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MSK Flashcards

1
Q

Define Osteoarthiritis

A

Non inflammatory degenerative arthiritis resulting in loss of perarticular cartilage

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2
Q

Osteoarthiritis epidemiology
- Affects who?
-Primary
Secondary

A
  • Most common arthiritis WW
  • Affects >60 y/o
  • Primary - Generalised
  • Secondary - joint disease, heamochromatosis and obesity
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3
Q

Osteoarthiritis RF

A 
Age 
Female 
Genetics 
obesity 
fracture through joint 
occupation - farming (hip) football (knees)
pre existing joint damage
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4
Q

Osteoarthirtis patho

A
  • Imbalance or damage and repair process
    cartilage undergoes erosion
  • disordered attempt at repair by chondrocytes
    Exposed bone becomes sclerotic
    -Increased vascularity and subchondral cyst formation
  • exposed bone grows outwards and forms osteophytes
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5
Q

Osteoarthiritis CP
symptoms

signs

A 
sx -
- Morning stiffnes <30mins
- Pain (ache)
  exaccerbated by movement
  pain at rest in severe OA
- reduced functionality
-Stiffness after rest 
signs -
- Crepitus 
-Herbeden nodes
-Bouchard nodes 
-joint deformity 
-muscle wasting 
limited joint movement
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6
Q

OA common joints affected

A 
PIP
DIP
MCP
Metatarsalphalangeal joints 
hips 
knees 
vertebrae
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7
Q

OA investigations

A 
X-ray 
L - loss of joint space 
O - Osteophytes 
S - Subchondral sclerosis
S -Sucbchondral cysts

FBC - CRP slightly elevated

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8
Q

Dx OA

A

activity related joint pain
<30 mins morning stiffness
X-ray

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9
Q

Tx OA
core
non pharm
pharm

A

core -

  • excercise - increase locaal muscle strength
  • Loose weight if obese
Non pharm - 
- acupuncture - knee
- joint support 
footwear w/ shock absorbing properties 
-Stretching 
-physio

Pharm -
1. paracetmaol + topical NSAIDs
If inneffective add Oral NSAIDs and PPI

  1. Codeine
  2. Intra- articular steroid injection
    temp pain relief in severe sx
  3. surgery
    joint replacement
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10
Q

DD and complications OA

A

comp - reduced mobility

DD -
R.A
Psoriatic arthiritis

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11
Q

Define R.A

A

Chronic systemic AI inflammatory disorder resulting in symmetrical polyarthritis

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12
Q

R.A epidemiology

  • gender
  • peak onset
  • associations
A

F>M
50-60 y/o
HLA-DR1/4 assosciations - with severity

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13
Q

R.A Aetiolgy

A
  • Family hx
  • Gender - increase incidence in premenopausal women
  • HLA-DR4 and HLA-DRB1 confers suceptibilty to R.A
  • smoking
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14
Q

R.A patho

A

-infliltration of synovium ny IC –> synovitis
-angiogenic cytokines result in new synovial blood vessel formation
-synovium proliferates and grows over surface of bone producing pannus
-pannus destroys cartilage and bone
cartilage thins leading to bony erosions and lesions

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15
Q

R.A CP
sx

signs

A

sx -

  • Painful joints - multiple
  • Morning stifness >30mins
  • symetrical swelling
  • Pain eases with use

signs

  • ulnar deviation
  • boutonniere defromity
  • swan neck deformity
  • z shaped thumb defromity
  • joints - warm, tender, swollen
  • muscle wasting
  • joint sublaxation
  • rheumatoid nodules
  • carpal tunnel syndrome
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16
Q

R.A extra articular manifestations

A

lung

  • interstital lung fibrosis
  • pleural effusions

cardio

  • IHD (increased risk of atheroma formation)
  • pericarditis
  • pericardial effusions

skin

  • rhematoid nodules
  • Raynauds
  • Carpal tunnel

eyes

  • scleritis
  • sjrogens syndorme

systemic:
fever
fatigue
weight loss

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17
Q

R.A common joints

A
  • MCP
  • PIP
  • MTP
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18
Q

R.A Investigations

A

investigations
- Rheumatoid Factor –> not specific

-Anti- cyclic citrullinated peptide (Anti - CCP)
very specific
marker of disease
+ve–> worse prognosis

