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Medicine > Rheumatology > Flashcards

Rheumatology Flashcards

1
Q

What is osteoarthritis

A

Wear and tear of the joint

Not an inflammatory condition

Occurs in synovial joints

Due to: genetic factors, overuse, injury

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2
Q

What are the risk factors for osteoarthritis

A

Obesity

Age

Occupation

Trauma

Female

Family history

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3
Q

What X-ray changes would be seen in osteoarthritis

A

Loss of joint space

Osteophytes

Subarticular sclerosis (increased density along joint line)

Subchondral cysts

Do not always correlate with symptoms

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4
Q

How might osteoarthritis present

A

Joint pain

Joint stiffness

Worsens with activity

Leads to: deformity, instability, reduced function

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5
Q

Which joints are commonly affected by osteoarthritis

A

Hip

Knee

Sacro-iliac

Distal-interphalangeal

Metacarpal-phalangeal (base of thumb)

Wrist

Cervical spine

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6
Q

What are the signs of osteoarthritis in the hands

A

Herbeden’s nodes (in DIP joints)

Bouchard’s nodes (in PIP joints)

Squaring at base of thumb

Weak grip

Reduced range of motion

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7
Q

What are the NICE guidelines for osteoarthritis diagnosis

A

Can be diagnosed without investigations in > 45s with:

  • Activity related pain
  • No morning stiffness
  • Stiffness lasting < 30 mins
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8
Q

What is the management for osteoarthritis

A

Patient education

Lifestyle modification

Physiotherapy

Analgesia

Intra-articular steroid injections (temporarily reduce inflammation)

Joint replacement

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9
Q

What is rheumatoid arthritis

A

Chronic inflammation of synovial lining of joints, tendon sheaths, and bursa

Inflammatory arthritis

‘Boggy’ joint swelling

Symmetrical

Affects multiple joints

F>M

Associated with HLA-DR4 and HLA-DR1

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10
Q

Which autoantibodies are associated with rheumatoid arthritis

A

Rheumatoid factor (70% patients, target Fc portion of IgG)

Cyclic citrullinated peptide antibodies (more sensitive than RF)

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11
Q

How might rheumatoid arthritis present

A

Symmetrical distal polyarthropathy

Can be rapid, or gradual onset

Systemic symptoms (fatigue, weight loss, flu like illness, muscle aches and weakness)

Most have > 6 weeks for diagnosis

Morning stiffness lasting > 30 mins

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12
Q

What is palindromic rheumatism

A

Self limiting, short episodes of inflammatory arthritis

Episodes last 1-2 days

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13
Q

Which joints are commonly affected by rheumatoid arthritis

A

Proximal interphalangeal

Metacarpophalangeal

Wrist

Ankle

Metatarsophalangeal

Cervical spine

Knee

Hip

Shoulder

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14
Q

What are signs of rheumatoid arthritis in the hands

A

Z-shaped deformity of thumb

Swan neck deformity (hyperextended PIPs, flexion of DIPs)

Boutonniere’s deformity (hyperextended DIPs, flexed PIPs)

Ulnar deviation of fingers

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15
Q

What are the extra-articular manifestations of rheumatoid arthritis

A

Pulmonary fibrosis

Bronchiolitis obliterans

Felty’s syndrome

Secondary Sjogren’s syndrome

Anaemia of chronic disease

Cardiovascular disease

Episcleritis/scleritis

Rheumatoid nodules

Lymphadenopathy

Carpal tunnel syndrome

Amyloidosis

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16
Q

What investigations are needed for rheumatoid arthritis

A

Clinical diagnosis if symptomatic

Rheumatoid factor

Anti-CCP

Inflammatory markers

Routine bloods

X-ray hands and feet

Ultrasound (confirm synovitis)

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17
Q

What X-ray changes are seen in rheumatoid arthritis

A

Joint destruction and deformity

Soft tissue swelling

Periarticular osteopenia

Bony erosions

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18
Q

What are the NICE guidelines for referral for rheumatoid arthritis

A

Any adult who has persistent synovitis (even if autoantibodies negative)

Urgent if: involves small joints of hands or feet, involves multiple joints, symptoms for > 3 months

