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Year 3 - Diseases > Musculoskeletal + Rheumatology > Flashcards

Musculoskeletal + Rheumatology Flashcards

1
Q

List the risk factors for gout

A
  • Age
  • Male
  • Alcohol
  • Obesity
  • Diet (purines - sardines, red meat)
  • Hypertension
  • Hyperparathyroidism
  • CKD
  • Psoriasis
  • Chemotherapy
  • CHD
  • Heart failure
  • Metabolic syndrome
  • Medications (eg. diuretics)
  • Recent infection, recent surgery, polycythaemia, trauma
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2
Q

List risk factors for pseudogout

A
  • Haemochromatosis
  • Hyperparathyroidism
  • Acromegaly
  • Low magnesium
  • Low phosphate
  • Wilsons
  • Hypothyroidism
  • Elderly women
  • Trauma, illness
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3
Q

List the 4 radiographic features of osteoarthritis

A
  • Loss of joint space
  • Sclerosis
  • Cyst formation
  • Chondrocalcinosis
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4
Q

What is first line treatment in osteoarthritis?

A
  • Weight loss
  • Social support
  • Education
  • Refer to physio
  • Refer to occupation therapist
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5
Q

How is polymyalgia rheumatica diagnosed?

A

ESR over 40mm/hr

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6
Q

How is polymyalgia rheumatica treated initially?

A

Oral prednisolone for 1-2 years

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7
Q

Define gout

A
  • Disorder of purine metabolism characterised by hyperuricaemia
  • Depositition of urate crystals in joints and other tissues
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8
Q

List symptoms and signs of gout

A
  • Pain associated with swelling, redness, warmth and tenderness (max intensity within 24 hours)
  • Most commonly in first MTPJ of the big toe, midfoot, ankle, knee, fingers, wrist and elbow
  • Usually monoarticular
  • Tophi (nodular masses which are urate crystal deposition)
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9
Q

Describe investigations of gout

A
  • Usually not needed, diagnosed clinically
  • Exclude differentials (septic, pseudogout, RA, OA)
  • Blood tests (FBC, U andE, LFT, HbA1c, lipids)
  • Serum urate (may be useful, can be normal, measured 4-6 weeks after acute attack)
  • Joint aspiration finds negative birefringent crystals, needle like crystals
  • X ray (swelling, subcortical cysts, punched out erosions)
  • Cardiovascular and renal risk factors
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10
Q

Describe management of gout

A
  • RICE (rest, ice, compression, elevation)
  • Lifestyle advice (diet, alcohol, alcohol, exercise, weight reduction, fluid intake)
  • In acute attack NSAIDs (naproxen), colchicine, steroids, PPI (to protect stomach episode)
  • Prevented with allopurinol (don’t start during the acute episode, start alongside something in case of acute flair)
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11
Q

Define pseudogout

A

A form of microcrystal synovitis caused by deposition of calcium pyrophosphate dihydrate crystals in the synovium

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12
Q

List signs and symptoms of pseudogout

A
  • Asymptomatic

- Acute synovitis affecting the knee wrist and/or shoulder

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13
Q

List investigations in pseudogout

A
  • X ray showing chondrocalcinosis

- Joint aspiration showing positive birefringent crystals on microscopy, rhomboid crystals

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14
Q

Describe management of pseudogout

A
  • Exclude differential (eg. septic arthritis)
  • Rest, ice, compression, elevation
  • NSAIDs
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15
Q

Define rheumatoid arthritis

A

A chronic systemic inflammatory disease (>6 weeks)

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16
Q

List symptoms and signs of RA

A
  • Affects hands and feet (PIPJ, MCPJ, MTPJ)
  • Large joints rarely affected
  • Morning stiffness over 30 mins, improving with use
  • Symmetrical polyarthritis
  • Systemic symptoms
  • Extra-articular features (eyes, heart, lung, vasculitis, neuropathies)
  • Rheumatoid nodules
  • Joint deformity (swan necking, hyperextension, ulnar deviation, Z thumb, boutonniered deformity)
  • DIP sparing
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17
Q

List risk factors for RA

A
  • More common in females
  • Age 30-50
  • Family history
  • HLA-DR4, HLA DR1 occassionally
  • Smoking
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18
Q

Describe investigations in RA

A
  • Blood test for rheumatoid factor (can be seronegative, can be false positive, 70% pts, IgM targets Fc of IgG), anti- CCP (more sensitivt, specific), CRP, ESR, anaemia, low albumin
  • X-ray hands and feet (joint space narrowing, bony erosions, juxta/periarticular osteopenia, soft tissue swelling)
  • Specialist referral
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19
Q

Define polymyalgia rheumatica

A

Chronic, systemic rheumatic inflammatory disease

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20
Q

Describe risk factors for polymyalgia rheumatica

A
  • Highest incidence over 65, more common in females
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21
Q

