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CCC > Primary Care - MSK > Flashcards

Primary Care - MSK Flashcards

1
Q

What is osteoarthritis?

A

A wear-and-tear degenerative disorder of synovial joints
-Cartilage breakdown&raquo_space; chondrocytes release inflammatory cytokines&raquo_space; thicken bone&raquo_space; osteophytes (bony lumps) > reduced joint space

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2
Q

What distinguishes between rheumatoid and osteoarthritis?

A

Rheumatoid

  • pain/stiffness relieved by exercise, exacerbated by lack of movement
  • worse in the morning
  • symmetrical joints
  • SPARING OF DIP

Osteoarthritis

  • pain exacerbated by exercise, relieved by rest
  • worse in evening
  • unilateral
  • stiffness after prolonged rest but <30 mins
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3
Q

What joints are primarily affected by osteoarthritis?

What hand signs are seen in osteoarthritis?

A

Knee and hip

Hand signs

  • Heberden’s nodes - DIP
  • Bouchard’s nodes - PIP
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4
Q

What would be noted on passive movement of the joint in osteoarthritis?

A

Decreased range of movement
Pain on movement
Crepitus

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5
Q

What changes are seen on an X-ray in osteoarthritis?

What about RA?

A 
OA-LOSS
Loss of joint space
Osteophytes
Subchondral cysts (white-under joint)
Subarticular sclerosis (black-either side of joint)
(Eventual joint destruction)

RA

  • erosions
  • periarticular osteopenia (area near joint turns grey instead of white)
  • ↓Joint space and destruction (late)
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6
Q

What is the treatment for osteoarthritis? (conservative and medical 1st line to 4th line, surgical)

A

Conservative

  • exercise to strengthen muscles
  • weight loss if overweight
  • appropriate footwear

Medical

  • 1st line: Paracetamol and TOP NSAIDS
  • 2nd line
    • Either codeine or
    • PO NSAIDS (± PPI)
  • 3rd line: Stronger opioids

**Intra articular steroid injections (temp relief for mod to severe pain)

Surgical (if significant impact on QofL and refractory to non surgical treatment)

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7
Q

Risk factors for RA?

A

Risk factors for RA

  • smoking
  • poor dental hygiene
  • FEMALE>M (2:1)
  • Age > 50/60 (adults of all ages)
  • HLA DR4/DR1 linked
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8
Q

What joints does RA affect?

What hand signs are seen in RA? (early vs late)

A

Small joints of hands (sparing of DIP)

Early signs
-inflamation (red, hot, swollen, painful)

Late signs (deformities due to joint damage)

  • Z thumb
  • Swan neck deformity = fixed flexion of DIP and hyperextension of PIP
  • Boutonniere’s = extension of MCP, flexion of PIP, extension of DIP
  • Ulnar deviation
  • Hand muscle wasting
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9
Q

What are the key rheumatoid complaints across the body?

A

PRISMS

Pain - polyarthritis
Rashes + skin lesions - ulcers, rashes, nail fold infarcts
Immune - Sjorgen’s = dry eyes, dry mouth, chronic cough
Stiffness - worse in morning lasting >1 hour
Malignancy
Swelling + sweats - especially in the morning

-Fatigue/weight loss

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10
Q

What score is used to classify and make diagnosis of RA?

What score is used to monitor severity/remission of RA?

A
  • ACR-EULAR RA classification for diagnosis (6 or more=diagnosis
  • DAS-28 used for severity (monitoring response, adequate is 1.2 points or more)
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11
Q

What are some extra articular effects of rheumatoid nodules? (lung, vascular, eyes, lymph nodes)

A

Affect of rheumatoid nodules

  • Lung-fibrosing alveolitis, obliterative bronchiolitis, pleural effusion
  • Vascular- Vasculitis, Reynaud’s
  • Lymphadenopathy
  • Eyes -Scleritis, Episcleritis, scleromalacia, conjunctivitis
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12
Q

How does Felty’s syndrome present?

A

Triad of:
Rheumatoid arthritis
Low WCC (big spleen eats them all)
Splenomegaly

E.g. woman with severe RA with cough (green sputum and crackles)

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13
Q

Investigations for Rheumatoid arthritis and what would you see?

A

Investigations for Rheumatoid arthritis

  1. Bloods
    - FBC (↑↑ESR ↑Platelets ↑CRP)
    - Rheumatoid factor (found in 70%)
    - Anti-CCP antibodies (more specific, found in 98%)
  2. Xray hands and feet
    - early to monitor progression
    - soft tissue swelling
    - deformaties may be seen
    - osteopenia and periarticular ostioporosis (early sign)
    - bony erosions
    - subluxation
    - ↓Joint space (late)
    - complete carpel destruction (late)
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14
Q

When would you refer Rheumatoid arthritis to rheumatologist?

