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Rheumatology Flashcards

1
Q

OSTEOARTHRITIS

  1. What is Osteoarthritis?
  2. What are the risk factors?
  3. What are the X-Ray changes associated?
  4. What are joints are commonly affected?
  5. What signs may be seen in hands?
  6. What is the stepwise management?
A
  1. A non-inflammatory condition of “wear and tear”
  2. Being elderly, female, obese, genetics, overuse, injury
  3. Loss of joint space, osteophytes, subchondral cysts, subchondral sclerosis
  4. Hips, knees, DIPs, MCPs, Cervical spine, Wrist, Sacroiliac joints
  5. Heberden’s nodes (DIP), Bouchard’s nodes (PIP), weak grip, reduced range of motion
  6. Help with weight loss, advice, muscle strengthening exercises initially. Then oral paracetamol and topical NSAIDs and topical Capsaicin. Then oral NSAID and PPI. Then opiates and codeine
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2
Q

OSTEOPOROSIS

  1. What is Osteoporosis and Osteopenia?
  2. What are the risk factors?
  3. What medications are a risk factor for Osteoporosis?
  4. What patients should be assessed for Osteoporosis?
  5. What are some baseline investigations for assessing Osteoporosis?
  6. What is the FRAX Tool?
  7. What are results of FRAX Tool if BMD is assessed?
  8. What are results of FRAX Tool if BMD not assessed?
  9. What is the T-score based on?
  10. What is the importance of Z-score?
  11. How do you interpret a T-score?
  12. What is the management of Osteoporosis?
  13. What are some side-effects associated with Bisphosphonates?
  14. How should Bisphosphonates be taken?
A
  1. Osteoporosis is reduced bone density, Osteopenia is a less severe form
  2. Risk factors include being elderly, low BMI, being female, post-menopausal, smoking, alcohol, low activity / mobility, being Caucasian or Asian, endocrine issues such as Hyperthyroidism, GH deficiency, DM
  3. Medications include Glucocorticoids, SSRIs, PPIs, anti-epileptics, anti-oestrogens
  4. Any female over 65, any male over 75, any other person who has had a fragility fracture, is currently or frequently uses glucocorticoids, has a history of falls, family history of osteoporosis, low BMI, smoker, drinks a lot of alcohol
  5. FBC, U&E, LFTs, TFTs, CRP, Bone Profile
  6. FRAX tool indicates your 10-year risk of a fragility fracture
  7. If BMD is assessed, FRAX gives one of 3 options 1) Reassure, 2) Consider treatment 3) Strongly consider
  8. If BMD is not assessed, FRAX gives one of 3 options 1) Low risk, reassure 2) Intermediate, offer BMD, 3) High, offer bone protection
  9. T-Score is based on bone health of a young person
  10. Z-Score is adjusted for age, gender, ethnicity
  11. If between 0 and -1, normal. If between -1 and -2.5, osteopenia, if below -2.5, osteoporosis. If below -2.5 and fracture, severe osteoporosis
  12. Offer all patients Calcium and Vitamin D. Also consider Bisphosphonates i.e. Alendronic acid. If cannot tolerate, consider Risendronate or Etidonate. If cannot tolerate, consider Ranelate, Raloxifene
  13. Gastric erosions, reflex, osteonecrosis of jaw, osteonecrosis of auditory canal
  14. On empty stomach, keep upright for 30mins
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3
Q

OSTEOMALACIA

  1. What is Osteomalacia? What is rickets?
  2. How is Vitamin D synthesized?
  3. What conditions may cause Vit D deficiency?
  4. What is the function of Vit D with respect to bone?
  5. Low Ca2+ has what effect on parathyroid?
  6. What are reference ranges for Vitamin D?
  7. What other investigations might you order, what may be seen?
  8. How do you manage Osteomalacia?
A
  1. Refers to bone softening due defective bone mineralisation. Rickets is the form in children before closure of growth plates
  2. Vitamin D is synthesized in the skin from cholesterol with the help of UV radiation
  3. Malabsorption diseases i.e. IBD, CKD whereby the kidneys fail to active Vitamin D to absorb Ca2+ and PO43-
  4. Vitamin D helps absorb Calcium and Phosphate from intestines and kidneys into blood, to facilitate bone mineralisation.
  5. Hypocalcemia will cause Type 2 hyperparathyroidism, stimulating osteoclast activity to increase serum calcium levels
  6. Below 25 = Vit D deficiency, 25-50 = Vit D insufficiency, above 75 = Optical
  7. Ca2+ (low), PO43- (low), PTH (high), ALP (high), XR (osteopenia), DEXA (low BMD)
  8. Vit D supplementation
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4
Q