List symptoms and tenderness of polymyalgia rheumatica

A
  • Rapid onset less than 1 month
  • Muscle stiffness and tenderness of proximal limbs (shoulder or pelvic girdle)
  • Worse with movement
  • Bilateral
  • Sleep interference
  • Stiffness for at least 45 mins in the morning
  • Low grade fever, fatigue, anorexia, weight loss and depression may also be symptoms
  • Check for temporal arteritis
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22
Q

Describe diagnosis of polymyalgia rheumatica

A
  • Typical symptoms
  • Blood tests ESR and CRP
  • Exclude other causes
  • Subchondral and trochanteric bursitis, synovitis in the shoulder and hips
  • Look for response to treatment (responds to steroids within 1-2 days)
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23
Q

Describe treatment of polymyalgia rheumatica

A
  • 15mg oral prednisolone
  • Assess response in 1 week
  • Weaned off steroids over time
  • Safety-net
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24
Q

Define giant cell arteritis

A

Chronic vasculitis characterised by granulomatous inflammation in the walls of medium and large arteries, commonly affecting the external carotid artery

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25
Q

List symptoms of giant cell arteritis

A
  • New onset, localised headache, usually in temporal area with tenderness, thickening or nodularity
  • Systemic features (fever, fatigue, anorexia, weight loss and depression)
  • Features of PMR
  • Jaw claudication, visual disturbances
  • Limb claudication
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26
Q

Describe management of giant cell arteritis

A
  • Same day referral to opthalmologist if eye involvement
  • High dose steroids (prednisolone) before confirmation of biopsy. Assess initial response within 48 hours. Reduce dose slowly over many months.
  • Osteoporosis prophylaxis
  • Treatment is often required for 1-2 years
  • Frequent follow ups for relapses and steroid side effects
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27
Q

List risk factors for giant cell arteritis

A
  • Unknown cause
  • Age. Giant cell arteritis affects adults only, and rarely those under 50. Most people with this condition develop signs and symptoms between the ages of 70 and 80.
  • Women are about two times more likely to develop the condition than men are.
  • Giant cell arteritis is most common among white people in Northern European populations or of Scandinavian descent.
  • Polymyalgia rheumatica.
  • Family history.
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28
Q

Describe epidemiology of giant cell arteritis

A
  • The annual incidence of giant cell arteritis in the UK population is approximately 20 per 100,000 people
  • A full-time GP is likely to see a new case every 1–2 years
  • It is rare before 50 years of age and the highest incidence is in people aged 70–79 years
  • It is seven times more common in white people than in black people and is particularly common in Scandinavian people, with an annual incidence of approximately 30 per 100,000 people in Norway
  • It is 2–3 times more common in women than in men
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29
Q

List investigations of giant cell arteritis

A
  • Blood tests: full blood count, urea and electrolytes, liver function tests, C-reactive Protein (CRP) and erythrocyte sedimentation rate (ESR). There is often evidence of an acute-phase response on blood tests, ie raised ESR, CRP, platelets, abnormal liver chemistry (particularly alkaline phosphatase)
  • ESR first line investigation (over 50mm/hr)
  • Chest X-ray
  • Urinalysis.
  • Temporal artery biopsy (multinuclear giant cells)
  • Ultrasound of temporal artery (halo sign)
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30
Q

List signs of GCA

A
  • Temporal artery may be tender, thickened, beaded. It may be difficult to feel the pulse
  • They may complain of scalp tenderness brushing the hair, touching the forehead
  • Jaw claudication leading to pain eating food
  • Evidence of large vessel vasculitis should be sought – delayed or absent pulses in upper limbs, subclavian or carotid bruits, blood pressure asymmetry
  • An ophthalmological exam should be carried out – look for transient or permanent visual loss, visual field defect, relative afferent papillary defect, anterior ischaemic optic neuritis, central retinal artery occlusion
  • Look for evidence of upper cranial nerve palsies.
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31
Q

Describe complications of giant cell arteritis

A
  • Total or partial loss of vision may occur in up to 20% of people with giant cell arteritis
  • The risk of vision loss was greater in older people.
  • Large artery complications include aortic aneurysm, aortic dissection, large artery stenosis, and aortic regurgitation.
  • Cardiovascular disease (such as myocardial infarction, heart failure, stroke, and peripheral arterial disease) is more common in people with giant cell arteritis.
  • Peripheral neuropathy.
  • Depression.
  • Confusion and encephalopathy (in about 30% of people).
  • Deafness.
  • Complications of long-term corticosteroid treatment (for example weight gain, bruising, osteoporosis and fractures, and diabetes).
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32
Q

