Rheumatology Flashcards

Question

Name some non-inflammatory causes of diffuse arthralgia and myalgia.

Answer 1

- fibromyalgia - benign hypermobility syndrome - OA - hypothyroidism - oestomalacia - multiple myeloma

Answer 2

- PMR - giant cell arteritis - SLE - Sjogren syndrome - Polymyositis

Answer 3

FBC, ESR, CRP, CK, thyroid function, serum electrolytes, creatinin, ferritin, BSL, liver biochemistry

Answer 4

- DDx: rheumatoid or reactive arthritis - Most cases of viral arthritis resolve spontaneously within 12 weeks - Investigations: FBC, ESR/CRP, RF, anti-CCP, ANA, serum uric cadi, liver biochem, creatinine and urinalysis, viral serology

Answer 5

- smoking cessation - NSAID + paracetamol - fish oil 2.7g daily (may take up to 3 months to take effect) - if severe may need to start prednisolone prior to specialist review however this may delay diagnosis (5-15mg daily)

Answer 6

- - lateral epicondylitis - first line = referral to physio - steroid injection may assist analgesia for 4-6 weeks however worse outcomes at seen than in comparison with the "wait and watch"/physio group - generally a self limiting inflammation which can last up to 12 months - occurs from chronic micro trauma

Answer 7

- most common = patellofemoral pain syndrome - usually due to poor foot biomechanics, patella alta or variation in femoral trochlea shapes - DDx: osgood schlatter, sindig larssen johansen, patella tendon pain, synovial plica pain XR is always warranted

Answer 8

Sinding-Larsen-Johansson (SLJ) syndrome is pain at the bottom of the kneecap (patella). It is caused by swelling and irritation of the growth plate there.

Answer 9

Osgood Schlatter

Answer 10

Calcanela apophysitis Inflammation of growth plate in heel Treatment is avoiding activity!

Answer 11

A) distal radiaus epiphyseal pain B) medial epicondyl avulsion or osteochronrosis of elbow capitellum (Panner's disease) C) rib stress factures D) pars interarticularis stress fractures E) pelvic apophyses irritation, sever's disease

Answer 12

- painful effused knee - in severe forms cartilage may seperate with or without associated bone and become a losse body in the knee - commonly associated with medial condyl of femur "Joint condition in which bone underneath the cartilage of a joint dies due to lack of blood flow. This bone and cartilage can then break loose, causing pain and possibly hindering joint motion"

Answer 13

- increase: aspirin, diuretics, especially thiazides - lower: fenofibrate, losartan, atorvastatin, CCB If able avoid HCT in patients with gout and hypertension

Answer 14

- common causes: infection, trauma and crystals - in setting of septic arthritis XR no role as destructive changes only become apparent after 10-14 days

Answer 15

Spondyloarthritis! - ankylosing spondylitis - psoriatic arthritis - reactive arthritis - enteropathic arthritis - seronegative arthritis

Answer 16

ACUTE RHEUMATIC FEVER

Answer 17

- FBC, ESR, CRP - antistreptolysin-O titre (ASOT) - ferritin, if \> 1000 likely systemic arthritis - e/LFT - connective tissue: ANA, dsDNA, ENA - urinalaysis - plain XR if bony changes suspected: perthes, OM, - US if suspect synovitis

Answer 18

1. systemic corticosteroids 2. conventional synthetic DMARDs 3. biological DMARDs 4. targeted synthetic DMARDs

Answer 19

- azathioprine - cyclophosphamide - hycroxychloroquine - methotrexate - sulfasalazine

Answer 20

Abacept, adalimumab, infliximab, rituximab

Answer 21

csDMARD - TPMT genotype testing because 1:300 individuals have homozygous genetic mutation which leads to severe myelosuppression if dosing is not reduced Note: FBC should be done veery 2 weeks during dose changes and then every 4-6 weeks once stable dose achieved

Answer 22

- peptic ulcer disease or UGIB - GRF 30, avoid long term use if GFR 30-60 - liver cirrhosis - avoid if possible in patients with established CVD

