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Finals > MSK/Rheum > Flashcards

MSK/Rheum Flashcards

1
Q

Paget’s disease aetiology

A

excessive bone turnover

patchy areas of high density (sclerosis) and low density (lysis)

pathological fractures in axial skeleton

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2
Q

Paget’s disease presentation

A

Bone pain
Bone deformity
Fractures
Hearing loss can occur if it affects the bones of the ear

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3
Q

Paget’s disease ivx

A

Xray Findings

Bone enlargement and deformity

“Osteoporosis circumscripta” describes well defined osteolytic lesions that appear less dense compared with normal bone

“Cotton wool appearance” of the skull - increased density (sclerosis) and decreased density (lysis)

“V-shaped defects” in the long bones are V shaped osteolytic bone lesions

Biochemistry

Raised alkaline phosphatase (and other LFTs are normal)

Normal calcium

Normal phosphate

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4
Q

Paget’s management

A

Bis
NSAIDs for bone pain
Calcium and vitamin D supplementation, particularly whilst on bisphosphonates

Surgery is rarely required for fractures, severe deformity or arthritis

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5
Q

osteomalacia ivx

A

Serum 25-hydroxyvitamin D

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6
Q

osteomalacia tx

A

Colecalciferol -one of:

50,000 IU once weekly for 6 weeks
20,000 IU twice weekly for 7 weeks
4000 IU daily for 10 weeks

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7
Q

When to use FRAX score

A

Women aged > 65
Men > 75
Younger patients with risk factors such as a previous fragility fracture, history of falls, low BMI, long term steroids, endocrine disorders and rheumatoid arthritis.

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8
Q

frax outcomes

A

Low risk – reassure
Intermediate risk – offer DEXA scan and recalculate the risk with the results
High risk – offer treatment

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9
Q

Bis SE

A

Reflux and oesophageal erosions. Oral bisphosphonates are taken on an empty stomach sitting upright for 30 minutes before moving or eating to prevent this.
Atypical fractures (e.g. atypical femoral fractures)
Osteonecrosis of the jaw
Osteonecrosis of the external auditory canal

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10
Q

pseudogout aetiology

A

crystal arthropathy caused by calcium pyrophosphate crystals

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11
Q

pseudogout aspiration findings

A

No bacterial growth
Calcium pyrophosphate crystals
Rhomboid shaped crystals
Positive birefringent of polarised light

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12
Q

Pseudogout x-ray finding

A

Chondrocalcinosis

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13
Q

Osteoarthritis/pseudogout x-ray findings

A

L – Loss of joint space
O – Osteophytes
S – Subarticular sclerosis
S – Subchondral cysts

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14
Q

Pseudogout tx

A 
NSAIDs
Colchicine
Joint aspiration
Steroid injections
Oral steroids
Joint washout (arthrocentesis) is an option in severe cases.
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15
Q

Gout tophi areas

A 
DIPJ
Helix of ear
Extensor surface of elbow
Base of the big toe (metatarsophalangeal joint)
Wrists
Base of thumb (carpometacarpal joints)
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16
Q

Gout aspiration findings

A

No bacterial growth
Needle shaped crystals
Negatively birefringent of polarised light
Monosodium urate crystals

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17
Q

Gout x-ray findings

A

Typically the space between the joint is maintained
Lytic lesions in the bone
Punched out erosions
Erosions can have sclerotic borders with overhanging edges

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18
Q

Acute flare gout management

A

During the acute flare:

NSAIDs (e.g. ibuprofen) are first-line
Colchicine second-line
Steroids can be considered third-line

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19
Q

gout prophylaxis

A

Allopurinol is a xanthine oxidase inhibitor

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20
Q

Behcet’s disease gene

A

HLA B51 gene

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21
Q

Behçet’s Disease aetiology

A

recurrent oral and genital ulcers

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22
Q

Behçet’s disease test

A

pathergy test involves using a sterile needle to create a subcutaneous abrasion on the forearm. This is then reviewed 24 – 48 hours later to look for a weal 5mm or more in size. It tests for non-specific hypersensitive in the skin. It is positive in Behçet’s disease, Sweet’s syndrome and pyoderma gangrenosum.

