Lectures : Med C

Question 1

4 Geriatric giants

Answer 1

1. Mobility impairment
2. Falls
3. Confusion
4. Incontinence

Question 2

Examples of surrogate measures that were used to identify frailty:

Answer 2

BOURNEMOUTH CRITERIA
1. Patients over 90 years of age

2. aged 75-89 w/ 2 or more of the following
   a) Immobility
   b) incontinence
   c) instability
   d) intellectual impairment
   e) iatrogenesis

Question 3

What is pseudomembraneous colitis?

Answer 3

• 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

Question 4

How might biopsy location affect the pathology:

Answer 4

1. Samples from subcapsular cortex
   
   • may give overestimation of glomerular sclerosis
   • this is area in kidney most affected by aging, HTN or non-specific scaring

Question 5

What classification is used for Acute Kidney Injury?

Answer 5

KDIGO Classification

Question 6

Drugs with narrow therapeutic index

Answer 6

Careful, Watch Drugs Possessing Low Therapeutic Indexes

Carbamazepine
Warfarin
Digoxin
Phenytoin
Lithium / levothyroxine
Theophylline
Immunosuppressants (tacrolimus / cyclosporin)

Question 7

Give examples of two drugs which are eliminated via biliary excretion:

Answer 7

1. Rifampicin
2. Fucidic acid

Question 8

Drugs that affect renal perfusion

Answer 8

1. NSAIDs
2. ACEi

Question 9

Instead of LMWH what might be better to give to patients who have renal impairment:

Answer 9

unfractionated heparin
- greater molecular weight
- not filtered

Question 10

Drugs which increase risk of spontaneous bacterial peritonitis in patients with ascites ?

Answer 10

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

Question 11

When might Paracetamol toxicity occur:

Answer 11

1. When glucuronidation and sulfation pathways are saturated
   
   • increases proportion converted to toxic metabolite NAPQI
     ——–>HEPATOCYTE NECROSIS

Question 12

When should a medication review be carried out in elderly patients?

Answer 12

1-3 drugs
- every 12 months

4 drugs or more
- every 6 months

Question 13

Churg-Strauss Syndrome aka

Answer 13

Eosinophilic granulomatosis with polyangiitis

Question 14

What is Berger’s disease?

Answer 14

Type of glomerulonephritis
- IgA1-IgG complex deposition in mesangium

Question 15

Two differential diagnoses for IgA nephropathy

Answer 15

1. Thin membrane disease
   
   • inherited, thinning of glomerular basement membrane by gene mutations of type 4 collagen a3 or a4
2. Alport disease
   
   • disease which damages tiny blood vessels in kidney, attacks glomeruli

Question 16

What histopathologic scoring system is used for prognostic staging in IgA nephropathy:

Answer 16

OXFORD classification - MEST-c SCORE

M-mesangial hyper cellularity

E-endothelial hyper cellularity

S-segmental glomerulosclerosis

T-Tubular atrophy / interstitial fibrosis

C- crescent formation

Question 17

Management of IgA nephropathy (non-immunosuppressive)

Answer 17

1. Lifestyle
2. BP < 130/80mmHg
3. ACEi
4. Lipid lowering therapy

Question 18

Sjogren’s syndrome characterised by:

Answer 18

• Dry eyes
• Dry mouth
• Dry vagina
• Dry skin

Question 19

What antibodies are associated with Sjogren’s syndrome?

Answer 19

Anti Ro / Anti La

20% have ANA

Question 20

Key features of giant cell arteritis

Answer 20

• diplopia
• amaurosis fugax
• visual loss
• tongue / jaw claudication

associated with polymyalgia RHEUMATICA

Question 21

Management of GCA

Answer 21

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

Question 22

Key investigations for GCA

Answer 22

1. ESR
2. Temporal artery USS
3. Temporal artery biopsy

Question 23

Long term management of GCA

Answer 23

1. Methotrexate
2. Azithorpine
3. Leflunomide
4. Mycophenolate mofetil

Question 24

Antibodies associated with SLE

Answer 24

dsDNA

anti-Smith

Question 25

Systemic sclerosis limited antibodies

Answer 25

anti-centromere

Question 26

Systemic sclerosis (diffuse) antibodies

Answer 26

Scl-70

Question 27

Steroid sparing management of GCA

Answer 27

TOCILIZUMAB - interleukin 6 receptor antibody - for relapsing / remitting

Question 28

**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:

Answer 28

Rheumatoid arthritis

Question 29

**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**

Answer 29

1. Female 2. Smoking 3. FH - HLA DRB1 4. Obesity 5. Diet and alcohol

Question 30

**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

Answer 30

Investigations - FBC (anaemic / chronic disease) - renal and liver profile - ESR and CRP - Rheumatoid factor - Urine dip - Plain XR hands and feet - **ANTI-CCP** - CXR

Question 31

Pharmacological treatment for Rheumatoid arthritis summarised:

Answer 31

**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

Question 32

If a patient has a prosthetic joint, what is important to remember:

Answer 32

- NEVER ASPIRATE A PROSTHETIC JOINT - done by orthopaedics - don’t forget blood cultures

Question 33

What criteria is used to indicate whether a joint may be septic:

Answer 33

**KOCHER CRITIERA** - Probability depending on score - 1 = 3% - 2 = 40% - 3 = 93% - 4 = 99% - non-weight bearing - temp > 38.5 - ESR > 40mm - WBC > 12000

Question 34

Management of septic joint :

Answer 34

1. aspiration before ABx 2. ABx per local pathway a) IV b) usually: **Flucloxacillin 2g QDS** 3. If Gonorrhoea a) gram negative --> ceftriaxone

Question 35

What bacteria is the cause of most septic joints:

Answer 35

- staph aureus - forms gram positive clusters - hence flucloxacillin can be used - if gonorrhoea - ceftriaxone

Question 36

Gout risk factors:

Answer 36

- alcohol - CKD - medication - genetics - high purine diet - metabolic syndrome

Question 37

Acute gout management:

Answer 37

**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

Question 38

Acute pseudogout treatment:

Answer 38

- Colchicine - NSAIDs - prednisolone

Question 39

Antibodies for rheumatoid arthritis

Answer 39

anti-CCP HLA-DRB1

Question 40

What is an important side effect to be aware of when prescribing allopurinol?

Answer 40

Steven Johnson Syndrome