MSK, Reproduction and Psychiatry Summary Flashcards

Question

What are the investigations for Pelvic Inflammatory Disease?

Answer 1

FBC, CRP, hCG (ensure negative), MSU, high vaginal swab, endocervical swabs, blood cultures if febrile, pelvic USS, screen for chlamydia and gonorrhoea (low vaginal swabs)

Answer 2

Low threshold for treatment Oral oflaxacin and oral metronidaole OR Intramuscular ceftrioaxone and oral doxycycline and oral metronidazole Surgical treatment may be indicated in the case of pelvic abscesses

Answer 3

Infertility Chronic pelvic pain Ectopic pregnancy

Answer 4

Intense fear of separation and rejection Clings to relationships, unfortunately this means that a lot of these people end up in abusive relationships. They hold on to someone who completely takes care of them. Lacks self confidence Difficulty making simple decisions e.g what to eat.

Answer 5

2 of the three - Polycystic ovaries on USS - Oligo ovulation or anovulation - Clinical hirsuitism, acne or biochemical signs of hyperandrogenism

Answer 6

Type 2 diabetes Sleep apnoea Cardiovascular risk Endometrial hyperplasia and carcinoma

Answer 7

Pelvic USS Testosterone and sex-hormone binding globulin Glucose tolerance test BP FSH:LH

Answer 8

**get BMI within 18-30 range, if BMI is normal** then use ovulation induction agent (clomiphene, gonadotrophins, GnRH, according to the group), **oral contraceptive pill** antiandrogen (combined hormonal contraception, spironolactone, eflornithine cream) endometrial protection (CHC, progestogens, mirena US (progestin IUD) (remember that endometrial hyperplasia is a complication. fertility (clomiphene/metformin) Cosmetic theapies for hirsuitism

Answer 9

asymptomatic, SOB/chest pain, unilateral leg welling/pain, unexplained tachycardia, calf muscle tenderness,

Answer 10

haemoptysis, pleural rub

Answer 11

D-dimer is unreliable, use ECG, leg Doppler, CXR, CTPA, V/Q scans to assess mismatch

Answer 12

low molecular weight heparin, (WARFARIN IS TERATOGENIC) thromboprophylaxis (stockings, increase mobility) should be considered in those with risk factors or following C section, for 6w post-partum

Answer 13

pregnancy is hypercoagulable state: increase in fibrogen, factor VIII, VW factor, platelets, decrease in natural anticoagulants (antithrombin III), increse in fibrinolysis)

Answer 14

older mothers, increasing parity, increased BMI, smokers, IV drug users, PET, dehydration (due to hyperemesis), decreased mobility, infections, operative delivery, prolonged labour, haemorrhage, blood loss \>2L, previous VTE, FH of VTE, sickle cell disease

Answer 15

primary infertility: unprotected sexual intercourse for over 1 year and no history of pregnancy secondary infertility: unprotected sexual intercourse for over 1 year with a previous history of pregnancy

Answer 16

change in shaving frequency (testosterone), mumps infection, STI (chlamydia/gonorrhoea), history of varicoceal repair, vasectomy, Klinfelter’s

Answer 17

semen analysis, repeat semen analysis if required CF screening if azoospermia, fat and hair distribution, STDs (chlamydia, gonorrhoea, NSTD), caryotype (Klinefelter syndrome), congenital absence of vas deferens,

Answer 18

rubella immunity, chlamydia, TSH, mid luteal progesterone if periods are regular, day 1-5 FSH, LH, PRL, testosterone if periods irregular, pelvic US, tubal patency test

Answer 19

surgical sperm retrieval, reversal of vasectomy, donor insemination, intra-uterine insemination, IVF/ICSI (intracytoplasmic sperm injection, injection of mature egg with single sperm, overnight incubation), DI (?) sperm donation

Answer 20

clomifene, gonadotrophins, laparoscopic ovarian drilling, GnRH, tubal surgery, oocyte donation

Answer 21

CF, testicular maldescent, testicular problem, pre-testicular (hypothalamus) or post-testicular. Previously mentioned that there can also be absence of vas deferens failure of production (35%) Klinfelter’s syndrome previous mumps or TB failure of transport sterilisation CF impotence

Answer 22

ovulatory disfunction (25%) PCOS premature menopause Turner’s surgical removal hyperprolactinaemia weight loss/stress Sheehan’s syndrome tubal dysfunction (25%) previous PID endometriosis sterilisation uterine abnormality

Answer 23

Becasue prolactin inhibits GnRH

Answer 24

Threatened Inevitable Incomplete Complete Septic Missed

Answer 25

This is when there is bleeding from the gravid uterus before 24 weeks gestation, when there is a viable fetus and no evidence of cervical dilation. The uterus may remain viable and the pregnancy continues without any further problems. The cervix is closed in speculum examination.

Answer 26

when there is dilation of the cervix

Answer 27

When there is only partial expulsion of the products of conception

Answer 28

Complete expulsion of the products of conception

Answer 29

Following incomplete abortion there is always a risk of ascending infection into the uterus which can spread through the pelvis and is known as septic abortion

Answer 30

When the fetus has died but the uterus has made no attempt to expel the products of conception. No symptoms or could have bleeding vaginally. Gestational sac seen on scan. No clear fetus or fetal pole with no fetal heart seen in the gestational sac.

Answer 31

**Abnormal conceptus** chromosomal, genetic, structural - It is estimated that 50% of spontaneous miscarriages may be due to abnormal chromosomes. **Uterine abnormality** congenital, fibroids - Congenital uterine abnormalities result from a failure of normal fusion of the mullerian ducts - incidence of spontaneous miscarriage in this group is estimated to be double that of the normal population. Submucosal fibroids are especially associated with spontaneous miscarriage due to distortion of the uterine cavity. **Cervical incompetence** Primary, secondary - The cervix opens prematurely with absent or minimal uterine activity and the pregnancy is expelled. Trauma to the cervix can be an important aetiological factor such as cone biopsy treatment? **Maternal** increasing age, diabetes - Hormonal imbalances are also said to be a cause of spontaneous miscarriage. The corpus luteum is essential for ensuring the survival of the pregnancy during the first 8 weeks of term. If the corpus luteum is to be removed surgically then abortion will usually occur within 7 days. In threatened miscarriage, those that continue to have inevitable miscarriages will have lower levels of progesterone than those that continue pregnancies to term. Maternal causes of spontaneous miscarriage can include **SLE**, **thyroid disease**, acute maternal **infection** such as appendicitis, pyelitis. Maternal infection causes general toxic illness with high temperature that can stimulate uterine activity and loss of pregnancy. Unknown

Answer 32

Minor bleed, positive, pregnancy test, vomitting Enlarged uterus Feeling of pelvic pressure

Answer 33

Increased beta HCG

Answer 34

**Molar pregnancy is an abnormal form of pregnancy in which a non-viable fertilized egg implants in the uterus and will fail to come to term**. A molar pregnancy is a gestational trophoblastic disease which grows into a mass in the uterus that has swollen chorionic villi. These villi grow in clusters that resemble grapes. A molar pregnancy can develop when fertilized egg had not contained an original maternal nucleus. The products of conception may or may not contain fetal tissue. It is characterized by the presence of a hydatidiform mole. Molar pregnancies are categorized as partial moles or complete moles, with the word mole, being used to denote simply a clump of growing tissue, or a growth.

Answer 35

Complete = single sperm fertalises enucleate egg, this means that the moile only contains paternal DNA. There are no fetal cells and there is a risk of GTN (gestational trophoblastic neoplasia) - this includes invasive mole, choriocarcinoma and placental site trophoblastic tumour. Partial = One normal egg cell fertilised by two normal sperm cells, usually triploid. Some fetal cells are evident such as amnion and RBC,s there isn't really an association with choriocarcinoma.

Answer 36

Spontaneous abortion Previous molar pregnancy Infertility Maternal age of extremes (less than or equal to 15 or older than 35) Low dietary carotene (this is a precursor for vitamin A)

Answer 37

Malignancy Hyperthyroidism Hypermesis gravidarum (associated with large amounts of beta HCG) Preeclampsia

Answer 38

Transvaginal ultrasound Chest X-Ray to look for malignant spread

Answer 39

remove tissue by curretage, if beta hCG returns to normal then no further treatment, if beta hCG stays high (persistent disease) then cure by methotrexate

Answer 40

period amenorrhoea +/- positive pregnancy test, +/- vaginal bleeding, +/- pain in the abdomen +/-GI or urinary symptoms, syncope, lower abdominal pain, bleeding (normally light)

Answer 41

US scan (no intrauterine gestational sac, may see adnexal masses, fluid in pouch of Douglas), serum Beta HCG levels, serum progesterone levels, FBC, diagnostic laparoscopy

Answer 42

- medical: methotrexate - surgical: laparoscopic salpingectomy/ salpinotomy for few indications conservative + USS in following pregnancies

Answer 43

- medical: methotrexate - surgical: laparoscopic salpingectomy/ salpinotomy for few indications conservative + USS in following pregnancies

Answer 44

Pelvic inflammatory disease Chlamydia Gonorrhoea Previous tubal surgery Previous ectopic Assisted conception

Answer 45

Fallopian tube is the most common (especially ampullary region) Cervical Abdominal Ovarian Uterine cesarean scar

Answer 46

Severe abdominal pain (may refer to shoulder with phrenic nerve irritation) Rebound tenderness Guarding indicates peritoneal irritation Haemodynamic instability (feeling faint, syncope, tachycardia, hypotension, diaphoresis)

Answer 47

Placenta praevia Placental abruption APH of unknown origin Local lesions of the genital tract Vasa praevia (very rare)

Answer 48

primary PPH :\>500 mL blood loss within first 24h delivery secondary PPH: \>500 mL blood loss after 24h of delivery

Answer 49

may present with tachycardia, tachypnoea, hypotension if severe bleeding

Answer 50

obstetric emergency, resuscitation and treat cause (fluids, uterine massage, drugs to stimulate contractility (oxytocin, ergometrine) if still bleeding then insertion of intrauterine balloon, uterine artery embolisation, uterine artery ligation, hysterectomy

Answer 51

pathology: 4 Ts tone (uterine atony) (commonest) trauma (cervical, vagina and perineal tears) tissue (retained placenta or membranes) thrombin (coagulation disorder)

Answer 52

PLacenta partially or completely covers the lower uterine segment

Answer 53

Asymptomatic or can present with painless PV bleeding which can range from light to torrential.