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23
Q

Behçet’s disease mx

A

Topical steroids to mouth ulcers (e.g. soluble betamethasone tablets)
Systemic steroids (i.e. oral prednisolone)
Colchicine is usually effective as an anti-inflammatory to treat symptoms
Topical anaesthetics for genital ulcers (e.g. lidocaine ointment)
Immunosuppressants such as azathioprine
Biologic therapy such as infliximab

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24
Q

Types of Vasculitis Affecting The Small Vessels

A

Henoch-Schonlein purpura
Eosinophilic Granulomatosis with Polyangiitis (Churg-Strauss syndrome)
Microscopic polyangiitis
Granulomatosis with polyangiitis (Wegener’s granulomatosis)

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25
Q

Types of Vasculitis Affecting The Medium Sized Vessels

A

Polyarteritis nodosa
Eosinophilic Granulomatosis with Polyangiitis (Churg-Strauss syndrome)
Kawasaki Disease

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26
Q

Types of Vasculitis Affecting The Large Vessels

A

Giant cell arteritis

Takayasu’s arteritis

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27
Q

Vasculitis Presentation

A

There are some generic features that apply to most types of vasculitis. These are things that should make you think about a possible vasculitis:

Purpura. These are purple-coloured non-blanching spots caused by blood leaking from the vessels under the skin.
Joint and muscle pain
Peripheral neuropathy
Renal impairment
Gastrointestinal disturbance (diarrhoea, abdominal pain and bleeding)
Anterior uveitis and scleritis
Hypertension

They are also associated with systemic manifestations of:

Fatigue
Fever
Weight loss
Anorexia (loss of appetite)
Anaemia
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28
Q

vasculitis ivx

A

Inflammatory markers (CRP and ESR) are usually raised in vasculitis.

Anti neutrophil cytoplasmic antibodies (ANCA)

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29
Q

ANCA blood test specific results

A

p-ANCA (MPO antibodies): Microscopic polyangiitis and Churg-Strauss syndrome
c-ANCA (PR3 antibodies): Wegener’s granulomatosis

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30
Q

vasculitis mx

A

Steroids can be administered to target the affected area:

Oral (i.e. prednisolone)
Intravenous (i.e. hydrocortisone)
Nasal sprays for nasal symptoms
Inhaled for lung involves (e.g. Churg-Strauss syndrome)

Immunosuppressants that are used include:

Cyclophosphamide
Methotrexate
Azathioprine
Rituximab and other monoclonal antibodies

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31
Q

Henoch-Schonlein purpura aetiology

A

IgA vasculitis - often triggered by URTI or gastroenteritis

purpuric rash affecting the lower limbs or buttocks in children

Deposits affect skin, kidneys and gastro-intestinal tract

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32
Q

Henoch-Schonlein purpura classic features

A

purpura (100%), joint pain (75%), abdominal pain (50%) and renal involvement (50%).

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33
Q

Eosinophilic Granulomatosis with Polyangiitis (Churg-Strauss syndrome) aetiology

A

severe asthma in late teenage years or adulthood. A characteristic finding is elevated eosinophil levels

lung and skin problem, occasionally kidneys

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34
Q

Microscopic polyangiitis presentation

A

Renal failure, also SOB and haemoptosis

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35
Q

Granulomatosis with polyangiitis (Wegener’s granulomatosis) aetiology

A

small vessel vasculitis, affects respiratory tract and kidneys

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36
Q

Granulomatosis with polyangiitis (Wegener’s granulomatosis) presentation

A

Epistaxis, crusty nasal secretions
hearing loss and sinusitis
Saddle shaped nose due to perforated septum
Wheeze, cough, haemoptysis - can be misdiagnosed as pneumonia on CXR

can lead to rapidly progressing glomerulonephritis

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37
Q

Polyarteritis Nodosa aetiology

A

medium vessel vasculitis. It is most associated with hepatitis B

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38
Q

Polyarteritis Nodosa presentation

A

livedo reticularis. This is a mottled, purplish, lace like rash.

renal, GI, stroke, MI etc

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39
Q

Kawasaki Disease presentation

A

Persistent high fever > 5 days
Erythematous rash
Bilateral conjunctivitis
Erythema and desquamation (skin peeling) of palms and soles
“Strawberry tongue” (red tongue with prominent papillae)

usually under 5 years of age

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40
Q

Kawasaki Disease comp

A

coronary artery aneurysms.

