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Rheumatology Flashcards

1
Q

Causes of scarring alopecia

A 
Trauma, burns
Radiotherapy
Lichen planus
Discoid lupus
Tinea capitis
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2
Q

Causes of non-scarring alopecia

A 
Male pattern baldness
Drugs = cytotoxic, carbimazole, heparin, oral contraeption, colchine
Iron deficiency, zinc deficiency
Alopecia areata
Telogen effluvium
Trichotillomania
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3
Q

How to manage any new synovitis

A

Refer urgently to rheumatology

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4
Q

Main side effect of colchicine

A

Diarrhoea

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5
Q

2nd line treatment for gout

A

febuxostat

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6
Q

Inheritance of McArdle’s disease

A

Autosomal recessive

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7
Q

Features of McArdle’s disease

A

Muscle pain and stiffness after exercise
Muscle cramps
Myoglobinuria
Low lactate levels during exercise

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8
Q

If a patient has undiagnosed primary hyperparathyroidism and is started on vitamin D replacement, what is a possible risk?

A

Severe hypercalcaemia and vitamin D toxicity

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9
Q

Side effects of gold

A

Proteinuria

Corneal opacities

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10
Q

Side effects of penicilliamine

A

Proteinuria

Exacerbation of myasthenia gravis

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11
Q

What test is most specific for SLE?

A

Anti-dsDNA

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12
Q

Supplements to be taken during pregnancy

A

400mcg folic acid pre-conception and until 12 weeks gestation (5mg if high risk for neural tube defect)

10mcg vitamin D throughout entire pregnancy

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13
Q

DEXA scan - what is the Z score adjusted for?

A

Age, gender and ethnic factors

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14
Q

Monitoring for patients on biologic therapy

A

FBC, U+E, LFTs every 3-4 months after starting therapy, then every 6 months one stable

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15
Q

Which blood test is a useful rule out test for SLE?

A

ANA

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16
Q

Ehler-Danlos syndrome inheritance

A

Autosomal dominant

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17
Q

Ehler-Danlos syndrome features

A 
Elastic, fragile skin
Joint hypermobility - multiple dislocations
Easy bruising
Aortic regurg, mitral valve prolapse
Aortic dissection
SAH
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18
Q

HLA B27 associations

A

Ankylosing spondylitis
Reactive arthritis
Acute anterior uveitis

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19
Q

HLA DR3 associations

A

Dermatitis herpetiformis
Sjogren’s syndrome
Primary biliary cirrhosis

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20
Q

DLA DR4 associations

A

T1DM

Rheumatoid arthritis

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21
Q

Secondary causes of Raynaud’s

A 
Connective tissue disorders: scleroderma, RA, SLE
Leukaemia
Type 1 cryoglobulinaemia
Using vibrating tools
Cervical rib
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22
Q

Drug causes of Raynaud’s

A

Oral contaceptive pill

Ergot (used in cluster headaches)

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23
Q

Raynaud’s - factors suggesting underlying connective tissue disorder

A 
Onset over 40
Unilateral
Rashes
Autoantibodies
Digital ulcers
Calcinosis
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24
Q

Raynaud’s - management

A

CCB - nifedipine
IV prostacyclin infusion
Refer all with suspected secondary Raynauld’s

