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Phase 2a Concise > MSK > Flashcards

MSK Flashcards

1
Q

Spondyloarthropathies

A

Group of chronic rheumatic inflammatory conditions, associated with tissue type HLA-B27

AS, ReA, PsA, enteropathic arthritis (joint problems related to IBD)

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2
Q

Ankylosing spondylitis

A

chronic inflammatory disease of the spine and sacroiliac joints (axial skeleton)

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3
Q

AS Patho

A
  • Enthesitis (inflammation at site of ligament, tendon and capsule insertion into bone) - lesions heal by fibrosis/ossification - formation of syndesmophytes (new bone) and bony fusion (ankylosis) of joints

Eg bamboo spine (fusion of spinous processes)

Extra-articular features - the As

  • anterior uveitis
  • amyloidosis
  • apical lung fibrosis
  • aortic regurgitation
  • AV node block
  • achilles tendonitis - due to enthesitis

HLA-B27 - positive doesn’t mean you have it, but most with AS are positive

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4
Q

AS Px

A

Arthritis in axial skeleton
Typically young man, lower back pain, stiffness
Pain at night, improves on getting up
Pain radiates from sacroiliac joints to hips
Progression to kyphotic position
Flare ups
Peripheral arthritis - 1/2 joints, asymmetrical
Peripheral enthesitis

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5
Q

Features of spondyloarthropathies

A

SPINEACHE

Sausage digit (dactylitis)
Psoriasis
Inflammatory back pain
NSAID good response
Enthesitis (heel)
Arthritis
Crohn's/colitis/elevated CRP (but can be normal)
HLA-B27
Eye (uveitis)
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6
Q

AS lx

A

Bloods - ERS/CRP raised, anaemia, HLA-B27 positive (not dx - some negative but still have AS)

Spirometry - may show restriction - fibrosis, kyphosis

X-ray - changes later in disease (eg joint fusion)

MR

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7
Q

AS Mx

A 
Exercise/physio
NSAID - eg diclofenac
DMARD - eg methotrexate
anti-TNF - infliximab, etanercept
Local steroid injections
Surgery - straighten spine, replace hip
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8
Q

AS Cx

A

Increased CVD, osteoporosis risk
Spinal fusion - resp problems
Blindness from recurrent uveitis

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9
Q

Bone tumours

A

Primary rare
Secondary - metastases from breast, prostate, kidney, lung, thyroid
Can be benign (may cause pain)

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10
Q

Bone tumours patho

A

benign
osteochondroma (in metaphysis of long bones)
giant cell tumour (in epiphysis of long bones)
osteoblastomas and osteoid osteomas (from osteoblasts)

malignant
osteosarcomas
fibrosarcomas
chrondrosarcomas (cartilage)
Ewing's tumour

metastases are osteolytic (prostate often osteosclerotic too - increased bone density on xray)

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11
Q

Bone tumours Px

A

signs
tender
fatigue
anaemia

symptoms
pain, unremitting, worse at night
wt loss
malaise
pyrexia
aches, pains, (maybe related to hypercalcaemia)
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12
Q

Bone tumours Ix

A 
skeletal isotope scan
X rays
MRI
Serum ALP from bone raised
Hypercalcaemia
PSA raised with prostatic metastases
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13
Q

Bone tumours Mx

A 
Analgesics, anti-inflammatory drugs
Radiotherapy
Chemo
Hormonal therapy
Bisphosphonates - alendronate
Surgery
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14
Q

Gout

A

Arthritis due to deposition of monosodium urate (MSU) crystals within joints

A crystal arthritis

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15
Q

Gout patho

A

Renal, drugs, diet -> excessive urate -> urate crystals -> phagocyte activation -> inflammation

Acute inflammation - gout attack

Long-term deposition - tophaceous gout

causes - underexcretion/overproduction
alcohol, diet, drugs, HTN, renal impairment, metabolic syndrome, obesity, diabetes, excess meat, shellfish, offal, hyperuricaemia