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41
Q

Kawasaki Disease tx

A

aspirin and IV immunoglobulins.

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42
Q

Takayasu’s arteritis

A

affects aorta (pulseless disease)

CT or MRI angiography

Doppler of carotids

b-type symptoms and arm claudication

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43
Q

Sjogren’s Syndrome aetiology

A

autoimmune condition that affects the exocrine glands. It leads to the symptoms of dry mucous membranes

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44
Q

Sjogren’s Syndrome classification

A

Primary Sjogren’s is where the condition occurs in isolation.

Secondary Sjogren’s is where it occurs related to SLE or rheumatoid arthritis.

It is associated with anti-Ro and anti-La antibodies.

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45
Q

Sjogren’s Syndrome presentation

A

dry mucous membranes, such as dry mouth, dry eyes and dry vagina.

46
Q

Sjogren’s Syndrome mx

A

Artificial tears
Artificial saliva
Vaginal lubricants
Hydroxychloroquine is used to halt the progression of the disease.

47
Q

Sjogren’s Syndrome comp

A

Eye infections such as conjunctivitis and corneal ulcers
Oral problems such as dental cavities and candida infections
Vaginal problems such as candidiasis and sexual dysfunction

48
Q

Sjogren’s Syndrome test

A

Schirmer test involves inserting a folded piece of filter paper under the lower eyelid with a strip hanging out over the eyelid. This is left in for 5 minutes and the distance along the strip hanging out that becomes moist is measured. The tears should travel 15mm in a healthy young adult. A result of less than 10mm is significant.

49
Q

Antiphospholipid Syndrome aetiology

A

antiphospholipid antibodies where the blood becomes prone to clotting. The patient is in a hyper-coagulable state. The main associations are with thrombosis and complications in pregnancy, particularly recurrent miscarriage.

50
Q

antiphospholipid antibodies:

A

Lupus anticoagulant
Anticardiolipin antibodies
Anti-beta-2 glycoprotein I antibodies

51
Q

Antiphospholipid Syndrome comp

A

Venous thromboembolism
Arterial thrombosis
Pregnancy complications

52
Q

Antiphospholipid Syndrome signs

A

Livedo reticularis
Libmann-Sacks endocarditis
Thrombocytopenia

53
Q

Antiphospholipid Syndrome dx

A

History of thrombosis or pregnancy complication plus:
Lupus anticoagulant
Anticardiolipin antibodies
Anti-beta-2 glycoprotein I antibodies

54
Q

Antiphospholipid Syndrome mx

A

Warfarin or LMWH plus aspirin in pregnancy

55
Q

Dermatomyositis autoamtibodies

A

Anti-Jo-1 antibodies: polymyositis (but often present in dermatomyositis)

Anti-Mi-2 antibodies: dermatomyositis.

Anti-nuclear antibodies: dermatomyositis.

56
Q

Dermatomyositis Skin Features

A

Gottron lesions (scaly erythematous patches) on the knuckles, elbows and knees

Photosensitive erythematous rash on the back, shoulders and neck

Purple rash on the face and eyelids

Periorbital oedema (swelling around the eyes)

Subcutaneous calcinosis (calcium deposits in the subcutaneous tissue)

57
Q

Dermatomyositis

A

Corticosteroids are the first line treatment of both conditions.

Other medical options where the response to steroids is inadequate:

Immunosuppressants (such as azathioprine)

IV immunoglobulins
Biological therapy (such as infliximab or etanercept)
58
Q

GCA presentation

A

Severe unilateral headache typically around temple and forehead
Scalp tenderness my be noticed when brushing hair
Jaw claudication
Blurred or double vision
Irreversible painless complete sight loss can occur rapidly

59
Q

GCA dx

A

Clinical presentation

Raised ESR: usually 50 mm/hour or more

Temporal artery biopsy findings - Multinucleated giant cells

60
Q

GCA mx

A

pred

Aspirin 75mg daily decreases visual loss and strokes

Proton pump inhibitor (e.g. omeprazole) for gastric prevention while on steroids

61
Q

Polymyalgia Rheumatica demographics

A

ass GCA
It usually affects old adults (above 50 years)
More common in women
More common in caucasians