-FBC - normocytic anaemia
thrombocytosis
raised CRP+ESR

-X-ray 
L - Loss of joint space 
E - peri-articular erosions 
S - soft tissue sewlling 
S- soft bones - osteopenia
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19
Q

R.A tx

A

smoking cessation - decrease c.v risk
physiotherapy
excercise
disease activity monitered by DAS28

1 . NSAIDs - relieve joint pain and stiffness
- Paracetamol and codeine - additional pain relief

  1. corticosteroids
    useful for acute flares
    suppress disease activity but large doses required–> toxicity
    - IM methylprednisolone
    depot for those waiting for DMARDs - contols severe flares
  2. DMARDs
    - inhibit inflamm cytokines so reduce disease progression and joint errosion
    INFECTION RISK
    - early use impoves long term outcomes (started within 3m of persistent sx)
    -6 weeks before effects
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20
Q

DMARDs name and S/E

A 
Methotrexate 
CI - Pregnancy 
S/E - mouth ulcers 
         tetarogenic 
         Diarrhoea 
         renal impairment 
Sulfasalazine - modertae disease
used in young women 
S/E: nausea 
        rash 
        mouth ulcers 
        GI upset 
        male infertility 
Leflunomide 
blocks t cell proliferation 
s/e: tetarogenic 
       oral ulcers 
       heaptotoxicity

TNF-aplha inhibitors –> Infliximab
etanercept
adalimumab

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21
Q

O.P defintion

A

systemic skeletal disease charecterised by low bone mass leading to bone fragility and increase fracture risk

