Rheum / MSK Flashcards

1
Q

Osteoporosis risk factors

A

SHATTERED Family

Steroid use >5mg/day prednisolone
Hyperthyroidism; hyperparathyroidism, hypercalciuria
Alcohol and tobacco use
Thin (BMI <22)
Testosterone low (e.g. anti androgen in cancer of prostate)
Early menopause
Renal or liver failure
Erosive/inflammatory bone disease (e.g. RA or myeloma)
Dietary Ca low/malabsorption or Diabetes mellitus type 1

Family history

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2
Q

Back pain history

A

SOCRATES

Early morning

Red flags
- Feel when wiping
- Urinary retention / incontinence
- Bowel incontinence
- Pain + weakness in legs

Weight loss
Bowel habit

Trauma - even minor falls
OP risk factors

Band like pain round chest or abdo

Infective - Fevers / Night sweats

Social
Alcohol
Smoking
IVDU

PMH
HIV
Immunosupression
Diabetes
Previous back surgery

DH
- Steroids
- Immunosupressives
- Any NSAIDs - important for Ank spond

FH
IBD
Psoriatis

Social
How affecting function and work
Smoking - especially for inflam back pains

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3
Q

Ank spond additional features to ask about

A

All the other seroneg arthritis

Skin rash - psoriasis
IBD / bowel symptoms
Recent infection / STI
Anterior uveitis
Enthesitis - Achillies / golfers / tennis elbow / plantar fasciitis

SOBOE
Pain ful red eyes
Frothy urine
pain achilies

AAAAAAs of ank spond
- Aortic regurg
- AV block
- Anterior uveitis
- AA Amyloidosis - Nephrotic syndrome
- Achilles tendonitis
- Apical pulm fibrosis

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4
Q

Which are the segregative arthritis

A

HLA B27

Psoriatic arthritis
Enteropathic - IBD
Ank spond
Reactive arthritis

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5
Q

Score for symotoms in Ank Spond

A

BASDI score
Bath Ank Spond disability index score

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6
Q

Main breathing issue in Ank Spond

A

Restrictive breathing defect

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6
Q

Exam of inflam back pain eg ankle

A

Hands nail pitting

Squeeze of joints

Spinal movements
Forward / back / side / twist
Schobers test

Spinal palpation
Precuss spine

Listen to heart and lungs
Chest expansion

Hip flexion / extension

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7
Q

How do you do schobers test

A

Draw a line between dimples

Draw line 10cm above and 5cm below

then bend foward and measure lumbar spine movement

Should be >10cm
If <5 likely pathological;

5-10cm intermediate

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8
Q

Ank spond Ix

A

ECG - AV block

Renal dip - protein -> ACR

CXR - fibrosis / failure

FBC / CRP evidence of infection

Consider HLAB27

If peripheral arthopathy
CCP / ANA / RF

Imaging
- XR sacroiliac joints
- MRI more sensitive but less specific

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9
Q

Management of Ank spond

A

Physio stretching

Education

NSAIDS x2 -> Anti-TNFa

If peripheral disease - DMARDS eg methotrexate / sulphasalazine

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10
Q

Discitis key risks

A

IVDU

Immunosuppressed

TB - ever treatment or from endemic area

Brucella - Mild / unpasterised cheese
- Farmers / vets (vets as aerosol from placenta high risk)

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11
Q

Myotonic dystrophy inheritence? what is it? Gene?

A

Autosomal dominant

-> Muscle weakness and myotonia (Inability of a contracted muscle to relax )

Type 1 - CTG repeat with anticipation
Type 2 - different gene, less anticipation more proximal weakness

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12
Q

What is myotonia

A

Inability of a contracted muscle to relax

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13
Q

Myotonic dystrophy exam CNs? Limbs? Extra bits?

A

Frontal balding
Bilateral and symmetrical ptosis
Facial muscle weakness
Cataracts

**CN exam **
-Eye movements usually normal
-Muscles of face tend to be wasted and weak
-Test for myotonia - ask patient to hold eyes tight shut for 10 seconds and they will struggle to re open
- Speech tends to be dysarthria
- Ask about swallowing

Fundoscopy to assess for cataracts

Test visual acuity

Limbs
Tone tends to be reduced
Distal weakness eg footdrop

Ask to grip hand for 5 seconds tight then relax- if myotonia they will struggle
Precussion myotonia - precuss thenar eminence -> involuntary thumb flexion

Additionals
Cataracts

Heart -
- Pulse for rate and rhythm - I would like an ECG
- Check for PPM / ICD

Endocrine
- Check for diabetic fingerprick marks
- Check for gynaecomastia
- State would perform scrotal exam for hypoplasia

