station 5 Flashcards
Causes of pyoderma gangrenosum
IBD (UC)
Sarcoidosis
Idiopathic
TB
Haematological malignancies, myeloproliferative disorders
Rheum - RA, ank spond, seronegative arthritis, SLE
Liver - PBC
Ix for non-healing ulcer
Bloods to look for underlying condition - autoimmune screen
Biopsy of the ulcer (pyoderma, Marjolin’s)
Imaging - colonoscopy, CT
Psoriasis
Types / classification
Triggers / exacerbating factors
Key management points
Measuring effect on QOL
Complications
Types: Plaque Pustular (palmar/plantar or generalised) Guttate (post-infection) Flexural Brittle (can be post steroids) Erythrodermic Psoriatic arthropathy (10-30%)
Triggers / exacerbating factors:
NSAIDs, Li, beta blockers
Trauma
Infection
Mx:
Topical - emollient and calcipotriol (vit-D derivative) +/- topical steroid (hydrocortisone)
Can also add dithranol, tar, topical retinoids and salicylic acid (keratinolytic)
Systemic: Phototherapy DMARDs - methotrexate, ciclosporin as first line agents Retinoids Biologics
Disease severity score:
DLQI - max 20 (very bad)
PASI - needed prior to biologics
Complications:
Psychosocial effects
Psoriatic arthropathy
Increased independent cardiovascular risk
Indications for bisphosphonate / bone protection
Those who have been taking steroids for over 3mths, or are likely to, AND
Age over 65
Under 65 but with fragility fracture (NOF)
Under 65 without fragility fracture but T-score <1.5
Drugs that can worsen Raynauds
Beta blockers
Cocaine
Sumatriptan
Key things to ask about if suspect CREST (Hx)
Key things o/e
Other things to examine
Raynauds sx
Oesophageal dysmotility and red flags
Fibrosis - ILD, renovascular disease causing htn
Other autoimmune conditions
O/e: Calcinosis and Raynauds of fingers Sclerodactyly Face - tight shiny skin, telangiectasia Hand function
Other:
Lung for ILD
BP - CREST is RF for malignant htn
Cardiovascular system - pul htn
Difference between Raynaud’s disease and Raynauds syndrome
Disease - colour change seen in fingers occurs in isolation without any associated condition
Syndrome (secondary) - Raynaud’s phenomenon occurs as a result of an associated condition (SLE, CREST)
Crohns disease
Indications for biologics
Fistulating disease
Disease refractory to steroids
Pts not suitable for surgery - eg short bowel, diffuse disease
Crohns disease
Indications for surgery
Emergency - perforation, intractable haemorrhage, failure of medical management of acute flare (obstruction or dilatation)
Elective - abscess, fistula, carcinoma; failure of medical mx, perianal disease (likely complex)
Crohns disease
Acute management of flare
ABCDE assessment, IVF, NBM
Induce remission - oral/IV steroids depending on severity of flare
5-ASA second line, with azathioprine/mercaptopurine or methotrexate if no response to 5-ASA
Inflixiamb third line acutely
Ix:
Obs, bloods, imaging
Mx:
Abx, steroids, analgesia, muscle relaxant
Indications for colonoscopy in context of UC and frequency
5yrly
No active inflammation
L sided colitis only
Crohns colitis in <50% of bowel
3yrly
Mild active inflammation
Polyps
Fhx colorectal malignancy occurring >50yrs
Yrly Mod to severe inflammation Stricture Prev dysplasia PSC or gallbladder involvement Fhx colorectal malignancy <50yrs
RA hx Features of examination Ix Scoring system Mx Complications Poor prognostic factors
Joint pain, stiffness, swelling Function Progression Numbness / sensory change Weakness
Systemic sx - Fever, fatigue
O/e: Hands, wrists, elbows Lungs Eyes Carpel tunnel
Ix: Bloods incl RF and CCP Hand and foot XR; wrist XR CXR USS joints if effusion
DAS28 score - aim <3 (>5.1 = high; <2.6 = remission)
Number of tender/swollen joints
Subjective perception of disease activity
ESR
Mx:
Aim to induce and maintain remission
Cons - PT, stop smoking
Med - analgesia, start methotrexate with short bridging course of steroids (methotrexate CI if nodule positive)
Biologics if 2 DMARDs have failed consecutively
Steroids for acute flare
Surgical - joint replacement, tendon reconstruction
Complications:
Disease related - Progression of disease, deformity, loss of function, extra-articular manifestations, megaloblastic anaemia, haemolytic anaemia
Treatment-related - steroids, immunosuppression, GI bleed from NSAIDs, BM suppression from DMARDs
Poor prognostic factors: Seropositive disease (RF, anti-CCP) Poor functional status at presentation Early erosions on XR Extra-articular disease
Extra-articular manifestations of RA
Lung - pleural effusion, ILD Heart - pericarditis Carpel tunnel syndrome Splenomegaly Anaemia of chronic disease Amyloidosis and renal impairment Eyes - scleritis / episcleritis
CXR changes in sarcoidosis