Describe prognosis of giant cell artertis

A
  • Relapses are common and can occur if corticosteroid treatment is reduced or withdrawn too quickly
  • About 30–50% of people have spontaneous exacerbations of disease, especially during the first 2 years, that are independent of the corticosteroid regimen
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33
Q

Define ankylosing spondylitis

A
  • Axial spondyloarthritis characterized by sacroiliitis on x-ray. Axial spondyloarthritis can also occur in the absence of x-ray changes and this is classified as non-radiographic axial spondyloarthritis (although changes may be visible on magnetic resonance imaging).
  • Spondyloarthritis is a term describing a group of clinically heterogeneous inflammatory rheumatologic conditions. It may be axial, affecting the sacroiliac joints and the spine, or peripheral (psoriatic arthritis, reactive arthritis, or enteropathic spondyloarthritis)
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34
Q

Describe epidemiology of ankylosing spondylitis

A
  • Prevalence of ankylosing spondylitis is believed to range from 0.05% to 0.23%
  • Estimates of the prevalence of ankylosing spondylitis vary between countries with mean prevalence per 10,000 of 31.9 in North America, 23.8 in Europe, 16.7 in Asia, 10.2 in Latin America, and 7.4 in Africa
  • Uveitis of 25.8% (95% CI 24.1 to 27.6).
  • Psoriasis of 9.3% (95% CI 8.1 to 10.6).
  • Inflammatory bowel disease of 6.8% (95% CI 6.1 to 7.7).
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35
Q

List risk factors for ankylosing spondylitis

A
  • Around twice as many men have ankylosing spondylitis compared with women, although this varies depending on
  • It most commonly begins between 20 and 30 years of age, with 90–95% of people aged less than 45 years at disease onset
  • Spondyloarthritis (particularly axial disease) is associated with the HLA-B27 antigen, although axial spondyloarthritis can occur in people without HLA-B27
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36
Q

List symptoms of ankylosing spondylitis

A
  • Episodic Pain – usually in the buttocks and/or lower back. The pain is:
  • Worse in the morning
  • Relieved by exercise
  • May wake the patient during the night – particularly in the second half of the night – after about 2am.
  • May be felt in the buttocks – especially if the sacroiliac joints are affected
  • Stiffness is typically worse in the mornings
  • Fever and weight loss may occur during episodes of pain
  • Anterior chest pain
  • 1/3 patients get anterior uveitis
  • Enesthitis
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37
Q

List signs of ankylosing spondyitis

A
  • Spinal stiffness – can be measured with Schoeber’s test where you measure 10cm above the dimples of Venus with the patient standing upright.
  • Place a dot here. As the patient to flex forward (touch their toes). Then re-measure the gap with the patient in this position. Normally, the gap should increase to >15cm. In AS, the gap increases less than this
  • Wall to tragus distance increased
  • Increased thoracic kyphosis – “question mark posture”
  • Retention of lumbar lordosis in flexion
  • Paraspinal muscle wasting
  • Uveitis
  • Pain when pressing on lower sacrum
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38
Q

Describe investigations of ankylosing spondylitis

A

Diagnosis requires any of:

  • 1 clinical criteria + radiological criteria met
  • 3 clinical criteria present
  • Radiological criteria present
  • Diagnosis does not require radiological evidence

Clinical criteria

  • Low back pain >3 months, improves with exercise, not relieved by rest
  • Limited chest expansion relative to normal values for age and sex
  • Limited lumbar spine motion in both the fontal and sagittal planes
  • Radiological criteria – sacroiliitis on x-ray, bamboo spine (ossification of ligaments)

Can also measure HLA B27, raised CRP and ESR, seronegative

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39
Q

Define osteoporosis

A

A disease characterized by low bone mass and structural deterioration of bone tissue, with a consequent increase in bone fragility and susceptibility to fracture.

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40
Q

List risks for osteoporosis

A
  • Age (bone breakdown by osteoclasts increases, and is not balanced by new bone formation)
  • Endocrine diseases
  • GI conditions causing malabsorption
  • CKD
  • chronic liver disease
  • COPD
  • Menopause
  • Immobility
  • Low BMI
  • Oral corticosteroids
  • Smoking
  • Alcohol
  • Fragility fracture
  • Rheumatological conditions
  • SSRI, PPI, Anticonvulsant drugs
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41
Q

Describe the epidemiology of osteoporosis

A
  • Women at increased risk at menopause
  • 2% at age 50 to 50% at age 80
  • 2 million women have osteoporosis
  • 1 in 3 women and 1 in 5 men will sustain an osteoporotic fracture in their lifetime
  • White men and women at increased risk
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42
Q

List signs and symptoms of osteoporosis, and common fracture sights

A
  • Stooped posture
  • Often fragility fracture is the first sign

Common fractures:

  • Neck of femur
  • Wrist (colles)
  • Lumbar spine (vertebral wedge fractures)
  • Shoulder (neck of humerus)
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43
Q

List investigations of osteoporosis

A
  • DEXA scan in at risk patients
  • T-score -2.5 or less is indicative of osteoporosis
  • T score is healthy young patient, Z score is age matched
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44
Q

Define osteoarthritis

A

Osteoarthritis is defined as a disorder of synovial joints which occurs when damage triggers repair processes leading to structural changes within a joint.