Answer 23

Celecoxib Meloxicam Etoricoxib

Answer 24

Highest = diclofenac Lowest = naproxen and potentially low dose celecoxib

Answer 25

Anti-dsDNA, anti-phospholipid antibodies, C3 & C4 complement levels

Answer 26

Naproxen 500mg BD for 7 days

Answer 27

A) transient hip synovitis, acute myositis, toddler's fracture, DDH B) transient hip synovitis, acute myositis, DDH, Perthe's C) Stress fractures and sprains, traction apophysitis (OGS or Sever's), SUFE ALL AGES Infection: OM/septic arthritis, bursitis, discitis, epidural collection Trauma NAI Malignancy: bone, haematological, soft tissue Immuno/Rheum: reactive arthritis, autoimmune, HSP, vasculitis, GBS Functional Intraabdominal pathology

Answer 28

- \> 7 days duration - history of fall, trauma or injury - severe localised joint pain (septic) - change to urinary or bowel habits - inability to walk/weight bare - nocturnal pain/symptoms - systemic symptoms: fever, sweats, rash - constitutional symptoms: fatigue, weight loss, anorexia - recent viral infection

Answer 29

4 criteria = fever \> 38.5, non weight baring, WCC \> 12, ESR\>4- or CRP \>20 0 = low 1 = very low 2= moderate (refer) 3 or 4 = very high (refer)

Answer 30

Benign acute childhood myositis - seen in school afted children recovering from URTI - more commonly seen in boys - can present in tip toe walking - rhabdo uncommon but serious complication, should always due urine analysis

Answer 31

- idopthaic inflammatory myopathy characterised by muscle weakness and skin changes - uncommon but up to 25% of cases are associated with malignancy - triggers: medications, malignany, viral infections, silica exposure - clinical features: face rash is common - "heliotrope rash": biltera lilac discolouration of eyelids and welling - "shawl sign" - fixed redness affecting chest/neck and back - Gottron papules: purple papules and plaques on top of small joints of the hands - Gottron sign: redness ove rback of hands, elbows and knees

Answer 32

- heliotrope rash of face - shawl sign on shoulders/chest - gottron papules - gottron sign

Answer 33

Muscle enzymes:: CK, AST and LH Antibodies: anti-Jo, anti-OJ, enti EK , anti KS, antzo DDx - SLE or connective tissue disorder Management - steroids or immunosuppression

Answer 34

- symptoms: burning sensation to outter side of thigh - involving entrapment/compression of lateral femoral cutaneous nerve - treatment options may include weight loss and wearing loose clothing

Answer 35

- short leg walking cast or boot for 6 weeks, with follow up every 2-4 weeks - healing time up to 6 weeks

Answer 36

- short leg walking cast or moonboot for 6 weeks, follow up every 2-4 weeks - healing time of 6 weeks

Answer 37

Short leg walking boot for 2 weeks with progressive mobility and ROM as tolerating - follow up every 2-4 weeks - healing time 4-8 weeks

Answer 38

- proximal fifth metatarsal # - short leg NON weightbaring for 6-8 weeks - if evidence of healing at 6-8 weeks start gradual weight baring - if no evidence of healing continue immobilsation for 4 weeks - healing time 6-12 weeks

Answer 39

- bony tenderness at base of 5th - bony tenderness at naviclar - inability to weight bare immediately after the injury and at time of examination

Answer 40

- often seen in sports with alot of running or jumping - swelling and pain typically 2-6 cm from tendon insertion into calcaenus - provocative tests: single heel raise (low load), hopping on affected leg (high load)

Answer 41

- often in sports with jumping suhc as volleyball, basketball, netball - patella tendon origin is at lower power of patella and this is where tenderness is felt - provocative testing: squat on feet on declining surface (low load), high single leg jump or landing from height (high load)

Answer 42

- avoid complete rest but also avoid high loads on tendon i.e. jumping - substitute isometric exercises and increase load as pain improves - nil good evidence for PRP at this stage - can take up to 4 mnoths or longer to improve

