General Flashcards
tell me the 5 seronegative spondyloarthropathies
reactive psoriatic ank spond enteropathic JIA
what makes seronegative spondyloarthropathies themselves?
negative rheumatoid factor spinal & sacroiliac joints affected HLA B27 asymmetric enthesitis
what allele are seronegative spondyloarthropathies
HLA B27
keratoderma blenorrhagica is rash on feet in what
reactive arthritis
does psoriasis usually precede psoriatic arthritis?
yes by a few years usually
which joints are affected in psoriatic arthritis?
DIP
pencil in cup erosions on X ray
what are the nail changes in psoriatic arthritis?
onycholysis
dactylitis
name some symptoms of ank spond
back pain + stiffness
infl of other joints e.g. knee
fatigue
kyphosis, loss of lumbar lordosis
give me an example of a medium vessel vasculitis
polyarteritis nodosa
name 3 conditions that can cause secondary vasculitis
RA
SLE
Hep B/C
which small vessel vasculitis causes adult onset asthma but uncommonly affects kidneys (unlike the others which affect kidaz and lungs)
churg strauss
eosinophilic granulamatous polyangitis
monosodium urate crystals deposition causes joint infl whats this?
gout
age, alcohol, obesity, venison and male are risk factors for gout. name 2 more.
diabetes
thiazide diuretics
what investigation for gout?
diagnosis clinical if typical.
if not,
joint aspiration
what does microscopy of synovial fluid on joint aspiration of GOUT show?
negative birefringent needle shaped crystals
what does microscopy of synovial fluid on joint aspiration of PSEUDOGOUT show?
positively birefringent diamond shaped crystals
why test glucose and lipids when diagnosing gout?
assoc w metabolic syndrome
and diabetes
what is the management of acute gout ?
RICE
NSAIDs
colchicine
corticosteroids if bad
what is the management of chronic gout.
lifestyle
allopurinol / febuxostat
(xanthine oxidase inhibitors)
(if >2 attacks a year)
how long do acute attacks of gout take to recur?
3-10days
an acute attack of gout reaches its peak within
24hrs!
deposition of calcium pyrophosphate crystals causing joint infl. whats this
pseudogout
what are the pseudogout crystals
calcium pyrophosphate
what is the management of pseudogout?
RICE
NSAIDs
IA steroids
acute attacks usually resolve in 10ds
elderly - dehydration, intercurrent illness
what is the triad of pagets
pain
fracture
deformity
high bone turnover, osteoclasts go crazy and we dont know why. osteoblasts cant keep up so make rubbish woven + lamelllar bone.
paget’s
what is paget’s?
high bone turnover, osteoclasts go crazy and we don’t know why. poor osteoblasts cant keep up so make rubbish mosaic of woven + lamellar bone.
is most paget’s asymptomatic?
yes - radiologically common but minority are symptomatic.
got a spot of paget’s on your x ray hun
which bones can paget’s affect?
pelvis
lumbar spine
skull
femur , tibia
i havent got any leg bones
what investigations for paget’s
plain X ray
alk phos - high
isotope scan
why is alk phos high in paget’s
high bone turnover
bones messy and fluffy on x ray (cortical thickening, abnormal texture)
paget’s
what is the treatment for paget’s ???
BISPHOSPHONATES
they disable osteoclasts
only treat if symptomatic
pain
fracture
deformity
= triad for what?
paget’s
low bone mass and microarchitectural destruction of bone –> increase in bone fragility and susceptibility to fracture
what’s this?
osteoporosis
name the 3 osteoporosis fragility fractures that happen
colles
NOF
vertebral
what questions are in FRAX
age height weight previous fractures parental hip fracture RA glucocorticoids smoker/alcohol
what does FRAX tell us
10yr fracture risk for untreated 40-90 yr olds
what does DEXA stand for
dual energy x ray absorptiometry
what does DEXA tell us
bone mineral density!!!
then calcs into T score
what does T score tell us
how much bone have you lost since young adult peak bone mass
how is Z score different to T score
Z = compared to pts same age T = compared to peak bone mass
-1 T score =
osteopenia
-2.5 T score =
osteoporosis
investigations for osteoporosis?
FRAX
DEXA scan - T score
vertebral fracture assessment (dexa of whole spine)
why do a vertebral fracture assessment?
these often go undiagnosed and are big risk factor
in osteoporosis thats not caused by endocrine, whats Ca PTH and vit D levels?
normal
if someones a rlly bad bone mineral density and youre suspicious, what other investigations might you do?
