Musculoskeletal and rheumatology Flashcards

Question

What is the aetiology/pathophysiology of gout?

Answer 1

High blood uric acid level means urate crystals are deposited in the joint causing it to become hot, swollen and painful.

Answer 2

Symptoms - Relapsing/remitting - patients present with recurrent episodes of red, hot, tender joints - Asymptomatic between flares - remission can last months - Rapid onset severe joint pain - Joint stiffness Signs: - Joint inflammation: tenderness, erythema and swelling - Monoarticular or oligoarticular (≤ 4 joints): 1st MTP most commonly affected in a first presentation (70%); ankle, wrist and knee Gouty tophi: nodular masses of urate crystals form, usually as a late complication

Answer 3

- Base of the big toe (metatarsophalangeal joint) - Wrists - Base of thumb (carpometacarpal joints) - Large joints like the knee and ankle.

Answer 4

1st line: joint aspiration: confirm the diagnosis and exclude septic arthritis - negative birefringent needle-shaped monosodium urate crystals under polarised microscopy

Answer 5

Dietary changes: decreased meat, increased dairy as protective against gout Acute flare: 1st line: NSAIDs/colchicine + corticosteroids + PPI to protect stomach Prevention - urate-lowering therapy: All patients given this after acute episode 1st line: allopurinol - xanthine oxidase inhibitors

Answer 6

Septic arthritis

Answer 7

Pseudogout is a crystal arthropathy caused by calcium pyrophosphate crystals. Calcium pyrophosphate crystals are deposited in the joint, causing synovitis.

Answer 8

Knees, shoulders and wrists

Answer 9

- Elderly (70+) - Female - Diabetes - Osteoarthritis

Answer 10

Symptoms: - Rapid onset severe joint pain: knee, shoulder and wrist are most commonly affected - Joint stiffness Signs: - Joint inflammation: pain, erythema and swelling - Monoarticular or polyarticular

Answer 11

1st line: Joint aspiration: confirms the diagnosis and rules out septic arthritis, weakly-positive birefringent rhomboid-shaped crystals under polarised microscopy Joint X-ray: chondrocalcinosis (calcification of articular cartilage) in 40% of cases - In the knee, this is seen as linear calcifications of the articular cartilage and meniscus

Answer 12

Similar treatment to gout with NSAIDs and corticosteroids Anti-inflammatory: NSAIDs or colchicine Corticosteroid: Monoarticular: intra-articuar Polyarticular: systemic steroids Joint replacement: only indicated in chronic, recurrent cases with severe joint degeneration

Answer 13

Septic arthritis - medical emergency!

Answer 14

Osteoporosis is the reduction in trabecular bone mass/density and disruption of bone architecture, resulting in porous bone with increased fragility and fracture risk.

Answer 15

Osteoporosis is caused by a prolonged imbalance of bone remodelling where resorption (osteoclastic activity) exceeds formation (osteoblastic activity). A combination of environmental and genetic factors involved

Answer 16

Fight Me! - Female - post-Menopausal SHATTERED - Steroids - Hyper/hypothyroidism - Alcohol + smoking - Thin (low BMI) - Testrosterone (low) - Early menopause (decreased oestrogen) - Renal/liver failure - Erosive/inflammatory disease - DMT1 or malabsorption

Answer 17

- 1st line + gold standard: Dual X-ray absorptiometry (DEXA) - T- and Z-score - Diagnosis = T-score ≤-2.5

Answer 18

Asymptomatic until fragility fractures occur Signs: Evidence of acute fracture: - Pain - Acute bony deformity - Inability to weigh bare Evidence of previous fractures: - Kyphosis (curvature of spine) - Chronic bony deformity

Answer 19

Z-scores compare the patient's bone density against age-matched controls T-scores compare the patient's bone density against healthy adults at peak bone density T-score ≤-2.5 = osteoporosis

Answer 20

Conservative: - Weight-bearing exercise - Dietary sources of vitamin D and calcium - Smoking cessation - Reduce alcohol consumption Medical: - Men and women with fragility fracture of DEXA T-score <2.5: 1st line: Bisphosphonates - reduce osteoclast activity through the inhibition of enzyme (Farnesyl Pyrophosphate synthase) e.g. alendronic acid Calcium and vitamin D supplements: adcal D3 Denosumab: post-menopausal women at high risk of fracture

Answer 21

It is a less severe loss of bone density compared to osteoporosis. Reduced bone density means bones are not as strong and are more prone to fractures Defined as a T-score of -1 to -2.5

Answer 22

A syndrome characterised by widespread pain and tender points at specific anatomical sites. It is often accompanied by depression, fatigue and sleep disturbance. MSK equivalent of IBS

Answer 23

CNS pathology (i.e., brain and spinal cord) and involves a problem with pain processing and pain/sensory amplification (increased pain response to painful stimuli and pain response to non-painful stimuli)

Answer 24

- Female sex: x1.5 more likely to be diagnosed - Family history of fibromyalgia Aged 30-60 - peak onset of symptoms and diagnosis

Answer 25

Symptoms: - Chronic pain - Fatigue - Sleep disturbances - Headaches - Difficulties with concentration Signs: Specific tender points throughout the body suggest fibromyalgia (see next flashcard)

Answer 26

- Occiput (base of skull) - Low cervical region (C3 - C7) - Trapezius (shoulder muscle) - Supraspinatus (shoulder muscle) - Second rib - Lateral epicondyle (outside of elbow) - Gluteal region - Greater trochanter (hip) - Knees Tenderness to these areas bilaterally was previously used as a diagnostic criterion for fibromyalgia.