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25
Lateral epicondylitis - what exacerbates the pain?
Wrist extension against resistance with elbow extended Supination of the forearm with elbow extended
26
Medial epicondylitis - what exacerbates the pain?
Wrist flexion and pronation
27
Blood tests in osteoporosis
Calcium normal Phosphate normal ALP normal PTH normal
28
Blood tests in osteomalacia
Calcium decreased Phosphate decreased ALP increased PTH increased
29
Blood tests in primary hyperparathyroidism
Calcium increased Phosphate decreased ALP increased PTH increased
30
Bone profile blood tests in CKD
Calcium decreased Phosphate increased ALP increased PTH increased
31
Blood tests in Paget's disease
Calcium normal Phosphate normal ALP increased PTH normal
32
Blood tests in osteopetrosis
Calcium normal Phosphate normal ALP normal PTH normal
33
Causes of dactylitis
``` Psoriasis Reactive arthritis Sickle cell disease TB Sarcoidosis Syphilis ```
34
Side effects of denosumab
``` Dyspnoea Diarrhoea URTI Hypocalcaemia Atypical femoral fractures ```
35
Causes of drug induced lupus
Procainamide Hydralazine Phenytoin
36
Fibromyalgia - management
Explanation Aerobic exercise CBT Pregabalin, duloextine, amitriptyline
37
Fibromyalgia - diagnosis
Clinical | Tender in 11/18 'tender points'
38
Fibromyalgia - features
``` Chronic pain at multiple sites Lethargy "Brain fog" sleep disturbance Headaches Dizziness ```
39
What is the minimum steroid intake a patient should be taking before they are offered osteoporosis prophylaxis?
7.5mg prednisolone or more each day for 3 months
40
Which rheumatoid drug causes retinopathy?
Hydroxychloroquine
41
T score > -1.0
Normal
42
T score -1.0 to -2.5
Osteopenia
43
T score < -2.5
Osteoporosis
44
Risk of calcium supplements
Increased MI
45
Which drugs cannot be prescribed with methotrexate and why?
Trimethoprim and cotrimoxazole - increase risk of marrow aplasia High dose aspirin - increased risk of methotrexate toxicity
46
How to alter the colchicine dose in renal failure
reduce dose by 50% if creatinine clearance is less than 50 Avoid if less than 10
47
Features of transient idiopathic osteoporosis
Third trimester of pregnancy Groin pain with limited range of movement Unable to weight bear Raised ESR
48
Age <75 and had a previous fragility fracture?
DEXA scan then FRAX assessment
49
Age >75 and previous fragility fracture?
No need to DEXA, start treatment
50
Blood test findings in antiphospholipid syndrome
Prolonged APTT | Low platelets
51
Scoring system used to assessed for hypermobility
Beighton score
52
What is ANCA?
anti-neutrophil cytoplasmic antibody
53
Conditions associated with pANCA
UC Crohn's Primary sclerosing cholangiits Eosinophilic granulomatosis polyangiitis Anti-GBM disease
54
Conditions associated with cANCA
granulomatosis with polyangiitis | microscopic polyangiitis
55
ANCA associated vasculitis - investigations
Urinalysis for proteinuria and haematuria U+E FBC CRP raised ANCA CXR: nodular, fibrotic or infiltrative lesions
56
ANCA associated vasculitis - features
Renal = proteinuria, haematuria, creatinine rise Respiratory = dysphoea, haemoptysis Fatigue, weight loss, fever Vasculitic rash Sinusitis
57
Types of malignant bone tumours
Osteosarcoma Chondrosarcoma Ewing's sarcoma
58
Osteosarcoma - predisposing factors
Rb gene (associated with retinoblastoma) Paget's disease Radiotherapy
59
Osteosarcoma - main location
Long bones prior to epiphyseal closure | Femur, tibia, humerus
60
Osteosarcoma - xray findings
Codman's triangle (due to periosteal elevation) Sunburst pattern
61
What is chondrosarcoma?
Malignant tumour of cartilage
62
Chondrosarcoma - main location
axial skeleton
63
Ewing's sarcoma - age of presentation
Children and adolescence
64
Ewing's sarcoma - main location
Pelvis and long bone
65
Ewing's sarcoma - presentation