Answer 43

- seocnd most comon running injury - most common cause of lateral knee pain in runners - associated with cycling - due to friction not a tendinopathy - focal tenderness over condyle, place pressure over condyle and move knee through 30 deg of flexion will reproduce pain - management = avoidance of aggravating activities for 4-6 weeks, ice and NSAIDs may help - ITB stretches to be held for 30 sec and repeated 5 x each session 3 times a day

Answer 44

Shin splints! - exercise induced pain along miedle to distal posterio-medial aspect of tibia - pain may be particularly related to heel strike - pain is felt on hopping or jumping - management: reduction in training load until pain resolves - alternative activities = cycling, swimming, deep water running - DDc; chronic exertional compartmet syndrome of deep posterior compartment can present with medial tibial pain

Answer 45

Gout - \<0.36 Gouty tophy \<0.3

Answer 46

May have ongoing flares for 12-18 months despite having target urate level

Answer 47

- NSAIDs OR - cholchicine (1.2mg followed by 0.6mg 6 hours later and then 0.6mg daily or BD for 2-3 days - steroids should be reserved for those who cannot have NSAIDs (0.5mg/kg prednisolong for 5-10 days or intraarticular steroid injection)

Answer 48

NO! This means therapeutic benefit will be lost and urate level will increase again

Answer 49

No - 2 x small recent studies suggest allopurinol can be started during an acute flare with symptomatic management

Answer 50

5-100mg per day, less in renal impairment - should uptitrate this to reach urate targets - should titrate every 2-5 weeks Example: 100mg daily for 2 weeks increase to 200mg daily for 2 weeks and then 200mg daily for 2 weeks with a repeat urate at this stage

Answer 51

900mg daily

Answer 52

allopurinol hypersentivity syndrome - patients of Asian descent - renal impairment - presence of human leucocyte antigen (HLA)-B\*5801 - rare and potentially fatal: desquamating rash, fever, hepatitis, eosinophilia and deteriorating renal function - often seen within first 3 months of treatment

Answer 53

- NSAID, naproxen: 250mg BD OR - Colchicine: 0.5 - 1mg per day American College of Rheumatology suggests prophylaxis sfor at least 6 months duration or three months after reaching target serum urate if nil tophi (or 6 months after if tophi present)

Answer 54

- 6 monthly urate tests to ensure adequate management and adherence

Answer 55

- low dose allopurinol 1.5mg/ml of GFR with very gradula up titration (25-50mg per month) - could consider low dose febuxostat

Answer 56

There isn't any!

Answer 57

- purine rich foods (meat/seafood), alcohol, fructose containing drinks - disorders of high cell turnover (haematological malignancy, psoriasis) can also increase serum ruic acid - drugs: thiazides, aspirin, loop diurectics, ciclosporin

Answer 58

- joint aspiration with identification of monosodium urate crystals

Answer 59

1. local corticosteroid injection 1. NSAID for 3-5 days 1. prednisolone 15-30mg daily for 3-5 days 2. colchicine 1mg orally and then 500mcg 1 hour later as a single day course

Answer 60

Calcium pyrophosphate deposition is seen in older patinets with men age between 65=75 - causes crystallisation in joints and is the most common cause of chondrocalcinsosis - most commonly affects knee and wrist - can be accompanied with fever and mimic septic arthritis - diagnosed through joint aspiration - management: intraarticular steroid, consider NSAIDs, steroids and colchicine if needed

Answer 61

- aerobic exercise with functional and progressive lower limb muscle strengthening is recommended - strengething and aerobic exercsie should be undertaken at least 3 times a week - also suggest balance traning to reduce falls - there is evidence for land based exercises including Ta Chi and water based exercise like aqua aerobics - weight loss is recommended, tager 5% reduction

Answer 62

- Evidence suggests that acupuncture, transcutaneous electrical nerve stimulation (TENS), lateral heel wedge insoles, manual therapy, magnets and valgus braces are not effective in the management of osteoarthritis. - CBT and psychology may be helpful in assisting patients to manage their pain

