MSK

Question 1

What is gout?

Answer 1

An inflammatory arthritis associtated with hyperuricaemia and intra-articular negativley bifingent needle shaped monosodium urate crystals. Generally occurs in middle aged men

Question 2

What causes gout?

Answer 2

Purine rich foods such as red meat, high alcohol intake (especially Beer), high fructose/saturated fat intake, high insulin levels, kidney disease and ischaemic heart disease

Question 3

Describe the process leading to gout?

Answer 3

In purine metabolism hypoxanthine is converted to xanthine, xanthine is then converted to uric acid. Excess uric acid which is not secreted by the kidneys is sometimes converted to monosodium urate crystals

Question 4

S&S of gout?

Answer 4

Extreme pain, swelling and redness of the first MTP joint (in the big toe), urate renal stones may also form and renal impariment may occur if gout is frequent

Question 5

Treatment of gout?

Answer 5

High dose NSAIDS or Colchicine, intra-articular corticosteroids
Allopurinol (inhibits xanthine oxidase) and weight loss/dietary changes = long term prevention

Question 6

What is psuedo gout?

Answer 6

Deposits of positivley bifingent rhomboid shaped calcium phosphate crystals. Generally occurs in older women

Question 7

S&S of pseudogout?

Answer 7

Painful, hot and swollen joint (tends to be knee/wrist) and fever due to synovitis

Question 8

What is an important test that should be done in pseudogout?

Answer 8

Joint fluid culture to exclude septic arthritis

Question 9

Treatment of psuedo gout?

Answer 9

Aspirate joint, intra-articular corticosteroids and high dose NSAIDs/Colchicine

Question 10

What is chronic tophaceous gout?

Answer 10

Occurs in those with persistantly high urate levels. Monosodium urate crystals form smooth white deposits (tophi) in the skin, joints and on the achille’s tendon. Tophi release proteolytic enzymes which errode bone.

Question 11

What is osteoarthritis?

Answer 11

A non-inflammatory degenerative arthririts characterised by cartilage loss with inflammation of the articular and periarticular structures

Question 12

What are the risk factors for osteoarthritis?

Answer 12

Joint hypermobility, increasing age, being female after menopause, diabetes, obesity, genetic predisposition and occupation (e.g. manual labour = small hand bones)

Question 13

S&S of osteoarthritis?

Answer 13

Mechanical pain (with movement), gradual onset but progressive symptoms, <30mins morning stiffness, pain relieved by rest, Herberden’s nodes (DIP) and Bouchard’s nodes (PIP). SYSTEMIC FEATURES ARE ABSCENT AS IT IS NON-INFLAMMATORY

Question 14

What is seen on X-rays/tests in osteoarthritis?

Answer 14

LOSS - Loss of joint space, Osteophytes, Subarticular sclerosis and Subchondral Cysts

Question 15

What is Rheumatoid Arthritis?

Answer 15

An inflammatory autoimmune disorder causing symetrical deforming polyarthropathy

Question 16

What are the risk factors for rheumatoid arthritis?

Answer 16

Being female, smoking, genetic predisposition (HLA-DR4/HLA-DRB1)

Question 17

S&S of rheumatoid arthritis?

Answer 17

Slow, progressivley worsening painful/warm/swollen/tender joints, morning stiffness > 30mins, ulnar deviation, swan neck thumb, boutonniere deformity and fatigue

Question 18

What is seen on X-rays/tests in rheumatoid arthritis?

Answer 18

LESS = Loss of joint space, Erosions (periarticular), Soft tissue swelling, Soft bones

Question 19

What are the best markers of rheumatoid arthritis

Answer 19

Anti-CCP antibodies present = THE BEST and rheumatoid factor positive

Question 20

What is the treatment specifically for rheumatoid arthritis?

Answer 20

DMARDs (such as methotrexate or sulfasalazine), may be accompanied by TNF-alpha antibodies. Monoclonal antibodies such as rituximab may also be used

Question 21

What is osteoporosis?

Answer 21

A systemic skeletal disease characterised by a microarchitectural deterioration of the bone tissue leading to increased bone fragility and fracture risk

Question 22

What are the primary causes of osteoporosis?

Answer 22

Menopause and increasing age

Question 23

What are the secondary causes of osteoporosis?

Answer 23

SHATTERED = Steroids, Hyperthyroidism/Hyperparathyroidism, Alcohol/cigarettes, Thin (BMI <22), Testosterone (low), Estrogen (low), Renal/liver failure, Erosive/inflammatory bone disease, Diabetes mellitus

Question 24

S&S of osteoporosis?