Ca, PTH, vit D - hyperPTH
TSH - hyperthyroid
coeliac antibodies
sex hormones (hypogonadism)
what 4 bits of lifestyle advice can you give to someone w osteoporosis?
less smoking/alcohol
more exercise
dietary calcium
vit D supplements
shout out the drug management of osteoporosis
bisphosphonates
HRT
denosumab
teriparatide
how often is IV zolendronate given?
annually!
how often are oral alendronate and risedronate given?
weekly
risedronate!
rare but bad SEs of bisphosphonates?
atypical femoral fractures
osteonecrosis of jaw
common SE of bisphosphonates?
oesophagitis
instructions for taking bisphosphonates?
first thing in morn empty stomach big glass of H2o , nothing else for 30 mins after dont lie down
“if youre vitamin D deficient, you can drink as much milk as you want but…
you’re not gonna absorb the calcium”
you need vit D to absorb ca from gut
what is the pathophys of osteomalacia?
low vit D - less Ca from gut - increased PTH - increased bone turnover + less mineralisation
what is the difference between osteporosis and osteomalacia?
porosis = low BD w lone bone mass. you’ve lost bone.
malacia = low BMD w normal amount of osteoid but softer cos less calcium.
what level of vit D counts as deficient?
<25
25 - 50 vit D =
insufficient
> 50 vit D =
sufficient
pt presents w bone pain, muscle aches, proximal muscle weakness. vit D level is 15.
osteomalacia and vit D def
osteomalacia :
alk phos
ca/phos
PTH
alk phos high (bone turnover)
PTH high (tryna increase ca)
Ca low (cant absorb)
vit D low
name some RFs for vit D def and osteomalacia
dark skin housebound body covering alcoholism vegetarian poverty obesity EBG >6 months LATE CKD
severe severe vit D def can cause
hypo Ca tetany seizures
plain X ray leg of someone with osteomalacia. what does it show?
cortical bone lucency
Looser’s zones
(strips of low density)
Loosers zones?
strips of low density on X ray of someone w osteomalacia
bone profile blood test involves what?
total protein
albumin
adjusted calcium
alk phos
(can add on phosphate)
osteomalacia investigations?
serum vit D
alk phos, ca/phos, PTH
plain x ray
dexa
treatment for osteomalacia
high dose vit D - CHOLECALCIFEROL 20,000 units for 12wks
+ Ca supplements
then continue low dose supplementation long term
why give Ca supplements alongside high dose vit D in treatment of osteomalacia?
help bone remineralise
what is AdCalD3
combined low dose vit D and calcium supplement
pt with end stage CKD has vit D def. how to treat?
CALCITRIOL (activated vit D)
what is cholecalciferol?
what is calcitriol?
cholecalciferol = skin vit D calcitriol = activated vit D (only give for renal pts)
autoimmune disease where there is too much fibroblast activity causing vascular damage and fibrosis of organs. what’s this?
systemic sclerosis aka scleroderma
what are the two types of systemic sclerosis
limited cutaneous and diffuse cutaneous (whole body skin involvement)
limited cutaneous sclerosis aka
CREST syndrome
what does CREST syndrome stand for
Calcinosis Raynaud's - nailfold capillaroscopy Esophageal dysmotility Sclerodactly Telangiectasia
WHAT ACTUALLY is systemic sclerosis
autoimmune
too much fibroblast activity
FIBROSIS OF ORGANS AND VESSELS
what ACTUALLY is polymyositis and dermatomyositis
autoimmune
INFLAMMATION OF MUSCLES
derm has skin involvement
proximal myopathy, hard to hold your head high. plus heliotrope eyelids and purple rash. can progres to interstit lung disease.
polymyositis and dermatomyositis
infl of muscles! proximal myopathy. skin involve.
middle aged woman presents struggling to comb her hair or even hold her head high. she has a purpley rash on her face.
polymyositis + dermatomyositis
investigations for polymyositis and dermatomyositis
high creatine kinase!
anti-Mi (derm)
anti-Jo (poly)
anti-ANA
EMG
diagnostic = muscle biopsy
which investigation is diagnostic for polymyositis and dermatomyositis?
muscle biopsy
polymyositis and dermatomyositis can be assoc w what
MALIGNANCY
PARANEOPLASTIC for breast gastric lung
also other autoimmune - hashimotos
treatment for polymyositis and dermatomyositis
prednisolone
what actually is lupus / SLE?
multisystem autoimmune conn tiss body attacks lots of its healthy tissues
complex
RFs for SLE
afro-caribbean women >40
HLA-DR2, 3
UV, EBV
ESR raised and CRP normal makes u think
SLE , lupus!