Severe pain
66
Ewing's sarcoma - xray findings
'onion skin' appearance
67
Types of benign bone tumours
Osteoma Osteochondroma Giant cell tumour
68
Osteoma - associations
Gardner's syndrome
69
What is osteoma?
Benign 'overgrowth'
70
Osteoma - main location
Skull
71
What is osteochondroma?
Cartilage capped bony projection on external surface of bone
72
Osteochondroma - who is affected
Males | Under 20
73
Giant cell tumour - xray findings
Double bubble or soap bubble sign
74
What is temporal arteritis?
A large vessel vasculitis
75
Temporal arteritis - features
``` Age >60 Headache Jaw claudication Visual changes - blurring, amaurosis fugas, double Tender, palpable temporal artery PMR symptoms Lethargy, low grade fever, night sweats ```
76
Temporal arteritis - investigations
Raised ESR >50 Raised CRP Temporal artery biopsy = skip lesions CK and EMG normal
77
Temporal arteritis - management
High dose steroids - oral if no visual changes - IV methylpred if visual loss Will also need bone protection
78
Antibodies in systemic lupus erythematous
``` ANA in 90% Rheumatoid factor in 20% Anti-dsDNA - highly specific Anti-smith Raised ESR normal CRP Low C3 and Low C4 during active disease ```
79
SLE - which antibody as a screening test?
ANA
80
SLE - which antibody is the most specific?
anti-dsDNA
81
SLE - MSK features
arthraglia | non-erosive arthritis
82
SLE - cardiovascular features
pericarditis | myocarditis
83
SLE - respiratory features
pleurisy | fibrosing alveolitis
84
SLE - renal features
proteinuria | glomerulonephritis
85
SLE - neuro features
anxiety, depression psychosis seizures
86
SLE - skin features
``` malar rash discoid rash photosensitive Raynaud's Livedo reticularis non-scarring allopecia ```
87
What is a discoid rash?
scaly, red, well demarcated patches | sun-exposed places
88
How to monitor SLE disease activity
ESR | anti-dsDNA
89
Which ethnic group is most at risk of SLE?
Afro-caribbean
90
SLE - management
NSAIDS corticosteroids hydroxychloroquine belimumab
91
What is Sjogren's syndrome?
Autoimmune disorder affecting exocrine glands resulting in dry mucous membranes
92
What can Sjogren's syndrome be secondary to?
Connective tissue diseases | Rheumatoid arthritis
93
Sjogren's syndrome - features
Dry eyes and mouth Vaginal dryness Arthralgia, myalgia Raynauld's Sensory polyneuropathy Renal tubular acidosis
94
Sjogren's syndrome - antibodies
Rheumatoid factor ANA anti-Ro antibodies in 70% anti-La antibodies in 30%
95
Sjogren's syndrome - investigations
antibodies | Schirmer's test = filter paper near conjuctival sca to measure tear formation
96
What malignancy are people with Sjogren's syndrome at risk of?
40-60 fold increase risk of lymphoid malignancy
97
Sjogren's syndrome - management
Artificial tears and saliva | Pilocarpine may stimulate saliva
98
What is reactive arthritis?
HLA-B27 associated seronegative arthropathy
99
Reactive arthritis - causes
STI - chlamydia GI infection
100
Reactive arthritis - features
Arthritis - asymmetrical, lower limbs Dactylitis Urethritis Conjunctivitis Anterior uveitis Skin = circinate balanitis, keratoderma blenorrhagica
101
Reactive arthritis - skin findings
Keratoderma blenorrhagica
102
Reactive arthritis - management
Analgesia, NSAIDs Intraarticular steroids In persistent disease: sulfasalazine, methotrexate
103
Reactive arthritis - prognosis
Symptoms generally last 4-6 months, in most people resolve within 12 months 25% have recurrent episodes 10% have chronic disease
104
What percentage of people with psoriasis develop psoriatic arthritis?
10-20%
105
Psoriatic arthritis - arthritis features
May be symmetrical similar to RA or asymmetrical Sacroilitis DIP joint Arthritis mutilans - severe hand defmority
106
Psoriatic arthritis - skin features
Psoriatic skin lesions Nail pitting Oncholysis
107