Answer 63

- topical NSAID QID - capsaicin application 3-4 times a day - paracetamol and NSAID if appropriate - duloxetine may reduce pain - 30mg daily for 1 week and increase to 60mg (max 120mg daily)

Answer 64

- glucosamine, fish oil and chondroitin - recent study has show fish oil may have some role in pain relief - nil evidence to support glucosamine or chondroitin

Answer 65

- alphaviruses: RRV, BFV, chikungunya - flaviviruses: dengue, zika, yellow fever - parvovirus B19 - rubella - hepatitis B and C - HIV Most causes of viral arthritis are self limiting and don't require investigation

Answer 66

- largely clinical diagnosis - generally presents as symmetrical polyarthritis - typically will also have myalgia, fever, headache and red eyes - maculopapular rashes also common - generally arthritis symptoms peak ~1-2 weeks and are largely resolved by 6 weeks - main ddx is early rheumatoid, however this will persist \>6 weeks - monoarthritis is very rarely viral!

Answer 67

- inflammatory arthropathies - ankylosing spondylitis, reactive arthritis, enteropathic arthritis, psoriatic arthritis - these all share clinical and radiological features - clinical features in peripheral joints, spine, enthese, skin, GIT tract Enthesitis is HALLMARK of all spongyloarthritides (inflammation of insertion sites), common in achilles, plantar fasciitis, anterior chest wall and pelvis

Answer 68

Articular/periarticular - enthesitis: inflammation of attachment sites - spondylitis: inflammation of spine with sacroillitis - peripheral arthritis: oligo, asymmetrical, lower limbs and large hoints - dactylitis: sausage digits Possible extra-articular features - psoriasis like skin and nail lesins - conjunctivitis or acute anterior uveitis - chronic GIT or GU inflammation

Answer 69

- onset: adolescent to 40 - predominantly males - gradual onsent - \> 90% have HLA-B27 - 100% involvement of spine with up to 20% peripheral joint involvement - associated with anterior uveitis in 30% of cases

Answer 70

- onset: childhood to middle age - predominantly males but 1:1 after GIT infection - acute onset - 75% prevalence of HLA-B27 - less than 50% involvement of spine, 90% involvement of peripheral joints - 33% of cases will be associated with conjunctivitis - strep infection of skin can trigger skin lesions - bacterial gastroenteritis is a common trigger

Answer 71

- onset: childhood to middle age - 1:1 Male:Female - variable onset - spine and peripheral joints commonly involved - diagnosis of IBD usually preceeds athritis

Answer 72

- onset: childhood to middle age - 1:1 gender distribution - 95% involvement of peripheral joints, up to 20% spinal involvement - 50% prevalence of conjunctivitis - commonly associated with skin and nail changes - increased risk of IBD

Answer 73

- gradual onset before age of 40 - duration of symptoms \> 3 months - prolonged morning stiffness and night pain - improvement with physical activity or exercise, failure to improve with rest - response to NSAIDs - spinal osteoporosis is common hence need to be suspicious for # in patients with acute back pain - inflammation (spondylitis) leads to stiffness (ankylosis)

Answer 74

Acute anterior uveitis, seen in up to 30% of patients with Ank Spond - symptoms: unilateral eye pain, photophobia, increased lacrimation, conjunctival injection around rim of iris is characteristic - treatment: corticosteroid drips and mydiatrics to reduce inflammation - less common extra-articular features: aortic insufficiency secondary to aortitis, cardiac conduction defes and apical pulmonary fibrosis

Answer 75

- inflammatory markers: ESR and CRP - plain XR - MRI: sensitive for detecting axial inflammation, good to be used as an adjunct but typical ank spond lesions can be noted in health population

Answer 76

- hip involvement - age \<16 at onset - presence of 3 or more of the following within 2 years of symptom onset 1. ESR \> 30, CRP \> 6 2. limitation of spinal movement 3. dactylitis 4. peripheral oligoarthritis 5. inadquate response to NSAIDs