Answer 27

Clinical diagnosis Diagnosis = presence of chronic, widespread body pain for > 3 months and associated symptoms such as fatigue and sleep disturbance A 31-point questionnaire assessing patients on: - A widespread pain index (WPI), body divided into 19 regions, patients report painful areas - A symptoms severity score (SS) assesses fatigue, sleep and cognitive symptoms Diagnosis is made if 3 conditions are met: - WPI ≥7 and SS ≥5 or WPI 3 - 6 and SS ≥9 - Symptoms ≥ 3 months - Other conditions that might cause the pain excluded Other tests are used to exclude other diagnoses.

Answer 28

TFTs: hypothyroidism Erythrocyte sedimentation rate +/- autoimmune screen: inflammatory arthropathy Creatine kinase: inflammatory myopathy Bone profile & LFTs: hyperparathyroidism and osteomalacia

Answer 29

Difficult and tailored to each patient First-line: - Patient Education - Physical therapy: individualised graded physical exercise, particularly aerobic exercise

Answer 30

Systemic auto-immune disorder Characterised by dry eyes (keratoconjunctivitis sicca) and dry mouth (xerostomia) caused by lymphocytic infiltration into the lacrimal and salivary glands

Answer 31

Primary Sjogren’s - occurs in isolation Secondary Sjogren’s - related to SLE or RA

Answer 32

Symptoms - Fatigue - Dry eyes - Dry mouth SIgns - Vasculitis (skin rash) - Dental caries

Answer 33

- Schirmer's test - filter paper inserted under the lower eyelid hanging over the eyelid. Test positive if <5mm paper is wetted after 5 mins (normal ~15mm) - Serology - anti-Ro and anti-La antibodies test - anti-Ro and anti-La autoantibodies associated with autoimmune diseases, present in around 90% patients with Sjogren's syndrome

Answer 34

1st line: Artificial tears, artificial saliva, vaginal lubricants Hydroxychloroquine might be considered by doctor to halt progression

Answer 35

Large vessel vasculitis, the most common type to affect adults Usually affects branches of the carotid artery: - Superficial temporal artery - Mandibular artery - Ophthalmic artery Aka temporal arteritis

Answer 36

Granulomatous inflammation along the affected vessel walls > intimal thickening and narrowed lumen > affects blood flow

Answer 37

Rare, ~0.5% population - Age: > 50 - Female - Caucasians - Polymyalgia rheumatica (PMR) - condition that causes pain, stiffness and inflammation in the muscles around the shoulders, neck and hips - Family history

Answer 38

Depends on the artery affected Symptoms - Superficial temporal artery: Headache and scalp pain when combing hair - Mandibular artery: Jaw claudication - Ophthalmic artery: Visual loss due to retinal ischaemia Signs - Superficial temporal artery tenderness - Absent temporal artery pulse - Reduced visual acuity - Pallor of the optic disc

Answer 39

Temporal artery biopsy: definitive test for diagnosis A positive biopsy = presence of granulomas Skip lesion - so take a large chunk otherwise could result in negative biopsy ESR: a value ≥ 50mm/h = 1 of 5 diagnostic criteria CRP - elevated FBC - normochromic, normocytic anaemia

Answer 40

3 or more criteria need to be met for a diagnosis of GCA. - Age ≥ 50 - New-onset headache - Temporal artery abnormality: e.g. tenderness on palpation or decreased pulsation - Elevated ESR ≥ 50mm/h - Abnormal temporal artery biopsy

Answer 41

1st line - Corticosteroid: - Prednisolone - IV methylprednisolone for visual symptoms - Oral aspirin: 75mg daily - may protect against cranial ischaemia Urgent ophthalmology review: if there is evidence of visual compromise

Answer 42

- Polymyalgia rheumatica - mainly causes stiffness and aching in shoulders and proximal limb muscles in morning - Solid organ caners and haematological malignancies - Takayasu's arteritis (main difference is TA age onset younger at 20 -30 and affects mainly women)

Answer 43

A chronic inflammatory rheumatic condition of unknown cause. Closely associated with GCA, 2 in 5 people with GCA develop PMR. Patients commonly present with bilateral pain, and stiffness in the shoulders + hips (>45 mins in morning/rest) Diagnosis of exclusion: ESR raised >40 mm/hr while creatine kinase (CK), rheumatoid factor (RF) normal Treatment = oral prednisolone then reduce dose weekly

