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Medicine > Rheum > Flashcards

Rheum Flashcards

1
Q

Common causes of monoarthritis?

A

septic arthritis

crystal arthritis: gout, pseudogout

Osteoarthritis

Trauma: haemarthrosis

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2
Q

common causes of oligoarthritis (5 or less joints)?

A

Crystal arthritis: gout

psoriatic arthritis

reactive arthritis

ank spond

osteoarthritis

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3
Q

common causes of polyarthritis (>5 joints)?

A

symmetrical:

RA

osteoarthritis

asymmetrical:

reactive arthritis

psoriatic arhtiritis

either:

systemic disease: SLE, amyloid, endocarditis

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4
Q

Classical radiological findings of OA?

A

Loss of joint space

Osteophytes

Subchondral cysts

Subchondral sclerosis

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5
Q

Classical radiological fiindings of Rheumatoid Arthritis?

A

Loss of joint space

soft tissue swelling

peri auricular osteopenia (erosions)

juxta articular osteoporosis

subluxation

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6
Q

classic radiological findings of gout?

A

joint effusion - early sign

normal joint space until late disease

soft tissue swelling

periarticular erosions

X ray of a patient with gout affecting his feet. It demonstrates juxta-articular erosive changes around the 1st MTP joint with overhanging edges and associated with a moderate soft tissue swelling. The joint space is maintained.

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7
Q

Mx of patients w moderate or high risk of diabetic foot disease?

A

follow up regularly by local diabetic foot centre

moderate risk: deformity/ neuropathy/ non critical limb ischaemia

high: anything further progression

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8
Q

Red Flags for Back Pain?

A

ge <20 or >55yrs

Neurological disturbance (inc. sciatica)

Sphincter disturbance

Bilateral or alternating leg pain

Current or recent infection

Fever, wt. loss, night sweats

History of malignancy

Thoracic back pain

Morning stiffness

Acute onset in elderly people

Constant or progressive pain

Nocturnal pain

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9
Q

Causes of Back Pain?

A

Mechanical:

Strain/idiopathic

Trauma

Pregnancy

Disc prolapse

Spondylolisthesis (forward shift of one vertebra)

Degenerative:

spondylosis, vertebral collapse, stenosis

Inflammatory:

Ank spond, Paget’s

Neoplasm:

Mets, myeloma

infection:

TB, abscess

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10
Q

Main weakness found on L2 lesion?

A

hip flexion

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11
Q

Main weakness found on L3 lesion?

A

Knee extension

Knee jerk

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12
Q

Main weakness found on L4 lesion?

A

foot inversion + dorsiflexion

knee jerk

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13
Q

Main weakness found on L5 lesion?

A

Great toe dorsiflexion

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14
Q

Main weakness found on S1 lesion?

A

foot eversion

ankle jerk

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15
Q

Ix of back pain?

A

necessary if red flags present

MRI spine

FBC, ESP, CRP, ALP

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16
Q

Mx of back pain?

A

Neurosurgical referral if neurology

Conservative:

Max 2d bed rest

Education: keep active, how to lift / stoop

Physiotherapy

Psychosocial issues re. chronic pain and disability

Warmth

Medical:

Analgesia: paracetamol ± NSAIDs ± codeine

Muscle relaxant: low-dose diazepam (short-term)

Facet joint injections

Surgical:

Decompression

Prolapse surgery: e.g. microdiscectomy

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17
Q

Acute Cauda Equina compression features?

A

neurosurgical emergency

alternating or bilat radicular pain in legs

back pain

saddle anaesthesia

loss of anal tone

bladder +/- bowel incontinence

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18
Q

Acute cord compression features?

A

bilat pain: back and radicular

LMN signs at compression level

UMN signs and sensory level below compression

sphincter disturbance

Neurosurgical emergency

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19
Q

Tx of Tumour causing acute cord compression/ acute cauda equina?

A

radiotherapy

steroids

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20
Q

Mx of abscesses causing acute cord compression/ cauda equina?

A

decompression

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21
Q

mx of large prolapse causing cauda equina/ acute cord compression?

A

lamiinectomy/ discectomy

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22
Q

definition of osteoarthritis?

A

degenerative joint disorder in which there is progressive loss of hyaline cartilage

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23
Q

Risk factors for OA?

A

Age (80% > 75yrs)

Obesity

Joint abnormality

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24
Q

Classification of OA?

A

Primary:

no underlying cause

Secondary:

obesity, joint abnormality

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25
Q

Symptoms of OA?

A

Affects: knees, hips, DIPs, PIPs, thumb CMC

Pain: worse w movement, background rest/night pain, worse @ end of day.

Stiffness: especially after rest, lasts ~30min (e.g. AM)

Deformity

↓ROM

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26
Q

Signs of osteoarthritis?

A

Bouchards nodes (proximal)

Heberdens (distal) nodes

Thumb CMC squaring

Fixed flexion deformity

crepitus on palpation of joint

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27
Q

Mx of osteoarthritis?

A

Conservative:

weight loss, physio (muscle strengthening), walking aids, home modifications (OT)

Medical:
Analgesia (1st line Paracetamol, topical NSAIDs- for OA knee/hand)

joint injection: local anaesthetic and steroids

Surgical:

arthroscopic washout: esp knee

arthroplasty: replacement
osteotomy: small area of bone cut out
arthrodesis: last resort for pain mx

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28
Q

complications of septic arthritis?

A

osteomyelitis

arthritis

ankylosis: fusion

sepsis

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29
Q

Mx of septic arthritis?

A

IV Abx: vanc + cefotaxime

consider joint washout under GA

analgesia

physiotherapy after infection resolved

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30
Q

Ix of septic arthritis?

A

joint aspiration for MCS

-> high WCC, mostly PMN

high CRP/ESR/ WCC, blood cultures

x ray joint

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31
Q

features of septic arthritis?

A

systemically unwell

decreased ROM

acutely inflamed tender, swollen joint

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32
Q

organisms causing septic arthritis?

A

commonest overall: staph aureus 60%

gonococcus: commonest in young sexually active

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33
Q

RFs for septic arthritis?

A

joint disease e.g. RA

CRF

immunosuppression e.g. DM

prosthetic joints

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34
Q

definition of rheumatoid arthritis?

A

chronic systemic inflammatory disease characterised by a symmetrical, deforming, peripheral polyarthritis

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35
Q

risk factors for rheumatoid arthritis?

A

smoking

female

family history

genetics- HLA DR4/DR1 linked

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36
Q

features of the arthritis in Rheumatoid arthritis?