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22
Q

O.P primary and secondary

A
  1. age related and menopause

2. Drugs and another condition

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23
Q

What is PBM determined by

A

genetics
nutrition
physical activity
hormones

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24
Q

O.P risk factors and aetiology

A 
Un-tx menopause 
Immobility 
Alcohol 
Inflammatory disease 
Cushings 
DM 
drugs - heparin 
smoking 
S - Steroids 
H - Hyperparathyroid/Thyroid 
A - Alcohol
T - Thin (low BMI)
T - Testosterone low 
E - Early menopause 
R - Renal/Liver failure 
E - erosice bone disease - R.A
D - Dietary low calcium
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25
O.P Patho
- Inadequate PBM reached - Increased resorption - Decreased formation
26
PBM influences patho - genetics - inflammatory disease - thyroid disease - cushings - post menopausal - ageing
- genetics - Higher PBM in africans - Inflammatory cytokines increase bone resorption - Increased PTH and TH increase bone turnover - High cortisol increases bone resorption and induces osteoblast apoptosis - Loss of oestrogen leads to high bone turnover microarchitectural disruption mainly trabecular bone loss - Naturally loss in bone dcrease in trabecular thickness preferential horizontal trabeculae boe loss leading to decrease bone strength
27
CP of O.P
``` asymptomatic until fracture - Vertebral fractrures Loss of height kyphosis - stooping posture back pain ``` - Colles' fracture fall on outstretched hand - Proximal femur fracture
28
Assesment of fracrture risk
- FRAX tool possibility of a fracture in the nect 10 years only for pts> 40 y/o
29
OP investgations
- Xray Detects fractures but not sensitive for osteopenia ``` -DEXA Assess bone densitometry low radiation dose T score - S.D score of young adult mean of same gender T score < -2.5 diagnostic ``` - Consider tests for secondary causes
30
OP managment
``` lifestyle: quit smoking and alcohol weight bearing excercise balance excercises fall prevention programme calcium and vit D rich diet ``` Pharma: 1. Bisphosphonates - Alendronic acid - Inhibit osteoclastic activity by inducing apoptosis 2. Different bisphosphonate - Risedronate 3. Strontium ranelate 4. Denosumab - MAB to RANKL - increase BMD - decrease fracture risk 5. Teripartide Increase bone density improves trabecular structure
31
Crystal Arthiritis
Gout - monosodium urate crystals Needle shaped urate crystals NEGATIVE bifringement Pseudogout - calcium pyrophosphate Small rhomboid shaped pyrophosphate crystals POSITIVE bifringement Neutrophils ingest crystals and innitiate pro-inflamm reaction
32
Gout definition + epidemiology
Inflammatory arthiritis due to deposition of monosodium urate - Acute monoarthropathy - PODAGRA
33
Gout aetiology
high purine foods - shellfish - red meat - alcohol * Increased urate production - Myeloproliferative - PCRV - Lymphoproliferative - Leukemia - Psoriasis - cytotoxic drugs * Decreased urate excretion - impaired renal function - HTN - diuretics - asprin
34
Gout patho and serum conc
``` Increased purines intake (diet, renal, drugs) - Xanthase oxidase converts to uric acid -Hyperuricaemia - Monosodium urate crystal deposition -phagocyte activation - Gouty attack - acute inflamm and pain ``` serum conc > 0.42mmol/L
35
Percipitants of an attack
``` trauma surgery diuretics dehydration sepsis infections alcohol ```
36
C.P of gout
``` Acute - pain - red - tender - swollen MTP joint --> PODAGRA ``` Chronic polyarticular gout (elderly women on LT diuretics) Chronic tophaceous gout Tophi - white smooth deposits onion aggregates of crystals w/ inflamm cells Bone erosions on x-ray -increases proteolytic enzymes Urate renal stone formation - reccurent gouty attacks
37
Investigations and DD
ASPIRATION - polarised light microscopy gout - negative bifringement pseudo - positive bifringement - X-ray bone erosions - punched out ST swelling - raised serum uric acid low during attacks ASPIRATE --> Septic arthiritis in monoarthropathy
38
Tx Gout
Acute - Anti-inflamm - High dose NSAIDs ``` -COLCHICINE Give if NSAIDs CI targets uric acid crystallisation toxic in overdose S/E - diarrhoea, abdo pain ``` - Corticosteroids IM- depot methylprednisolone - Rest, elevate, ice packs
39
Gout prevention - Lifestyle - Pharma