Answer 44

- Ischaemic cranial complications: visual loss and cerebrovascular accidents (stroke) - Aortic aneurysms

Answer 45

Granulomatosis with polyangiitis (Wegener's granulomatosis) is a systemic vasculitis affecting small and medium vessels. The classic triad of organ systems affected: - Upper respiratory tract - Lower respiratory tract - Renal with pauci-immune glomerulonephritis (small vessel vasculitis that leads to renal failure)

Answer 46

Upper respiratory tract: - Nose bleeds (epistaxis) - Saddle-shaped nose due to perforated nasal septum - Hearing loss - Sinusitis Lungs: - Cough - Wheeze - Haemoptysis (coughing up blood) Kidneys Rapidly progressing glomerulonephritis

Answer 47

Anti neutrophil cytoplasmic antibodies (ANCA) - definitive blood test in vasculitis The test is positive for c-ANCA - Urinalysis and microscopy - haematuria, proteinuria, dysmorphic RBCs, RBC casts - CT chest - lung nodules, infiltrates - FBC and differential - anaemia - Inflammatory markers (CRP and ESR) elevated

Answer 48

1st line: - Corticosteroids, e.g. prednisolone - Immunosuppressant - severe disease = rituximab (anti-B-lymphocyte mAb), non-severe disease = methotrexate

Answer 49

- Ankylosing spondylitis (AS) - Reactive arthritis - Psoriatic arthritis They are associated with the HLA B27 gene

Answer 50

Mnemonic: SPINE-ACHE S - Sausage fingers (dactylitis) P - Psoriasis I - Inflammation + backache N - NSAIDs- good response E - Enthesitis (inflammation where tendons and ligaments attach to bones) - plantar fasciitis, inflamed knee tendon) A - Arthritis C - Crohn's or colitis H - HLAB27 E - Eyes > uveitis

Answer 51

An inflammatory condition mainly affecting the spine. - Causes progressive stiffness and pain. - Part of the seronegative spondyloarthropathy group of conditions relating to the HLA B27 gene

Answer 52

Strong link with the HLA B27 gene. - ~90% of patients with AS have the HLA B27 gene - ~2% of people with the gene will get AS This number is higher (around 20%) if they have a first-degree relative that is affected.

Answer 53

Key joints affected: - Sacroiliac joints - Vertebral column joints The inflammation causes pain and stiffness in these joints. It can progress to the fusion of the spine and sacroiliac joints - “bamboo spine” on spinal x-ray

Answer 54

Typical presentation in exams - young adult male in his late teens/the early 20s Although studies show it affects men and women in similar numbers Symptoms: - Lower back pain, stiffness, reduced spinal movement - Worse with rest, improves with movement - Worse at night - Painful red eye Signs: - Sacroiliac pain in the buttock region - Uveitis - Schober’s Test shows decreased spine flexion (<20cm) when patient tries to touch their toes while standing Symptoms can fluctuate with “flares” of worsening symptoms and other periods where symptoms improve.

Answer 55

- 1st line: spinal x-ray/MRI - sacroiliitis (inflammation of sacroiliac joint) and bamboo spine (fused spine) - Inflammatory markers (CRP and ESR) elevated

Answer 56

- 1st line: regular exercise regime and NSAIDS as it stops new spinal bone formation - Steroids - used during flares to control symptoms - DMARD if NSAIDs ineffective - anti-TNF-alpha (proinflammatory cytokine) medications, e.g. infliximab

Answer 57

Vertebral fractures

Answer 58

- Osteoarthritis - Psoriatic arthritis - Reactive arthritis

Answer 59

Psoriatic arthritis is an inflammatory arthritis associated with psoriasis. Can be mild with stiffening and soreness in the joint Severe: arthritis mutilans where joints are completely destroyed 10-20% of patients with psoriasis within 10 years.

Answer 60

Symptoms: - Painful, swollen, stiff joints Signs: - Psoriatic plaques on the skin - Pitting of the nails - Onycholysis (separation of the nail from the nail bed) - Dactylitis (inflammation of the full finger) - Enthesitis (inflammation of the entheses, which are the points of insertion of tendons/ligaments into bone)

Answer 61

Telescopic finger - osteolysis (destruction) of the bones around the joints in the digits leads to the shortening of the digits

Answer 62

X-ray of hands and feet - erosion of DIP joints and classic sign is "pencil-in-cup appearance" of digit joints

Answer 63

1st line: - NSAIDs for pain and inflammation - Physiotherapy Patients with joint erosion/polyarthritis - Disease-modifying antirheumatic drugs (DMARDs) (e.g. methotrexate) - Anti-TNF medications (e.g. infliximab) if DMARDs fail

Answer 64

- Rheumatoid arthritis (RA) - Gout - Erosive osteoarthritis

Answer 65

Reactive arthritis is where synovitis occurs in the joints as a reaction to certain recent gastrointestinal and genitourinary infections.