GOUT

  1. What is gout?
  2. How is an acute episode of gout treated?
  3. What is the prophylaxis for gout? 1st and 2nd line
  4. When is gout prophylaxis offered?
  5. What are some lifestyle modifications to reduce gout?
  6. What joint is most commonly affected?
  7. What other joints are affected?
  8. What crystals are seen in gout on joint aspiration?
  9. What radiological features are associated with gout?
  10. What drug(s) may exacerbate gout?
A
  1. An inflammatory arthritis, where patients have discrete episodes lasting several days followed by being symptom free
  2. Colchicine and NSAIDs
  3. Allopurinol, 1st line, Febuxostat, 2nd line
  4. Offered after the first flare has settled. During subsequent flares can continue taking them
  5. Reduce alcohol intake, reduce purine rich foods, weight loss if obese
  6. MTP of foot
  7. Ankle, feet, hand joints, wrist, elbow, knee
  8. Negatively birefringent needle shaped crystals
  9. Punched out erosions with overhanging edges, preservation of joint space, eccentric erosions. No osteopenia
  10. Thiazides, ARBs i.e. Losartan
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5
Q

PSEUDOGOUT

  1. What is Pseudogout? What crystals?
  2. On joint aspiration, what is seen?
  3. On XR, what is seen?
  4. What are risk factors?
  5. What is the management?
A
  1. A crystal arthropathy caused by deposition of calcium pyrophosphate
  2. Positively birefringent rhomboid shaped crystals
  3. Chondrocalcinosis
  4. Haemochromatosis, Acromegaly, Wilson’s Disease, low Mg, low Phosphate, hYPERparathyroidism
  5. NSAIDs, Steroids
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6
Q

REACTIVE ARTHRITIS

  1. What is it?
  2. When does it occur?
  3. What is it commonly caused by?
  4. What is an important differential diagnosis?
  5. What are the features?
  6. What is the management?
  7. What is the prognosis?
A
  1. A synovitis in the joint as a reaction to a recent infective trigger
  2. Usually within 4 weeks of infection
  3. Gastroenteritis, STIs i.e. Chlamydia
  4. Septic Arthritis
  5. Bilateral conjunctivitis, Urethritis, Arthritis, Anterior Uveitis, Circinate balinitis, Keratoderma blenorrhagica
  6. NSAIDs, Steroids
  7. Better by 6 months
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7
Q

PAGET’S DISEASE

  1. What is it?
  2. Which bones are commonly affected?
  3. What are the symptoms?
  4. What is the specific blood test result?
  5. What are XR findings?
  6. What is the management?
  7. What are the complications?
A
  1. A disease characterised by disordered bone turnover, both increased osteoclast and osteoblast activity
  2. Long bones, the skull, spine and pelvis
  3. Bone pain, fractures, hearing loss
  4. Solitary rise in ALP
  5. Sclerosis and lysis, skull thickening, cotton wool skull, V shaped defects on long bones
  6. Bisphosphonates
  7. Osteosarcoma, spinal stenosis
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8
Q

ANTIPHOSPHOLIPID SYNDROME

  1. What is it?
  2. What is it associated with?
  3. What are some features?
  4. How is it diagnosed? Blood test results?
  5. How is it managed in patients who are pregnant?
  6. How is it managed as primary prophylaxis?
  7. How is it managed as secondary prophylaxis?
A
  1. An acquired disorder associated with antiphospholipid antibodies where blood is prone to clotting
  2. Associated with SLE and Libman Sachs Endocarditis
  3. Venous and arterial thromboembolism, livedo reticularis, thrombocytopenia, recurrent miscarriages
  4. Diagnosed with clinical features alongside prolonged APTT and positive cardiolipin antibodies or lupus anticoagulant
  5. Aspirin + LMWH
  6. Low dose aspirin
  7. Lifelong warfarin, INR 2-3, or 3-4 if recurrent
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9
Q

PSORIATIC ARTHRITIS

  1. What is it?
  2. When does it develop?
  3. What is the severe form of this condition called?
  4. What are the features seen in hands?
  5. What is seen on XRay?
  6. How is it managed?
A
  1. An inflammatory arthritis associated with psoriasis
  2. Usually within 10 years of Psoriasis diagnosis
  3. Arthritis Mutilans
  4. Psoriatic skin plaques, nail pitting, onychylosis, dactylitis, enthesitis
  5. Pencil in cup appearance
  6. Similar to Rheumatoid Arthritis, so NSAIDs, DMARDs, Anti-TNF medications
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10
Q