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19
Q

How is rheumatoid arthritis diagnosed

A

Scored based on: joint involvement (number), serology, inflammatory markers, duration

Score > 6 means rheumatoid arthritis

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20
Q

What is the DAS28 score

A

Disease activity score for rheumatoid arthritis

Based on 28 joints

Points given for: swelling, tenderness, ESR/CRP

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21
Q

What factors lead to a poor prognosis in rheumatoid arthritis

A

Young onset

Male

More joints affected

Autoantibodies present

Erosion seen on X-ray

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22
Q

What is the management for rheumatoid arthritis

A

First presentation and flare ups: NSAIDs (+PPI), aim to induce remission

NICE first line: methotrexate, leflunomide, sulfasalazine, hydroxychloroquine

NICE second line: 2 drugs in combination

NICE third line: methotrexate plus a biological agent

NICE fourth line: rituximab

Physiotherapy

Surgery

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23
Q

What is psoriatic arthritis

A

Inflammatory arthritis associated with psoriasis

Varies in severity

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24
Q

What are the different patterns of psoriatic arthritis

A

Symmetrical polyarthritis: similar to RA, F>M, MCPs not affected

Asymmetrical pauciarthritis: affects digits and feet

Spondylitic: M>F, back stiffness, sacroiliitis, atlanto-axial involvement

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25
Q

What are the signs of psoriatic arthritis

A

Plaques of psoriasis on skin

Pitting of nails

Onycholysis (separation of nail from bed)

Dactylitis (inflammation of whole finger)

Enthesitis (inflammation of point of insertion of tendon to bone)

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26
Q

What other features are associated with psoriatic arthritis

A

Eye disease (conjunctivitis, anterior uveitis)

Aortitis

Amyloidosis

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27
Q

What screening tool is used for psoriatic arthritis

A

Psoriasis epidemiological screening tool (PEST)

Based on: joint pain, swelling, history, nail pitting

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28
Q

What X-ray changes are seen in psoriatic arthritis

A

Periostitis (inflammation of periosteum)

Ankylosis (bones fuse together)

Osteolysis

Dactylitis (inflammation of whole digit)

Pencil in cup appearance (central erosion of bone)

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29
Q

What is arthritis mutilans

A

Most severe form of psoriatic arthritis

Often in phalanxes

Osteolysis of bone around joints

Get progressively shortening digits (telescopic finger)

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30
Q

What is the management for psoriatic arthritis

A

NSAIDs

DMARDs (methotrexate, lefunomide, sulfasalazine)

Anti-TNF inhibitors (infliximab)

Ustekinumab (last line)

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31
Q

What is reactive arthritis

A

Synovitis in joints due to recent infective trigger

Usually acute monoarthritis

Joint warm, swollen, painful

Common triggers: gastroenteritis, STIs

Linked to HLA-B27

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32
Q

What is reactive arthritis associated with

A

Bilateral conjunctivitis

Anterior uveitis

Circinate balanitis (dermatitis of head of penis)

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33
Q

What investigations are needed for reactive arthritis

A

Serology

Inflammatory markers

Joint aspiration (rule out septic/crystal arthritis)

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34
Q

What is the management for reactive arthritis

A

Antibiotics

Aspiration (send for gram stain and crystal examination)

Once septic arthritis rules out: NSAIDs, steroid injections, systemic steroids

Most recover in 6 months

If have recurrence: DMARDs, anti-TNFs

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35
Q

What is ankylosing spondylitis

A

Inflammatory condition mainly affecting spine

Progressive stiffness and pain

Related to HLA-B27

Key joints: sacroiliac, vertebral column

Can get fusion of joints (bamboo spine)

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36
Q

How might ankylosing spondylitis present

A

M = F

> 3 months

Lower back pain and stiffness

Sacroiliac pain in buttocks

Worse on rest (improves with movement)

Worse at night and in morning

May wake from sleep

Takes > 30 mins for stiffness to improve

Get flare ups

Can get vertebral fractures

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37
Q

What is ankylosing spondylitis associated with

A

Systemic symptoms (weight loss, fatigue)

Chest pain (costovertebral and costosternal joints)