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14
Q

Myotonic dystrophy differentials

A

If ptosis unilateral
-> CN III palsy / Horner’s syndrome

Bilateral ptosis
- Myaesthenia / congenital ptosis

Myotonic
Mytonic congenita
Hypokalaemic periodic paralysis

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15
Q

Investigations myotonic dystrophy

A

Bloods
CK
b12 /
Genetic testing - gold standard

EMG - ‘dive bomber’ poentials

Cardio complications - ECG + ECHO
Overnight pulse oximetry / sleep studies
Screen Thyroid function / diabetes / testosterone
Visual testing - ref to opthal if cataract

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16
Q

Management of myotonic dystrophy

A

No cure - MDT conservative
SLT / dietetics
Physiotherapy
Genetic counselling - 50% risk of kids
Palliative care if deteriorating - life expectancy around mid 50s

Annual review
- Test visual function for cataracts
- ECG if abnormal for cardio / PPM if heart block
- OSA

Drugs
Mexiletine (Na channel blocker) for management of myotonia

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17
Q

Rheum Arthritis painful hands history

A

Tell me a bit more about it

Early morning stiffness > 1 hour each morning
Duration of symptoms (≥ 6 months)

Pattern of joint involvement (symmetrical / asymmetric, small joint / large joint, oligo/polyarthritis)
expect small joint symmetrical

Constitutional symptoms
-Fever
-Malaise
-Lymphadenopathy

Extra-articular manifestations
Episcleritis (painless) and scleritis
- Have you ever noticed that your eyes are red?
- Have you ever had pain in your eyes?
Interstitial lung disease
-Do you feel breathless when you walk?
- Have you had a cough which has not gone away?
** Rheumatoid nodules
- Have you noticed any unusual bumps on your skin?
** Raynaud’s phenomenon

- Have you noticed your hands changing colour in the cold?
Glomerulonephritis
- Have you ever noticed blood in your urine?
Systemic vasculitis
- Have you noticed any rashes anywhere on your body?
- Have you noticed any unusual bruises on your body?
- Any skin ulcers?
Mononeuritis / polyneuropathy
- Have you noticed any tingling in your hands or feet?
- Have you noticed any weakness in your hands or feet?

Rule out other disorders
Connective tissue disease
- Systemic lupus erythematosus – mouth ulcers, alopecia
- Mixed connective tissue disease – tightening of skin over digits
Arthritides
- Psoriatic arthritis – itchy plaques on extensors
- Polyarticular gout – asymmetric involvement, precipitants (meat, alcohol, diuretics)
- Osteoarthritis – gets better with activity
- Enteropathic arthritis Change in bowel habit

Screen for complications
[Rhem SOFAA]
Secondary amyloidosis
– nephrotic syndrome
Osteoporosis
- Have you ever fractured a bone?
- How did this happen?
Felty’s syndrome (neutropaenia, splenomegaly + RA, usually > 20 years)
- Have you noticed any fullness in your tummy?
- Do you feel you are getting the flu more often than usual?
Atlanto-axial subluxation
- Is there any pain at the back of the head or neck?
- Have you ever experienced the room spinning around you?
Anaemia
- Do you feel tired?
- Do you get any chest pain or short of breath when you walk?
Carpal tunnel syndrome
- Do you notice any tingling in your thumb or index finger?
- Do you have any problems using your thumb?

Functional status
- How is this affecting your life?
- Make sure you ADDRESS CONCERNS
- Are you able to do things like unlock a door with a key or uncap a bottled drink?
- Do you have any difficulty with buttons?

Social history
- Smoking - makes much worse
- Alcohol - consider gout

DH
- Tried any thing to help?
- Gp prescribed anything?

Familty historu
- Any inflammatory conditions / arthritis

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18
Q

Common drugs used for Rheum A and thier main complications? Best for pregnancy?

A

Steroids – exogenous Cushing’s, osteoporosis, cataracts, weight gain

Methotrexate – pulmonary fibrosis, marrow suppression

Sulphasalazine – rash, funny coloured secretions eg eye / urine…
- Best for pregnancy

Hydroxychloroquine – retinitis, need screening within 6 months

Lefulamide - Hangs in body for 2 years -> may need to have cholestryramine washout if pregnant

Biologics – opportunistic infections

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19
Q

Difference in joints affected in hand of psoriatic vs rheum arthritis

A

Rhem more MCP and PIP

Psoriatic more DIP

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20
Q

Rheum patient presents with breathlessness. Key things to screen in history?