``` Lifestyle: -loose weight -decrease purine rich food -avoid low dose asprin -avoid excess alcohol stop diuretics --> ARB ``` ``` Prophylaxis: ALLOPURINOL - inhibits xanthine oxidase decrease uric acid so decreased crystals WAIT 3 WEEKS - can induce attack S/E- rash, fever, decrease WCC ``` Febuxosat - Non purine xanthine oxidase inhibitor If allopurinol CI URICOSURIC drugs - increased urate excretion
40
Pseudo-gout definition and distribution
Deposition of calcium pyrophosphate on joint surface and in articular cartilage crystals elicit and inflammatory response Distribution: MCP, Ankles, Wrist, Knees
41
Patho of P-gout
Deposition of calcium pytophosphate crystals in AC and periarticular tissue leads to chondracalcinosis radiologically - A trigger leads to shedding of crystals into joint producing acute synovitis
42
Presentation of P-gout
``` Acute attack: -Acute synovitis Painful, red,hot,swollen joint stiffness - Fever - Large joints ```
43
Triggers
Joint injury intercurrent illness surgery - parathyroidectomy spontaneous
44
Risk factors for P-gout
``` Old age haemochromatosis hyperparathyroidism hypophosphataemia wilsons' disease ```
45
P-gout investigations
Aspiration - R/O septic arthiritis - MIcroscopy--> RHOMBOID crystals POSITIVE bifringement X-ray - Chondracalcinosis linear calcification parallel to articular surface Bloods: Raised CRP
46
Management of P-gout
acute attack: - NSAIDs - Colchicine - Aspiration - physio - Intra-articular steroid injections Long term/chronic: - Trial - anti rheumatic drugs Methotrexate Sulfasalazine
47
Describe spondyloarthropathies - seronegative - features - Blood - MSK - Extra
Group of related chronic inflammatory conditions tend to affect axial sekleton common features: 1. HLA-B27 Associaton 2. Rhematoid factor negative 3. Dactylitis 4. Enthesitis inflamm at site of tendon/ligament insertion 5.Asymetrical large joint oligoarthiritis 6. extra articular: oral ulcers IBD Aortic valve incompetance
48
Ankolysing spondylitis definition and epidemiology
Chronic inflammatory disorder of the spine and sacro-iliac joints More common in MEN - Late teens
49
CP ankolysing spondylitis Typical presentation sx signs
``` typical: Man - lower back pain + stiffness - Pain + stiffness worse with rest and improves with movement - pain worse at night + morning (Can wake pt from sleep) - >30 mins for morning stiffness to ease ``` sx: - Weight loss - fever - fatigue - pain in buttock region - neck/back stiffness - loss of spine movement signs: - Increased kyphosis - Limitation of lumbar spine mobility --> Schober test - Loss of lumbar lordosis - decreased thoracic expansion - Posture- fixed hip flexion with compensatory kneee flexion
50
Ankylosing spondylitis investigations
1. X-ray: - Sacroilitis - Enthesitis - Dagger sign - Advanced stage: Syndesmophytes MRI - Bone marrow oedema more sensitive than X-ray as it shows early changes FBC - Normocytic anaemia - raised ESR/CRP
51
Tx ankylosing.S
Early diagnosis to prevent syndesmophyte formation and progressive calcification 1. Excercise + physio - In the mornings to maintain posture and mobility 2. NSAIDs - Relieve night pain and morning stiffness 3. TNF-alpha inhibitors - INFLIXIMAB - ETANERCEPT prevent syndesmophyte formation 4. Local steroid injections - temp relief 5. surgery - correct spinal deformities 6. Possible hip replacement NO response to DMARDs
52
Complications of Ankylosing.S
- Anaemia - Aortitis - Anterior uveitis - Heart block - Pulmonary fibrosis - IBD - Chest pain
53
Ankylosing.S patho
- excessive Enthesitis and erosive repair phase leads to Syndesmophytes formation - Fusion of syndesmophytes (Ankylosis) - Flexion and rotation prevented - End stage: Bamboo spine
54
Psoriatic Arthiritis | - Defenition
Chronic progressive inflammatory arthiritis assosciated with psoriasis - Seronegative spondyloarthropathy
55
Psoriatic arthiritis patterns
- Symmetrical polyarthirits Hands/Wrists/Ankles/DIP MCP joints less common unlike R.A - Arthritis mutulans Severe form: Osteolysis of bones in phalanxes --> Telescopic finger
56
Psoriatic.A Signs
- Psoriatic plaques - Oligoarthiritis - Dactylitis - Enthesitis Nail: - Hyperkeratosis - Pitting of the nails - Onycholysis DIPJ affected
57
Psoriatic. A Assosciations
Conjunctivitis Anterior Uveitis Aortitis Amyloidosis
58
Psoriatic.A investigations
X-ray: - Pencil in cup deformity (Central erosions) - Dactylitis --> S.T swelling - Osteolysis - Periostitis - Ankylosis Nail changes: - Distrophic - Hyperkeratinosis - Pits - Onicholysis Bloods: - RF -ve
59
Psoriatic.A Management
