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Phase 2a > MSK > Flashcards

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
Q

O.P Patho

A
  • Inadequate PBM reached
  • Increased resorption
  • Decreased formation
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26
Q

PBM influences patho

  • genetics
  • inflammatory disease
  • thyroid disease
  • cushings
  • post menopausal
  • ageing
A
  • 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
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27
Q

CP of O.P

A 
asymptomatic until fracture 
- Vertebral fractrures 
Loss of height 
kyphosis - stooping posture
back pain
  • Colles’ fracture
    fall on outstretched hand
  • Proximal femur fracture
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28
Q

Assesment of fracrture risk

A
  • FRAX tool
    possibility of a fracture in the nect 10 years
    only for pts> 40 y/o
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29
Q

OP investgations

A
  • 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
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30
Q

OP managment

A 
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
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31
Q

Crystal Arthiritis

A

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

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32
Q

Gout definition + epidemiology

A

Inflammatory arthiritis due to deposition of monosodium urate

  • Acute monoarthropathy
  • PODAGRA
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33
Q

Gout aetiology

A

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
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34
Q

Gout patho and serum conc

A 
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

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35
Q

Percipitants of an attack

A 
trauma 
surgery 
diuretics 
dehydration 
sepsis 
infections 
alcohol
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36
Q

C.P of gout

A 
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

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37
Q

Investigations and DD

A

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

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38
Q

Tx Gout

A

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
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39
Q

Gout prevention

  • Lifestyle
  • Pharma
A 
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

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40
Q

Pseudo-gout definition and distribution

A

Deposition of calcium pyrophosphate on joint surface and in articular cartilage
crystals elicit and inflammatory response

Distribution: MCP, Ankles, Wrist, Knees

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41
Q

Patho of P-gout

A

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
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42
Q

Presentation of P-gout

A 
Acute attack: 
-Acute synovitis 
Painful, red,hot,swollen joint 
stiffness 
- Fever
- Large joints
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43
Q

Triggers

A

Joint injury
intercurrent illness
surgery - parathyroidectomy
spontaneous

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44
Q

Risk factors for P-gout

A 
Old age 
haemochromatosis 
hyperparathyroidism 
hypophosphataemia 
wilsons' disease
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45
Q

P-gout investigations

A

Aspiration
- R/O septic arthiritis
- MIcroscopy–> RHOMBOID crystals
POSITIVE bifringement

X-ray
- Chondracalcinosis
linear calcification parallel to articular surface

Bloods:
Raised CRP

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46
Q

Management of P-gout

A

acute attack:

  • NSAIDs
  • Colchicine
  • Aspiration
  • physio
  • Intra-articular steroid injections

Long term/chronic:
- Trial - anti rheumatic drugs
Methotrexate
Sulfasalazine

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47
Q

Describe spondyloarthropathies - seronegative

  • features
  • Blood
  • MSK
  • Extra
A

Group of related chronic inflammatory conditions tend to affect axial sekleton
common features:
1. HLA-B27 Associaton
2. Rhematoid factor negative

  1. Dactylitis
  2. Enthesitis
    inflamm at site of tendon/ligament insertion

5.Asymetrical large joint oligoarthiritis

  1. extra articular:
    oral ulcers
    IBD
    Aortic valve incompetance
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48
Q

Ankolysing spondylitis definition and epidemiology

A

Chronic inflammatory disorder of the spine and sacro-iliac joints

More common in MEN
- Late teens

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49
Q

CP ankolysing spondylitis
Typical presentation
sx
signs

A 
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
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50
Q

Ankylosing spondylitis investigations

A
  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
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51
Q

Tx ankylosing.S

A

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

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52
Q

Complications of Ankylosing.S

A
  • Anaemia
  • Aortitis
  • Anterior uveitis
  • Heart block
  • Pulmonary fibrosis
  • IBD
  • Chest pain
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53
Q

Ankylosing.S patho

A
  • excessive Enthesitis and erosive repair phase leads to Syndesmophytes formation
  • Fusion of syndesmophytes
    (Ankylosis)
  • Flexion and rotation prevented
  • End stage:
    Bamboo spine
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54
Q

Psoriatic Arthiritis

- Defenition

A

Chronic progressive inflammatory arthiritis assosciated with psoriasis
- Seronegative spondyloarthropathy

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55
Q

Psoriatic arthiritis patterns

A
  • Symmetrical polyarthirits
    Hands/Wrists/Ankles/DIP
    MCP joints less common unlike R.A
  • Arthritis mutulans
    Severe form: Osteolysis of bones in phalanxes –> Telescopic finger
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56
Q