Answer 24

This tends to be asymptomatic until there is a fracture (often a proximal femur/vertebral crush/colle’s fracture), kyphosis seen in thoracic vertebral fracutures

Question 25

What is a T-score?

Answer 25

A standard deviation gender-matched score of bone mass using DEXA. It is compared to the young adult average. -1 to -2.5 = osteopenia, >-2.5 = osteoporosis,

Question 26

Treatment for osteoporosis?

Answer 26

Bisphosphonates, HRT/testosterone replacement, Denosumab (inhibits RANK ligand which normally stimulates osteoclasts), diet and lifestyle modification, weight bearing exercises

Question 27

What is osteomalacia?

Answer 27

Defective mineralisation of bone leading to uncalcified osteoid/cartilage despite normal bone amount occuring AFTER the fusion of the epiphyses (if before it will be rickets).

Question 28

What causes osteomalacia?

Answer 28

Malabsorption disorders (e.g. coeliac's/chron's), lack of sunlight, renal failure, liver disease/cirrhosis and tumours

Question 29

S&S of osteomalacia?

Answer 29

Muscle weakness with waddling gait, bone pain worse on weight bearing, bone tenderness and fractures

Question 30

S&S of rickets?

Answer 30

Growth retardation/hypotonia, knock-knees/bow-legs, widened epiphyses at the wrist

Question 31

What is hypophosphataemia?

Answer 31

The main cause of osteomalacia. Low vitamin D = low calcium = increased PTH secretion = low phosphate (calcium will remain low due to lack of vitamin D)

Question 32

What are the risk factors of SLE?

Answer 32

Epstein-Barr virus, genetic (linked to HLA genes), being a woman, being Afro-carribean or Asian

Question 33

S&S of SLE?

Answer 33

Butterfly/photosensitive rash, reynaud's phenomenom, glomerulonephritis with persisitant proteinuria, mouth ulcers, soft tissue swelling, small joint arthralgia, seizures

Question 34

What is found in blood samples of SLE?

Answer 34

Raised ESR but normal CRP, Anti-nuclear antibody positive, anti-dsDNA positive (most specific but only positive in 60%), some will also be RF positive

Question 35

Treatments for SLE?

Answer 35

Non-specific (can't be cured), anti-CD20 e.g. rituximab, immunosuppresants e.g. azathoprine/methotrexate, hydroxychloroquine (for fatigue/arthralgia not controlled by NSAIDs), corticosteroids

Question 36

What is antiphospholipid syndrome?

Answer 36

Thrombosis with or without reccurent miscarriages with positive blood tests for anitphospholipid antibodies

Question 37

S&S of antiphospholipid syndrome?

Answer 37

CLOT = Coagulation defects, Livedo reticularis, Obstetric issues, Thrombocytopenia

Question 38

How is antiphospholipid syndrome diagnoses?

Answer 38

A poitive on 2 of 3 of the following >12 weeks apart: Anticardiloipin test (detects antibodies which bind to cardilolpinin a -vely charged posholipid) Lupus anticoagulant test Anti-B2-glycoprotein 1 test (detects proteins that bind to B2-glycoprotein 1)

Question 39

Treatment for anti-phospholipid syndrome?

Answer 39

Long term warfarin. Oral aspirin and SC heparin in early pregnancy to prevent miscarriage

Question 40

What is Sjorgen's syndrome?

Answer 40

An antiinflammatory autoimmune condition characterised by the destruction of epithelial exocrine cells

Question 41

What are the primary/secondarry causes of Sjorgen's syndrome?