A

Symmetrical, polyarthritis of MCPs, PIPs of hands and feet

→ pain, swelling, deformity

  1. Swan neck
  2. Boutonniere
  3. Z-thumb
  4. Ulnar deviation of the fingers
  5. Dorsal subluxation of ulnar styloid

Morning stiffness >1h

Improves w exercise

Larger joints may become involved

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37
Q

Features of Rheumatoid arthritis

A

ANTI CCP Or RF

arthritis

nodules: commonly elbows

Tenosynovitis: De Quervains, Atlanto-axial subluxation

immune: AIHA, vasculitis, amyloid, lymphadenopathy

Carpal tunnel syndome

Cardiac: pericarditis + pericardial effusion

Pulmonary: lower zone fibrosis, pleural effusions

Ophthal: epi/scleritis, sjogrens

Raynauds

Felty’s Syndrome

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38
Q

what is Feltys syndrome?

A

RA + splenomegaly + neutropenia

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39
Q

Diagnosis of rheumatoid arthritis?

A

4/7 of :

  1. Morning stiffness >1h (lasting >6wks)
  2. Arthritis ≥3 joints
  3. Arthritis of hand joints
  4. Symmetrical
  5. Rheumatoid nodules
  6. +ve RF
  7. Radiographic changes
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40
Q

Ix of Rheumatoid Arthritis?

A

Bloods: FBC (anaemia), high ESR/CRP

RF +ve in 70% (high titre assoc w severe disease, erosions and extraarticular disease)

Anti-CCP: 98% specific

ANA +ve 30%

Xray, US, MRI

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41
Q

Mx of Rheumatoid Arthritis?

A

Conservative:

refer to rheumatologist

regular exercise, physio, OT for aids, splints

Medical:

Pain relief NSAIDs

1st line: DMARDs monotherapy +/- short course of bridging prednisolone

biologics

Steroids PO or intraarticular for exacerbations

Mx CV risk

prevent osteoporosis and gastric ulcers

Surgical:

Ulna stylectomy

joint prosthesis

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42
Q

What scoring system is used to monitor disease activity of Rheumatoid arthritis?

A

DAS28

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43
Q

What DMARDs are available for use in RA?

A

DMARDs are 1st line in treating RA, early use assoc w better long term outcome

all DMARDs can -> myelosuppression -> pancytopenia

  1. Methotrexate
  2. Sulfasalazine
  3. Hydroxychloroquine
  4. Leflunomide
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44
Q

What biologics are available for use in RA?

A

anti-TNFa: infliximab, etanercept (TNFR), adalimumab (human Ab)

-> used after inadequate response to at least 2 DMARDs

Rituximab: anti-CD20

-> results in B cell depletion

screen and tx TB first
SEs: infection risk, autoimmune disease, ca

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45
Q

Pathophysiology of Boutonnieres vs Swanneck deformity?

A

Boutonierre’s: rupture of central slip of extensor expansion → PIPJ prolapse through “button-hole” created by the two lateral slips.

Swan: rupture of lateral slips → PIPJ hyper-extension

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46
Q

pathophysiology of gout?

A

deposition of monosodium urate crystals in and around joints -> erosive arthritis

may be precipitated by surgery, infection, fasting, diuretics

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47
Q

presentation of gout?

A

M>F

acute monoarthritis w severe joint inflammation

most commonly great toe MTP = Podagra

urate deposits in pinna and tendons (tophi)

renal disease: radiolucent stones, interstitial nephritis

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48
Q

differential for gout?

A

septic arthritis

pseudogout

haemarthrosis

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49
Q

acute mx of gout?

A

NSAIDs: diclofenac or indomethacin

Colchicine

Both are contraindicated in renal impairment -> use steroids

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50
Q

prevention of gout?

A

conservative:

lose weight, avoid prolonged fasts and alcohol excess

Xanthine oxidase inhibitors: allopurinol

Uricosuric drugs (Rarely used): e.g. probenecid

recombinant urate oxidase: rasburicase (may be used pre-cytotoxic tx)

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51
Q

Causes of Gout?

A

Hereditary

Drugs: diuretics, NSAIDs, cytotoxics, pyrazinamide

↓ excretion: renal impairment

↑ cell turnover:

lymphoma, leukaemia, psoriasis, haemolysis, tumour lysis syndrome

EtOH excess

Purine rich foods: beef, pork, lamb, seafood

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52
Q

Ix of Gout?

A

Polarised light microscopy: negatively birefringent needle shaped crystals

raised serum urate

xray changes occur late: punched out erosions in the juxta articular bone, reduced joint space

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53
Q

Ix of Pseudogout?

A

Polarized light microscopy: Positively birefringent rhomboid-shaped crystals

X-ray may show chondrocalcinosis: Soft-tissue Ca deposition (e.g. knee cartilage)

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54
Q

Mx of Pseudogout?

A

Analgesia

NSAIDs

may try steroids: PO, IM, intraarticular

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55
Q

Risk factors for pseudogout?

A

increased age

OA

DM

hypothyroid

hyperPTH

hereditary haemochromatosis

Wilsons disease

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56
Q

Fibromyalgia Mx?

A

educate pt

CBT

graded exercise programmes

amitriptyline or pregabalin

venlafaxine SSRI

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57
Q

Ix of fibromyalgia

A

all normal

rule out any organic cause

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58
Q

features of fibromyalgia?

A

Chronic, widespread musculoskeletal pain and tenderness

Morning stiffness

Fatigue

Poor concentration

Sleep disturbance

Low mood

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59
Q

Fibromyalgia assoc w?

A

chronic fatigue syndrome

irritable bowel syndrome

chronic headache syndromes

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60
Q

risk factors for fibromyalgia?

A

Depression, anxiety, stress

Dissatisfaction at work

Overprotective family or lack of support

Middle age

Low income

Divorced

Low educational status

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61
Q

What is Wegeners Granulomatosis?

A

aka granulomatosis w polyangiitis

necrotizing granulomatous inflammation and small vessel vasculitis w predilection for URT, lungs, kidneys

cANCA +ve

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62
Q

features of Wegener’s?

A

URT: chronic sinusitis, epistaxis, saddle nose deformity

LRT: cough, haemoptysis, pleuritis

Renal: RPGN, haematuria, proteinuria

other: palpable purpura, conjunctivitis/ keratitis/ uveitis

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63
Q

Ix of Granulomatosis w polyangiitis?

A

cANCA

dipstick: haematuria and proteinuria

CXR: bilar nodular and cavity infiltrates

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64
Q

features of Churg-Strauss?

A

aka eosinophilic granulomatosis w polyangiitis?

pANCA +ve

late onset asthma, eosinophilia

RPGN, palpable purpura, GIT bleeding

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65
Q

features of HSP?