Psoriatic.A Signs

A
  • Psoriatic plaques
  • Oligoarthiritis
  • Dactylitis
  • Enthesitis

Nail:

  • Hyperkeratosis
  • Pitting of the nails
  • Onycholysis

DIPJ affected

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57
Q

Psoriatic. A Assosciations

A

Conjunctivitis
Anterior Uveitis
Aortitis
Amyloidosis

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58
Q

Psoriatic.A investigations

A

X-ray:

  • Pencil in cup deformity (Central erosions)
  • Dactylitis –> S.T swelling
  • Osteolysis
  • Periostitis
  • Ankylosis

Nail changes:

  • Distrophic
  • Hyperkeratinosis
  • Pits
  • Onicholysis

Bloods:
- RF -ve

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59
Q

Psoriatic.A Management

A
  1. NSAIDs
  2. Intra-articular corticosteroids injections
  3. DMARDs
    Methotrexate/Sulfasalazine
  4. Anti-TNF meds - Etanercept
  5. USTEKINUMAB -
    Interleukin 12/23
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60
Q

Reactive.A Defenition + Causes

A
  • Sterile synovitis due to AI response to infection by:
    GI: - Shigella/Salmonella/Campylobacter
  • STI: Chlamydia trachomatis
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61
Q

Reactive.A patho

A

Persistent bacterial Ag in inflammed synovium drives inflamm process

HLA-B27 +ve - Increase susceptibilty to R.Arthiritis

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62
Q

Reactive.A CP

A
  • Acute monoarthiritis
  • Lower limb - Knees/Ankles
  • Warm/swollen/Painful joint

Can-t see, pee, or climb a tree

  • Bilateral conjunctivitis
  • Arthiritis
  • Urethritis
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63
Q

Reactive.A Investigations

A
  • Bloods - Raised ESR/CRP
  • Aspiration
    Sterile joint aspirate -
    Raised neutrophils
  • STI Screen
  • X-Ray
    Enthesitis
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64
Q

Reactive.A tx

A
  1. Exclude Septic arthiritis
    - Abx
    - Joint aspiration
    staining + culture/sensitivity
  2. NSAIDs
  3. Local steroid injections
  4. Multiple joints affected –>
    Systemic steroids
  5. Sx>6m –> DMARDs

*Rest + Splint joints

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65
Q

Septic Arthiritis definition

A

Joint inflammation due to bacterial infection leads to irrversible joint damage within 24hrs
- Acute,Red,Hot,Swollen joint

66
Q

Septic arthiritis causes

A 
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
Q

Septic Arthiritis RF

A 
Pre- exisitng joint damage 
Penetrating trauma
DM
Skin breaks/Ulcers - DM
Intra-articular steroid injection
Joint surgery
68
Q

Septic Arthiritis CP

A
  • Acute,Red,Hot,Swollen,Painful
  • Decrease ROM
  • Fever
  • Monoarthritis –> Knee

Early:
Joint effusion
Loss of function
Pain

Late:
Pain
Mechanical dysfunction

69
Q

Septic arthritis Investigations

A

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
Q

Septic Arthiritis Tx

A
  1. Broad spectrum Abx
    Flucloxacillin

Allergic –> Clindamycin

If Immunocompromised –> Gentamicin (covers gram -ve)

MC&S –> Specific Abx
IV = 2 wks
PO = 2-4wks

  1. Immobolisation
    - Physio to prevent muscle wasting + stifness
  2. Joint damage
    - Needle aspiration
  3. NSAIDs
    - Ibuprofen –> Pain relief
71
Q

What must you stop when treating septic arthiritis

A

Stop immnosuppresion - DMARDs + Anti-TNF

Chronic long term steroids –> Double dose

72
Q

Osteomyelitis

-Defenition (Acute + Chronic)

A

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
Q

Osteomyelitis Mechanism of infection

A 
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
Q

Osteomyelitits RF for bacteremia

A

central lines
dialysis
catheter
recurrent UTI

75
Q

Osteomyelitis host susceptibility factors

A

Immunosuppressed
DM
Prosthetic material
Trauma

76
Q

Osteomyelitis causes

A

S.Aureus
Salmonella - SSA
E.Coli
Haemophilius influenzae

77
Q

Osteomyelitis Patho

A
  • Inflammatrory exudate in BM
  • Increases Intramedullary pressure
  • Extension
78
Q