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16
Q

Gout Px

A 
hot, swollen joints
shiny red, taut
pain
inflammation, fever, malaise
tophi - long-term (large crystal deposits)
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17
Q

Gout DDx

A

septic arthritis, pseudogout, reactive arthritis, OA, RA

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18
Q

Gout Ix

A 
X-ray - BETS
Bony hooks (from erosions)
Erosions - punched out
Tophi - more opaque
Space intact (no loss of joint space)

Polarised light microscopy of aspirated synovial fluid - negative birefringent needles

U+E - serum uric acid, urea, creatinine

USS/CT/MRI

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19
Q

Gout Mx

A

NSAIDs, colchicine (inhibits phagocyte activation, inflammation), intra-articular steroids, rest, ice

Lose weight, reduce diet factors

Allopurinol / febuxostat (inhibits purine conversion into uric acid by xanthine oxidase)

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20
Q

Pseudogout

A

deposition of calcium pyrophosphate crystals (CPP) on joint surface

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21
Q

Pseudogout patho

A

CPP crystal deposition, inflammation

Knee > wrist > shoulder > ankle > elbow

Acute attack triggers - trauma, illness, surgery, blood transfusion…

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22
Q

Pseudogout Px

A

Monoarthritic
severe pain, stiffness, swelling
fever
synovitis

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23
Q

Pseudogout Ix

A

X ray - chondrocalcinosis - linear calcification parallel to articular surfaces

Polarised light microscopy - positively birefringent rhomboids

FBC

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24
Q

Pseudogout Mx

A

Reduce food with high purine content

NSAIDs, analgesia, aspiration, joint injection, physio, rest

Anti-rheumatics - methotrexate, hydroxychloroquine

Surgery, synovectomy

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25
Q

Fibromyalgia

A

Chronic unexplained widespread pain, with soft-tissue tenderness on examination

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26
Q

Fibromyalgia Px

A 
soft tissue tenderness, multiple sites
widespread pain, poor analgesic response
fatigue
sleep disturbance
poor concentration
headache
paraesthesia
anxiety/depression
altered bowel habit
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27
Q

Fibromyalgia Ix

A

clinical dx, Ix to rule out other dx

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28
Q

Fibromyalgia Mx

A 
Educate, physio, exercise
CBT
TCA - amitriptyline
anticonvulsant - pregabalin, gabapentin
Dual reuptake inhibitors (antidepressant that inhibits reuptake of serotonin and NAd)- duloxetine
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29
Q

Fractures

A

Break in bone/cartilage (there is break in surface continuity)

Various patterns of fracture

Healing
Haematoma, fibrocartilaginous callus, bony callus, replaced by trabecular bone, remodelled into lamellar bone

RFs - osteoporosis, osteomalacia, Paget’s, infiltration

Mx - analgesia, examination (neurovascular, before and after stabilising break), reduce, immobilise, rehabilitate

Cx - damage to surrounding structures, infection, compartment syndrome, various systemic cx

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30
Q

NOF fracture

A

Intracapsular/extracapsular
Blood supply cut off to femur head

Px
externally rotated leg and short
fall
groin pain
can't weight bear

Mx
analgesia - morphine, nerve block
surgery - hip replacement (intra), DHS (extra)

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31
Q

Ankle fracture

A

Types - Weber classification

Dislocation - bone pressure on skin from underneath, relocate asap

Sprain - tender over joint line, RICE, get moving asap

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32
Q

Open fractures

A

Tetanus, infection risk - ABs
straight to theatre
Checking pulse, sensation - damage to nerves and vessels

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33
Q

Compartment syndrome

A

Fluid in compartment formed by fascia - pressure on veins, nerves, arteries, ischaemia (6 Ps)

Mx - fasciotomy

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34
Q

ACL injury

A

ACL limits anterior translation of tibia, rotational stability

Px - swelling, pain, knee giving way

Ix - Positive Lachman’s, anterior draw test, MRI

Mx - RICE, physio, surgical

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35
Q

Shoulder dislocation

A

Most commonly anterior dislocation

Struggle to lift arm, pain

Check neurovascular supply (axillary nerve)