  • Localised loss of cartilage
  • Remodeling and formation of osteophytes
  • Mild synovitis
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45
Q

Describe prevalence of osteoarthritis

A
  • 8.5 million people age over 45in the UK
  • 18% of over 45s have sought treatment for osteoarthritis of the knee
  • 8% of the UK population age over 45 have sought treatment for osteoarthritis of the hip
  • 6% of over 45 have sought treatment for the hand and hip
  • 1/3 women and 1/4 men between 45-64
  • Half of people age over 75
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46
Q

List risk factors for osteoarthritis

A
  • Genes
  • Increasing age
  • Female sex
  • Obesity
  • High bone density
  • Low bone density
  • Joint injury and damage
  • Joint laxity and reduced muscle strength
  • Joint malalignment
  • Exercise stresses
  • Occupational stresses
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47
Q

List symptoms of osteoarthritis

A
  • Activity related joint pain (one or a few joints affected at any time, develops over months or years)
  • No morning joint stiffness or not lasting longer than 30 minutes
  • CMC, DIP or PIP pain radiating towards the thumb or distal forearm
48
Q

List signs of osteoarthritis

A
  • Bony swelling and joint deformity
  • Joint effusions
  • Joint warmth and/or tenderness
  • Muscle wasting and weakness
  • Restricted painful range of joint movement, crepitus
  • Joint instability
  • Wasting of thenar muscles
  • CMC fixed flezion deformity with hyperextension of distal joints
  • In advanced disease, squaring at the joint caused by subluxation
  • Ulnar or radial deviation
  • Mucoid cysts
  • Heberden and bouchards nodes
  • Antalgic gait, tendelenburg gait
49
Q

Describe investigation of osteoarthritis

A
  • X ray of affected joint
  • Subcondral bone thickening or cysts
  • Osteophyte formation
  • Narrowing of joint space
50
Q

List causes of high ALP

A
  • Liver
  • Obstructive liver disease and bone disease (malignancy, fracture, Pagets)
  • In myeloma, ALP is NORMAL as osteoblasts make ALP and plasma cells suppress osteoblasts
51
Q

Define carpal tunnel syndrome

A

A collection of symptoms and signs caused by compression of the median nerve in the carpal tunnel.

52
Q

List risk factors of carpal tunnel syndrome

A
  • Variations in the anatomy of the carpal tunnel
  • Age over 30 years
  • High body mass index, pregnancy
  • Occupations involving repetitive movements of the wrist
  • Familial and psychosocial factors
53
Q

Describe epidemiology of carpal tunnel syndrome

A
  • More common in developed countries and white people. Very rare in South African populations
  • 3.5 per 1000
54
Q

List symptoms and signs of carpal tunnel syndrome

A
  • Numbness of the hand, relieved by shaking
  • Worse at night
  • In median nerve distribution
  • Intermittent symptoms
  • Gradual onset
  • Weak hand
  • Clumbsy
  • Weakness of thenar muscles
  • Normal reflexes
  • Stiff fingers
  • Cold sensitivity
  • Tinels sign (pain on tapping the median nerve)
55
Q

List investigations for carpal tunnel syndrome

A
  • EMG slowing of conduction through median nerve
  • Ultrasound of the wrist
  • Wrist MRI (may find space occupying lesion)
56
Q

Which is the most commonly torn knee ligament?

A

ACL (heard as a pop)

57
Q

Define reactive arthritis

A
  • An inflammatory arthritis that occurs after exposure to certain gastrointestinal and genitourinary infections.
  • Spondylarthropathy assoicated with HLA B27
58
Q

Describe epidemiology of reactive arthritis

A
  • Occurs mainly in adults.
  • The prevalence is thought to be 30 to 40 cases per 100,000 adults, with an annual incidence of 4.6 per 100,000 for Chlamydia-induced arthritis and 5 per 100,000 for enterobacteria-induced arthritis.
  • The attack rate of ReA after a C trachomatis infection ranges from about 4% to 8%, and that of post-dysentery ReA ranges from 1.5% to about 30%.
  • One study found that the arthritis persisted at 2 years in nearly half (47%) of affected patients
59
Q

Describe aetiology of reactive arthritis

A
  • The most commonly implicated bacterial species are Chlamydia, Salmonella, Campylobacter, Shigella, and Yersinia species
  • Chlamydia most common cause
60
Q