Answer 54

Low-lying placenta identified at 20 week anomaly ultrasound Needs confirmation in third trimester as may migrate away from lower segment

Answer 55

Delivery by caesarean section

Answer 56

Post-partum haemorrhage

Answer 57

Premature separation of the placenta from the uterine wall

Answer 58

Trauma Higher risk in multiple pregnancy, polyhydramnios, pre-eclampsia, smokers

Answer 59

Pain Vaginal bleeding May be concealed and present with abdominal pain Woody hard uterus is a classic sign

Answer 60

May have to do immediate C section in worst cases but vaginal delivery may be achieved

Answer 61

complications include maternal shock, collapse, fetal death, maternal DIC (disseminated intravascular coagulation), renal failure, postpartum haemorrhage, ‘couvelaire uterus’

Answer 62

onset of labour before 37 completed gestational weeks. sign is contraction with evidence of cervical change on vaginal examination

Answer 63

Acute illness Low BMI Multiple pregnancy Polyhydramnios Pre-term rupture of membranes Previous cervical surgery Previous preterm deliver Smoking Uterine abnormalities

Answer 64

The mother should deliver the baby in a unit where adequate facilities to care for the neonate are available Medical = corticosteroids associated with significant reduction in neonatal death, respiratory distress syndrome and intraventricular haemorrhage in the newborn Tocolytics = atosiban, nifedipine Surgical = cervical cerclage for those at risk or identified as having a short cervix

Answer 65

primary: chancre lesion, raised painless papule with ulcerated centre, usually found at the site of inoculation; lymphadenopathy secondary: widepsread mucocutaneous lesions, fever, malaise, headache, lymphadenopathy, sore throat tertiary: characteised by gumma, usually found in liver, bone and testes

Answer 66

Spirochaete - treponema pallidum

Answer 67

primary: **chancre lesion**, raised painless papule with ulcerated centre, usually found at the site of inoculation; **lymphadenopathy** secondary: widepsread mucocutaneous lesions, fever, malaise, headache, lymphadenopathy, sore throat tertiary: characteised by gumma, usually found in liver, bone and testes

Answer 68

**microscopy** of fluid from mucocutaneous lesions, veneral diseases research lab (VDLR), **treponema pallidum haemagglutination assay** (TPHA), CXR, CT/MRI, lumbar puncture looking for complications

Answer 69

Penicillin

Answer 70

Spontaneous abortion, birth defects

Answer 71

Aortic aneurysmn Aortic regurgitation

Answer 72

Tabes dorsalis Brain atrophy Argyll Robertson Pupil

Answer 73

Bacterial infection caused by Neisseria Gonorrhoeae

Answer 74

Purulent penile discharge Often asymptomatic in women

Answer 75

Microscopy of discharge reveals characteristic gram-negative diplococci

Answer 76

Cephalosporin, widespread antibiotic resistance

Answer 77

Septic arthritis - most common cause of monoarthritis in sexually active adults

Answer 78

female: usually none, sometime cervicitis/cystitis, lower abdominal pain, intermenstrual bleeding male: often asymptomatic discharge, dysuria

Answer 79

Chlamydia Trachomatis

Answer 80

enzyme immunoassays, nucleic acid amplification test, urine testing for Chlamydia

Answer 81

The two most commonly prescribed antibiotics for chlamydia are: azithromycin – given as 2 or 4 tablets at once doxycycline – given as 2 capsules a day for a week Your doctor may give you different antibiotics, such as amoxicillin or erythromycin, if you have an allergy or are pregnant or breastfeeding. A longer course of antibiotics may be used if your doctor is concerned about complications of chlamydia.

Answer 82

Peri-hepatitis (fitz hugh-curtis syndrome)

Answer 83

mother is given antiviral therapy anyway (highly active anti-retroviral therapy, HAART), C-section and no breastfeeding if high load of anti-viral (zidovudine) prior to delivery and given to infant, maybe vaginal delivery if low viral load

Answer 84

usually asymptomatic, symptomatic trush (itching, discharge, classically thick, ‘cotton cheese’, but often just increased amount) Itch and discharge fissuring, erythema with satellite lesions, characteristic discharge

Answer 85

Gram stained preparation, culture

Answer 86

azole antifungals (clotrimazole (+ clotrimazole HC if vulvitis) and fluconazole)

Answer 87

Candida albicans

Answer 88

risk factors: diabetes, oral steroids, immune suppression including HIV, pregnancy, reproductive age group

Answer 89

usually asymptomatic, watery grey/yellow ‘fishy’ discharge, may be worse after period/sex, sometimes sore/itch from dampness,

Answer 90

Gram stained smear of vaginal discharge

Answer 91

Gram stained smear of vaginal discharge

Answer 92

oral metronidazole for 5-7 days 70-80% initial cure rate relapse rate \> 50% within 3 months the BNF suggests topical metronidazole or topical clindamycin as alternatives

Answer 93

Amsel's criteria for diagnosis of BV - 3 of the following 4 points should be present ## Footnote thin, white homogenous discharge clue cells on microscopy: stippled vaginal epithelial cells vaginal pH \> 4.5 positive whiff test (addition of potassium hydroxide results in fishy odour)

Answer 94

increased gardnerella, ureaplasma, mycoplasma, anaerobes, reduced lactobacilli Bacterial vaginosis (BV) describes an overgrowth of predominately anaerobic organisms such as Gardnerella vaginalis. This leads to a consequent fall in lactic acid producing aerobic lactobacilli resulting in a raised vaginal pH

Answer 95

lifestyle changes change in medication as ACE inhibitors like ramipril and enalopril cause birth defects and impaired growth), use angiotensin receptor blockers (losartan, candesartan), anti diuretics and lower dietary sodium. Aim to keep BP \< 150/100 (**labetolol** (Beta blocker), **nifedipine** (ARB), **methyldopa** (alpha2 receptor adrenergic agonist), monitor for superimposed pre-eclampsia, if on beta-blockers for hypertension then monitor fetal growth,

Answer 96

Normal signs of hypertension Headaches Dizziness Blurred vision Epistaxis Angina Syncope Signs of heart failure

Answer 97

asymtomatic or headache, blurry vision, epigastric pain, pain below ribs, vomiting, sudden swelling of hands, face and legs, clonus, brisk reflexes, papilloedema, reduced urine output, convulsions, epigastric pain, right upper quadrant pain, visual disturbance, leg swelling Eclampsia is characterised by tonic clonic seizures Can also cause pulmonary oedema, cerebral haemorrhage, HELLP syndrome, placental abruption HELLP syndrome is haemolysis, elevated liver enzymes and low platelets

Answer 98

High Bp Raised liver enzymes Bilirubin Raised urea and creatinine Raised urate Low platelets Low haemoglobin Signs of haemolysis Features of DIC

Answer 99

IUGR Intrauterine death Iatrogenic preterm delivery

Answer 100

creatinine ratio \>30mg/mmol, 24h urine protein collection \>300mg/day, mild HT on two occasions or more, more than 4 hours apart or moderate to severe HT

Answer 101

Serial blood pressure Urinalysis Urine protein/creatinine ratio FBC U and E LFT Coagualtion Group and save if delivery thought to be likely CTG to assess fetal well-being

Answer 102

oral labetalol is now first-line following the 2010 NICE guidelines. Nifedipine and hydralazine may also be used delivery of the baby is the most important and definitive management step - caesarean section Magnesium sulphate is used to prevent seizures Methyldopa can also be used for lowering blood pressure. Steroids are given for fetal lung maturity Induction of labour (avoid ergometrine - this precipitates

Answer 103

mother: eclampsia, severe HT, cerebral haemorrhage, stroke, hemolysis, elevated liver enzymes, low platelets, liver and renal failure, disseminated intravascular coagulation, renal failure, pulmonary oedema, cardiac failure, impaired placenta perfusion,, growth, HELLP syndrome, pappiloedema, pulmonary oedema, placental abruption, disseminated intravascular coagulation

Answer 104

on fetus: increased risk of congenital anomalies, perinatal mortality, macrosomial, shoulder dystocia, polyhydramnios

Answer 105

on mother: diabetic nephropathy and retinopathy may deteriorate. Increased risk of miscarriage, pre-eclampsia and operative delivery

Answer 106

on mother: diabetic nephropathy and retinopathy may deteriorate. Increased risk of miscarriage, pre-eclampsia and operative delivery

Answer 107

Important to note that there is increase in insulin requirement, early induction of labour and early feeding of baby to reduce neonatal hypoglycaemia before pregnancy, to prevent malformations: make sure blood sugars are 4-7mmol/L pre-conception and HbA1c \<6,5% (\<48mmol/L), folic acid 5mg, dietary advice, retinal and renal assessement during pregnancy, to prevent metabolic complications: increase insulin, can continue oral anti-diabetic agents, should be aware of hypos risk, watch for ketonuria/infections, repeat retinal assessement 28 and 34w, watch fetal growth, observe mother for PET, oral hypoglyacemics are usually avoided (according to book page 259) giving birth: induction of labout at 38-39 weeks is the norm, consider C-section if significant fetal macrosomia, maintain blood glucose in labour with insulin-dextrose insulin infusion, continuous CTG fetal monitoring in labour, early feeding of baby to reduce neonatal hypoglycaemia, switch back to pre-pregnancy regimen for insulin post delivery

Answer 108

increased risk of congenital fetal abnormalities (especially if blood sugars high peri-conception), miscarriage, pre-eclampsia, fetal macrosomia, polyhydramnios, operative delivery, shoulder dystocia, worsening of maternal nephropathy, retinopathy, hypoglycaemia, reduced awareness of hypoglycaemia, infections, stillbirth, increased perinatal mortality, neonatal death (impaired lung activity, neonatal hypoglycaemia, jaundice, obstruction of labour)

Answer 109

never had period, either \>14 and no secondary sexual characteristics or \>16 and sexual characteristics

Answer 110

GnRH, hCG, TFT, LH, FSH, prolactin, chromosomal karyotype, pelvic USS, oestrogen, TSH, progesterone challenge test (oral progesterone for 5 days, if there is endogenous oestrogen and normal anatomy, withdrawal bleeding will occur), pregnancy test, testosterone?

Answer 111

Gradual build up with estrogen Effect on breast development Add progesterone Once maximum height potential is reached At least 20 mg of estrogen dose

Answer 112

So if there is anovulation then - progesterone given and then removed, bleeding 2-7 days later. This is dependant on sufficient estradiol concentration in the serum. If no bleeding = Low serum estradiol, hypothalamic pituitary axis dysfunction, non-reactive endometrium, outflow tract abnormality such as cervical stenosis. If it is not an outflow tract obstruction then it is likely to be due to low oestrogen. Withdrawal bleeding occurs after removal of oestrogen / progesterone therapy.

Answer 113

Pregnancy PCOS Hypothalamic disorders Hyperprolactinaemia Ovarian failure / menopause Thyroid disease Anatomical disorders of outflow

Answer 114

absence of menstruation \> 6 months in a woman who has previously menstruated

Answer 115

hirsutism and other androgen-linked features (enlarged clitoris, acne, deep voice)

Answer 116

control BMI, HRT if premature ovarian insufficiency, emotional support anatomical causes: surgery for imperforate hymen/transverse septum

Answer 117

causes: pregnancy, breast feeding, contraception, polycystic ovaries, early menopause, thyroid disease, cushing’s, raised prolactin (medication related or prolactinoma), hypothalamic, androgen secreting tumour (high testosterone), Sheehans syndrome (pituitary failure), Asherman’s syndrome (intrauterine adhesions)

Answer 118

“mass down below”, “dragging sensation” vaginal: feeling/seeing a bulge, sensation of bulge, difficulty in inserting tampons, **dyspareunia** urinary: hesitancy, incomplete emptying, poor stream, prolonged stream, urinary incontinence, frequency/urgency, manual reduction of prolapse to start or complete void bowel: incontinence of void/flatus, feeling of incomplete emptying, straining, urgency, digital evacuation to complete defecation, splinting or pushing on or around the vagina or perineum to start or complete defecation

Answer 119

POP quantification (POPQ score) stage 0-6, measure of cm, USS/MRI (thickness of levator ani), urodynamics (exclude concurrent UTI), IVU (view ureters, bladder and kidneys with contrast), renal USS (if suspicion of obstruction)

Answer 120

prevention: avoid constipation, manage chronic chest pathology (COPD, asthma), smaller family size, muscle training (PFMT)? (cannot treat fascial cases) conservative: pelvic floor exercises, ring and shelf pessaries (except if inability to hold it for 2 weeks) surgical: vaginal hysterectomy, anterior and posterior vaginal wall repair + perineometer, biofeedback, vaginal cones, electrical stimulation,

Answer 121

Caused by weakening of pelvic floor normally secondary to child birth

Answer 122

usually asymptomatic or dysmenorrhoea (painful periods), menorrhagia (excessive bleeding), pelvic pain, pressure symptoms on bladder, intermenstrual bleeding (for submucous or intramural types), bloating

Answer 123

large fibroids are palpable abdominally, uterus may be enlarged on pelvic examination Transvaginal USS, Pelvic USS, hysteroscopy?