Answer 66

- Gastroenteritis or sexually transmitted infection. - Chlamydia is the most common STI cause - Gonorrhoea commonly causes gonococcal septic arthritis. Think of reactive arthritis + septic arthritis if someone had a recent STI

Answer 67

Can’t see - Uveitis (middle layer of eye inflammation) Can’t pee - Urethritis (inflammation of urethra)/ Balanitis (inflammation of penis head) Can’t climb a tree - arthritis

Answer 68

Septic arthritis - if a patient presents with acute warm, swollen, painful and hot joints, give Abx until excluded as cause

Answer 69

Joint aspiration - the absence of microorganisms excludes septic arthritis. Raised WCC will be seen Swab from the infected site: urethral, cervical or rectal swab to demonstrate evidence of an STI Stool sample: if the history is consistent with infective gastroenteritis as a precipitant

Answer 70

- NSAIDs - Intra-articular steroid injections into affected joints if monoarticular - Systemic corticosteroids when polyarticular - Abx for STI - Most resolve within 6 months and don’t recur.

Answer 71

Septic arthritis describes an infection of a joint. Septic arthritis must be considered a medical emergency due to the risk of permanent joint destruction, osteomyelitis and sepsis.

Answer 72

Up to 90% of cases are caused by staphylococci or streptococci, often as a complication of other pathologies such as cellulitis, chronic osteomyelitis, or IV drug abuse.

Answer 73

Staphylococcus epidermidis - Prosthetic joints Streptococcus pyogenes - Children under 5 years old Neisseria gonorrhoeae - Young, sexually-active adults

Answer 74

Symptoms: - Fever - Difficulty weight bearing on affected side - Typically affects a single joint Signs: - Hot, tender, erythematous, swollen joint - Very limited range of movement

Answer 75

Definitive investigation: joint aspiration (arthrocentesis) before starting antibiotics, synovial fluid sent to the lab for culture and microscopy: - Colour: yellow and cloudy (normally clear) - WBC/ul: >50,000 - PMN cells (e.g. neutrophils): >50% Blood cultures: should be performed on all patients before commencing antibiotics - FBC: leukocytosis - CRP and ESR: elevated

Answer 76

Used in children to diagnose septic arthritis in the hip, each criterion gives 1 point: Non-weight bearing Temp > 38.5 ESR > 40mm/hr WCC > 12 x 109/L - score ≥ 3 = 93% probability

Answer 77

Combination of antibiotics and joint aspirations to dryness: Abx: IV 2 weeks then oral 4 weeks - 1st line: flucloxacillin - Penicillin allergy: clindamycin - MRSA: vancomycin - Gonococcal arthritis or gram-negative infection: cefotaxime or ceftriaxone

Answer 78

Osteomyelitis: the spread of infection from the joint to the surrounding bone Permanent joint destruction Sepsis

Answer 79

- Osteoarthritis - Psoriatic arthritis - Rheumatoid arthritis

Answer 80

Osteomyelitis (OM) is an inflammatory condition affecting any bone in the skeleton, usually as a result of bacterial infection

Answer 81

The underlying infection may occur due to haematogenous spread from, e.g. septic arthritis or direct penetration by a causative microorganism e.g. trauma. OM can be both acute or chronic in its presentation.

Answer 82

The most common causative microorganism: - Staphylococcus aureus: most common (90%) - Salmonella species: most common cause in sickle-cell disease patients

Answer 83

- Penetrating injury - Intravenous drug use: S. aureus, Pseudomonas - Diabetes mellitus - particularly if foot ulcers present - Sickle cell disease - Rheumatoid arthritis

Answer 84

Symptoms: - Fatigue - especially with chronic OM - Fever - Pain at infection site - Reduced range of movement Signs: - Puncture wound: may be visibly infected - Not weight-bearing (common in children) - Local inflammation - Local erythema - Swelling - Vertebral osteomyelitis - Ulceration or Charcot foot: diabetics

Answer 85

- FBC: raised in acute infection, may be normal in chronic osteomyelitis - ESR: raised in acute, often normal in chronic - CRP: raised in acute, often normal in chronic - Blood cultures: to identify causative microorganism and microbial sensitivities - X-ray of the affected area: - Osteopenia - Bone destruction

Answer 86

Sepsis - treat immediately! Acute OM: - 1st line: IV flucloxacillin - Suspected MRSA infection: vancomycin - Supportive therapy: analgesia, hydration - Acute OM in a patient with diabetic foot: MDT referral (diabetologist, orthopaedic surgery, podiatry, microbiology)

Answer 87

Vertebral osteomyelitis: Referral to infectious diseases team and spinal surgery If neurological involvement, progressive disease or spinal instability: surgery No neurological involvement: broad spectrum IV abx - vancomycin and ceftriaxone Supportive therapy: analgesia, hydration

Answer 88

Chronic osteomyelitis = >3 months Diabetic foot ulcer infection > osteomyelitis - MDT referral: diabetologist, orthopaedic surgery, podiatry, microbiology - Consideration for surgery - Optimisation of contributing co-morbidities: diabetes, nutrition, sickle cell disease - Treat acute flares: IV antibiotics.