List risk factors of reactive arthritis

A
  • Male sex
  • HLA-B27 genotype
  • Preceding chlamydial or gastrointestinal infection
  • BCG immunotherapy
  • Age 20-30
61
Q

List signs and symptoms of reactive arthritis

A
  • Peripheral or axial arthritis (painful, swollen, warm, stiff, asymmetrical oligoartritis)
  • Fever, fatigue, weight loss
  • Enesthitis (tendon inflammation)
  • Mucous membrane involvement
  • Skin rash (keratoderma blenorrhagica, circinate balanitis)
  • Genital ulcer, urethral symptoms
  • Ocular manifestations (anterior uveitis)
  • Cardiac manifestations (aortitis)

Rieters syndrome: reactive arthritis, urethritis, conjunctivitis

62
Q

List investigations for reactive arthritis

A
  • Erythrocyte sedimentation rate (ESR high)
  • C-reactive protein (CRP high)
  • Antinuclear antibody (ANA negative)
  • Rheumatoid factor (negative)
  • Anti CCP - most specific
  • Urogenital and stool cultures
  • Plain x-rays (sacroilitis or enthesopathy)
  • Arthrocentesis with synovial fluid analysis (negative)
  • HLA-B27
  • Nucleic acid amplification tests
  • MRI
63
Q

Define idiopathic inflammatory myopathies

A
  • A heterogeneous group of sub-acute, chronic, and, rarely, acute diseases of skeletal muscle that have in common the presence of moderate-to-severe proximal muscle weakness and inflammation on muscle biopsy.
  • Based on distinct features, they are divided into 3 groups: polymyositis, dermatomyositis, and inclusion body myositis.
64
Q

Describe epidemiology of idiopathic inflammatory myopathies

A
  • Dermatomyositis age 15 to 59, affects women more than men. 1819 people in 2007 admitted in UK
  • Polymyositis 2nd decade of life, rare in childhood, higher incidence in women
  • Inclusion body myositis rare, 4.9 cases per million. 3 times more common in women, more likely over 50 years. More common in white people (while dermatomyositis and polymyositis more common in black people)
65
Q

Describe aetiology of idiopathic inflammatory myopathies

A
  • Infection (coxsackie, influenza, retroviruses, cytomegalovirus, EBV)
  • Genetic (HLA)
  • Environmental (UV radiation, hydroxyurea)
  • Immunological (20% of patients
66
Q

List risk factors of idiopathic inflammatory myopathies

A
  • Children and age >40 years
  • Exposure to high intensity of global UV radiation
  • Genetic predisposition
  • Female sex and/or black ethnicity (polymyositis and dermatomyositis)
  • Male sex and/or white ethnicity (inclusion body myositis)
  • Lipid-lowering agents
  • HIV
  • Viral infections (excluding HIV)
  • Non-viral infection
  • Vaccination
  • D-penicillamine
  • Other drugs or toxins
67
Q

List symptoms of idiopathic inflammatory myopathies

A
  • Frequent falls
  • Fatigue and generalised malaise
  • Proximal myopathy over months
  • Weight loss
  • SOB
  • Dysphagia, dysphonia
  • Myalgia
  • Arthralgia
  • Palpatations
  • Symptoms of MI

Dermatomyositis:

  • Facial rash
  • Erythematous rash
  • Facial muscle weakness
  • Heliotrope rash (around the eyes)
  • Gottrons papules (hands)
  • Shawl sign (rash across upper back)
  • Mechanics hands
68
Q

List signs of idiopathic inflammatory myopathies

A
  • Abnormal breath sounds
  • Mild fever
  • Nail fold changes (dilation of capillary loops or periungual area)
  • Skin calcinosis
  • Joint swelling
  • Arrhythmias
  • Signs of heart failure/MI
  • Physical findings of malignancy (in up to 45% of patients)
  • Systemic signs
  • Peripheral neuropathy

Skin changes in dermatomyositis

69
Q

List investigations for idiopathic inflammatory myopathies

A

Dermatomyositis - ANA< Anti-Mi-2, anti-Jo abs
Polymyositis - anti-Jo antibodies

  • CK (raised)
  • EMG (short duration, low amplitude)
  • Muscle biopsy (polymyositis, muscle necrosis, atrophy, muscle fibre regeneration)
  • Aldolase (elevated)
  • LDH (elevated)
  • Alanine transaminases (elevated)
  • Myoglobin (elevated)
  • ESR (elevated)
  • ANA (positive), SLE dsDNA, ENA ro and la (sjogrens), systemic sclerosis centrometer sc170
  • Myositis-specific antibodies (type-specific antibodies)
70
Q

Define pagets disease of bone

A
  • A chronic bone disorder that is characterised by focal areas of increased bone remodelling, resulting in overgrowth of poorly organised bone. Increased osteoclasts and osteoblasts associated with reultent remodelling.
  • This unbalanced process may lead to osseous deformities, altered joint biomechanics, nerve compressions, and pathological fractures.
71
Q