A

Extra articular pulm fibrosis

Methotrexate therapy

Anaemia
- Chronic disease
- NSAIDs / GI symotoms

Infection
Immunosupressed
- Felty syndrome
- Medication related

Lymphoma
- Fever weight loss night sweats

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21
Q

Rheumatoid hand exam

A

Ask if any particular pain first

Inspection:
- Vasculitic lesions
- Nail fold infarcts
- Wasting of the small muscles of the hand
- Swollen joints and their distribution
- Symmetry
- Deformities of rheumatoid hand:
- Rheumatoid nodules (usually over extensor surfaces of elbow and finger joints)
- Scars suggesting previous decompression of carpal tunnel / tendon release
- Look for active synovitis
- Ulnar deviation at MCP / swan neck / Boutonnier

Palpate
- Ask if any joints are painful again
- Examine each small joint of the hand, then the other joints in turn

Function
Power
- Make a fist
- Squeeze my fingers as tight as possible
- Make a ring with index and thumb and then I do same and pull
Function
- Do up a button
- Write with a pen
- Prayer sign / reverse prayer sign
- Put your hands behind your head

Extra-articular manifestations
- Look at eyes for scleritis / episcleritis
- Listen for fine basal crepitations of interstitial lung disease
- Listen for aortic regurgitation

Complications
- Conjunctival pallor
- Test forward flexion and extension of the cervical spine
- Look for evidence of exogenous Cushing’s
- Check for cataracts secondary to steroid use
- Tinnel’s test for carpal tunnel syndrome

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22
Q

What are the deformities seen in rheumatoid hand

A

Swan neck deformity: hyperextension of PIPJ with flexion at DIPJ and MCPJ

Boutonnier’s deformity: flexion at PIPJ with hyperextension of DIPJ and MCPJ

Z deformity of thumb: hyperextension of IPJ, fixed flexion and subluxation of MCPJ
Ulnar deviation of fingers
Subluxation of MCPJ

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23
Q

Rhem differential differentials

A

Small joint polyarthritis
- Rheum most likely

Seronegative
- Psoriatic, more likely DIP + nail changes
- Enteropathic - GI symptoms / mount ulcers usually affects a larger joints
- Reactive - Eye signs, urethitis (though 50% dont get symptoms
- Ank spond - Alternating buttock pain
- Gout - especially big toe and tophi
- Calciumpyrophospate deposition

Osteoarthitiis
- Especially if lack of inflammatory symptoms

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24
Q

Rheum investigations

A

FBC
- Anaemia
- Raised platelets (inflammation)
- Neutropenia eg felty
ESR / CRP
- U&E / LFTs - drugs
- Rheumatoid factor + Anti-CCP (disease progression)
- Consider ANA / ANCA especially if rash on face / connective disease symptoms
- Consider HLA B27 if history unclear

Protein Dip / Albumin creatinine ratio

Plain XRs of hands and feet as baseline
- May affect how aggressive treatment if erosions

25
Q

Rheumatoid factor is what

A

IgM antibody to FC portion of IgG
-Not specific, and actually more prevelant in sjorgrens syndrome

26
Q

Management of Rheumatoid

A

MDT from begining
- Physio for joint function
- OT (50% not in same job at 2 years)
- Scoring systems
- Patient groups / support groups

Disease Activity Score for symptoms to help direct management / response to treatment

Medications
- Usually trial of NSAIDs + PPI / paracetamol
- Steroids especially if symptoms for 3 months already
DMARDS
- Methotrexate first line usually + folic acid
-

26
Q

Patient treated for rheum A comes in after treatment for UTI completely run down ….

A

Given trimethropim and on methotrexate -> myelosupression

27
Q

DMARD best for preg and breast feeding in rheum A

A

Sulphasalazine

28
Q

Biologics in Rheum? screening?

A

Anti- TNF
- Etanercept, Adalidumab, Infliximab
- Screening for TB / BBV
- High risk for infection
- Keep vaccines eg flu / pneumococcus updated

Anti CD20
- Rituxumab

Anti - IL6
- Toculizamab

29
Q

Renal impairment in Rheum - what do you need to screen?

