MSK / Rheum Flashcards
Which is the genetic component most associated with ankylosing spondylitis?
HLA-B27
88M. Severe pain in lower legs, lasting many months. Bowing of the tibia laterally seen on examination
The suspected diagnosis is Paget’s disease, what blood test results would support this (ALP, PTH, Calcium, phosphate, 25-hydroxyvitamin D)
Elevated ALP, normal PTH, normal calcium, normal phosphate, normal 25-hydroxyvitamin D
EVERYTHING NORMAL EXCEPT ALP
Loss of knee jerk is is caused is caused by vertebral disc prolapse at what level?
L4
An 18 year old male presents at your GP surgery complaining of acute knee pain. The joint is hot, swollen, and tender. He has no other joint symptoms although does complain of some eye pain and painful urination. He undergoes joint aspiration which excludes septic arthritis, and so you suspect reactive arthritis.
Which of the following infections is most likely in this case?
A. Epstein Barr virus
B. Chlamydia
C. Gonorrhoea
D. E.Coli
E. Staphylococcus aureus
B. Chlamydia
19F, IVDU with septic arthritis.
A joint aspiration and culture reveals gram negative rod-shaped microorganisms are present within the synovial fluid.
What is the causative agent?
A. Pseudomonas aeruginosa
B. Staphylococcus aureus
C. Neisseria gonorrhoeae
D. Haemophilus influenzae
E. Streptococcus agalactiae
A. Pseudomonas aeruginosa
27F. Joint pain affecting both hands, worse in the morning. Movement improves the pain.
Bilateral tenderness over both wrists and 2 DIP joints in the left hand. Occasionally the pain surrounding the DIP joints is accompanied with swelling and inflammation of the whole finger, to such an extent that she can no longer wear rings on them.
Most likely diagnosis?
Psoriatic arthritis
59F presents to A&E with transient unilateral loss of vision occurring multiple times in the last 4 hours. She also notes generalised aching in her body that she has just put down to aging, and pain when brushing her hair.
What is the most likely diagnosis? What should be the immediate treatment?
Giant cell arteritis
Prednisolone (immediate IV steroids)
74M. Acute shoulder pain for 2 days. Severe with limited mobility due to swelling.
Joint aspiration shows positively birefringent rhomboid crystals under polarised light.
Based on this, what is the likely diagnosis and another likely feature to be seen on XR?
Pseudogout
Calcification parallel to articular surfaces
‘you squeeze her metacarpophalangeal joints and she winces in pain’
No rash / skin change.
Most likely diagnosis?
Rheumatoid arthritis
Causative organism of reactive arthritis if presenting with urinary symptoms
Chlamydia
Causative organism of reactive arthritis if also presenting with GI symptoms (from up to 2wks before onset of joint pain)
E.Coli
Causative organism of reactive arthritis if also presenting with glandular fever symptoms
EBV
Causative organism reactive arthritis with eye irritation, recent upset stomach.
Campylobacter jejuni
Which antibody in the typical screen used in the diagnosis of Sjogren’s syndrome is most specific?
Anti-La
Give 2 surgical treatment options for osteoarthritis
- arthroscopy
- arthroplasty
- osteostomy
- fusion
Name 2 ‘hidden’ places where psoriasis can be found
- behind the ear
- inside the ear
- nails
- scalp
- genitals
- soles of feet
Give 5 RFs for septic arthritis / osteomyelitis
- IVDU
- age over 80
- pre existing joint disease e.g. rheumatoid arthritis
- diabetes mellitus
- immunosuppression
- recent joint surgery
- prosthetic joint
- recent intra articular steroid injections
- penetrating trauma
Name 2 antibodies that many be found in a pt with SLE
- antinuclear antibodies (ANA) - highly sensitive
- anti double stranded DNA antibodies (anti-dsDNA) - specific
- anti smith antibodies (anti Sm) - most specific, least sensitive
State the class of drugs which is first line in osteoporosis
Give an example
Give brief instruction for how it should be taken
Bisphosphonates e.g. Alendronic Acid
Taken once a week, on an empty stomach
Name 3 characteristic deformities of the hands in rheumatoid arthritis.