Describe epidemiology of pagets disease of bone

A
  • Rare under 40
  • Incidence rises with age (3% over 55)
  • Commoner in temperate climates and anglo-saxans
  • Mean age of onset 55
  • May be monostotic (25%) or polyostotic (75%)
72
Q

Describe aetiology of pagets disease of bone

A
  • Genetics - autosomal dominant with variable penetrance, relative risk as high as 7 in first degree relatives
  • Infection (paramyxoviruses - measles, respiratory syncitial)
  • Environmental (high levels of arsenic, contact with pets)
73
Q

List risks of pagets disease

A
  • Family history of Paget’s disease
  • Age >50 years
  • Male sex (45- to 74-years age group)
  • Infection (paramyxovirus)
  • Environmental factors (arsenic, cattle, dogs)
74
Q

List symptoms and signs of pagets

A
  • 70% asymptomatic
  • Deep, boring pain
  • Bony deformity and enargement, typically of the pelvis, lumbar spine, skill, femur, tibia (frontal bossing, pronathism, bone bowing)
  • Pathological fractures
  • Osteoarthritis
  • Nerve compression due to bone overgrowth (eg. deafness, carpal tunnel)
  • High output CCF)
  • Osteosarco,a (1% of those affected for over 10 years)
75
Q

Describe diagnosis of pagets

A
  • Plain x ray (pelvis, long bones, skill, lytic changes commonly seen in the scull, occaisonal incomplete fractures in late stages sclerotic. Pepper pot skull, enlargement of bone, cortical thickening, )
  • Bone scan (tec 99 tracer shows areas of dense uptake)
  • Alk phos, bone specific alk phos (raised)
  • Serum calcium, procollagen 1 N-terminal peptice, serum C terminal propeptide of type 1 collagen (calcium normal others raised)
  • Potassium and PTH normal
  • LFT (norm)
  • Vit D (norm)
  • CT/MRI
  • Bone biopsy (most sensitive and specific test - osteoclasts with multiple nuclei, wide canaliculi with disorganised bone matrix, mosaic pattern of poorly organised lamellar bone)
76
Q

Describe pathophysiology of pagets

A
  • Lytic phase (bone lysis due to ostroclasts)
  • Mixed phase (compensation by osteoblasts)
  • Sclerotic phase (hyperactive osteoblasts with woven bone).
77
Q

Define osteomyelitis

A
  • An inflammatory condition of bone caused most commonly by Staph aureus
  • Can affect multiple bones
78
Q

Describe epidemiology of osteomyelitis

A
  • 2% per year in developed countries (peripheral)

- Higher for men than women, increases with increasing age

79
Q

Describe aetiology of osteomyelitis

A
  • Direct inoculation of microorganisms to bone, or contiguous focus of infection
  • IVDU
  • Most commonly after injury or surgery, often implant related
  • Most patient groups S aureus most common causative agent, older adults gram negative bacilli most common causative agent
  • Slamonella Spp more common in sickle cell pts
  • Cellulitis, localised infection
80
Q

List risk factors for osteomyelitis

A
  • Previous penetrating injury
  • IVDU
  • Diabetes
  • HIV infection
  • Recent surgery
  • Sickle cell disease
  • RA
  • CKD
  • Immunocompromising conditions
81
Q

List symptoms and signs of osteomyelitis

A
  • Limp
  • Non-specific pain
  • Malaise and fatigue
  • Local back pain
  • Paravertebral muscle tenderness and spasn
  • Tenderness, erytema, swelling
  • Fever, rigors
  • Uncommonly spinal cord compression
  • Reduced range of movement
  • UTI symptoms on older adults
  • Discharge from associated wound
82
Q

List investigations for osteomyelitis

A
  • FBC
  • ESR, WCC (raised)
  • CRP
  • Blood culture
  • Plain X rays (no changes first 2 weeks, then darkening and periosteal thickening in infected areas)
  • Bone samples and biopsy
  • PCR
  • Swabs
  • Urine dip
83
Q

Define septic arthritis

A

Infection of one or more joints caused by pathogenic inoculaton of microbes

84
Q

Describe epidemiology of septic arthritis

A
  • 6 per 100000 population per year

- In patients with underlying joint disease or prosthetic joints, increased incidence (x10_

85
Q

Describe aetiology/risks of septic arthritis

A
  • Direct or haematogenous
  • Predominantly staphylococci or streptococci (91% of cases)
  • Staph aureus over 30, neisseria gonorrhoea under 30

Risks

  • Pre existing joint disease
  • Joint prostheses
  • IVDU
  • Immunosuppressive medication
  • HIV infection
  • Alcohol use disorder
  • Diabetes
  • Steroid injection
  • Joint surgery
  • Skin infections
  • Ticks
86
Q