Answer 124

same as menorrhagia medical treatment is less efficient if fibroids are large and distort the cavity only if symptomatic **myomectomy**, hysteroctomy, transcervical resection (submucous), GnRH analogues or **ulipristal acetate** to temperarily shrink the fibroids (pre-op) progestin IUD, tranexamic acid, OCP, surgery interventional radiology: uterine artery embolisation and MRI- guided ablation of fibroids may be possible in specialist centres

Answer 125

Pain Malpresentation/obstruction of labour

Answer 126

smooth muscle growth, can be: submucosa (protrude into uterine cavity) intramural (within uterine wall) subserosal (project out of uterus into peritoneal cavity)

Answer 127

Benign tumour arising from the myometrium

Answer 128

Uterine fibroids Dysfunctional uterine bleeding Coagulopathies Pelvic malignancies

Answer 129

Heavy menstrual bleeding (more than 80ml per cycle)

Answer 130

FBCs TFTs Pelvic USS hCG Hysteroscopy and endometrial biopsy if simple treatment fails or suspicous features

Answer 131

medical: progesterone only pill, tranexamic acid, mefenamic acid, combined oral contraceptive, mirena, GnRH analogues, surgery: trans-cervical resection of submucous fibroids, endometrial ablation, myomectomy, hysterectomy

Answer 132

dysmenorrhoea, deep dyspareunia, chronic pelvic pain, ovulation pain, infertility, dyschezia (pain of defecation), tenderness or palpable nodules on bimanual examination, frozen pelvis Passmedicine: chronic pelvic pain dysmenorrhoea - pain often starts days before bleeding deep dyspareunia subfertility non-gynaecological: urinary symptoms e.g. dysuria, urgency, haematuria. Dyschezia (painful bowel movements) on pelvic examination reduced organ mobility, tender nodularity in the posterior vaginal fornix and visible vaginal endometriotic lesions may be seen

Answer 133

adnexal masses or tenderness nodules or tenderness in posterior vaginal fornix or uterosacral ligaments, fixed (because of fibrous scar tissue) retroverted uterus, rectovaginal nodules

Answer 134

laparoscopy (gold standard) look for clear, red, bluish lack or with lesions, pelvic MRI for deep endometriosis, if severe disease is suspected and surgical planning necessary pelvic USS can diagnose endometrioma (chocolat cyst) or large nodules

Answer 135

medical: NSAIDs, COCP, danazol/gestrinone, mirena IUS, GnRH agonist (leuprorelin), progesterone, levonorgestrel (LNG), GnRH analogues surgical: remove endometriosis, goes from laparoscopic ablation of lesions to hysterectomy and bilateral salpingo-oophorectomy pain management

Answer 136

Endometriosis Pelvic adhesions Chronic PID Ovarian cysts Pelvic venous conegestion Uterine fibroids

Answer 137

dysmenorrhoea, dysparenunia, menorrhagia, bulky tender uterus Endometriosis doesn't have menorrhagia by the looks of it so this would be the key difference between the two

Answer 138

MRI, hysterectomy and histological diagnosis as diagnostic is often flawed

Answer 139

Hormonal contraception for heavy/painful periods (mirena US, progestogens, combined OCP)

Answer 140

Presence of endometrial tissue in the myometrium

Answer 141

non-speciifc bowel symptoms (indigestion, early satiety, loss of appetite, altered bowel habit/pain, bloating, discomfort, weight loss) overlap with IBS symptoms pelvic mass (asymptomatic or pressure symptoms), adnexal mass on pelvic examination, late-stage disease may present as a large pelvic mass, ascites, palpable lymph nodes and pleural effusion

Answer 142

diagnosis: Ca125 (carcinoma antigen), pelvic USS, staging: pelvic MRI/CT chest/abdomen/pelvis, colonoscopy/OGD may be indicated is there is a possibility of primary GI malignancy, US guided biopsy of omentum, staging (1-4) stage 1 (tumour limited to ovaries) stage 2 (tumour involves one or both ovaries with pelvic extension stage 3 (tumour with peritoneal implants outside the pelvis or retroperitoneal and or inguinal nodes) stage 4 (tumour with distant metastasis) Diagnosis is difficult and often relies on diagnostic laparotomy

Answer 143

protective: OCP, prophylactic oophorectomy, having many children Platinum based chemotherapy stage 1: total abdominal hysterectomy and bilateral salpingoophorectomy and omentectomy +/- chemotherapy stage 2: stage 1 + /- lymphadenectomy with surgical effort to remove all disease stage 3: stage 2 +/- neoadjuvant chemotherapy to reduce tumour mass before surgery stage 4: stage 3 + pallative chemotherapy

Answer 144

genes associated: BRAC1, BRAC2, HNPCC/Lynch type 2 familial cancer syndrome

Answer 145

around 90% of ovarian cancers are epithelial in origin, with 70-80% of cases being due to serous carcinomas

Answer 146

FH, \>30 y/o, FH (2 or more relatives), cancer gene mutation carriers) for risk (combines menopausal status, ultrasound score and CA 125) use RMI I score (if 250 or greater then referral to specialist team)

Answer 147

CA 125 (glyco-protein antigen) can indicate malignancies (ovary, colon/pancreas and breast) and benign conditions such as menstruation, PID, endometriosis, liver disease, recent surgery, effusions

Answer 148

post-menopausal bleeding is most common feature, abnormal vaginal bleeding

Answer 149

women \>= 55 years who present with postmenopausal bleeding should be referred using the suspected cancer pathway first-line investigation is trans-vaginal ultrasound - a normal endometrial thickness (\< 4 mm) has a high negative predictive value hysteroscopy with endometrial biopsy MRI pelvis/CT chest, abdomen, pelvis for staging

Answer 150

(FIGO stage 1-4 according to depth of myometrial invasion, cervical involvement and lymph node involvement) and type (1 or 2) stage 1 (carcinoma strictly confined to the uterus) stage 2 (carcinoma extended to the endocervix (2A) or cervical stoma (2B)) stage 3 (spread to serosa of uterus, pelvic peritoneum or pelvic lymph nodes) stage 4 (local metastasis to bladder/bowel (4A) or distant metastasis (4B))

Answer 151

surgery: stage 1: total abdominal hysterectomy and bilateral salpingoophorectomy stage 2: radical total abdominal hysterectomy (TAH) + bilateral salpingoophorectomy (BSO) + radiotherapy +/- lymphadenactomy stage 3: surgery + radiotherapy or radiotherapy alone stage 4: palliative radiotherapy (with progesterone if advanced stage) other: peritoneal washings (all laparoscopically), chemo if high risk histology, radiotherapy (external beam or caesium insertion)

Answer 152

type 1 (commonest): endometrioid adenocarcinoma, linked to excess oestrogen, hyperplasia with atypia precursor type 2: uterine serous & clear cell carcinoma, high grade, more aggressive, worse prognosis, generally older ladies, serous intraepithelial carcinoma precursor 95% is adenocarcinoma

Answer 153

Obesity Tamoxifen therapy (although antagonistic with respects to breast tissue tamoxifen may serve as an agonist at other sites. Therefore risk of endometrial cancer is increased cancer) Early menarche / late menopause Oestrogen secreting tumours HRT Endometrial hyperplasia with atypia Genetic predisposition (lynch syndrome)

Answer 154

lack of menstruation for \>1 year hot flushes and night sweats (vasomotor symptoms) vaginal dryness/soreness (vasomotor symptoms) dyspareunia (vasomotor symptoms) atrophy and thinning of vaginal epithelium overactive bladder symptoms (urgency, frequency) mood changes, loss of libido osteoporosis increase in cardiovascular risk

Answer 155

FSH and LH ar high Oestrogen is low

Answer 156

DEXA scan for bone density LH FSH Oestrogen Progesterone

Answer 157

Combined (oestrogen and progestogen) for a women with a uterus Oestrogen alone for those with hysterectomy Can be given sequentially (monthly withdrawal bleeding) or can be given continuously (period free)

Answer 158

VTE Breast cancer Endometrial cancer Gall bladder disease Vascular disease

Answer 159

first trimerster screening: combined test nuchal translucency, hCG and PAPP-A (pregnancy associated plasma protein A), AFP (alpha fetoprotein) first and second trimester: intergrated test combined test and ALP (alpha fetoprotein), oestriol, inhibin A second trimester: quadruple test hCG, estriol, AFP, inhibin A second trimester: anomaly USS if risk is \<1 in 250 then are offered chorionic villus sampling or amniocentesis

Answer 160

constant lower abdominal pain, purulent vaginal discharge, deep dyspareunia, pyrexia, irregular PV bleeding, adnexal tenderness dysuria, irregular periods

Answer 161

Cervical excitation

Answer 162

FBC, CRP, hCG (ensure negative), MSSU, high vaginal swab, endocervical swabs, blood cultures if febrile, pelvic USS, screen for chlamydia and gonorrhoea (low vaginal swabs)

Answer 163

medical: - mild: oral ofloxacin + metronidazole for 14 days - moderate: intramuscular ceftriaxone + oral doxycycline + metronidazole for 14 days severe: inpatient IV therapy if clinically unwell and severe surgical: may be indicated in severe cases with evidence of pelvic abscess prevention: contact tracing for sexual partners

Answer 164

Ectopic pregnancy Appendicitis Endometriosis IBS Ovarian cyst accident / cyst rupture UTI

Answer 165

Causative organisms ## Footnote Chlamydia trachomatis - the most common cause Neisseria gonorrhoeae Mycoplasma genitalium Mycoplasma hominis

Answer 166

infertility (10-20% after first episode), ectopic pregnancies, chronic pelvic pain, Fitz-Hugh-Curtis syndrome (in 10% cases)

Answer 167

hard lump, fixed mass, tethering to skin, dimpling of skin, often painless lump or thickening in breast, discharge or bleeding, change in size or contours of breast, change in colour of areola, redness or pitting of skin over the breast like the skin of an orange

Answer 168

triple assessement of any breast lump (clinical examination, radiological investigation (mammography/US) and biopsy) FNA cytology, core biopsy, mammography, US, sentinel lymph node biopsy (assess lymphatic spread), nipple scrape (Paget’s disease) or use discharge for analysis if present,

Answer 169

staging investigations: Hb FBC, U&Es, LFTs, CXR, CT thorax and abdomen, isotope bone scan if lymph node spread,

Answer 170

he Scottish Breast Screening Programme invites women aged between 50 and 70 years old for screening every three years. Women over 70 years old are able to attend through self-referral.

Answer 171

Non-invasive = Ductal carcinoma in situ, lobular carcinoma in situ Invasive = Invasive ductal carcinoma (most common) Invasive lobular carcinoma and its variants

Answer 172

Local skin Pectoral muscles Lymphatic axillary and internal mammary nodes Blood Bone Lungs Liver Brain

Answer 173

Histological assessment should be carried out to assess tumour type and to deter- mine oestrogen and progesterone receptor (ER/PR) status and HER2 status

Answer 174

wide local excision or mastectomy, removal of sentinel lymph node; hormonal markers predict response to hormonal treatment (trastuzumab herceptin) antihormonal therapy is tamoxifen or chemotherapy tumours \<4cm usually are eligible for breast conservation therapy if sentinal node biopsy contains tumour then radiotherapy on all of the axillary lymph nodes or remove all (clearance) micrometastases are treated with hormonal therapy or chemo trastazumab to patients with over expression of Her2 (monoclonal Ab) +follow up (yearly mammograms for 10 years)

Answer 175

What Type of Hormone Therapy do we Usually Give? If premenopausal – tamoxifen for 5 years If postmenopausal – tamoxifen for 5 years if excellent prognosis. BUT others get an aromatase inhibitor, eg ANASTROZOLE for 5-10 years

Answer 176

About 70% of breast cancers are ER positive. They respond well to treatment with hormonal therapies. Most commonly used hormone therapy drugs used to treat breast cancer are: tamoxifen aromatase inhibitors (anastrozole, exemestane and letrozole) goserelin (Zoladex) fulvestrant (Faslodex)

Answer 177

Node posistive Stage 3

Answer 178

Both genetic and hormonal factors play a role; about 5–10% of breast cancers are hereditary and occur in patients with mutations of BRCA1, BRCA2, AT or TP53 genes

Answer 179

Some breast cancers have high numbers of receptors for the protein HER2 (human epidermal growth factor 2). They are called HER2 positive breast cancers. About 1 in 7 women (15%) with early breast cancer have HER2 positive cancer. A drug called trastuzumab (Herceptin®) is an effective treatment for this type of breast cancer.