1. NSAIDs 2. Intra-articular corticosteroids injections 3. DMARDs Methotrexate/Sulfasalazine 4. Anti-TNF meds - Etanercept 5. USTEKINUMAB - Interleukin 12/23
60
Reactive.A Defenition + Causes
- Sterile synovitis due to AI response to infection by: GI: - Shigella/Salmonella/Campylobacter - STI: Chlamydia trachomatis
61
Reactive.A patho
Persistent bacterial Ag in inflammed synovium drives inflamm process HLA-B27 +ve - Increase susceptibilty to R.Arthiritis
62
Reactive.A CP
- Acute monoarthiritis - Lower limb - Knees/Ankles - Warm/swollen/Painful joint Can-t see, pee, or climb a tree - Bilateral conjunctivitis - Arthiritis - Urethritis
63
Reactive.A Investigations
- Bloods - Raised ESR/CRP - Aspiration Sterile joint aspirate - Raised neutrophils - STI Screen - X-Ray Enthesitis
64
Reactive.A tx
1. Exclude Septic arthiritis - Abx - Joint aspiration staining + culture/sensitivity 2. NSAIDs 3. Local steroid injections 4. Multiple joints affected --> Systemic steroids 4. Sx>6m --> DMARDs *Rest + Splint joints
65
Septic Arthiritis definition
Joint inflammation due to bacterial infection leads to irrversible joint damage within 24hrs - Acute,Red,Hot,Swollen joint
66
Septic arthiritis causes
``` Direct Injury/Blood bourne - S.Aureus - N.Gonorrhoeae Young pts - Sexually active - S.Epidemidis Joint replacement - E.Coli /Klebsiella Elderly/Immunocompromised -Haemophilus influenzae Children ```
67
Septic Arthiritis RF
``` Pre- exisitng joint damage Penetrating trauma DM Skin breaks/Ulcers - DM Intra-articular steroid injection Joint surgery ```
68
Septic Arthiritis CP
- Acute,Red,Hot,Swollen,Painful - Decrease ROM - Fever - Monoarthritis --> Knee Early: Joint effusion Loss of function Pain Late: Pain Mechanical dysfunction
69
Septic arthritis Investigations
Joint aspiration - BEFORE ABX - MC&S - Polarised light microspcopy Bloods - FBC - Elevated CRP + ESR - Blood culture - Before Abx - Neutophilia Swab - If suspected gonoccocal infection
70
Septic Arthiritis Tx
1. Broad spectrum Abx Flucloxacillin Allergic --> Clindamycin If Immunocompromised --> Gentamicin (covers gram -ve) MC&S --> Specific Abx IV = 2 wks PO = 2-4wks 2. Immobolisation - Physio to prevent muscle wasting + stifness 3. Joint damage - Needle aspiration 4. NSAIDs - Ibuprofen --> Pain relief
71
What must you stop when treating septic arthiritis
Stop immnosuppresion - DMARDs + Anti-TNF Chronic long term steroids --> Double dose
72
Osteomyelitis | -Defenition (Acute + Chronic)
Bone marrow inflammation Acute - Inflammatory bone changes due to pathogenic bacteria Sx 2wks after infection onset Chronic - Charecterised by bone necrosis Sx 6wks after infection
73
Osteomyelitis Mechanism of infection
``` 1. Direct inoculation Trauma/Surgery 2.Haematogenous seeding Children - long bones Adults - Vertebrae 3.Contiguous spread Spread from adjacent tissue DM/Chronic ulcers/PVD ```
74
Osteomyelitits RF for bacteremia
central lines dialysis catheter recurrent UTI
75
Osteomyelitis host susceptibility factors
Immunosuppressed DM Prosthetic material Trauma
76
Osteomyelitis causes
S.Aureus Salmonella - SSA E.Coli Haemophilius influenzae
77
Osteomyelitis Patho
- Inflammatrory exudate in BM - Increases Intramedullary pressure - Extension
78
Osteomyelitis differential diagnosis
``` Cellulitis Gout Fracture Malignancy Charcot joint - DM ```
79
Osteomyelitits CP
- Fever - Dull localised bone pain - Pain worse on movement - Tenderness - Erythema - Sweats - Malaise - Chronic --> Draining sinus tract + Deep ulcers
80
Osteomyelitis | Acute + Chronic changes
Acute - Inflamm cells --> Oedema Vascular congestion Small vessel thrombosis ``` Chronic - Neutrophil exudates Sequestra Involucrum Lymphocytes ```
81
Osteomyelitis Investigations
``` Bloods: WCC + CRP/ESR Imaging 1st line - X-ray 2nd line - MRI more sensitive BM oedema + ST inflamm ``` *DIAGNOSTIC Bone biopsy + culture Blood culture --> Organism + sensitivities
82
Osteomyelitis tx
Immobilisation Surgical drainage of abscess Surgical debridement Abx - Flucloxacillin -Guided by ESR/CRP monitoring
83
SLE Defenition
Systemic AI chronic inflammatory CT disease | - Charecterised by serum Anti-nuclear ab and Anti dsDNA Ab
84
SLE Epidemiology
Female- child bearing age 20-40y/o Afro-carribeans Asians
85
SLE aetiology genetic environmental
AI Condition *Genetic HLA DR2/3 Family hx ``` *Environmental UV radiation EBV Exposure Penicillamine Isoniazid Hydralazine ```
86
SLE Patho
