Medicine C Flashcards

Question

What is the up and go test?

Answer 1

• Timed UP and GO test: stand up from chair, walk 3m, turn round, walk back and sit down. >10s frailty likely

Answer 2

Benzodiazepines NSAID’s Antihypertensives Opioids Anticholinergics

Answer 3

Anticholinergics: unsteadiness, blurred vision, dry mouth, urinary retention, confusion

Answer 4

Amitryptiline Chlorphenamine (piriton) Oxybutinin (urinary incontinence) Baclofen Prochlorperazine Loperamide (diarrhoea) Antipsychotics

Answer 5

Benzodiazepines: falls, regular use increases all-cause mortality, confusion

Answer 6

Hypotension -> falls AKI

Answer 7

Opioids: constipation, falls, delirium

Answer 8

NSAID: AKI and gastric ulceration

Answer 9

•Previous osteoporotic fragility fracture. •Current or frequent recent use of oral corticosteroids. •Low body mass index (less than 18.5 kg/m2) •Smoker. •Alcohol intake > 14 units per week. •A secondary cause of osteoporosis: eg endocrinological: eg POI (untreated) in females, hyperthyroidism, GI malabsorption (eg IBD, coeliac), Rheumatological eg RA

Answer 10

Calculate 10 year fragility fracture score (eg FRAX or Qfracture) DEXA if score >10% or Straight to DEXA if PMH fragility fracture

Answer 11

A measurement of bone mineral density as compared to that of a 30 year old adult (Z score compares your BMD to what is normal in someone your age and body size). • Osteopenia: T score -1 to -2.4 (based on WHO criteria) • (Osteoporosis T-score -2.5 and below, normal range -1 and above)

Answer 12

• Modify risk factors (smoking, alcohol, BMI modification, medication review) • Weight bearing exercise • Dietary modification: sufficient calcium (Edinburgh score?) • Consider calcium and vitamin D supplementation • Plan to repeat DEXA usually within 2 years (CKS)

Answer 13

Bisphosphonate

Answer 14

Check good dental hygiene and ongoing dental care (risk osteonecrosis of jaw). Upper GI irritation Atypical fractures (sudden onset hip/thigh pain)

Answer 15

Diarrhoea and lactic acidosis

Answer 16

Should not go above 20mg simvastatin with patients taking amlodipine

Answer 17

AKI GI Bleed

Answer 18

Personal / family history of the following HLAB27: - Anterior uveitis - IBD - Skin psoriasis - Peripheral joint disease - Breathlessness - Soreness in ankle (achilles)

Answer 19

Sacroiliac Vertebral column

Answer 20

Presents in young adults with symptoms developing over approx 3 months: The main presenting features are lower back pain and stiffness and sacroiliac pain in the buttock region. The pain and stiffness is worse with rest and improves with movement. The pain is worse at night and in the morning and may wake them from sleep. It takes at least 30 minutes for the stiffness to improve in the morning and it gets progressively better with activity throughout the day. Symptoms can fluctuate with “flares” of worsening symptoms and other periods where symptoms improve. Vertebral fractures are a key complication of AS.

Answer 21

Dactylitis is inflammation in a finger or toe.

Answer 22

- Systemic symptoms such as weight loss and fatigue - Chest pain related to costovertebral and costosternal joints - Enthesitis is inflammation of the entheses. This is where tendons or ligaments insert into bone. This can cause problems such as plantar fasciitis and achilles tendonitis. - Dactylitis is inflammation in a finger or toe. - Anaemia - Anterior uveitis - Aortitis is inflammation of the aorta - Heart block can be caused by fibrosis of the heart’s conductive system - Restrictive lung disease can be caused by restricted chest wall movement - Pulmonary fibrosis at the upper lobes of the lungs occurs in around 1% of AS patients - Inflammatory bowel disease is a condition associated with AS

Answer 23

Have the patient stand straight. Find the L5 vertebrae. Mark a point 10cm above and 5cm below this point (15cm apart from each other). Then ask the patient to bend forward as far as they can and measure the distance between the points. If the distance with them bending forwards is less than 20cm, this indicates a restriction in lumbar movement and will help support a diagnosis of ankylosing spondylitis.

Answer 24

- Inflammatory markers (CRP and ESR) may rise with disease activity - HLA B27 genetic test - Xray of the spine and sacrum - MRI of the spine can show bone marrow oedema early in the disease before there are any xray changes.