A

post URTI

palpable purpura on buttocks

colicky abdo pain

arthralgia

haematuria

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66
Q

Goodpastures Features?

A

Anti-GBM abs

Haemoptysis + Haematuria (RPGN)

CXR: bilat lower zone infiltrates (haemorrhage)

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67
Q

Mx of goodpastures?

A

immunosuppression + plasmapheresis

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68
Q

cryoglobulins causing joint pain, splenomegaly, skin, nerve and kidney involvement. sometimes associated with hep C infection.

A

Essential mixed cryoglobulinaemia

Type III hypersensitivity

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69
Q

Features of simple cryoglobulinaemia?

A

monoclonal IgM

secondary to myeloma/ CLL/ Waldenstroms

  • > hyperviscosity
  • visual disturbance, bleeding from mucous membranes, thrombosis, headache, seizures
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70
Q

Mixed cryoglobulinaemia features?

A

polyclonal IgM

secondary to SLE, Sjogrens, Hep C, Mycoplasma

-> immune complex disease

GN, palpable purpura, arthralgia, peripheral neuropathy

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71
Q

Cutaneous Leukocytoclastic Vasculitis?

A

similar to HSP but w/o abdo pain/ blood in urine

Palpable purpuric rash ± arthralgia ± GN

Causes:

HCV

Drugs: sulphonamides, penicillin

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72
Q

features of limited systemic sclerosis?

A

CREST

Calcinosis

Raynauds (white -> blue -> red)

Oesophageal and gut dysmotility -> GOR

Sclerodactyly

Telangiectasia

*skin involvement limited to face, hands and feet

  • beak nose, microstomia
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73
Q

features of diffuse systemic sclerosis?

A

diffuse skin involvement (predominantly trunk and proximal limbs)

organ fibrosis

GI: GOR, aspiration, dysphagia

Lung: fibrosis, pulm HTN

Cardiac: arrhythmias and conduction defects

Renal: acute hypertensive crisis (commonest cause of death)

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74
Q

Ix of systemic sclerosis?

A

Bloods: FBC (anaemia), U+E (renal impairment)

Abs: centromere (limited), Scl70 / topoisomerase (diffuse)/ RNA pol 1,2,3 (diffuse)

urine: dipstick, PCR

Imaging:

CXR- cardiomegaly, bibasal fibrosis

Hands: calcinosis

Ba swallow: impaired oesophageal motility

HR CT

ECG + echo: pulm HTN

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75
Q

what antibodies are assoc w limited systemic sclerosis?

A

anti-centromere

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76
Q

what antibodies are assoc w diffuse systemic sclerosis?

A

Scl70/ topoisomerase

RNA poly 1,2,3

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77
Q

mx of systemic sclerosis?

A

conservative:

exercise and skin lubricants: reduce contractures

hand warmers: raynauds

Medical:

  • immunosuppression
  • Raynauds: CCBs, ACEi, IV prostacyclin
  • Renal: intensive BP control - 1st line ACEi
  • Oesophageal: PPIs, prokinetics (metoclopramide)
  • Pulm HTN: sildenafil, bosentan
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78
Q

features of dermatomyositis?

A

striated muscle inflammation

progressive symmetrical prxomal muscle weakness

  • wasting of shoulder and pelvic girdle

assoc myalgia and arthralgia

heliotrope rash on eyelids +/- oedema

macular rash (shawl sign +ve: over back and shoulders)

nailfold erythema

Gottrons papules

mechanics hands: painful, rough skin cracking of finger tips

Retinopathy: haemorrhages and cotton wool spots

subcut calcifications

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79
Q

features of polymyositis and dermatomyositis?

A

progressive symmetrical proximal muscle weakness

  • wasting of shoulder and pelvic girdle
  • dysphagia, dysphonia, resp weakness

assoc myalgia and arthralgia

commoner in females

often a paraneoplastic phenomenon: lung, pancreas, ovarian, bowel

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80
Q

Dermatomyositis Vs polymyositis?

A

Dermatomyositis = myositis + skin signs

e.g. heliotrope rash, Gottrons papules

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81
Q

extra muscular features of polymyositis/ dermatomyositis?

A

fever

arthritis

bibasal pulm fibrosis

Raynauds phenomenon

Myocardial involvement: myocarditis, arrhythmias

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82
Q

Ix of dermatomyositis?

A

raised Creatinine Kinase, AST, ALT, LDH

Abs: Anti-Jo1

EMG

Muscle biopsy

Screen for malignancy: tumour markers, CXR, CT

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83
Q

differential diagnosis of dermatomyositis?

A

inclusion body myositis

muscular dystrophy

polymyalgia rheumatica

endocrine/ metabolic myopathy

drugs: steroids, statins, colchicine, fibrates

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84
Q

Mx of dermatomyositis?

A

screen for malignancy

immunosuppression: steroids,

cytotoxics - azathioprione, methotrexate

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85
Q

features of Takayasu’s Arteritis?

A

Pulseless disease

rare outside japan

20-40yo

constitutional symptoms: fever, fatigue, weight loss

weak pulses in upper extremities

visual disturbance

HTN

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86
Q

features of polyarteritis nodosa?

A

medium vessel necrotising arteritis involving kidneys and other organs but spares the lungs

“rosary sign” beading on angiography

assoc w Hep B

constitutional symptoms, rash, renal -> HTN

GIT -> melaena and abdo pain

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87
Q

microaneurysms on the angiography “beading” “rosary sign”

A

polyarteritis nodosa

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88
Q

polyarteritis nodosa associ w which underlying infection?

A

Hep B

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89
Q

mx of polyarteritis nodosa?

A

prednisolone + cyclophosphamide

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90
Q

Features of Kawasakis Disease?

A

CRASH and BURN

fever for >5 days

Conjunctivitis bilaterally non-purulent

Rash (polymorphic)

lymphAdenopathy (cervical)

Strawberry tongue (dry peeling lips)

Hands (swelling and erythema of extremities)

-> eventually leads to coronary artery aneurysms

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91
Q

Mx of Kawasaki’s disease?

A

IVIg + high dose aspirin

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92
Q

Types of large vessel vasculitis?

A

Giant cell arteritis

Takayasu’s arteritis

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93
Q

Types of medium vessel vasculitis?

A

Polyarteritis Nodosa

Kawasakis Disease

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94
Q

types of small vessel vasculitis?

A

pANCA+ve: Churg strauss, microscopic polyangiitis

cANCA: wegener’s granulomatosis

ANCA -ve: HSP, Goodpastures, Cryoglobulinaemia, Cutaneous leukocytoclastic vasculitis

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95
Q

features of giant cell arteritis?