Answer 180

If the cancer does not have receptors for either HER2 or the hormones oestrogen and progesterone, it is called triple negative breast cancer. It affects up to 1 in 5 women (15–20%) with breast cancer and is more common in younger women

Answer 181

Tumour (T) T1 – 0-2cm T2 - 2-5cm T3 - \>5cm T4 – fixed to skin or muscle Nodes (N) N0- none N1 – nodes in axilla N2 – large or fixed nodes in the axilla Metastases (M) M0 – none M1 - metastases

Answer 182

Nottingham prognosis index This accounts for tumour size, lymph node score and grade score

Answer 183

Female sex Age Family history (BRCA1 and BRCA2) Early menarche late menopause Nullparity, higher age at first pregnancy Higher socioeconomic group HRT

Answer 184

screening: 25-64 y/o, smear test every 3 years when \<50 y/o, every 5 years when \>50 y/o If low grade dyskariosis then repeat in 6 months

Answer 185

Abnormal cells in the cervix detected by biopsy and histological examination are classified as cervical intraepithelial neoplasia (CIN). Graded 1 to 3 according to the proportion of cervix affected.

Answer 186

HPV 16 and 18 are highr risk subtypes

Answer 187

Grading is determined by how abnormal the cells look under a microscope as well as how much of the cervical tissue is affected. Epithelial lining of the transdformation zone of the cervix is the part that is affected

Answer 188

Three consecutive inadequate smear samples Three borderline dmears (squamous) Mild, moderate or severe dyskariosis Suspected invasive disease Dyskariosis (this is when the squamous epithelial cells have abnormal cytologic changes as well as charactersitic hyperchromatic nuclei and/or irregular nuclear chromatin). Another word for dyskariosis is dysplasia

Answer 189

colposcopy involves inspection of ectocervix under magnification. Acetic acid and Lugol’s iodine is applied to identify abnormality.

Answer 190

Histological diagnosis is achieved with biopsies of abnormal area

Answer 191

CIN 1: low grade dysplasia–will regress CIN 2: moderate dysplasia – may regress CIN 3: severe dysplasia – unlikely to regress

Answer 192

LLETZ (large loop excision of the transformation zone) Thermal coagulation Laser ablation + follow-up LBC at 6 months for cytology to check for recurrence of disease and to reassure, also regular smears are required after treatment to ensure adequate treatment

Answer 193

HPV infects basal layers of cells, viral genes expressed as host cell matures, deregulation of host cycles as viral DNA is integrated in cells

Answer 194

dyskariosis (abnormal cells may be few, nucleus is increased in size and nuclear/cytoplasmic ratio, variation in size, shape, outline, coarse, irregular chromatin, nucleoli)

Answer 195

asymptomatic or irregular PV bleeding, postcoital bleeding, intermenstrual bleeding, discharge, pain late cases present with disease progression; renal failure following ureteric obstruction or bowel and bladder involvement classical hard, craggy, bleeding cervix on pelvic examination or colposcopy

Answer 196

HPV infection Smoking STDs Immunodeficiency Persistent infection

Answer 197

Screening (prophylactic investigation) Cervical biopsy MRI of pelvis, CT of chest, abdomen, pelvis (to assess the spread)

Answer 198

stage 1 (carcinoma strictly confined to the cervix) stage 2 (carcinoma that extends into the parametrium or upper 2/3 of vagina) stage 3 (carcinoma has extended to pelvic side wall, lower 1/3 of vagina or causes hydronephrosis) stage 4 (carcinoma that has extended beyond the pelvis)

Answer 199

excision biopsy for stage 1a, radical hysterectomy or chemo-radio for stage 1b or 2, chemo-radio for stage 2b-4, chemothrapy is cisplatin, caesium insertion (brachy therapy) is another means of management

Answer 200

80-90% = squamous cell 10-20% = adenocarcinoma Ectocervix = squamous cell Endocervix = columnar cell

Answer 201

HPV 16 & 18 produces the oncogenes E6 and E7 genes respectively E6 inhibits the p53 tumour suppressor gene E7 inhibits RB suppressor gene

Answer 202

Human papillomavirus (HPV), particularly serotypes 16,18 & 33 is by far the most important factor in the development of cervical cancer. Other risk factors include: smoking human immunodeficiency virus early first intercourse, many sexual partners high parity lower socioeconomic status

Answer 203

urine leakage on coughing, laughing, sneezing, exercise, sexual intercourse. May be demonstrated on examination with a full bladder. Severity ranges from mild to severe. (dysuria, haematuria, voiding symptoms (interrupted flow, recurrent UTI, straining to void, prolapse symptoms (vaginal lump, dragging sensation in vagina), bowel symptoms (anal incontinence, constipation, faecal evacuation, dysfunction, IBS))

Answer 204

MSSU, urodynamics (3 day urinary diary, urine dipstick, Post voiding residual volume assessment Urodynamics (indicated if surgery is contemplated)

Answer 205

conservative: pelvic floor exercises, lifestyle changes (smoking cessation, lose weight, eat more healthily to avoid constipation, stop drinking alcohol or caffeine) tension free vaginal tape (for suburethral hammock theory) (TVT) or colposuspension but TVT is now 1st choice, physiotherapy (pelvic floor muscle training), medical: duloxetine surgery: tension-free vaginal tape, colposuspension, urethral bulking agents

Answer 206

Defect in anterior vaginal wall and pubo-urethral ligament Suburethral hammock

Answer 207

Age Parity Menopause Smoking Medical problems Increased intra abdominal pressure Pelvic floor trauma Denervation Connective tissue disease Surgery

Answer 208

conversative: physiotherapy, bladder retaining, lifestyle modifications, normalise fluid intake, reduce caffeine, fizzy drinks, chocolate, stop smoking, weight loss, medical: anticholinergics (oral or transdermal antimuscarinic), tri-cyclic antidepressants, surgical: Botox injections, clam cystoplasty, urinary diversion

Answer 209

involuntary loss of urine when there is involuntary detrusor activity symptoms of urgency and frequency with or without associated incontinence

Answer 210

Cartilage = chondroma - chondrosarcoma Bone = osteochondroma - osteosarcoma Fibrous tissue = fibroma - fibrosarcoma

Answer 211

Activity related pain Swelling Pathological fracture Deformity Neurovascular effects (limb weakness, numbness)

Answer 212

- MRI - XR (lesion is inactive or aggressive), - CT (ossification and calcification) - isotope bone scans (bone mets for staging) - angiography - PET - biopsy There may be tumour biomarkers in the blood

Answer 213

bony projection of bone which is capped with cartilage - exotosis

Answer 214

Giant cell tumour = forms multi-cystic bone lesions that look like soap bubbles

Answer 215

Lytic bone lesions which form a sunburts effect Osteosarcomas often cause the periosteum to lift and this is called codman's triangle

Answer 216

Ewings sarcoma - forms lytic bone lesions that look like an onion ring appearance

Answer 217

Osteochondroma

Answer 218

Pain NOT- activity related Deep-deated boring nature Night pain Difficulty weight bearing Analgesics are usually ineffective Swelling Warmth Pathological fractures Osteoporosis Joint effusion Deformtity Neurovascular effects

Answer 219

**chemotherapy**, **surgery**, **radiotherapy**, referral to specialist Tumour Centre for soft tissue tumours, **prophylactic internal fixation** to prevent pathological fracture fracture risk assessement is **Mirel’s Scoring System** (score 1-3 depending on site, pain, lesion type and size, if \>8 then internal fixation before radiotherapy) surgical excision, endoprosthetic replacement, chemotherapy, radiotherapy (in Ewing’s)

Answer 220

Be prepared for the laughing kid Breast Prostate Thyroid Lungs Kidneys

Answer 221

Chondrosarcoma Osteosarcoma Fibrosarcoma - fibrous tissue Multiple myeloma - this is from plasma cells

Answer 222

Osteosarcoma?

Answer 223

assocaited mutations include abnormal pRB protein which is associated with retinoblastoma, also the p53 protein which is associated with li-fraumeni syndrome which is a multi - system cancer syndrome. Osteosarcoma is caused by osteoblast cells which are pleomorphic and produce too much osteoid tissue

Answer 224

primary bone cancer spreads to breast, bronchus, prostate, kidney, thyroid

Answer 225

secondary bone tumour 25x commoner than primary

Answer 226

associated with t(11;22) translocation which results in an EWS-FLI1 gene product

Answer 227

patient over 45 and activity-related joint pain (pain after exertion) plus either morning stiffness \< 30 minutes, reduced ROM, deformity pain after exertion, IF linked to trauma, prolonged morning-related stiffness, rapid deterioration of symptoms, hot swollen joint then -\> gout, other inflammatory arthrides, septic arthritis, malignancy

Answer 228

patient over 45 and activity-related joint pain (pain after exertion) plus either morning stiffness \< 30 minutes, reduced ROM, deformity pain after exertion, If linked to trauma, prolonged morning-related stiffness, rapid deterioration of symptoms, hot swollen joint then -\> gout, other inflammatory arthrides, septic arthritis, malignancy

Answer 229

Loss of joint space Osteophytes Subchondral sclerosis Subchondral cyst

Answer 230

non-operative: analgesia (NSAIDs, codeins, topical capsaicin) lifestyle changes (social, quality of sleep, especially weight loss) physiotherapy occupational therapy walking aids intra-articular steroid injection thermotherapy, electrotherapy, aids and devices) operative: arthroscopy (NICE advise only if symptoms of mechanical locking) osteotomy (aims to correct malaligned joint) arthroplasty (joint replacement, ex: total hip replacement) arthrodesis (joint fusion)

Answer 231

Inflamatory process Progressive cartilage loss Subchondral bone formation and bony osteophytes May be secondary to trauma, infection or ceongenital conditions such as developmental dysplasia of the hip.

Answer 232

age of onset \<16y/o, duration of disease \>6 weeks, presence of arthritis is assessed by joint swelling or 2 of the following: painful or limited joint motion tenderness warmth

Answer 233

Polyarticular (5 joints or more) Pauci articular (4 joints or less) Stills disease which is systemic onset

Answer 234

Pauciarticular (this is 55%) THEN Polyarticular (25%) Systemic onset (20%)

Answer 235

Type 1 pauciarticular = uveitis Type 2 pauciarticular = iridocyclitis Type 3 pauciarticular = iridocyclitis, dactylitis, potential family history of psoriasis For pauciarticular constitutional symptoms are rare _Polyarticular_ Can be RF positive or RF negative Constitutional sypmtoms such as low grade fever and malaise RF negative = hepatosplenomegaly, growth abnormalities, mild anaemia RF positive = erosions in X-rayoccur early, can be complicated by sjrogens, feltys, aortic regurgitation or pulmonary fibrosis

Answer 236

Spiking fever for at least 2 weeks (high in the evening normal in the morning). Salmon red rash on trunk and thighs that accompanies the fever. Can be brought on by scratching ( Koebner's phenomenon) Generalised lymphadenopathy 50-75%. Non-tender. Hepatosplenomegaly Abdominal pain With or without transaminases Serositis (polyserositis, pericarditis in 36%). Tamponade and myocarditis is rare.

Answer 237

infant: failure to thrive, drowsy or irritable, metaphyseal tenderness + swelling, decreased range of motion positional change, commonest around knee child: severe pain, reluctant to bear body weight, tender fever + tachycardia, malaise, fatigue, nausea, vomiting), reduced range of motion adult: backache, history of UTI/urological procedure, history of diabetes, immunosuppression, commonest in thoracolumbar spine, limp, pain, general malaise, loss of appetite, fever, pseudoparalysis

Answer 238

Staph. aureus is the most common cause except in patients with sickle-cell anaemia where Salmonella species predominate.