Type 3 Hypersensitivity - environmental trigger leads to cell apoptosis and release of nuclear Ag - Anti nuclear Ab produced by B cells - Ab-Ag complex formed - immune complex deposition - complement activation --> cell lysis - Inflammation - neutophil influx + abnormal cytokines leads to SLE sx
87
SLE CP | sx
Non specific sx - Fatigue - fever - malaise - myalgia - arthralgia - weight loss - S.O.B - Hair loss Relapsing and remitting pattern
88
``` SLE signs skin joints GI Kidney CNS CV Lung ```
``` *Skin Erythema rash Photosensitive rash discoid rash -can scar Alopecia Vaculitis lesions - fingertips Raynauds Lymhadenopathy ``` * Joints Non erosive arthiritis small joint arthralgia - symetrical * Kidney Glomerulonephritis *GI mouth ulcers *CNS Seizures depression *CV Increased IHD/stroke risk pericarditis pericardial effusions *Lungs Pleural effusions ``` *Bloods Anaemia - CD/Haemolytic thrombocytopenia leucopenia secondary vasculitis ```
89
SLE Investigations
- Auto Ab 1. Screen with - Anti-nuclear Ab V sensitive but not specific 2. Anti- dsDNA Ab Specific but not sensitive *Anti - smith Ab - Complement reduced C3 and C4 - FBR (HIGH ESR + normal CRP) - Anaemia - Renal biopsy
90
SLE dx criteria
4/11 --> MD SOAP BRAIN M - Malar rash D - Discoid rash S - Serositis O - Oral ulcers A - Arthralgia/ arthiritis P - Photosensitvity ``` B - Blood - Pancytopenia R - Renal disorder A - ANA +VE I - Immunological - Anti-dsDNA N - Neurological - seizures ```
91
Which Ab in SLE are assosciated with increased thromboembolism risk
- Antiphospholipid Ab
92
SLE complications
*CVD Chronic inflammation in BV leads to HTN and CAD * Infection * Anaemia * Peicarditis * Interstitial lung disease * Glomerulonephritis * Pulmonary fibrosis * Recurrent miscarraiges
93
SLE general management
- Avoid triggers --> UV radiaiton - High factor sun screen - Decrease CVD RF
94
SLE Tx | 1st line
1. Analgesia - NSAIDs 2. Steroids - prednisolone 3. Hydroxycholroquine
95
SLE tx | - severe/resistant
Methotrexate Rituximab - CD20 Severe flare ups IV cyclophosphamide + High dose prednisolone
96
SLE DD
``` Antiphospholipid syndrome Sjrogren syndrome Undifferentiated CT disease Scleroderma R.A Polymyositis ```
97
SLE inflamm markers detection
High ESR but CRP remains normal
98
Reasons for false positive ESR results
Age Female Obesity Anaemia
99
R.A diagnostic criteria
4/7 required - Morning stiffness - Arthiritis >3 or more joints - Arthiritis of hands - Symmetrical - Rheumatoid nodules - Rheumatoid factor +ve - Radiographic changes
100
Osteoperosis Primary prevention
- Adcal D3 - Vit D + calcium - Calcum rich diet - HRT (Pre-menopausal) - Corticosteroids - Regular weight bearing excercise - Smoking - Alcohol
101
What is Anti - phospholipid syndrome
AI syndrome charecterised by thrombosis, recurrent miscarraiges and positive blood tests for ApL Ab - Primary - Secondary to SLE
102
Anti - phospholipid syndrome pathophysiology
Ab bind to phospholipids on surface of cells - Binding alters function - Thrombosis
103
Anti phospholipid syndrome causes and increased risk of
``` CLOTS!! C- coagulation defects (DVT/Stroke) L - Livedo Reticularis purple skin discoulouration O - Obstetric Recurrent miscarraiges T - Thrombocytopenia ```
104
APS investigations
- Anti Cardiolipin Ab - Lupus Antigoagulant - Anti - B2 - glycoprotein I
105
APS tx
Manage CVS risk factors - HTN - Smoking - Diet Previous thrombosis - Long Term warfarin - LMWH (If trying to concieve) Prophylaxis - Asprin
106
What is Raynauds syndrome
Intermittent spasm in arteries supplying fingers and toes precipitated by cold or emotion - Relieved by heat
107
Diseases leading to Raynauds phenomenon
``` SLE RA dermatomyositis Polymyositis Systemic sclerosis ```
108
Examples of when raynauds phenomenon is exhibited
- Vibrating tools - Thrombocytosis - Beta blockers - Hypothyroidism - Atheroma
109
Raynauds syndrome clinical presentation
- Numbness - Tingly - Pain - Ischaemia White fingers - Tissue hypoxia Blue fingers - Reactive hyperaemia Red fingers
110
Raynauds tx
Stop smoking Keep warm CCB - Nifedipine
111
What is Systemic sclerosis/ Scleroderma
Multisystem AI diseasewith skin involvement and raynauds phenomenon
112
Scleroderma features
Scleroderma - skin fibrosis Internal organ fibrosis Microvascular abnormalities
113
What is limited scleroderma
CREST syndrome | - Limited cutaneous scleroderma
114
What is CREST syndrome - Features - Acronym - Late stage complications
