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MSK Flashcards

1
Q

List the most commonly affected joints in osteoarthritis

A

Knee
Hip
Hands
Cervical/Lumbar spine

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2
Q

What joints do osteoarthritis classically not affect

A

MCP joints

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3
Q

Give the pathophysiology for osteoarthritis

A

Inflammatory response affecting the ENTIRE joint:
* Cartilage
* Subchondral bone
* Ligaments
* Menisci
* Synovium
* Capsule
Leads to:
* Loss of cartilage, sclerosis, eburnation of the subchondral bone
* Osteophytes
* Subchondral cysts

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4
Q

List the factors associated with increased risk of OA

A

Increased age
Family history
Female sex
Obesity
Congenital articular deformities
Joint trauma

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5
Q

List the local mechanical factors facilitating the progression of OA

A

Peripheral muscle weakness
Malalignment
Structural joint abnormalities eg. meniscal tear

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6
Q

What enzymes are found in higher concentrations in OA cartilage

A

Metalloproteinases eg. collagenases

Catalyses collagen and proteoglycan degradation
Activated by nitric oxide

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7
Q

List the secondary causes for OA

A

(antecedent insult to the joint)

Pre-existing joint damage:
* Rheumatoid arthritis
* Spondyloarthritis
* Septic arthritis
* Gout
* Overuse/ abnormal use
* Trauma
* Paget’s disease
* Avascular necrosis eg. corticosteroid therapy
Metabolic disease:
* Cartilage calcification
* Hereditary haemochromatosis
* Acromegaly
Systemic disease:
* Haemophilia (recurrent haemarthrosis)
* Haemoglobinopathies eg. SCD
* Neuropathies

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8
Q

List the physical examination findings in OA

A

Swelling
Bone deformities
* Hand PIP joint enlargement (Bouchard nodes)
* Hand DIP joint enlargement (Bouchard nodes)
Malalignment of affected joints
Crepitus

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9
Q

List the X ray signs in OA

A

Joint space narrowing
Subarticular sclerosis
Subchondral cysts
Osteophytes

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10
Q

Give the clinical diagnostic criteria for OA

A

Activity-related joint pain
No morning joint-related stiffness / morning stiffness <30 mins
Age > 45 yrs

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11
Q

List the pharmacological managements for OA

A

(Topical analgesics)
Capsaicin
NSAIDs eg. diclofenac, methylsalicyclate

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12
Q

Give the management in OA if acute exacerbation/NSAIDs contraindicated, not tolerated

A

(Intra-articular corticosteroid injections)
methylprednisolone acetate
triamcinolone acetonide

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13
Q

List the three subgroups of inflammatory arthritis

A

Rheumatoid arthritis - associated with antibodies
Spondyloarthritis - associated with HLA-B27
Crystal arthritis - associated with crystals

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14
Q

List the causes of monoarthritis

A

Crystal arthritis
Septic arthritis
Palindromic rheumatism
Trauma/haemarthrosis
Juxta-articular bone tumour

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14
Q

List the causes of oligoarthritis

A

Crystal arthritis
Septic arthritis
Palindromic rheumatism
Reactive arthritis

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15
Q

List the causes of polyarthritis

A

Reactive arthritis
Psoriatic arthritis
Axial spondyloarthritis
Enteropathic arthritis
Post-viral
Lyme arthritis

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16
Q

What age group does rheumatoid arthritis most commonly affect

A

40~60

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17
Q

Give the general preponderance in rheumatoid arthritis

A

Female preponderance 3:1

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18
Q

What does RA primarily affect

A

Small joints of hands and feet
Synovium of joints (synovitis)

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19
Q

Give the genetic predisposition in RA

A

HLA-DRw4

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20
Q

What joint does RA not affect

A

DIP

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21
Q

Give the usual clinical presentation in RA

A

Bilateral, symmetrical pain and swelling of small joints in the hands and feet that has lasted for more than 6 weeks
* at least 3 symmetric joints involved
Morning stiffness lasting over 1 hour

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22
Q

List the joint signs in RA

A

Hands and wrists
* Ulnar drift and palmar subluxation of the MCPs
* PIP joints:
* fixed flexion (buttonhole/boutonnière deformity)
* fixed hyperextension (swan-neck deformity)
Feet
* Broad foot, hammer-toe deformity
* Painful swelling of MTP joints
* Ankle often assumes valgus position
Shoulders
* Global stiffening
* Rotator cuff tear common
Cervical spine - Painful stiffness of the neck
Knees
* Synovitis
* Knee effusions
Hips

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23
Q

List the extra-articular features in RA

A

Scleritis
Scleromalacia
Sjögren’s syndrome
* Dry eyes
* Dry mouth
Atlantoaxial subluxation (cervical cord compression)
Lymphadenopathy
Pericarditis
Lung
* Pleural effusion
* Interstitial lung disease
* Caplan’s syndrome
* Small airway disease
* Nodules
Splenomegaly (Felty’s syndrome)
Amyloidosis
Bursitis/nodules
Tendon sheath swelling
Tenosynovitis
Carpal tunnel syndrome
Nail fold lesions of vasculitis
Anaemia
Sensorimotor polyneuropathy
Leg ulcers
Ankle oedema

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24
Q

Give the triad in Felty syndrome

A

Rheumatoid arthritis
* Severe erosive joint disease and deformity
* Rheumatoid nodules
* Vasculitis (mononeuritis multiplex, necrotising skin lesions)
Reduced white blood cell
Splenomegaly

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25
Q

List the clinical manifestations in severe RA

A

Pericarditis
Pleuritis
Interstitial lung disease
Inflammatory eye disease

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26
Q

List the lab test features in RA

A

Rheumatic factor +ve
Anti-cyclic citrullinated peptide antibody (anti-CCP) +ve
ESR/CRP elevated
Blood count - normocytic normochromic anaemia

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27
Q

List the X ray signs in RA

A

Juxta-articular osteopenia
Soft tissue swelling
Joint deformity
Loss of joint space
Periarticular erosions