Enthesitis

Dactylitis

Anaemia

Anterior uveitis

Aortitis

Heart blocks

Reactive lung disease

Pulmonary fibrosis

Inflammatory bowel disease

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38
Q

What is Schober’s test

A

For ankylosing spondylitis

Stand, mark 10 cm above and 5cm below L5, lean forwards. If < 20cm, suggests restricted lumbar movement

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39
Q

What investigations are needed for ankylosing spondylitis

A

Inflammatory markers

HLA-B27 test

X-ray spine and sacrum

MRI spine (see bone marrow oedema before X-ray changes)

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40
Q

What are the X-ray changes associated with ankylosing spondylitis

A

Bamboo spine

Squaring of vertebral bodies

Subchondral sclerosis and erosions

Syndesmophytes (bone growth where ligaments insert into bone)

Ossification

Fusion of facet. sacroiliac and costovertebral joints

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41
Q

What is the management for ankylosing spondylitis

A

NSAIDs

Steroids (for flare ups)

Anti-TNF medications

Secukinumab (monoclonal antibody against IL 17)

Physio

Exercise

Smoking cessation

Bisphosphonates

Treat complications

Surgery

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42
Q

What is systemic lupus erythematosus

A

Inflammatory autoimmune connective tissue disease

Affects multiple organs and systems

More common in asian women

Young - middle age

Remitting and relapsing course

Shortened life expectancy

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43
Q

How might systemic lupus erythematosus present

A

Fatigue

Weight loss

Arthralgia

Non-erosive arthritis

Myalgia

Fever

Photosensitive malar rash

Lymphadenopathy

Splenomegaly

Shortness of breath

Pleuritic chest pain

Mouth ulcers

Hair loss

Raynaud’s phenomenon

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44
Q

What are the investigations for systemic lupus erythematosus

A

Antinuclear antibodies

Anti-double stranded DNA (anti-dsDNA, specific to SLE)

Antiphospholipid antibodies

FBC (normocytic anaemia of chronic disease)

C3 and C4 (decreased activity)

Inflammatory markers

Immunoglobulins

Urinalysis

Urine protein:creatinine ratio

Renal biopsy (investigate lupus nephritis)

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45
Q

How is systemic lupus erythematosus diagnosed

A

SLICC criteria

ACR criteria

Suggestive clinical features and bloods

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46
Q

What are the complications of systemic lupus erythematosus

A

Cardiovascular disease

Infection

Anaemia of chronic disease

Pericarditis

Pleuritis

Interstitial lung disease

Lung nephritis

Neuropsychiatric SLE (optic neuritis, transverse myelitis, psychosis)

Recurrent miscarriage

VTE

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47
Q

What is the management for systemic lupus erythematosus

A

No cure

First line: NSAIDS, steroids (for flare ups), hydroxychloroquine (first line if mild), suncream

Immunosuppressants (if first line not working): methotrexate, azathioprine, tacrolimus, ciclosporin

Biological therapies: rituximab, belimumab

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48
Q

What is discoid lupus erythematosus

A

Non-cancerous chronic skin condition

F>M

20-40s

More common in darker skin

Associated with smoking

Can progress to SCC

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49
Q

How might discoid lupus erythematosus present

A

Lesions on face, ears, scalp

Photosensitive

Scarring alopecia

Hyper/hypopigmentation

Lesions: inflamed, dry, erythematous, patchy, crusty, scaling

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50
Q

What is the management for discoid lupus erythematosus

A

Skin biopsy (confirm)

Sun protection

Topical steroids

Intralesional steroid injections

Hydroxychloroquine

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51
Q

What is systemic sclerosis

A

Autoimmune inflammatory and fibrotic connective tissue disease

Affects skin and internal organs

Patterns: limited, diffuse (cardiovascular/lung/kidney issues)

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52
Q

What are the features of systemic sclerosis

A

Scleroderma (hardening of skin)

Sclerodactyly (skin changes in hands)

Telangiectasis (dilated blood vessels)

Calcinosis (calcium deposits under skin)