Answer 41

``` Primary = being female between 40-60 Secondary = connective tissue disorders such as RA/SLE ```

Question 42

S&S/treatment of Sjorgen's syndrome

Answer 42

Dry mouth/eyes | Treat with artificial saliva/tears and hydroxycholoquire/NSAIDs for pain and arthralgia

Question 43

Test for Sjorgen's syndrome?

Answer 43

Schirmer tear test, salivary gland biopsy and ANA/SSA antibodies present

Question 44

S&S of Systemic sclerosis/scleroderma?

Answer 44

Raynaud's phenomenom, CREST syndrome, flexion deformities (affects skin on hands, feet, face and fingers ONLY) pseudo colon obstruction, CKD, lung disease

Question 45

What is CREST syndrome?

Answer 45

Calcinosis (calcium deposits in the SC tissues), Raynaud's, Esophageal dysmobility/strictures, Sclerodactyly (thickening/tightness in skin on the fingers/toes), Telenagiectasia (spider veins)

Question 46

What are seronegative spondlyoarthropathies?

Answer 46

Conditions with axial inflammation, asymmetrical peripheral arthritis, absence of RF and a strong association with HLA-B27

Question 47

What is Ankylosing Spondylitis?

Answer 47

The abnormal stiffening and immobitility of the spine, ribs and sacroiliac joints due to new bone formation associated with Klebsiella/shigella/salmonella infection. It is worse and more common in men.

Question 48

S&S of Ankylosing Spondylitis?

Answer 48

Gradual onset lower back pain which is worse at night, with morning stifness and relieved by exercise. Entesitis, anterior uveitis, loss of lumbar lordosis and increased kyphosis. Think of this if seen in men under 30!!!

Question 49

Tests for Ankylosing Spondylitis?

Answer 49

Patients will have normocytic anaemia, raised ESR & CRP and be HLA-B27 positive. X-rays will show spinal bony spurs (syndesmophytes) and sacroiliac joint fusion/erosion

Question 50

Treating Ankylosing Spondylitis?

Answer 50

NSAIDs at night, Methotrexate for peripheral arthritis, TNF-alpha-blockers to delay syndesmophyte formation

Question 51

S&S of Psoratic Arthritis?

Answer 51

Asymmetrical oligoarthritis or symmetrical polyarthritis, dactylitis, spondylits, DIPJ involvment ONLY, arthritis mutalins

Question 52

Tests for Psoratic Arthritis?

Answer 52

Central erosions with concave articulating bone seen on X-ray, skin and nail disease

Question 53

Treatments for Psoratic Arthritis?

Answer 53

NSAIDs, DMARDs and Ciclosporin for severe disease, anti-TNF-al[pha agents

Question 54

What is Reactive Arthritis?

Answer 54

Sterile infalmmation of the synovial membrane, tendons and fascia triggered by a distal infection e.g. salmonella, shigella, chlamidyia and gonorrhoea

Question 55

S&S of Reactive Arthritis?

Answer 55

Reiter's syndrome: urethritis, arthritis, conjunctivitis | Also painless penile ulceration, mouth ulcers and enthesitis

Question 56

What is Arthritis Mutalins?

Answer 56

A complication of psoratic arthritis, there is periarticular osteolysis and bone shortening leading to telescopic fingers - pencil in cup x-ray changes

Question 57

What are the main sites for secondary bone tumours to develop from?

Answer 57

Bronchus, breast, prostate, kidney, thyroid

Question 58

S&S of bone cancer?

Answer 58

Fatigue, appetite loss, weight loss, fever, malaise, bone pain, increased fractures (weakened bones) and swelling

Question 59

What % bone density must be lost before it shows as an osteolytic area on X-ray?

Answer 59

60%

Question 60

What are the four common primary bone tumours?

Answer 60

Osteosarcomas, fibrosarcomas, chondrosarcomas and Ewing's tumour

Question 61

What is an osteosarcoma?

Answer 61

Occurs in the metaphyses of the long bones, produces immature bone and presents with a painless tumour and destroys surrounding bone/tissues before metastasising to the lung

Question 62

What is an Ewing's sarcoma?

Answer 62

Arises from the mesenchymal stem cells, presents as painful swelling/redness in teh area surrounding the tumour

Question 63

What is a chondrosarcoma?

Answer 63

Occurs in the cartilage and presents with a deep, dull pain - the affected area is swollen and tender

Question 64

What is acute vertebral disc disease?

Answer 64

A prolapse of the intervertebral disc leading to lower back pain (lumbago) commonly affecting the lower three discs in those age 20-40

Question 65

Treatment for acute vertebral disc disease?

Answer 65

Analgesics (e.g. epidural corticosteroid injection), bed rest with a firm mattress, surgery if neurological impariment

Question 66

What is chronic vertebral disc disease?

Answer 66

Degenerative changes in the lower discs and facet joints leading to long standing mechanical pain

Question 67

Name some causes of mechanical back pain?

Answer 67

Heavy manual handling, stooping/twisting whilst lifting, whole body vibration, smoking, increasing age, fractures, osteoarthritis, stress, more common in females

Question 68

What is lumbar spondylosis?

Answer 68

Degeneration of the lumbar discs causing circumferential bulging of the intervertebral ligaments, the bone becomes sclerotic and osteophytes form - usually affects L4/5 and L5/S1. Pain is episodic with progressive stifness

Question 69

What is facet joint syndrome?

Answer 69

Osteoarthritis of the misaligned facet joints secondary to lumbar spondylosis. Leads to lumbar pain raditating from the buttock, the pain is worse on bending backwards/straightening from flexion

Question 70

What is Paget's disease?

Answer 70

A focal disorder of bone remodelling leading to weaker bone being formed. It most commonly affects the skull, legs, pelvis and spine

Question 71

S&S of Paget's disease?

Answer 71

Usually asymptomatic, leads to bone and joint pain, nerve decompression (may causes deafness and paraparesis), hydrocephalus, osteosarcoma and myocardial hypertrophy

Question 72

Tests for Paget' disease?

Answer 72

Increased serum alkaline phosphate with normal calcium and phosphorus, increased urinary hydroxyproline excretion, isotope bone scan

Question 73

What is Fibromyalgia?

Answer 73

Widespread musculoskeletal pain after other diseases have been excluded - it is pain in at least 11 of the 18 tender points on examination and symptoms must be present for at least 3 months

Question 74

S&S for fibromyalgia?

Answer 74

Widespread central non-nociceptive pain aggravated by stress, cold and activity. Generalised morning stiffness paraesthesia of the hands and feet as well as extreme pain and non-restorative sleep

Question 75

What is vasculitis and what are the types (with examples of what they affect)?

Answer 75

Inflammation of the vessel wall Small vessel = small arterioles, venules and capillaries Medium vessel = medium/small arteries/arterioles Large vessel = aorta and major tributaries

Question 76

Name examples of the types of vasculitis?

Answer 76