- Hands/feet/ face - Beak like nose - Microstomia - Anti-centromere Ab ``` C - Calcinosis R - Raynauds E - Oesophageal dysmotiliy Reflux S - Sclerodactyly Skin tightening on toes and fingers T - Telenagiectasia B.V dilation os skin ``` Late stage complication: Pulmonary HTN
115
Diffuse cutaneous scleroderma - GI - Kidney - Lungs - Cardio
All skin + organ involvement - Dysphagia - Dyspepsia - Malabsorption - Pseudo - obstruction - Kidney disease (AKI/CKD) - Pulmonary fibrosis - Pulmonary HTN - Myocardial fibrosis
116
Systemic sclerosis investigations
Serum Ab Limted --> Anti-Nuclear AB Diffuse --> Anti - Topoisomerase Ab (Anti - Scl 70) Anti - RO Ab X-ray: - Ca2+ deposition Barium swallow: Oesophageal dysmotility
117
What is Sjrogren syndrome
Chronic AI inflammatory disease | - AI destruction of exocrine glands
118
What is primary sjrogren syndrome
SICCA syndrome | - Primary fibrosis of exocrine glands
119
Causes of secondary sjrogren syndrome
SLE RA Scleroderma PBC
120
Sjrogren syndrome presentation - glands - systemic
SICCA COMPLEX: Dry eyes + dry mouth - Keratoconjunctivitis - Xerostomia - Parotid gland swelling - Vaginal dryness - Dysphagia - Dry cough Systemic: - Arthiritis - Raynauds - Diabetes insipidus - Vasculitis - Pulmonary fibrosis
121
Sjrogren syndrome investigations
Schirmer's test - Measures conjunctival dryness Serum Ab: - Anti-nuclear Ab - Anti Ro Ab
122
Sjrogren syndrome tx
- Artificial tears - Saliva replacement solutions - NSAIDs (Arthralgia)
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What is Polymyositis and Dermatomyositis
Progressive symmetrical proximal muscle weakess due to Striated muscle inflammation Dermatomyositis + Skin involement
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Polymyositis presentation
Symmetrical muscle weakeness and wasting - Shoulder - Pelvic gridle ``` STAIRS, CHAIRS, HAIRS - Pts have difficulty: Squatting climbing stairs rising from chairs hands above head ```
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Dermatomyositis presentation
- Raynauds phenomenon - Helitrope (Macular rash) Purple eyelid rash - Gottrons papules scaly, erythromatous plaques over knuckles
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Polymyositis/Dermatomyositis investigations
Muscle Biopsy = DIAGNOSTIC - muscle fibre necrosis - inflamm cell infiltration Muscle enzymes elevated: - Creatnine kinase - AST - ALT - LDH ESR not raised Malignancy screen
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Polymyositis/ Dermatomyositis tx
1. Prednisolone - slowly taper down 2. Immuno suppressive therapy - Azathioprine - Methotrexate Disease relapse when tapering down steroids 3. Skin issues: - Topical Tacrolimus
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Name 3 primary bone tumours
Osteosarcoma EWing sarcoma Chondrosarcoma
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Causes of secondary metastases to the bone + apperance on X -ray
``` Breast Prostate Kidney Thyroid Lung ``` Osteolytic
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Describe the 2 different forms for zone of transition
Wide - ill defined - Malignancy Narrow - well defined
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Name 3 periosteal reactions
Codmans triangle Onion skinning Sunburst spicules
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Bone tumours presentation
- Bone pain - nocturnal - Local red swelling - Unexplained fractures - Constant non mechanical pain - Fatigue - Weight loss - Anaemia - Night sweats
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Bone tumours investigation
X-ray MRI Bone biopsy Skeletal isotope scan - bony mets appear as hotspots before radiological chnages
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Bone tumours tx
- Analgesia - Anti inflammatory drugs - Chemotherapy - Radiotherapy - Bisphosphonates * chemo + radio - useful in Ewings - not useful in condrosarcoma
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Grading for primary bone tumours
Enneking system
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Grading for metastatic bone tumours
Mirels Score > 8 indicates benefit of prophlactic nailing
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Osteosarcoma - Association - Location - Xray findings
- Pagets disease - Knee Proximal humerus - Bone destruction Bone formation Sunburst spicules Codmans triangle
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Ewings sarcoma - Genetic mutation - location - Xray
- t( 11 ; 22 ) - Diapheseal lesions Femur Pelvis Distal tibia - Codmans triangle Onion like apperance