Raynaud’s phenomenon

Oesophageal dysmotility

Systemic and pulmonary hypertension

Pulmonary fibrosis

Scleroderma renal crisis

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53
Q

What are the autoantibodies associated with systemic sclerosis

A

Antinuclear antibodies

Anti-centromere antibodies

Anti-Scl-70 antibodies

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54
Q

How is systemic sclerosis diagnosed

A

Based on ACR or EULAR criteria

Clinical features

Autoantibodies

Nailfold capillaroscopy

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55
Q

What is the management for systemic sclerosis

A

Steroids and immunosuppressants for diffuse disease

Smoking cessation

Gentle stretching of skin

Emollients

Physio

Nifedipine (for Raynaud’s)

PPIs and pro-motility medications (for GI issues)

Analgesia

Antibiotics (for skin infections)

Antihypertensives

Supportive management (for pulmonary fibrosis)

56
Q

What is polymyalgia rheumatica

A

Inflammatory condition causing pain and stiffness in shoulders, pelvic girdle, and neck

Strong association with giant cell arteritis

> 50s

F>M

More common in Caucasians

57
Q

What are the core features of polymyalgia rheumatica

A

At least 2 weeks

Bilateral shoulder pain

Bilateral pelvic girdle pain

Worse on movement

Interferes with sleep

Stiff for > 45 mins in morning

Reduced range of movement

Muscle strength normal

Muscle tenderness

58
Q

What are the additional symptoms of polymyalgia rheumatica

A

Systemic symptoms (weight loss, fatigue, low grade fever, low mood)

Upper arm tenderness

Carpal tunnel syndrome

Pitting oedema

59
Q

What are the differentials for polymyalgia rheumatica

A

Osteoarthritis

Rheumatoid arthritis

CLE

Myositis

Cervical spondylitis

Adhesive capsulitis

Thyroid dysfunction

Osteomalacia

Fibromyalgia

60
Q

What investigations are needed for polymyalgia rheumatica

A

Based on clinical presentation and response to steroids

Raised inflammatory markers

61
Q

What is the management for polymyalgia rheumatica

A

Steroids (assess at 3-4 weeks, if good response, start reducing dose, can increase again if symptoms recur)

Methotrexate (if repeatedly relapsing)

62
Q

What is giant cell arteritis

A

Systemic vasculitis of medium and large arteries

Presents with temporal arteritis

Strongly linked to polymyalgia rheumatica

> 50s

F>M

63
Q

What are the risk factors for giant cell arteritis

A

> 50

F>M

White

64
Q

What might giant cell arteritis present

A

Headache (severe, unilateral)

Scalp tenderness

Jaw claudication

Blurred/double vision

Irreversible, painless sight loss

Systemic symptoms

65
Q

How is giant cell arteritis diagnosed

A

> 50s need 2+ of: high inflammatory markers, new onset localised headache, tenderness over scalp arteries, new visual symptoms, biopsy shows necrotising arteritis

Duplex ultrasound (hypoechoic halo sign of temporal arteries)

66
Q

What is the management for giant cell arteritis

A

Steroids (start before confirming diagnosis) + PPI

67
Q

What are the complications of giant cell arteritis

A

Early: vision loss, cerebrovascular accident

Late: relapse of condition, cerebrovascular accident, aortitis leading to aortic aneurysm/aortic dissection

68
Q

What are polymyositis and dermatomyositis

A

Autoimmune conditions causing inflammation of striated muscle

69
Q

What is the key investigation for diagnosing myositis

A

Creatine kinase

70
Q

How might polymyositis and dermatomyositis present

A

Muscle pain

Fatigue

Weakness

Bilateral

Usually affects proximal muscles

71
Q

What autoantibodies are associated with polymyositis and dermatomyositis

A

Anti-Jo-1

Anti-Mi-2

ANA

72
Q

What investigations are needed for polymyositis and dermatomyositis

A

Elevated creatine kinase

Autoantibodies

EMG

Muscle biopsy

73
Q

What is the management for polymyositis and dermatomyositis

A

Physio

Corticosteroids

Immunosuppressants

IV immunoglobulins

Biological therapies

74
Q

What is antiphospholipid syndrome

A

Associated with antiphospholipid antibodies

Causes hyper-coagulable state

Associated with: thrombosis, complications in pregnancy (recurrent miscarriages, stillbirth)