A

Use of NSAIDs -> intersitial nephritis

Renal toxicity in DMARDs eg Methrexate (may need dose reduction)

Glomerulonephritis in other autoimmune disease

AA Amyloidosis due to chronic inflammation

30
Q

What would signify poor prognosis in Rheum A

A

RF / CCP / HLA-DR4 positive

Erosive disease early

Female

31
Q

Systemic sclerosis history

A

Raynauds
- Are your fingers more sensitive to the cold. Do you get any skin colour changes
- May affect toes / ears / nose

Skin
- Sclerodactyly - skin thickening
- Puffy fingers
- Calcium nodules
- Telangectasia New red vessles on hands

GI - replacement of luminal wall with fibrosis
- Oesophageal dysmotility- Reflux / vomiting
- Gastroparesis
- Small bowel overgrowth - bloating / diarrhoea

Pulmonary fibrosis
- Worsening SOBOE
- Dry cough

Cardiac
- Syncope - conduction disturbance
- Angina - accelerated atherosclerosis
- Sob / swelling of ankles secondary to pulm hypertension

Erectile dysfunction

Renal
- Any rise in usual blood pressure

Arthralgia / muscle pain

Social
- How does raynauds affect work / life
- Increased in silicon mining etc
- Smoking - much more rapid fibrosis / vascular disease

PMH
- Autoimmune / Ca

DH
- Other autoimmune eg levothyroxine
- Prev cytotoxic
- Any other drug use eg cocaine

FH
- Autoimmiune

32
Q

Causes of raynauds

A

Primary idiopathic

Autoimmune

Carpal tunnel

Cushings

Hypothyroidism

Drugs
- Cytotoxic chemo microvascular damage
- Drugs for ADHD

32
Q

Primary vs secondary raynauds

A

Primary
- Starts around menarche

Secondary
- Features of autoimmune
- Later in life 20+
- involves thumb

32
Q

3 main Antibodies in sclerosis

A

Anti-centromere
- Limited cutaneous
- More vascular injury / raynauds / ulceration

Anti SCL-70
- Significant lung fibrosis
- Pulm HTN

RNA polymerase 3
- Ealy rapidly progressive diffuse
- Lots of liung fibrosis
- Highest risk for renal crisis

32
Q

Unilateral raynauds?

A

Subclavian steal possiblity

32
Q

Limied vs systemic systemic sclerosis? Why differentiate

A

Limited
- Skin changes limited to face, fingers and hands

Diffuse
- Proximal to elbows / knees

Prognosis is different
- Diffuse tend to have more significant GI / pulmonary disease
- Limited more severe hand disease eg raynauds -> ulcerating

32
Q

Systemic sclerosis management

A

Patient education
Regularly meaure blood pressure - monitor for renal crisis

33
Q

Systemic sclerosis exam

A

Hands
- Feel temp of hand towards finger tips
- Sclerodactyly / ppuffy
- Evicence previous ulcers (pits on end of fingers)
- Telangectasia - small dilated capilaries (grow in areas of localised hypoxia)
- calcinosis lumps on palpation
- Look in nail folds for dilated capilaries

Feel bilat pulses
- Unilateral would include large vessle vasculitis

BP - renal crisis

Neck
JVP

Face
- Ask to examine things on face
- Ask for mouth opening

Lungs auscultaion
Fibrosis

Feet
- Leg swelling
- Ulcers on toes

Consider skin changes indicating diffuse

34
Q

Systemic slcerosis differentials

A

Raynauds + pulm fibrosis
- Rheum arthritis - Often a clinical overlap between too
- Polymyositis / dermatomyositis - Significant myositis / weakness
- Lupus - Malar rash

Unilateral raynauds
- Thoracic outlet obstruction
- Large vessle vasculitis

Signifcant smoking history
- Beurgers disease

35
Q

Systemic sclerosis investigations

A

Bedside
- BP / urine dip - renal crisis
- Oxygen sats - especially on exertion
- ECG - conduction disturbance / RHS

Bloods
- FBC (anaemia), renal funcion, thyroid function, inflammatory markers, CK if muscles
- Consider ProBNP if ?pulm htn
- ANA / antibody profile (centromere, scl-70, RNA polymerase)

Nailfold capiliroscopy
- Few areas on body where you can directly visulise capilarie
- Get signifcant capilary drop out and large capilaries

Consider CXR

If pulm fibrosis - HRCT
Lung funciton tests

Echo if RHS

Unlikely go for barium swallow / OGD unless refractory symptoms

36
Q

Systemic sclerosis management

A

Patient education
MDT
- Dietician / palliative care
- Resp / GI / cardio input

Yearly monitoring
- Echo
- Pulm function tests

Medical
Reflux - PPI
Small bowel overgrowth - cyclical Abx
Raynauds - nifedipine
Pulm HTN - sildenafil (also works for raynauds)
Fibrosis - immunomodulatory (anti cd20 - rituxumab, anti IL6 - Toculizumab) + ninetanib

Early diffuse high risk disease
- Consider stem cell transplant (10% mortalty)

36
Q

Pulm function tests in Pulm HTN?
Pure fibrosis ?