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28
Q

List the management approaches for RA

A

(Conventional synthetic disease-modifying anti-rheumatic drugs (DMARDs))
Methotrexate (1st line)
Leflunomide (MTX contraindicated/intolerated)
Hydroxychloroquine (pregnancy/non-erosive disease)
Sulfasalazine

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29
Q

What may be given for acute flare of RA

A

Intra-articular glucocorticoid injection
* methylprednisolone acetate
* triamcinolone acetonide

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30
Q

Give the options for severe RA / inadequate response to methotrexate

A

(Biologics)
TNF-a inhibitor:
* Anakinra (IL6 inhibitor)
* Abatacept
* Rituximab
Oral JAK inhibitor (e.g., tofacitinib, baricitinib, upadacitinib)

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31
Q

List the problems with corticosteroid use

A

Weight gain
Thin, easily damaged skin
Monitor for diabetes and hypertension
Accelerated cataract formation
Osteoporosis develops within 3 months on doses above 7.5 mg daily (monitor with DXA, vitamin D, bisphosphonate)

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32
Q

Give the adverse effect of hydroxychloroquine

A

Retinopathy

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33
Q

Give the mechanism for hydroxychloroquine

A

TNF and IL-1 suppressor

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34
Q

Give the mechanism for sufasalazine

A

TNF and IL-1 suppressor

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35
Q

Give the mechanism for leflunomide

A

Pyrimidine synthesis inhibitor

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36
Q

Give the mechanism for methotrexate

A

Folate antimetabolite

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37
Q

List the sufasalazine adverse effects

A

Nausea, mouth ulcers
Hepatotoxicity
Neutropenia/thrombocytopenia
Skin rash

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38
Q

List the Methotrexate adverse effects

A

Nausea, mouth ulcers, diarrhoea
Hepatotoxicity
Neutropenia/thrombocytopenia
Renal impairment
Pulmonary fibrosis

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39
Q

List the Leflunomide adverse effects

A

Diarrhoea
Hepatotoxicity
Neutropenia/thrombocytopenia
Alopecia
Hypertension

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40
Q

List the rituximab adverse effects

A

Hypo/hypertension
Pruritus and skin rash
Back pain
Toxic epidermal necrolysis

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41
Q

Give the hallmark in Spondyloarthritis

A

Enthesitis

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41
Q

What HLA antigen is spondyloarthritis associated with

A

HLA-B27

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42
Q

List the types of seronegative spondyloarthropathy

A

Axial spondyloarthritis (sacroiliac/spine)
Psoriatic arthritis
Reactive arthritis (sexually transmitted)
Post-dysenteric reactive arthritis
Enteropathic arthritis (CD/UC)

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43
Q

What age group does Ankylosing spondylitis. commonly affect?

A

20 years and older

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44
Q

List the hallmark clinical features in Ankylosing spondylitis

A

Inflammatory back pain
* Insidious onset
* Worse/stiff in the morning
* Improves with exercise
Alternating buttock pain
Waking up in the second half of the night with back pain
Resolution of symptoms with NSAIDs

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45
Q

List the Ankylosing spondylitis associated features

A

Family history of spondyloarthropathy
Anterior uveitis
Enthesitis
Psoriasis
Inflammatory bowel disease
Dyspnoea
Fatigue
Sleep disturbance

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46
Q

List the physical examination findings in Ankylosing spondylitis

A

Loss of lumbar lordosis and flexion
Tenderness at sacroiliac joints
Kyphosis in chronic cases
Peripheral joint involvement

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47
Q

List the X ray signs in Ankylosing spondylitis

A

Sacroiliitis
Syndesmophytes
Vertebral squaring
Erosion
Sclerosis
Bamboo spine

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48
Q

Give the first line management for Ankylosing spondylitis

A

NSAIDs

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49
Q

Give the management for ankylosing spondylitis when there is intra-articular inflammation/enthesitis

A

Hydrocortisone

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50
Q

Give the management for ankylosing spondylitis when there is peripheral joint involvement

A

Conventional DMARDs (sulfasalazine, methotrexate)

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51
Q

Give the inheritance mechanism in psoriatic arthritis

A

Paternal imprinting
(Inheritance of an allele from 16q chromosome from the father increases the risk of arthritis)

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52
Q

List the distinguishing features between psoriatic arthritis and rheumatoid arthritis

A

Presence of dactylitis
DIP involvement
Absent anti-CCP antibodies
Frequent mono/oligoarticular initial pattern of joint involvement

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53
Q

List the clinical features of psoriatic arthritis

A

Psoriasis
Prolonged morning stiffness in joints lasting > 30 mins
Morning first-step foot pain
Joint/digit swelling

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54
Q

List the X ray signs of psoriatic arthritis

A

Erosion in the DIP joint
Peri-articular new bone formation
Early disease: soft tissue swelling
Late disease:
* Osteolysis leading to arthritis mutilans
* Pencil-in-cup deformity
Characteristic asymmetric sacroiliitis

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55
Q

List the management options for psoriatic arthritis

A

DMARDs
NSAIDs
Physiotherapy

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56
Q

Give the pathology in reactive arthritis

A

Sterile synovitis after exposure to certain GI/GU infections
Bacterial DNA may be discovered in the synovial tissue

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57
Q

List the common associated species in Reactive arthritis

A

Chlamydia
* C trachomatis
* C pneumoniae
Salmonella enteritidis
Campylobacter jejuni
Shigella
Yersinia

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58
Q

List the classical triad in reactive arthritis

A

Post-infectious arthritis
Non-gonococcal urethritis
Conjunctivitis

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59
Q

List the presentations in reactive arthritis

A

Fever
Peripheral arthritis - asymmetrical, oligoarticular, affects large joints of the lower limb
Conjunctivitis
Axial arthritis
Enthesitis
Dactylitis
Nail dystrophy
Skin lesions:
* Circinate balanitis:
* Painless superficial ulceration of glans penis in uncircumcised
* Raised, red, scaly lesion in circumcised
* Keratoderma blenorrhagicum - Painless, red, raised plaques and pustules on skins of the feet and hand

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60
Q

Give the first line management in reactive arthritis

A

NSAIDs
Corticosteroid - Prednisolone

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61
Q

Give the management in reactive arthritis if persisting/chronic

A

Sulfasalazine

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62
Q

In what population does Enteric arthritis occur

A

Occurs in up to 10–15% of patients who have ulcerative colitis or Crohn’s disease

Remission of ulcerative colitis/total colectomy usually leads to remission.
But arthritis can persist in well-controlled Crohn’s disease.