Answer 25

“Bamboo spine” is the typical exam description of the x-ray appearance of the spine in later-stage ankylosing spondylitis. This is worth remembering for your exams. Xray images in ankylosing spondylitis can show: - Squaring of the vertebral bodies - Subchondral sclerosis and erosions - Syndesmophytes are areas of bone growth where the ligaments insert into the bone. They occur related to the ligaments supporting the intervertebral joints. - Ossification of the ligaments, discs and joints. This is where these structures turn to bone. - Fusion of the facet, sacroiliac and costovertebral joints

Answer 26

- NSAIDs can be used to help with the pain. If the improvement is not adequate after 2-4 weeks of a maximum dose then consider switching to another NSAID. - Steroids can be used during flares to control symptoms. This could be oral, intramuscular slow-release injections or joint injections. - Anti-TNF medications such as etanercept or a monoclonal antibody against TNF such as infliximab, adalimumab or certolizumab pegol are effective in treating the disease activity in AS.

Answer 27

- Physiotherapy essential mainstay! Ideally by a specialist. - Exercise and mobilisation - Avoid smoking - Bisphosphonates to treat osteoporosis - Treatment of complications - Surgery is occasionally required for deformities to the spine or other joints

Answer 28

Symptomatic pain relief Also disease modifying!

Answer 29

Apical fibrosis AV block Aortic regurge Anterior uveitis Achilles Tendonitis

Answer 30

This is the most severe form of psoriatic arthritis. This occurs in the phalanxes. There is osteolysis (destruction) of the bones around the joints in the digits. This leads to progressive shortening of the digit. The skin then folds as the digit shortens giving an appearance that is often called a “telescopic finger”.

Answer 31

The condition does not have a single pattern of affected joints in the same way as osteoarthritis or rheumatoid. There are several recognised patterns: Symmetrical polyarthritis presents similarly to rheumatoid arthritis and is more common in women. The hands, wrists, ankles and DIP joints are affected. The MCP joints are less commonly affected (unlike rheumatoid). Asymmetrical pauciarthritis affecting mainly the digits (fingers and toes) and feet. Pauciarthritis describes when the arthritis only affects a few joints. Spondylitic pattern is more common in men. It presents with: - Back stiffness - Sacroiliitis - Atlanto-axial joint involvement - Plaques of psoriasis on the skin - Pitting of the nails - Onycholysis (separation of the nail from the nail bed) - Dactylitis (inflammation of the full finger) - Enthesitis (inflammation of the entheses, which are the points of insertion of tendons into bone) - Eye disease (conjunctivitis and anterior uveitis) - Aortitis (inflammation of the aorta) - Amyloidosis

Answer 32

PEST Tool (Psoriasis Epidemiological Screening Tool) NICE recommend patients with psoriasis complete the PEST tool to screen for psoriatic arthritis. This involves several questions asking about joint pain, swelling, a history of arthritis and nail pitting. A high score triggers a referral to a rheumatologist.

Answer 33

- Periostitis is inflammation of the periosteum causing a thickened and irregular outline of the bone - Ankylosis is where bones join together causing joint stiffening - Osteolysis is the destruction of bone - Dactylitis is inflammation of the whole digit and appears on the x-ray as soft tissue swelling - Pencil-in-cup appearance The classic x-ray change to the digits is the “pencil-in-cup appearance”. This is where there are central erosions of the bone beside the joints and this causes the appearance of one bone in the joint being hollow and looking like a cup whilst the other is narrow and sits in the cup.

Answer 34

Management is similar to rheumatoid arthritis, and treatment is often coordinated between dermatologists and rheumatologists. Depending on the severity, the patient might require NSAIDs for pain, DMARDS (methotrexate, leflunomide, or sulfasalazine), anti-TNF medications (etanercept, infliximab, or adalimumab), or ustekinumab, which is a monoclonal antibody that targets interleukin 12 and 23.

Answer 35

Axial sponyloarthropathy increases risk of osteoporosis.

Answer 36

Axial sponyloarthropathy increases risk of osteoporosis.

Answer 37

Circinate balanitis is dermatitis of the head of the penis.

Answer 38

Multinucleated giant cells are found on the temporal artery biopsy.

Answer 39

Giant Cell Arteritis (GCA) is a disease that causes inflammation of the arteries, particularly those at the side of the head (the temples). It is also known as temporal arteritis.

Answer 40

GCA usually presents with some combination of the following features in an elderly person: temporal headache, jaw claudication, amaurosis fugax, thickened, tender temporal artery, and scalp tenderness. The onset can be acute or insidious. In addition, GCA and polymyalgia rheumatica (PMR) often occur together, and so symmetrical proximal muscle weakness and an oligoarthritis may occur.

Answer 41

The potential complications of GCA include permanent monocular blindness and stroke.

Answer 42

First line tests to order in suspected GCA are inflammatory markers (particularly ESR), FBC, and LFTS. The definitive investigation is temporal artery biopsy. If negative on the side with symptoms, the asymptomatic side may also be biopsied. If large-vessel involvement is suspected, this may be diagnosed by conventional angiography, magnetic resonance angiography, or CT scan.

