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Year 4 Med > Medicine C > Flashcards

Medicine C Flashcards

1
Q

What genes are associated with rheumatoid arthritis?

A
  • HLA DR4
  • HLA DR1
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2
Q

What role does rheumatoid factor play in RA?

A

Rheumatoid Factor(RF) is an autoantibody presenting in around 70% of RA patients.

This autoantibody targets IgG causing systemic inflammation.

Rheumatoid factor is most often IgM however they can be any class of immunoglobulin.

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3
Q

What antibodies are seen in RA?

A

Anti-ccp
RF

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4
Q

Anti-CCP antibodies vs RF?

A

Cyclic citrullinated peptide antibodies (anti-CCP antibodies)are autoantibodies that are more sensitive and specific to rheumatoid arthritis than rheumatoid factor.

  • note Anti-CCP often predates RA and can indicate whether the patient may go on to develop the condition.
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5
Q

Presentation of RA:

A

It typically presents with asymmetrical distal polyarthropathy. The key symptoms are joint:

  • Pain
  • Swelling
  • Stiffness
  • Nodules around the joints
  • Early hand involvement affecting MCP and PIP
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6
Q

What joints are commonly affected in RA?

A
  • Proximal Interphalangeal Joints (PIP) joints
  • Metacarpophalangeal (MCP) joints
  • Wrist and ankle
  • Metatarsophalangeal joints
  • Cervical spine
  • Large joints can also be affected such as the knee, hips and shoulders.
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7
Q

Systemic symptoms of RA:

A
  • Fatigue
  • Weight loss
  • Flu like illness
  • Muscles aches and weakness
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8
Q

Painful DIP joints = ?

A

Osteoarthritis

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9
Q

What is atlantoaxial subluxation?

A

Atlantoaxial subluxation occurs in the cervical spine. The axis (C2) and the odontoid peg shift within the atlas (C1). This is caused by local synovitis and damage to the ligaments and bursa around the odontoid peg of the axis and the atlas. Subluxation can cause spinal cord compression and is an emergency. This is particularly important if the patient is having a general anaesthetic and requires intubation. MRI scans can visualise changes in these areas as part of the pre-operative assessment.

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10
Q

Signs in the hands on examination in a patient with rheumatoid arthritis:

A

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

Key changes to look for and mention when examining someone with rheumatoid arthritis are:

  • Z-shaped deformity to the thumb
  • Swan neck deformity (hyperextended PIP with flexed DIP)
  • Boutonnieres deformity (hyperextended DIP with flexed PIP)
  • Ulnar deviation of the fingers at the knuckle (MCP joints)
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11
Q

Extra-articular manifestations of RA:

A
  • Pulmonary fibrosis with pulmonary nodules (Caplan’s syndrome)
  • Bronchiolitis obliterans (inflammation causing small airway destruction)
  • Felty’s syndrome(RA, neutropenia and splenomegaly)
  • Secondary Sjogren’s Syndrome(AKA sicca syndrome)
  • Anaemia of chronic disease
  • Cardiovascular disease
  • Episcleritis and scleritis
  • Rheumatoid nodules
  • Lymphadenopathy
  • Carpel tunnel syndrome
  • Amyloidosis
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12
Q

Diagnosis and investigations for RA:

A
  • Check rheumatoid factor
  • If RF negative, check anti-CCP antibodies
  • Inflammatory markers such as CRP and ESR
  • X-ray of hands and feet

Ultrasound scan of the joints can be used to evaluate and confirm synovitis. It is particularly useful where the findings of the clinical examination are unclear.

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13
Q

What X-ray changes are seen in RA?

A
  • Joint destruction and deformity
  • Soft tissue swelling
  • Periarticular osteopenia
  • Bony erosions
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14
Q

When to refer a patient to rheumatology in suspected RA?