Can be secondary to SLE

75
Q

How is antiphospholipid syndrome diagnosed

A

History of thrombosis or pregnancy complications

Plus persistent antibodies (lupus anticoagulant, anticardiolipin, anti-beta 2 glycoprotein I)

76
Q

What is the management for antiphospholipid syndrome

A

Long term warfarin (target INR 2-3)

Pregnant women: LMWH and aspirin

77
Q

What is Sjogren’s syndrome

A

Autoimmune condition affecting exocrine glands

Get symptoms of dry mucous membranes

Can be secondary to SLE or rheumatoid arthritis

Schirmer test: filter paper under eyelid, see how far moisture travels

78
Q

Which antibodies are associated with Sjogren’s syndrome

A

Anti-Ro

Anti-La

79
Q

What is the management for Sjogren’s syndrome

A

Artificial tears

Artificial saliva

Vaginal lubricants

Hydroxychloroquine (halts disease progression)

80
Q

What are the complications of Sjogren’s syndrome

A

Eye infections (conjunctivitis, corneal ulcers)

Oral problems (dental cavities, candida infections)

Vaginal problems (candidiasis, sexual dysfunction)

Pneumonia

Non-Hodgkin’s lymphoma

Peripheral neuropathy

Vasculitis

Renal impairment

81
Q

Which types of vasculitis affect small vessels

A

Henoch-Schonlein purpura

Eosinophilic granulomatosis with polyangiitis

Microscopic polyangiitis

Granulomatosis with polyangiitis

82
Q

Which types of vasculitis affect medium vessels

A

Polyarteritis nodosa

Eosinophilic granulomatosis with polyangiitis

Kawasaki disease

83
Q

Which types of vasculitis affect large vessels

A

Giant cell arteritis

Takayasu’s arteritis

84
Q

How might vasculitis present

A

Purpura (purple non-blanching spots due to bleeding from vessels under skin)

Joint and muscle pain

Peripheral neuropathy

Renal impairment

GI disturbance

Anterior uveitis, scleritis

Hypertension

Systemic features (fatigue, fever, weight loss)

85
Q

What investigations are needed for vasculitis

A

Inflammatory markers

Anti-neutrophil-cytoplasmic antibody (ANCA)

86
Q

What is the management for vasculitis

A

Refer to specialist

Steroids

Immunosuppressants (cyclophosphamide, methotrexate, azathioprine, rituximab)

87
Q

What is Henoch-Schonlein purpura

A

IgA vasculitis (IgA deposited in affected organs)

Purpuric rash on lower limb/buttocks in children (mostly < 10s)

Often triggered by infection (tonsillitis, gastroenteritis)

Classical features: purpura, joint pain, abdo pain, renal involvement (IgA nephritis)

Management: analgesia, rest, fluids

Kidney involvement resolves in 4-6 weeks

1/3 get recurrence in 6 months

88
Q

What is eosinophilic granulomatosis with polyangiitis

A

Churg-Strauss syndrome

Small and medium vessel vasculitis

Associated with lung and skin problems

Presents with severe asthma

Mostly in late teens/adults

Raised eosinophils on FBC

89
Q

What is microscopic polyangiitis

A

Small vessel vasculitis

Get renal failure

Can affect lungs (SOB, haemoptysis)

90
Q

What is granulomatosis with polyangiitis

A

Small vessel vasculitis

Affects respiratory tract and kidneys

91
Q

What is polyarteritis nodosa

A

Medium vessel vasculitis

Associated with Hep B, Hep C, HIV

Affects skin, GI tract, kidneys, heart

Associated with livedo reticularis (mottled, purplish, lace-like rash)

92
Q

What is Kawasaki disease

A

Medium vessel vasculitis

Young children (<5)

Presentation: persistent high fever (>5 days), erythematous rash, bilateral conjunctivitis, erythema and desquamation of palms and soles, strawberry tongue

Management: aspirin, IV immunoglobulins

Key complication: coronary artery aneurysm

93
Q

What is Takayasu’s arteritis

A

Large vessel vasculitis

Affects aorta and its branches

Affects pulmonary arteries

Large vessels swell to form aneurysms

Presentation: fever, malaise, muscle aches, arm claudication, syncope

Diagnosis: CT, MRI angiography, doppler ultrasound

94
Q

What is Behcet’s disease

A

Complex inflammatory condition

Presents with recurrent oral and genital ulcers

Inflammation in: skin, GI tract, lungs, vessels, MSK system, CNS

Associated with HLA-B51 gene

95
Q

What are the main differentials for mouth ulcers

A

Simple aphthous ulcers

Inflammatory bowel disease

Coeliac disease

Vitamin deficiency (B12, folate, iron)