Answer 43

GCA should be treated immediately with high-dose steroids (60mg OD prednisolone) to prevent blindness and stroke. Once symptoms resolve, prednisolone is gradually tapered, usually over a long period of 1-2 years, because relapses can occur when tapering too quickly. If weaning off of steroids is problematic and steroid-sparing agents may be used to lower the dose such as azathioprine. Low-dose aspirin is usually also given to further reduce the risk of stroke and blindness.

Answer 44

The potential side effects of high-dose corticosteroids include osteoporosis, gastric ulcers, and increased risk of infection. Bisphosphonates and proton pump inhibitors may be warranted to prevent osteoporosis and gastric ulcers.

Answer 45

Steroid-sparing agents such as azathioprine may be used to lower the corticosteroid dose.

Answer 46

Low-dose aspirin is usually given to further reduce the risk of stroke and blindness.

Answer 47

Granulomatosis with polyangiitis is an autoimmune condition associated with necrotizing granulomatous vasculitis, affecting both the upper and lower respiratory tract as well as the kidneys.

Answer 48

Features of granulomatosis with polyangiitis include upper respiratory tract symptoms, lower respiratory tract symptoms, and rapidly progressive glomerulonephritis. Other features may include a saddle-shape nose deformity, vasculitic rash, eye involvement, and cranial nerve lesions.

Answer 49

Treatment for granulomatosis with polyangiitis includes steroids, cyclophosphamide, and plasma exchange. Median survival is 8-9 years.

Answer 50

The key feature of granulomatosis with polyangiitis is low complement.

Answer 51

The classic triad of granulomatosis with polyangiitis includes upper respiratory tract involvement, lower respiratory tract involvement, and pauci-immune glomerulonephritis.

Answer 52

Radiological features of granulomatosis with polyangiitis include bilateral nodular and cavity infiltrates on chest X-ray.

Answer 53

Palpation of thesynoviumin around joints when the disease is active will give a “boggy” feeling related to the inflammation and swelling.

Answer 54

There is a 3-6 month window where damage is reversible. After this damage is irreversible and there will be permanent deformity.

Answer 55

Z-thumb Ulnar deviation Swan neck Boutonnieres deformity

Answer 56

FH of: Arthritis Autoimmune conditions Psoriasis

Answer 57

Skin - rashes? Lungs? Kidneys? Weight loss Temperature

Answer 58

joint pain

Answer 59

Squaring of the thumb Bouchard's nodes (cool to touch bony swelling). Heberden's nodes

Answer 60

Typically CRP may be normal but ESR is raised.

Answer 61

Bedside tests: Urine dip - to look for vasculitis, nephrotic syndrome, glomerulonephritis. Bloods: FBC, U&E's, LFT's, calcium, CRP, ESR. Important to do this to allow monitoring for when the patient starts taking medications. Immunology depending on the presentation. Imaging: Plain x-ray, chest x-ray, ultrasound / mri. Microbiolgy: Synovial fluid analysis (hot swollen joint).

Answer 62

Ankylosing spondylitis is an inflammatory condition mainly affecting the spine that causes progressive stiffness and pain.

Answer 63

HLA B27 is a gene that is strongly linked to AS, as about 90% of patients with AS have the HLA B27 gene. However, only around 2% of people with the gene will get AS.

Answer 64

Ankylosing spondylitis can affect other organ systems causing systemic symptoms such as weight loss and fatigue, chest pain related to costovertebral and costosternal joints, enthesitis, dactylitis, anemia, anterior uveitis, aortitis, heart block, restrictive lung disease, pulmonary fibrosis, and inflammatory bowel disease.

Answer 65

1. Sacroiliitis on x-ray + 1 other ank spond feature 2. HLAB27 on genetic testing + 2 ank spond features

Answer 66

The diagnostic criteria for AS include the presence of sacroiliitis on imaging plus one or more SpA feature, or HLA-B27 plus two or more SpA features, or acute anterior uveitis plus one SpA feature, or a first-degree relative with AS plus one SpA feature.

Answer 67

Physiotherapy, exercise and mobilization, avoiding smoking, bisphosphonates to treat osteoporosis, treatment of complications. Medical: NSAIDs (analgesic + disease modifying) steroids (only symptom control), DMARD methotrexate, anti-TNF medications such as etanercept or a monoclonal antibody against TNF such as infliximab, adalimumab, or certolizumab pegol). Surgery is occasionally required for deformities to the spine or other joints.

Answer 68

Psoriatic arthritis is an inflammatory arthritis associated with psoriasis.

Answer 69

There are several recognized patterns of psoriatic arthritis: - Symmetrical polyarthritis - Asymmetrical pauciarthritis - Spondylitic pattern

Answer 70

Signs of psoriatic arthritis include plaques of psoriasis on the skin, pitting of the nails, onycholysis (separation of the nail from the nail bed), dactylitis (inflammation of the full finger), and enthesitis (inflammation of the entheses, which are the points of insertion of tendons into bone). Other associations include eye disease (conjunctivitis and anterior uveitis), aortitis (inflammation of the aorta), and amyloidosis.