  • when should this be an urgent referral?
A

NICE recommend referral for any adult with persistent synovitis, even if they have negative rheumatoid factor, anti-CCP antibodies and inflammatory markers.

The referral should be urgent if it involves the small joints of the hands or feet, multiple joints or symptoms have been present for more than 3 months.

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15
Q

What is the DAS 28 score?

A

The DAS28 is theDisease Activity Score. It is based on the assessment for 28 joints and points are given for:

  • Swollen joints
  • Tender joints
  • ESR/CRP result

It is useful in monitoring disease activity and response to treatment.

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16
Q

Short term management of RA?

A

A short course of steroids can be used at first presentation and during flare-ups to quickly settle the disease.NSAIDs/COX-2 inhibitorsare often effective but risk GI bleeding so are often avoided or co-prescribed withproton pump inhibitors(PPIs).

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17
Q

First line for long term management of RA?

A

First-line monotherapy with methotrexate, leflunomide or sulfasalazine. Hydroxychloroquine can be considered in mild disease and is considered the “mildest” anti rheumatic drug.

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18
Q

Epidemiology of rheumatoid arthritis:

A

Affects 1% of the population.
3:1 Female: Male
Any age most commonly starting in middle age (58).

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19
Q

Rheumatoid arthritis risk factors:
(remember for osce histories)

A

Female sex
No live births
Breastfeeding decreases risk
Smoking
Obesity
Alcohol
Genetics - HLA DRB1

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20
Q

What is methotrexate and what cautions need to be taken?

A

Folate antagonist
- prescribe with folic acid
-Teratogenic
- Needs regular monitoring with FBC, U&E, liver profile
- Can cause acute pneumonitis

  • Caution using with other folate antagonists e.g trimethoprim
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21
Q

What are the complications of rheumatoid arthritis?

A

Deformity resulting in disability
Osteoporosis (directly from RA and due to steroid treatments)
Cardiovascular disease x2
Infection (due to disease and treatment)

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22
Q

What is dactylitis and what is it seen in?

A

Dactylitis or sausage digit is inflammation of an entire digit, and can be painful.
- seen in psoriatic arthritis

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23
Q

Frailty syndromes

A

Falls: collapse, legs gave way, ‘found lying on floor’

Immobility: sudden change in mobility, ‘gone off legs’ stuck in toilet’

Delirium: new acute confusion or sudden worsening of confusion in someone with previous dementia/memory loss

Incontinence: new onset or worsening of urine or faecal incontinence

Susceptibility to side effects of medication: confusion with codeine, hypotension with antidepressants, drug to drug interactions, AKI

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24
Q

How can frailty be assessed?

A

Up and go test

•PRISMA 7
• Edmonton Frailty Scale PDF
•Rockwood Frailty Score
•Clinical Frailty Scale app: based on Rockwood
• Beware assessing in acute illness

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25
Q

What is the up and go test?

A

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

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26
Q

What drugs are associated with adverse outcomes in frailty?

A

Benzodiazepines
NSAID’s
Antihypertensives
Opioids
Anticholinergics

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27
Q

Complications of anticholinergics in the elderly

A

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

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28
Q

Commonly prescribed anticholinergics in the elderly

A

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

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29
Q

Complications of benzo’s in the elderly

A

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

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30
Q

Complications of antihypertensives in the elderly

A

Hypotension -> falls
AKI

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31
Q

Complications of opioids in the elderly

A

Opioids: constipation, falls, delirium

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32
Q

Complications of NSAID’s in the elderly

A

NSAID: AKI and gastric ulceration

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33
Q

Risk factors for fragility fracture

A

•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

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34
Q

How to assess someone at risk of a fragility fracture:
- investigations?

A

Calculate 10 year fragility fracture score (eg FRAX or Qfracture)

DEXA if score >10% or Straight to DEXA if PMH fragility fracture

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35
Q

What is a DEXA Score?
How to interpret the score?

A

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)

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36
Q

Management of osteopenia in the elderly

A

• 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)

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37
Q

What is alendronic acid?