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63
Q

What joints does Enteric arthritis affect

A

Predominantly affects lower-limb joints, asymmetrical

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64
Q

List the first line managements in Enteric arthritis

A

NSAIDs

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65
Q

Give the managements in enteric arthritis when there is intra-articular involvement

A

TNF-a inhibitors (treat both arthritis and IBD)
* Infliximab
* Adalimumab

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66
Q

List the two main types of crystal arthritis

A

Gout and hyperuricemia
Calcium pyrophosphate dihydrate deposition arthropathy

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67
Q

What joints do gout commonly affect

A

First toe (podagra)
Foot
Ankle
Knee
Fingers
Wrist
Elbow

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68
Q

List the complications of gout

A

Joint destruction
Nephrolithiasis
Tophi
Chronic arthritis

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69
Q

List the complications of hyperuricemia

A

Cardiovascular disease
Chronic kidney disease

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70
Q

What are urates

A

metabolite of purines (adenine, guanine), ionised form of uric acid

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71
Q

List the causes of hyperuricemia

A

Impaired excretion
* Chronic renal disease
* Thiazide diuretics
* Low-dose aspirin
* Hypertension
* Alcohol, exercise, starvation (increased lactic acid production)
* Lead toxicity
* Primary hyperparathyroidism and hypothyroidism
* Glucose-6-phosphatase deficiency (interferes with renal excretion)
Increased purine turnover:
* Myeloproliferative disorders eg. polycythaemia vera
* Lymphoproliferative disorders eg. leukaemia
* Others eg. carcinoma, severe psoriasis

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72
Q

List the clinical features in gout

A

Recurrent acute monoarthritis of the first metatarsophalangeal joint (podagra)
Acute onset of severe joint pain
Swelling, effusion, warmth, erythema, tenderness of involved joints

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73
Q

List the investigations and findings in gout

A

Arthrocentesis with synovial fluid analysis
* Elevated synovial WCC
* Needle shaped monosodium urate crystals
Serum uric acid level - elevated

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74
Q

List the ultrasound signs in gout

A

Tophi
Erosion
Double contour sign

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75
Q

How is gout diagnosis confirmed

A

Arthrocentesis showing strongly negative birefringent needle-shaped crystals under polarised light

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76
Q

List the first line managements in gout

A

NSAIDs
Corticosteroids
Colchicine

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77
Q

List the second line managements in gout

A

IL-1 inhibitor
* Anakinra
* Canakinumab

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78
Q

List the long-term prevention treatments for gout

A

(Uric acid-lowering drugs)
Allopurinol
Febuxostat
Probenecid/Sulfinpyrazone
Pegloticase

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79
Q

List the colchicine side effects

A

Diarrhoea
Nausea/vomiting
Colicky abdominal pain

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80
Q

List the dietary advices in gout

A

Reduce alcohol
Reduce total calorie and cholesterol intake
Avoid purine rich food
* Offal
* Red meat
* Shellfish
* Spinach

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81
Q

What metabolic conditions are Calcium pyrophosphate deposition associated with

A

Hyperparathyroidism
Hypomagnesaemia
Haemochromatosis

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82
Q

Give the hallmark in calcium pyrophosphate deposition

A

Deposition of CPP crystals in the mid-zone of articular hyaline and fibrocartilage

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83
Q

Give the presentations of calcium pyrophosphate deposition

A

Painful and tender joints
Osteoarthritis-like involvement of joints
Involvement of joints not typically involved in osteoarthritis (shoulders, wrists, MCP) in a patient with clinical osteoarthritis suggests CPP arthritis

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84
Q

List the major contraindications to arthrocentesis

A

Bacteraemia
Active infection overlying the joint

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85
Q

Give the investigations and findings in calcium pyrophosphate deposition

A

Arthrocentesis - positively birefringent rhomboid-shaped crystals

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86
Q

List the management options for calcium pyrophosphate deposition

A

Intra-articular corticosteroids
* Triamcinolone hexacetonide
* Dexamethasone
NSAIDs
Low dose colchicine

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87
Q

Give the predominant causative organism in septic arthritis

A

S aureus

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88
Q

When should non-gonococcal septic arthritis be suspected

A

Joint disease
Chronic systemic disease (impaired host defences)
Corticosteroids/immunomodulators
Recent intra-articular injections
Skin/soft tissue infection
IVDU

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89
Q

When should gonococcal septic arthritis be suspected

A

Sexually active
Localised septic arthritis
Arthritis-dermatitis syndrome (malaise, polyarthralgias, tenosynovitis, and dermatitis)

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90
Q

When should MRSA septic arthritis be suspected

A

Recent hospitalisation
Residence in nursing home

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91
Q

When should Gram -ve septic arthritis be suspected

A

Indwelling catheters/current UTI
Recent abdominal surgery
Advanced age

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92
Q

When should anaerobic septic arthritis be suspected

A

Penetrating trauma

93
Q

When should Borrelia burgdorferi septic arthritis be suspected

A

Exposure to ticks
Lyme-endemic areas

94
Q

List the risk factors for septic arthritis

A

Pre-existing joint disease (eg. RA/osteoarthritis)
Joint prostheses
IVDU
Immunosuppressive medication
HIV
Alcohol use disorder
Diabetes
Previous intra-articular corticosteroid injection
Recent joint surgery
Presence of other infections (eg. skin infections and cutaneous ulcers)
Exposure to ticks (Lyme disease)

95
Q

List the presenting symptoms in septic arthritis

A

Hot, swollen, acutely painful joint with restriction of movement
Onset of joint pain typically 2 weeks or less

96
Q

List the investigations for septic arthritis

A

Blood culture and sensitivities
Repeat aspiration to dryness
* Pain relief
* Therapeutic in removing source of infection
* Diagnostic / monitoring