Osteomyelitis differential diagnosis

A 
Cellulitis 
Gout
Fracture 
Malignancy 
Charcot joint - DM
79
Q

Osteomyelitits CP

A
  • Fever
  • Dull localised bone pain
  • Pain worse on movement
  • Tenderness
  • Erythema
  • Sweats
  • Malaise
  • Chronic –> Draining sinus tract + Deep ulcers
80
Q

Osteomyelitis

Acute + Chronic changes

A

Acute -
Inflamm cells –> Oedema
Vascular congestion
Small vessel thrombosis

Chronic -
Neutrophil exudates 
Sequestra 
Involucrum
Lymphocytes
81
Q

Osteomyelitis Investigations

A 
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
Q

Osteomyelitis tx

A

Immobilisation
Surgical drainage of abscess
Surgical debridement
Abx - Flucloxacillin

-Guided by ESR/CRP monitoring

83
Q

SLE Defenition

A

Systemic AI chronic inflammatory CT disease

- Charecterised by serum Anti-nuclear ab and Anti dsDNA Ab

84
Q

SLE Epidemiology

A

Female- child bearing age
20-40y/o
Afro-carribeans
Asians

85
Q

SLE aetiology
genetic
environmental

A

AI Condition
*Genetic
HLA DR2/3
Family hx

*Environmental 
UV radiation 
EBV Exposure
Penicillamine
Isoniazid 
Hydralazine
86
Q

SLE Patho

A

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
Q

SLE CP

sx

A

Non specific sx

  • Fatigue
  • fever
  • malaise
  • myalgia
  • arthralgia
  • weight loss
  • S.O.B
  • Hair loss

Relapsing and remitting pattern

88
Q 
SLE signs 
skin
joints
GI
Kidney
CNS
CV
Lung
A 
*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
Q

SLE Investigations

A
  • Auto Ab
    1. Screen with
  • Anti-nuclear Ab
    V sensitive but not specific
  1. Anti- dsDNA Ab
    Specific but not sensitive

*Anti - smith Ab

  • Complement reduced
    C3 and C4
  • FBR (HIGH ESR + normal CRP)
  • Anaemia
  • Renal biopsy
90
Q

SLE dx criteria

A

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
Q

Which Ab in SLE are assosciated with increased thromboembolism risk

A
  • Antiphospholipid Ab
92
Q

SLE complications

A

*CVD
Chronic inflammation in BV leads to HTN and CAD

  • Infection
  • Anaemia
  • Peicarditis
  • Interstitial lung disease
  • Glomerulonephritis
  • Pulmonary fibrosis
  • Recurrent miscarraiges
93
Q

SLE general management

A
  • Avoid triggers –> UV radiaiton
  • High factor sun screen
  • Decrease CVD RF
94
Q

SLE Tx

1st line

A
  1. Analgesia - NSAIDs
  2. Steroids - prednisolone
  3. Hydroxycholroquine
95
Q

SLE tx

- severe/resistant

A

Methotrexate
Rituximab - CD20

Severe flare ups
IV cyclophosphamide + High dose prednisolone

96
Q

SLE DD

A 
Antiphospholipid syndrome 
Sjrogren syndrome 
Undifferentiated CT disease
Scleroderma 
R.A
Polymyositis
97
Q

SLE inflamm markers detection

A

High ESR but CRP remains normal

98
Q

Reasons for false positive ESR results

A

Age
Female
Obesity
Anaemia

99
Q

R.A diagnostic criteria

A

4/7 required

  • Morning stiffness
  • Arthiritis >3 or more joints
  • Arthiritis of hands
  • Symmetrical
  • Rheumatoid nodules
  • Rheumatoid factor +ve
  • Radiographic changes
100
Q

Osteoperosis Primary prevention

A
  • Adcal D3 - Vit D + calcium
  • Calcum rich diet
  • HRT
    (Pre-menopausal)
  • Corticosteroids
  • Regular weight bearing excercise
  • Smoking
  • Alcohol
101
Q

What is Anti - phospholipid syndrome

A

AI syndrome charecterised by thrombosis, recurrent miscarraiges and positive blood tests for ApL Ab

  • Primary
  • Secondary to SLE
102
Q

Anti - phospholipid syndrome pathophysiology

A

Ab bind to phospholipids on surface of cells

  • Binding alters function
  • Thrombosis
103
Q

Anti phospholipid syndrome causes and increased risk of

A 
CLOTS!!
C- coagulation defects 
     (DVT/Stroke)
L - Livedo Reticularis 
     purple skin 
    discoulouration 
O - Obstetric 
      Recurrent miscarraiges 
T - Thrombocytopenia
104
Q