``` Large = polymyalgia rheumatica, giant cell arteritis Medium = polyarteritis nodosa Small = microscopic polyangitis, essential cryoglobulinaemia ```

Question 77

S&S of Polymyalgia Rheumatica?

Answer 77

Sudden onset pain/stiffness of the shoulders, neck, hips and lumbar spine. Pain is worse in the morning and may come with mild polyarthritis of the peripheral joints

Question 78

Tests for Polymyalgia Rheumatica?

Answer 78

Raised ESR/CRP, ANCA negative, temproal artery biopsy.

Question 79

S&S of Giant Cell Arteritis?

Answer 79

Severe headache with temproal pulsating, tender scalp, jaw claudication when eating, dysponea, sudden painless vision loss (EMERGENCY)

Question 80

What is the diagnostic criteria for Giant Cell Arteritis?

Answer 80

Three of: Raised ESR, >50, new headache and temporal artery tenderness This is also ANCA negative

Question 81

S&S for Polyarteritis Nodosa?

Answer 81

Mononeuritis multiplex, abdominal pain, GI/SC haemorrhage, heamaturia/proteinuria, fever, weight loss

Question 82

What gender is most affected in vasculitis? What are their ANCA statuses?

Answer 82

``` Large = female Medium = male Large/medium = ANCA -ve Small = ANCA +ve ```

Question 83

What are polymyositis and dermatomyositis?

Answer 83

PM is a muscle disorder mainly affecting women. It cuases inflammation/necrosis of skeletal muscles and when it affects the skin is DM. The cause is often unknown but rubella and influenza are thought to stimulate it

Question 84

S&S of Polymyositis?

Answer 84

Dysphagia, dysphonia, respiratory failure. Symmetrical progressive muscle weakening/wasting affecting the proximal shoulder muscles and pelvic girdle - this leads to dificulty squatting, going up stairs and raising hands above the head

Question 85

S&S of Dermatomyositis?

Answer 85

Scaly erythematous plaques over the knuckles known as Gottron's papules, Heliotrope rash, arthralgia, dysphagia, Reynaud's phenomenom

Question 86

Treatment of polymyositis and dermatomyositis?

Answer 86

Bed rest and a gentle programme, oral prednisolone, hydroxychloroquine for skin and ciclosporin/methotrexate upon relapse

Question 87

What are common causes of Septic Arthritis?

Answer 87

Staph. aureus, N. gonorrhoea, Group A streptococci invading the joints (may be introduced by the bloodstream or directly by injection)

Question 88

S&S of Septic Arthritis?

Answer 88

Warm, red and painful joint, fever, monoarthritis, decreased joint movement. THIS IS A MEDICAL EMERGENCY

Question 89

Treatment for Septic Arthrits?

Answer 89

Antibiotics (2 weeks IV, 4 weeks oral) and joint aspiration

Question 90

What are common causes of Osteomyelitis?

Answer 90

Staphylococcus from the bloodstream (commonly staph. aureus), fracture and sickle cell bone infarcts

Question 91

S&S of Osteomyelitis?

Answer 91

Swollen, red and warm limb, fever, pain and loss of range of motion. It mainly affects the ends of the long bones - the bone begins to produce pus and necrose (pus blocks the blood supply)

Question 92

Treatment for Osteomyelitis?

Answer 92

Antibiotics (vancomycin in gram +ve), drain the affected area, remove diseased bone, may require limb amputation

Question 93

What is spinal stenosis?

Answer 93

Narrowing of the spinal canal. This can cause neurogenic claudication. Pain is worse walking downhill and relieved leaning forward as this opens up the spine.