Answer 71

Reactive arthritis is a condition where synovitis occurs in the joints as a reaction to a recent infective trigger. It is sometimes referred to as Reiter Syndrome. The most common infections that trigger reactive arthritis are gastroenteritis or sexually transmitted infections. Chlamydia is the most common sexually transmitted cause of reactive arthritis.

Answer 72

Reactive arthritis typically causes acute monoarthritis, affecting a single joint in the lower limb, most often the knee, presenting with a warm, swollen, and painful joint. The obvious differential diagnosis is septic arthritis (infection in the joint). However, in reactive arthritis, there is no infection in the joint. Diagnosis is made by clinical presentation.

Answer 73

Ankle swelling - can lead to a prescribing cascade e.g then prescribing furosemide.

Answer 74

Solutions of small molecules in water (e.g. sodium chloride, Hartmann’s, dextrose)

Answer 75

Solutions of larger organic molecules (e.g. albumin, Gelofusine)

Answer 76

Research has shown that crystalloids are superior in initial fluid resuscitation. Colloids are used less often than crystalloid solutions as they carry a risk of anaphylaxis.

Answer 77

Sodium chloride 0.9% Hartman's

Answer 78

25-30 ml/kg/day of water

Answer 79

Approximately 1 mmol/kg/day of potassium, sodium and chloride.

Answer 80

Approximately 50-100 g/day of glucose to limit starvation ketosis (however note this will not address the patient’s nutritional needs)

Answer 81

When prescribing routine maintenance fluids for obese patients you should adjust the prescription to their ideal body weight. You should use the lower range for volume per kg (e.g. 25 ml/kg rather than 30 ml/kg) as patients rarely need more than 3 litres of fluid per day.

Answer 82

For the following patient groups you should use a more cautious approach to fluid prescribing (e.g. 20-25 ml/kg/day): - Elderly patients - Patients with renal impairment or cardiac failure - Malnourished patients at risk of refeeding syndrome

Answer 83

- Bloods: electrolytes/renal function/haemoglobin - Clinical examination: hydration status assessment - Stop intravenous fluids once they are no longer required. - Nasogastric fluids or enteral feeding is preferable when maintenance needs are more than 3 days.

Answer 84

Creatinine Clearance = [[140 - age(yr)]*weight(kg)]/[72*serum Cr(mg/dL)] (multiply by 0.85 for women).

Answer 85

Photosensitive malar rash. This is a “butterfly” shaped rash across the nose and cheekbones that gets worse with sunlight.

Answer 86

FBC (normocytic anaemia can be seen in chronic disease). C3 & C4 are both decreased in active disease. CRP & ESR Immunoglobulins Urinalysis and urine:creatinine ratio to assess for lupus nephritis. (Renal biopsy if suspected).

Answer 87

ANA Anti-dsDNA

Answer 88

Sjogren’s syndrome)

Answer 89

- NSAIDs - Steroids (prednisolone) - **Hydroxychloroquine** (first line for mild SLE). - Suncream and sun avoidance for the photosensitive malar rash

Answer 90

Ophthalmology review for bulls eye maculopathy / retinopathy in patients on hydroxychloroquine. Bloods monitoring (FBC and LFT's).

Answer 91

Systemic lupus erythematosus (SLE) is an inflammatory autoimmune connective tissue disease that affects multiple organs and systems.

Answer 92

SLE is more common in women and Asians and usually presents in young to middle-aged adults but can present later in life.

Answer 93

Common symptoms of SLE include fatigue, weight loss, joint pain, muscle pain, fever, photosensitive malar rash, lymphadenopathy, splenomegaly, shortness of breath, pleuritic chest pain, mouth ulcers, hair loss, Raynaud's phenomenon.

Answer 94

Investigations used to diagnose SLE include autoantibodies, full blood count, C3 and C4 levels, CRP and ESR, immunoglobulins, urinalysis and urine protein:creatinine ratio for proteinuria in lupus nephritis, and renal biopsy.

Answer 95

Methotrexate Mycophenolate mofetil Azathioprine Tacrolimus Leflunomide Ciclosporin.

Answer 96

Rituximab Belimumab.

Answer 97

GPA (granulomatosis with polyangitis).

Answer 98

is a type of non-bacterial endocarditis where there are growths (vegetations) on the valves of the heart. The mitral valve is most commonly affected. It is associated with SLE and antiphospholipid syndrome.

Answer 99

Long term warfarin with an INR range of 2-3 is used to prevent thrombosis (3-4 may be used with recurrent thrombosis).