Pop back in, get moving asap

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36
Q

Rotator cuff injury

A

Acute/chronic, partial/full thickness tears

Analgesia, physio, activity modification, corticosteroid injection, surgery

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37
Q

Mechanical lower back pain

A

Back pain common, watch out for red flags:

TUNAFISH (some of them)
Trauma, TB
Unexplained wt loss, night sweats
Neurological deficits, bowel/bladder incontinence
Age <20, >55
Fever
IDVU
Steroid use, immunocompromised
History of cancer

Ix - clinical exam, find cause, x ray, MRI

Mx - neuro referral if neurological deficit, education, analgesia, exercise, physio

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38
Q

Spondylolisthesis

A

One vertebra slips forward/backwards

Pain, marked limitation of straight leg raising

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39
Q

Spinal stenosis

A

Narrowing of spinal canal, can cause neurogenic claudication

Pain worse walking downhill, relieved leaning forward

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40
Q

Osteoarthritis

A

Degenerative disease - joint pain and functional limitation / stiffness

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41
Q

OA patho

A

commonly affects peripheral joints - knees, hips, small joints of hands

Loss of cartilage, disordered bone repair (osteophytes - calcified cartilaginous growths at joint margins), inflammation

Exposed subchondral bone becomes sclerotic

wear and tear essentially

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42
Q

OA Px

A 
signs
reduced range of movt
pain on movt
joint swelling, instability
tenderness
crepitus
absence of systemic features (fever, rash)
bone swelling and deformity from osteophytes (Herbedens - DIP, Bouchards - PIP)
Asymmetrical joint involvement
symptoms
pain exacerbated by exercise, relieved by rest
reduced function
worsens with prolonged activity
stiffness in morning <30min/none
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43
Q

OA Ix

A 
X-ray - LOSS
Loss of joint space
Osteophyte formation
Subchondral sclerosis
Subchondral cysts

FBC - CRP maybe raised
MRI
Joint aspiration - exclude septic arthritis, gout

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44
Q

OA Mx

A 
Exercise, wt loss
Physio/occ therapy, walking aids
Analgesia
Joint steroid injections
Surgery - joint replacement / fusion
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45
Q

Osteomalacia

A

Normal amount of bone but mineral content low - excess uncalcified osteoid and cartilage

Rickets in children

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46
Q

Osteomalacia causes

A

Vit d deficiency
Hypophosphataemia (due to xs PTH release in response to low Ca absorption, so decreased phosphate absorption in kidneys, more excretion)
Renal disease - cannot produce active vit D
Drug induced
Liver disease
Tumour induced

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47
Q

Osteomalacia Px

A

muscle weakness - waddling gait, difficulty climbing stairs
widespread bone pain, tenderness
fractures, esp femoral neck

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48
Q

Rickets Px

A

growth retardation, hypotonia
knock knees, bowed legs
widened epiphyses at wrist
features of hypocalcaemia (tetany - severe)

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49
Q

Osteomalacia Ix

A

Bloods
Low Ca, phosphate, raised ALP, PTH, low 25-OH vit D

Biopsy - shows incomplete mineralisation

X-ray - defective mineralisation, Looser’s zones - low density bands

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50
Q

Osteomalacia Mx

A

Vit d replacement:
Dietary insufficiency - calcium D3 forte tablet
Malabsorption - oral ergocalciferol/calcitriol
Renal - alfacalcidol/calcitriol

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51
Q

Osteomyelitis

A

infection of bone marrow

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52
Q

OM Patho

A

results in inflammatory destruction of bone, abscess formation, ischaemia, necrosis

acute/chronic (necrosis)

Can form from direct inoculation (via trauma/surgery), contagious spread (from adjacent soft tissues), haematogenous seeding (blood flow)

Commonly S.aureus

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53
Q

OM Px

A

signs
systemic - fevers, rigors, sweats, malaise
Acute, local - tenderness, warmth, erythema, swelling
Chronic - as above, non-healing ulcers/fractures

symptoms
onset over several days
dull pain
may be aggravated by movt

54
Q

OM Ix

A 
Increased WCC, ESR, CRP
X-ray
MRI/CT
Nuclear bone scan
Bone biopsy
Blood cultures
55
Q