APS investigations

A
  • Anti Cardiolipin Ab
  • Lupus Antigoagulant
  • Anti - B2 - glycoprotein I
105
Q

APS tx

A

Manage CVS risk factors

  • HTN
  • Smoking
  • Diet

Previous thrombosis

  • Long Term warfarin
  • LMWH (If trying to concieve)

Prophylaxis
- Asprin

106
Q

What is Raynauds syndrome

A

Intermittent spasm in arteries supplying fingers and toes precipitated by cold or emotion
- Relieved by heat

107
Q

Diseases leading to Raynauds phenomenon

A 
SLE
RA
dermatomyositis 
Polymyositis
Systemic sclerosis
108
Q

Examples of when raynauds phenomenon is exhibited

A
  • Vibrating tools
  • Thrombocytosis
  • Beta blockers
  • Hypothyroidism
  • Atheroma
109
Q

Raynauds syndrome clinical presentation

A
  • Numbness
  • Tingly
  • Pain
  • Ischaemia
    White fingers
  • Tissue hypoxia
    Blue fingers
  • Reactive hyperaemia
    Red fingers
110
Q

Raynauds tx

A

Stop smoking
Keep warm
CCB - Nifedipine

111
Q

What is Systemic sclerosis/ Scleroderma

A

Multisystem AI diseasewith skin involvement and raynauds phenomenon

112
Q

Scleroderma features

A

Scleroderma - skin fibrosis
Internal organ fibrosis
Microvascular abnormalities

113
Q

What is limited scleroderma

A

CREST syndrome

- Limited cutaneous scleroderma

114
Q

What is CREST syndrome

  • Features
  • Acronym
  • Late stage complications
A
  • 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
Q

Diffuse cutaneous scleroderma

  • GI
  • Kidney
  • Lungs
  • Cardio
A

All skin + organ involvement

  • Dysphagia
  • Dyspepsia
  • Malabsorption
  • Pseudo - obstruction
  • Kidney disease (AKI/CKD)
  • Pulmonary fibrosis
  • Pulmonary HTN
  • Myocardial fibrosis
116
Q

Systemic sclerosis investigations

A

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
Q

What is Sjrogren syndrome

A

Chronic AI inflammatory disease

- AI destruction of exocrine glands

118
Q

What is primary sjrogren syndrome

A

SICCA syndrome

- Primary fibrosis of exocrine glands

119
Q

Causes of secondary sjrogren syndrome

A

SLE
RA
Scleroderma
PBC

120
Q

Sjrogren syndrome presentation

  • glands
  • systemic
A

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
Q

Sjrogren syndrome investigations

A

Schirmer’s test
- Measures conjunctival dryness

Serum Ab:

  • Anti-nuclear Ab
  • Anti Ro Ab
122
Q

Sjrogren syndrome tx

A
  • Artificial tears
  • Saliva replacement solutions
  • NSAIDs (Arthralgia)
123
Q

What is Polymyositis and Dermatomyositis

A

Progressive symmetrical proximal muscle weakess due to Striated muscle inflammation

Dermatomyositis
+ Skin involement

124
Q

Polymyositis presentation

A

Symmetrical muscle weakeness and wasting

  • Shoulder
  • Pelvic gridle
STAIRS, CHAIRS, HAIRS
- Pts have difficulty:
Squatting
climbing stairs
rising from chairs
hands above head
125
Q

Dermatomyositis presentation

A
  • Raynauds phenomenon
  • Helitrope (Macular rash)
    Purple eyelid rash
  • Gottrons papules
    scaly, erythromatous
    plaques over knuckles
126
Q

Polymyositis/Dermatomyositis investigations

A

Muscle Biopsy = DIAGNOSTIC

  • muscle fibre necrosis
  • inflamm cell infiltration

Muscle enzymes elevated:

  • Creatnine kinase
  • AST
  • ALT
  • LDH

ESR not raised

Malignancy screen

127
Q

Polymyositis/ Dermatomyositis tx

A
  1. Prednisolone
    • slowly taper down
  2. Immuno suppressive therapy
    - Azathioprine
    - Methotrexate
    Disease relapse when tapering down steroids
  3. Skin issues:
    - Topical Tacrolimus
128
Q