Answer 100

Pregnant women are started on low molecular weight heparin (e.g. enoxaparin) plus aspirin to reduce the risk of pregnancy complications. Warfarin is contraindicated in pregnancy.

Answer 101

Patients are usually managed jointly between rheumatology, haematology and obstetrics (if pregnant).

Answer 102

Antiphospholipid syndrome is a disorder associated with antiphospholipid antibodies where the blood becomes prone to clotting. The patient is in a hyper-coagulable state.

Answer 103

The main associations are with thrombosis and complications in pregnancy, particularly recurrent miscarriage.

Answer 104

Lupus anticoagulant Anticardiolipin antibodies Anti-beta-2 glycoprotein I antibodies

Answer 105

Diagnosis is made when there is a history of thrombosis or pregnancy complication plus persistent antibodies: Lupus anticoagulant, Anticardiolipin antibodies, or Anti-beta-2 glycoprotein I antibodies.

Answer 106

Drug induced SLE

Answer 107

Limited cutaneous systemic sclerosis

Answer 108

Diffuse systemic sclerosis

Answer 109

Bilateral, proximal (hip and shoulder girdle) muscle weakness, developing over weeks to months.

Answer 110

Presents with the proximal bilateral hip and muscle weakness of polymyositis + any of the following rashes. - Heliotrope rash -which is a lilac discolouration of the eyelid skin in addition to periorbital oedema - Gottron's papules which are scaly, erythematous papules over knuckles and extensor surfaces of knees and elbows - Macular erythematous rash is generally found on the head and neck, trunk or hands - Periungual (nailfold) erythema - Cutaneous vasculitis which can present as rashes and lead to ulcers - Calcinosis

Answer 111

Muscle biopsy which shows: Endomysial inflammatory infiltrates, muscle necrosis and atrophy

Answer 112

Adult-onset Still's disease

Answer 113

Ankylosing spondylitis (remember the 5 associated A's).

Answer 114

Diuretics ACE Inhibitors Metformin

Answer 115

Exacerbates the already present dehydration.

Answer 116

Risk of lactic acidosis.

Answer 117

Pulmonary fibrosis

Answer 118

500mg IV methylprednisolone

Answer 119

- D - Drugs and Alcohol (Anti-cholinergics, opiates, anti-convulsants, recreational) - E - Eyes, ears and emotional (sensory deficits) - L - Low Output state (MI, ARDS, PE, CHF, COPD) - I - Infection - R - Retention (of urine or stool) - I - Ictal - U - Under-hydration/Under-nutrition - M - Metabolic (Electrolyte imbalance, thyroid, wernickes - (S) - Subdural, Sleep deprivation

Answer 120

- Cognitive impairment - Previous delirium - Severe illness - Multiple medications - Dependance syndromes (opiods / alcohol). - Sensory impairment

Answer 121

Hypertension Peripheral neuropathy

Answer 122

Mobility impairment Falls Confusion Incontinence

Answer 123

- In response to screening - Age - Frailty score - Acute illness - High health care utilisation - Change in circumstances - Frailty syndromes - Chronic disease conditions

Answer 124

- Usually to refuse treatment E.G. ventilation - Must be in writing and state 'even if life is at risk'/ 'may die' if for life prolonging treatment

Answer 125

- Not end of life plan - Designed to reduce risk to patient - Tries to anticipate medical 'crises' and plan response

Answer 126

- The decision is based on the individual patient's clinical circumstances - The decision should be made by a senior clinician in consultation with the patient or their representative. - The decision should be clearly documented in the patient's medical record - The decision should be reviewed regularly and updated as necessary - The decision should be communicated clearly to all relevant healthcare professionals involved in the patient's care

Answer 127

Prescribing in the elderly is different to prescribing in a healthy adult because the aging process can affect how medications are absorbed, distributed, metabolized, and eliminated in the body. Additionally, elderly patients may have multiple comorbidities, requiring multiple medications that can interact with one another. There is also an increased risk of adverse drug reactions and medication errors in this population. Therefore, it is important for healthcare professionals to consider the specific needs and risks of elderly patients when prescribing medications.

Answer 128

Pharmacokinetics and pharmacodynamics of commonly prescribed medicines can be altered in the elderly due to changes in renal and hepatic function, decreased body water and muscle mass, and increased body fat. This can lead to changes in drug absorption, distribution, metabolism, and elimination, as well as changes in drug efficacy and toxicity.

Answer 129

STOPP criteria START criteria

Answer 130

STOPP criteria are designed to identify potentially inappropriate medications that may pose a risk to elderly patients, such as medications with a high risk of adverse effects or drug interactions.

Answer 131

START criteria, on the other hand, identify medications that are underused in elderly patients, such as medications for osteoporosis or cardiovascular disease.

Answer 132

Orthostatic hypotension Sedation

Answer 133

Polypharmacy - 5 or more medications used daily. 2 or more meds in children.