Answer 89

SLE is a chronic systemic autoimmune condition caused by a type 3 hypersensitivity reaction (immune complexes) - IgG mediated. Apoptotic debris is poorly cleared > activates an immune response -producing antibody-antigen complexes (IgG antibodies against double-stranded DNA) immune complex deposit in tissues > complement activation > tissue inflammation & damage Immune complex deposition can affect any organ, such as the skin, joints, kidneys, heart and brain.

Answer 90

- Middle-aged: peak onset age - 15 and 45 - Female gender: x12 more likely - African and Afro-Caribbean - more prevalent and severe - Family history Drugs: procainamide, isoniazid, hydralazine may cause drug-induced Lupus

Answer 91

HLA genes: HLA-B8, HLA-DR2, HLA-DR3

Answer 92

SLE is a multi-system disorder which most commonly affects the joints and skin - many other signs/symptoms in other organs Classic presentation: - Malar "butterfly" rash - Fatigue - Widespread MSK pain - Middle-aged African female - Relapsing/remitting with acute flares

Answer 93

- Joint pain - Skin - discoid rash, photosensitive rash - Serositis (inflammation of serous membrane) - scleritis, pericarditis, pleuritis, oral ulcers - Kidneys - Glomerulonephritis with proteinuria (lupus nephritis) - CNS - depression, psychosis

Answer 94

FBC: anaemia, thrombocytopaenia and leukopaenia U&E: lupus nephritis can cause chronic kidney disease ESR raised in active disease CRP is usually normal; raised CRP = underlying infection Antibodies: ANA (antinuclear antibodies): most sensitive test and present in 99% of patients - associated with autoimmune disease Anti-dsDNA & anti-Smith - highly specific for SLE and can confirm the diagnosis

Answer 95

Treatment for acute flares: Mild: - Prednisolone (corticosteroid) - Hydroxychloroquine (DMARD) - NSAIDs Moderate/severe: - Prednisolone and hydroxychloroquine - An immunosuppressant e.g. azathioprine Maintenance therapy: Once patient is stable - reduce steroid dose The goal = hydroxychloroquine alone. Avoid the sun and use sunscreen

Answer 96

Paget’s disease (or Paget’s disease of the bone) is a condition characterised by increased bone turnover due to increased osteoclast activity. This leads to metabolic hyperactivity within the bone > patchy areas of high density (sclerosis) and low density (lysis) > long-bone and skull deformities

Answer 97

- Males are slightly more at risk than females - Age: mean onset 55 years - Family history of Paget’s disease - Infection: paramyxoviruses

Answer 98

- Asymptomatic: incidental finding on x-ray or LFT in most patients - Bone pain: femur/pelvis 75% of patients, skull involvement 37% - Facial pain: if skull disease with CN V involvement - Hearing loss: if skull disease with CN VIII involvement

Answer 99

- Bony deformities: skull bossing, bone bowing, prognatism (protrusion of lower jaw) - Pathological fracture - Reduced visual acuity: if CN II involvement (rare) - Local temperature rise: due to increasing metabolic activity

Answer 100

Plain film x-ray: early-stage = osteolytic lesions, fractures, late stage = sclerotic changes Radionucleotide bone scan: to identify pagetoid bone Liver function tests: raised ALP Bone profile: calcium normal but sometimes raised Vitamin D level: normal in Paget’s but decreased in osteomalacia

Answer 101

Treatment depends on whether a patient is asymptomatic or disease is in a high-risk area of bone e.g. skull or affecting a joint Asymptomatic: Observation: regular follow-up, education, e.g. regarding high-risk activities Symptomatic or high-risk: 1st line: Bisphosphonates: alendronic acid to reduce osteoclastic activity Severe disease: Surgery: i.e. total hip replacement if hips affected

Answer 102

Osteomalacia - low vitamin D levels in osteomalacia vs normal levels in Paget's disease

Answer 103

A disorder associated with antiphospholipid antibodies where the blood becomes prone to clotting. The patient is in a hyper-coagulable state. Associated with thrombosis and pregnancy complications such as recurrent miscarriages.

Answer 104

Antiphospholipid syndrome can be primary or secondary to an autoimmune condition, particularly SLE. It is associated with antiphospholipid antibodies: - Lupus anticoagulant - Anticardiolipin antibodies - Anti-beta-2 glycoprotein I antibodies These antibodies interfere with coagulation and create a hypercoagulable state where the blood is more prone to clotting.

