Lectures : Med C Flashcards
4 Geriatric giants
- Mobility impairment
- Falls
- Confusion
- Incontinence
Examples of surrogate measures that were used to identify frailty:
BOURNEMOUTH CRITERIA
1. Patients over 90 years of age
- aged 75-89 w/ 2 or more of the following
a) Immobility
b) incontinence
c) instability
d) intellectual impairment
e) iatrogenesis
What is pseudomembraneous colitis?
- inflammatory condition of colon
- C. DIFFICLE
- volcanic-like eruption with superficial pseudo membrane formation
- raised yellow white plaques that coalesce to form pseudo membrane on mucosa
How might biopsy location affect the pathology:
-
Samples from subcapsular cortex
- may give overestimation of glomerular sclerosis
- this is area in kidney most affected by aging, HTN or non-specific scaring
What classification is used for Acute Kidney Injury?
KDIGO Classification
Drugs with narrow therapeutic index
Careful, Watch Drugs Possessing Low Therapeutic Indexes
Carbamazepine
Warfarin
Digoxin
Phenytoin
Lithium / levothyroxine
Theophylline
Immunosuppressants (tacrolimus / cyclosporin)
Give examples of two drugs which are eliminated via biliary excretion:
- Rifampicin
- Fucidic acid
Drugs that affect renal perfusion
- NSAIDs
- ACEi
Instead of LMWH what might be better to give to patients who have renal impairment:
unfractionated heparin
- greater molecular weight
- not filtered
Drugs which increase risk of spontaneous bacterial peritonitis in patients with ascites ?
PPI
- leads to reduction in gastric acidity
- increase in intestinal permeability
- promotes bacterial translocation and colonization of mesenteric lymph nodes
H2 receptor antagonists
- decrease gastric acid secretion
- reversibly binding to histamine H2 receptors on gastric parietal cells
When might Paracetamol toxicity occur:
- When glucuronidation and sulfation pathways are saturated
- increases proportion converted to toxic metabolite NAPQI
——–>HEPATOCYTE NECROSIS
- increases proportion converted to toxic metabolite NAPQI
When should a medication review be carried out in elderly patients?
1-3 drugs
- every 12 months
4 drugs or more
- every 6 months
Churg-Strauss Syndrome aka
Eosinophilic granulomatosis with polyangiitis
What is Berger’s disease?
Type of glomerulonephritis
- IgA1-IgG complex deposition in mesangium
Two differential diagnoses for IgA nephropathy
-
Thin membrane disease
- inherited, thinning of glomerular basement membrane by gene mutations of type 4 collagen a3 or a4
-
Alport disease
- disease which damages tiny blood vessels in kidney, attacks glomeruli
What histopathologic scoring system is used for prognostic staging in IgA nephropathy:
OXFORD classification - MEST-c SCORE
M-mesangial hyper cellularity
E-endothelial hyper cellularity
S-segmental glomerulosclerosis
T-Tubular atrophy / interstitial fibrosis
C- crescent formation
Management of IgA nephropathy (non-immunosuppressive)
- Lifestyle
- BP < 130/80mmHg
- ACEi
- Lipid lowering therapy
Sjogren’s syndrome characterised by:
- Dry eyes
- Dry mouth
- Dry vagina
- Dry skin
What antibodies are associated with Sjogren’s syndrome?
Anti Ro / Anti La
20% have ANA
Key features of giant cell arteritis
- diplopia
- amaurosis fugax
- visual loss
- tongue / jaw claudication
associated with polymyalgia RHEUMATICA
Management of GCA
No visual disturbance –> 40mg OD pred
Visual disturbance –> 60mg OD pred
Visual loss –> IV methylpred 500-100mg up to 3 doses
REFER TO OPTHAL and RHEUM
Think about gastroprotection, bone prophylaxis and diabetes
Key investigations for GCA
- ESR
- Temporal artery USS
- Temporal artery biopsy
Long term management of GCA
- Methotrexate
- Azithorpine
- Leflunomide
- Mycophenolate mofetil
Antibodies associated with SLE
dsDNA
anti-Smith
Systemic sclerosis limited antibodies
anti-centromere
Systemic sclerosis (diffuse) antibodies
Scl-70
Steroid sparing management of GCA
TOCILIZUMAB
- interleukin 6 receptor antibody
- for relapsing / remitting
Case 1: 45 Female
PC: 6/52 joint pain and swelling. Stiffness lasting for at least 45 mins. Minimal relief with paracetamol and ibuprofen.
HPC: started in MCP now in wrist and PIP.
PMH: Graves disease, previous thyroidectomy
DH: levothyroxine 100 micrograms daily
Most likely diagnosis:
Rheumatoid arthritis
Case 1: 45 Female
PC: 6/52 joint pain and swelling. Stiffness lasting for at least 45 mins. Minimal relief with paracetamol and ibuprofen.
HPC: started in MCP now in wrist and PIP.
PMH: Graves disease, previous thyroidectomy
DH: levothyroxine 100 micrograms daily
Risk factors for diagnosis
- Female
- Smoking
- FH - HLA DRB1
- Obesity
- Diet and alcohol
Case 1: 45 Female
PC: 6/52 joint pain and swelling. Stiffness lasting for at least 45 mins. Minimal relief with paracetamol and ibuprofen.
HPC: started in MCP now in wrist and PIP.
PMH: Graves disease, previous thyroidectomy
DH: levothyroxine 100 micrograms daily
INVESTIGATIONS
Investigations
- FBC (anaemic / chronic disease)
- renal and liver profile
- ESR and CRP
- Rheumatoid factor
- Urine dip
- Plain XR hands and feet
- ANTI-CCP
- CXR
Pharmacological treatment for Rheumatoid arthritis summarised:
NSAID +/- simple analgesia
- naproxen
- COX-2 selective: celecoxib, etoricoxib
Steroids
- intermittent for active disease
- IM methylpred –> intrarticular if single joint
DMARDS
–> methotrexate
–> sulphasalazine
–> hydroxychloroquine
–> leflunomide
Targetted
- anti TNF
- anti IL6
- anti CD20
- JAK inhibitors
If a patient has a prosthetic joint, what is important to remember:
- NEVER ASPIRATE A PROSTHETIC JOINT
- done by orthopaedics
- don’t forget blood cultures
What criteria is used to indicate whether a joint may be septic:
KOCHER CRITIERA
- Probability depending on score
- 1 = 3%
- 2 = 40%
- 3 = 93%
- 4 = 99%
- non-weight bearing
- temp > 38.5
- ESR > 40mm
- WBC > 12000
Management of septic joint :
- aspiration before ABx
- ABx per local pathway
a) IV
b) usually: Flucloxacillin 2g QDS - If Gonorrhoea
a) gram negative –> ceftriaxone
What bacteria is the cause of most septic joints:
- staph aureus
- forms gram positive clusters
- hence flucloxacillin can be used
- if gonorrhoea
- ceftriaxone
Gout risk factors:
- alcohol
- CKD
- medication
- genetics
- high purine diet
- metabolic syndrome
Acute gout management:
1. Colchicine
–> 500mg QDS (beware of diarrhoea)
–> use with caution in liver disease and low eGFR
2. NSAIDS
–> caution! if previous GI bleed
–> PPI in addition
3. Prednisolone
–> if colchicine and NSAIDs contraindicated then pred can be given with PPI
Acute pseudogout treatment:
- Colchicine
- NSAIDs
- prednisolone
Antibodies for rheumatoid arthritis
anti-CCP
HLA-DRB1
What is an important side effect to be aware of when prescribing allopurinol?
Steven Johnson Syndrome