62
Q

Polymyalgia Rheumatica signs

A

Bilateral shoulder pain that may radiate to the elbow

Bilateral pelvic girdle pain
Worse with movement

Interferes with sleep

Stiffness for at least 45
minutes in the morning

Other features:

Systemic symptoms such as weight loss, fatigue, low grade fever and low mood
Upper arm tenderness
Carpel tunnel syndrome
Pitting oedema

63
Q

PMR ivx

A

Full blood count
Urea and electrolytes
Liver function tests
Calcium can be raised in hyperparathyroidism or cancer or low in osteomalacia
Serum protein electrophoresis for myeloma and other protein disorders
Thyroid stimulating hormone for thyroid function
Creatine kinase for myositis
Rheumatoid factor for rheumatoid arthritis
Urine dipstick

64
Q

PMR special tests

A

Anti-nuclear antibodies (ANA) for systemic lupus erythematosus
Anti-cyclic citrullinated peptide (anti-CCP) for rheumatoid arthritis
Urine Bence Jones protein for myeloma
Chest xray for lung and mediastinal abnormalities

65
Q

PMR mx

A

15mg of prednisolone

66
Q

long term Steroid important factors

A

Don’t STOP

DON’T – Make them aware that they will become steroid dependent after 3 weeks of treatment and should not stop taking the steroids due to the risk of adrenal crisis if steroids are abruptly withdrawn
S – Sick Day Rules: Discuss increasing the steroid dose if they become unwell (“sick day rules”)
T – Treatment Card: Provide a steroid treatment card to alert others that they are steroid dependent in case they become unresponsive
O – Osteoporosis prevention: Consider osteoporosis prophylaxis whilst on steroids with bisphosphonates and calcium and vitamin D supplements
P – Proton pump inhibitor: Consider gastric protection with a proton pump inhibitor (e.g. omeprazole)

67
Q

Systemic Sclerosis aetiology

A

autoimmune inflammatory and fibrotic connective tissue disease.

Limited cutaneous systemic sclerosis
Diffuse cutaneous systemic sclerosis

68
Q

Limited cutaneous systemic sclerosis

A 
C – Calcinosis
R – Raynaud’s phenomenon
E – oEsophageal dysmotility
S – Sclerodactyly
T – Telangiectasia
69
Q

Diffuse Cutaneous Systemic Sclerosis

A

Cardiovascular problems, particularly hypertension and coronary artery disease.

Lung problems, particularly pulmonary hypertension and pulmonary fibrosis.

Kidney problems, particularly glomerulonephritis and a condition called scleroderma renal crisis.

PLUS CREST

70
Q

Systemic Sclerosis antibodies

A

ANA

Anti-centromere antibodies are most associated with limited cutaneous systemic sclerosis.

Anti-Scl-70 antibodies are most associated with diffuse cutaneous systemic sclerosis.

71
Q

Systemic Sclerosis medical mx

A

Steroids and immunosuppressants are usually started with diffuse disease and complications such as pulmonary fibrosis

Nifedipine can be used to treat symptoms of Raynaud’s phenomenon

Anti acid medications (e.g. PPIs) and pro-motility medications (e.g. metoclopramide) for gastrointestinal symptoms

Analgesia for joint pain

Antibiotics for skin infections

Antihypertensives

72
Q

Systemic Sclerosis non- medical mx

A

Avoid smoking
Gentle skin stretching to maintain the range of motion
Regular emollients
Avoiding cold triggers for Raynaud’s
Physiotherapy to maintain healthy joints
Occupational therapy for adaptations to daily living to cope with limitations

73
Q

Discoid Lupus Erythematosus presentation

A

women aged 20-40
SLE ass.
Photosensitive
Scarring alopecia and hyper/hypo-pigmented scars

74
Q

Discoid Lupus Erythematosus lesions

A 
Inflamed
Dry
Erythematous
Patchy
Crusty and scaling
75
Q

Discoid Lupus Erythematosus mx

A

Sun protection
Topical steroids
Intralesional steroid injections
Hydroxychloroquine