Answer 77

- smoking cessation - exercise - NSAIDs - education/bio/psycho/social approach - local corticosteroid injections may be used for peripheral enthesitis - bDMARDS are effective to treat axial inflammation and enthesitis, used by specialists in severe disease

Answer 78

- post infective disease which usually presents 1-3 weeks after infection - following GU infections occurs predominantly in males between 20-40 (generally following chlamydia) - reactive arthritis following GIT infections affects males and females equally

Answer 79

- Salmonella - Shigella - Yersinai - Campylobacter

Answer 80

6 months in 80% of cases however 20% of cases will havce chronic reactive arthritis

Answer 81

- triad: arthritis, conjunctivitis, urethritis - commonly inflammatory peripheral arthropathy with asymmetrical oligoarticular distribution - generally affects lower limbs and commonly causes dactylitis - enthesitis can also occur - extra-articular features: conjunctivitis in 33% of caes, urethrethritis, prostatitis, balantitis, keratoderma blennorhagica (pustular rash on palms and soles of feet)

Answer 82

- inflammatory arthropathy occurs inconjunction with IBD, specifically Crohn's disease and ulcerative colitis - enteropathic arthritis is the most common extra-intestinal feature of IBD - tends to be oligoarticular, asymmetrical and predominantly affect the lower limbs, entersitis may be seen - other extra intestinal features of IBD: acute anterior uveitis, conjunctivitis, episcleritis, cutaneous lesions

Answer 83

Erythema nodosum - characterised by red and tender lumps, most commonly on the shins

Answer 84

Pyoderma gangrenosum - inflammatory skin disorder that is characterized by small, red bumps or blisters (papules or nodules) that eventually erode to form swollen open sores (ulcerations)

Answer 85

- typically presents in young to middle aged adults - 1:1 gender distribution - associated with increased cardiovascular risk - generally affects peripheral joints and may present with dactylitis oe enthesitis - most cases with present with oligoarticular peripheral arthritis (50%) however with time will progress to polyarticular disease (\>5 joints)

Answer 86

Affects 5% of patients with psoriatic arthritis - presents as osteolysis or dissolution of bone affecting small joint sof hands and feel resulting in shortening of digits and flail joints

Answer 87

- NSAIDs - corticoid steroid injections - csDMARDs: methotrexate, sulfasalazine, leflunomide

Answer 88

Involved cytokines, effector cells and signalling pathways TNF, IL6 and 1 appear to be key cytokine mediators

Answer 89

- family history of inflammatory arthritis - early morning stiffness lasting \> 1 hour - swelling in 5 or more joints (polyarthralgia) - symmetry of areas affected - bilateral compression tenderness of metatarsophalangeal joints - RF positivity - anti-CCp antibody positivity - symptoms present for \> 6 weeks - bony erosions evident on XRs of wrists, hands or feet (uncommon in early disease) - raised inflammatory markers CRP, ESR (in absence of infection) - presece of rheumatoid nodules

Answer 90

- high RF titre and or positive anti-CCP - sustained raised inflammatory markers - swelling in more than 20 joints - impaired function early in disease - bony erosions on XR early in disease - smoking

Answer 91

- atherosclerosis - osteoporosis - depression - vasculitis - peptic ulcer disease - lung disease - neuropathy - atlanto-axial involvement

Answer 92

- remission = symptom relief, normal inflam markers, absence of joint swelling - convential synthetic DMARDs are used to induce remission in combination with steroids - if csDMARDs fail may require b or tsDMARD - remission can be achieved in ~40% of patients

Answer 93

Methotrexate 10mg weekly, increasing to 25mg plus 5-0mg folic acid per week (not on same day as methotrexate) Methotrexate can be used in combination with other csDMARDS (leflunomide, sulfasalazine, hyroxychloroquine) Should see responde to csDMARDs within 12 weeks