Stage 0 - normal CXR Stage 1 - BHL alone Stage 2 - BHL with pulmonary infiltrates / reticulonodular changes Stage 3 - Pulmonary infiltrates alone Stage 4 - fibrosis
Which skin feature is pahthognomic of sarcoidosis
Lupus pernio - malar rash
Lupus pernio is pathognomic of which condition
Sarcoidosis
Triggers worsening gout
Diet - purine rich
Alcohol
Drugs - thiazides, loop diuretics, aspirin
Renal impairment
Features on examination of Marfans
Increased arm span (arm:height >1.05) Lens dislocation - upward Aortic regurgitation and mitral regurg AAA High arched palate Skin stretch marks Thumb across palm with fingers over Bend thumb to wrist Bend little finger backwards Thumb and little finger around wrist
Tx for Raynauds
Tx underlying cause if present
Cons - stop smoking, gloves
Medical - CCB (nifedipine), PDEi (sildenafil), topical GTN
Features to ask about in presence of Raynauds
Digital ulceration Mouth ulcers Dysphagia, reflux, malabsorption Serositis - pericarditis, pleurisy Eyes Rash Joint pain Alopecia Dyspnoea - ILD, Pul htn
Complications of acromegaly
Compression - bitemporal hemianopia
Diabetes
CV - cardiomyopathy
Increased risk of GI malignancy
Features of acromegaly
G - hypogonadism
T - hypothyroidism
A - hypoadrenalism
Hyperprolactinaemia - galactorrhea DM - polyuria, polydipsia Proximal muscle weakness Carpel tunnel Htn - headache Hypercalcaemia - stones Hx of bowel polyps / malignancy
Focussed examination of acromegaly
Insp - coarse features Bitemporal hemianopia Evidence of carpel tunnel syndrome Hearing aids Fundoscopy to assess papilloedema Proximal weakness
Acromegaly
Ix
Tx
Dx - IGF, OGTT with no suppression of GH
Ix - BP, ECG, MRI head, pituitary function testing, visual field testing, echo (for hypertrophy)
Tx:
1st line - surgery
2nd - medical:
Somatostatin analogues - octreotide
Dopamine agonists - cabergoline, bromocritpine
GH antagonists - pegvisomant
Radiotherapy
Tx complications - DM, htn, carpel tunnel
Ddx of acutely painful knee
Reactive arthritis RA Psoriatic arthritis Gout / pseudogout Septic arthritis
Htn and hypo-K
Ddx
Ix
Mx
Ddx:
Hyperaldosteronism - Conns, Cushings, renal artery stenosis
Liddles syndrome - pseudohyperaldosteronism - tx with amiloride for direct ENaC antagonism
Ix:
Screening - renin:aldosterone ratio, having stopped anti-htn drugs and diuretics
Confirmation - saline suppression test - aldosterone doesn’t fall with saline load
Imaging - CT/MRI adrenals looking for adenoma or bilateral adrenal hyperplasia
To distinguish one side from the other - adrenal vein sampling for raised aldosterone
Mx:
Medical - spironolactone and eplerenone
If glucocorticoid suppressible - steroids (1-3%)
Surgical - resection of adenoma or adrenalectomy
Ix for suspected Cushings
Mx
Ix:
24hr urine cortisol
Low dose dexamethasone suppression test - cortisol should suppress. If not -> Cushing’s disease or ectopic ACTH release
If no suppression, high dose dex suppression test. If cortisol suppresses -> pituitary adenoma secreting ACTH, if no suppression -> ectopic source of ACTH
Imaging of pituitary
Mx:
MDT - PT
Medical - bone protection, ketoconazole/metyrapone (inhibit cortisol synthesis)
Surgical - resection of source (pituitary, lung, adrenal)
Bilateral adrenalectomy if refractory disease with ectopic ACTH
Can consider radiotherapy
Back/neck pain and stiffness
Hx:
Examination
Ix
Mx
Scoring system
Hx: Duration and worsening Triggers Occupation and function FLAWS Sx of caudal equina Neurology Sciatic pain Associated features of any spond - heart (AR, AV node block), lung (ILD), Achilles tendonitis, amyloid (CTS), eyes (ant uveitis) Enthesitis - plantar fasciitis Red flags - night pain
Questions / concerns
O/e:
Neck/back - look, feel, move.
Flexion, lateral flexion, extension and rotation at neck and back
Sacroiliac pain
Other features - Schobers test, wall test (wall-occiput)
Ix: Bloods incl HLA-B27 XR - neck/back, CXR, sacroiliac joints Echo Spirometry MRI
Mx:
MDT - PT, OT, rheumatology (consider DMARDs)
Analgesia
Bone changes - squaring of the vertebrae, syndesmophytes, sacroiliitis
BASDAI (Bath ank spond disease activity index) - >4/10 -> active disease
Prolactinoma
Classification
Micro vs macro
Mx:
1st line - medical - cabergoline
If compression causing bitemporal hemianopia - surgery is 1st line
Replacement of pituitary hormones if necessary
Osteogenesis imperfecta
Problem with collagen type 1
Mainly AD inheritance, some AR
Type 1 commonest -
Type 2 - lethal
Type 3 - progressive
Type 4-8 also
Hx:
Fractures and surgery
FHx
O/e: Bowing of bones Evidence of fractures Blue sclera Hearing aids
Ix:
Genetic analysis
Monitor with echo for aortic root dilatation
Mx:
MDT
Bone protection
Acute back pain
Hx
Examination
Red flags - rule out cord compression, caudal equina and possible malignant cause