Answer 134

Deprescribing is the process of reducing or discontinuing medications that are no longer necessary or beneficial for a patient. This is typically done in order to minimize the potential harms associated with polypharmacy and to improve patient outcomes.

Answer 135

Populations at risk of problematic polypharmacy include elderly patients, individuals with multiple chronic conditions, and those with cognitive impairment or limited functional status.

Answer 136

Those taking more than 10 meds per day - the population group that need to be targeted.

Answer 137

GI bleeding, haematuria, high INR, haematoma

Answer 138

ABCD I: Anaphylactic II: Binding antibodies III: Complex-mediated IV: Delayed

Answer 139

Subchondral erosions Sclerosis Squaring of lumbar vertebrae

Answer 140

Methotrexate may cause pneumonitis - typically presents with cough, dyspnoea and fever.

Answer 141

Bisphosphonates are used for the prevention and treatment of osteoporosis, hypercalcaemia, Paget's disease, and pain from bone metastases.

Answer 142

The duration of bisphosphonate treatment varies according to the level of risk. Some authorities recommend stopping bisphosphonates at 5 years if the patient is < 75-years-old, has a femoral neck T-score of > -2.5, and is low risk according to FRAX/NOGG.

Answer 143

The BNF suggests the following counselling for patients taking oral bisphosphonates: 'Tablets should be swallowed whole with plenty of water while sitting or standing; to be given on an empty stomach at least 30 minutes before breakfast (or another oral medication); the patient should stand or sit upright for at least 30 minutes after taking the tablet.'

Answer 144

Hypocalcemia/vitamin D deficiency should be corrected before giving bisphosphonates. However, when starting bisphosphonate treatment for osteoporosis, calcium should only be prescribed if dietary intake is inadequate. Vitamin D supplements are normally given.

Answer 145

Prednisolone

Answer 146

- Procainamide (anti-arrhythmic) - Hydralazine (antihypertensive)

Answer 147

Ultrasound is the screening test for adult polycystic kidney disease.

Answer 148

- Peaked or 'tall-tented' T waves (occurs first) - **loss of P waves** - broad QRS complexes - sinusoidal wave pattern

Answer 149

Post-streptococcal glomerulonephritis: raised anti-streptolysin O titres are used to confirm the diagnosis of a recent streptococcal infection

Answer 150

Testosterone

Answer 151

pANCA = eosinophilic granulomatosis with polyangiitis aka Churgg-strauss.

Answer 152

Staphylococcal aureus

Answer 153

The risk factors for gout include a diet high in purines, alcohol consumption, and certain medical conditions such as hypertension, CKD, and diabetes.

Answer 154

Gout is caused by the buildup of uric acid crystals in the joints, while pseudogout is caused by the buildup of calcium pyrophosphate crystals in the joints.

Answer 155

1. Modify lifestyle factors (lifestyle/diet/weightloss). Cherry’s have a urate-lowering effect. 2. Patient education 3. Treat diabetes, CKD, hypertension. 4. Allopurinol - started low and increased incrementally until a low urate level is reached. (400mg average). (Xanthase oxidase inhibitor). Can cause SJS or Dress syndrome. F 5. Febuxostat is 2nd line if allopurinol is not suitable.

Answer 156

Kocher criteria

Answer 157

The Kocher criteria for septic arthritis include fever, inability to bear weight, elevated ESR, and elevated WBC count.

Answer 158

Acutely swollen, tender joint, typically a monoarthritis, and restricted range of movement.

Answer 159

- Joint aspiration before any antibiotics are given. Joint aspirate shows WCC over 50,000 in SA. - Bloods: CRP / ESR / FBC /LFT / U&E’s / urate levels / CCP or RF - Blood Cultures to check for SA! - X-ray (can show chondrocalcinosis pg / trauma) - Urinalysis - MRI - osteomyelitis - Genital swabs - gonnohorroea

Answer 160

The differentials for a hot joint include septic arthritis, crystal arthritis (gout/pseudogout), inflammatory arthritis, trauma, and haemoarthrosis.

Answer 161

1. Predisposition to infection (immunosuppression / alcohol) 2. Damaged joints - RA / OA / Joint replacement 3. Opportunistic infections: Skin wound / IVDU / IA steroid injections.

Answer 162

- IV abx - flucloxacillin - Note: If gonorrhoea is the causative organism then ceftriaxone or cefuroxime. - Referral to Ortho / Rheum - either abx continued for 6 weeks or washed outs.

Answer 163

1. Colchicine - avoid in patients with eGFR less than and use with caution in liver disease. Interacts with other drugs. Can cause myopathy if prescribed with statins. 2. NSAID - GI bleed is a contraindication. +ppi? 3. Prednisolone - orally, IM, or intraarticular.

