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5thyr > MSK > Flashcards

MSK Flashcards

1
Q

What is Polymyalgia Rheumatica?

Risk factors?

A

Polymyalgia Rheumatica

  • chronic, systemic rheumatic inflammatory condition
  • not a true vasculitis (pathogenesis unknown)

Risk factors

  • PMR and GCA share the same demographic characteristics (age >55, female)
  • PMR more common with people who have had synovitis of proximal large joints, tenosynovitis, and bursitis
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2
Q

Clinical presentation of Polymyalgia Rheumatica?

joint presentation?

peripheral?

systemic?

A

Clinical presentation of Polymyalgia Rheumatica

  • Aches/tenderness in PROXIMAL joints (shoulder, pelvic girdle, neck)
  • Morning stiffness (45 mins)> struggle to role over or stand in morning
  • Normally bilateral
  • Sub-acute onset (<2 weeks) or rapid (< 1 month)

Peripheral MSK symptom (50%):

  • Carpal tunnel syndrome
  • Peripheral arthritis (knees and wrists), which is asymmetric +self limiting
  • Swelling with pitting oedema of hands, wrists, feet, and ankles

Systemic symptoms (50%)

  • fatigue (muscle weakness is NOT a feature)
  • weight loss and anorexia
  • low grade fever
  • depression
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3
Q

Investigations for Polymyalgia Rheumatica?

(think about what you want to rule out

A

Polymyalgia Rheumatica
*important to exclude GCA, current infection or cancer , arthritis, thyroid disease, and statin-induced myalgia or myositis)

Bloods

  • FBC
  • ↑CRP, ↑ESR > 40 (can be normal)
  • LFTs (↑ALP), ↓T-cells,
  • CK (normal) -helps distinguish from myositis/myopathies
  • Us and Es
  • TSH (hypothyroid myopathy)
  • Ca (cancer)
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4
Q

Treatment of Polymyalgia Rheumatica?

A

Treatment of Polymyalgia Rheumatica

  • Trial of ORAL PREDNISOLONE with follow up 1 week to assess response (if no dramatic fall-consider differential)
  • ↓Dose slowly e.g. 1mg/month (according to Sx + ESR)
  • Continue Prednisolone for 2 years-provide blue steroid card)
  • Gastric (PPI) and bone protection (bisphosphonates)

*If initial rapid relief needed: IV IV Methylprednisolone (not always required)

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5
Q

How often should you review Polymyalgia Rheumatica?

What should you review?

A

Polymyalgia Rheumatica
-Review 1 wk after dose change and 3 monthly after that

What to review

  • review symptoms
  • screen for GCA
  • Side effects of steroids (weight gain, dyspepsia, weakness, thin skin, bruising
  • FBC, U+E (if needed)
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6
Q

What is Ankylosing Spondylitis?

What happens over time?

A

Ankylosing Spondylitis

  • chronic, inflammatory disease of SPINE + SACROILIAC JOINTS
  • causing bony outgrowths and ENTHESITIS (bamboo fusion of the spine)
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7
Q

What is the aetiology of Ankylosing Spondylitis?

A
  • Ankylosing Spondylitis has unknown aetiology
  • 90% are HLA-B27 +ve
  • MALE present earlier > Female (6:1 at 16yo, 2:1 at 30yo)
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8
Q

What is the clinical presentation of ankylosing spondylitis? (relieved by, radiation, assosiated symptoms

A

Ankylosing spondylitis

  • Typically a young man with gradual onset lower back pain + stiffness
  • Improves as day progresses and relieved by exercise
  • Radiates from macro-iliac joints to hip/buttocks
  • Associated symptoms: Enthesitis inflammation of tendons/ligaments (achilles tendon, plantar fasciitis)
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9
Q

What is the affect of ank spond on range of movement and on the shape of the spine?

A

Ankylosing spondylitis
Range of movement
-↓Lateral flexion + ↓Forward flexion (< 5cm = +ve Schober’s test)

Shape of spine
-Question mark deformity (loss of lumbar lordosis, exaggerated thoracic kyphosis and neck hyperextension)

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10
Q

what are the 7 extra articular manifestations of ank spond? (rule of A’s)

A

Ankylosing spondylitis

  1. anterior uveitis/iritis (results in blindness if untreated)
  2. aortic regurgitation
  3. apical fibrosis
  4. achilles tendon rupture
  5. av node block
  6. amyloidosis
  7. caudA equina
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11
Q

Investigations for ankylosing spondylitis?