A

Bisphosphonate

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38
Q

Complications of bisphosphonates

A

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

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39
Q

Side effects of metformin

A

Diarrhoea and lactic acidosis

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40
Q

Patients on simvastatin and amlodipine have a much higher risk of rhabdomyolysis

A

Should not go above 20mg simvastatin with patients taking amlodipine

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41
Q

Risks of taking aspirin

A

AKI
GI Bleed

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42
Q

Essential questions to ask in an axial spondyloarthropathy history:
(related diseases)

A

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

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43
Q

Key joints affected in ankylosing spondylitis:

A

Sacroiliac
Vertebral column

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44
Q

How does AS present?

A

Presents in young adults with symptoms developing over approx 3 months:

The main presenting features are lower back pain and stiffness and sacroiliac painin 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 takesat least 30 minutesfor 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 fracturesare a key complication of AS.

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45
Q

Dactylitis

A

Dactylitisis inflammation in a finger or toe.

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46
Q

Associated symptoms of ankylosing spondylitis:

A
  • Systemic symptomssuch as weight loss and fatigue
  • Chest painrelated tocostovertebral andcostosternaljoints
  • Enthesitisis inflammation of theentheses. This is where tendons or ligaments insert into bone. This can cause problems such asplantar fasciitisandachilles tendonitis.
  • Dactylitisis inflammation in a finger or toe.
  • Anaemia
  • Anterior uveitis
  • Aortitisis inflammation of the aorta
  • Heart blockcan be caused by fibrosis of the heart’s conductive system
  • Restrictive lung diseasecan be caused by restricted chest wall movement
  • Pulmonary fibrosisat the upper lobes of the lungs occurs in around 1% of AS patients
  • Inflammatory bowel diseaseis a condition associated with AS
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47
Q

Schobers test

A

Have the patient stand straight. Find theL5 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 isless than 20cm, this indicates a restriction in lumbar movement and will help support a diagnosis of ankylosing spondylitis.

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48
Q

Investigations for ankylosing spondylitis:

A
  • 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 showbone marrow oedema early in the disease before there are any xray changes.
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49
Q

What X-ray changes are seen in ankylosing spondylitis?

A

“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
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50
Q

Medications used to to treat ankylosing spondylitis:

A
  • NSAIDscan 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 amonoclonal antibody against TNF such as infliximab, adalimumab or certolizumab pegolare effective in treating the disease activity in AS.
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51
Q

Holistic management of ankylosing spondylitis:

A
  • 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
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52
Q

Effect of NSAID’s on ankylosing spondylitis:

A

Symptomatic pain relief
Also disease modifying!

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53
Q

What are the 5 A’s of ankylosing spondylitis?

A

Apical fibrosis
AV block
Aortic regurge
Anterior uveitis
Achilles Tendonitis

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54
Q

What is arthritis mutilans?

A

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”.

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55
Q

Presentation of psoriatic arthritis:

A

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 patternis 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 (conjunctivitisandanterior uveitis)
  • Aortitis (inflammation of the aorta)
  • Amyloidosis
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56
Q

What screening tool is used to psoriatic arthritis?

A

PEST Tool (Psoriasis Epidemiological Screening Tool)

NICE recommend patients with psoriasis complete thePEST 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.

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57
Q

X-ray changes in the joints for psoriatic arthritis:

A
  • Periostitisis inflammation of the periosteum causing a thickened and irregular outline of the bone
  • Ankylosisis where bones join together causing joint stiffening
  • Osteolysisis the destruction of bone
  • Dactylitisis 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 erosionsof 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.

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58
Q

Management of psoriatic arthritis:

A

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.

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59
Q

Axial sponyloarthropathy increases risk of osteoporosis.

A

Axial sponyloarthropathy increases risk of osteoporosis.

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59
Q

Axial sponyloarthropathy increases risk of osteoporosis.