97
Q

List the antibiotics for septic arthritis

A

Staphylo/streptococci - Flucloxacillin
Gonococcal - Ceftriaxone
MRSA - Vancomycin + Ceftriaxone
Gram-ve - Ceftriaxone

98
Q

List the antibiotic options for Lyme arthritis

A

Doxycycline 21 days
Amoxicillin 21 days
Azithromycin 17 days

99
Q

List the antibodies found in Systemic Lupus Erythematosus

A

Anti-dsDNA
Anti-Ro (SS-A)
Anti-La (SS-B)
Anti-Sm
Anti-UI-RNP

100
Q

List the antibodies found in Drug-induced lupus

A

Anti-histone

101
Q

List the antibodies found in Primary Sjögren’s

A

Anti-Ro (SS-A)
Anti-La (SS-B)
Antinuclear antibodies

102
Q

List the antibodies found in Polymyositis and Dermatomyositis

A

Anti-Jo-1 (antisynthetase)

103
Q

List the antibodies found in Limited scleroderma and Diffuse cutaneous SSc

A

Limited scleroderma - Anti-centromeric
Diffuse cutaneous SSc
* Anti-topoisomerase-1
* Anti-RNA polymerase III

104
Q

Give the pathophysiology in Systemic Lupus Erythematosus

A

Loss of immune tolerance due to:
* Failure of rapid clearance of cells through apoptosis that typically prevents nuclear antigen exposure to the immune system
* Loss of mechanisms that confer immune tolerance to nuclear antigens
High-affinity IgG antibodies to dsDNA and nuclear proteins
Evidenced by presence of antinuclear antibodies

105
Q

What age group does Systemic Lupus Erythematosus commonly affect

A

Women in reproductive years

106
Q

List the clinical features in Systemic Lupus Erythematosus

A

(Normal CRP, low complement)
General
* Fever
* Depression
* Fatigue
* Weight loss
Eye - Sjogren’s
Skin
* Photosensitivity
* Butterfly rash
* Vasculitis
* Purpura
* Urticaria
Joints
* Aseptic necrosis of hip
* Arthritis in small joints
Raynaud’s phenomenon
Chest
* Pleurisy/effusion
* Restrictive lung defect
Heart
* Pericarditis
* Endocarditis
* Aortic valve lesions
Abdominal pain
Glomerulonephritis
Anemia
* Normochromic normocytic
* Coombes+ve haemolytic
Leucopenia/lymphopenia
Thrombocytopenia
Nervous system
* Fits
* Hemiplegia
* Ataxia
* Polyneuropathy
* Cranial nerve lesions
* Psychosis
* Demyelinating syndromes
Myositis

107
Q

List the causes of Drug-induced Lupus

A

Sulfasalazine
Procainamide
Isoniazid
Phenytoin
Carbamazepine

108
Q

List the managements for mild to moderate serositis/arthritis in Lupus

A

1st line: Hydroxychloroquine (antimalarials)
NSAIDs
Corticosteroids

109
Q

List the managements for severe lupus

A

Immunosuppressive agents
* Methotrexate
* Azathioprine
* Mycophenolate
* Cyclophosphamide
B-cell targeting agents
* Rituximab
* Belimumab

110
Q

List the antibodies found in antiphospholipid syndrome

A

Lupus anticoagulant
Anticardiolipin antibody
Anti-β2-glycoprotein I

111
Q

Give the diagnostic criteria for antiphospholipid syndrome

A

at least 1 of the clinical criteria of vascular thrombosis or pregnancy morbidity is present
presence of antiphospholipid antibodies on 2 or more occasions, 12 weeks apart

112
Q

What is antiphospholipid syndrome associated with

A

Arterial/venous thrombosis
Recurrent miscarriages

113
Q

Define Obstetric APS

A

Female patients with antiphospholipid antibodies and a history of pregnancy-related morbidity but no history of thrombosis

114
Q

Define Incidental APS

A

Patients with antiphospholipid antibodies but no thrombotic or related obstetric complications

115
Q

Give the managements for antiphospholipid syndrome

A

Long term anticoagulation
* Low molecular weight heparin (enoxaparin)
* Vitamin K antagonist (warfarin)

116
Q

Define Catastrophic APS

A

Multiorgan impairment due to widespread thrombosis involving 3 or more organs

117
Q

Give the management for Catastrophic APS

A

Low molecular weight heparin
Immunosuppressive therapy
* Prednisolone and plasma exchange / IV immunoglobulin
* Rituximab
* Eculizumab

118
Q

What is scleroderma characterised by

A

Functional and structural abnormalities of small blood vessels
Fibrosis of skin and internal organs
Auto-antibodies

119
Q

List the two subtypes of scleroderma

A

Limited cutaneous SSc (LcSSc)
* Less severe internal organ involvement
* Better prognosis
Diffuse cutaneous SSc (DcSSc)

120
Q

List the clinical features of scleroderma

A

Tight skin over face, small mouth, beaky nose
Telangiectasia
Thickened skin
* DcSSc - all over the body
* LcSSc - limited to hands, feet, face
Oesophageal dysmotility/stricture
Raynaud’s
Myocardial fibrosis
Lungs
* DcSSc - pulmonary fibrosis
* LcSSc - pulmonary hypertension
Scleroderma renal crisis
Intestine
* malabsorption
* hypo motility
* incontinence

121
Q

What is the most common cause of death in scleroderma

A

acute hypertensive renal crisis

122
Q

List the characteristics of scleroderma

A

Acute renal failure
Accelerated hypertension
Microangiopathic haemolytic anaemia
Histology = onion skin thickening of arterioles

123
Q

List the three groups in idiopathic inflammatory myopathies and their distinguishing features

A

Polymyositis (autoimmune) - inflamed striated muscle causing proximal muscle weakness
Dermatomyositis (autoimmune) - characteristic rash
Inclusion body myositis (autoimmune and degenerative) - slowly progressive weakness of mainly distal muscles

124
Q

Define antisynthetase syndrome

A

20~30% people with PM/DM have anti-tRNA synthetase antibodies
* anti-histidine-tRNA ligase (Jo-1)
* anti-signal recognition particle (SRP)
* anti-Mi-2

125
Q

What do people with antisynthetase syndrome more likely to develop?

