Nephro + Rheuma - OSCE

[Dr.Designer]

it's your chance my colleague to find yourself in our 4th Medicine OSCE session series .
special thanx to Dr.FM + Dr.Hanaa + Dr.Happy tears
and all who support us even just by a pray and al7amas .

let's go

[dr.FM]

Rheumatoid Arthritis Criteria
1- Morning Stiffness >1h ... duration 6 wks or more
2- Swelling of at least 3 joints .. duration 6 wks or more
3- Swelling of wrist joint, MCP, PIP .. duration 6 wks or more
4- symmetry of swollen joint area .. duration 6 wks or more
5- Subcutaneous nodules
6-+ve RF
7- Radiological Features: dec joint space, soft tissue sweeling, erosion & periacticular osteopenia.

4 or more criteria are needed for dignosis of RA.

[Dr.hanaa44]

[dr.FM]

SLE Criteria:
American College of Rheumatology has designated 11 criteria for classification. To be classified as having lupus, a person must have 4 or more of these criteria
1-Convulsion, Psychosis
2-Butterfly rash
3- Discoid lesion
4-Photosensetivity
5-Oral Ulcers
6-Serositis: Pericarditis,Pleuritis
7-Hematology: hemolytic anemia (+ve Coomb test), thrombocytopenia < 1000, leukopenia <4000, Lymphopenia <500
8-Renal involvment: Proteinurea >500 mg/dl (nephrotic syndrome), RBC cast, Glomerulonephritis.
9-Arthritis
10- +ve ANA
11- +ve dsDNA, VDRL, Anti-Smith Ab

-----------------------------
Just to make it easy for you to remember these criteria
1-CNS
2,3,4- Skin
5,6- Membranes (mucus & serous)
7-Blood
8-Kidney
9-Joints
10,11- Lab

-----------------------------

Discoid rash: These are red, raised patches with scaling of the overlying skin. A subgroup of patients have "discoid lupus" with only skin involvement and do not have systemic lupus erythematosus. All patients with discoid lupus should be screened for systemic involvement.


Photosensitivity: A rash develops in response to sun exposure. This is not to be confused with heat rash that develops in body folds or moist areas of the body with exposure to heat.

Arthritis: The arthritis of lupus usually does not cause deformities of the joints. Swelling and tenderness must be present.

[dr.FM]

Hand deformaty in RA
Swan neck
Boutonniere
Z deformity - thumb
radial deviation - wrist
ulnar deviation -MCP
swelling of MCP & PIP

[dr.FM]

[dr.FM]

[IMG]http://www.medscape.com/*******/2004/00/48/77/487710/art-487710.fig7.jpg[/IMG]

X-ray: Cervical Spine. The anterior edge of the odontoid process (O) is abnormally separated from the posterior margin of the arch of the atlas (A) in this lateral roentgenogram of the cervical spine of a patient with rheumatoid arthritis. Subluxations of the lower cervical vertebral bodies (arrows) are also visible.

[dr.FM]

Joint symptoms include:
-Increased pain and stiffness in the morning (>30 min) and after inactivity, gradually releived by activity (Vs OA pain & stiffness which is typically worsen by joinj movement)
-Pain and stiffness symmetrically (Vs OA)
-Red, swollen, warm joints (effusion & inflammation)
-Deformed, misshapen joints ( deformity or Sublaxation)
-RA usually affect small joints (Vs OA affect large wt beiring joints)

** joint effusion & wasting of ms around the affected joint are early features.

** Very imp in the Hx that you ask about the Function of the joint & if their is any disability.

Extrarticular Symptoms of RA:
-Periarticular Features: Bursitis, Tenosynovitis, ms wasting.
-SC Nodules: typically in the forearm below the elbow (usually sero +ve ptn)
-Systemic: Fever, fatigue, wt loss.
-Eye: 2ry Sojegren syndrom, scleritis.
-Neuro: AtlantoAxial Sublaxation, CTS, Polyneuropathy
-Lymphadenopathy.
-Felty Syndrome (RA, Spleenomegaly, neutropenia)
-Anemia (of chronic dis OR hypersplenism OR 2ry to NSAID OR hemolysis)
-Thrombocytosis
-Pulmonary: PLeural effusion, Rheumatoid nodules, Small airway dis
-CVS: pericarditis, pericardial effusion
-Renal: Amylodosis, Analgesic nephropathy (MCQ: RA does NOT cause glomerulonephritis)
-Vasculitis.

[dr.FM]

This young woman has a malar rash (the so-called "butterfly" rash because of the shape across the cheeks// Sparing nasolabial fold). Such a rash suggests lupus. Discoid lupus erythematosus (DLE) involves mainly just the skin and is, therefore, relatively benign compared to systemic lupus erythematosus (SLE). In either case, sunlight exposure accentuates this erythematous rash ("photosensitivity"). A small number (5 to 10%) of DLE patients go on to develop SLE (usually the DLE patients with a positive ANA).

[dr.FM]

Here is a patient with the taut and shiny skin typical of sclerodactyly. The skin becomes inelastic and it is hard to move the fingers. If sclerodactyly is seen along with calcinosis, Raynaud phenomenon, esophageal dysmotility, and telangietasias, then the best diagnosis is CREST syndrome ("limited" scleroderma).




A serious consequence of the "R" in the CREST syndrome (limited scleroderma) is seen here. The fingertips are blackened and additional portions of the hand purplish with early gangrenous necrosis from vasospasm with the Raynaud phenomenon.

[dr.FM]

Causes Of ARF

[dr.FM]

How to calculate Createnin Clearance



يمكن يكون شي مو مرة مهم للأوسكي..
بس كانوا الدكاترة عندنا يسألونا دايما عنها
خصوصا المعادلة الأولى


أهميته..
staging of chronic renal failure
& w/ consequent readings we can know if the ptn will need dialysis or not





Management
Stage I
Diagnose and treat type of kidney disease; treat comorbid conditions; slow progression of CKD; treat modifiable CVD risk factors; periodically re-stage

StageII
action to stage I + Adjust drug dosages for level of GFR

Stage III
Evaluate for and treat complications of CKD; avoid nephrotoxic drugs

Stage IV
Prepare for kidney replacement therapy

Stage V
Start kidney replacement therapy when uremia present

[dr.FM]

What are the clinical features that indicate that the ptn has Chronic rather than Acute Renal Failure??

Hint

Think about the complication

[dr.FM]

Complications of Nephrotic Syndrome:
*Venus thronbosis: DVT, Renal vein thrombosis
*Infection: SBP or Sepsis (loss og Ig)
*inc risk of Cardiovascular dis ( due to hyperlipidemia)
*ARF: 2ry to dehydration/ renal vein thrombosis

[Dr.hanaa44]