A

Axial sponyloarthropathy increases risk of osteoporosis.

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60
Q

Circinate balanitis

A

Circinate balanitisis dermatitis of the head of the penis.

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61
Q

What is found on temporal artery biopsy in GCA?

A

Multinucleated giant cells are found on the temporal artery biopsy.

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62
Q

What is GCA?

A

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.

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63
Q

What are the common features of GCA?

A

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.

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64
Q

What are the potential complications of GCA?

A

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

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65
Q

What investigations are necessary in suspected cases of GCA?

A

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.

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66
Q

How is GCA treated?

A

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.

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67
Q

What are the potential side effects of high-dose corticosteroids, and how can they be managed?

A

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.

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68
Q

What other medications might be used to lower the corticosteroid dose?

A

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

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69
Q

Why is low-dose aspirin usually given to patients with giant cell arteritis?

A

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

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70
Q

What is granulomatosis with polyangiitis?

A

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.

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71
Q

What are the features of granulomatosis with polyangiitis?

A

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.

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72
Q

How is granulomatosis with polyangiitis managed?

A

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

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73
Q

What is the key feature of granulomatosis with polyangiitis? (in inv)

A

The key feature of granulomatosis with polyangiitis is low complement.

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74
Q

What are the classic triad of granulomatosis with polyangiitis?

A

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

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75
Q

What are the radiological features of granulomatosis with polyangiitis?

A

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

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76
Q

What does palpation of the joints in active RA show?

A

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

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77
Q

Imaging for kidney stones?

A

CT KUB

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78
Q

Why does rheumatoid arthritis require urgent referral?

A

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

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79
Q

4 hand signs of RA

A

Z-thumb
Ulnar deviation
Swan neck
Boutonnieres deformity

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80
Q

What family history should be asked about when taking a rheum history?

A

FH of:
Arthritis
Autoimmune conditions
Psoriasis

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81
Q

What should be included in review of systems in a rheum history?

A

Skin - rashes?
Lungs?
Kidneys?
Weight loss
Temperature

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82
Q

Arthralgia

A

joint pain

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83
Q

Hand deformities seen in OA?

A

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

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84
Q

How are CRP and ESR affected in connective tissue diseases?

A

Typically CRP may be normal but ESR is raised.

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85
Q

Common rheumatological inv (for OSCE):

A

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).

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86
Q

What is ankylosing spondylitis?

A

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

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87
Q
  • What is the link between ankylosing spondylitis and the HLA B27 gene?
A

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.

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88
Q

What are the main presenting features of ankylosing spondylitis?

A

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.

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89
Q

Diagnosis of AS?

A
  1. Sacroiliitis on x-ray + 1 other ank spond feature
  2. HLAB27 on genetic testing + 2 ank spond features
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90
Q

What is the diagnostic criteria for AS?

A

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.

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91
Q

Management of AS for the OSCE:

A

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.

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92
Q

What is psoriatic arthritis and what is it associated with?

A

Psoriatic arthritis is an inflammatory arthritis associated with psoriasis.

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93
Q
  • What are the different patterns of psoriatic arthritis?
A

There are several recognized patterns of psoriatic arthritis:

- Symmetrical polyarthritis
- Asymmetrical pauciarthritis
- Spondylitic pattern
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94
Q

What are some signs and other associations of psoriatic arthritis?

A

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.

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95
Q

What is reactive arthritis, and what causes it?

A

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.

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96
Q

What are the symptoms of reactive arthritis, and how is it diagnosed?

A

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.

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97
Q

Common side effect of amlodipine in the elderly:

A

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

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98
Q

Explain what crystalloid fluids are:
- examples

A

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

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99
Q

Explain what colloid fluids are:
- examples

A

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

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100
Q

Which class of fluids are preferred in resuscitation and why?

A

Research has shown that crystalloids are superior in initial fluid resuscitation.

