Long term conditions Flashcards
Vit D def risk factors
Pigmented skin • Use of sun cream/concealing clothes • Old age • Nursing home • Malabsorption • Short bowel • Renal disease • Cholestatic liver disease • Drugs (anticonvulsants, rifampicin, HAART)
Vit D présentation
- Proximal muscle weakness/pain (osteomalacia may be asymptomatic)
- ↓ bone density on DEXA or osteopenia on plain x-ray may indicate vitamin D deficiency
- Severe vitamin D deficiency causes hypocalcaemia, tetany, seizures
- Rickets in children presents with deformities (knock knees, bowed legs) and impaired growth
Investigations for Vitamin D Deficiency
- ↓ serum 25-hydroxy-D3
- <25mmol/Linosteomalacia
- 25-50mmol/LinvitaminDinsufficiency
- ↑ ALP, PTH
- ↓/normal phosphate and calcium
- X-ray shows characteristic defective mineralisation and Looser’s pseudofractures (low density bands running perpendicular to the cortex, commonest in femur/pelvis)
Management of Vitamin D Deficiency
Vitamin D supplementation
• Initial loading dose stage and subsequent maintenance
phase (oral/IM)
• Supplementary calcium (1000-1200mg/day)
• e.g. Cholecalciferol / calcichew
RA presentation
- Insidious onset of pain, early morning stiffness (>30 mins)
- Symmetrical swelling of proximal joints of hands/feet
- PIPJs affected, but DIPJs not affected
- Ulnar deviation, MCP/PIPJ swelling, Z-shaped thumb, Boutonniere deformity, Swan-neck deformity
- May also involve wrists, elbows, shoulders, cervical spine, knees, ankles, feet
joints for RA
• PIPJs affected
MCP/PIPJ swelling, Z-shaped thumb, Boutonniere deformity, Swan-neck deformity
Investigation for RA
Investigations for Rheumatoid Arthritis
• FBC: Normochromic, normocytic anaemia; thrombocytosis
• ESR, CRP raised in proportion with inflammatory activity
• Rheumatoid Factor (RhF) not specific for RA
• Anti-CCP
• X-ray
• Synovial fluid: sterile, raised neutrophils
Management of Rheumatoid Arthritis
• NSAIDs and Coxibs (± Paracetamol, codine)
• Relieve pain but do not slow disease progression
• Corticosteroids
• Suppress disease activity but require high doses (short-term use)
• Disease Modifying Anti-Rheumatic Drugs (DMARDs); start <6 weeks from first presentation
• Methotrexate (mouth ulcers, diarrhoea, liver fibrosis, pulmonary fibrosis, renal impairment,
teratogenic)
• Sulfasalazine (mouth ulcers, hepatitis, reversible male infertility)
• Leflunomide (diarrhoea, hypertension, hepatitis, alopecia)
• Biologics
• TNF-α blockers (CXR before starting; immunosuppression risks latent TB)
• Stop smoking
Clinical Features of Psoriatic Arthritis
Peripheral arthritis
• Absence of RhF or Anti-CCP (“seronegative”)
• DIPJ swelling
• Dactylitis (“sausage fingers”)
• Arthritis mutilans is a severe form with destruction of small bones in hands and feet
Investigations for Psoriatic Arthritis
Routine bloods, ESR normal
• RhF, anti-CCP negative
• X-ray: “pencil-in-cup” deformity in IPJs
Management of Psoriatic Arthritis
- NSAIDs ± paracetamol
- Intra-articular corticosteroid injections
- If severe, methotrexate/TNF-α blockers
- Emollients for skin disease
Parathyroid hormone (PTH)
Kidney→increased calcium resorption and reduced reabsorption of phosphate convert vitamin D to active form
Bone→release of calcium
Small intestine→increased absorption of dietary calcium
Primary Hyperparathyroidism causes
Primary = Hypersecretion of PTH Causes:
• 85% isolated parathyroid adenoma
• 15% diffuse parathyroid hyperplasia
• <1% parathyroid carcinoma
Primary Hyperparathyroidism presentation
PTH - raised
Calcium - increased
phosphate decreased
2ndary Hyperparathyroidsim causes
Causes:
• Chronic kidney disease
• Vitamin D deficiency
2ndary Hyperparathyroidsim presentation
PTH - raised
Calcium - low or normal
phosphate increased or decreased
Hypercalcaemia presentation
Thirst • Increased urination • Constipation • Bone pain • Fatigue • Depression • Confusion • Kidney stones • Palpitations
Hypoparathyroidism = Reduced or absent PTH
PTH low
Calcium decreased
Phosphate increased
Clinical Features of Paget’s Disease of bone
Common sites: pelvis, femur, lumbar spine, skull, tibia
• Most cases asymptomatic
• Pain in bone/nearby joint (cartilage/adjacent bone damage)
• Deformities: enlargement of skull, bowing of tibia
• Complications: nerve compression (deafness, paraparesis), pathological fractures, high output heart failure, osteosarcoma
Investigations for Paget’s Disease
- ↑ ALP (reflects level of bone formation) • Often >1000 u/L
- Normal Ca2+, PO43-
- Urine hydroxyproline excretion ↑
- X-ray shows localised bony enlargement and distortion, sclerotic changes (↑ density) and osteolytic areas (loss of bone and ↓ density)
- Radionucleotide bone scan shows ↑ uptake of bone- seeking radionucleotides
Management of Paget’s Disease
- Bisphosphonates (zoledronate IV)
- Inhibitboneresorptionby↓osteoclasticactivity
- Indicated in symptomatic patients and asymptomatic patients at risk of complications