Psoriatic arthritis - periarticular disease
Enthesitis Tenosynovitis Dactylitis
108
Psoriatic arthritis - xray changes
Erosive changes and new bone formation Periostitis "pencil in cup" appearance
109
Uses of methotrexate within rheumatology
inflammatory arthritis - RA | psoriasis
110
Methotrexate and pregnancy
Avoid for 6 months after treatment in men and women
111
Methotrexate side effects
Mucositis Pneumonitis Myelosuppression Pulmonary fibrosis Liver fibrosis
112
Methotrexate - monitoring
FBC, U+E, LFT Before starting then weekly until stable, 2-3 months when stable
113
Methotrexate - prescribing
weekly | with folic acid 5mg weekly on a different day
114
Methotrexate - treatment for toxicity
Folinic acid
115
What is dermatomyositis?
inflammatory disorder causing symmetrical, proximal muscle weakness and characteristic skin lesions
116
Dermatomyositis - skin features
Photosensitive Macular rash over back and shoulder Heliotrope rash around eyes Gottron's papules = red papules over back of fingers Mechanics hands Nail fold capillary dilation
117
Dermatomyositis - non-skin features
Proximal muscle weakness, may be tender Raynaud's Respiratory muscle weakness Interstitial lung disease Dysphagia Dysphonia
118
Dermatomyositis - causes
Idiopathic Connective tissue disease Malignancy
119
Dermatomyositis - investigations
ANA in 80% Anti-Jo-1 antibodies Anti SRP antibodies Anti-Mi-2 antibodies Screen for underlying malignancy
120
Marfan's syndrome - inheritance
Autosomal dominant
121
Marfan's syndrome - features
``` tall high arched palate long, slim fingers pectus excavatum pes plantus (flat foot) scoliosis ```
122
Marfan's syndrome - complications
Dilation of aortic sinuses = aortic aneurysms, aortic dissection, aortic regurg, mitral valve prolapse Repeat pneumothorax Eyes = upwards lens dislocation, blue sclera, myopia
123
Marfan's syndrome - management
beta blockers avoid vigorous exercise and contact sports surgery - aortic root graft replacement
124
Osteoarthritis - main joints affected in the hand
carpometacarpal DIP PIP
125
Osteoarthritis - xray changes
Loss of joint space Subchondral sclerosis Subchondral cysts Osteophytes at joint margins
126
Osteoarthritis - management
weight loss, support braces, muscle strengthening exercises 1st = paracetamol + topical NSAIDS 2nd = oral NSAIDS (+PPI), opioids, capsaicin cream, intraarticular steroids If not working refer for joint replacement
127
Rheumatoid arthritis - features
Swollen, painful joints in hand and feet Gradually gets worse and involves larger joints Stiffness worse in morning Positive squeeze test
128
Rheumatoid arthritis - late signs O/E of the hands
swan neck deformity boutonniere's deformity
129
Rheumatoid arthritis - investigations
Rheumtaoid factor in 70-80% Anti-cyclic citrulinated antibody - in 70%, specific Raised ESR Raised CRP
130
Most specific antibody test for rheumatoid arthritis?
anti-cyclic citrulinated antibody
131
Rheumatoid arthritis - xray findings
Loss of joint space Juxta-articular osteoporosis Soft tissue swelling Periarticular erosins Subluxation
132
Rheumatoid arthritis - poor prognostic factors
``` Rf positive Anti-CCP antibodies positive Poor functional status at diagnosis Xray shows early erosions (<2 years) HLA DR4 Insidious onset Female ```
133
Rheumatoid arthritis - complications
pulmonary fibrosis, pleural effusion keratoconjunctiva sicca episcleritis, scleritis corneal ulcer, keratits osteoporosis IHD depression
134
What is Felty's syndrome
RA + splenomegaly + low WCC
135
Rheumatoid factor - initial therapy
DMART + bridging prednisolone
136
Rheumatoid factor - treating flares
Oral or IM corticosteroids
137
Rheumatoid arthritis - management
1st line = DMARTS TFT inhibitors if inadequate response to 2x DMARTs
138
Types of DMARDS
Methotrexate Sulfasalazine Lefluzonmide Hydroxychloroquine
139