Herpes simplex ulcer

Squamous cell carcinoma

96
Q

What are the clinical features of Behcet’s disease

A

Mouth ulcers

Genital ulcers

Easily inflamed skin

Eye problems (uveitis, retinal vasculitis, retinal haemorrhage)

Arthralgia

GI inflammation and ulceration

Memory impairment, headaches

Thrombosis

Pulmonary artery aneurysms

97
Q

What are the investigations for Behcet’s disease

A

Clinical diagnosis

Pathergy test (cause abrasion with sterile needed, review in 48 hrs, look for wheal)

98
Q

What is the management for Behcet’s disease

A

Topical steroids (mouth)

Systemic steroids

Colchicine (anti-inflammatory)

Topical anaesthetic (genital ulcers)

Immunosuppressants

Biological therapy

99
Q

What is the prognosis for Behcet’s disease

A

Remitting and relapsing course

Increased mortality of have haemoptysis or neurological involvement

100
Q

What is gout

A

A crystal arthropathy

Chronically high blood uric acid levels

Urate crystals deposited in joints

Joints hot, swollen, painful

Gouty tophi: subcutaneous deposits of uric acid, affects small joints and connective tissue

101
Q

What are the risk factors for gout

A

M>F

Obesity

High purine diet (meat, seafood)

Alcohol

Diuretics

Existing cardiovascular or kidney disease

Family history

102
Q

Which joints are typically affected by gout

A

Metatarcophalangeal joint (base of big tow)

Wrist

Carpometacarpal joint (base of thumb)

Can affect large joints)

103
Q

How is gout diagnosed

A

Aspirate fluid: no bacterial growth, needle shaped crystals, negative birefringent of polarised light, monosodium urate crystals

Joint X-ray: joint space maintained, lytic lesions in bone, ‘punched out’ erosions

104
Q

What is the management for gout

A

Acute phase: NSAIDs, colchicine, steroids

Prophylaxis: allopurinol (xanthine oxidase inhibitor, reduces uric acid levels), lifestyle changes (diet, alcohol…)

105
Q

What is pseudogout

A

Crystal arthropathy

Caused by calcium pyrophosphate crystals

Mostly in older adults

106
Q

How might pseudogout present

A

Hot, swollen, stiff, painful joint

Knee, shoulder, wrist, hip

107
Q

How is pseudogout diagnosed

A

Aspirate fluid: no bacterial growth, calcium pyrophosphate crystals, rhomboid shaped crystals, positive birefrengent of polarised light

X-ray: chondrosclerosis (white line in joint space), loss of joint space, osteophytes, subarticular sclerosis, subchondral cysts

108
Q

What is the management for pseudogout

A

Usually resolves spontaneously in a few weeks

NSAIDs

Colchicine

Joint aspiration

Steroid injections

Oral steroids

Joint washout (in severe cases)

109
Q

What is osteoporosis

A

Reduced density of bone

Bones weaker, more prone to fracture

110
Q

What are the risk factors for osteoporosis

A

Older age

F>M

Reduced mobility and activity

Low BMI

Rheumatoid arthritis

Alcohol

Smoking

Long term corticosteroids

SSRIs, PPIs, antiemetics, anti-oestrogens

111
Q

What is the FRAX tool

A

Predicts risk of a fragility fracture in the next 10 years

Measures: age, BMI, co-morbidities, smoking, alcohol, family history

112
Q

What is bone mineral density

A

Measured by DEXA scan

X-ray measuring how much radiation is being absorbed by bones

Z-score: standard deviations below mean for age

T-score: standard deviations below mean for healthy young people

113
Q

How is osteoporosis assessed for

A

FRAX tool: F > 65, M > 75, young with significant risk factors

NOGG guidelines

114
Q

How is osteoporosis managed

A

Lifestyle changes

Calcium and vitamin D supplements

Bisphosphonates (interferes with osteoclast activity, causes GORD)