Colloids are used less often than crystalloid solutions as they carry a risk ofanaphylaxis.

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101
Q

What fluids are used specifically in fluid resuscitation?

A

Sodium chloride 0.9%
Hartman’s

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102
Q

What are the daily maintenance requirements of water?

A

25-30 ml/kg/day of water

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103
Q

What are the daily maintenance requirements of electrolytes?

A

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

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104
Q

What are the daily maintenance requirements of glucose?

A

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

105
Q

How should maintenance fluid requirements be adjusted for obese patients?

A

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.

106
Q

What patient groups should you have a more cautious approach to prescribing fluids in?

A

For the following patient groups you should use a morecautious 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
107
Q

How should patients on maintenance fluids be monitored?

A
  • 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.
108
Q

How to calculate creatinine clearance?

A

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

109
Q

What rash is seen in SLE?

A

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

110
Q

What monitoring is done to check for active flares in SLE?

A

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).

111
Q

What antibodies are present in SLE?

A

ANA
Anti-dsDNA

112
Q

Anti-Ro and Anti-La antibodies are associated with what disease?

A

Sjogren’s syndrome)

113
Q

First line treatments for SLE:

A
  • NSAIDs
  • Steroids (prednisolone)
  • Hydroxychloroquine (first line for mild SLE).
  • Suncream and sun avoidance for the photosensitive malar rash
114
Q

What monitoring is needed for patients on hydroxychloroquine?

A

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

115
Q

What is SLE?

A

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

116
Q

Who is most likely affected in SLE?

A

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

117
Q

What are the common symptoms of SLE?

A

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.

118
Q

Investigations when diagnosing SLE:

A

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.

119
Q

What are some of the other commonly used immunosuppressants in SLE?
(used in more severe / resistant lupus).

A

Methotrexate
Mycophenolate mofetil
Azathioprine
Tacrolimus
Leflunomide
Ciclosporin.

120
Q

What biologic therapies are used for patients with severe resistant SLE?

A

Rituximab
Belimumab.

121
Q

cANCA =

A

GPA (granulomatosis with polyangitis).

122
Q

What is Libmann-Sacks endocarditis?

A

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.

123
Q

Medical management of antiphospholipid syndrome:

A

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

124
Q

Medical management of antiphospholipid syndrome if pregnant:

A

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.

125
Q

What specialties manage patients with antiphospholipid syndrome?

A

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

125
Q

What is antiphospholipid syndrome?

A

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

126
Q

What are the main associations of antiphospholipid syndrome?

A

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

127
Q

What are the three types of antiphospholipid antibodies?

A

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

128
Q

How is antiphospholipid syndrome diagnosed?

A

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.

129
Q

Anti-histone antibodies are specific to what…?

A

Drug induced SLE

130
Q

Anti-centromere antibodies =

A

Limited cutaneous systemic sclerosis

131
Q

Anti-Scl-70 antibodies=

A

Diffuse systemic sclerosis

132
Q

Main feature of polymyositis:

A

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

133
Q

Presentation of dermatomyositis:

A

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
134
Q

What is the definitive test for polymyositis?

A

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

135
Q
  • Pyrexia (often very high and of uncertain origin at first)
  • Arthralgia
  • A fine non-pruritic salmon pink rash

Triad of what disease?

A

Adult-onset Still’s disease

136
Q

Achilles tendonitis + back pain?

A

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

137
Q

What 3 important groups of medications should be stopped according to NICE sick day rules?

(During illness which can result in dehydration e.g. vomiting, diarrhoea and fever).

A

Diuretics

ACE Inhibitors

Metformin

138
Q

Why should diuretics be stopped according to NICE sick day rules?

A

Exacerbates the already present dehydration.

139
Q

Why should ACE inhibitors be stopped according to NICE sick day rules?

A

AKI

140
Q

Why should metformin be stopped according to NICE sick day rules?

A

Risk of lactic acidosis.