Types of TNF inhibitors
Etanercept Infliximab Adalimumab
140
Side effects of etanercept
Demyelination | Reactivation of TB
141
Side effects of infliximab
Reactivation of TB
142
Side effects of adalimumab
Reactivation of TB
143
Osteomalacia - causes
Vit D deficiency - malabsorption, lack of sunlight, diet CKD Drugs - anticonvulsants Inherited - hypophosphaemic rickets
144
Osteomalacia - xray changes
Translucent bands called looser's zones or pseudofracture
145
Osteomalacia - management
Vit D supplementation | Calcium supplement if dietary calcium insufficient
146
What is leflunomide?
DMARD used in rheumatoid arthritis
147
Leflunomide - what to monitor
FBC LFT Blood pressure
148
Leflunomide - side effects
Diarrhoea HTN Weight loss Peripheral neuropathy Myelosuppression Pneumonitis
149
Leflunomide - pregnancy
Avoid pregnancy for 2 years after stopping in women and 3 months after stopping in men
150
Leflunomide - contraindications
Pregnancy Pre existing lung disease Pre existing liver disease
151
Hydroxychloroquine - pregnancy
Can be used in pregnancy and breastfeeding
152
Hydroxychloroquine - uses
Rheumatoid arthritis SLE Discoid lupus
153
Hydroxychloroquine - side effects
Retinopathy (bull's eye retinopathy) | Corneal deposits
154
Hydroxychloroquine - monitoring
Annual ophthalmology screening for retinopathy
155
Systemic sclerosis - antibodies
ANA Rheumatoid factor Anti-scl-70 antibodies in diffuse cutaneous Anti-centromere antibodies in limited cutaneous
156
Limited cutaneous systemic sclerosis
CREST is a subtype Scleroderma affects face and distal limbs Anti-centromere antibodies
157
Features of CREST syndrome
``` Calcinosis Raynaud's oEsophageal dismotility Sclerodactyly Telangiectasia ```
158
Diffuse cutaneous systemic sclerosis
Scleroderma affects trunk and proximal lumbs Scl-70 antibodies Interstitial lung disease Pulmonary artery hypertension Renal disease HTN
159
Scleroderma
No internal organ involvement Tightening and fibrosis of skin Plaques on liver
160
Sulfasalazine - uses
Inflammatory arthritis e.g. RA | IBD
161
Sulfasalazine - cautions
G6PD deficiency Allergy to aspirin or sulphonamides
162
Sulfasalazine - side effects
Oligospermia Steven Johnsons Syndrome Pneumonitis/ lung fibrosis Coloured tears, stained contact lens Myelosuppression Heinz body anaemia Megaloblastic anaemia
163
Azathioprine - side effects
Bone marrow suppression N+V Pancreatitis Increased risk of non-melanoma skin cancer
164
Azathioprine - interactions
Allopurinol therefore need lower dose
165
Azathioprine - in pregnancy
Safe
166
What is polymyositis?
Inflammatory disorder causing symmetrical proximal muscle weakness
167
Polymyositis - pathophysiology
T cell mediated cytotoxic process against muscle fibres
168
Polymyositis - associations
Idiopathic Connective tissue disorders Malignancy
169
Polymyositis - features
Proximal muscle weakness, may be tender Raynaud's Respiratory muscle weakness Interstitial lung disease Dysphagia Dysphonia
170
Polymyositis - investigations
Raised CK Muscle biopsy Anti-Jo-1 antibodies
171
Polymyositis - management
Sunblock Exercise to maintain strength Steroids Azathioprine if steroids fail
172
What is polyarteritis nodosa?
Vasculitis affecting medium sized arteries with necrotising inflammation leading to aneurysm formation
173
Polyarteritis nodosa - associations
Hep B
174
Polyarteritis nodosa - who is typically affected?
Middle aged men
175
Polyarteritis nodosa - features
Fever, malaise, arthralgia Hypertension Mononeuritis multiplex Sensorimotor polyneuropathy Testicular pain Haematuria Renal failure Livedo reticularis
176
Polyarteritis nodosa - investigations
Hep B surface antigen pANCA in 20% Biopsy of small artery = necrotising inflammation Arteriography = microaneurysms
177
How many people with Paget's disease of the bone are symptomatic?
1 in 20
178