- Disease activity monitored by serum ALP or urinary hydroxyproline
Osteoporosis vs Osteopenia
Osteoporosis = bone mineral density >2.5 SD below young adult mean value (T-score ≤ –2.5) •Osteopenia = T-score –1 to –2.5
Risk Factors for Osteoporosis
- ↑ age
- Previous fragility fracture • Family history of #NOF
- ↓ BMI
- Smoking
- Alcohol abuse
- Glucocorticoid therapy
- ↑ bone turnover
- ↑ risk of falls
- Rheumatoid arthritis
Clinical Features of Osteoporosis
- Symptoms result from fractures, typically • Thoracicvertebrae
- Lumbarvertebrae
- Proximalfemur
- Distal radius (Colles’ fracture)
- Thoracic vertebral fractures may lead to kyphosis and loss of height (“widow’s stoop”)
Osteoporosis tests
X-rays detect fractures but are insensitive for osteopenia
• Dual Energy X-ray Absorptiometry (DEXA)
• Gold standard measurement of bone mineral density
• Indicated in radiographic osteopenia, previous fragility
fracture (<75 years), glucocorticoid therapy (<65 years), BMI <19, maternal history #NOF, BMD-dependent risk factors
• FRAX assessment tool
• Estimates 10 year probability of osteoporotic fracture for
untreated patient aged 40-90
Management of Osteoporosis
• New vertebral fractures require bed rest for 1-2 weeks and strong analgesia
• Muscle relaxants (e.g. diazepam), calcitonin SC, pamidronate IV
• Non-spinal fractures treated by orthopaedics
• Stop smoking, ↓ alcohol, adequate dietary
calcium/vitamin D, regular weightbearing exercises
• Elderly: physiotherapy, assessment of home safety to ↓ risk of falls, hip protectors as required
medical
• Bisphosphonates (e.g. alendronate, risedronate, zoledronate); inhibit osteoclasts, ↑ bone mass at hip/spine, ↓ fracture incidence
• Denosumab (monoclonal Ab to RANKL) SC 6 monthly; anti- resorptive agent, ↑ bone mineral density, ↓ fracture incidence
• Selective oestrogen-receptor modulators (SERMs, e.g. raloxifene, bazedoxifene); activate bone oestrogen receptors (not endometrial oestrogen receptors)
• Recombinant human parathyroid peptide 1-34 (teriparatide); stimulate bone formation, indicated in severe/refractory osteoporosis
• Oestrogen therapy (e.g. HRT); early post-menopausal women
• Testosterone; men with evidence of hypogonadism
Microbial keratitis causes
Microbial keratitis
Infection of the cornea causing an epithelial breach with underlying stromal involvement
Broad range of causes:
• Bacterial – most common
• Protozoan (acanthoemeba) – uncommon but severe
• Fungus – rare in UK (common elsewhere)
• Viral – HSV, VZV
Bacterial keratitis: organisms
Common organisms:
Pseudomonas Aeruginosa
Staphylococcus Aureus Streptococci (pyogenes, pneumonia) Neisseria Gonorrhoeae
Bacterial keratitis: risk factors
Risk factors: *Contact lens wear* • Extended wear • Poor hygiene • Swimming/shower/sleeping Trauma Ocular surface disease Immunosuppression/diabetes/vit A def
microbial keratitis symtoms
Symptoms and signs:
Painful red eye, watering and photopobia
White infiltrate on the cornea with overlying epithelial defect
Bacterial keratitis management
Rx: Topical antibiotics (moxifloxacin). Stop contact lens wear for now
fungal keratitis symtoms
Symptoms and signs:
Gradual onset of pain, blurred vision, watery, red eye and photophobia.
White fluffy lesion on cornea, filamentary or satellite lesions +/- hypopyon (white blood cells)
fungal keratitis management
Rx: topical amphotericin/natamycin + antibacterial drops.
Slower recovery, long treatment duration
Acanthamoeba keratitis:
Ubiquitous protozoa in soil, water and upper respiratory tract Cystic, highly resilient Risk factors: *Contact lens wear* • Extended wear • Poor hygiene • Swimming/shower/sleeping Trauma
Acanthamoeba keratitis: symtoms
Symptoms: Blurred vision, red eye and severe disproportionate pain
Signs: Early subtle signs such as white lines and later circular ring infiltrate
Acanthamoeba keratitis: treatment
Treatment: topical amoebicides (polyhexamethylene biguanide PHMB +/- chlorhexidine)
Later corneal transplant if scarring
Viral keratitis:
Common organisms: Herpes simplex Herpes zoster
Risk factors:
History of cold sores or other herpetic rashes
History of trauma Atopy/ocular surface disease Poor sanitation Immunosuppression/diabetes
Viral keratitis: symtoms
Symptoms: mild discomfort, red eye, watering, photophobia and blurred vision
Signs: Red eye with dendritic corneal ulcer staining with fluorescein. Reduced corneal sensation.
Viral keratitis treatment
Treatment: topical antiviral (acyclovir or ganciclovir) 5 x day for around 2 weeks
keratitis tests
Not always enough to recognize aetiology clinically so will need lab diagnosis via corneal scrape
Empirical cover with hourly topical antibiotic with 48 hour review Contact lens education important
gout what is this - things that cause this
Impaired renal excretion of uric acid
• Drugs (e.g. thiazide diuretics, low-dose aspirin)
• Hypertension
• Hypothyroidism
• Primary hyperparathyroidism
• Increased lactic acid production (e.g. alcohol, exercise, starvation)