A

Pulm HTN
- FVC preseved
- TLco reduced

Pulm firbosis
- Restrictive
- TLco falls with FVC

37
Q

Critical distal ischemia / pulm HTN drug

A

IV ilaprost

38
Q

Systemic sclerosis - what immunomodulary drug do you avoid

A

STEROIDS
- may precipitate renal crisis
- especially if anti-rna polymerase 3

38
Q

What causes renal crisis in systemic sclerosis? Rx?

A

Vasospasm of renal arteries
-> kidneys produce lots of renin to raise BP
-> viscious cycle

Treat with ACEi

39
Q

GCA history key bits

A

HPC
- Explore general headache questions
- Unilateral headache subacute onset
- Pain on palpation of side of head
- Fever / rash / night sweats
- Jaw claudication / tongue pain
- Any changes in vision

PMH
- polymyalgia rheumatica - early morning pain in shoulders / hips

DH
- Steroids for other reasons

Family history
- increased risk if first degree

Social history
- Smoking bad
- Alcohol
- Work / function

40
Q

GCA investigations

A

GCAPS risk score

Bedside
- Observations including BP in both arm

Bloods
- FBC (anaemia / thrombcytosis) / LFTs (often rise in ALP) / renal function
- Inflam markers espectially ESR
- Consider myeloma screen
- consider vasculitis screen
- Calcium, vit D, HBA1C if for long term steroids

Imaging
Temporal artery US

Special
Temporal artery biopsy - if unclear / negative US with suspicious history

41
Q

Focused exam in GCA

A

Palpate temporal arteries

Cranial nerves especially eyes

Palpate pulses BP both sides

Consider Auscultate heart
- AR in dissection

42
Q

GCA differential diagnosis

A

Classic history of GCA
Mimick
- Tempomandibular joint dysfunction
- Migraine (unusual in elderly)

Infection

Fever - any infective / neoplastic cause

43
Q

US of temportal artery in GCA

A

Non compressible halo sign
- marker of inflammation

[May mimmick if atherosclerosis]

44
Q

GCA management how long steroids?

A

Any visual involvement
- Opthalmology review prior to rheum

Acute
- PPI + Pred 40mg / day.
- If opthal / jaw claudication / tongue claudication / prominent temporal arteries - > 60mg
- would expect response around 24-36 hours
- Likely for 12-18 months

Adcal d3 + alendronic acid

45
Q

GCA relapse on Pred next steps

A

Consider methotrexate / leflunomide

[After anti-IL6 eg toculizumab]

46
Q

How swollen monoarthropathy key differentials - additionals in history

A

Time frame

Septic / crystal
- Fevers, CRP and pain are not specific for either

Reactive
- urethitis
- Uveitis
- Sexual history
- Recent illness

Psoriatic - CRP often very low
- History of rashes
- Often previous joint

Haemarthorsis
- Hx trauma

DH
- Anticoagulation
- Diuretics
- Immunocompromised

PMH
- Joint replacement or metalwork eg heart valves anywhere in the body
- Recent infection/catheter (bacteraemia)
- CKD
- Immunocompromised

SH
- Smoking
- Meat, shellfish, fizzy drinks, alcohol
- Overweight - biggest risk factor for gout
- IVDU

47
Q

Hot swollen joint exam

A

Examine the joint

Then examine elbow - tophi
Hands / behind ears - tophi / psoriasis

48
Q

How swollen joint what is your differential

A

Septic arthritis most important
Gout pseudogout
Reactive arthritis
Autoimmune - psoriatic
Consider TB and haemarthrosis

Would be very unlikely to be rheumatoid

49
Q

How swollen joint investigations

A

Joint aspiriation is the most important investigation ideally before antibiotics

Bedside set of obs fever / septic

Bloods - inflam markers including platelets
Blood culutres
Uric acid - if raised likely to be significant as usually reduced in inflammation. Low does not rule out gout
[Consider RF & ccp, HLAB27 (reactive/psoriatic/ank spond),]

Xrays - calcification / destruction

50
Q

What would make you not want to aspirate a hot swollen knee?

A

Lots of overlying cellulitis

Previous replacement - as if introduce infection will likely need a whole re-do

Uncontrolled anticoagulation

51
Q

If the joint aspirate has crystals does this rule out septic arthritis

A

NO
Septic arthritis affects damaged joints eg gout