Answer 94

Risk of infection without usual signs of fever

Answer 95

NSAIDS Fish oil 2.7g daily

Answer 96

Exercise: land and water based aerobic exercises, regular aerobic exercise improves physical function, strengething exercise is also recommended to prevent muscle wasting Diet: contraversial, some small evidence to suggest gluten free/strict vegan and mediterranea diet may slightly reduce RA symptoms Smoking cessation

Answer 97

The name given to inflammatory arthritis beginning before age 16, present for at least 6 weeks with nil underlying cause found after appropriate investigation Most commonly oligoarthritis with 4 or fewer joints affected (50-60%) Investigations: ANA, RF, HLA B27

Answer 98

Perthes - occurs in children 3-12 and more common in boys, present with hip/groin pain and limp but may also have referred knee pain, hip abduction and internal rotation are limited, confirm on XR SCFE - adolescent boys, limp and groing pain which may radiate to knee, leg is externally rotated and abducted with limited internal rotation, confirm on XR Irritable hip - transient synovitis of help, self limiting, usually seen between 3-8 years, often in setting of recent URTI, pt will appear well and have normal XR, FBC and ESR

Answer 99

Systemic lupus erythemtosus - chronic autoimmune disease - peak incidence in women of child bearing age - clinical course generally remission and relapse - diagnosis: need 4/11 of American College of Rheumatology classification - investigation: ANA, dsDNA, complement, phospholipid

Answer 100

- malar erythema, flat or raised - "butterfly rash"

Answer 101

- erythematous raised patches with ketartotic scaling and follicular plugging

Answer 102

1. Malar/butterfly rash 2. Discoid rash 3. Photosensitivity 4. Oral ulcers - usually painless 5. Arthritis 6. Serositis: pleurisy or pericarditis 7. Renal features: proteinuria or casts 8. Neuro: seizures or psychosis 9. Haematological: haemolytic anaemia, lecopenia, lymphopenia, thrombocytopenia 10. Immunological: dsDNA antibodies, anti-SMith antibody or antiphospholipid antibodies 11. ANA antibody postive

Answer 103

- chronic autoimmune disease associated lymphoid infiltration of exocrine glands \* especially slivary and lacrimal glands causes dysfunction and sicca symptoms - can be primary or secondary when occuring with rheumatoid or SLE - symptoms of sicca + fatigue, arthralgia and arthritis + Raynaud phenomenon - can rarely transform into a lymphoid malignancy of B cell origin

Answer 104

- significant and persistent sicca symptoms (i.e dry eyes requiring lubricant several times a day) - polyclonal hypergammaglobulinaemia - positive ANA - presence of Ro (SS-A) and La (SS-B) - rasied ESR, positive RF and anaemia of chronic disease are also common in Sjogren's

Answer 105

Symptomatic relief and patient education No cure

Answer 106

- systemic form of scleroderma - characterised by vascular abnormalities, inflammation and fibrosis of skin and rang of other organs - Raynaus phenomenon is generally first symptoms and usually ANA positive

Answer 107

1. Limited cutaneous disease: calcinosis, Raynaud, oesophgeal dysmotility, sclerodactyly, tlangiectasis and positive nati-centromere antibody (CREST) 2. Diffuse cutaneous disease: rapidly progressive, more severe, interstitial lung disease, scleroderma renal crisis, antibodies to Scl-70 or RNA polymerase III may be present

Answer 108

- inflammatory condition characterised by bilateral aching stiffness of shoulders and hip-girdle causes by low grade synovitis - morning stiffness if hallmark feature - unable to turn over in bed and difficulty getting out of bed - occurs almost exclusively in patient \> 50 - diagnosis: elevated ESR and or CPR DDx: fibromyalgia, drug induced, parkinsons Should display rapid response to corticosteroids

Answer 109

15% of patients with polymyalgia have giant cell arteritis Symptoms: jaw claudication, severe headache, visual symptoms, scalp tenderness, malaise

Answer 110

- long course of steroids is required with tapering - prednisolone 15mg daily for 4 weeks, reduce daily dose by 2.5mg every 4 weeks to 10mg daily - then reduce daily dose by 1mg every 4-8 weeks to stop Do not reduce dose if patient has signs of active disease