76
Q

SLE presentation

A 
Fatigue
Weight loss
Arthralgia (joint pain) and non-erosive arthritis
Myalgia (muscle pain)
Fever
Photosensitive malar rash. This is a “butterfly” shaped rash across the nose and cheek bones that gets worse with sunlight.
Lymphadenopathy and splenomegaly
Shortness of breath
Pleuritic chest pain
Mouth ulcers
Hair loss
Raynaud’s phenomenon
77
Q

SLE ivx

A

Autoantibodies (see below)
Full blood count (normocytic anaemia of chronic disease)
C3 and C4 levels (decreased in active disease)
CRP and ESR (raised with active inflammation)
Immunoglobulins (raised due to activation of B cells with inflammation)
Urinalysis and urine protein:creatinine ratio for proteinuria in lupus nephritis
Renal biopsy can be used to investigate for lupus nephritis

78
Q

SLE dx

A

SLICC Criteria or the ACR Criteria

79
Q

SLE tx

A

First line treatments are:

NSAIDs
Steroids (prednisolone)
Hydroxychloroquine (first line for mild SLE)
Suncream and sun avoidance for the photosensitive the malar rash

Other commonly used immunosuppressants in resistant or more severe lupus:

Methotrexate
Mycophenolate mofetil
Azathioprine
Tacrolimus
Leflunomide
Ciclosporin

Rituximab is a monoclonal antibody that targets the CD20 protein on the surface of B cells
Belimumab is a monoclonal antibody that targets B-cell activating factor

80
Q

Ankylosing Spondylitis aetiology

A

seronegative spondyloarthropathy group of conditions relating to the HLA B27 gene

Spine fusion - “bamboo spine”

81
Q

Ankylosing Spondylitis associations

A

Systemic symptoms such as weight loss and fatigue
Chest pain related to costovertebral and costosternal joints
Enthesitis is inflammation of the entheses. This is where tendons or ligaments insert in to bone. This can cause problems such as plantar fasciitis and achilles tendonitis.
Dactylitis is inflammation in a finger or toe.
Anaemia
Anterior uveitis
Aortitis is inflammation of the aorta
Heart block can be caused by fibrosis of the heart’s conductive system
Restrictive lung disease can be caused by restricted chest wall movement
Pulmonary fibrosis at the upper lobes of the lungs occurs in around 1% of AS patients
Inflammatory bowel disease is a condition associated with AS

82
Q

Ankylosing spondylitis tests

A

Inflammatory markers (CRP and ESR) may rise with disease activity
HLA B27 genetic test
Xray of the spine and sacrum
MRI of the spine can show bone marrow oedema early in the disease before there are any xray changes

83
Q

Ankylosing spondylitis xray signs

A

Squaring of the vertebral bodies
Subchondral sclerosis and erosions
Syndesmophytes are areas of bone growth where the ligaments insert into the bone. They occur related to the ligaments supporting the intervertebral joints.
Ossification of the ligaments, discs and joints. This is where these structures turn to bone.
Fusion of the facet, sacroiliac and costovertebral joints

84
Q

Ankylosing spondylitis mx

A

NSAIDs can be used to help with for pain.

Steroids can be use during flares to control symptoms. This could oral, intramuscular slow release injections or joint injections.

Anti-TNF medications such as etanercept or a monoclonal antibody against TNF such as infliximab

Secukinumab is a monoclonal antibody against interleukin-17. It is recommended by NICE if the response to NSAIDS and TNF inhibitors is inadequate.

85
Q

Reactive arthritis aetiology

A

Synovitis following recent infection

aka Reiter syndrome

Acute mono-arthritis

gastroenteritis or sexually transmitted infection. Chlamydia is most common

HLA B27 gene - seronegative spondylarthropathy

86
Q

Reactive arthritis associations

A

Bilateral conjunctivitis (non-infective)
Anterior uveitis
Circinate balanitis is dermatitis of the head of the penis

“can’t see, pee or climb a tree”.