141
Q

Methotrexate has a strong association with what resp condition?

A

Pulmonary fibrosis

142
Q

Gene for behcets

A

HLA-B51

143
Q

Treatment for GCA with eye involvement (vision loss)

A

500mg IV methylprednisolone

144
Q

Causes of delirium:
D
E
L
I
R
I
U
M
S

A
  • 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
145
Q

Risk factors of delirium

A
  • Cognitive impairment
  • Previous delirium
  • Severe illness
  • Multiple medications
  • Dependance syndromes (opiods / alcohol).
  • Sensory impairment
146
Q

Key side effects of leflunomide:

A

Hypertension
Peripheral neuropathy

147
Q

Antibodies for GPA

A

c-ANCA

148
Q

Frailty syndromes:

A

Mobility impairment
Falls
Confusion
Incontinence

149
Q

When should a CGA be carried out?

A
  • In response to screening
    • Age
    • Frailty score
  • Acute illness
  • High health care utilisation
  • Change in circumstances
  • Frailty syndromes
  • Chronic disease conditions
150
Q

What is advanced care planning (ACP)?

A
  • 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
151
Q

What is anticipatory care planning (AnCP)?

A
  • Not end of life plan
  • Designed to reduce risk to patient
  • Tries to anticipate medical ‘crises’ and plan response
152
Q

Principles of DNACPR

A
  • 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
153
Q

Explain why prescribing in the elderly is different to prescribing in a healthy adult.

A

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.

154
Q

Explain how the pharmacokinetics and pharmacodynamics of commonly prescribed medicines alters in the elderly.

A

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.

155
Q

What criteria should be used when reviewing an elderly patients medication?

A

STOPP criteria
START criteria

156
Q

Explain the STOPP criteria.

A

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.

157
Q

Explain the START criteria.

A

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

158
Q

Side effects of tricyclic antidepressants e.g amytriptiline

A

Orthostatic hypotension
Sedation

159
Q

Define polypharmacy for adults and children:

A

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

160
Q

Define deprescribing:

A

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.

161
Q

What populations are at risk of problematic polypharmacy?

A

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

162
Q

Why is hyperpolypharmacy?

A

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

163
Q

Adverse reactions of warfarin:

A

GI bleeding, haematuria, high INR, haematoma

164
Q

How to remember the different type hypersensitivity reactions?

A

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

165
Q

Ankylosing spondylitis x-ray findings:

A

Subchondral erosions
Sclerosis
Squaring of lumbar vertebrae

166
Q

Methotrexate may cause what respiratory issue?

A

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

167
Q

What are the clinical uses of bisphosphonates?

A

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

168
Q

What is the duration of bisphosphonate treatment?

A

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.

169
Q

What counselling should be given to patients taking oral bisphosphonates?

A

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.’

170
Q

What should be done before giving bisphosphonates?

A

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.

171
Q

Minimal change glomerulonephritis treatment?

A

Prednisolone

172
Q

Most common causes of drug induced lupus?

A
  • Procainamide (anti-arrhythmic)
  • Hydralazine (antihypertensive)
173
Q

What is the screening test for polycystic kidney disease?

A

Ultrasound is the screening test for adult polycystic kidney disease.

174
Q

What are the ECG changes that can occur in hyperkalaemia?

A
  • Peaked or ‘tall-tented’ T waves (occurs first)
  • loss of P waves
  • broad QRS complexes
  • sinusoidal wave pattern
175
Q

What test is done in suspected post-streptococcal glomerulonephritis?

A

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

176
Q

Osteoporosis in a man - check…

A

Testosterone

177
Q

pANCA are most strongly associated with what?

A

pANCA = eosinophilic granulomatosis with polyangiitis aka Churgg-strauss.

178
Q

What is the most common pathogen causing septic arthritis?

A

Staphylococcal aureus

179
Q

Risk factors for gout:

A

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

180
Q

What is the difference between gout and pseudogout?