Denoxumab (monoclonal antibody)

Strontium ranelate (stimulates osteoblasts, blocks osteoclasts)

Raloxifine (selective oestrogen receptor modulator)

HRT

115
Q

What is involved in the follow up of patients with osteoporosis

A

Low risk: repeat assessment in 5 years

On bisphosphonates: repeat FRAX and DEXA every 3-5 years, consider treatment holiday if no longer at risk

116
Q

What is osteomalacia

A

Defective bone mineralisation

‘Soft’ bones

Insufficient vitamin D

If in children before growth plates close, get rickets

117
Q

How might osteomalacia present

A

Fatigue

Bone pain

Muscle weakness

Pathological/abnormal fractures

118
Q

What investigations are needed for osteomalacia

A

Serum 25-hydroxyvitamin D (low)

Serum calcium (low)

Serum phosphate (low)

Serum ALP (high)

PTH (high)

X-ray (osteopenia)

DEXA (low mineral density)

119
Q

What is the management for osteomalacia

A

Vitamin D supplements (high dose colecalciferol for 6-10 weeks, then maintenance dose)

120
Q

What is Paget’s disease of bone

A

Disorder of bone turnover

Excessive bone turnover (increased osteoblast and osteoclast activity, not coordinated)

Enlarged and misshapen bones

Increased risk of pathological fractures

Mostly affects head and spine

Mostly in older adults

121
Q

How might Paget’s disease of bone present

A

Bone pain

Bone deformity

Fractures

Hearing loss (ear bones affected)

122
Q

What investigations are needed for Paget’s disease of bone

A

X-ray: bone enlargement and deformity, osteoporosis circumscripta (well defined osteolytic lesions), cotton wool appearance (poorly defined patches of high and low density), V-shaped deformity (osteolytic lesions in long bones)

ALP high

Calcium normal

Phosphate normal

123
Q

What is the management for Paget’s disease of bone

A

Bisphosphonates (interfere with osteoclast activity)

NSAIDs

Calcium and vitamin D supplements

Monitor

124
Q

How are the complications of Paget’s disease of bone

A

Osteogenic sarcoma

Spinal stenosis

125
Q

What are the features of inflammatory joint problems

A

Morning stiffness > 1 hour

Better with activity

Worse with rest

Significant fatigue

Have systemic involvement

126
Q

What are the features of mechanical joint problems

A

Morning stiffness < 30 mins

Worse with activity

Better with rest

Minimal fatigue

No systemic symptoms

127
Q

What is Raynaud’s phenomenon

A

Vasospasm of digits

Colour changes in digits due to cold

F>M

Associated with: scleroderma, SLE, dermatomyositis and polymyositis, Sjogren’s syndrome, beta blockers

128
Q

What is the management for Raynaud’s phenomenon

A

Avoid cold

Stop smoking

CCBs (first line)

ARBs, ACE inhibitors, SSRIs

129
Q

What are the complications of Raynaud’s phenomenon

A

Digital ulceration

Severe digital ischaemia

Infection

130
Q

What is hypermobility spectrum disorder

A

Joints move beyond normal limits

Due to laxity of ligaments, capsules, and tendons

Pain due to microtrauma

F>M

More in asians

131
Q

How might hypermobility spectrum disorder present

A

Pain around joints

Worse on activity

Fatigue

Soft tissue rheumatism

Marfanoid habitus

Arachnodactyly

Drooping eyelids

Hernias

Uterine/rectal prolapse

132
Q

What is the management for hypermobility spectrum disorder

A

Physio

Splinting

Paracetamol

Surgery

133
Q

What is fibromyalgia

A

Chronic widespread pain in all 4 quadrants of body

Induced by deliberate sleep deprivation

F>M

40 - 50s

134
Q

How might fibromyalgia present

A

Pain

Joint stiffness

Profound fatigue

Unrefreshed sleep

Numbness

Headache

Irritable bowel/bladder

Depression and anxiety

Poor memory

135
Q

What is the management for fibromyalgia

A

Education

Reassurance

Opiates not recommended

Amityiptyline

CBT

Medicine (9 decks)

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