OM Mx

A

Surgical - debridement, hardware replacement

ABs

56
Q

Osteoporosis

A

Low bone mass, microarchitectural deterioration of bone tissue -> bones are fragile, susceptible to fracture

57
Q

Osteoporosis patho

A

Bone mass decreases in old age - increased fracture risk

Common fractures - hip, vertebral, Colles (radius/wrist)

Postmenopause - higher bone turnover with lower oestrogen, osteoporosis risk

58
Q

Osteoporosis RFs

A

SHATTERED

Steroid use
Hyperparathyroidism, hyperthyroidism, hypercalciuria
Alcohol, tobacco
Thin (underweight BMI)
Testosterone use
Early menopause
Renal, liver failure
Erosive/inflammatory bone disease (myeloma, RA)
Dietary decreased Ca/malabsorption / T1DM

59
Q

Osteoporosis Px

A

Asymptomatic

More fractures

60
Q

Osteoporosis Ix

A

FRAX - assess risk of fracture

DEXA scan - measures bone mineral density - T score given (std deviation compared with peak bone mass), osteopenia before osteoporosis

X-ray - normally in hindsight after fracture

61
Q

Osteoporosis Mx

A

Stop smoking, reduce alcohol, weight bearing exercises, calcium and vit d rich diet, home fall prevention

Anti-resorptive - decrease osteoclast activity, bone turnover
Bisphosphonates - alendronate
HRT - oestrogen
Denosumab - Mab to RANK ligand

Anabolic - increase osteoblast activity and bone formation
Teriparatide - PTH analogue

62
Q

Osteoporosis Cx

A

Death, permanent disability, unable to walk independently, reduced ADL

63
Q

Paget’s disease

A

focal disorder of bone remodelling

Unknown cause. Increased osteoclast bone resorption, formation of weaker new bone, increased bone blood flow, fibrosis - deformity and increased fracture risk

64
Q

Paget’s Px

A

Common sites - pelvis, spine, femur, skull, tibia

60-80% asym

signs
deformities - bowed tibia, skull changes

symptoms
bone pain
joint pain
neurological cx - nerve compression - deafness (CN8), paraparesis (partial paralysis of lower limbs)
Hydrocephalus

Rarely - high-output cardiac failure, heart hypertrophy due to increased bone blood flow, osteosarcoma

65
Q

Paget’s Ix

A

Increased serum ALP, normal Ca and phosphate - increased bone turnover

Urinary hydroxyproline excretion raised - marker of disease activity

X-ray
localised deformity
sclerotic changes
osteolytic areas (reduced density)

Isotope bone scans

66
Q

Paget’s Mx

A

Orthotics, sticks, walkers

Bisphosphonates - alendronate

NSAIDs - ibuprofen

Surgery to correct problems

67
Q

Psoriatic arthritis

A

inflammatory arthritis associated with psoriasis, a spondyloarthropathy

68
Q

PsA Px

A 
Psoriatic arthritis mutilans - finger deformity
Nail changes - pitting, onycholysis
Psoriatic rash - knees, elbows, hidden sites (behind ear, scalp...)
Dactylitis (finger swelling)
Joint stiffness, pain, swelling
Tender tendons, enthesitis
DIP joint disease
Sacroilitis
69
Q

PsA Ix

A

Bloods - RF negative, ESR, CRP often elevated

X-ray
DIP predominantly affected (rather than MCPJ and PIP as in RA)
Erosions central in joint
Pencil-in-cup deformity

Synovial fluid aspirate - no crystals, WCC high

70
Q

PsA Mx

A 
NSAIDs
DMARDs - sulfasalazine, methotrexate
Joint steroid injections
Anti-TNF - etanercept
Surgery, physio, exercise, heat tx
71
Q

Reactive arthritis

A

Arthritis occurring as an autoimmune response to infection elsewhere

a spondyloarthropathy (HLA-B27 associated)