Answer 239

MRI Others include: US, aspiration (swelling?), isotope bone scan, labelled white cell scan, MRI, FBC + WBC, ESR, CRP, CK, 3x blood cultures at peak of temperature, U&Es if ill dehydrated, bone biopsy, tissue swabs from up to 5 sites around implant at debridement in prosthetic infections but sinus tract and superficial swab results may be misleading (skin contaminants)

Answer 240

hydration and analgesia, rest & splintage, AB (choice depends on microbiology), IV AB for children, surgery is indicated for abscess drainage, debridement of dead/infected tissue, drainage of subperiosteal abscess, drainage of joint sepsis, Antibiotic therapy is usually: flucloxacillin for 6 weeks clindamycin if penicillin-allergic

Answer 241

diabetes mellitus sickle cell anaemia intravenous drug user immunosuppression due to either medication or HIV alcohol excess

Answer 242

Haematogenous spread in children and elderly Local spread from site of infection (trauma in open fracture, bone surgery or joint replacement) Secondary to vascular insufficiency

Answer 243

septicaemia death metastatic infection pathological fracture septic arthritis altered bone growth

Answer 244

Starts at the metaphysis of long bones

Answer 245

6 years old

Answer 246

long term AB (local: gentamicin cement, systemic: IV AB) surgery (mutliple ops to eradicate) deformity correction, massive reconstruction, amputation

Answer 247

fever, warm, red, swollen, painful joint, may also be an erythematous rash in adults: acute pain in single large joint, limping, swollen red joint, refusal to move joint (knee, ankle, wrist) (reluctancy to make any movement, increase T° and pulse, increase tenderness)

Answer 248

bloods: FBC, WCC, ESR, CRP, blood cultures, XR, US, uric acid (exclude gout), Ab (exclude RA), synovial fluid: aspiration, culture (cloudy?), increased leucocytes urine: MC&S (microscopy, culture, sensitivity) microbiology: urethral, cervical and anorectal swabs XR: soft tissue swelling, joint distension, later juxta-articular osteoporosis, periosteal elevation, joint space narrowing, bony erosions and possible osteomyelitis

Answer 249

fluid and pain control, AB, surgical drainage lavage, infected joint replacement, arthroscopy (knee, shoulder, ankle), arthrotomy, physiotherapy Passmedicine: synovial fluid should be obtained before starting treatment intravenous antibiotics which cover Gram-positive cocci are indicated. The BNF currently recommends flucloxacillin or clindamycin if penicillin allergic antibiotic treatment is normally be given for several weeks (BNF states 6-12 weeks) needle aspiration should be used to decompress the joint arthroscopic lavage may be required

Answer 250

Blood Eruption of bone abscess Direct invasion (penetrating wound, intra-articular injury, arthroscopy) Dissemination from osteomyelitis

Answer 251

Complete recovery OR partial loss of the articular cartilage OR Fibrous bony ankylosis Joint destruction

Answer 252

Articular cartilage is attacked by abcterial toxin and cellular enzyme Complete destruction of the articular cartilage source of infection can be from blood, adjacent sites (osteomyelitis, bone abscess) or it can be through direct introduction of the organism via trauma / instrumentation

Answer 253

most common organism overall is Staphylococcus aureus in young adults who are sexually active Neisseria gonorrhoeae should also be considered

Answer 254

acute osteomyelitis, trauma, irratable joint, haemophilia, rheumatic fever, gout, Gaucher’s disease

Answer 255

pain nerve, blood vessel, skin damage visceral damage (pneumotheorax in rib fracture) disruption to overlying soft tissue

Answer 256

Fractures have a variety of names. Below is a listing of the common types that may occur: Greenstick - Incomplete fracture. The broken bone is not completely separated. Transverse - The break is in a straight line across the bone. Spiral - The break spirals around the bone; common in a twisting injury. Oblique - Diagonal break across the bone. Compression - The bone is crushed, causing the broken bone to be wider or flatter in appearance. Comminuted - The break is in three or more pieces and fragments are present at the fracture site. Segmental - The same bone is fractured in two places, so there is a "floating" segment of bone. Main types are open vs closed

Answer 257

Grades are according to soft tissue injury: Type 1: low-energy clean wound \< 1 cm with minimal soft tissue injury and fracture communition Type 2: Wound 1-10 cm with moderate soft tissue damage and fracture communition Type 3: high-energy wound \>10cm (3A no periosteal stripping, 3B periosteal stripping, 3C major vascular injury)

Answer 258

ABC, analgesia, assess VTE risk and implement prophylaxis low-molecular weight heparin plus anti-embolism stockings if appopriate ie. hip fractures) prophylaxis for crush syndrome, infection (open fractures), tetanus, as required - compartment syndrome can follow on from crush syndrome so be prepared. Crush syndrome causes acute tubular necrosis of the kidneys (rep fracture-specific treatment: reduce for displaced fractures non operative: simple splinting: neighbouring strap (metacarpal fractures) plaster of Paris: easily moulded, cheap. often applied acutely as a backslab to allow for swelling fibreglass cast: lighter, less bulky, more rigid (disadvantage if swelling occurs) and more durable than POP operative: internal fixation Kirschner wire (screws and plates) external fixation uniplanar or ring (ie. Ilizarov frame) rehabilitate physiotherapy occupational therapy

Answer 259

minutes to hours complications (immediate): **fat embolism** hours to days complications (early): **compartement syndrome** immobility wound infection **DVT and PE** neurovacular damage weeks to months complications (late): stiffness Sudek’s atrophy malunion pseudoarthrosis - a joint formed by fibrous tissue bridging the gap between the two fragments of bone of an oldfracture that have not united secondary osteoarthritis chronic osteomyelitis avascular necrosis CRPS type 1 implant failure psycholigcal & social aspects complications from bed rest

Answer 260

non-operative: radiotherapy operative: partial fasciectomy (+ physio), dermo-fasciectomy (+ intense physio, no recurrence), arthodesis, amputation, percutaneous needle fasciotomy (potential recurrence, risk of nerve injury), collagenase (30% recurrence, radical, cost)

Answer 261

Autosomal dominant but onset may be sex linked, white people disease

Answer 262

Ring finger follwed by little and middle fingers

Answer 263

Formation of abnormal connective tissue within the palmar fascia

Answer 264

Male Old age Alcohol Diabetes Tobacco HIV Epilepsey

Answer 265

Starts in the palms causing puckering of the skin. Metacarpophalangeal (MCP) joints affected before the proximal interphalangeal (PIP) joints.

Answer 266

clicking sensation with movement of digit, clicking may progress to locking, may have to use other hand to “unlock” Lump in palm under pulley

Answer 267

Rest and medication – avoiding certain activities and taking non-steroidal anti-inflammatory drugs (NSAIDs) may help relieve pain. Splinting – where the affected finger is strapped to a plastic splint to reduce movement. Corticosteroid injections – steroids are medicines that can reduce swelling. Surgery on the affected sheath – surgery involves releasing the affected sheath to allow the tendon to move freely again. It's usually used when other treatments have failed. It can be up to 100% effective, although you may need to take 2 to 4 weeks off work to fully recover.

Answer 268

Trigger finger occurs if there's a problem with the tendon or sheath, such as inflammation and swelling. The tendon can no longer slide easily through the sheath and can bunch up to form a small lump (nodule). This makes bending the affected finger or thumb difficult. If the tendon gets caught in the sheath, the finger can click painfully as it's straightened.

Answer 269

Women Over 40 People who have had dupuytrens disease Diabetes RA

Answer 270

extensor pollicis brevis and abductor pollicis longus tendons

Answer 271

Usually affects women who are aged 30-50 years old

Answer 272

Finklestein's

Answer 273

* pain on the radial side of the wrist * tenderness over the radial styloid process * abduction of the thumb against resistance is painful * Finkelstein's test: with the thumb is flexed across the palm of the hand, pain is reproduced by movement of the wrist into flexion and ulnar deviation

Answer 274

analgesia steroid injection immobilisation with a thumb splint (spica) may be effective surgical treatment is sometimes required

Answer 275

Non - operative = aspiration Operative = excision (including the root)

Answer 276

Joint capsule, tendon sheath or ligament

Answer 277

pain (opening jars, pinching), stiffness, swelling, deformity, loss of function

Answer 278

non op: NSAIDs, splint, steroid injection op: trapeziectomy (gold standard), fusion, replacement

Answer 279

Ape-hand deformity - this is when you cannot abduct or oppose the thumb due to paralysis of the thenar muscles. Sensory deficit on volar aspect of thumb.

Answer 280

Wrist lacerations Carpal tunnel syndrome

Answer 281

Ulnar nerve

Answer 282

•motor deficit - claw hand, hypothenar & 1st dorsal interosseous wasting Sendory deficit is in little finger

Answer 283

Motor wasting (wrist drop - extensors) Sensory deficit - 1st web space dorsally

Answer 284

claw hand (affects small muscles of hand, wasting of intrinsic muscles of hand, decreased sensaton over T1 dermatome)

Answer 285

waiter’s tip position, arm is adducted and IR, elbow is extended and pronated, wrist is flexed, decreased sensation over C5, C6 dermatomes

Answer 286

breech delivery, T1 damage (upward traction): occurs with shoulder disclocation or cervical rib

Answer 287

birth injury or fall on side of neck (downward traction): forced contralateral neck adbuction Shoulder dystocia

Answer 288

Scaphoid fracture

Answer 289

avascular necrosis in proximal part of scaphoid (AVN) (because blood supply is distal to proximal), non-union

Answer 290

More common in girls More common in the left hip Common in the eastern euroean demographic

Answer 291

First born Oligohydramnios Breech presentation Family history Lower limb deformities

Answer 292

Ortolani's sign and Barlow's sign One leg appears longer than the other Uneven skin folds in the buttocks One leg dragging behind the other

Answer 293

Pavlik harness Surgery may be needed if your baby is diagnosed with DDH after they're 6 months old, or if the Pavlik harness has not worked Surgical options include: closed reduction – the ball is placed in the socket without making any large cuts (incisions) open reduction – an incision is made in the groin to allow the surgeon to place the ball in the socket

Answer 294

Part or all of the femoral head (top of the thigh bone: the ball part of the ball-and-socket hip joint) loses its blood supply and may become misshapen. This may lead to arthritis of the hip in later years.

Answer 295

hip pain: develops progressively over a few weeks limp stiffness and reduced range of hip movement

Answer 296

x-ray: early changes include widening of joint space, later changes include decreased femoral head size/flattening

Answer 297

plain x-ray technetium bone scan or magnetic resonance imaging if normal x-ray and symptoms persist

Answer 298

Premature fusion of growth plates OA Phases = Avascular necrosis Fragmentation - revascularisation (pain) Reossification - bony healing Residual deformity

Answer 299

To keep the femoral head within the acetabulum: cast, braces If less than 6 years: observation Older: surgical management with moderate results Operate on severe deformities

Answer 300

More likely to be seen in overweight children (more likely to be male) Typical age is 9-14 years

Answer 301

Acute v chronic (3 weeks) Syable vs unstable

Answer 302

Detection: Pain in hip or knee Externally rotated posture and gait Reduced internal rotation, especially in flexion Plain X-Rays

Answer 303

_Acute Slip:_ In an acute slip, pain in the hip is so severe that your child is unable to walk or stand. You may notice that one leg seems shorter than the other. They won't want to move their hip because it is painful. You may notice that their leg is turned outwards. _Chronic Slip:_ Limping Walking may be painful Pain worse on excersize Stiffness Leg on affected side may be shorter Muscle wasting on affected side

Answer 304

Physical examination X-Ray CT scan If avascular necrosis is suspected then an MRI or a bone scan may be necessary

Answer 305

Avascular necrosis: Stable slips (able to bear weight) have a low risk of AVN Unstable slips (unable to bear weight) have a high risk of AVN Chondrolysis Deformity Early osteoarthritis

Answer 306

Transient synovitis

Answer 307

Typical age group = 2-10 years Acute hip pain associated with viral infection

Answer 308

apyrexial, allowing joint to be examined, low CRP, normal WCC, not that unwell (as opposed to septic artheritis and osteomyelitis)

Answer 309

joint pain exacerbated by movement, morning stiffness, immobility, poor function, , joint swelling, affects various joints, systemic symptoms, non-specific: fatigue/lethargy (secondary fibromyalgia due to dysregulation of the HPA axis), weight loss, anaemia, anorexia, mild fever specific: eyes, lungs (interstitial lung disease, fibrosis), nerves, skin, kidneys, muscles (sarcopenia), bones (osteoporosis), secondary Sjogren’s syndrome, liver (elevated acute-phase response, anaemia of chronic disease (IL6 increases hepatocyte production of hepcidin, an iron-regulatory hormone) long term: CVS (altered lipid metabolism, elevated acute-phase reactants, increased endothelial activation), malignancy 2010 EULAR/ACR RA classification depends on joint involvement, serology, acute-phase reactants, duration of symptoms disease activity score: DAS 2,4 represents clinical remission DAS \>5,1 represents eligibility for biologic therapy joints: swollen, warm, tender joints, limitation of movement joint deformities: swan neck, boutonniere, subluxation lymphadenopathy, splenomegaly, rheumatoid nodules, muscle weakness, evidence of amyloidosis and vasculitis diagnosis criteria: need 4 out of 7 (RF RISES) Rheumatoid factor Finger/hand joint involvement Rheumatoid nodules Involvement of 3 or more joints Stiffness - early morning Erosions/decalcification on XR Symmetrical arthritis

Answer 310

bloods: ESR + CRP (degree of synovial inflammation), anaemia of chronic disease, low albumin (correlates directly with disease severity), neutropenia (in Felty’s syndrome)

Answer 311

rheumatoid factor IgG, IgM anti-cyclic citrullinated antibodies (anti CCP, ACPA) ANA(?)