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Chondrosarcoma - what is it - location - Xray
- Malignancy of cartilage - Pelvis Proximal femur Proximal humerus - Patchy lytic lesions
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What is fibromyalgia
chronic widespread MSK pain syndrome with no underlying cause - strong yellow flag influence
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Yellow flag - defenition - features
Psychological risk factors for chronic pain + long term disability development ``` - Belief that pain and activity are harmful - Social withdrawl - Low mood - Anxiety - Dissatisfaction at work - Lack of support ```
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Fibromyalgia presentation
``` - Widespread pain L. epicondyle G trochnater Mid trapezius Shoulder ``` - Fatigue - Easily woken + unable to fall back asleep - Fatigue + pain (with small increases in physical exertion) - Tender points - Poor memory - Low mood -Parasthesiae - Headache (Tension + Migrane)
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Mechanical back pain presentation
- sudden onset - pain worse in evening - morning stiffness - excercise increases pain
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Mechanical back pain causes
- stop and twist when lifting - heavy manual handling - fractures - spinal stenosis - lumbar disc prolapse - whole body vibration
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Osteomalacia
inadequate bone mineralisation of osteoid frameworks leading to soft bones
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What are the 2 forms of soft bones that can occur
Rickets - Epiphseal growth plates not closed Osteomalacia - Epiphseal growth plates closed
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Osteomalacia risk factors
``` Pigmented skin sunscreen old age instiutionalisation Malabsorption - coeliac - crohns renal disease liver disease phenytoin ```
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Giant cell arteritis presentation
Temporal branch - severe headaches Opthalmic branch - visual disturbances - blindness Facial artery - Claudication when chewing Scalp tenderness - when combing hair fever weight loss dyspnoea morning stiffness
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what is polymyalgia rheumatica
Auto inflammatory proccess affecting joints and muscles - muscle pain - joint stiffness
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what is polyarteritis nodosa
necrotising vasculitis leading to aneurysms and thrombosis in medium sized arteries
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Rheumatoid arthiritis - subcutaneous nodules pathophysiology
- Area on fibrinoid necrosis - Ring of pallisading macrophages around cuff of lymphocytes
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percentage of bone density lost for a lytic tumour to be visible on X-ray
60%
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Alcohols effect on gout patients
- causes hyperuricaemia - competes with uric acid for excretion at the tubules
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Difference between arthiritis and SLE
``` Lupus: - correctable arthiritis - no erosions but shape change - deforming arthiritis ```
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What do Anti-TNF drugs do S/E
Induces lupus
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What is Ustekinuab
Interlukin 12/23 blocker - B27 spondyloarthiritis - decreases inflammation
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Mechanical lower back pain red flags
T - Thoracic back pain/ Hx TB U - Unexplained weight loss N - Nocturnal pain A - Age (<20) (>55) F - Fever/ night sweats I - Immunosuppressed S - Spinal stenosis H - Hx of malignacy
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Cauda equina red flags
Neurological defecit of legs - motor weakness - knee extension - foot dorsiflexion - Bilateral sciatica - Urinary retention/overflow incontenince - Perianal sensory loss - Laxity of anal sphincter PR exam - tone
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What is reiter's syndrome | and what condition is it linked to
Can't see. pee or climb a tree - Urethritis - conjunctivitis - arthiritis Reactive arthiritis
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Gout - 1st line management
Diclofenac

Phase 2a (11 decks)

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