A

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.

181
Q

Management of chronic gout:
- osce style answer

A
  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.
182
Q

What criteria is used to assess septic arthritis risk?

A

Kocher criteria

183
Q

What are the Kocher criteria for septic arthritis?

A

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

184
Q

Typical features of the ‘hot joint’

A

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

185
Q

Investigations for the hot swollen joint?

OSCE style

A
  • 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
186
Q

Differentials for the hot joint:

A

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

187
Q

Septic arthritis risk factors:

A
  1. Predisposition to infection (immunosuppression / alcohol)
  2. Damaged joints - RA / OA / Joint replacement
  3. Opportunistic infections: Skin wound / IVDU / IA steroid injections.
188
Q

Management of septic arthritis after joint aspiration?

A
  • 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.
189
Q

Acute management of gout:

A
  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.
190
Q

Acute management of pseudogout:

A

Colchicine / NSAID’s / Prednisolone

191
Q

Treatment for chronic pseudogout:

A

Refer to rheumatology

192
Q

Visible haematuria following a recent URTI.

A

IgA nephropathy classically presents as visible haematuria following a recent URTI

193
Q

Hypercalcaemia =

A

Bones, Stones, Groans and Psychiatric Moans

194
Q

How often should methotrexate be prescribed?

A

Once a week
+ folic acid cover

195
Q

Complications of atriovenous fistulas?

A

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.

196
Q

KDIGO AKI Staging

A

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

197
Q

SLE rule out test

A

ANA - 99% of SLE patients are ANA positive.

198
Q

Old man, bone pain, raised ALP

A

Paget’s disease

199
Q

Most common joints affected in pseudoarthritis?

A

Wrist / knee

200
Q

Osteoporosis in a man… check levels of what?

A

Testosterone

201
Q

Early x-ray feature in rheumatoid arthritis?

A

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

202
Q

What are the geriatric giants?

A

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

203
Q

Rheumatoid arthritis x-ray finding:

A

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

204
Q

Head CT for alzheimers what do you see?

A

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

205
Q

What symptoms are seen in a posterior circulation stroke?

A

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.

206
Q

Furoesemide mechanism of action:

A

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

207
Q

Limited (central) systemic sclerosis = anti-centromere antibodies

A

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

208
Q

Anti-coagulation for someone post stroke without AF?

A

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.

209
Q

How to calculate an anion gap?

A

(sodium + potassium) - (bicarbonate + chloride)

210
Q

Treatment of polymyositis / dermatomyositis

A

Corticosteroids monitor CK changes
Hydroxychloroquine for rash in dermatomyositits

211
Q

How does acute graft failure present in a renal transplant patient?

A

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

212
Q

What are the features of CREST syndrome?
(systemic sclerosis)?

A

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).

213
Q

Blood test findings in osteoporosis?

A

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

214
Q

What should be given to prevent the renal complications of systemic sclerosis?

A

ACE Inhibitors

215
Q

Renal cell carcinoma treatment:

A

Radical nephrectomy is the most effective management option in renal cell carcinoma

  • RCC is usually resistant to radiotherapy or chemotherapy.
216
Q

Upper respiratory tract symptoms, lower respiratory tract symptoms, and rapidly progressive glomerulonephritis. Other features may include a saddle-shaped nose deformity, vasculitic rash, eye involvement, and cranial nerve lesions.

What is this a description of?

A

Granulomatosis with polyangitis

217
Q

Raynaud’s phenomenon and digital ulceration is specific to what rheumatology condition?

A

Systemic Sclerosis

218
Q

Treatment for GPA?

A

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

219
Q

Explain what systemic sclerosis is:

A

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

220
Q

Explain the difference between limited and diffuse cutaneous sclerosis:

A
  • Limited (Skin fibrosis islimitedto 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.
221
Q

What are the features of limited cutaneous sclerosis.