A

aka temporal arteritis

common in elderly

assoc w polymyalgia rheumatica

systemic signs: fever, malaise, fatigue

headache

temporal artery and scalp tenderness

jaw claudication

amaurosis fugax

prominent temporal arteries +/- pulsation

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96
Q

what is GCA assoc w?

A

polymyalgia rheumatica

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97
Q

Ix of GCA?

A

1st line: ESR (and start pred 40-60mg/d PO)

to diagnose: temporal artery biopsy

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98
Q

Mx of GCA?

A

Prednisolone 40-60mg/d PO

taper steroids gradually, guided by symptoms and ESR

PPI and alendronate cover (2 yr course usually)

Urgent Opthalmology review:

Patients with visual symptoms should be seen the same-day by an ophthalmologist. Visual damage is often irreversible

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99
Q

presentation of polymyalgia rheumatica?

A

>50 yo

severe pain and stiffness in shoulders, neck and hips

  • > sudden / subacute onset
  • > symmetrical
  • > worse in the morning
  • > NO weakness

+/- mild polyarthritis, tenosynovitis, carpal tunnel syndrome

Systemic signs: Fatigue, fever, weight loss

15% develop GCA

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100
Q

IX of Polymyalgia rheumatica?

A

High ESR (>40 mm/hr) and CRP

high ALP

normal CK and EMG

reduced CD8+ T cells

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101
Q

Mx of polymyalgia rheumatica?

A

prednisolone 15 mg/ d PO:

taper according to symptoms and ESR

PPI and alendronate cover (2 yr course usually)

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102
Q

definition of SLE?

A

multisystem autoimmune inflammatory disease in which autoabs to a variety of autoantigens result in formation and deposition of immune complexes

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103
Q

Features of SLE?

A

relapsing, remitting history

constitutional symptoms: fatigue, weight loss, fever, myalgia

Arthritis

Renal: proteinuria and HTN

Pleuritis, Pericarditis

Haematological: AIHA, low WCC, Pl

photosensitivity

oral ulcers

malar rash

discoid rash

ANA (+ve in 95%)

anti-dsDNA, anti-Sm, Anti-phospholipid

104
Q

what is the most specific ab for SLE?

A

anti-ds DNA

105
Q

most sensitive ab for SLE?

A

anti-Smith

106
Q

Antibodies in SLE?

A

ANA +ve 95%

anti-dsDNA (v specific)

Anti-Ro, La, Smith, RNP

Anticardiolipin Abs

107
Q

what is used to monitor disease activity of SLE?

A

anti-dsDNA titres

low C3 and C4 (during active disease)

raised ESR

108
Q

what antibody is assoc w drug induced lupus?

A

anti-histone abs

109
Q

what drugs are assoc w drug associated lupus?

A

anti-histone +ve

procainamide, phenytoin, hydralazine, isoniazod

disease remits if drug stopped

110
Q

classification of anti phospholipid syndrome?

A

primary 70%

secondary to SLE: 30%

111
Q

what antibodies are assoc w anti phospholipid syndrome?

A

anti-cardiolipin and lupus anticoagulant

112
Q

features of anti phospholipid syndrome?

A

CLOTS: venous and arterial

Coagulation defect: prolonged APTT

Livido reticularis

Obstetric complications: recurrent 1st trimester abortions

Thrombocytopenia

113
Q

mx of antiphospholipid syndrome?

A

low dose aspirin

warfarin if

initial VTE: 2.5

arterial thrombosis: lifelong warfarin INR 2.5

recurrent thromboses: lifelong INR 3.5

114
Q

Mx of SLE?

A

specialist SLE and lupus nephritis clinics

Severe Flares:

(AIHA, nephritis, pericarditis, CNS disease)

-> high dose prednisolone + IV cyclophosphamide

cutaneous symptoms: tx w topical steroids and prevent w sun cream

maintenance: for joints/ skin
- NSAIDs and hydroxychloroquine +/- low dose steroids

115
Q

Mx of Lupus nephritis?

A

proteinuria: ACEi

Aggressive GN: immunosuppression

116
Q

Presentation of Raynauds Phenomenon?

A

Digit pain + triphasic colour Change: WBC

White -> blue -> crimson red

digital ulceration and gangrene

117
Q

what antibody is assoc w multiconnective tissue disease?

A

anti-U1RNP

118
Q

Mx of raynaud’s phenomenon?

A

wear gloves

1st line CCBs: nifedipine

IV prostacyclin infusions

119
Q

what is raynauds phenomenon?

A

peripheral digital ischaemia precipitated by cold or emotion

120
Q

classification of raynauds phenomenon?

A

idiopathic

secondary: to systemic sclerosis, SLE, RA, Sjogrens

Thrombocytosis

121
Q

what is mixed connective tissue disease?

A

combined features of SLE, RA, Systemic Sclerosis, myositis (poly/ dermato)

anti-U1 RNP

122
Q

types of sjogrens syndrome?

A

primary

secondary: to RA, SLE, systemic sclerosis

123
Q

Features of Sjogrens?

A

decreased tear production -> dry eyes

decreased salivation -> xerostomia

bilateral parotid swelling

vaginal dryness -> dyspareunia

Systemic: Polyarthritis, Raynauds, Bibasal Pulm Fibrosis, Vasculitis, Myositis

124
Q

Sjogrens assoc w?

A

AI: thyroid disease, Autoimmune hepatitis, PBC

Marginal zone MALT lymphoma (parotid)

125
Q

Ix of Sjogrens?

A

Schirmer tear test

Abs: ANA- Ro and La, RF

hypergammaglobulinaemia

parotid biopsy

126
Q

what antibodies are assoc w sjogrens?

A

anti-Ro and La

127
Q

mx of Sjogrens?

A

artificial tears

saliva replacement solutions

NSAIDs, and hydroxychloroquine for arthralgia

immunosuppression for severe systemic disease

pilocarpine may stimulate saliva production

128
Q

what is Behcet’s Disease?

A

systemic vasculitis of unknown cause

recurrent oral and genital ulceration

eyes: ant/ post uveitis

skin lesions: erythema nodosa

Vasculitis

Joints: non-erosive large joint oligoarthropathy

neuro: CN palsies

GI: diarrhoea, colitis

129
Q

Ix of Behcets disease?

A

no definitive test

skin pathergy test (needle prick -> papule formation) is suggestive

130
Q

mx of Behcet’s disease?

A

immunosuppression

131
Q

What is RF +ve in ?