Main causes - GI infections, sexually acquired

72
Q

ReA Px

A 
Asymmetrical joint pain / arthritis - warm, red, sudden onset
Malaise, fatigue, fever
Dactylitis
Mouth ulcers
Nail dystrophy

Reiter’s syndrome - can’t see, can’t pee, can’t climb a tree
conjunctivitis, anterior uveitis
urethritis - pain on urination
enthesitis

Skin - circinate balanitis, keratoderma, blennorrhagia

Sacroiliitis, spondylitis

73
Q

ReA Ix

A 
Bloods - ESR/CRP raised
Culture stool if diarrhoea
GUM referral
Aspirate synovial fluid - sterile, high neutrophil count
Xray - may show enthesitis
74
Q

ReA Mx

A 
Splint joint
NSAIDs, local steroid injections
ABs
DMARDs - sulfasalazine, methotrexate
TNF-alpha blockers - etanercept/golimumab
75
Q

Rheumatoid arthritis

A

Chronic autoimmune disease - inflammation of synovial joints

76
Q

RA Px

A

signs
inflammation - red, hot, pain, swelling
symmetrical, polyarthropathy of smaller joints (MCP, PIP, wrist, MTP joints)
loss of function
deformity (swan neck, boutonniere, z-thumb, ulnar deviation, subluxation)
extra-articular involvement (see cx)

symptoms
pain worse in morning, stiffness >30min
fatigue, malaise
pain progressively gets worse

77
Q

RA DDx

A

OA, septic arthritis (single joint), ReA, spondyloarthropathies, PsA, SLE

78
Q

RA Ix

A

Bloods - anaemia, high ESR/CRP
RF - positive in 60-70%
anti-CCP

X-ray - LESS
loss of joint space
erosions (focal)
soft tissue swelling
soft bones (osteopenia)
79
Q

RA Mx

A

Physio/occ therapy, podiatry, surgery, stop smoking

DMARDs - methotrexate, sulfasalazine, hydroxychloroquine

Biological agents - TNF inhibitors, B-cell depletion

Prednisolone

NSAIDs - ibuprofen, naproxen, diclofenac

Analgesics - paracetamol, codeine

80
Q

RA Cx

A

Eyes - scleritis, secondary Sjogren’s
Skin - ulcers, rashes, nail fold infarcts, vasculitis
Soft tissues - nodules, bursitis
Rheumatoid nodules
Neuropathies
Haem - anaemia, Fe-deficiency, splenomegaly
Resp - pleural effusion, rheumatoid nodules
CV - increased MI risk
Kidneys - amyloidosis, nephropathy
Liver
Depression

81
Q

Antiphospholipid syndrome

A

autoimmune disorder characterised by arterial, venous thrombosis, adverse pregnancy outcomes, raised levels of antiphospholipid (aPL) ABs

associated with SLE, RA, systemic sclerosis, GCA

Perhaps aPL ABs -> hypercoagulable

82
Q

APS Px

A

CLOT

Coagulation issue
Livedo reticularis - purple skin
Obstetric issues - pregnancy loss, pre-eclampsia, intrauterine growth restriction (IUGR)
Thrombosis/thrombocytopenia - DVT, stroke, MI, PE, organ infarction, haemolytic anaemia

83
Q

APS Ix

A

screen for aPL ABs (<50 with ischaemic stroke, women with 3+ miscarriages)

lupus anticoagulant test, anticardiolipin test, anti-B2-glycoprotein test, - positive

FBC - thrombocytopenia, haemolytic anaemia

Clotting screen

CT/MRI/ECHO (heart)

Doppler USS - DVT

84
Q

APS Mx

A

Healthy lifestyle to prevent CVD
Acute thrombosis - heparin
Prophylactic - warfarin, aspirin
Clopidogrel

85
Q

Sjogren’s syndrome

A

autoimmune destruction of exocrine glands, esp lacrimal, salivary

Primary/secondary (RA, SLE, systemic sclerosis)