Answer 105

- Venous thromboembolism - DVT, PE - Arterial thrombosis: strokes, MI, renal thrombosis - Pregnancy complications: recurrent miscarriage, stillbirth, preeclampsia - Thrombocytopenia (low platelets)

Answer 106

A patient with APS usually presents with signs/symptoms of associated conditions e.g.: - History or current diagnosis of vascular thrombosis - History of pregnancy loss - History of SLE - Joint stiffness/arthritis - Thrombocytopenia (low platelets caused by idiopathic thrombocytopenic purpura)

Answer 107

Diagnosis based on history of thrombosis or pregnancy complication and persistent antibodies: Lupus anticoagulant Anticardiolipin antibodies Anti-beta-2 glycoprotein I antibodies

Answer 108

APS with thrombosis (non-pregnant) - 1st line: Low-molecular weight heparin - Follow-up with warfarin APS with thrombosis (pregnant) - 1st line: LMWH - Follow-up with fetal monitoring + MDT - Warfarin post delivery - Management of risk factors (e.g. hypercholesterolemia, smoking cessation etc.)

Answer 109

Polymyositis and dermatomyositis are autoimmune disorders with muscle inflammation (myositis). They are rare.

Answer 110

A condition where there is chronic inflammation of the muscles

Answer 111

A connective tissue disorder where there is chronic inflammation of the skin and muscles.

Answer 112

- Muscle pain, fatigue and weakness - Occurs bilaterally and mostly affects the shoulder and pelvic girdle - Develops over weeks Polymyositis occurs without any skin features whereas dermatomyositis is associated with involvement of the skin.

Answer 113

General symptoms: Muscle pain, fatigue and weakness Occurs bilaterally and mostly affects the shoulder and pelvic girdle Develops over weeks Additional skin features (signs): - 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)

Answer 114

- Clinical presentation - Elevated creatine kinase - Electromyography (EMG) - Muscle biopsy - definitive diagnosis - Autoantibodies test: Anti-Jo-1 antibodies: polymyositis (but often present in dermatomyositis)

Answer 115

Similar to polymyositis except for different autoantibodies. - Clinical presentation - Elevated creatine kinase - Autoantibodies: anti-Mi-2 antibodies, anti-nuclear antibodies - Electromyography (EMG) - Muscle biopsy - definitive diagnosis

Answer 116

1st line: corticosteroids If no response to steroids: - Immunosuppressants (such as azathioprine) - IV immunoglobulins - Biological therapy (such as infliximab)

Answer 117

- Osteosarcoma (most common malignancy), associated with Paget's, most commonly onsets between 15 - 19 years old - Ewing's sarcoma - from mesenchymal stem cells, 15 years old, very rare - Fibrosarcoma - Osteochondroma - Benign, very common in M < 25yo

Answer 118

Overproduction of bone which deposits on the metaphysis (growth plates)

Answer 119

Osteolytic metastases occur when metastatic cancer cells destroy bone, causing the bone to become weak. Osteolytic metastases often happen when breast cancer spreads to the bone.

Answer 120

Osteoblastic metastases develop when cancer cells invade the bone and cause excess bone proliferation. The bone becomes very dense (sclerotic). Osteoblastic metastases often happen when prostate cancer spreads to the bone.

Answer 121

BLT KP (bacon leuttce tomato and KP notes) B - Breast L - Lung T - Thyroid K - Kidney P - Prostate

Answer 122

Local - Severe bone pain worst at pain - enough to wake patient up - Reduced range of movement of vertebrates/long bones if affected - Pathological fractures. Systemic - weight loss, fatigue, fever, malaise

Answer 123

Bloods: FBC - normal ALP - raised PSA - raised in prostate cancer Imaging: X-rays - can show osteolysis CT scans. -shows metastates

Answer 124

- Pain Management - Bisphosphonates (e.g. alendronic acid) - slows down osteoclast activity - Radiotherapy - Chemotherapy

Answer 125

- Scleroderma (aka systemic sclerosis) is a multi-system, autoimmune disease. - Functional and structural abnormalities of small blood vessels - Fibrosis of skin and internal organs - Production of auto-antibodies. - Subdivided into Diffuse Cutaneous Systemic Sclerosis and Limited Cutaneous Systemic Sclerosis.

Answer 126

Diffuse Cutaneous Systemic Sclerosis is a subcategory of systemic sclerosis that affects multiple organ systems but no skin involvement like in systemic sclerosis

Answer 127

a subcategory of systemic sclerosis that affects fewer organs, notably sparing the kidneys and the skin on the trunk and proximal limbs

Answer 128

Another name for Limited Cutaneous Systemic Sclerosis and describes the main clinical features

Answer 129

Related to increased production of collagen in tissues. Immunological - auto-antibodies are associated with the conditions: - 90% of patients are positive for Anti-Nuclear Antibodies - Limited sclerosis - Anti-centromere antibodies - Systemic sclerosis - Anti-topoisomerase I (Scl-70) antibodies

Answer 130

Women aged between 30 - 50

Answer 131

Symptoms: Skin involvement - skin thickening distal to elbows and knees: face and distal limbs predominantly Raynaud’s phenomenon often comes before skin changes (fingers turn cold and blue to minor triggers) CREST syndrome: - Calcinosis (calcium deposits in soft tissue) - Raynaud’s phenomenon - Esophageal dysmotility - Sclerodactyly (hardening of the skin on hand > claw-like) - Telangiectasia (spider veins)