List signs and symptoms of septic arthritis

A
  • Hot swollen, painful restricted joint
  • Acute presentation
  • Fever
  • Most common joint knee
87
Q

List investigations for septic arthritis

A
  • Synovial fluid microscopy, gram stain (aspirate is turbid, yellow, low viscosity)
  • Culture and sensitivities + white count of fluid
  • Blood culture
  • WCC
  • ESR/CRP
  • U and E
  • LFT
  • Plain X ray
  • Ultrasound
88
Q

Describe epidemiology of gout and pseudogout

A

Gout

  • 3-6% men and 1-2% women
  • Increases with age

Pseudogout

  • More common with increasing age, and in women
  • 4.5% prevalence in UK
89
Q

List associations with axial spondylarthropathy

A
  • Anterior uveitis
  • Mucosal and skin lesions
  • IBD
  • Psoriasis
  • Myocardial involvement (aortic regurg and cardiac conduction defects)
90
Q

Describe felty syndrome

A
  • Felty syndrome is usually described as associated with or a complication of rheumatoid arthritis.
  • This disorder is generally defined by the presence of three conditions: rheumatoid arthritis (RA), an enlarged spleen and neutropenia
91
Q

List 6 extra non-spondylitis related features of ankylosing spondylitis

A
  • Anterior uveitis
  • Aortitis
  • Aortic vavle regurg
  • AV conduction fibrosis (heart block)
  • Apical lung fibrosis
  • IgA nephropathy
92
Q

Define fibromyalgia

A

a chronic pain syndrome diagnosed by the presence of widespread body pain

93
Q

Describe epidemiology of fibro myalgia

A
  • 0.5-5% population
  • In the US 2%
  • More common in women than men (possibly due to previous diagnostic criteria)
  • 20-60 year onset, average age 35 years
  • Prevalence increases wit age
  • First degree relatives 8 times more likely
94
Q

Describe the aetiology of fibromyalgia

A
  • Chronic pain disorder - central sensitisation syndrome
  • Nociplastic pain
  • Familial (serotinergic, dopaminergic and catecholaminergic gene abnormalities)
  • Sometimes comorbid psychiatric conditions
95
Q

List risks for fibromyalgia

A
  • Family history
  • Rheumatological conditions (esp. autoimmune)
  • Age 20-60
  • Female sex
  • Presence of associated conditions (IBS, tension headache, CFS, TMJ, cystitis)
96
Q

List signs and symptoms of fibromyalgia

A
  • Chronic pain (widespread)
  • Diffuse tenderness
  • Fatigue unrelieved by rest
  • Sleep disturbance
  • Mood disturbance
  • Cognitive dysfunction
  • Headaches
  • Numbness/tinglign sensations
  • Stiffness
  • Sensitivity to sensory stimuli (eg. bright lights, odours, noises)
97
Q

List investigations for fibromyalgia

A
  • Clinical diagnosis (presence of chronic (>3 monthh) widespread body pain with associated symptoms)
  • Consider ESR/CRP, TFT, FBC, RA, anti-CCP, ANA, vit D
98
Q

Define radiculopathy

A
  • A conduction block in the axons of a spinal nerve or its roots, with impact on motor axons causing weakness, and sensory axons causing paraesthesia and or anaesthesia
99
Q

Describe aetiology of radiculopathy

A
  • Most commonly nerve compression
  • Intervertebral disc prolapse mainly affecting lumbar spine
  • Degenerative diseases leading to stenosis (cervical)
  • Fracture
  • Malignancy
  • Infection (eg. extradural abscess, osteomyelitis, herpes zoster)
100
Q

List signs and symptoms of radiculopathy

A
  • Paraesthesia, numbness, weakness
  • Radicular pain is burning, deep, strap like or narrow. May be intermittent.
  • May radiate to the legs (sciatic)
  • Red flag - cauda equina symptoms, immunosuppression, unexplained fevers, trauma, new onset after 50 years
  • Decreased reflexes, weakness, hypotonia (LMN)
101
Q

Describe epidemiology of radiculopathy

A
  • Most common 30-50
  • Males more commonly affected
  • 5% of back pain causes
  • Herniation most commonly L5-S1, second most common L4-L5
102
Q

Describe investigations for radiculopathy

A
  • Straight leg raising manouvres (striaght leg raises causes pain in the ipsilateral leg, radiating to affected nerve root)
  • Bragard sign (ankle dorsiflexion on straight leg raise causes reproduction of pain)
  • Crossed straight leg raise (opposite leg raised increases contralateral pain)
  • Spurling manouvre (forward flexion, tilting and rotation of the head towards the affected side and application of sownward pressure causes pain in cervical spine radiculopathy)
  • MRI to confirm diagnosis (disc degeneraion sclerosed hypodense disc, prolapse herniation with oedema, look for mass)
  • CT myelogram to analyse bone structure
  • Plain radiograph for tumours
103
Q