Lymphocytic infiltration and fibrosis of glands

86
Q

Sjogren’s Px

A

Decreased tear production - dry eyes, blurring, itching, redness
Decreased salivation - dry mouth, caries, cracks, difficulty tasting/swallowing
Parotid swelling
Ulceration of nasal sputum
Vaginal dryness, dry cough, painful intercourse
Systemic signs - polyarthritis, Raynaud’s, lymphadenopathy, fatigue,

87
Q

Sjogren’s Ix

A 
Schirmer's test
Rose Bengal staining may show keratitis
Anti-RO (SS-A), anti-LA (SS-B) ABs
RF +ve in 38%
USS salivary glands
88
Q

Sjogren’s Mx

A

Sicca (dryness) - hypromellose (artificial tears), frequent drinks

NSAIDs, hydroxychloroquine for arthralgia

89
Q

Myositis

A

autoimmune disorder - inflammation of muscles, also necrosis

90
Q

Myositis patho

A

Polymyositis - muscles affected

Dermatomyositis - immune system attacks muscle and skin

Can also affect other body parts - joints, oesophagus, lungs, heart

Causes - virus, genetics

91
Q

Myositis Px

A

Polymyositis
symmetrical, progressive muscle weakness, wasting - affects large proximal muscles (shoulders, hips)
difficulty squatting, going upstairs, rising from chair, raising hands above head
involvement of pharyngeal, laryngeal, resp muscles - dysphagia, dysphonia, resp failure
fatigue, myalgia, muscle cramps
fine motor movts affected later

dermatomyositis
same as above
heliotrope - purple discolouration of eyelids
Gottron’s sign - scaly erythematous plaques over knuckles
GI ulcers/infections

Fever, arthralgia, Raynauds, interstitial lung fibrosis

92
Q

Myositis Ix

A

EMG (electromyography) - detect muscle changes

ABs - Jo-1, PM-SCl, Mi-2, ANA

Muscle/skin biopsy

Muscle enzymes - raised creatinine kinase, aldolase, AST, LDH

CXR, PFTs, HRCT, MRI

93
Q

Myositis Mx

A 
Use sun block
Exercise therapy
Prednisolone
Immunosuppression - azathioprine
Hydroxychloroquine/topical tacrolimus for skin rashes
94
Q

Systemic sclerosis

A

multisystem autoimmune disease - increased fibroblast activity, abnormal growth of connective tissue, vascular damage, fibrosis

Scleroderma - the skin component

95
Q

SSc patho

A

Limited - more common, face, forearms, lower legs, CREST

Diffuse - more skin involved, mortality higher

3 cardinal features of SSC

  • excessive collagen production, deposition
  • vascular damage
  • immune system activation via auto-AB production, cell-mediated

Causes - genetics, infectious agents, chemicals, drugs, silica dust exposure…

96
Q

SSC Px

A

limited - CREST
Calcinosis - calcium deposits in skin
Raynaud’s phenomenon
Esophageal dysfunction, acid reflux, decrease in motility
Sclerodactyly - thickening, tightening of skin on fingers and hands
Telangiectasias - dilation of capillaries causing red marks on skin (spider veins)

is limited to hands, face, feet, forearms

diffuse
more rapid, widespread skin changes
GI - dilatation, loss of strength
Renal - disease
Lung - fibrosis
Myocardial fibrosis, arrhythmias
97
Q

SSc Ix

A

Bloods - anaemia, raised ESR, auto-ABs (anticentromere (limited), anti-topoisomerase-1 and anti-RNA (diffuse), RF, ANA)

Urinalysis - raised urea, creatinine in AKI, proteinuria

Imaging - CXR, hand xray, barium swallow, HRCT

98
Q

SSC Mx

A

No cure, steroids, immunosuppressants

Raynauds - hand-warmers, vasodilators (CCB nifedipine, bosentan, iloprost, sildenafil), fluoxetine (SSRI)