87
Q

Reactive arthritis mx

A

Aspirate - gram stain, culture etc - crystal inv.

treat with NSAIDS, steroid injections

88
Q

Psoriatic Arthritis aetiology

A

seronegative spondyloarthropathy

89
Q

Psoriatic Arthritis signs

A 
Plaques of psoriasis on the skin
Pitting of the nails
Onycholysis 
Dactylitis 
Enthesitis

inflammatory arthritis

90
Q

Psoriatic Arthritis screening

A

Psoriasis Epidemiological Screening Tool (PEST)

91
Q

Psoriatic Arthritis xray

A

Periostitis is inflammation of the periosteum causing a thickened and irregular outline of the bone

Ankylosis is where bones joining together causing joint stiffening

Osteolysis is destruction of bone

Dactylitis is inflammation of the whole digit and appears on the xray as soft tissue swelling

Pencil-in-cup appearance

92
Q

Psoriatic Arthritis mx

A

NSAIDs for pain
DMARDS (methotrexate, leflunomide or sulfasalazine)

Anti-TNF medications (etanercept, infliximab or adalimumab)

Ustekinumab is last line (after anti-TNF medications) and is a monoclonal antibody that targets interleukin 12 and 23

93
Q

Psoriatic arthritis most severe sign

A

Osteolitis of phalanxes/joints - progressive shortening of digit - skin folds over digit - telescopic finger

94
Q

RF genes

A

HLA DR4 (a gene often present in RF positive patients)

HLA DR1 (a gene occasionally present in RA patients)

95
Q

RF autoantibodies

A

anti-CCP

RF

96
Q

Palindromic Rheumatism

A

This involves self limiting short episodes of inflammatory arthritis with joint pain, stiffness and swelling typically affecting only a few joints. The episodes only last 1-2 days

97
Q

RA joints

A

Proximal Interphalangeal Joints (PIP) joints
Metacarpophalangeal (MCP) joints
Wrist and ankle
Metatarsophalangeal joints
Cervical spine
Large joints can also be affected such as the knee, hips and shoulders

98
Q

RA hand signs

A

Z shaped deformity to the thumb

Swan neck deformity (hyperextended PIP with flexed DIP)

Boutonnieres deformity (hyperextended DIP with flexed PIP)

Ulnar deviation of the fingers at the knuckle (MCP joints)

99
Q

RA Extra-articular Manifestations

A

Pulmonary fibrosis with pulmonary nodules

(Caplan’s syndrome)
Bronchiolitis obliterans
(inflammation causing small airway destruction)

Felty’s syndrome (RA, neutropenia and splenomegaly)

Secondary Sjogren’s

Syndrome (AKA sicca syndrome)

100
Q

RA xray signs

A

Joint destruction and deformity
Soft tissue swelling
Periarticular osteopenia
Boney erosions

101
Q

RA scoring

A

The joints that are involved (more and smaller joints score higher)
Serology (rheumatoid factor and anti-CCP)
Inflammatory markers (ESR and CRP)
Duration of symptoms (more or less than 6 weeks)

102
Q

RA mx

A 
NSAIDS
PPI
Methotrexate etc
2 second line
Plus biologic 3rd line
103
Q

Common biologics

A

Anti-TNF (adalimumab, infliximab, etanercept, golimumab and certolizumab pegol)
Anti-CD20 (rituximab)
Anti-IL6 (sarilumab)
Anti-IL6 receptor (tocilizumab)
JAK inhibitors (tofacitinib and baricitinib)

104
Q

Methotrexate prescribing consideration

A

Folic acid 5mg, on a different day to methotrexate

105
Q

Unique DMARD side-effects

A

Methotrexate: pulmonary fibrosis
Leflunomide: Hypertension and peripheral neuropathy
Sulfasalazine: Male infertility (reduces sperm count)
Hydroxychloroquine: Nightmares and reduced visual acuity
Anti-TNF medications: Reactivation of TB or hepatitis B
Rituximab: Night sweats and thrombocytopenia

106
Q

OA hand signs

A 
Heberden’s nodes (in the DIP joints)
Bouchard’s nodes (in the PIP joints)
Squaring at the base of the thumb at the carpo-metacarpal joint
Weak grip
Reduced range of motion
107
Q

OA management

A

Physio/lifestyle/education

Paracetamol
NSAIDS plus PPI
Opiates

joint injections

108
Q

Felty’s syndrome

A

rheumatoid arthritis, enlargement of the spleen and low neutrophil count

109
Q

types of psoriasis

A

rheumatoid arthritis, enlargement of the spleen and low neutrophil count

110
Q

Telescope finger aka

A

Arthritis mutilans

Finals (18 decks)

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