Answer 111

- previously known as temporal arteritis - vasculitis which affects cranial arteries including opthalmic artery - peak incidence 70-79 - jaw claudication, headache, tenderness, PMR, visual changes - do not need to delay treatment to wait for biospy, but will need a biopsy within ~1 week - management: prednisolone 40-60mg daily for minimum for 4 weeks and then taper when markers have normalised and symptoms have settled - if hx of visual loss given methylprednisolone - use aspirin to prevent ischaemic events

Answer 112

- vasospasm of digits in repsonse to cold exposure or stress - episodic blanching cyanosis and then erythema of digits - often painful - can be primary or secondary to systemic sclerosis - secondary raynaud's can cause digital ischaemia - advised to avoid cold exposure, wear gloves, cease smoking and avoid beta blockers which can worsen symptoms - if severely affected: amlopdipine 5-10mg daily

Answer 113

Supraspinatus Infraspinatus Subscapularis Teres minor

Answer 114

25% of cases will resolve within 1 months 50% of cases resolve within 3 months Many partial thickness tears progress to full thickness tears over time

Answer 115

- frozen shoulder - most common in patients aged 50-60 and more common in diabetics - self limiting course but can last 2-3 years - initial phase: painful for 2-9 months - intermediate phase: frozen phase 4-12 months - recovery phase: gradual return to movemet 5-24 months - can use prednisolone in initial painful phase (30mg daily for 3 weeks and then taper) - avoid concurrent use of NSAIDs and steroids

Answer 116

- lateral = tennis - medial = golfers - pain, tenderness over epicondyl and pain with resisted movements, tennis elbow: pain with resisted dorsiflexion, golfers elbow: resisted volar flexion of wrist - generally self limiting and recover within 12 month - management: analgesia, avoiding aggrevating activities, physiotherapy for progressive loading progam - limited evidece to support ice/heat, bracing, strapping, splinting or acupuncture.

Answer 117

- affects abductor pollicis longus and extensor pollicic brevis at distal end of the radius - pain and swelling occur over radial aspect of the wrist extending to the thumb - seen in patients who perform repetitive manual tasts and in pregnancy - treatment: steroid injection, NSAID, splinting of thumb for 6 weeks

Answer 118

To diagnose De Quervains tenosynovitis which affects EPB and APL

Answer 119

Phalen's - wrists held at full flexion and pushed together, should reproduce carpal tunnel symptoms (reverse prayer) Hoffmann-Tinel sign - tap over the carpal tunnel to reproduce symptoms

Answer 120

ulna - 4th and 5th fingers median - thumb, 2nd + 3rd finger (Mockingjay)

Answer 121

Pregnancy Diabetes Hypothyroidism Rheumatoid arthritis Overuse of forearms

Answer 122

- NSAIDs - elevation of wrist at night - splinting and bracing - corticosteroid injection

Answer 123

Trigger finger - commonly seen between aged 50-60 - ddx: dupuytren contracture or underlying inflammatoyr disease - management: NSAIDs, splinting, local CSI injection at A1 pulley has 50-70% success rate - surgery is suggested in patients with ongoing symptoms despite conservative management

Answer 124

- trochanteric bursitis, gluteus medius/minimums tendonitis all collectively are known as greater trochanteric pain syndrome - physio for exercise program to strengthen glutes - avoid compression of gluteal tendons over GT (cross legged sitting, hip hanging, side lying i n bed) - NSAIDs are suggested - consider ICS if severe symptoms but shouldn't be done more than twice a year

Answer 125

Ciprofloxacin (fluoroquinolone antibiotics)

Answer 126

- pain at anteromedial aspect of calcaneus - worst during first few steops in the morning and improves during the day - may reperesent enthesitis associated with spondyloarthritis - most cases that aren't associated with spondyloarthritis will resolve within 12 months - heel spurs are common incidental finding and not related to the experience of pain! - need to modify aggrevating activities, stretch the fascia and calf muscles and ice massage, ICS may be of use - refer if not imroved after 6 month rehab program