Answer 164

Colchicine / NSAID’s / Prednisolone

Answer 165

Refer to rheumatology

Answer 166

IgA nephropathy classically presents as visible haematuria following a recent URTI

Answer 167

Bones, Stones, Groans and Psychiatric Moans

Answer 168

Once a week + folic acid cover

Answer 169

infection thrombosis may be detected by the absence of a bruit stenosis may present with acute limb pain Steal syndrome - ischaemia in their hand, they wear gloves.

Answer 170

1.5-2 = Stage 1 2-2.9 = Stage 2 3< = Stage 3

Answer 171

ANA - 99% of SLE patients are ANA positive.

Answer 172

Paget's disease

Answer 173

Wrist / knee

Answer 174

Testosterone

Answer 175

Juxta-articular osteoporosis/osteopenia is an early x-ray feature of rheumatoid arthritis

Answer 176

Immobility Incontinence Impaired cognition (confusion) Instability e.g postural - falls

Answer 177

Juxta-articular osteoporosis/osteopenia is an early x-ray feature of rheumatoid arthritis.

Answer 178

Alzheimer's disease causes widespread cerebral atrophy mainly involving the CORTEXand HIPPOCAMPUS

Answer 179

Common presenting symptoms of a posterior circulation stroke include vertigo, imbalance, unilateral limb weakness, slurred speech, double vision, headache, nausea, and vomiting. Exam findings include unilateral limb weakness, gait ataxia, limb ataxia, dysarthria, and nystagmus.

Answer 180

Furosemide - inhibits the Na-K-Cl cotransporter in the thick ASCENDING limb of the loop of Henle.

Answer 181

Anti-Scl-70 antibodies = Diffuse cutaneous systemic sclerosis.

Answer 182

Aspirin 300 mg daily for 2 weeks should be given immediately after an ischaemic stroke is confirmed by brain imaging. Following this, clopidogrel 75 mg daily should be given long-term -if it can be tolerated and is not contraindicated.

Answer 183

(sodium + potassium) - (bicarbonate + chloride)

Answer 184

Corticosteroids monitor CK changes Hydroxychloroquine for rash in dermatomyositits

Answer 185

Acute graft failure happens within months, is usually asymptomatic and is picked up by a rising creatinine, pyuria and proteinuria. Pyuria = high wcc in urine

Answer 186

Calcinosis (white deposits) Raynaud’s (cold, white fingertips precipitated by cold weather) oEsophogeal dysmotility (dysphagia) Sclerodactyly (thickened skin on top of hands and inability to straighten fingers) Telangiectasia (excessive number of spider naevi).

Answer 187

Osteoporosis is commonly associated with normal blood test values (e.g. normal ALP, normal calcium, normal phosphate, normal PTH).

Answer 188

ACE Inhibitors

Answer 189

Radical nephrectomy is the most effective management option in renal cell carcinoma - RCC is usually resistant to radiotherapy or chemotherapy.

Answer 190

Granulomatosis with polyangitis

Answer 191

Systemic Sclerosis

Answer 192

Treatment for granulomatosis with polyangiitis includes steroids, cyclophosphamide, and plasma exchange. Median survival is 8-9 years.

Answer 193

Connective-tissue disease, characterised by fibrosis of the skin and internal organs. Vascular abnormalities, including vasospasm, ischaemia vessel into more hyperplasia, resulting in organ disease. There are two types of systemic sclerosis: - Limited - Diffuse

Answer 194

- Limited (Skin fibrosis is limited to the hands and forearms, feet and legs, and the head and neck). - Diffuse (involving more proximal skin). Skin involvement is over widespread areas at onset and is characterised by early visceral involvement. Very poor prognosis.

Answer 195

Skin fibrosis is limited to the hands and forearms, feet and legs, and the head and neck. Other features include calcinosis, Raynaud's phenomenon, oesophageal dysmotility, sclerodactyly, and telangiectasia.

Answer 196

Skin involvement is over widespread areas at onset and is characterised by early visceral involvement. Other features include digital pits or ulcers, skin thickening, sclerodactyly, loss of function of the hands, and telangiectasia.

Answer 197

Skin fibrosis presents as thickened plaques, and other features include sclerodactyly, microstomia, telangiectasia, and calcinosis.

Answer 198

The vast majority of patients experience Raynaud's phenomenon, pericarditis, and myocardial fibrosis.

Answer 199

Pulmonary fibrosis and pulmonary hypertension.

Answer 200

Scleroderma renal crisis, which causes a rapidly progressive renal failure, usually with hypertension.

Answer 201

Anti-centromere antibodies = limited (they are anti to the centre of the body) Anti-Scl-70 antibodies = diffuse

Answer 202

Renal monitoring: Monitor blood pressure and renal function regularly. Pulmonary monitoring: Regular spirometry (shows restrictive lung disease) and echocardiography (shows pulmonary hypertension).