Answer 312

Loss of joint space Peri-articular erosions Juxta articular osteoporosis Subluxation

Answer 313

Incerased WBC Increased protein

Answer 314

Pain Decreased movement Loss of deltoid coutour Arm held internally rotated and adducted

Answer 315

Firstly consider anaesthesia / sedation Closed reduction (e.g Kocher's) Open reduction if closed reduction techniques fail Immobalise the arm for 3 weeks Physiotherapy Surgery

Answer 316

Secondary to epileptic seizures

Answer 317

Antero-inferiorly

Answer 318

It is most common in middle-aged females. The aetiology of frozen shoulder is not fully understood. Associations ## Footnote diabetes mellitus: up to 20% of diabetics may have an episode of frozen shoulder

Answer 319

Features typically develop over days ## Footnote external rotation is affected more than internal rotation or abduction both active and passive movement are affected patients typically have a painful freezing phase, an adhesive phase (decreased ROM especially on internal rotation and a recovery phase bilateral in up to 20% of patients the episode typically lasts between 6 months and 2 years

Answer 320

Management ## Footnote no single intervention has been shown to improve outcome in the long-term treatment options include NSAIDs, physiotherapy, oral corticosteroids and intra-articular corticosteroids

Answer 321

Disc = L5/S1 Actual root value = S1

Answer 322

Disc = L4/5 Actual root value = L5

Answer 323

Disc = L3/L4 Actual root value = L4

Answer 324

Most commonly C5/6

Answer 325

injury or precipitating event symptoms located in buttock bilaterally, leg pain, back pain, varying dysaethesiae + weakness; leg weaknees together with absent reflexes bowel and/or bladder sphincter dysfunction (urinary retention +/- incontinence overflow) saddle anaesthesia, loss of anal tone & anal reflex

Answer 326

MRI PR exam Lumbar CT myelogram if MRI is contraindicated

Answer 327

compression of cauda equina due to: central lumbar disc prolapse (commonest), cord tumours, vertebral mets trauma (burst, fracture disc, spinal stenosis) infection (epidural abscess) iatrogenic (spinal surgery or manipulation, spinal epidural injection)

Answer 328

if admission + MRI scan + operation \>48h then may result in permanent dysfunction of bladder and anal sphincter

Answer 329

Spinal claudication

Answer 330

Complete and incomplete complete: no motor or sensory function distal to lesion, no anal squeeze, no sacral sensation, ASIA grade A, no chance of recovery incomplete: some function is present below site of injury, more favourable prognosis Patterns of injury: patterns of injury: tetraplegia/quadriplegia central cord syndrome anterior cord syndrome Brown-Sequard syndrome

Answer 331

prevent a secondary insult, particularly in patients with incomplete injuries Airway- C spine control Breathing- ventilation and oxygenation Circulation- fluids, consider neurogenic shock (low BP and HR, loss of sympathetic tone, injuries about T6, TREAT WITH vasopressors) Disability- assess neuro function including PR and perianal sensation, logrolling surgical fixation for unstable fractures (vast majority fixed from posteriorly, pedicle screws preferred method) long-term management: spinal cord injury unit- intermediate term, physiotherapy, occupational therapy, psychological support, urological/sexual counselling

Answer 332

Weakness of arms moreso than legs, perianal sensation and lower extremity power is preserved

Answer 333

Fine touch and proprioception is preserved, profound weakness (Fine touch is in the ventral spinothalamic pathway which is in the anterior portion of the spinal cord) Complete motor paralysis below the level of the lesion due to interruption of the corticospinal tract Loss of pain and temperature sensation at and below the level of the lesion due to interruption of the spinothalamic tract Retained proprioception and vibratory sensation due to intact dorsal columns Autonomic dysfunction may be present and can manifest as hypotension (either orthostatic or frank hypotension), sexual dysfunction, and/or bowel and bladder dysfunction Areflexia, flaccid internal and external anal sphincter, urinary retention and intestinal obstruction may also be present

Answer 334

Immediately unconscious and in cardiac arrest Sudden onset - headache 'the worst headache in my life' Neck stiffness Photophobia

Answer 335

CT Cerebral angiogram

Answer 336

Excessive bone resorption follwoed by disorganised compensatory bone formation

Answer 337

Unclear, possible causes include Slow virus infection of osteoclasts Mutations of SQSTM1, RANK genes involved in Osteoclasts' function regulation

Answer 338

Affects femur, lumbar vertebrae and the skull Bone pain Pathological fractures Bony malformations (enlarged skull, bowing of long bones) Increased temperature (hypervascularity) Arthritis in assocaited joints Hearing impairment (sclerosis of the skull bones, cranial nerve compression) Decreased ROM

Answer 339

Osteoporisis circumscripta (well defined osteolytic lesions of the skull in early course) Cotton wool appearance Squaring of vertebrae seen on lateral X-ray Tam O'shanter sign (enlarged overriding frontal bone) Bone scan scintigraphy is a potential investigation (focal increased radionuclide uptake)

Answer 340

Normal Ca2+ but raised alkaline phosphatase

Answer 341

don’t treat if asymptomatic uness in skull or area needing surgery do not treat based on raised alkaline phosphatase alone use **IV bisphosphonate therapy** and one-off **zoledronic acid infusion** **calcitonin** for severe pain/extensive lytic disease

Answer 342

Osteoarthritis Heart failure - excessive demand on the heart dues to increased hypervascularity Neural tissue compression Rarely - malignant transformation (osteosarcoma)

Answer 343

Mosaic pattern of lamellar bone Large numerous osteclasts with up to 100 nuclei normal is 5-10) Affected bone marrow field is filled with highly vascular stroma

Answer 344

normal bony tissue but decreased mineral content rickets if when growing osteomalacia if after epiphysis fusion

Answer 345

rickets: knock-knee, bow leg, features of hypocalcaemia osteomalacia: bone pain, fractures, muscle tenderness, proximal myopathy

Answer 346

vitamin D deficiency e.g. malabsorption, lack of sunlight, diet renal failure drug induced e.g. anticonvulsants vitamin D resistant; inherited liver disease, e.g. cirrhosis

Answer 347

low 25(OH) vitamin D (in 100% of patients, by definition) raised alkaline phosphatase (in 95-100% of patients) low calcium, phosphate (in around 30%) PTH is raised x-ray: children - cupped, ragged metaphyseal surfaces; adults - translucent bands (Looser's zones or pseudofractures)

Answer 348

calcium with vitamin D tablets

Answer 349

abnormality in type 1 collagen due to decreased synthesis of pro-alpha 1 or pro-alpha 2 collagen polypeptides

Answer 350

fragile bones from mild trauma or even daily acts of life other non-bone clinical features growth deficiency defective tooth formation (dentigenesis imperfecta) hearing loss blue sclera scoliosis/barrel chest ligamentous laxity (Beighton score) easy bruising

Answer 351

surgical: treat fractures medical: IV bisphosphonates (to prevent fractures) social: education and social adaptations genetic: genetic counselling for parents and next generation

Answer 352

FRAX Qfracture

Answer 353

qfracture only uses data from the UK Can be used for patients aged 30-99 which is better than FRAX (40-90)

Answer 354

Alongside a fracture assessment to make results more accurate (intermediate risk as assessed by the FRAX test requires a BMD scan) ## Footnote before starting treatments that may have a rapid adverse effect on bone density (for example, sex hormone deprivation for treatment for breast or prostate cancer). in people aged under 40 years who have a major risk factor, such as history of multiple fragility fracture, major osteoporotic fracture, or current or recent use of high-dose oral or high-dose systemic glucocorticoids (more than 7.5 mg prednisolone or equivalent per day for 3 months or longer).

Answer 355

Family history Female sex Increasing age Deficient diet Sedentary lifestyle Smoking Premature menopause Low body weight Caucasians and Asians

Answer 356

Family history Female sex Increasing age Deficient diet Sedentary lifestyle Smoking Premature menopause Low body weight Caucasians and Asians

Answer 357

Minimise risk factors Ensure good calcium and Vitamin D status Falls prevention strategies Medications - hormone replacement therapy Side effects of HRT - increased risk of blood clots increased risk of breast cancer with extended use into late 50's/early 60's Increased risk of heart disease and stroke if used after large gap from menopause. Selective oestrogen receptor modulator raloxifene - only effective in preventing vertebral body fractures - doesn't affect hip fractures. Negative effects of SERMS- hot flushes if taken close to menopause, increased clotting risks, lack of protection at hip site Bisphosphonates are the main Rx option Oral Bisphosphonates generally the first line of treatment Adequate Renal function required Adequate Calcium and Vitamin D status Good Dental Health and Hygiene advised Notify dentist on Bisphosphonates Encourage regular check ups / well fitting dentures Alendronate - this is one of the popular bisphosphonates used to treat osteoporosis Side effects of bisphosphonates - Oesophagitis Iritis/uveitis Not safe when eGFR\<30 mls/min ONJ Atypical femoral shaft fractures Drug Holiday for 1-2 years Usually after 10 years Oral Bisphosphonates Bisphosphonates can also cause osteonecrosis of the jaw. - very rare Even though you increase the chance of atypical femoral shaft fracture - you are still 200 times more likely to break your hip by osteoporosis than bisphosphonates Denosumab - this is a monoclonal antibody against RANKL The RANK L ligand is responsible for regulating osteoclast activity Denosumab requires a subcutaneous injection every 6 months - safer in patients with significant renal impairment than bisphosphonates. Osteoclasts do not get the signal to resporb bone There is no negative feedback signal to osteoblasts continue to lay down bone Side effects of Denosumab: Allergy / rash Symptomatic hypocalcaemia if given when vitamin D deplete ONJ? Atypical femoral shaft fracture? Teriparatide - intermittent human parathyroid hormone - this is the first portion of parathyroid hormone - makes osteoblasts lay down bone - only anabolic bone treatment (only treatment that actually aids in the laying down of bone Side effects of Teriparatide - injection site irritation

Answer 358

Endocrine: glucocorticoid excess (e.g. Cushing's, steroid therapy), hyperthyroidism, hypogonadism (e.g. Turner's, testosterone deficiency), growth hormone deficiency, hyperparathyroidism, diabetes mellitus Multiple myeloma, lymphoma Gastrointestinal problems: inflammatory bowel disease, malabsorption (e.g. Coeliacs), gastrectomy, liver disease Rheumatoid arthritis Long term heparin therapy Chronic renal failure Osteogenesis imperfecta, homocystinuria Another list from Laszlo's table: risk factor endocrine: thyrotoxicosis, hyper and hypoparathyroidism, Cushings, hyperprolactinaemia, hypopituitarism, low sex hormone levels ( rheumatic: rheumatoid arthritis, ankylosing spondylitis, polymyalgia rheumatica, osteomalacia GI: inflammatory- UC and Crohns liver- PBC, CAH, alcoholic cirrhosis, viral cirrhosis (hepC) malabsorption- CF, chronic pancreatitis, coeliac disease, Whipple’s disease, short gut syndromes, ischaemic bowel medication, chronic renal failure medications, steroids, PPI, enzyme inducting antiepileptic medications, aromatase inhibitors, GnRH inhibitors, warfarin

Answer 359

metabolic bone disease characterised by low bone mass and micro architectural deterioration of bone tissue, leading to enhanced bone fragility and a consequent increase in fracture risk

Answer 360

Steroids PPI Enzyme inducting antiepileptic mediations Aromatase inhibitors GnRH inhibitors Warfarin