POLYMYALGIA RHEUMATICA

  1. What is it?
  2. What is it strongly associated with?
  3. What patients are commonly affected?
  4. Do patients get weakness?
  5. What do blood tests show?
  6. What is the management?
  7. What is the DON’T STOP mnemonic for steroids?
A
  1. An inflammatory condition which causes pain and stiffness, in neck, shoulders, pelvic girdle
  2. Strongly associated with Giant Cell Arteritis
  3. Women, older age >50, caucasion
  4. NO WEAKNESS
  5. Raised ESR, CRP, Plasma viscosity
  6. 15mg Prednisolone a day, re-assess after 1 week if no improvement reconsider diagnosis. Re-assess again after 3-4 weeks
  7. Educate patients not to discontinue due to risk of adrenal crisis. Sick day rules: increase dose if unwell. Treatment card: Carry one around. Osteoporosis prevention i.e. Bisphosphonates, Vitamin D and calcium supplementation. PPI for protection against steroids causing ulcers
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11
Q

ANKYLOSING SPONDYLITIS

  1. What is it?
  2. What patients are commonly affected?
  3. What may be seen on XRay?
  4. What may be seen on blood tests?
  5. What may be seen on examination?
  6. What are the associated features?
  7. What is the management?
A
  1. An inflammatory condition affecting the spine, causing stiffness and pain
  2. Young males (3:1), 20-30 years old
  3. Bamboo spine, squaring of vertebrae, sacroiliitis. On CXR: apical fibrosis
  4. Raised CRP, ESR
  5. Schober’s test <5 cm
  6. Apical fibrosis, anterior uveitis, aortic regurgitation, AV heart block, amyloidosis, achilles tendonitis, arthritis (peripheral), and cauda equina
  7. Regular exercise, NSAIDs, physio, DMARDs, Anti-TNF
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12
Q

RHEUMATOID ARTHRITIS

  1. What is it?
  2. What genes are associated with it?
  3. What antibodies are associated with it?
  4. What joints are affected? Which aren’t?
  5. What are the symptoms?
  6. What is Palindromic Rheumatism?
  7. What is Atlantoaxial Subluxation?
  8. What tests must be ordered for patients with Atlantoaxial Subluxation?
  9. What signs may be visible in hands?
  10. What are some extra-articular manifestations?
  11. What may be seen on XR?
  12. How can Rheumatoid Arthritis be monitored?
  13. What is 1st, 2nd, 3rd, 4th line management?
  14. What is used to induce remission of a flare?
  15. Side effects of MTX?
  16. Side effects of SSZ?
  17. Side effects of Levoflunamide?
  18. Side effects of Hydroxychloroquine?
  19. Side effects of Biologics? What must be ordered?
  20. What is Felty’s Syndrome?
  21. What are some complications of Rheumatoid Arthritis?
  22. What drugs for Rheumatoid Arthritis are safe in pregnancy?
  23. What are some poor prognostic factors of Rheumatoid Arthritis?
A
  1. Rheumatoid Arthritis is an autoimmune, inflammatory, symmetrical, distal polyarthropathy
  2. HLA-DR1 and HLA-DR4
  3. Rheumatoid Factor, Anti-CCP
  4. MTP, PIP joints. Ankle, wrist, cervical spine. DIP is rarely affected
  5. Pain, stiffness, swelling, muscle aches, fatigue, weakness, weight loss
  6. Symptoms which only last for 1-2 days
  7. A feature in some patients with Rheumatoid Arthritis, affecting the cervical spine. C2 and odontoid peg shift, causing spinal cord compression which is important if having anaesthetic
  8. AP and lateral radiographs
  9. MCP/PIP joints affected. May have Swan Neck or Boutonniere deformity. Z-shaped deformity and Ulnar deviation
  10. Pulmonary fibrosis, Felty’s syndrome, Bronchiolitis Obliterans, Secondary Sjorgen’s syndrome
  11. Joint destruction, soft tissue swelling, bony erosions, periarticular osteopenia
  12. CRP and DAS28
  13. 1st line (Any DMARD i.e. MTX, SSZ, Levoflunamide, Hydroxychloroquinine). 2nd line (Any two of these in combination). 3rd line (MTX plus a Biologic). 4th line (MTX plus Retuximab)
  14. Oral / IM Prednisolone
  15. Pneumonitis, Pulmonary fibrosis
  16. Reduced Sperm count
  17. HTN, Peripheral neuropathy
  18. Nightmares, retinopathy, corneal deposits
  19. Reactivation of TB, hence must request CXR
  20. RA + splenomegaly + neutropenia
  21. Respiratory (Pulmonary fibrosis, bronchiolitis obliterans, MTX pneumonitis), Ocular (Episcleritis, scleritis), Osteoporosis, IHD, Felty’s
  22. SSZ and Hydroxychloroquine
  23. RF, anti-CCP, HLA DR4 positive, male, younger onset, poor symptoms on initial presentation
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13
Q