GORD - PPI

Prevent renal crisis - ramipril

Pulmonary fibrosis - cyclophosphamide

99
Q

Septic arthritis

A

Infection in joint, produces inflammation

100
Q

Septic arthritis patho

A

S.aureus most commonly
Neisseria gonorrhoea - consider in sexually active
Staph epidermidis
consider Lyme disease if own a dog/in high risk area
H.influenzae in children
G- bacteria, eg E.coli,

101
Q

Septic arthritis RFs

A

Prosthetic joints, DM, immunosuppression, pre-existing joint disease, low SES, young and v old, IVDU, osteomyelitis

102
Q

Septic arthritis Px

A

hip, knee, shoulder common

signs
red, hot, swollen joint, non-weight bearing
tachycardia, fever, rash, malaise, anorexia

symptoms
painful joint, loss of function

103
Q

Septic arthritis Ix

A

FBC - raised WCC

Blood culture

Joint aspiration - before ABs, fluid opaque/pus

STI screen, HIV, skin wound swabs, sputum, throat

104
Q

Septic arthritis Tx

A

IV ABs
flucloxacillin - most G+, eg S.aureus
erythromycin/clindamycin if allergic to penicillin
cefotaxime for G-/gonococcal
vancomycin for MRSA
if immunocompromised - fluclox + gentamicin

Double prednisolone dose if already on prednisolone

Needle aspiration to decompress joint

Arthroscopic lavage

105
Q

Systemic lupus erythematosus

A

chronic, inflammatory multisystem autoimmune disease, characterised by auto-ABs to nuclear material

abnormal immune function - T/B cell dysfunction, complement dysfunction, aberrant apoptosis, impaired immune complex clearance

106
Q

SLE RFs

A

sun exposure, FHx, smoking, drugs, EBV

107
Q

SLE Px

A

Factors that can trigger flare up - sunlight, oestrogen contraception, pregnancy, drugs, infection, stress

signs
Raynaud’s
Jaccoud’s arthropathy - reversible joint deformities, eg ulnar deviation, swan neck

symptoms
fatigue, malaise, fever, wt loss
arthralgia - polyarticular
myalgia, myositis
butterfly rash on nose and cheeks (malar rash)
secondary fibromyalgia
108
Q

SLE - MD SOAP BRAIN

A 
Malar rash
Discoid rash
Serositis
Oral ulcers
Arthritis, like RA
Photosensivity
Blood - all low (anaemia, leukopenia, thrombocytopenia)
Renal disease - proteinuria
ANA positive
Immunological disorder - anti-dsDNA
Neurological disorder - seizures, cerebrovascular disease, myasthenia gravis
109
Q

SLE Ix

A

Bloods - auto-ABs - anti-RO, anti-LA, anti-dsDNA, ANA

certain MHC antigens (HLA-DR2/3) confer increased susceptibility

110
Q

SLE Mx

A

Sun block
Hydroxychloroquine
Glucocorticosteroids
Immunosuppressants - azathioprine, cyclophosphamide, methotrexate

111
Q

Vasculitis

A

Inflammation of vessel wall

Seen in many diseases - RA, SLE, myositis, some drug reactions, scleroderma, Goodpasture’s, IBD

Patho
Inflammation, necrosis of vessel wall, impaired blood flow, results in - vessel wall destruction, endothelial injury

Large-vessel - GCA, polymyalgia rheumatica, Takayasu’s arteritis

Medium-vessel - polyarteritis nodosa, Kawasaki’s disease

Small-vessel - ANCA associated (microscopic polyangiitis, granulomatosis with polyangiitis), ANCA negative

All associated with anaemia, raised ESR, can be primary/secondary

112
Q

Polymyalgia rheumatica

A

Inflammatory condition of unknown cause, often coexists with GCA, kind of a large vessel vasculitis

113
Q

PMR patho

A

inflammatory disorder causes pain in limb girdles

Muscles actually spared, pain comes from bursae/tendons - referred pain

114
Q

PMR Px

A 
sub acute onset <2wks
sudden onset severe pain, stiffness of shoulders, neck, hips, lumbar spine (limb girdle pattern)
symptoms worse in morning
mild polyarthritis of peripheral joints
fatigue, fever, wt loss, depression
115
Q

