Clinical consultation viva facts Flashcards
Besides apical fibrosis, are there any other causes in ankylosing spondylitis that could result in breathlessness?
Anaemia - may be related to a microcytic anaemia secondary to NSAID use or anaemia of chronic disease.
Mechanical restriction secondary to fusion of the spine causing a restriction.
Malignancy.
Cardiac causes: aortic regurgitation which has a known association with ankylosing spondylitis.
What investigations would you recommend in a patient you suspect has ankylosing spondylitis?
Bloods: CRP / ESR (for evidence of disease activity), FBC, UEs and LFTs (thinking about future treatments / NSAIDs). HLA-B27 test.
Imaging: XRs of spine and pelvis (looking for sacroiliitis and fusion in the spine). Consider MRI spine if XRs normal.
Special tests: pulmonary function tests (spirometry and transfer factor may differentiate pulmonary fibrosis from mechanical restriction), high-resolution CT, ECG, echo, observations including o2 sats
What pulmonary function abnormalities might you expect in a patient with ankylosing spondylitis and SOB?
I’d expect to see a restrictive pattern. That is a reduced FEV1 and FVC with a maintained ratio.
Is there any way to tell the difference between pulmonary fibrosis, and a mechanical restriction due to the thorax being fused, using PFTs?
Look closely at the transfer factor.
In mechanical restriction, would expect the transfer factor to be preserved due to the normal underlying lung, however in pulmonary fibrosis, would expect it to be reduced due to the underlying damaged lung.
What treatments are available for ankylosing spondylitis?
Non-pharmacological: patient education, physiotherapy, OT, hydrotherapy, smoking cessation, calculate BASDAI score (>4 = active disease)
Pharmacological: NSAIDs (ibuprofen / naproxen), MTX / sulfasalazine, anti-TNF agents in refractory disease (adalimumab / etanercept)
Do you know of any pre-treatment considerations before considering anti-TNF treatments?
Immunisations
Screening for latent or active TB (bloods / CXR)
How would you investigate a patient in hospital for whom you suspect has Crohn’s colitis?
Full set of observations - looking for signs of sepsis.
Bedside: stool sample for faecal calprotectin, stool culture
Bloods: FBC (anaemia), WCC and neutrophils (infection), U+Es (looking for signs of dehydration and the need for electrolyte replacement), and baseline LFTs.
Imaging: AXR (looking for evidence of dilatation).
How would you manage a patient presenting with an acute flare of Crohn’s disease?
Analgesia, IV hydrocortisone and IV abx dependent on baseline investigations.
IV fluid replacement and consider electrolyte replacement.
Start LMWH due to increased risk of VTE.
What complications of Crohn’s disease would prompt you to make a surgical referral?
Evidence of dilatation on the AXR.
Evidence of fistulating disease.
Refractory to full medical management.
How would you manage a patient hospitalised for an acute flare of Crohn’s disease on discharge?
IBD nurse and dietician input.
Long-term tapering dose of steroids.
Calcium and vit D replacement.
Refer to gastroenterology to consider escalation of treatment (anti-TNF agents).
Consider referral for flexible sigmoidoscopy.
What are the differences in endoscopic appearances of Crohn’s disease and UC?
Crohn’s: aphthous ulcers, cobble stoning, skip lesions, transmural inflammation. May be isolated involvement of the terminal ileum and normal rectum.
UC: more superficial inflammation, restricted to sub-mucosa or mucosa only, and evidence of crypt abscesses.
What would you receommend in terms of screening for malignancy in patients with IBD?
After 10 years of onset of symptoms, patients are recommended to have an index surveillance colonoscopy looking for signs of malignancy with appropriate biopsies.
Further colonoscopic investigations are then carried out dependent on the patient’s risk level at that stage.
Describe the clinical features of pseudoxanthoma elasticum (PXE)
Skin: Small, yellowish papular lesions on skin.
Cutaneous laxity affecting neck, axillae, groin and flexural creases.
Eyes: ‘Peau d’orange’ on Bruch membrane of retina.
Angioid streaks on retina with retinal haemorrhages.
GI: gastric bleeding
Vascular: intermittent claudication, angina and MI, stroke. IC haemorrhage and SAH.
What is the genetic mutation associated with pseudoxanthoma elasticum?
