
-IL-1 receptor blocker ….

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Side effects of methotrexate

Kills babies - stop 3months prior to conception
Mouth ulcers, diarrhoea
Liver/pulmonary fibrosis
Renal impairment

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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

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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

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Ix in hypothyroid

Serum free t4 - low
Thyroid autoantibodies
Anaemia, hyponatraemia

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Mx of hypothyroid

Levothyroxine - assessed after 6 weeks

Annual measurement of TSH

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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

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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

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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