A

Ankylosing spondylitis
Diagnosis is clinical (supported by imaging)
-X ray is 1st line
>sacroiliitis
>bamboo spine (fusing of supraspinous and interspinous ligaments)

Bloods

  • 90% will be HLA-B27 +ve
  • FBC (normocytic anemia)
  • ↑↑ESR/CRP
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12
Q

Managment of Ankylosing spondylitis

A

Ankylosing spondylitis
-chronic condition with NO CURE
-Things that may help improve symptoms:
-exercise
-1st line NSAIDS (Iboprufen and Naproxen) with PPI
>switch is not working
>can also add para, codeine or corticosteroids on top

-TNF-a inhibitors (adalimumab, etanercept, golimumab) – for severe active AS if Sx poorly controlled with NSAIDs
(must be monitored by rheumatologist)
Surgery – Hip Replacement (↓pain, ↑mobility)

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13
Q

Classic complications of Ankylosing spondylitis? (what do you do about it)

A

Ankylosing spondylitis
-Loss of vision from anterior uveitis/iritis (acutly painful red eye U/L eye → refer to ophthalmology immediately SAME DAY!!

-osteoporotic spinal fractures – Bisphosphonates

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14
Q

Where in the back is spinal compression most common?

Name 3 causes of spinal compression?

A

Cord compression (most commonly thoracic 66%)

  1. Oncological
    - extension of tumour from vertebral body
    - metastasis
  2. MSK
    - crush fracture
    - trauma/penetrating injury (Brown sequard syndrome)
    - prolapsed disk (lumbar)
  3. Inflammatory
    - Rheumatoid arthritis (weakness of ligaments attaching to odontoid peg→ rupture→ atlas (C1) slips forward
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15
Q

Clinical presentation of cord compression

A

Clinical presentation of cord compression

  • Back pain (90%)
  • Localised, or band like, radiating to extremities along spinal root
  • Worse lying flat, straining, coughing
  • Parasthesia/weakness/pain in legs or saddle (symetrical)
  • Bowel/bladder dysfunc: urinary retention (insidious), constipation or incontinence
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16
Q

Investigations for cord compression? (start top and work down)

How would reflexes be affected?

A

Investigations for cord compression

  • Neurological assessment CNS AND PNS (all 4 limbs)
  • Palpate spine for tenderness
  • Palpate abdo to assess urinary retention (distended)
  • Anal tone – ALWAYS CHECK

Reflexes

  • Reflexes: ↑below compression, absent at level, normal above
  • Clonus may be present
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17
Q

Management of spinal cord compression?

what is the prognosis?

A

Management of spinal cord compression
Full ABCDE assessment
-Stabilise + immobilise spine – lie flat
-Dexamethasone (16mg) w/ PPI cover (Omeprazole)
-URGENT MRI spine within 24 hrs of suspected SCC
Not all pts. present w/ back pain; if suspected ALWAYS DO MRI!! (Ct if C/I)
-Refer to neurosurgeons or oncologist

Prognosis: if motor function lost for 48 hours> recovery is unlikely

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18
Q

What is the prognosis of spinal cord compression?

What are the complications of spinal cord compression?

A

Spinal cord compression
-Prognosis: if motor function lost for 48 hours> recovery is unlikely

Complication

  • Paraplegia (thoracic) and quadriplegia (above C3,4,5)
  • Incontinence
  • Paralytic Ileus – common
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19
Q

What is brown sequard syndrome?

how does it present?

A

Brown sequard syndrome

  • Total hemisection of the spinal cord
  • Ipsilateral weakness, proprioception,fine touch, vibration
  • Contralateral loss pain and temp
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20
Q

Patient with graze on chin, weakess in upper limbs

A

Central cord syndrome

  • Man in a barrel syndrome
  • upper limbs>lower limbs
  • cervical injury
21
Q

What is osteoporosis?