A

Pulmonary interstitial fibrosis
Raynaud’s phenomenon
Arthritis
Hardening, fissuring of skin over the pulp surface of hands
Poor outcome with respiratory and esophageal muscle involvement

126
Q

List the malignancies most frequently associated with polymyositis

A

Non-hodgkin’s lymphoma
Lung cancer
Bladder cancer

127
Q

List the malignancies most frequently associated with dermatomyositis

A

Non-hodgkin’s lymphoma
Pancreatic cancer
Ovarian cancer

128
Q

List the presentations in idiopathic inflammatory myopathies

A

Increasing difficulties in performing tasks predominantly requiring proximal muscles
Fine motor tasks requiring distal muscles (sewing, knitting, writing) are affected
* Early in inclusion body myositis
* Late in polymyositis and dermatomyositis
Falling is common in inclusion body myositis
* Due to early quadriceps involvement
Weight loss, fatigue, generalised malaise

129
Q

List the extra-muscular symptoms in idiopathic inflammatory myopathies

A

Arthralgia
Dysphagia
Shortness of breath
Palpitations
Syncope
Rash
Inflammatory arthritis/Raynaud’s phenomenon
Myocardial infarction symptoms

130
Q

List the characteristic skin lesions in dermatomyositis

A

Heliotrope rash with eyelid oedema
Gottron’s papules - Erythema of knuckles with raised violaceous scaly eruption
Facial rash
Erythematous rash over the knees, elbows, malleoli, base of neck and chest
Nail fold changes eg. dilation of capillary loops of periungual area

131
Q

List the laboratory investigations and findings in idiopathic inflammatory myopathies

A

+ve myositis-specific and associated autoantibodies
Elevated creatinine kinase (most sensitive)
Elevated aldolase, myoglobin, ALT, AST, LDH

132
Q

List the EMG findings in idiopathic inflammatory myopathies

A

Spontaneous fibrillation potentials at rest
Polyphasic potentials on voluntary contraction
Repetitive potentials on mechanical stimulation of the nerve

133
Q

List the MRI findings in idiopathic inflammatory myopathies

A

Muscle inflammation / atrophy
Muscle fatty replacement

134
Q

Give the gold standard investigation in idiopathic inflammatory myopathies

A

Muscle biopsy

135
Q

List the management options for idiopathic inflammatory myopathies

A

IV corticosteroids
Long term immunosuppression
* Methotrexate
* Azathioprine
* Mycophenolate
IV immunoglobulin

136
Q

What genomic susceptibility is Sjogren’s syndrome associated with

A

HLA-B8/DR3

137
Q

List the diagnostic features in Sjogren’s syndrome

A

Positive
* Anti-Ro (SS-A)
* Anti-La (SS-B)
* Antinuclear antibodies
Decreased tear and saliva production
Lymphocytic infiltration in labial salivary gland biopsy

138
Q

List the characteristic symptoms in Sjogren’s syndrome

A

Dry eyes (keratoconjunctivitis sicca)
* Dry, itchy, burning, gritty eyes
* Redness of eyes
* Sensitivity to light and wind
Dry mouth (xerostomia)
* Dry mouth, burning, difficulty in chewing and swallowing
* Altered/decreased taste acuities
* Difficulty speaking for long periods
* Awake at night to drink
* Severe dental caries leading to teeth loss
* Increased bacterial and fungal infections
* Thicker and opaque saliva
* Enlarged and painful salivary glands

139
Q

List the extraglandular presentations in Sjogren’s syndrome

A

Fatigue
MSK - Arthritis, arthralgia, myalgia
Vasculitis - Rash (anti-Ro, anti-La)
Renal tubular acidosis
Peripheral neuropathy
Facial pain
* Glossodynia (orofacial pain/burning mouth syndrome)
* Osteonecrosis of the jaw
* Trigeminal neuralgia
Venous thromboembolism
Aortic aneurysm/dissection

140
Q

List the management options for sicca symptoms in Sjogren’s syndrome

A

Artificial tear substitutes
Ciclosporin eye drops
Cholinergic drugs (pilocarpine, cevimeline)

141
Q

List the management options for xerostomia symptoms in Sjogren’s syndrome

A

Salivary substitutes
Cholinergic drugs (pilocarpine, cevimeline)

142
Q

List the management options for MSK symptoms in Sjogren’s syndrome

A

Paracetamol
NSAIDs
Corticosteroid
Hydroxychloroquine
Methotrexate

143
Q

List the management options for Vasculitis symptoms in Sjogren’s syndrome

A

Corticosteroids
IVIG

144
Q

List the management options for Renal tubular acidosis symptoms in Sjogren’s syndrome

A

Potassium repletion and alkali

145
Q

List the management options for Neuropathy symptoms in Sjogren’s syndrome

A

IVIG

146
Q

List the common causes of a Trendelenburg gait

A

Painful hip joint problems - osteoarthritis
Weak hip abductors
* poliomyelitis
* hip replacement
Developmental hip dysplasia

147
Q

What causes winging of scapula

A

Long thoracic nerve (C5–C7) injury

148
Q

Describe Trendelenburg’s sign

A

Normally, the iliac crest on the side with the foot off the ground should rise.
The test is abnormal if the unsupported hemipelvis falls below the horizontal

149
Q

List the types of systemic vasculitis

A

Large vessels
* Giant cell arteritis
* Polymyalgia rheumatica
* Takayasu’s arteritis
Medium vessels
* Polyarteritis nodosa
* Kawasaki’s disease
Small vessels - ANCA POSITIVE
* Granulomatosis with polyangiitis
* Microscopic polyangiitis
* Eosinophilic granulomatosis with polyangiitis
Small vessels - ANCA NEGATIVE
* Anti-GBM disease
* IgA vasculitis (Henoch–Schönlein)
* Cryoglobulinemic vasculitis
* Hypocomplementemic urticarial vasculitis (HUV, anti-C1q vasculitis)
* Cutaneous leukocytoclastic vasculitis

150
Q

What age group and gender does Polymyalgia rheumatica tend to occur

A

Typically occurs in age ≥50
More common in women

151
Q

What is Polymyalgia rheumatica associated with

A

15~20% of PMR patients have giant cell arteritis (GCA).
40~60% of GCA patients have PMR.