A

100% Sjogrens

100% Feltys

70% Rheumatoid arthritis

132
Q

ANA +ve in which conditions?

A

SLE >95%

Autoinnue hepatitis 75%

Sjogrens 70%

133
Q

anti-dsDNA?

A

SLE

134
Q

anti-histone Abs?

A

Drug induced lupus

135
Q

anti-centromere abs?

A

CREST Syndrome

136
Q

anti Ro/La Abs?

A

Sjogrens

SLE

137
Q

anti-smith abs?

A

SLE

138
Q

anti-U1RNP?

A

Mixed connective tissue disease

SLE

139
Q

anti Jo1 Abs?

A

Dermatomyositis

Polymyositis

140
Q

Anti-Scl70, RNA Pol1/2/3?

A

Diffuse systemic sclerosis

141
Q

what is relapsing polychondritis?

A

rare inflammatory disease of cartilage

presents w:

tenderness, inflammation and destruction of cartilage

ear-> floppy ears

nose -> saddle nose deformity

Larynx -> stridor

142
Q

relapsing polychondritis assoc w?

A

aortic valve disease

polyarthritis

vasculitis

143
Q

mx of relapsing polychondritis?

A

immunosuppression

144
Q

Enteropathic arthritis features?

A

assoc w UC or Crohns

asymmetrical large joint oligoarthritis mainly affecting the lower limbs

sacroilitis common

145
Q

Mx of enteropathic arthritis?

A

Treat the IBD

NSAIDs or articular steroids for arthritis

Colectomy-> remission in UC

146
Q

Mx of reactive arthritis?

A

NSAIDs and local steroids

relapse may need sulfasalazine or methotrexate

147
Q

IX of reactive arthritis?

A

raised ESR/ CRP

stool culture if diarrhoea

urine chlamydia PCR

148
Q

what is reactive arthritis?

A

sterile arthritis 1-4 wks after urethritis or dysentery

asymmetrical lower limb oligoarthritis esp knee

ant uveitis

urethritis

Keratoderma blenorrhagica: plaques on soles/ palms

Circinate balanitis: painless penile ulceration

Mouth ulcers

149
Q

what organisms are responsible for reactive arthritis?

A

urethritis: chlamydia

Dysentery: Campylobacter jejuni, salmonella, shigella, yersinia

150
Q

patterns of joint involvement in psoriatic arthritis?

A

Asymmetrical oligoarthritis: 60% (commonest)
Distal arthritis of the DIP joints: 15% (classical)
Symmetrical polyarthritis: 15% (like RA but ̄c DIPJs) Arthritis mutilans (rare, ~3%)
Spinal (like AS)

151
Q

other features of psoriatic arthritis?

A

psoriatic plaques

nail changes: pitting, subungual hyperkeratosis, onycholysis

Enthesitis: achilles tendonitis, plantar fasciitis

Dactylitis

152
Q
A

painless separation of the nail from the nail bed

e.g in psoriatic arthritis

153
Q

what is subungual hyperkeratosis?

A

scaling under the nail due to excessive proliferation of keratinocytes in the nail bed and hyponychium.

154
Q

What Xray finding is classic of Psoriatic arthropathy?

A

Classical deformity is called “cup-and-pencil deformity”

Erosion of one end of bone with expansion of the base of the contiguous metacarpal

Radiograph of both hands demonstrates cup-and-pencil deformities of
both thumbs and erosion of DIP joint of left middle finger

155
Q

Mx of psoriatic arthritis?

A

NSAIDs

sulfasalazine, methotrexate, ciclosporin

anti-TNF

156
Q

What inflammatory arthritides are assoc w HLA-B27 allele?

A

Ank Spond

Psoriatic arthritis

Reactive Arthritis

Enteropathic arthritis

157
Q

what is ankylosing spondylitis?

A

Chronic disease of unknown aetiology characterised by stiffening and inflammation of the spine and sacroiliac joints.

M>F

158
Q

features of ankylosing spondylitis?

A

gradual onset back pain

  • worse @ night w morning stiffness
  • relieved by exercise
  • radiates from sacroiliac joints to hips and buttocks

progressive loss of all spinal movements

  • Schober’s test <5cm

? posture -> thoracic kyphosis and neck hyperextension

Enthesitis: Achilles tendonitis, plantar fasciitis

Costochondritis

159
Q

extra articular manifestations of ank spond?

A

Osteoporosis: 60%
Acute iritis / anterior uveitis: 30%

Aortic valve incompetence: <3%

Apical pulmonary fibrosis

160
Q

Mx of Ank Spondy?

A

Conservative:

Exercise

Physio

Medical:

1st line NSAIDs: e.g. indomethacin

Anti-TNF: if severe (not inflixi)
Local steroid injections
Bisphosphonates

DMARDs: if peripheral joint involvement

Surgical:

Hip replacement to ↓ pain and ↑ mobility

161
Q

ix of ank spondylitis?

A

Clinical Dx as radiological changes appear late
- Sacroliliitis: irregularities, sclerosis, erosions

  • Vertebra: corner erosions, squaring syndesmophytes (bony proliferations)
  • Bamboo spine: calcification of ligaments, periosteal bone formation

FBC (anaemia), ↑ESR, ↑CRP , HLA-B27

DEXA scan (osteoporosis) and CXR (pulm fibrosis)

162
Q

common features of inflammatory arthritides w HLA B27 allele?

A

Axial arthritis and sacroiliitis

Asymmetrical large-joint oligoarthritis or monoarthritis

Enthesitis

Dactylitis

Extra-articular: iritis, psoriaform rashes, oral ulcers, aortic regurg, IBD

163
Q

adverse effects of hydroxychloroquine?

A

used in mx of RA and SLE

  • pharmacologically similar to chloroquine which is used in malaria
  • Bulls eye retinopathy -> severe and permanent visual loss

most recent RCOphth guidelines (March 2018) suggest colour retinal photography and spectral domain optical coherence tomography scanning of the macula

monitor: Ask patient about visual symptoms and monitor visual acuity annually

164
Q

most specific ab for diffuse systemic sclerosis?

A

anti-Scl-70 antibodies

Although ANA is positive in 90% of patients with systemic sclerosis, not specific!!

165
Q

mx of corticosteroid-induced osteoporosis?

A

if T score offer bone protection

1st line: alendronate

+ calcium and Vit D

166
Q

2nd line pain mx for Osteoarthritis after paracetamol/ topical NSAIDs?

A

oral NSAIDs/COX-2 inhibitors (+PPI), opioids, capsaicin cream and intra-articular corticosteroids.

167
Q

adverse effects of methotrexate?