Genetic disease that causes mineralisation of elastic fibres in some tissues.
Most signs are in the skin and eyes, and later in the blood vessels (premature atherosclerosis).
PXE is caused by autosomal recessive mutations in the ABCC6 gene.
Do you know of any risk stratification tools that can be used to assess bleeding risk for patients on warfarin?
HASBLED score: takes into account HTN, renal and liver failure, age, drug use, alcohol, labile INRS and anticoagulant use. Scored out of 9, if patient scores 3 or more, caution with anticoagulation is advised.
Do you know of a tool you can use to predict stroke risk for patients with AF?
CHA2DS2-VASc score
Score out of 9, the higher the score the greater the risk of stroke. Dependent on the score, a percentage stroke risk per year for a patient is given.
Under what circumstances would you use NOACs over warfarin?
Clinician-dependent and local guideline-dependent.
NOACs may be indicated if a patient struggles to attend appointments for blood tests, if they had a CV event on warfarin, if they have labile INRs, or cognitive impairment.
Disadvantages of NOAC: compliance is required (if miss a dose, do not receive benefit), not all are safe in renal failure.
How would you manage a patient with suspected ACS?
Bedside: o2 if hypoxic, BP both arms, 12-lead ECG, history and systems exam.
Bloods: IV access and send troponin, Hb, VBG, glucose, cholesterol and renal function.
Imaging: CXR (heart failure, mediastinal widening, consolidation).
If ACS diagnosis confirmed with CP, ECG changes and / or trop rise, I would give 300mg aspirin, analgesia, antiemetics, GTN spray, telemetry.
Start on beta-blockers, ACEi and a statin.
If NSTEMI / unstable angina, risk stratify with GRACE score which predicts 6-month mortality and use this to guide further management (i.e., the need for angiography, clopidogrel, anti-thrombin and glycoprotein II agents)
If STEMI, liaise urgently with nearest PCI team.
What medications are prone to causing oesophagitis?
NSAIDs, doxycycline, bisphosphonates.
What medications relax the lower oesophageal sphincter and predispose to reflux?
Nitrates
CCBs
Anticholinergics (TCAs)
What are the immunological associations with ankylosing spondylitis?
Seronegative spondyloarthropathy
HLA-B27 positive in >90% of individuals
TNF alpha and interleukin-1 also implicated in disease activity
Differential diagnosis for sacroiliitis?
Psoriatic arthritis
Enteropathic arthritis
Reactive arthritis
How is the diagnosis of ankylosing spondylitis made?
Mainly clinical from history and examination, with supporting radiological evidence.
Young patients <40y, possible FH.
Plain radiograph: erosions, fibrosis / sclerosis of SI joints, squaring of vertebrae ‘bamboo spine’.
Bloods: raised ESR / CRP, normocytic anaemia (of chronic disease)
Genetic testing: HLA-B27
What is the treatment for ankylosing spondylitis?
Physio, exercise, smoking cessation.
Analgesia: NSAIDS
Corticosteroid injections
Biologics: etanercept, adalimumab, infliximab (anti-TNF for axial disease once failed 2 NSAIDs at max dose for 4 weeks).
Treat complications such as iritis / osteoporosis. Liaise with other specialties for treatment of complications.
Calculate BASDAI score to guide management.
What are the extra-articular manifestations of ankylosing spondylitis? (7 A’s)
Anterior uveitis
Aortitis / aortic regurgitation
Apical fibrosis
AVN block
Amyloidosis (secondary)
Atlantoaxial dislocation
IgA nephropathy
What disease-scoring system can be used for ankylosing spondylitis?
Bath ankylosing spondylitis disease activity index (BASDAI)
What changes woudl you see on spine XR in ankylosing spondylitis?
Bilateral sacroiliac erosive changes with eventual fusion of the sacroiliac joint.
Syndesmophytes bridge multiple vertebrae causing a ‘bamboo spine’ appearance.
Squaring of vertebral bodies on lateral film.
What diagnostic criteria are used in rheumatoid arthritis?
ACRC: American College of Rheumatologists Criteria.
The criteria can be applied in those with synovitis and clinical suspicion of RA. Look at 4 areas: number and size of joints affected, duration of symptoms, serology (RF or anti-CCP) and ESR / CRP.