- Swan neck deformity
- Z thumb deformity
- Boutonnière deformity
- Ulner deviation
What is the mechanism of Allopurinal?
Inhibition of xanthine oxidase, therefore preventing the conversion of hypoxanthine to xanthine to uric acid
What is Allopurinol used for?
To treat gout
What is the treatment for acute gout?
Colchicine and high dose NSAIDs
What is prescribed to prevent future bouts of gout?
Allopurinol
Describe the 3 phases of the Pathophysiology of Pagets
- Lytic phase: excessive osteoclastic reabsorption
- Mixed phase: excessive reabsorption and disorganised bone formation
- Blastic/latent: disorganised osteoclastic bone formation, causing weak bone
Give 2 complications of Paget’s
- osteosarcoma
- fractures
- tibial bowing
- deafness
What is the first line treatment in Pagets
Bisphosphonates
Define GCA
Chronic granulomatous large vessel vasculitis, mainly affecting the carotid arteries and its branched e.g. the temporal artery.
What is the acute management of GCA and why?
High dose corticosteroids e.g. Prednisolone
Prevent blindness
Describe the diagnostic criteria for GCA
- > 50 yrs old
- temporal artery abnormality e.g. tenderness
- abnormal temporal artery biopsy
- elevated ESR
What condition that causes shoulder pain is associated with GCA?
Polymyalgia rheumatica
What type of hypersensitivity is SLE?
Type III
Give 3 signs of SLE
- malar rash
- fatigue
- muscle pain
- lymphadenopathy
- arthralgia
- mouth ulcers
- alopecia
- lupus nephritis
What marker is used to monitor SLE?
ESR
How do you treat arthralgia / skin symptoms associated with SLE?
Hydroxychloroquine
A 28 year old woman presents to her with her 3rd recurrent miscarriage. She has a history of recurrent DVTs and one pulmonary embolism. On examination you identify a blotchy pattern on her skin. On investigation, her blood results show a prolonged APTT.
Most likely diagnosis?
Anti phospholipid syndrome
What is the name of the rash seen in anti phospholipid syndrome?
Livedo Reticularis
What 3 antibodies are associated with anti phospholipid syndrome?
- Lupus anticoagulant
- Anti-cardiolipin
- Anti-beta2 GP1
What is the main group affected my fibromyalgia?
Female, age 30-60
List 2 RFs for osteomalacia
- lack of sun exposure
- lack of dietary intake of vitamin D
Which reflex is lost with a nerve root lesion at S1?
Ankle jerk
What is the clinical test used in Ankylosing SPondilitis to examine spine mobility?
Schober’s test
Ask pt tho stand up straight, draw 2 points along their spine - 10cm above and 5cm below the L5 vertebrae. Ask the pt the bend as far forward as they can. If the distance between the two marks is less than 20, this indicates reduced spine mobility and supports a diagnosis of ankylosis spondylitis
Osteomyelitis: most common causative organisms in normal pts
Staphylococcus aureus
Osteomyelitis: most common causative organism in sickle cell pts
Salmonella
Describe the XR finding is Ewings Sarcoma
Lytic bone lesions, onion skin appearance in periosteum
Describe the osteosarcoma XR findings
‘Sun ray spiculation’
Codman’s Triangle
Describe the chondrosarcoma XR findings
Popcorn calcifications, endosteal scalloping, Lytic lesion
What is the most common sarcoma in children?
Rhabdomyosarcoma
Describe the difference in inflammatory markers in active lupus and an acute infection in lupus
Active lupus: raised ESR, normal CRP
Acute infection: raised ESR, raised CRP
What are the risk factors for osteoporosis?
SHATTERED
Steroid use
Hyperthyroidism / hyperparathyroidism
Alcohol and smoking
Thin (low BMI)
Testosterone decrease
Early menopause
Renal or liver failure
Erosive / inflammatory bone disease
Dietary calcium decrease / T2DM
Give 3 RFs for Paget’s disease
- older age
- male
- northern latitude
- family history
What bones are often affected by Pagets ?
- skull
- spine
- pelvis
- femur
- tibia
What disease is associated with cANCA ?