What are the risk factors? (primary and secondary)

A

Osteoporosis

  • reduced bone mass
  • assymptomatic, can present with fragility fractures
Risk factors 
Primary 
-age 
-female 
-prolonged immobility(bone needs microdamage to repair)

Secondary (SHATTERED)

  • steroids
  • hyperthyroidism/parathyroidism (quickens bone turnover)
  • alcohol/tobacco
  • ↓Testosterone
  • Thin (BMI < 22)
  • Early menopause (protective oestrogen falls)
  • Renal or liver failure
  • Errosive/inflammatory bone disease
  • Diet (↓Ca2+)
22
Q

What are the investigations for osteoporosis? (bedside/bloods/imaging)

A 
Osteoporosis 
Bloods 
-TFT
-Calcium and phosphate  
-ALP 
-TSH (affect bone turnover) 
-Myeloma screen 
-Coelic screen

Imaging

  • Xray (low sens and spec-although good to see fractures)
  • Dexa scan (gold standard ∆)

Special

  • FRAX sore (fracture risk assessment)
  • high risk=treat
  • mod risk=do DEXA
  • low risk=lifestyle
23
Q

Explain the findings of a DEXA scan

A

DEXA scan measures bone density
T > -1.0 (normal);
T -1 to -2.5 (osteopenia)
< -2.5 (osteoporosis)

24
Q

Managment of osteoporosis? (conservative and medical-5)

A

Lifestyle measures

  • Quit smoking, ↓Alcohol
  • Weight bearing exercise → ↑Bone density
  • Balance exercises (Tai Chi) → ↓Falls risk

Medical
-Bisphosphonates for pts. with T score < -2.5 (Alendronate is 1st line, not if eGFR < 35)

-Ca2+ supplements and Vit. D if deficient

Additional
HRT – can prevent osteoporosis in post-menopausal women
Testosterone – hypogonadal men
IV bisphosphonates or denosumab injection given if oral not tolerated

25
Q

How do you take bisphosphonates?

What are the side effects of bisphosphonates?

A

Take bisphosphonates 30 mins before breakfast and stand

Common side effects of bisphosphonates (Alendronate)

  • fever
  • myalgia
  • arthralgia
  • GORD
  • osophagitis (stop)
26
Q

Adverse effects of bisphosphonates?

A

Adverse effects of bisphosphonates

  • osteonecrosis of jaw
  • hypophosphateamia/hypocalceamia
  • atypical femoral fractures (e.g. thigh pain)
27
Q

What are contraindications to bisphosphonates?

What do you do if they cant take?

A

Contraindications to bisphosphonates

  • X osophagitis
  • X memory problems (wont be able to take)
  • X egfr<35

Options if cant take

  • IV zolendronic acid (needs egfr >45)> once a year
  • DENOSUMAB (1st line for RENAL FAILURE)>every 6 months
28
Q

Differential for osteoporosis? (what would bloods show)

A

Osteomalacia (defect in mineralisation and ↓ bone quality)

  • ↓Ca2+/↓Phos
  • Increased ALP
29
Q

What antibodies are seen in lupus?

A

Lupus

  • ANA (if neg its not lupus!!)
  • dsDNA
  • anti smith
  • anti-histone in DRUG induced

*also do a urine dip and check complement (low c4)

30
Q

How does lupus present?

A

Lupus (RANCHeS)
RENAL impairment (ACR, egfr, creatinine)
AUTOIMMUNE (Anti-dsDNA, antiphospholipid antibodies, Coombs test in cases of heamolysis, antiSmith)
NEUROLOGICAL (seizures, psychosis, myelitis)
CUTANEOUS (rashes, ulcers, alopecia)
HAEMATOLOGICAL (heamolysis, leukopenia, thrombocytopenia)
SEROUS and SYNOVIAL (pleurisy, pericarditis, arthritis 90% patients)

31
Q

Whats the treatment for Lupus?

A
  • NSAIDS, steroids and hydroxychoraquine

- DMARDS and biologics if not

32
Q

What antibodies are seen in myositis?

A

-Anti-Jo-1 antibodies are specific for polymyositis and dermatomyositis (PM/DM).

also strongly related to interstitial lung disease (ILD)

33
Q

What is scleroderma (systemic sclerosis)?

What are the 2 types?