A

mucositis

myelosuppression

pneumonitis

pulmonary fibrosis

liver fibrosis

women should avoid pregnancy for at least 3 months after treatment has stopped

168
Q

prescribing info about methotrexate?

A

taken weekly

FBC, U&E and LFTs need to be regularly monitored (repeated weekly until therapy stabilised, thereafter patients should be monitored every 2-3 months’)

folic acid 5mg once weekly should be co-prescribed, taken more than 24 hours after methotrexate dose

avoid prescribing trimethoprim or cotrimoxazole concurrently - increases risk of marrow aplasia

169
Q

what medications increase the risk of marrow aplasia when given alongside methotrexate?

A

trimethoprim or cotrimoxazole

170
Q

features of adult Still’s disease?

A

arthralgia

elevated serum ferritin

rash: salmon-pink, maculopapular
pyrexia: typically rises in the late afternoon/early evening in a daily pattern and accompanies a worsening of joint symptoms and rash

lymphadenopathy

rheumatoid factor (RF) and anti-nuclear antibody (ANA) negative

171
Q

mx of adult Stills disease?

A

1st line NSAIDs

then 2nd: + steroids

3rd line: methotrexate, anti-TNF therapy, IL1

172
Q

what is Paget’s disease of the bone?

A

increased but uncontrolled bone turnover.

with excessive osteoclastic resorption followed by increased osteoblastic activity

173
Q

features of Pagets disease?

A

only 5% of patients are symptomatic

bone pain (e.g. pelvis, lumbar spine, femur)

classical, untreated features: bowing of tibia, bossing of skull

raised alkaline phosphatase (ALP) - calcium* and phosphate are typically normal

skull x-ray: thickened vault, osteoporosis circumscripta

174
Q

mx of Pagets Disease?

indications?

A

Indications for treatment include bone pain, skull or long bone deformity, fracture, periarticular Paget’s

1st line bisphosphonate (either oral risedronate or IV zoledronate)

calcitonin is less commonly used now

175
Q

complications of Pagets disease?

A

deafness (cranial nerve entrapment)

bone sarcoma (1% if affected for > 10 years)

fractures

skull thickening

high-output cardiac failure

176
Q
A

Pelvic x-ray from an elderly man with Paget’s disease. There is a smooth cortical expansion of the left hemipelvic bones with diffuse increased bone density and coarsening of trabeculae.

177
Q
A

The radiograph demonstrates marked thickening of the calvarium. There are also ill-defined sclerotic and lucent areas throughout. These features are consistent with Paget’s disease.

178
Q

most common cardiac manifestation of SLE?

A

pericarditis

179
Q

most common type of glomerulonephritis due to SLE?

A

diffuse proliferative

180
Q

risk factors for osteoporosis?

A

age and female gender. Other risk factors include:

corticosteroid use

smoking

alcohol

low body mass index

family history

181
Q

screening tool for osteoporosis?

A

FRAX or QFracture to assess the 10-year risk of a patient developing a fragility fracture

A patient who has sustained a fragility fracture (e.g. following a Colles’ wrist fracture) should also be assessed for osteoporosis.

182
Q

mx of osteoporosis?

A

1st line: oral bisphosphonate

183
Q

what monitoring do Marfans patients need?

A

regular echo monitoring

heart: dilation of the aortic sinuses (seen in 90%) which may lead to aortic aneurysm, aortic dissection, aortic regurgitation, mitral valve prolapse (75%),

184
Q

radiographic findings of ankylosing spondylitis?

A

sacroilitis: subchondral erosions, sclerosis

squaring of lumbar vertebrae

‘bamboo spine’ (late & uncommon)

syndesmophytes: due to ossification of outer fibers of annulus fibrosus

chest x-ray: apical fibrosis

185
Q
A

Ankylosing spondylitis with well formed syndesmophytes

syndesmophytes: due to ossification of outer fibers of annulus fibrosus

186
Q
A

ank spond

Syndesmophytes and squaring of vertebral bodies. Squaring of anterior vertebral margins is due to osteitis of anterior corners. Syndesmophytes are due to ossification of outer fibers of annulus fibrosus

187
Q

spirometry in ank spond?

A

restrictive defect due to a combination of pulmonary fibrosis, kyphosis and ankylosis of the costovertebral joints.

188
Q

causes of dactylitis?

A

spondyloarthritis e.g. psoriatic and reactive arthritis

sickle cell disease

other rare causes: TB, sarcoidosis, syphilis

189
Q

info regarding alendronate administration?

A

for all bisphosphonates

given on an empty stomach at least 30 minutes before breakfast (or another oral medication); patient should stand or sit upright for at least 30 minutes after taking tablet’

190
Q

adverse effects of bisphosphonates e.g. alendronate?

A

oesophageal reactions: oesophagitis, oesophageal ulcers (especially alendronate)

osteonecrosis of the jaw

increased risk of atypical stress fractures of the proximal femoral shaft in patients taking alendronate

acute phase response: fever, myalgia and arthralgia may occur following administration

hypocalcaemia: due to reduced calcium efflux from bone. Usually clinically unimportant

191
Q

most specific antibody for Sjogrens?

A

anti-Ro

192
Q

what malignancy is assoc w Sjogrens?

A

lymphoid malignancy (MALToma)

193
Q
A

Rheumatoid arthritis

There is symmetric erosion of the metacarpal heads in this patient with severe ulnar subluxation of the MCP joints due to rheumatoid arthritis. Note also the abnormal appearance of the fifth fingers due to Boutonniere deformities – the proximal interphalangeal joints are flexed while the DIP joints are extended.

194
Q
A

The combination of nail changes, skin changes and arthritis points to a diagnosis of psoriatic arthropathy.

195
Q

mx of osteoporosis if pt unable to tolerate bisphosphonates due to upper GI problems?

A

Offer Strontium Ranelate and Raloxifene (strict T scores e.g. T

strictest criteria for denosumab

Raloxifene: selective oestrogen R modulator

* increases risk of thromboembolic events/ worsens menopausal symptoms

Strontium ranelate: increased risk of CV events, thromboembolic events, SJS

Denosumab: inhbits RANK ligand -> inhibits osteoclast maturation

196
Q

A 59-year-old man with a history of gout presents with a swollen and painful first metatarsophalangeal joint. He currently takes allopurinol 400mg od as gout prophylaxis. What should happen to his allopurinol therapy?

A

Continue allopurinal at current dose

Patients already prescribed allopurinol should continue to take it at the same dose during acute episodes. This is of course in contrast to the advice that patients should not be started on allopurinol until an acute attack has settled.