Answer 132

Skin involvement: - Skin thickening extends proximally: trunk and proximal limbs predominantly - Raynaud’s phenomenon can occur before or after skin changes Early visceral involvement: - Interstitial lung disease - Pulmonary hypertension - Renal crisis: acute renal failure with hypertension - Hypertension

Answer 133

- Sclerodactyly (prayer sign) - Skin tightening and fibrosis; may present as plaques (morphoea) or linear - Digital ulcers - Calcinosis: lumpy calcium deposits - Telangiectasia Typical facies: - Perioral furrowing: wrinkles in the skin around the mouth - Beaked nose - Microstomia: tightening of the skin around the mouth

Answer 134

Serum auto-antibodies: - Anti-nuclear antibodies (ANA): positive in 90% of patients - Anti-centromere: more common in limited systemic sclerosis - Anti-Scl 70 (Anti-topoisomerase): more common in diffuse systemic sclerosis Bloods: - FBC: anaemia of chronic disease (microcytic anaemia) - U&Es: may demonstrate evidence of renal failure - CRP and ESR: elevated inflammatory markers

Answer 135

There is no cure and the disease is generally progressive - Immunosuppressants are used to slow the disease progression - particularly cyclophosphamide - Physiotherapy - Occupational therapy - Symptomatic treatment for clinical features: - Analgesia - Calcium channel blockers for Raynauds (i.e. nifedipine) - Topic skin emollients - PPI for oesophageal reflux - Treating hypertension (bosentan, sildenafil, iloprost)

Answer 136

1) osteoporosis 2) Bisphosphonate, they are adsorbed onto hydroxyapatite crystals in bone, slowing both their rate of growth and dissolution, and therefore reducing the rate of bone turnover. 3) Alopecia; anaemia; appetite decreased; arthralgia;

Answer 137

1) Ankylosing spondylitis, pain and inflammation in rheumatoid arthritis and osteoarthritis 2) Selective inhibition of cyclooxygenase-2 (COX-2), which is responsible for prostaglandin synthesis, involved in pain and inflammation 3) Angina pectoris; benign prostatic hyperplasia; cough

Answer 138

1) Superficial eye infection, outer ear infection, typhoid fever 2) Chloramphenicol is a potent broad-spectrum antibiotic. 3) With parenteral use: aplastic anaemia (rare) Ear: blood disorder; bone marrow depression Eye (topical): angioedema; bone marrow disorders

Answer 139

1) Severe acute ulcerative colitis refractory to corticosteroid treatment, severe RA 2) Ciclosporin inhibits production and release of lymphokines, thereby suppressing cell-mediated immune response. 3) Eye inflammation, appetite decreased; diarrhoea

Answer 140

1) Superficial eye infection, outer ear infection, corneal ulcer 2) Broad-spectrum Abx, inhibition of the enzymes topoisomerases, required for bacterial DNA replication, transcription, repair, and recombination. 3) Quinolones can cause convulsions and tendon damage

Answer 141

1) Oestrogen deficiency, post-menopausal osteoporosis prophylaxis 2) Prevents accelerated bone loss by inhibiting bone resorption, restoring the balance of bone resorption and formation 3) Breast abnormalities; cervical mucus increased; cholelithiasis

Answer 142

1) Disease-modifying antirheumatic drugs (DMARD) in rheumatoid arthritis and Crohn's 2) Immunosppredsant that inhibits the enzyme dihydrofolate reductase, essential for the synthesis of purines and pyrimidines. Thus, Methotrexate prevents nucleic acid synthesis and causes cell death. 3) Alopecia; arthralgia; bone marrow disorders, folate deficiency - patients need folic acid supplement

Answer 143

Pain that is elicited with spinal motion and decreases with rest

Answer 144

1) Lumbar strain/sprain (most common 70% cases) - Strain - disruption of muscle fibres within the muscle belly > intense pain 24 - 48 hrs - Sprain - stretch of ≥ 1 spinal ligament 2) Vertebral disc degeneration 3) Herniated disc 4) Spondylolisthesis (anterior displacement of a vertebra out of line with the one below) 5) Scoliosis (curved spine)

Answer 145

SOCRATES mnemonic: S – Site O – Onset C – Character R – Radiation A – Associations T – Timing E – Exacerbating and relieving factors S – Severity

Answer 146

Key symptoms: - Recent major trauma? (spinal fracture) - Stiffness in the morning or with rest (ankylosing spondylitis) - Age under 40 (ankylosing spondylitis) - Gradual onset of progressive pain (ankylosing spondylitis or cancer) - Night pain (ankylosing spondylitis or cancer) - Age over 50 (cancer) - Weight loss (cancer) - Bilateral neurological motor or sensory symptoms (cauda equina) - Saddle anaesthesia (cauda equina) - Urinary retention or incontinence (cauda equina) - Faecal incontinence (cauda equina) - History of cancer with potential metastasis (cauda equina or spinal metastases) - Fever (spinal infection) - IV drug use (spinal infection)