Answer 203

Unfortunately, there is no cure for systemic sclerosis. Treatment is focused on managing symptoms and preventing complications. This may include medications to reduce inflammation, immunosuppressants, and medications to manage specific symptoms such as Raynaud's phenomenon. In addition, physical therapy and occupational therapy may be recommended to help maintain joint mobility and function. Regular monitoring for complications such as pulmonary fibrosis and renal crises is also important.

Answer 204

Normocytic anaemia Lymphopenia Thrombocytopenia Low complement (C3 and C4) Raised CRP and ESR reflecting inflammation.

Answer 205

Dermatomyositis - Description of erythematous raised papules overlying the metacarpal and interphalangeal joints is that of Gottron's papules.

Answer 206

Sjogren's syndrome is an autoimmune disorder affecting exocrine glands resulting in dry mucosal surfaces. It may be primary (PSS) or secondary to rheumatoid arthritis or other connective tissue disorders, where it usually develops around 10 years after the initial onset. Sjogren's syndrome is much more common in females (ratio 9:1). There is a marked increased risk of lymphoid malignancy (40-60 fold).

Answer 207

Symptomatic only: Artificial saliva and tears Pilocarpine may stimulate saliva production

Answer 208

DIFFUSE Systemic Sclerosis

Answer 209

Churg-Strauss

Answer 210

Triad of atopy (asthma, allergies, eosinophillia) = Churgg strauss

Answer 211

Saddle-shape nose deformity (erosive - therefore cocaine use is a differential). Epistaxis

Answer 212

- procainamide - hydralazine

Answer 213

Polymyositis

Answer 214

Sterile synovial fluid with high white cell count.

Answer 215

Kocher criteria is used to screen for septic arthritis: Fever > 38.5 WCC >12 ESR >40 Non-weight bearing

Answer 216

- Joint aspiration before any antibiotics are given. - IV abx - flucloxacillin - Note: If gonorrhoea is the causative organism then ceftriaxone or cefuroxime. - Referral to Ortho / Rheum - either abx continued for 6 weeks or washed outs.

Answer 217

Negatively birefringent needles

Answer 218

Positively birefringent rhombus-shaped crystals

Answer 219

Tertiary hyperparathyroidism is characterised by extremely high serum PTH with moderately raised serum calcium

Answer 220

Gottron’s papules, roughened red papules over the knuckles mainly, are seen in dermatomyositis

Answer 221

1. NSAIDS 2. Intra articulated steroids 3. Methotrexate / Sulfasalazine for refractory disease

Answer 222

Sarcoidosis?

Answer 223

Family history = strong indicator for FTD

Answer 224

Anti-TNF alpha inhibitors should be used in axial ankylosing spondylitis that has failed on 2 different NSAIDS and meets criteria for active disease on 2 occasions 12 weeks apart

Answer 225

Sterile pyuria and white cell casts in the setting of rash and fever should raise the suspicion of acute interstitial nephritis, which is commonly due to antibiotic therapy.

Answer 226

Group A beta-haemolytic streptococci

Answer 227

Thickened skin on top of hands and inability to straighten fingers

Answer 228

Skin fibrosis is limited to the hands and forearms, feet and legs, and the head and neck

Answer 229

Prognosis is poor due to a rapid malignant disease course with death secondary to respiratory failure, kidney failure, heart failure, and/or intestinal malabsorption.

Answer 230

Skin fibrosis presents as thickened plaques. In the initial stages they may appear inflamed (red/purple, puffy, itchy or painful) before settling into a more fibrosed state with the following features: - Loss of normal skin creases. - Hypo or hyper pigmented or shiny. - Flexion contractures if overlying joints. Other skin features include: - Sclerodactyly - thickening and contracture of an entire digit. - Microstomia - restricted mouth opening, often with skin furrowing. - Telangiectasia - small non-blanching red dots, often around the mouth. - Calcinosis. In limited cutaneous SSc, these lesions are limited to the hands and forearms, feet and legs, and the head and neck, whereas they can occur anywhere in diffuse. In addition, most patients have some form of arthralgia.

Answer 231

- The vast majority of patients experience Raynaud's phenomenon. - Pericarditis. - Myocardial fibrosis which can cause heart failure and arrhythmias.

Answer 232

Unfortunately, there is no cure for systemic sclerosis. Treatment is focused on managing symptoms and preventing complications. This may include medications to reduce inflammation, immunosuppressants, and medications to manage specific symptoms such as Raynaud's phenomenon. In addition, physical therapy and occupational therapy may be recommended to help maintain joint mobility and function. Regular monitoring for complications such as pulmonary fibrosis and renal crises is also important.

Answer 233

Nifedipine IV prostacyclin infusion in severe cases Needs referral to secondary care

Answer 234

ANA Anti-Jo1