Answer 361

There is environmental damage of DNA - release of nuclear antibodies. Antinuclear antibodies and antigens form immune complexes (this is a type 3 hypersensitivity reaction, these immune complexes deposit themselves in tissues) Organs affected = kidneys, skin, joints and heart Individuals may develop antibodies which target certain molecules such as phosphilipids on red or white blood cells marking them for phagocytosis (this is a type 2 hypersensitivity reaction)

Answer 362

classification criteria (any 4 “ORDER HIS ANA): Oral ulcers malar Rash Discoid rash (raised, scarring, permanent marks, alopecia) Exaggerated photosensitivity Renal disorders (significant proteinuria or cellular casts in urine) Haematological (low WCC, platelets, lymphocytes, haemolytic anaemia) Immunological (anti ds-DNA, SM ( I think this is anti-smith, cardiolipin, lupus anticoagulant, low complement) Serositis (pleurisy or pericarditis) Arthritis/arthralgia (2 joints at least) Neuro (unexplained seizures or psychosis) ANA (anti-nuclear Ab) Also has fever

Answer 363

Cardiovascular disease: Libman–Sacks endocarditis, myocardial infarction (MI) Serious infections; renal failure; hypertension Antiphospholipid syndrome: Hypercoagulable state; individuals prone to develop clots (e.g. deep vein thrombosis, hepatic vein thrombosis, stroke)

Answer 364

bloods: Coomb’s +ve haemolytic anaemia, neutropenia, lymphocytopenia, thrombocytopenia, increased ESR, normal CRP, renal profile

Answer 365

management depends on organ threat: mild/moderate- hydroxychloroquine, - azathioprine, methotrexate, mycophenolate, NSAIDs, anti-malarials, low-dose steroids severe- cyclophosphamide, rituximab, steroids, immunosuppressants

Answer 366

This is SLE arthritis - notice how there is no bone damage - In lupus the deformity arises because the ligaments become weak.

Answer 367

T helper cell mediated immune response, causes a chronic inflammatory response resulting in excessive collagen deposition and damage to microvasculature

Answer 368

**Limited (80%)** Skin involvement limited to fingers, forearms,face Late visceral involvement Some individuals develop CREST syndrome: Calcinosis, Raynaud's phenomenon, esophageal dysmotility, sclerodactyly, telangiectasia Associated with anticentromere antibodies Relatively benign **Diffuse (20%)** Widespread skin involvement Early visceral involvement Rapid progression Associated with anti-DNA topoisomerase I antibodies Poor prognosis

Answer 369

Raynaud phenomenon Cutaneous changes of face, extremities: Skin thickening, tightening, sclerosis (most common); edema, erythema (precede sclerosis) GI involvement ▫ Esophageal fibrosis → dysphagia, GI reflux Small intestine involvement → abdominal pain, obstructions, constipation, diarrhea, malabsorption syndrome (weight loss, anemia) ▪ Pulmonary involvement with interstitial fibrosis Right-sided cardiac dysfunction/ pulmonary hypertension ▪ Cardiac involvement ▫ Pericardial effusions, myocardial fibrosis → congestive heart failure, arrhythmias Renal involvement (diffuse disease) → fatal hypertensive crisis (rare)

Answer 370

**DIAGNOSTIC IMAGING** Upper endoscopy Esophageal fibrosis/reflux esophagitis **LAB RESULTS** Serologic tests ▫↑ANAs in almost all individuals with systemic sclerosis; low specificity ↑ACAs highly specific (limited) - anticentromere antibodies Anti-topoisomerase I antibodies (anti-Scl-70) highly specific (diffuse) Complete blood count (CBC) Anemia due to malabsorption, increased serum creatinine due to renal dysfunction **OTHER DIAGNOSTICS** Clinical presentation Skin thickening, swollen fingers, Raynaud's phenomenon, GI reflux **Pulmonary function tests** Restrictive ventilatory defect due to pulmonary interstitial fibrosis

Answer 371

ANA positive in 90% RF positive in 30%

Answer 372

Chronic autoimmuned infalmmatory disease Lymphocytic infiltration Destruction of exocrine glandsof eyes and mouth

Answer 373

Primary = sicca syndrome Secondary (to other autoimmune diseases, RA is the most common)

Answer 374

Dry eyes (irritation, itching foreign body sensation, **keratoconjuncitivits**) Oral dryness reflecting salivary hypofunction Salivary gland enlargement (parotid, subamndibular etc) Extraglandular manifestations (MSK symptoms such as arthralgias and arthritis, rashes, interstitial nephritis, vasculitis)

Answer 375

Leukopenia Thrombocytopenia Anaemia Increased ESR

Answer 376

Proteinuria/haematuria reflecting glomerulonephritis

Answer 377

Focal lymphocyte foci (collections of tightly aggregated lymphocytes)

Answer 378

rheumatoid factor (RF) positive in nearly 100% of patients ANA positive in 70% anti-Ro (SSA) antibodies in 70% of patients with PSS anti-La (SSB) antibodies in 30% of patients with PSS also: hypergammaglobulinaemia, low C4

Answer 379

Schirmer's test: filter paper near conjunctival sac to measure tear formation

Answer 380

artificial saliva and tears pilocarpine may stimulate saliva production Moderate to severe SS = immunosuppressive treatment

Answer 381

Peridontal complications, oral infections, mucosal assocaited lymphoid tissue lymphoma There is a marked increased risk of lymphoid malignancy (40-60 fold).

Answer 382

Sjogren's syndrome is much more common in females (ratio 9:1).

Answer 383

B cell mediated release of free radicals from neutrophils Free radicals damage neighbouring endothelial cells - vasculitits granulomatosis with polyangitis only affects small vessels (nasopharynx, kidneys and lungs)

Answer 384

Focal necrotising vasculitis Necrotizing granulomas in the upper airway, lungs Necrotizing glomerulonephritis (renal vasculitis)

Answer 385

Chronic pain (oral ulcers, bloody nasal mucus, **chronic sinusitis**, saddle nose) Haemoptysis, dyspnoea, cough, pleuritic chest pain (inflammation of the lung vessels) Decreased urine production, hypertension, haematuria, red cell casts, proteinuria (glomerular filtration) **Myalgia** **Arthralgia** Episcleritis

Answer 386

Polymyositis = proximal muscle weakness Dermatomyositis = proximal muscle weakness + gottron's papules and heliotrope rash

Answer 387

Jo-1 (this is a specific ANA profile)

Answer 388

Giant cell arteritis Takayasu arteritis

Answer 389

Kawasaki's disease Polyarteritis nodosa

Answer 390

3 of the following: Age at onset (over 50 years) New headache Temporal artery tenderness / reduced pulsation ESR greater than or equal to 50 Abnormal temporal biopsy Other signs and symptoms include: Jaw claudication Transient unilateral vision loss Carotid bruits, decreased pulse in arms, aortic regurgitation Tender palpable nodules, absent temporal pulse Increased risk of aortic dissection, aortic aneurysm

Answer 391

Extremely elevated ESR (over 100mm/hr) Temporal artery biopsy

Answer 392

Corticosteroids

Answer 393

Corticosteroids Cyclophosphamide / rituximab

Answer 394

Sicca syndrome is a variant of Sjögren syndrome characterized by xerostomia and keratoconjunctivitis without rheumatoid arthritis. (dry mouth, dry eyes and RA)

Answer 395

inflammatory back pain, limitation of movements in antero-posterior as well as lateral planes at lumbar spines, limitation of chest expansion, bilateral sacroiliitis on XR Achilles tendonitis, dactylitis uveitis cardiac-aortic incompentence, heart block pulmonary-restrictive disease, apical fibrosis GI-IBD osteoporosis and spinal fractures neurological- AAD and cauda equina syndrome renal-secondary amyloidosis Tenderness over sacroiliac joints (grading of radiographic sacroilitis (grade 0-4 on ASAS classification)

Answer 396

X-ray of lungs (remember they have apical fibrosis and restrictive lung disease) MRI Bloods

Answer 397

Chronic anaemia RhF negative Increased ESR

Answer 398

XR (**sacroiliitis**, juxta-articular sclerosis, **syndesmorphyte** formation, marginal erosion, **fusion of adjacent vertabrae** (bamboo spine)), **disk calcification**, pseudoarthritis; MRI _Passmedicine_: sacroilitis: subchondral erosions, sclerosis squaring of lumbar vertebrae 'bamboo spine' (late & uncommon) syndesmophytes: due to ossification of outer fibers of annulus fibrosus chest x-ray: apical fibrosis

Answer 399

typically a young man who presents with lower back pain and stiffness of insidious onset stiffness is usually worse in the morning and improves with exercise the patient may experience pain at night which improves on getting up

Answer 400

Schober's test

Answer 401

Physiotherapy Occupational therapy NSAIDs DMARDs (sulfasalazine) Anti-TNF therapy (such as etanercept and adalimumab) Treatment of osteoporosis Joint replacement surgery and spinal surgery

Answer 402

Oncholysis Transverse nail ridging Nail pitting

Answer 403

Asymmetric large joint arthritis, axial arthritis, asymmetric sacroiliitis, peripheral small joint arthritis, DIP joint arthritis, and arthritis mutilans Enthesitis Dactylitis

Answer 404

AS = Axial Enteropathic = Axial and peripheral Psoriatic = Axial and asymmetrical peripheral Reactive = Axial and asymmetrical peripheral

Answer 405

Raised ESR RhF negative ANA negative

Answer 406

imaging: XR (para-marginal erosions, fluffy periosteal bone formation, **bony ankylosis, asymmetrical sacroiliitis**

Answer 407

sulfasalazine, methotrexate, leflunomide, cyclosporine, anti-TNF therapy, anti-IL-17 and IL-23, steroids, physiotherapy and occupational therapy, axial disease treated similar to ankylosing spondylitis NSAIDs, DMARD

Answer 408

Infections include- Salmonella, Shigella, Yersinia, Campylobacter, Chlamydia trachomatis or pneumoniae, Borrelia, Neisseria and streptococci Infections- throat, urogenital & GI

Answer 409

mono or oligoarthritis, dactylitis and enthesitis also seen, disease may be systemic with skin and mucous membrane involvement (keratoderma blenorrhagica, circinate balanitis, urethritis, conjunctivitis, iritis) Reiter’s syndrome (arthritis, urethritis and conjunctivitis)

Answer 410

acute: NSAID, joint injection (if infection excuded), AB in chlamydia infection (contacts as well) chronic: NSAID, DMARD (ex: sulphasalazine, methotrexate)

Answer 411

Commonly associated with inflammatory bowel disease (Crohn’s or UC) Rarely seen with infectious enteritis, Whipple’s disease and Coeliac disease

Answer 412

can be both peripheral and axial disease, enthesopathy commonly seen If there is arthritis with IBD / Crohn's it's important to suspect enteropathic origin

Answer 413

Gout = monosodium urate Pseudogout = Calcium pyrophosphate

Answer 414

Increased production of uric acid (Purines) **Diet high in red meat, shellfish, anchovies** Increase in cell turnover Cancer treatment - tumour lysis syndrome Polycythemia vera (5-10% develop gout) Lesch-Nyhan syndrome (HGPRT deficiency) **Dehydration, alcoholic beverage consumption - decreased clearance of uric acid** **Chronic kidney disease**

Answer 415

Age (20-30+ years of hyperuricaemia increases the risk Male Alcohol Obesity Drugs that decrease urate excretion and increase production (thiazides, aspirin) Chronic lead toxicity

Answer 416

Gout = needle shaped, negatively birefringent Pseudogout = Rhomboid, positively birefringent

Answer 417

Stone passage causing renal colic Renal failure - death in 20% of individuals with chronic gout

Answer 418

acute: monoarthritis, severe pain lasting 7-10 days, most commonly first metatarsophalangeal joint (podogra) chronic: gouty tophi on pinnae, hands +/- polyarthritis

Answer 419

Joint destruction, bony erosions (rarely present on the first acute episode) Imaging findings tend to become more likely with disease duration X-Ray - radiolucent uric acid nephrolithiasis

Answer 420

Anti-inflammatory treatment ASAP GLucocorticoids (oral and or intraarticular injections) NSAIDs (naproxen, indomethacin) Colchicine (inhibits leukocyte migration) Biological agents (IL-1 inhibitors)

Answer 421

Limit medications that alter urate balance (e.g thiazides, aspirin) Initiate medications that decrease uric acid levels Xanthine oxidase inhibitors (allopurinol, febuxostat) Uricosuric medications (increase urate excretion at the kidney) Uricase medications - mimic enzyme that catalyzes urate conversion Other interventions = * management of obesity/diabetes * Diet modification (avoidance of soda, red meat and seafood) * Alcohol moderation * Increase in physical activity Note for uricosuric medications: Gouty patients with normal or low excretion of uric acid (underexcretors) may be candidates for treatment with uricosuric drugs with little risk of urinary calculi. Measurement of the amount of excreted urate has also been recommended to identify these patients.