Wegeners Granulomatosis (Granulomatosis with polyangiitis)
What diseases are associated with pANCA ?
- Microscopic polyangiitis
- Eosinophilic granulomatosis with polangitis
What are the 4 features of anti phospholipid syndrome?
CLOT
Coagulopathy
Livedo reticularis
Obstetric emergencies e.g. recurrent miscarriage
Thrombocytopenia
What is the treatment for primary anti phospholipid syndrome?
Low dose aspirin
What is the treatment for secondary anti phospholipid syndrome?
Lifelong warfarin
What is the 1st line treatment of neuropathic pain?
Serotonin 5-HT3 receptor antagonist e.g. Amitryptyline
What genes are associated with SLE?
HLA B8
HLA DR2
HLA DR3
Name 4 features of SLE that are required to make a clinical diagnoses
‘A RASH POINTS AN MD’
Arthritis
Renal disorder
ANA+
Serositis
Haematological disorder
Photosensitivity
Oral ulcers
Immunological disorder
Neurological disorder
Malar rash
Discoid rash
What are two lifestyle changes that can be made to reduce SLE symptoms?
- decrease sunlight exposure
- wear high factor suncream
- decrease cardiovascular risk factor e.g. obesity, smoking, exercise, cholesterol
What medications should be given for an acute attack of SLE and what route should they be given
IV cyclophosphamide and Prednisolone
What causes the articular cartilage damage in OA?
Apoptosis of Chondrichthyes
Loss of cartilage
What causes joint ‘locking’
Loose body/bone/cartilage fragment in the joint
T2DM patient on methotrexate. Presents with septic arthritis.
What change should be made to her meds regimen and why?
STOP METHOTREXATE
It is immunosuppressive
What is now a rare cause of joint infection due to the standard immunisation schedule in the UK?
Haemophilus influenzae
What is the most specific blood test result for RA?
Positive anti-cyclic citrullinted peptide antibody
During active SLE, what will the CRP and complement 3 and 4 be?
Low serum complement 3 and 4
High CRP
Px: Dry eyes, dry skin, vaginal dryness.
Bloods: ANA positive, anti-Ro positive, anti-La positive, anti-dsDNA negative
Most likely diagnosis and which cancer is it associated with?
Sjogrens
Lymphoma
What kind of cancer is osteosarcoma
Malignant tumour of the bone
What is Felty’s syndrome and what is the first line investigation?
Complication of RA, including splenomegaly and low white cell count
Abdominal US
What is the first sign of ankylosing spondylitis on XR?
Sacroiliitis (inflammation of sacroiliac joint)
ANkylosing spondylitis gene association?
HLA B27
Reactive arthritis 1st line Tx?
NSAIDs
What needs to be monitored post fall and long lie?
Potassium, creatinine kinase, myoglobin
Rhabdomyolysis increases risk of AKI and cardiac complications
What diagnosis would a T score of -2.3 give?
Osteopenia
What does DEXA stand for?
Dual energy X-ray absorptiometry
Explain how menopause can cause osteoporosis
- post menopause means lower oestrogen levels
- increased number of osteoclasts / premature arrest of osteoblastic synthetic activity
- high bone turnover
What test could differentiate osteoporosis from osteomalacia? What result would be each?
Blood test-
Ca2+/phosphate/alkaline phosphatase is normal in osteoporosis.
Low Ca/low phosphate/high alkaline phosphatase in osteomalacia
Gout preceipitating factors
- trauma
- surgery
- starvation
- infection
- diuretics
Gout prophylaxis medication? What enzyme does it inhibit?
Allopurinol
Xanthine oxidase inhibition
What is the crystal that causes pseudogout? What is the most common joint involved
Calcium pyrophosphate
Knee
Chronic gout pathognomic sign?
Tophi
What muscles are innervated by the musculocutaneous nerve?
BBC: - biceps brachii
- brachialis
- coracobrachialis
With loss of sensation over the right lateral upper arm, and weakening of flexion, extension, abduction, external rotation, which nerve is damaged and therefore which muscles are weakened?
Axillary nerve - there’s minor and deltoid muscle
Sensory loss over the ‘regimental badge’
What is the main source of IL-1?
Macrophages