A

Scleroderma aka. Systemic sclerosis

  • multisystem autoimmune disorder
  • increase collagen and fibrosis

2 types:

  1. Limited cutaneous (ACA)
    - common, milder and slower
    - Puffy hands can be 1st sign
    - CREST SYNDROME (Calcinosis, Reynaud’s, Esophgeal dysmotility, Sclerodactyly telangiectasia)
  2. Diffuse cutaneous (SCL70)
    - less common, rapid onset, high mortality
    - can get ACCELERATED HTN (lung and kidney involvement)
34
Q

Classic presentation of scleroderma? (classical and systemic)

A 
Scleroderma
C-Chalky nodules (calcinasis) 
R-Reynauds 
E-REFLUX/heartburn 
S-Sausage fingers (sclerodactyly)+ hardened skin
T-Telangiectasia

Systemic

  • Classic autoimmune (tired/weight loss)
  • Lung involvement (fibrosis, pulmonary HTN)
  • Renal involvement (glomerulonephritis)
  • Cardiac involvement (pericarditis)
  • ERECTILE DYSFUNCTION
35
Q

What antibodies are assosiated with scerloderma?

Whats the treatment (3)

A

Centromere=limited
Anti-Scl 70 (more spesific to diffuse)

Treatment:

  • Ace inhibitors for accelerated HTN
  • Nifedipine/Losartan 1st line for Raynauds (prostaglandins if severe)
  • Immunotherapy: Methotrexate (MTX) or Mycophenolate mofetile
36
Q

SMALL VESSEL VASCILITIS
What are the ANCA+ve ones? (defining features?)
What are the ANCA-ve ones (defining features?)

A

SMALL VESSEL VASCILITIS
ANCA+
-Wegners/glanulomatosis polyangitis (nose bleeds/sinisitis) cANCA
-Churg strauss/eosinophilic (think asthma, eosinophils) pANCA

ANCA-

  • Polyarteritis nodosum
  • Goodpastures/antiglomerular basement membrane (anti-GBM with pulmonary heamorrgage and renal involvement-AKI)
  • All others (HSP/bechets/SLE/sjogrens)
37
Q

What are the treatment for vasculitis?

A

Treatment for vasculitis

  • High dose steroids
  • Biologics if not
38
Q

What is a vasculitic screen

A

Vasculitic screen

  • Biopsy and angiography is diagnostic for vasculitis
  • Antibodies
  • Urine dip
  • Complement level
39
Q

Management of Rheum arthritis during pregnancy?

A

Pregnancy and RA
Methotrexate is CI
-Give Hydroxychloroquine and/or Sulfasalazine with concomitant Folic Acid

40
Q

What can happen if you stop steroids suddenly?

Whats the treatment?

A

-addrenal insufficiency (hypothalamus axis is surpessed)
HYPERKALEMIC HYPOTENSION

-Treatment is IV hydrocortisone.

41
Q

What are sick day rules for people taking steroids?

A

‘Sick day rules’
-if acutely unwell double the usual dose of prednisolone or supplement IV hydrocortisone if unable to tolerate oral medication.

42
Q

2 important things to prescribe for a post menopausal women with fracture?

A

Any post-menopausal woman with fracture must be put on Bisphosphonates and Calcium supplements

43
Q

General features of vascilitis?

A

General features: fever/malaise/weight loss/skin changes/splinter heamorrgaes

44
Q

What conditions are ACA (anticentromere antibodies) found?

A

ACA antibodies

-characteristic of CREST syndrome of scleroderma (also Anti-Scl)

45
Q

Examples of medium vessel vascilitis?

A

MEDIUM VESSEL VASCILITIS

  • Polyarteritis nodosa
  • Kawasakis
46
Q

Examples of large vessel vascilitis?

A

LARGE VESSEL VASCILITIS

  • Takayasu (aortic arch syndrome)
  • Giant cell arteritis
47
Q

What is a classic sign of Polyarteritis nodosum?

What is PAN assosiated with?

A

Polyarteritis nodosum (spares the lung)

  • rosey bead sign on renal artery
  • associated with HepB
48
Q

What antibodies are seen in Sjögrens?

A

Sjögrens

  • anti-Ro and anti-La (these also pop up in Lupus)
  • Raised Immunoglobulins/ ESR/RF as well
49
Q

How would you describe Lupus rash?

A

Lupus rash

  • Malar BUTTERFLY rash
  • Discoid rash
  • Photosensitivity – often causes disease flare (spare nasallabial folds)

5thyr (18 decks)

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