Answer 147

Key findings on examination are: - Localised tenderness to the spine (spinal fracture or cancer) - Bilateral neurological motor or sensory signs (cauda equina) - Bladder distention implying urinary retention (cauda equina) - Reduced anal tone on PR examination (cauda equina)

Answer 148

1) Mechanical/non-specific lower back pain - diagnosed clinically and warrant no further investigations 2) Spinal fractures - CT/MRI of the spine 3) Emergency MRI spine for suspected cauda equina 4) Investigations for suspected ankylosing spondylitis are: - Inflammatory markers (CRP and ESR) - X-ray of the spinal and sacrum (may show a fused “bamboo spine” in later-stage disease) - MRI of the spine (may show bone marrow oedema early in the disease)

Answer 149

A tool used to assess the risk of a patient with acute back pain developing chronic back pain. - Total score (out of 9) - Subscore (psychosocial factors) Low risk: total ≤ 3, subscore ≤ 3 Medium risk: total > 3, subscore ≤ 3 High risk: total > 3, subscore > 3

Answer 150

1) First, exclude serious underlying causes. Suspected cauda equina: same-day referral to the on-call orthopaedic team for an urgent MRI scan Ankylosing spondyltis: - Inflammatory markers and an urgent rheumatology review - Major trauma - spinal immobilisation, admission and x-rays/CT scans Patients at low risk of chronic back pain according to STarT back tool can generally be managed with: - Self-management - Education - Reassurance - Analgesia (1st line: NSAIDs ibuprofen/naproxen) - Staying active and continuing to mobilise as tolerated

Answer 151

- Physiotherapy - Group exercise - Cognitive behavioural therapy

Answer 152

- Lumbar muscular strain/sprain - Herniated disc - Spinal stenosis

Answer 153

Cervical spondylosis - osteoarthritis of the spine, which includes the spontaneous degeneration of the disc or facet joints Most common complications: - Cervical spondylotic radiculopathy - arm pain pattern, mild weakness and sensory loss in muscles and skin innervated by affected nerve root - Degenerative cervical myelopathy (loss of neurological function from pressure on the cervical spinal cord)

Answer 154

- Commonly asymptomatic (look for risk factors: e.g. over 40, FHx, spinal trauma) - Spontaneous onset of neck pain - Cervical muscle pain and spasm - Headache or occipital pain

Answer 155

Cervical MRI - bone destruction, spinal cord or nerve compression Cervical x-ray - presence of degenerative joint disease/degenerative disc disease, spinal canal stenosis

Answer 156

Axial neck pain - 1st line: physiotherapy Cervical spondylotic radiculopathy - 1st line: analgesia Degenerative cervical myelopathy - If moderate/severe + fit for surgery - surgical decompression - Mild/not fit for surgery - immobilisation with a hard cervical collar

Answer 157

- Whiplash injury - Acute disc herianation - Metastatic malignancy

Answer 158

Back pain where the primary source of pain is thought to be from the affected disc It is a complex multi-factorial clinical condition characterised by low back pain in the presence of radiological confirmed degenerative disc disease

Answer 159

- Persistent lower back pain - worsened with sitting or standing, improves with lying down - Radicular leg pain - results from nerve root compression - Activity-related symptoms - pain exacerbated by motion and relieved by rest

Answer 160

Erect lumbar spine X-ray - presence of osteoporosis, features, metastasis or degenerative changes MRI spine - signs of degeneration (appearing as black disc)

Answer 161

1) Emergency - cauda equina syndrome send for neural decompression 2) Acute back pain < 3. months, or chronic pain exacerbation - analgesia - paracetamol/NSAIDs 3) Chronic pain > 3 months - paracetamol, NSAIDs, opioids (codeine/tramadol) for short-term use only

Answer 162

- Spinal tumour - Spinal infection - Postural back pain

Answer 163

Ehlers-Danlos syndrome (EDS) is a connective tissue disorder caused by mutations of connective tissue proteins, with collagen being the most commonly affected. These mutations lead to weakened connective tissue in the skin, bones, blood vessels, and organs. This results in clinical features: - Musculoskeletal - joint hypermobility and pain and recurrent dislocation - Skin - hyperelasticity, easy bruising - Cardiovascular - mitral valve prolapse, aortic dissection and AAA - Neuro - subarachnoid haemorrhage

Answer 164

Marfan syndrome is an autosomal dominant condition caused by the fibrillin-1 gene responsible for creating fibrillin. Fibrillin is an important component of connective tissue, and the mutation affects the mechanical stability and elastic properties of connective tissue.

Answer 165

Results in the following features: - Tall stature - Long neck - Long limbs - Long fingers (arachnodactyly) - High arch palate - Hypermobility - Pectus carinatum (chest sticking out) or pectus excavatum (chest caving in) - Positive wrist sign - thumb and little finger overlap when hand wraps around the opp wrist - Positive thumb sign - when patients cross their thumb across their palm, if the thumb tip goes past the opposite edge of the hand this indicates arachnodactyly

Answer 166

- Rheumatic arthritis - Antiphospholipid syndrome