A

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.

222
Q

What are the features of diffuse cutaneous sclerosis.

A

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.

223
Q

Dermatological features of systemic sclerosis

A

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

224
Q

Cardiac features of systemic sclerosis

A

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

225
Q

Respiratory features of systemic sclerosis

A

Pulmonary fibrosis and pulmonary hypertension.

226
Q

What are the renal features in systemic sclerosis?

A

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

227
Q

What are the blood tests used in systemic sclerosis?

A

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

228
Q

How should patients with systemic sclerosis be monitored?

A

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

229
Q

What is the treatment for systemic sclerosis?

A

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.

230
Q

What bloods abnormalities are seen in patients with SLE?

A

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

231
Q

Proximal muscle weakness + erythematous raised papules overlying the metacarpal and interphalangeal joints.

  • What’s the diagnosis?
  • What is the hallmark rash associated with this condition described?
A

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

232
Q

Explain what Sjrogen’s sydrome is:
+
- Primary vs Secondary?
- Who does it affect?
- What are these patients at increased risk of?

A

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).

233
Q

Management of Sjogren’s syndrome?

A

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

234
Q

Raynaud’s phenomenon and digital ulceration is specific to what rheumatology condition?

A

DIFFUSE Systemic Sclerosis

235
Q

Eosinophilic granulomatosis with polyangiitis aka

A

Churg-Strauss

236
Q

How does eosinophilic granulomatosis with polyangiitis present?

A

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

237
Q

Granulomatosis with polyangiitis presents with what ENT symptoms?
- what is a funny differential?

A

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

238
Q

What drugs are the most common causes of drug induced lupus?

A
  • procainamide
  • hydralazine
239
Q

Malignancy + raised CK =…?

A

Polymyositis

240
Q

What is seen on joint aspiration in reactive arthritis?

A

Sterile synovial fluid with high white cell count.

241
Q

Fully explain what the Kocher criteria is:

A

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

242
Q

The perfect OSCE answer on how to manage septic arthritis:

A
  • 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.
243
Q

Gout microscopy =

A

Negatively birefringent needles

244
Q

Pseudogout microscopy =

A

Positively birefringent rhombus-shaped crystals

245
Q

Extremely high serum PTH with moderately raised serum calcium =

A

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

246
Q

What are Gottron’s papules and what condition are they seen in?

A

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

247
Q

Reactive arthritis treatment

A
  1. NSAIDS
  2. Intra articulated steroids
  3. Methotrexate / Sulfasalazine for refractory disease
248
Q

Facial rash + resp signs = what top differential?

A

Sarcoidosis?

249
Q

Frontotemporal dementia presents with social disinhibition and often has a family history

A

Family history = strong indicator for FTD

250
Q

When to start anti-TNF alpha inhibitors for axial spondylitis?

A

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

251
Q

How does acute interstitial nephritis present?

A

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.

252
Q

What cause post streptococcal glomerulonephritis?

A

Group A beta-haemolytic streptococci

253
Q

Sclerodactyly

A

Thickened skin on top of hands and inability to straighten fingers

254
Q

Limited systemic sclerosis affects where?

A

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

255
Q

Prognosis of diffuse systemic sclerosis

A

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

256
Q

Dermatological manifestations of systemic sclerosis:
- can read tbf
- articulate a couple

A

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.

Inlimitedcutaneous 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.

257
Q

Cardiac symptoms of systemic sclerosis

A
  • The vast majority of patients experience Raynaud’s phenomenon.
  • Pericarditis.
  • Myocardial fibrosis which can cause heart failure and arrhythmias.
258
Q

Read management of systemic sclerosis

A

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.

259
Q

Raynauds medical tax

A

Nifedipine
IV prostacyclin infusion in severe cases

Needs referral to secondary care

260
Q

What antibody is positive in dermatomyositis?

A

ANA
Anti-Jo1

Year 4 Med (28 decks)

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