why is SLE called lupus?
rash looks like a wolf bite
shoot me some symptoms of SLE
photosensitive butterfly rash (naso-labial sparing) oral ulcers dry eye/mouth fatigue fever splenomegaly lymphadenopathy arthralgia pleuritic pain / pericarditis Raynaud's psychosis nephritic / nephrotic syndrome
is there increased CVD risk in lupus?
yes
photosensitive skin eruption w/o systemic symps =
discoid lupus
what are the KEY investigations for SLE
anti-dsDNA
ant-Sm
low C3/4
why test antiphospholipid antibodies in SLE?
antiphospholipid syndrome assoc w SLE
some investigations for SLE
FBC, ESR, CRP anti-ANA anti-dsDNA anti-Sm low C3/4 antisphospolipid antibodies
what might FBC show in lupus
haemolytic anaemia, low plts
is there a cure for SLE?
no. just reducing flares.
people die much younger :(
what is the management of SLE?
NSAIDS, prednisolone
HYDROXYCHLOROQUINE
immunosuppressants -azathioprine
dry mouth and dry eyes and enlarged parotids. positive rheumatoid factor. in middle aged woman.
sjorgens syndrome
she needs artificial tears and saliva
sjorgens syndrome can be primary or secondary to?
RA, SLE
treatment for sjorgens syndrome?
artificial tears and saliva
hypercoagulable , autoimmune. causing thrombosis and adverse preg outcomes. what this
antiphospholipid syndrome
antiphospholipid assoc w what disease?
SLE
treatment for antiphospholipid syndrome?
long term warfarin
in preg : LMWH and low dose aspirin
localised loss of cartilage, remodelling of adjacent bone, infl. triggered by trauma and need for joint to repair itself. what’s this?
osteoarthritis
wear and tear
name some RFs for osteoarthritis
FHx ageing female obesity joint injury / occupational stresses on joint
which joints does OA effect?
hip
knee
hand
hip pain, worse w exercise relieved by rest , morning stiffness <30 mins . what might you find on examination?
reduced ROM
crepitus
swelling/warmth
bony swelling e.g. Bouchards Heberdens nodes
= OA
heberdens nodes are
DIP
bouchards nodes are
PIP
when can a clinical diagnosis of osteoarthritis be made
> 45 + activity related + stiffness <30mins
OA plain X ray signs
Loss of joint space
Osteophytes
Subchondral cysts
Subarticular sclerosis
talk to me about non pharma management of OA
exercise weight loss physio walking aids supportive footwear
talk to me about pharma management of OA
paracetamol topical NSAIDs oral NSAID IA corticosteroids knee/hip replacement
autoimmune infl of synovial lining of joints, tendon sheaths and bursa. what’s this?
rheumatoid arthritis
a symmetrical polyarthritis
what allele is rheumatoid arthritis?
HLA DR4 /1
what antibodies for rheumatoid arthritis
rheumatoid factor
anti-CCP
two RFs for RA
woman
HLA DR4 /1
what do rheumatoid arthritis swellings feel like?
boggy, soft
as opposed to bony swellings in OA
atlanto-axial subluxation in
rheumatoid arthritis
when it affects C spine
risk of cord compression
which joints does RA tend to affect?
wrist, ankle, MCP, PIP
sometimes c spine, hips, knees
tell me about the onset of RA
can be overnight or gradual
name 5 things you might see on hand examination with rheumatoid arthritis
ulnar deviation boutonniere swan neck Z thumb elbow nodules
is rheumatoid arthritis a symmetrical polyarthritis ?
yeah
name some symptoms of rheumatoid arthritis
pain swelling stiffness in small joints of hands and feet
worse in morn
stiffness >30mins
improves with activity
does rheumatoid improve with activity?
yes
does osteoarthritis improve with ativity?
no - gets worse w activity
is DIP affected in RA?
NEVER
which joint is NEVER affected in RA?
DIP
what is caplan’s
pulmonary fibrosis in RA
extra-articular RA - lung: ?
pulmonary fibrosis
bronchiolitis obliterans
extra-articular RA - eye: ?
sjorgens sclerosis
keratoconjunctivitis sicca
extra-articular RA - cardiovascular: ?
pericardial effusion
vasculitis
accelerated atherosclerosis
anaemia of chronic disease
what is Felty’s syndrome
RA + splenomegaly + neutropenia
what organ does Felty’s syndrome affect in RA?
spleen
extra-articular RA - wrist: ?
carpal tunnel
what might FBC show in RA?
normocytic anaemia of chronic disease
what scan can show synovitis
Ultrasound
what does X ray show in RA
soft tissue swelling
joint destruction
main drugs for rheumatoid arthritis?