Paget's disease of the bone - typical presentation
older man with bone pain and isolated rise in ALP
179
Paget's disease of the bone - features
Bone pain - pelvis, lumbar spine, pelvis Bowing of tibia Bossing of skull
180
Paget's disease of the bone - skull xray findings
Thickened vault | Osteoporosis circumscripta
181
Paget's disease of the bone - complications
``` Deafness Bone sarcoma Fracture Skull thickening High output cardiac failure ```
182
Paget's disease of the bone - predisposing factors
Increased age Male Northern latitude Family history
183
Paget's disease of the bone - treatment
Bisphosphonates - oral risedronate or IV zoledronate
184
Indications to treat Paget's disease of the bone
Bone pain Skull or long bone deformity Fracture Peri-articular Paget's
185
What is Paget's disease of the bone?
Increased and uncontrolled bone turnover
186
What is gout?
Microcrystal synovitis caused by deposition of monosodium urate monohydrate in synovium
187
Causes of reduced excretion of uric acid
Diuretics CKD Lead toxicity
188
Causes of increased production of uric acid
Myeloproliferative or lymphoproliferative disorders Cytotoxic drugs Severe psoriasis
189
Gout - features
Pain, swelling, erythema 70% first presentations affect the 1st metatarsophalangeal joint
190
Gout - xray features
Joint effusion Punched out lesions with sclerotic margins Joint space is preserved until late disease Eccentric erosions Soft tissue tophi
191
Gout - acute management
Colchicine or NSAIDS (+PPI) Steroids if both contraindicated Continue allopurinol if already on it
192
Gout - when to start chronic management
After first attack
193
Gout - 1st line chronic management
Allopurinol | With colchicine cover
194
Gout - 2nd line chronic management
febuxostat
195
Gout - precipitating drugs
Thiazide diuretics
196
What is behcet's syndrome?
Autoimmune mediated inflammation of arteries and veins
197
Behcet's syndrome - features
Oral ulcers Genital ulcers Anterior uveitis
198
Antiphospholipid syndrome - secondary causes
SLE Lymphoproliferative disorders
199
Antiphospholipid syndrome - features
Venous and arterial thrombosis Recurrent fetal loss Livedo reticularis
200
Antiphospholipid syndrome - investigations
prolonged APTT | Thrombocytopenia
201
Antiphospholipid syndrome - primary thromboprophylaxis
Low dose aspirin
202
Antiphospholipid syndrome - secondary thromboprophylaxis
1st VTE: warfarin with target INR 2-3 Further VTE: warfarin with target INR 3-4 Arterial thrombus then warfarin INR 2-3
203
Ankylosing spondylitis - features
Young men with lower back pain and stiffness Insidious onset Stiffness worse in the morning and better with exercise Pain at night
204
Ankylosing spondylitis - examination
Reduced lateral flexion Reduced forward flexion, assessed using Schober's test Reduced chest expansion
205
Ankylosing spondylitis - non joint features
Atypical fibrosis Anterior uveitis Aortic regurg AV node block Achilles tendonitis Amyloidosis Cauda equina Peripheral arteritis
206
Ankylosing spondylitis - investigations
Raised ESR, raised CRP MRI spine Xray sacroiliac joint = sacroilitis, squaring of lumbar vertebrae, bamboo spine, syndesmophytes
207
Ankylosing spondylitis - xray of sacroiliac joint findings
sacroilitis squaring of lumbar vertebrae bamboo spine syndesmophytes
208
Ankylosing spondylitis - management
Regular exercise NSAIDS physiotherapy DMARDS only if peripheral joint involvement
209
Osteoporosis - major risk factors
Steroids RA Family history of hip fracture Smoking Alcohol Low BMI
210
Osteoporosis - drug causes
Steroids SSRIs Antiepileptics PPIs Glitazones Heparin
211
Osteoporosis - first line investigations for secondary cause
``` FBC U+E LFT CRP TFT Bone profile ```
212
Bone protection against osteoporosis - management if high risk and <65 years