Answer 127

- due to compression or irritation of nerve roots in cervical spine - C6/7 most commonly involved - rare non-compressive causes: shingles, malignancy, nerve root infarction, demyelination - cervical radiculopathy may be associated with spinal cord compromise - incidence peaks 50-54 - favourable prognosis with most improving within 4 weeks and many recovered within 6 months - MRI preferred

Answer 128

- wearing a semi hard collar during the day with rest for 3-6 weeks or supervised graded exercise program with home exercises for 6 weeks may benefit acute symptoms (\<1 month) - limited evidence for short course steroids to reduec pain and function (30mg for 5-10 days and the taper over 1-3 weeks) - surgical consult is needed for all aptients with progressive neurological deficit, may consider referring if ongoing pain for 6-8 weeks despite conservative mx

Answer 129

- results from midline disc herniation compressing the spinal cord - requires surgical decompression to prevent progressive neurological damage - will present with difficulty walking, unsteady gait, loss of proprioception, positive ROmberg's - lhermitte phenonmeon: paracesthis occuring with neck flexion may be present - may have weakness, hyper or hyporeflexia, upgoing pkantars with sensory loss - MRI is preferred

Answer 130

- atlanto-axial instability arises due to erosive damage to complex ligament and joint structures which link the atlas (c1) to the axis (C2) - in severe cases the peg moved backwards related to C1 and compresses the upper spinal cord - with use of DMARDs incidence is declining - investigation: XR in flexion and extension, MRI

Answer 131

- often asymptomatic - most commonly at L4/L5 - herniated portion of disc may regress over time, most patients will improve rapidly within 2 weeks, 80% of patienst with recover within 8 weeks and 95% recover witin a year - assessment: positive straight leg test in highly sensitive (91%) will reproduce symptoms if positive - early imaging (before 6-8 weeks) if unncesesarry unless severe or progressive deficit - MRI preferred but otherwise CT if not available

Answer 132

a) L3/L4: reduce knee extension, reduced sensation anterior and lateral aspects of thight, reduced or absent knee jerk b) L5: reduce dorsiflexion of big toe and ankle, reduced sensation dorsum of foot, reduced or absent ankle jerk c) S1: reduced plantar flexion of ankle, reduce lateral aspect of foot, reduced or absent ankle jerk d) cauda equina: progressive bilateral foot or leg weakness, saddle parasthesia, altered bladder and/or bowel function

Answer 133

- conservative management recommended for first 6-8 weeks - imaging not suggested at this stage unless concerns - neuropathic agents could be used for radicular pain - consider referral if ongoing severe pain in same distribution as disc herniation

Answer 134

- presents with low back pain, radiating down buttocks and legs - usually bilateral, may only present with leg pain - pain may be aggrevavted by walking or standing, relieved by sitting or leaning forward - radicular leg pain in single dermatomal distribution is more suggestive of single nerve root compression - MRI indicated or CT if unable to access MRI - surgical referral indicated

Answer 135

- pain in bilateral legs aggrevated by walking or standing and relieved by sitting or leaning forward - arterial claudication will be relieved by standing/resting

Answer 136

- amitriptyline 10-25mg nocte or dosulepin 25mg nocte - can trial gabapentin or pregabalin second line

Answer 137

- pain is typically widespread and in both tissues and joints - severity fluctuates but doesn't follow consistent diurnal pattern of inflammatory disorders - chronic widespread musculoskeletal pain is hallmark but may be associated with cognitive clouding (fibrofog), fatigue, impaired concentration, sleep dysfunction, depression, GIT and GU dysfunction - allodunia should be sought in history and examination, good test would be pain with syphmomanometer cuff

Answer 138

- unknown aetiology - affects developing intervertebral disc, typically in thoracic spin and associated with kyphosis - XR: end plate irregularity, schmorl nodes in thoracic vertebar - treat as non specific thoracic spine pain

Answer 139

NSAID - naproxen 500mg BD for 5 days