197
Q

A 71-year-old woman is diagnosed with polymyalgia rheumatica. She is started on prednisolone 15mg od. What is the most appropriate approach to bone protection?

A

if it likely that the patient will have to take steroids for at least 3 months then we should start bone protection straight away

start alendronate + calcium + Vit D

198
Q

in OA, what is the first reduction of movement of the hip?

A

Reduction in internal rotation is often the first sign

199
Q

what nerve may cause referred lumbar spine pain?

A

Femoral nerve compression may cause referred pain in the hip

Femoral nerve stretch test may be positive - lie the patient prone. Extend the hip joint with a straight leg then bend the knee. This stretches the femoral nerve and will cause pain if it is trapped

200
Q

what is greater trochanteric pain syndrome?

ie trochanteric bursitis

A

Due to repeated movement of the fibroelastic iliotibial band
Pain and tenderness over the lateral side of thigh
Most common in women aged 50-70 years

201
Q
A

Retroperitoneal perforation

instead of the free air outlining the small bowel wall (Rigler’s sign), it will outline retroperitoneal structures such as the kidneys (‘RK’ and ‘LK’ on this image), the caecum and ascending/descending colon (caecum is labelled here) and the psoas muscles (arrows). The air will often extend around the gastro-oesophageal junction resulting in a pneumomediastinum.

202
Q

what are the types of hypersensitivity?

A

Type I - Anaphylactic

Antigen reacts with IgE bound to mast cells

Type II - Cell bound

IgG or IgM binds to antigen on cell surface

Type III - Immune complex

Free antigen and antibody (IgG, IgA) combine

Type IV - Delayed hypersensitivity

T-cell mediated

Type V

Antibodies that recognise and bind to the cell surface receptors.

This either stimulating them or blocking ligand binding

e.g. Graves, Myasthenia Gravis

203
Q

presents in childhood

fractures following minor trauma

blue sclera

deafness secondary to otosclerosis

dental imperfections are common

A

Osteogenesis imperfecta

group of disorders of collagen metabolism resulting in bone fragility and fractures

autosomal dominant

abnormality in type 1 collagen

204
Q
A

erythema nodosum

assoc w

infection: streptococcal, TB

Autoimmune: IBD, Behcets, Sarcoidosis

205
Q

oral ulces + genital ulcers + anterior uveitis?

A

behcet’s syndrome

206
Q

Causes of hereditary haemolytic anaemias?

A

enzyme: G6PD deficiency, Pyruvate Kinase deficiency

membrane:

hereditary spherocytosis

hereditary elliptocytosis

haemoglobinopathy:

SCD, thalassaemia

207
Q

causes of acquired haemolytic anaemia?

A

immune mediated: direct antiglobulin test +ve

  • AIHA: warm, cold, paroxysmal cold haemoglobinuria

paroxysmal nocturnal haemoglobinuria

Mechanical:

  • MAHA: DIC, HUS, TTP
  • heart valve

Infection: malaria

Burns

208
Q

what happens at the cellular level w haemolytic anaemia?

e.g. bilirubin levels

A

anaemia w high MCV + polychromasia = reticulocytosis

high unconj Br

high urinary urobilinogen

high serum LDH

bile pigment stones

intravascular: low serum haptoglobins,

high urine haemosiderin

haemoglobinuria

methaemalbuminaemia

extravasc:

splenomegaly

209
Q

signs of IDA?

A

koilonychia

angular stomatitis/ cheilosis

Post- cricoid Web: pulmmer-Vinson

210
Q
A

angular stomatitis

ie in IDA

211
Q

gout, renal failure, neurological deficits, learning difficulties, self-mutilation

A

Lesch-Nyhan syndrome

x-linked recessive therefore only seen in boys

hypoxanthine-guanine phosphoribosyl transferase (HGPRTase) deficiency

212
Q

risk factors for gout?

A

Decreased excretion of uric acid

drugs*: diuretics

chronic kidney disease

lead toxicity

Increased production of uric acid

myeloproliferative/lymphoproliferative disorder

cytotoxic drugs

severe psoriasis

213
Q

when to offer allopurinol in pt w first presentation of gout attack?

A

once his symptoms of gout have fully settled

the British Society of Rheumatology Guidelines now advocate offering urate-lowering therapy to all patients after their first attack of gout

214
Q

mx of acute gout in elderly pts taking warfarin?

A

colchicine

avoid NSAIDs due to risk of life threatening GI haemorrhage

215
Q

xray difference between gout and pseudogout?

A

presence of chondrocalcinosis on the x-ray confirms the diagnosis of pseudogout.

216
Q

examination findings of pt with ankylosing spondylitis?

A

reduced lateral flexion of lumbar spine

reduced forward flexion of lumbar spine- Schober’s test - a line is drawn 10 cm above and 5 cm below the back dimples (dimples of Venus). The distance between the two lines should increase by more than 5 cm when the patient bends as far forward as possible

reduced chest expansion

217
Q

Other features of Ankylosing Spondylitis?

A

the As

Apical fibrosis

Anterior uveitis

Aortic regurgitation

Achilles tendonitis

AV node block

Amyloidosis

and cauda equina syndrome

peripheral arthritis (25%, more common if female)

218
Q

A 75-year-old female was recently started on alendronate for treatment of osteoporosis following a fragility fracture. She returns to your clinic as she has suffered troubling upper gastrointestinal side effects. What is the most appropriate next step in her management?

A

Change to risedronate

NICE guidance recommends that if patients suffer significant upper gastrointestinal side effects from the use of alendronate, then this should first be changed to risedronate or etidronate

219
Q

A diagnostic angiogram is performed which shows an abrupt cut off at the level of the anterior tibial artery, together with the formation of corkscrew shaped collateral vessels distally.

A

Buergers disease

most common in young male smokers.

220
Q

what is Buergers disease?

A

Segmental thrombotic occlusions of the small and medium sized lower limb vessels

Commonest in young male smokers

Proximal pulses usually present, but pedal pulses are lost

An acuter hypercellular occlusive thrombus is often present

Tortuous corkscrew shaped collateral vessels may be seen on angiography

221
Q

Angiography may show saccular or fusiform aneurysms and arterial stenoses

A

polyarteritis nodosa

222
Q

features of Ehlers Danlos?

A

autosomal dominant connective tissue disorder that mostly affects type III collagen

results in the tissue being more elastic than normal leading to joint hypermobility and increased elasticity of the skin.

elastic, fragile skin

joint hypermobility: recurrent joint dislocation

easy bruising

aortic regurgitation, mitral valve prolapse and aortic dissection

subarachnoid haemorrhage

angioid retinal streaks

223
Q

what is the main Ig found in breast milk?