Name 3 primary bone tumours

A

Osteosarcoma
EWing sarcoma
Chondrosarcoma

129
Q

Causes of secondary metastases to the bone + apperance on X -ray

A 
Breast 
Prostate 
Kidney 
Thyroid 
Lung

Osteolytic

130
Q

Describe the 2 different forms for zone of transition

A

Wide - ill defined
- Malignancy

Narrow - well defined

131
Q

Name 3 periosteal reactions

A

Codmans triangle
Onion skinning
Sunburst spicules

132
Q

Bone tumours presentation

A
  • Bone pain - nocturnal
  • Local red swelling
  • Unexplained fractures
  • Constant non mechanical
    pain
  • Fatigue
  • Weight loss
  • Anaemia
  • Night sweats
133
Q

Bone tumours investigation

A

X-ray

MRI

Bone biopsy

Skeletal isotope scan
- bony mets appear as hotspots before radiological chnages

134
Q

Bone tumours tx

A
  • Analgesia
  • Anti inflammatory drugs
  • Chemotherapy
  • Radiotherapy
  • Bisphosphonates
  • chemo + radio
  • useful in Ewings
  • not useful in condrosarcoma
135
Q

Grading for primary bone tumours

A

Enneking system

136
Q

Grading for metastatic bone tumours

A

Mirels

Score > 8 indicates benefit of prophlactic nailing

137
Q

Osteosarcoma

  • Association
  • Location
  • Xray findings
A
  • Pagets disease
  • Knee
    Proximal humerus
  • Bone destruction
    Bone formation
    Sunburst spicules
    Codmans triangle
138
Q

Ewings sarcoma

  • Genetic mutation
  • location
  • Xray
A
  • t( 11 ; 22 )
  • Diapheseal lesions
    Femur
    Pelvis
    Distal tibia
  • Codmans triangle
    Onion like apperance
139
Q

Chondrosarcoma

  • what is it
  • location
  • Xray
A
  • Malignancy of cartilage
  • Pelvis
    Proximal femur
    Proximal humerus
  • Patchy lytic lesions
140
Q

What is fibromyalgia

A

chronic widespread MSK pain syndrome with no underlying cause
- strong yellow flag influence

141
Q

Yellow flag

  • defenition
  • features
A

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
142
Q

Fibromyalgia presentation

A 
- 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)
143
Q

Mechanical back pain presentation

A
  • sudden onset
  • pain worse in evening
  • morning stiffness
  • excercise increases pain
144
Q

Mechanical back pain causes

A
  • stop and twist when lifting
  • heavy manual handling
  • fractures
  • spinal stenosis
  • lumbar disc prolapse
  • whole body vibration
145
Q

Osteomalacia

A

inadequate bone mineralisation of osteoid frameworks leading to soft bones

146
Q

What are the 2 forms of soft bones that can occur

A

Rickets
- Epiphseal growth plates
not closed

Osteomalacia
- Epiphseal growth plates
closed

147
Q

Osteomalacia risk factors

A 
Pigmented skin
sunscreen
old age 
instiutionalisation
Malabsorption
- coeliac
- crohns
renal disease
liver disease
phenytoin
148
Q

Giant cell arteritis presentation

A

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

149
Q

what is polymyalgia rheumatica

A

Auto inflammatory proccess affecting joints and muscles

  • muscle pain
  • joint stiffness
150
Q

what is polyarteritis nodosa

A

necrotising vasculitis leading to aneurysms and thrombosis in medium sized arteries

151
Q

Rheumatoid arthiritis
- subcutaneous nodules
pathophysiology

A
  • Area on fibrinoid necrosis
  • Ring of pallisading
    macrophages around cuff
    of lymphocytes
152
Q

percentage of bone density lost for a lytic tumour to be visible on X-ray

A

60%

153
Q

Alcohols effect on gout patients

A
  • causes hyperuricaemia
  • competes with uric acid for
    excretion at the tubules
154
Q

Difference between arthiritis and SLE

A 
Lupus:
- correctable arthiritis
- no erosions but shape 
  change 
- deforming arthiritis
155
Q

What do Anti-TNF drugs do S/E

A

Induces lupus

156
Q

What is Ustekinuab

A

Interlukin 12/23 blocker

  • B27 spondyloarthiritis
  • decreases inflammation
157
Q

Mechanical lower back pain red flags

A

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

158
Q

Cauda equina red flags

A

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
159
Q

What is reiter’s syndrome

and what condition is it linked to

A

Can’t see. pee or climb a tree

  • Urethritis
  • conjunctivitis
  • arthiritis

Reactive arthiritis

160
Q

Gout - 1st line management

A

Diclofenac

Phase 2a (11 decks)

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