PMR DDx

A

RA, spondyloarthropathies, SLE, myositis, OA, malignancy, fibromyalgia

116
Q

PMR Ix

A 
Clinical history
ESR/CRP raised
ANCA negative
serum ALP raised
Mild anaemia (normocytic, normochromic)
Temporal artery biopsy - GCA
Creatinine kinase normal - distinguish from myopathies
117
Q

PMR Mx

A

Prednisolone long-term

lansoprazole and alendronate to prevent osteoporosis and GI upset

118
Q

Giant cell arteritis

A

Inflammatory granulomatous arteritis of large cerebral arteries, other large vessels, eg aorta

occurs in association with PMR (50%)

119
Q

GCA Px

A

signs
tenderness, swelling of temporal/occipital arteries
Sudden painless vision loss - arteritis anterior ischaemic optic neuropathy - emergency

symptoms
severe headache (temporal pulsating)
scalp tender
jaw claudication (when eating)
malaise, lethargy, fever
limb claudication, polymyalgia
120
Q

GCA DDx

A

migraine, tension headache, trigeminal neuralgia, polyarteritis nodosa

121
Q

GCA Ix

A 
anaemia
ANCA negative
ESR/CRP high
serum ALP may be raised
temporal artery biopsy
USS, PET/CT scan
temporal artery tenderness
122
Q

GCA Mx

A

prednisolone, lansoprazole, alendronate

visual changes - methylprednisolone

DMARDs if failure to wean steroids - methotrexate, tocilizumab

123
Q

Polyarteritis nodosa

A

Medium-vessel necrotising vasculitis, causes aneurysms, thrombosis, leading to organ infarction

124
Q

PAN Px

A

fever, malaise, wt loss, myalgia, then features due to organ infarction:

Neurological - mononeuritis multiplex (due to arteritis of vessel supply to peripheral nerves)
Abdo - pain due to arterial involvement of abdo viscera
Renal - haematuria, proteinuria, HTN, kidney disease
Cardiac - coronary arteritis -> MI, HF
Skin - subcut haemorrhage, gangrene

125
Q

PAN DDx

A

fever from infection, Crohn’s, SLE, RA, other vasculitis

126
Q

PAN Ix

A

Bloods - anaemia, WCC ESR raised
ANCA negative
Biopsy - eg of kidney, check for damage
Angiography - microaneurysms

127
Q

PAN Mx

A

Ramipril - control BP
Prednisolone
Immunosuppression - azathioprine/cyclophosphamide

128
Q

ANCA-associated vasculitis

A

Granulomatosis with polyangiitis, microscopic polyangiitis - necrotising vasculitis of small vessels

patho
pathogenic anti-neutrophil cytoplasmic ABs (ANCA) - can activate neutrophils - drive inflammation - granulomatous

Px
varies from limited to generalied multi-system disease
epistaxis, crusts, stuffiness, hearing loss, stridor
iritis, diplopia
cough, SOB, haemoptysis
rash
numbness, tingling, wrist/foot drop
joint pain, swelling
saddle nose deformity

Ix
Confirm dx - H+E, ANCA testing, tissue biposy
Assess organ involvement - CT, tests ets
Assess disease activity - Birmingham vasculitis activity score, vasculitis damage index

Mx
cyclophosphamide/rituximab, corticosteroids, DMARDs, steroid taper

129
Q

Acute disc disease

A

prolapse of intervertebral disc, results in acute back pain

older patients, sciatica more likely

Px
sudden onset severe back pain, often following strenuous activity
pain related to position, aggravated by movt
muscle spasm
pain radiation and clinical findings depend on disc affected

Ix
Xray, MRI (see notes for nerve root lesions)

Mx
analgesia, surgery, physio

130
Q

Chronic disc disease

A

associated with degenerative changes in lower lumbar discs and facet joints

Px
pain, aggravated by movt
sciatic radiation may occur - pain in buttocks, radiating to posterior thigh

Mx
NSAIDs, physio, wt reduction, surgery (fusion)

Phase 2a Concise (9 decks)

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