A

ig A

also found in the secretions of digestive, respiratory and urogenital tracts and systems

Provides localized protection on mucous membranes

224
Q

A 25-year-old man with a history of Crohn’s disease presents asking for advice. He currently takes methotrexate and asks if it is alright for him and his partner to try for a baby.
What is the most appropriate advice?

A

wait for at least 3 months after stopping tx

225
Q

joint aspiration shows calcium phosphate crystals associated with degeneration of cartilage, coffin-lid shaped with no birefringence

A

osteoarthritis

226
Q

joint aspiration shows cholesterol crystals, these are rhombic/brick-shaped with a negative birefringence

A

rheumatoid arthritis

227
Q

Lateral epicondylitis

Which one of the following movements would characteristically worsen the pain?

A

worse on resisted wrist extension/supination whilst elbow extended

228
Q

Diarrhoea

Skin rash

Liver failure -> jaundice, LFTs deranged

pancytopenia

blood transfusion 4-30d ago?

A

Graft vs Host Disease

  • viable lymphocytes transfused into immunocompromised host

irradiate blood for vulnerable hosts

229
Q

jaundice, anaemia, dropping Hb, fever, haemoglobinuria

1-7d after blood transfusion?

A

delayed haemolytic reaction

  • recipient anti-Rh Abs
230
Q

after blood transfusion,

hypothermia, high K, low Ca,

low f5 and f8

low platelets

A

Massive transfusion

231
Q

Mx of fluid overload from blood transfusion?

A

slow transfusion

O2 + frusemide 40mg IV

232
Q

Who is vulnerable to Allergic reactions following blood transfusion?

A

recipient IgA deficiency

with anti-IgA antibodies

233
Q

Mx of haemolytic reaction following transfusion?

A

stop transfusion

tell lab

keep IV open w Normal saline

tx DIC; FFP, Pl

234
Q

features of aplastic anaemia?

A

Pancytopenia

hypocellular marrow

Age: 15-24 or >60

anaemia, infections, bleeding

235
Q

Causes of aplastic anaemia?

A

inherited:

Fanconis anaemia

Dyskeratosis congenita: premature ageing

Swachman- Diamond synd

acquired:

Parvovirus B19

Drugs- Carbamazepine, Carbimazole, Chloramphenicol

Autoimmune: SLE

236
Q

Biopsy of temporal arteritis is -ve. do you keep pt on Steroids?

A

Continue

Skip lesions occur in giant cell arteritis and may show a normal biopsy

237
Q
A

keratoderma blenorrhagica (waxy yellow/brown papules on palms and soles)

seen in reactive arthritis

also see circinate balanitis

238
Q

What is Felty’s syndrome?

A

splenomegaly + neutropenia + Rheumatoid arthritis

239
Q

Serum monoclonal protein and or BM plasma cells ≥10%

no CRAB

A

Smouldering/ Asymptomatic myeloma

240
Q

Serum monoclonal protein <30g/L

Clonal BM plasma cels <10%

no CRAB

A

MGUS

monoclonal gammopathy of unknown significance

241
Q

Monoclonal igM band

hyperviscosity: CNS + ocular symptoms

Lymphadenopathy + splenomegaly

A

Waldenstroms Macroglobulinaemia

242
Q

Ix of Waldenstroms Macroglobulinaemia?

A

high ESR

IgM paraprotein

243
Q

Solitary bone/soft tissue plasma cell lesion

Se or urinary monoclonal protein

Normal BM and normal skeletal survey (except lesion)

No CRAB

A

Solitary Plasmacytoma

244
Q

What is AA Amyloidosis?

A

amyloid derived from serum Amyloid A (an acute phase protein)

ie. in chronic inflammation:

RA, IBD, chronic infection - TB, bronchiectasis

245
Q

features of AA Amyloidosis?

A

Renal: proteinuria and nephrotic syndrome

hepatosplenomegaly

246
Q

What is AL Amyloidosis?

A

Clonal proliferation of plasma cells w production of amyloidogenic light chains

primary

secondary to myeloma, waldenstroms, MGUS, lymphoma

247
Q

Features of AL Amyloidosis?

A

Renal: nephrotic syndrome

Heart: restrictive cardiomyopathy, arrhythmias, echo

Nerves: peripheral and autonomic neuropathy, carpal tunnel

GIT: macroglossia, malabsorption, perf, haemorrhage, hepatomegaly, obstruction

Vascular, periorbital purpura (characteristic)

248
Q

what type of cardiomyopathy does amyloid cause?

A

restrictive cardiomyopathy

249
Q

Diagnostic feature of Ank Spond on imaging?

A

Plain x-ray of the sacroiliac joints is the most useful investigation in establishing the diagnosis.

250
Q

A 45-year-old lady, with a past medical history of rheumatoid arthritis, is scheduled to have a laparoscopic cholecystectomy. What imaging should be performed pre-operatively?

A

AP and Lateral cervical radiographs

Atlantoaxial subluxation is a rare complication of rheumatoid arthritis, but important as it can lead to cervical cord compression. Anteroposterior and lateral cervical spine radiographs preoperatively screen for this complication, ensuring the patient goes to surgery in a C-spine collar and the neck is not hyperextended on intubation.

251
Q

mx of neutropenic sepsis?

A

Sepsis Six protocol A->E

senior support

Start Broad spec abx: local guidelines e.g. piptazobactam

Consider G-CSF

252
Q

Features of Hyperviscosity?

A

CNS: headache, confusion, seizures, faints

Visual: retinopathy -> visual disturbance

Bleeding: mucous membranes, GI, GU

Thrombosis

253
Q

Mx of hyperviscosity due to leukaemia?

A

leukopheresis

254
Q

What is Tumour Lysis Syndrome?

A

massive cell destruction

high K, high urate -> renal failure

Prevention: increase fluid intake + allopurinol

255
Q

what is DIC?

A

Widespread activation of coagulation from release of pro-coagulants into the circulation.

Clotting factors and plats are consumed → bleeding

Fibrin strands → haemolysis

256
Q

Mx DIC?

A

Tx cause

Replace: cryoprecipitate, FFP

Consider Heparin and activated protein C

257
Q

Schobers test in Ank Spondy

what is +ve?

A

limited lumbar flexion

<5 cm

Schober’s test is performed by identifying L5, and then marking 10cm above and 5cm below this point whilst the patient is stood upright. The patient is then asked to bend forwards to touch their toes whilst keeping their knees straight. If <5 cm-> reduced flexion of the lumbar spine, which is a sign of ankylosing spondylitis.

Medicine (16 decks)

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