GP Flashcards
(128 cards)
Anaphylaxis is what type of hypersensitivty reaction?
Anaphylactic shock is a rapid onset Type 1 IgE-mediated hypersensitivity reaction.
What dose of adrenaline is given in anaphylaxis for adults?
500micrograms
(0.5ml of 1 in 1000units)
What medications are used alongside adrenaline to manage anaphylaxis?
High flow oxygen and fluid challenge.
Hydrocortisone and Chlorphenamine after initial resuscitation.
What is septic shock?
Septic shock is sepsis with a systolic blood pressure <90mmHg that is not responsive to fluids.
Four key x-ray changes seen in osteoarthritis:
LOSS
L – Loss of joint space
O – Osteophytes
S – Subchondral sclerosis (increased density of the bone along the joint line)
S – Subchondral cysts (fluid-filled holes in the bone, aka geodes)
Presentation of osteoarthritis:
Osteoarthritis presents with joint pain and stiffness. This pain and stiffness tends to be worsened by activity in contrast to inflammatory arthritis where activity improves symptoms. It also leads to deformity, instability and reduced function in the joint.
Commonly affected joints in osteoarthritis:
Hips
Knees
Sacro-iliac joints
Distal-interphalangeal joints in the hands (DIPs)
The CMC joint at the base of the thumb
Wrist
Cervical spine
Signs of osteoarthritis seen in the hands:
Heberden’s nodes (in the DIP joints)
Bouchard’s nodes (in the PIP joints)
Squaring at the base of the thumb at the carpo-metacarpal joint
Weak grip
Reduced range of motion
Management of osteoarthritis:
Start with patient education about the condition and advise on lifestyle changes such as weight loss if overweight to reduce the load on the joint, physiotherapy to improve strength to support the joint and occupational therapy and orthotics to support activities and function.
Stepwise use of analgesia to control symptoms.
Intra-articular steroid injections provide a temporary reduction in inflammation and improve symptoms.
Joint replacement can be used in severe cases. The hip and knee are the most commonly replaced joints.
Stepwise analgesia approach for osteoarthritis:
Oral paracetamol and topical NSAIDs or topical capsaicin (chilli pepper extract).
Add oral NSAIDs and consider also prescribing a proton pump inhibitor (PPI) to protect their stomach such as omeprazole. They are better used intermittently rather than continuously.
Consider opiates such as codeine and morphine. These should be used cautiously as they can have significant side effects and patients can develop dependence and withdrawal. They also don’t work for chronic pain and result in patients becoming depending without benefitting from pain relief.
Summarise rheumatoid arthritis:
Practice aloud for OSCE’s.
- What is it? Pathophysiology? Who does it affect most commonly? How does it present?
Rheumatoid arthritis is an autoimmune condition that causes chronic inflammation of the synovial lining of the joints, tendon sheaths and bursa. It is an inflammatory arthritis. Synovial inflammation is called synovitis. Rheumatoid arthritis tends to be symmetrical and affects multiple joints. Therefore it is a symmetrical polyarthritis. Inflammation of the tendons increases the risk of tendon rupture.
It is three times more common in women than men. It most often develops in middle age but can present at any age. Family history is relevant and increases the risk of rheumatoid arthritis.
Genetic associations with rheumatoid arthritis:
HLA DR4 (a gene often present in RF positive patients)
HLA DR1 (a gene occasionally present in RA patients)
What antibodies are associated with rheumatoid arthritis?
Rheumatoid Factor (RF).
Cyclic citrullinated peptide antibodies (anti-CCP antibodies).
Why does rheumatoid factor cause rheumatoid arthritis?
Rheumatoid Factor (RF) is an autoantibody presenting in around 70% of RA patients. It is an autoantibody that targets the Fc portion of the IgG antibody. All antibodies have an Fc portion on them that is used to bind to cells of the immune system. Rheumatoid factor targets this Fc portion on immunoglobin G (IgG). This causes activation of the immune system against the patients own IgG causing systemic inflammation. Rheumatoid factor is most often IgM however they can be any class of immunoglobulin.
Explain anti-CCP in relation to rheumatoid arthritis.
Cyclic citrullinated peptide antibodies (anti-CCP antibodies) are autoantibodies that are more sensitive and specific to rheumatoid arthritis than rheumatoid factor. Anti-CCP antibodies often pre-date the development of rheumatoid arthritis and give an indication that a patient will go on to develop rheumatoid arthritis at some point.
Presentation of rheumatoid arthritis:
It typically presents with a symmetrical distal polyarthropathy. The key symptoms are joint:
Pain
Swelling
Stiffness
Patients usually attend complaining of pain and stiffness in the small joints of the hands and feet, typically the wrist, ankle, MCP and PIP joints in the hands. They can also present with larger joints affected such as the knees, shoulders and elbows. The onset can be very rapid (i.e. overnight) or over months to years.
There are also associated systemic symptoms:
Fatigue
Weight loss
Flu like illness
Muscles aches and weakness
Presentation of RA vs OA:
Pain from an inflammatory arthritis is worse after rest but improves with activity. Pain from a mechanical problem such as osteoarthritis is worse with activity and improves with rest.
Palindromic rheumatism:
This involves self limiting short episodes of inflammatory arthritis with joint pain, stiffness and swelling typically affecting only a few joints. The episodes only last 1-2 days and then completely resolve. Having positive antibodies (RF and anti-CCP) may indicate that it will progress to full rheumatoid arthritis.
Common joints affected in RA:
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.
The distal interphalangeal joints are almost never affected by rheumatoid arthritis. If you come across enlarged painful distal interphalangeal joints this is most likely to be Heberden’s nodes due to osteoarthritis.
Atlantoaxial subluxation
Atlantoaxial subluxationoccurs in the cervical spine. Theaxis(C2) and theodontoid pegshift within theatlas(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 causespinal cord compressionand 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.
Hand signs for RA:
Palpation of the synovium in 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)
Boutonnieres deformity:
Boutonnieres deformity (hyperextended DIP with flexed PIP).
Boutonnieres deformity is due to a tear in the central slip of the extensor components of the fingers. This means that when the patient tries to straighten their finger, the lateral tendons that go around the PIP (called the flexor digitorum superficialis tendons) pull on the distal phalynx without any other supporting structure, causing the DIPs to extend and the PIP to flex.
Extra-articular manifestations of rheumatoid:
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
Investigations done for rheumatoid:
The diagnosis of rheumatoid arthritis is clinical in patients with features of rheumatoid arthritis (i.e. symmetrical polyarthropathy affecting small joints). A few extra investigations are required at diagnosis:
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.