152
Q

List the symptoms in Polymyalgia rheumatica

A

Difficulty rising from seated/prone positions
Acute onset of pain and stiffness in neck/shoulder/hip girdle, worse in the morning
Varying degrees of muscle tenderness
Shoulder/hip bursitis
Oligoarthritis

153
Q

List the investigations and findings in Polymyalgia rheumatica

A

Rapid response to corticosteroids within 24 to 72 hours
ESR/CRP Elevated
Thyroid function tests - Exclude hypothyroidism (arthralgia, stiffness)
FBC and serum protein electrophoresis - Exclude myeloproliferative disorders (fatigue, bony pain, elevated ESR)
Rheumatoid factor and anti-CCP antibodies - Exclude RA

154
Q

Give one differential diagnosis for Polymyalgia rheumatica and its distinguishing features

A

Myositis
In polymyalgia rheumatica, there is normal creatinine kinase

155
Q

List the management options in polymyalgia rheumatica

A

Low-dose corticosteroids
Short term NSAIDs
Methotrexate

156
Q

List the presentations of Giant cell arteritis

A

Age >50 yrs
New onset headache
Limb, jaw, tongue claudication
Scalp tenderness
Acute visual symptoms (amaurosis fugax)
Unexplained raised ESR/CRP
Constitutional symptoms:
* Fever
* Fatigue
* Night sweats
* Weight loss

157
Q

How is Giant cell arteritis diagnosis confirmed

A

Ultrasonography
* Non-compressible halo sign (wall thickening)
* Stenosis/Occlusion
Temporal artery biopsy - Intramural inflammation characteristic of GCA

158
Q

Give the typical demographic in Takayasu’s arteritis

A

Commonly affects women
Typically presents before <40

159
Q

Define Takayasu’s arteritis

A

Vasculitis of large vessels that particularly affects the aorta and its primary branches.

160
Q

List the typical symptoms in Takayasu’s arteritis

A

Claudication on exertion
Chest pain
Systemic symptoms:
* Fatigue
* Myalgia
* Weight loss
* Low grade fever

161
Q

List the physical signs in Takayasu’s arteritis

A

Cool extremities
Absent pulses (pulseless disease)
Differences in blood pressure >10mmHg on each arm

162
Q

List the investigations and findings in Takayasu’s arteritis

A

Elevated ESR/CRP
Normocytic anaemia
Thrombocytosis

163
Q

List the management options in Takayasu’s arteritis

A

1st line: Oral glucocorticoids
Immunosuppressants
* Methotrexate
* Leflunomide
* Azathioprine
* Mycophenolate

164
Q

What does Polyarteritis nodosa affect

A

Medium-sized vessels

165
Q

Give the characteristic pathology in Polyarteritis nodosa

A

Focal and segmental transmural necrotising inflammation with fibrinoid necrosis in medium sized vessels

166
Q

List the clinical features for polyarteritis nodosa

A

Non-specific systemic symptoms
* Fever
* Weight Loss
* Weakness
* Myalgia
MSK - Arthritis, arthralgia, myalgia, muscle weakness
Nervous system
* Mononeuritis multiplex (sensory symptoms preceding motor deficits)
* CNS involvement (stroke, seizures, encephalopathy)
Skin
* Purpura
* Nodules
* Livedo reticularis
* Ulcers
* Bullous/vesicular eruptions
* Segmental skin oedema
Abdomen
* Pain (mesenteric artery disease)
* Appendicitis/cholecystitis/pancreatitis (ischaemia/infarction)
* Renal arteries vasculitis

167
Q

What is Polyarteritis nodosa associated with

A

HBV
In 7~38.5% of patients diagnosed with PAN, HBV infection is implicated as the underlying cause

168
Q

List the investigations and findings in Polyarteritis nodosa

A

Elevated ESR/CRP
Raised fibrinogen (Acute inflammation)
FBC - Anaemia due to chronic inflammation/GI blood loss
Low complement levels
Normal/elevated creatinine kinase
Raised serum creatinine without haematuria/proteinuria (Renal ischaemia/infarction)
Abnormal LFT - HBV/ischaemic hepatitis
HBV serology - Positive in HBV-related PAN
ANCA -ve

169
Q

List the management for non-HBV-related PAN

A

Prednisolone and cyclophosphamide

170
Q

List the management for HBV-related PAN

A

Short course high-dose oral prednisolone
Antiviral therapy - Lamivudine
Plasma exchange

171
Q

List the findings in ANCA associated vasculitis

A

Renal impairment (immune complex glomerulonephritis)
Respiratory symptoms
* Dyspnoea
* Haemoptysis
* Sinusitis
Systemic symptoms
* Fatigue
* Weight loss
* Fever

172
Q

List the laboratory investigations and findings in ANCA associated vasculitis

A

Urinalysis for haematuria and proteinuria
urea and creatinine for renal impairment
Full blood count: normocytic anaemia and thrombocytosis
CRP: raised

173
Q

What may be seen on chest X ray in ANCA associated vasculitis

A

nodular, fibrotic or infiltrative lesions

174
Q

What is cANCA associated with

A

Granulomatosis with polyangiitis
Microscopic polyangiitis (40%)

175
Q

What do cANCA and pANCA target?