DMARDS
biologics
which DMARDs for rheumatoid arthritis?
methotrexate
leflunomide
sulfasalazine
*hydroxychloroquine if mild
what biologics for rheumatoid arthritis?
TNF blockers
rituximab
name 3 TNF blockers
adalimumab
infliximab
etanercept
complications of taking biologics for rheumatoid arthritis?
immunosuppression
reactivation of Hep B /C
apart from DMARDs and biologics, what else is the management of rheumatoid arthritis ?
MDT IM/IA steroids for flare ups NSAIDs + PPIs physio + OT manage CV risk and stop smoking
side effect of methotrexate?
pulmonary fibrosis
side effect of leflunomide?
peripheral neuropathy
side effect of sulfasalazine?
low sperm count
sulfasalazine sperm
3 general side effects of all DMARDs
mouth ulcers
bone marrow suppression
teratogenic
what actually is sarcoma
malignancy of mesenchymal origin
i.e. anything thats not carcinoma (epithelial)
e.g. leiomyo, rhabdomyo, lipo, fibro, angio, osteo, chondro
malignancy of mesenchymal origin = ?
sarcoma
4 SIGNS OF SARCOMA
lump >5cm
lump increasing in size
lump deep to fascia
pain
lump >5cm
lump increasing in size
lump deep to fascia
pain
=?
= sarcoma
why CT thorax in all sarcomes?
common met is lung
which 5 cancers most commonly spread to bone
PB-KTL
prostate breast kidney thyroid lung
in adults, what bones does osteomyelitis affect? and in kids?
in kids - long bones
adults- vertebrae
(these are well vascularised ones)
symptoms of osteomyelitis?
dull pain
fever/rigors
swelling/erythema
what are the three ways infection can get to the bone for osteomyelitis
direct e.g. open fracture
adjacent soft tissues e.g. DM ulcer
haematogeneous e.g. TB bacteraemia
investigations for osteomyleitis?
MRI
blood cultures
bone biopsy w culture
treatment for osteomyleitis?
surgical debridement
IV Abx
is septic arthritis a M E D I C A L E M E R G E N C Y?
Yes
mortality
joint destruction in 24hrs
which organism tends to cause septic arthritis / osteomyelitis in intravenous drug users
pseudomonas
investigation for septic arthritis?
URGENT JOINT ASPIRATION
microscopy and culture of synovial fluid
name 3 differentials for septic arthritis
gout
pseudogout
reactive arthritis
what is treatment for septic arthritis?
IV Abx
3-6wks
e.g. fluclox + rifampicin
may need washout + immobilise
how do you prevent prosthetic joint infection?
peri op Abx and Abx cement in prosthesis
if bad might need exchange arthroplasty
which 4 muscles make up the rotator cuff?
supraspinatus, infraspinatus, teres minor, subscapularis
what are the commonest 4 causes of shoulder pain?
1) rotator cuff disorders
2) glenohumeral disorders
3) acromioclavicular disorders
4) referred neck pain!!
what causes glenohumeral disorders?
adhesive capsulitis (aka forzen shoulder) osteoarthritis of shoulder
what causes rotator cuff disorders?
subacromial impingement
rotator cuff tear
what causes acromioclavicular disorders?
trauma
osteoarthritis
pain on external rotation =
frozen shoulder aka adhesive capsulitis
adhesive capsulitis aka
frozen shoulder
scarf test =
acromioclavicular disorder
pain on cross body adduction
painful arc=
subacromial impingement (rotator cuff tendonitis)
can’t put on your jacket, impaired external rotation. what shoulder pathology?
adhesive capsulitis aka frozen shoulder
rotator cuff TEAR is usually who
young ppl w trauma
painful arc is what
70-120 of abduction
then deltoid takes over (not rotator cuff muscles)
–> SUBACROMIAL IMPINGEMENT
more worrying causes of shoulder pain that arent rotator cuff, glenohumeral, acromioclavicular or referred neck pain include…
MI
gallbladder / subphrenic abscess
apical lung cancer
polymyalgia rheumatica (friend of giant cell)
what scan is best for shoulder?
ultrasound!!
x ray only if suspect arthritis / dislocation
if you suspect referred neck pain causing shoulder pain, what scan
x ray c spine
when you dislocate your shoulder which joint is it
glenohumeral joint