Define spondylosis

A
  • Degeneration of the vertebral column from any cause
  • Spinal osteoarthritis is the most common cause
  • Can compress on spinal cord or nerve root
104
Q

Describe epidemiology of spondylosis

A
  • Most adults age over 40 have severe degeneration of at least 1 cerical level (commonly C5/6) but only a subset present with neck pain
  • Radiculopathy and myopathy incidence much lower
  • Affects women more
  • Prevalence increases with age, 50-59 years most commonly
  • 18-23 per 1000 GP neck pin, 10% becomes chronic
105
Q

Describe aetiology/risks of spondylosis

A
  • Underlying joint regenration
  • Genetic predisposition
  • Occupational factors
  • Trauma, daily wear and tear
  • Osteoarthrtiis most common cause
106
Q

List signs and symptoms of spondylosis

A
  • Radiculopathy (pain, paraesthesia, muscle weakness)
  • Stiffness
  • Poor balance
  • Limited range of movement
  • Tenderness
  • Radiating arm pain (if neck)
  • Reflex changes
  • Gait ataxia (cervical myelopathy)
107
Q

List investigations for spondylosis

A
  • X ray for osteophytes, narrowing of joint spaces with encroachment of intervertebral coraminae
  • MRI
  • Cervical compression test (latrally flex and downward pressure causes pain)
  • Lhermitte sign (electric shock with neck flexion)
108
Q

Define Sjogren syndrome

A

A systemic autoimmune disorder characterised by dry eyes and dry mouth due to lymphocytic infiltration to the lacrimal and salivary glands.

109
Q

Describe epidemiology of Sjogren syndrome

A
  • Primary 9:1 female to male, onset age 40-50
  • 0.5-1.56% prevalence
  • Secondary associated with connective tissue disease (RA, SLE, systemic sclerosis) - 60%
  • 20-30 peak, post menopause peak.
110
Q

Describe aetiology of Sjogren syndrome

A
  • Unknown
  • HLAII markers A1, B8 or DR3/DQ2 have been associated
  • HLA-DR3 linked in anti-Ro and anti-La production
  • ANA +ve
  • Greater prevalence in females may be due to oestrogen and/or androgen deficiency
  • EBV and adenovirus may be associated
111
Q

List symptoms and signs of Sjogren’s syndrome

A
  • Dry eyes (keratoconjunctivitis sicca) due to reduced tear production
  • Decreased salivation (xerostomia - dry mouth, caries)
  • Fatigue
  • Parotid swelling
  • Other glands affected causing vaginal dryness, dysparaunia (painful sex), dry cough, dysphagia
  • Systemic - polyarthritis/arthralgia, raynauds, lymphadenopaty, vasculitis, lung, liver, kidney involvement, peripheral neuropathy, myositis, atigue
112
Q

List risk factors for Sjogren syndrome

A
  • Female
  • SLE
  • RA
  • Systemic sclerosis
  • HLAII markers
  • 20-30 or post menopause
  • Genetic
113
Q

List investigations for Sjogren syndrome

A
  • Schirmers test, measure tears by placing tracing paper below the conjunctival sac. Positive if less than 5mm paper wetted after 5 mins
  • Anti-60kD Ro and anti-La (90% patients with Sjogren)
  • ANA
  • Rheumatoid factor
  • Rose Bengal staining shows keratitis
  • Biopsy of salivary gland shows focal lymphocytic aggregation
114
Q

List extraarticular features of RA

A
  • Episcleritis, scleritis
  • Lymphadenopathy
  • Carpal tunnel syndrome
  • Rheumatoid nodules (occur in areas of repeated trauma or pressure (eg. elbow, fingers, forearms), in those who are seropositive)
  • Secondary Sjogrens/ sicca
  • Pulmonary fibrosis/ pleuritis
  • Bronchiolitis obliterans
  • Pericarditis
  • Tenosynovitis, bursitis
  • Amyloidosis
  • Felty syndrome
  • ACD
115
Q

Describe felty syndrome

A
  • Complications of RA

- Neutropenia, splenomegaly, Rh artritis

116
Q

Define seronegative spondylarthropathies and list types

A
  • Chronic inflammatory diseases which are seronegative (ie. no Rh factor)
  • HLA B27 association, more common in men
  • Psoriatic arthritis
  • Enteropathic arthritis
  • Ankylosing spondylitis
  • Reactive arthritis
117
Q

Describe x ray appearance in osteomyelitis

A
  • Soft tissue changes
  • Loss of normal fat pad planes
  • Effusions in adjacent joints

Year 3 - Diseases (27 decks)

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