A

cANCA - Serine proteinase 3
pANCA - Myeloperoxidase

176
Q

What is pANCA associated with

A

Eosinophilic granulomatosis with polyangiitis
Microscopic polyangiitis
Ulcerative colitis (70%)
Primary sclerosing cholangitis (70%)
Anti-GBM disease (25%)
Crohn’s disease (20%)

177
Q

What geographical regions is Behcet’s syndrome commonly seen in

A

Commonly seen in Turkey, Israel, Mediterranean, and East Asia

178
Q

What HLA type is Behcet’s syndrome associated with

A

HLA-B51

179
Q

Give the international diagnostic criteria for Behcet’s syndrome

A

Oral ulcers + any two of:
* Genital ulcers
* Eye lesions (anterior/posterior uveitis, retinal vascular lesions)
* Skin lesions (erythema nodosum, pseudofolliculitis, papulopustular lesions)
* Positive skin pathergy test (skin needle prick injury leads to pustular formation within 24~48 hours)
* Oral ulcers (aphthous/herpetiform)

180
Q

List the management options for Behcet’s syndrome

A

Corticosteroids
* Triamcinolone topical
* Prednisolone
Immunosuppressant
* Azathioprine
* Hydroxychloroquine
Colchicine
TNF-a inhibitor (infliximab)

181
Q

Give the clinical diagnostic criteria for Fibromyalgia

A

Chronic multifocal pain for longer than 3 months
With other symptoms
* Fatigue
* Memory problems
* Sleep and mood disturbances
Normal physical examination

182
Q

What is Fibromyalgia associated with

A

(central sensitisation syndrome)
Irritable bowel syndrome
Tension headaches
Temporomandibular joint disorder
Interstitial cystitis
Vulvodynia

183
Q

List the management options for Fibromyalgia

A

Tricyclic antidepressants
* Amitriptyline
* Cyclobenzaprine
SSRI
* Duloxetine
* Milnacipran
Gabapentinoids
* Pregabalin
* Gabapentin

184
Q

List the hallmarks in Osteoporosis

A

Low bone mass
Micro-architectural deterioration of bone tissue
Enhanced bone fragility and increased fracture risk

185
Q

List the biochemical markers of bone formation

A

Bone-specific ALP (Alkaline phosphatase)
Carboxyterminal (P1CP) and aminoterminal (P1NP) pro-peptides (Type 1 collagen propeptides)
Osteocalcin

186
Q

List the biochemical markers of bone resorption

A

Serum/urine N-terminal (NTX) and C-terminal (CTX) cross-linked telopeptides

187
Q

List the risk factors for osteoporosis

A

(SHATTERED)
Steroid use
Hyperthyroidism, hypercalciuria and hyperparathyroidism
Alcohol and smoking
Thin – BMI < 18.5
Testosterone ↓ - ↑ bone turnover, hypogonadism, Turner/Klinefelter
Early menopause - premature ovarian failure
Renal/liver failure
Erosive/inflammatory bone disease – RA/myeloma
Dietary calcium ↓ or malabsorption, T1DM

188
Q

List the physical examination findings in osteoporosis

A

Low body mass index
Spinal kyphosis due to asymptomatic fracture

189
Q

Give the gold standard investigation and findings in osteoporosis

A

Dual-energy X-ray absorptiometry (DXA)
* T-score ≤−2.5 = osteoporosis
* T-score ≤−1.0 to <−2.5 = osteopenia
* T-score >−1.0 = normal BMD
* Z scores ≤−2.0 is ‘low BMD for age’

190
Q

List the laboratory investigations for Osteoporosis

A

Biomarkers of bone resorption (NTX, CTX) in conjunction with BMD
Normal serum calcium, serum phosphate, ALP and PTH

191
Q

List the non-osteoporotic causes for fragility fractures

A

Metastatic bone disease
Multiple myeloma
Osteomalacia
Paget’s disease

192
Q

Give the first line therapy in osteoporosis

A

Bisphosphonate + Calcium and vitamin D supplementation
Teriparatide

193
Q

What geographical areas are Paget’s disease of the bone most often seen in?

A

Europe, particularly N. England

194
Q

List the pathophysiology in Paget’s disease of the bone

A

Increased osteoclastic bone resorption
Followed by a compensatory increase in new bone formation
Increased local bone blood flow and fibrous tissue in adjacent bone marrow
Ultimately, formation exceeds resorption
However, the new woven bone is weaker than the normal bone. Leads deformity and leads to fracture risk.

195
Q

List the three stages in Paget’s disease of the bone

A
  1. Initial, short-lived burst of multinucleated osteoclast activity causing bone resorption.
  2. Mixed phase of both osteoclastic and osteoblastic activity.
    Increased levels of bone turnover lead to deposition of structurally abnormal bone.
  3. Chronic sclerotic phase, bone formation outweighs bone resorption.
196
Q

List the risk factors for Paget’s disease of the bone

A

Genetics
Infection by paramyxovirus
* Measles
* Respiratory syncytial virus
* Canine distemper virus

197
Q

Where does Paget’s disease of the bone most commonly affect?

A

femur

198
Q

List the presentations in Paget’s disease of the bone

A

Bone
* Pain
* Fractures
* Osteosarcoma
Bowed tibia
Skull enlargement
Arthritis
Neurological
* Nerve compression (CN2, 5, 7, 8 (deafness))
* Spinal stenosis
* Hydrocephalus (blockage of Sylvius aqueduct)
Hypercalcaemia (immobility)
High-throughput heart failure and myocardial hypertrophy

199
Q

List the X ray findings for Paget’s disease of the bone

A

First stage: lytic changes, most commonly seen in skull (osteoporosis circumscripta cranii)
Second stage: maybe occasional fractures
Late stage: osteosclerotic changes. Thickened coarse trabeculae

200
Q

List the laboratory investigations and findings in Paget’s disease of the bone

A

Elevated:
* Bone-specific ALP
* P1NP/P1CP
Serum 25-hydroxyvitamin D - Vitamin D deficiency

201
Q

List the medical management options in Paget’s disease of the bone

A

Bisphosphonates
* Zoledronic acid
* Alendronic acid
* Risedronate sodium
If contraindicated: Calcitonin-salmon

202
Q

Define Osteomalacia and Rickets

A

Osteomalacia - incomplete mineralisation of the bone matrix (osteoid) following growth plate closure in adults
Rickets - defective mineralisation of the epiphyseal growth plate cartilage in children, resulting in skeletal deformities and growth retardation

203
Q

What is the primary cause of osteomalacia

A

Vitamin D deficiency
Vitamin D deficiency → hyperparathyroidism → hypophosphatemia