DEXA scan T score >0 = reassure T score 0 to -1.5 = repeat in 3 years T score < -1.5 = bone protection
213
Bone protection against osteoporosis - management if high risk and >65 years
If high risk or previous fragility fracture then treat
214
Bone protection against steroid induced osteoporosis
Give if taking steroids >3 months Treat with alendronate Should be vitamin D and calcium replete
215
Osteoporosis - 1st line management
Alendronate
216
Osteoporosis - 2nd line management
Risedronate or etidronate
217
Osteoporosis - 3rd line management
If can't tolerate bisphosphonates Strontium ranelate or raloxifene
218
Osteoporosis - who should we treat?
Post-menopausal women and men over 50 with DEXA T score < -2.5 Women >75 with fragility fracture Long term steroids
219
Raloxifene - mechanism of action
Selective oestrogen receptor modulator Prevents bone loss and reduces vertebral fracture No impact on non-vertebral fractures
220
Raloxifene - side effects
Menopausal symptoms Increased risk of VTE Decreased risk of breast cancer
221
Strontium ranelate - mechanism of action
Reduces resorption by osteoclasts and increases deposition by osteoblasts
222
Osteoclasts
Resorb bone
223
Osteoblasts
Deposit bone
224
Strontium ranelate - side effects
Increased cardiovascular events Increased VTE Steven Johnson syndrome
225
Strontium ranelate - contraindications
previous cardiovascular events | previous VTE
226
Bisphosphonates - mechanism of action
inhibit bone absorption by osteoclasts by promoting apoptosis
227
Bisphosphonates - indications
prevention and treatment of osteoporosis hypercalcaemia Paget's disease pain from bony metastases
228
Bisphosphonates - side effects
Oesophagitis, oesophageal ulcers Osteonecrosis of the jaw Atypical stress fractures of femur Hypocalaemica Acute phase response after administration - fever, myalgia, arthralgia
229
Bisphosphonates - instructions when taking
Whilst sitting or standing upright at least 30 minutes before food with water stay upright for 30 minutes afterwards
230
Bisphosphonates - duration when treating osteoporosis
Reassess need after 5 years Stop if patient <75, T score > -2.5, low risk according to FRAX
231
Bisphosphonates - calcium and vitamin D
Give vitamin D | Give calcium only if dietary intake is inadequate
232
What is chronic fatigue syndrome?
>4 months of fatigue affecting function more than 50% of the time No other disease which may explain symptomes
233
Chronic fatigue syndrome - features
``` Fatigue Sleep disturbance Muscle or joint paint Headaches Painful lymph nodes without enlargement Sore throat Lack of concentration ```
234
Chronic fatigue syndrome - investigations
All normal FBC U+E LFT CRP ERP Calcium Ferritin CK Ceoliac screen Glandular fever Urinalysis
235
Chronic fatigue syndrome - management
CBT Graded exercise therapy Pacing Low dose amitryptilline for poor sleep
236
Discoid lupus erythematous - features
``` Erythematous, raised rash May be scaly Photosensitive On face, neck, ears, scalp Lesions heal with atrophy, scarring and pigmentation ```
237
Discoid lupus erythematous - management
Topical steroids Hydroxychloroquine Avoid sun exposure
238
Who should take vitamin D supplements?
Pregnant and breastfeeding Children aged 6 months to 5 years Adults >65 People not exposed to much sun
239
Follow up when taking vitamin D supplements
Calcium level at one month
240
Polymyalgia rheumatica - features, patient age and symptom onset
Patient >60 years Onset in <1 month Aching and morning stiffness in proximal limb muscles
241
Polymyalgia rheumatica - investigations
Raised ESR >40 Raised CRP Normal CK
242
Polymyalgia rheumatica - management
Oral prednisolone Bone protection
243
Polymyalgia rheumatica - management if does not respond well to prednisolone
Refer to secondary care to consider other diagnoses

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