Answer 422

Sporadic Hereditary component Secondary to previous joint damage, hyperparathyroidism, haemachromatosis, hypothyroidism, ochronosis, diabetes

Answer 423

Usually affects individuals over 50 years Decreased magnesium levels

Answer 424

Acute flares: NSAIDs Colchicine Glucocorticoids Management and prevention: Colchicine

Answer 425

typically patient \> 60 years old usually rapid onset (e.g. \< 1 month) aching, morning stiffness in proximal limb muscles (not weakness) - typically lasts more than 1 hour also mild polyarthralgia, lethargy, depression, low-grade fever, anorexia, night sweats Muscle power is normal

Answer 426

ESR \> 40 mm/hr Increased CRP note CK and EMG normal reduced CD8+ T You tend to find that there is a dramatic response to steroids

Answer 427

Genetic defects (assocaited with HLA DR4) Exposure to adenovirus / human parovirus B19

Answer 428

Low dise corticosteroids The condition can regress after 1 or 2 years (or it can remain chronic)

Answer 429

Giant cell arteritis

Answer 430

Buckle = 3/4 weeks Greenstick = 4-6 weeks Complete = 6 weeks

Answer 431

Compartment syndrome Refracture Non-union Superficial radial nerve injury Posterior interosseous nerve injury

Answer 432

fracture of radial shaft with dislocation of the distal radio-ulna joint

Answer 433

Fracture of proximal ulna with dislocation of radial head

Answer 434

Forearm fracture - 80% of which occur in the distal third

Answer 435

**bunions**, pressure symptoms from shoe wear, pain from crossing over of toes, **metatarsalgia**

Answer 436

clinical, XR (determine severity of underlying bony deformity, exclude associated degenerate change)

Answer 437

non-operative: shoe wear modification (wide +/- high toe box) orthotics to offload pressure/correct deformity activity modification analgesia

Answer 438

(if non-operative fails or unacceptable to patient): release lateral soft tissues osteotomy 1st metatarsal +/- proximal phalanx

Answer 439

Genetic foot wear

Answer 440

lateral angulation of great toe tendon pull realigned to lateral of centre of rotation of toe worsening deformity vicious cycle of increased pull creating increased deformity sesamoid bones sublux - less weight goes through great toe as deformity progresses abnormalities of lesser toes occur

Answer 441

Stiff big toe Asymptomatic Pain (often at extreme of dorsiflexion) Limited ROM

Answer 442

Non-operative: - Activity modification, shoe wear with rigid sole, analgesia Operative: cheilectomy (remove dorsal bone impingement) arthrodesis = 1st MTPJ fusion (gold standard, permanent) arthroplasty

Answer 443

unknown, possibly genetic (typical shape of metatarsal head is slightly pointed rather than rounded), possible multiple microtrauma O/A of the first MTP?

Answer 444

hammer toe is flexion between proximal and intermediate phalanx of any lesser toe

Answer 445

Flexion between proximal and intermediate phalynx AND between intermediate and distal phalynx of any lesser toe

Answer 446

mallet toe is flexion between intermediate and distal phalanx of any lesser toe

Answer 447

activity modification, shoe wear (flat shoes with high toe box to accomodate deformity) orthotic insoles (metatarsal bar/dome support)

Answer 448

flexor to extensor transfer **fusion** of interphalageal joint release of metatarsophalangeal joint shortening **osteotomy** of metatarsal

Answer 449

Imbalance between flexors/extensors Shoe wear Neurological Rheumatoid arthritis Idiopathic

Answer 450

Shoewear/orthotics/activity Operative: - 1st MTPJ arthrodesis (this is also a treatment in hallux rigidus) 2-5th toe excision arthroplasty

Answer 451

Activity/shoewear/orthotics XR guided injections Fusion

Answer 452

Post-traumaic arthritis Osteoarthritis Rheumatoid arthritis

Answer 453

asymptomatic unless very large or on weightbearing area

Answer 454

Progressive connsctive tissue build up

Answer 455

non operative: avoid pressure, shoewear/orthotics operative: excision (80% recurrence) radiotherapy (80% recurrence) combination surgery/radiotherapy (higher complications risk, less recurrence)

Answer 456

Simmonds - squeeze test Matles test - angle of dangle

Answer 457

Non-operative: ## Footnote activity modification, weight loss, shoe wear modification (slight heel), physiotherapy (eccentric stretching), extra-corporeal shockwave treatment, immobolisation (in below knee cast) Operative: Gastrocnemius recession Release and debridement of tendon

Answer 458

pain first thing in the morning, pain on weight bearing after rest (post-static dyskinesia), pain located at origin of plantar fascia, frequently long-lasting (2 years or more)

Answer 459

diagnosis is clinical mainly, XR, USS and MRI

Answer 460

rest, change training, streching of Achilles, ice, NSAIDs, orthoses (heel pads), physiotherapy, weight loss, injections (corticosteroid (good in short term but may make conditon worse long term), night splinting newer/3rd line treatment: extracorporeal shockwave therapy topaz plasma coblation nitric oxide platelet rich plasma endoscopic/open surgery

Answer 461

chronic degenerative change, fibroblast hypertrophy, absence inflammatory cells, disorganised and dysfunctional blood vessels and collagen, avascularity, can’t make extra cellular matrix required for repair and re-modelling -\> (microtears?)

Answer 462

athletes associated with high intensity or rapid increase in training, running with poorly padded shoes or hard surfaces, obesity, occupations involving prolonged standing, foot/lower limb rotational deformities, tight gastro-soleus complex

Answer 463

Tibialis posterior tendon dysfunction

Answer 464

clinical diagnosis (double & single heel raise; heel should swing for valgus to varus as heel rises)

Answer 465

Clinical MRI to assess tendon

Answer 466

orthoses or surgery (reconstruction of tendon (tendon transfer), triple fusion (subtalar, talonavicular and calcaneocuboid)

Answer 467

prevention modify the main detriments to healing (diabetic control, smoking, vascular supply, external pressure (splints/shoes/weight bearing), internal pressure (deformity), infection, nutrition surgical: improve vascular supply, debride ulcers and get deep samples for microbiology, correct any deformity to offload area, amputation

Answer 468

Charco neuropathy

Answer 469

prevention immobilisation/non-weight bearing until acute fragmentation resolved correct deformity (deformity leads to ulceration leads to infection leads to amputation)

Answer 470

2 theories: neurotraumatic (lack of proprioception and protective pain sensation) neurovascular (abnormal autonomic nervous system results in increased vascular supply and bone resorption characterised by rapid bone destruction occuring in 3 stages (fragmentation, coalescence, remodelling)

Answer 471

effective suppression of inflammation will improve symptoms and prevent joint damage and disability ## Footnote analgesics NSAIDs: disease modifying anti-rheumatic drugs (DMARD): methotrexate, sulfasalazine, hydroxychloroquine, leflunomide, penicillamine, gold biologics: TNF alpha inhibitor (Anakinra), anti B cell therapies (CD20, Rituximab), anti T cell therapies (Abatacept), IL-6 inhibitors (Tocilizumab) corticosteroids: (short term benefit vs long term toxicity) rarely appropriate as single drug therapy patient education: encourage to alternate rest with exercise

Answer 472

Morning stiffness, improves with use Bilateral symptoms Systemic upset Joint swelling (joints are swollen and warm, limitation of movement Lymphadenopathy Splenomegaly Systemic - fatigue/lethargy, weight loss, anaemia swollen, painful joints in hands and feet stiffness worse in the morning gradually gets worse with larger joints becoming involved presentation usually insidiously develops over a few months positive 'squeeze test' - discomfort on squeezing across the metacarpal or metatarsal joints Swan neck and boutonnière deformities are late features of rheumatoid arthritis and unlikely to be present in a recently diagnosed patient.

Answer 473

diagnosis criteria: need 4 out of 7 (RF RISES) Rheumatoid factor Finger/hand joint involvement Rheumatoid nodules Involvement of 3 or more joints Stiffness - early morning Erosions/decalcification on XR Symmetrical arthritis

Answer 474

bloods: ESR + CRP (degree of synovial inflammation), anaemia of chronic disease, low albumin (correlates directly with disease severity), neutropenia (in Felty’s syndrome)

Answer 475

immunology: rheumatoid factor IgG, IgM anti-cyclic citrullinated antibodies (anti CCP, ACPA) ANA(?)

Answer 476

A wide variety of extra-articular complications occur in patients with rheumatoid arthritis (RA): respiratory: pulmonary fibrosis, pleural effusion, pulmonary nodules, bronchiolitis obliterans, methotrexate pneumonitis, pleurisy ocular: keratoconjunctivitis sicca (most common), episcleritis, scleritis, corneal ulceration, keratitis, steroid-induced cataracts, chloroquine retinopathy osteoporosis ischaemic heart disease: RA carries a similar risk to type 2 diabetes mellitus increased risk of infections depression Less common Felty's syndrome (RA + splenomegaly + low white cell count) amyloidosis

Answer 477

Progesterone decreases whilst oxytocin and prostaglandins increase to allow for labour to initiate

Answer 478

**Latent** stage - intermittent, often irregular or painful contractions which bring about some cervical effacement and dilatation up to 4 cm. **Established** stage - Contractions become regular and painful. Result in progressive effacement and cervical dilation from 4 cm Complete when cervix is fully dilated (10 cm) Primagravida = 8 hours (usually not longer than 18 hours) Multigravida = 5 hours (unlikely to last more than 12 hours) Anticipated progress 0.5-1.0 cm per hour

Answer 479

Full cervical dilation to the birth of the baby Passive second stage of labour - Full dilation of the cervix with or without expulsive contractions Active second stage - Presenting part is visible, expulsive contractions with full dilatation of the cervix, active maternal effort following confirmation of full dilatation of the cervix in the absence of expulsive contractions. Primagravida = birth would be expected within two hours of active second stage commencing Multigravida = 1 hour

Answer 480

Birth of the baby to the expulsion of the placenta and membranes Active management management includes: Routine use of **uterotonic** drugs Deferred **clamping and cutting of the cord** Controlled **cord traction** after signs of separation of the placenta. Physiological management includes: No routine use of uterotonic drugs No clamping of the cord until pulsation has stopped Delivery of the placenta by maternal effort. Prolonged in: Active management over 30 mins Physiological management after 60 mins

Answer 481

Monitoring of liquor (colour, smell and volume) Auscultation of fetal heart (doppler, pinards or with CTG) - intermittent monitoring is undertaken every 15 minutes in the first stage of labour and every 5 minutes in the second stage. Palpation of uterine muscle contractions.

Answer 482

Vertex Sinciput (forehead) Brow Face Chin

Answer 483

Anterior parietal

Answer 484

Descent Flexion Internal rotation of the head Crowning and extension of the head Restitution Internal rotation of the shoulders External rotation of the head Lateral flexion

Answer 485

Analgesia in labour Breathing, massage, TENS, paracetamol and dihydrocodeine TENS = transcutaneous electrical nerve stimulation Water Entonox (inhalational nitrous oxide and oxygen) Opioids (morphine, diamorphine, pethidine) Remifentanil patient controlled analgesia Epidural Consider maternal position and mobility as means of reducing pain and facilitating progress in labour Evidence demonstrates that continuous midwifery care reduces the need for analgesia and increased likelihood of SVD and maternal satisfaction with birth experience (RCM, 2012: Bohren et al 2017).