204
Q

List the causes of osteomalacia

A

Acquired:
Nutritional deficiency (vitamin D, phosphates, calcium)
* Low dietary intake
* Malabsorption
* Lack of UV-B exposure
Anticonvulsants
Chronic kidney disease - metabolic bone disease
Paraneoplastic syndrome of renal phosphate wasting
Bisphosphonate toxicity

Inherited:
Vitamin D-dependent rickets
Hypophosphatasia (Inborn error of metabolism)
Hypophosphatemic rickets

Acquired/inherited
Fanconi’s syndrome
Renal tubular acidosis

205
Q

What is Hypophosphatasia characterised by

A

Subnormal activity of tissue-non-specific ALP
Associated with development of osteomalacia and severe periodontal disease

206
Q

List the risk factors for Osteomalacia

A

Increasing age
Poor dietary intake of vitamin D and calcium
Hx. limited sunlight exposure
Sunscreen use
GI malabsorption
Anticonvulsant use
Liver / renal impairment

207
Q

List the common signs for Osteomalacia

A

Proximal muscle weakness
* Difficulty rising from a sitting position
* Waddling gait
Diffuse bony pain
Bone tenderness to percussion
Pseudofractures
Skeletal deformities

208
Q

List the investigations and findings in Osteomalacia

A

Elevated ALP, PTH, FGF23
Low serum calcium, phosphate, 25-hydroxyvitamin D3

209
Q

List the X ray findings in Osteomalacia

A

Decreased bone mineralisation
Looser’s pseudofractures (characteristic) - radiolucent lines with sclerotic borders running perpendicular to the cortex, most commonly in the femur and pelvis

210
Q

List the managements for osteomalacia

A

Vitamin D
* Ergocalciferol
* Cholecalciferol
Calcium
* Calcium carbonate
* Calcium citrate

211
Q

When should acute osteomyelitis be suspected

A

Unwell child with a limp or in an immunocompromised patient

212
Q

When should chronic osteomyelitis be suspected

A

Patient with Hx. open fracture, orthopaedic surgery, discharging sinus

213
Q

What is osteomyelitis most commonly caused by

A

Staphylococcus aureus

214
Q

List the common organisms implicated in acute osteomyelitis

A

S aureus
Streptococci
Enterobacteriaceae
Anaerobic bacteria

215
Q

When should native vertebral osteomyelitis be suspected

A

New onset neck pain and systemic symptoms

216
Q

List the common organisms implicated in osteomyelitis by age

A

Infants
* S aureus
* Group B streptococci
* Aerobic gram-negative bacilli (Escherichia coli)
* Candida albicans
Children 3 months up to 5 years:
* S aureus
* Kingella kingae
* Group A streptococcus (S pyogenes)
* Streptococcus pneumoniae
* Haemophilus influenzae (unimmunised)
* Pseudomonas (foot puncture wounds)
Children >5 years:
* S aureus
* Group A streptococcus (S pyogenes)
Adults:
* S aureus
* Coagulase-negative staphylococci
* Aerobic gram-negative bacteria
* Peptostreptococcus species
Older adults - Gram-negative bacilli

217
Q

List the common organisms implicated in osteomyelitis in patients with intravascular devices

A

S aureus
Candida species

218
Q

List the common organisms implicated in osteomyelitis in patients who misuse intravenous drugs

A

S aureus
Pseudomonas aeruginosa

219
Q

List the common organisms implicated in osteomyelitis in patients with sickle cell disease/from developing countries

A

Salmonella species
S aureus

220
Q

List the suggestive features of native vertebral osteomyelitis

A

New/worsening neck/back pain AND
* Fever
* Elevated ESR/CRP
* Bloodstream infection / infective endocarditis

221
Q

List the risk factors for native vertebral osteomyelitis

A

Elderly
Immunocompromised
Active IVDU
Have indwelling central catheters
Have undergone recent instrumentation

222
Q

List the symptoms suggestive of acute osteomyelitis

A

Limb deformity
Limping/reluctance to bear weight in children
Fever
Bone pain
Local erythema and swelling
Reduced range of movement
Sinus/wound drainage
Recent incidental trauma
Malaise and fatigue
Infections (skin/ urinary tract)

223
Q

List the symptoms suggestive of chronic osteomyelitis

A

Vague, non-specific bone pain
Low grade fever 1~3 months
Wound/sinus tract drainage
Lethargy and malaise

224
Q

Give the gold standard investigation for osteomyelitis

A

Microbiology samples (blood culture/bone biopsy) prior to commencing antibiotics

225
Q

Give the empirical antibiotics for acute osteomyelitis

A

IV flucloxacillin
* Penicillin allergy: IV vancomycin

226
Q

Give the typical population in Osteosarcoma

A

Peak incidence between 13 and 16 years of age.
More common in males than females.

227
Q

List the risk factors for Paget’s disease of the bone

A

Paget’s disease of the bone
Hx. radiotherapy
Chemotherapy
Bone conditions
* Fibrous dysplasia
* Bone infarct
* Chronic osteomyelitis
* Prosthetic implants
Inherited conditions
* Familial retinoblastoma syndrome
* Li-Fraumeni syndrome
* Rothmund-Thomson syndrome

228
Q

List the symptoms in Osteosarcoma

A

Pain
Swelling
Limping
Limited range of motion
Pathological fractures
* Common in purely lytic tumours (telangiectatic osteosarcoma)

229
Q

Give the first-line diagnostic test and findings in osteosarcoma

A

Radiolucent lesion
Areas of mottled radiodensity and ill-defined margins
Neoplasm is usually located in the metaphysis of a long bone
Codman’s triangle - reactive new bone formation under the periosteum

230
Q

Give the definitive diagnostic test in osteosarcoma

A

Core needle / open biopsy

231
Q

List the causes for True vs Functional Leg Length Discrepancy

A

True
* Idiopathic developmental abnormalities
* Fracture
* Trauma to the epiphyseal endplate prior to skeletal maturity
* Degenerative disorders
* Legg-Calvé-Perthes Disease
* Malignancy
* Infections
Functional
* Shortening of soft tissues
* Joint contractures
* Ligamentous laxity
* Axial malalignments
* Foot biomechanics

232
Q
A

Medicine (8 decks)

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