A

Referral to rheumatologist if persistent synovitis and any of the following apply:

  • Small joints of hand + feet affected
  • > 1 joint affected
  • Delay of ≥ 3 months between onset + seeking medical advice
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15
Q

What medical treatment do you give for rheumatoid arthritis (analgesia and other drugs)

How often should they be reviewed?

A

Treatment of rheumatoid arthritis
Analgesia
-regular NSAIDS or COX 2 inhibitors
-Gluco-corticoids i.e. Prednisolone, IM depot or IA (short term for flares

Combo DMARDs
(1st line) for newly diagnosed active RA
-Methotrexate + at least 1 other DMARD (e.g. TNF inhibitor sulfasalazine + hydroxychloroquine)
-6-12wks for benefit

*Can give mono therapy for newly diagnosed RA where combo not appropriate i.e. pregnancy or drug CI

Biologics if don’t work

  • Sarilumab (2nd line) if inadequate response to combo
  • Rituximab (2nd line) if inadequate resp to combo

REVIEWED ANNUALLY-If unresponsive: surgery

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16
Q

Side effects of Sulfasalazine

What is a contraindication of sulfasalazine?

A

↓Sperm count, Oral ulcers,Rash

Aspirin hypersensitivity because it is an aminosalicylate

17
Q

What are some side effects of methotrexate?

A

SE of methotrexate

  • Anaemia - inhibits folate production (therefore also teratogenic so use sulfasalazine in women wanting to conceive)
  • Pneumonitis
  • Mouth ulcers
18
Q

Side effects of Hydroxychloroquin?

A

Irreversible retinopathy

19
Q

What is reactive arthritis?

What gene is assosiated with it?

What is the classic triad of reactive arthritis and when do the symptoms usually start?
and how long do they last?

A

An autoimmune response to infection elsewhere in the body causing arthritis

HLA-B27 mediated 60-80%

Reiter’s syndrome (cant pee/cant see/cant climb a tree)

  1. Uveitis or Conjunctivitis (50%)
  2. Urethritis or Cervicitis
  3. Arthritis (usually one joint, lower limb

Symptoms occur 4 weeks post-infection
Symptoms last around 6 months (recurrence likely if HLA-B27 +ve)

20
Q

What other symptoms may occur in reactive arthritis?

A

Other symptoms in reactive arthritis

  • Keratoderma blenorrhagica = brown raised plaques on soles/palms
  • Circinate balanitis – painless penile ulceration (rings)
  • Malaise + fatigue
  • Fever
  • Painful mouth ulcers
21
Q

Investigations for reactive arthritis?

A

Investigations for reactive arthritis

-Bloods FBC (↑ESR, ↑CRP)
-Look for cause of infection
> screen for STIs (Chlamydia and Gonorrhoea)
>stool culture (Shigella, Salmonella, Campylobacter)
>if not-do they have active TB? > Poncets disease (MALES>females)

22
Q

Managment of reactive arthritis ?

A

Managment of reactive arthritis

a) Splint affected joint (acute)
b) Treat ongoing infection
b) First line: NSAIDs, Corticosteroids or Local steroid injections for pain
c) If no improvement of very sever> DMARDs (methotrexate and sulfasalazine)

23
Q

Complications of reactive arthritis?

A

Complications of reactive arthritis
1 -Destructive Arthritis
2 -Spondyloarthritis
3 - Enthesitis-inflammation of the entheses, the sites where tendons or ligaments insert into the bone

24
Q

What length of time differentiates acute, subacute and chronic back pain?

A 
Acute = <4 weeks duration
Subacute = 4-8 weeks duration
Chronic = >12 weeks duration
25
Q

What signs and symptoms are red flags for chronic back pain?

A
  • Non-mechanical pain worse at rest
  • Thoracic pain
  • Fevers/rigors
  • General malaise
  • Urinary retention
  • Saddle anaesthesia
  • Reduced anal tone
  • Hip or knee weakness
  • Generalised neurological deficit
  • Progressive spinal deformity
26
Q

What features of a patient’s history are also red flags for chronic back pain?

A
  • Previous history of malignancy, no matter how long ago
  • Age <16 or >50 with new onset pain
  • Unexplained weight loss
  • Previous longstanding steroid use
  • Recent serious illness
  • Recent significant infection
27
Q

x

A

z

28
Q

How do you calculate BMI

What is a healthy BMI
What is overwieght BMI
what is obese BMI

A

BMI = weight/height2
healthy 18.5-24.9
overweight 25–29.9
obese 30+

29
Q

When should you consider hospital referal for obesity?

A

BMI ≥40 kg/m2;
or
BMI ≥35 kg/m2 with a comorbid condition improvable by weight loss; or
or
BMI ≥30 kg/m2 despite undergoing lifestyle interventions

30
Q

When can you diagnose OA without investigations?

A

Can diagnose OA without investigations if:
≥ 45 yo
AND activity related joint pain and
AND No morning joint-related stiffness or morning stiffness that lasts no longer than 30 mins

CCC (15 decks)

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