SYSTEMIC LUPUS ERYTHEMATOSUS

  1. What is it?
  2. What are the features?
  3. What are some investigations?
  4. What is useful to monitor the disease?
  5. What are some complications of SLE?
  6. What is the management?
A
  1. An inflammatory, autoimmune connective tissue disorder
  2. Hair loss, photosensitive malar butterfly rash, lymphadenopathy, shortness of breath, splenomegaly, arthralgia, myalgia, Reynaud’s phenomenon
  3. FBC (anaemia of chronic disease), C3 & C4 complement (low during active disease), CRP & ESR (high during active disease), Urinalysis + renal biopsy (Lupus nephritis), ANA (rule out test, high sensitivity), anti-dsDNA (high sensitivity)
  4. C3 & C4, will be low during active disease
  5. CVD (leading cause of death), infection from immunosupression, anaemia of chronic disease, pericarditis, lupus nephritis, recurrent miscarriage / VTE (link with antiphospholipid syndrome)
  6. NSAIDs, Steroids, Hydroxychloroquine (for mild disease), MTX (for more severe)
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14
Q
  1. What are the skin disorders associated with SLE?
  2. What can DLE progress into?
  3. Which patients is DLE more common in?
A
  1. Photosensitive, malar butterfly rash, alopecia, livedo reticularis and discoid lupus erythematosus
  2. Squamous cell carcinoma
  3. Young, african women
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15
Q

What drugs may cause Lupus?

What investigation will confirm this?

A

Isoniazid
Procainamide
Phenytoin
Hydralazine

PRESENCE OF ANTI-HISTONE ANTIBODIES

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16
Q

SJOGREN’S SYNDROME

  1. What is it?
  2. What are the symptoms?
  3. What is the management?
  4. What antibodies is it associated with?
  5. What is primary and secondary Sjogren’s? What is it associated with?
  6. What test can be used to help diagnose? What is a positive result?
  7. What are the complications?
A
  1. An autoimmune condition affecting the exocrine glands, causing dry mucous membranes
  2. Dry eyes, dry mouth, dry vagina
  3. Artificial tears, artificial saliva, vaginal lubricants, hydroxychloroquine
  4. Anti-Ro and Anti-La
  5. Primary, appears on it’s own. Secondary is to rheumatoid arthritis or SLE
  6. Schirmer’s test, anything below 10mm is significant
  7. Complications include:
    Eye - corneal ulcers, infection, conjunctivitis
    Mouth - oral candidiasis, dental cavities
    Vagina - candidiasis, sexual dysfunction
17
Q

SYSTEMIC SCLEROSIS

  1. What is it?
  2. What are the three main forms?
  3. What is Limited Cutaneous Systemic Sclerosis?
  4. Where does LCSS primarily affect?
  5. What is the antibody associated with LCSS?
  6. What is Diffuse Cutaneous Systemic Sclerosis?
  7. where does DCSS primarily affect?
  8. What is the antibody associated with DCSS?
  9. How can it be diagnosed?
A
  1. An autoimmune, inflammatory fibrotic connective tissue disorder
  2. Limited Cutaneous Systemic Sclerosis, Diffuse Cutaneous System Sclerosis, Scleroderma
  3. LCSS has features of CREST (Calcinosis, Reynaud’s, Esophageal dysmotility, Sclerodactyly, Telangiectasia)
  4. Face and distal limbs
  5. Anti-centromere antibodies
  6. Has features of CREST, plus internal involvement of organs i.e. CV problems, lung problems, renal problems
  7. Trunk and proximal limbs
  8. Scl-70 antibodies
  9. Nailfold capillaroscopy
18
Q

POLYMYOSITIS & DERMATOMYOSITIS

  1. What is it?
  2. What does blood tests show?
  3. What auto-antibodies are associated?
  4. What are the clinical features of polymyositis?
  5. What are the clinical features dermatomyositis?
  6. What should be also be investigated?
  7. What is the management?
A
  1. An autoimmune disorder of chronic inflammation, of muscles and skin
  2. Elevated Creatinine Kinase
  3. Anti-Jo, Anti-Mi2, ANA
  4. Muscle pain, fatigue, weakness, bilaterally affecting shoulder muscles and pelvic girdle, lasts many weeks
  5. As above PLUS skin features i.e. Gottron papules, purple rash on eyelids and face, photosensitive rash, subcutaneous calcinosis, Raynaud’s, periorbital oedema
  6. It is also a paraneoplastic syndrome, hence investigate for malignancy i.e. Breast, Lung, Ovarian, Gastric
  7. Corticosteroids
19
Q

In lateral and medial epicondylitis, what movements make the pain worse?

A

Lateral epicondylitis -> extension and supination

Medial epicondylitis -> flexion and pronation

20
Q

MARFAN’S SYNDROME

  1. What is it?
  2. What is the inheritance pattern?
  3. What are some signs?
  4. How do you manage it?
  5. What might you perform on examination during an OSCE?
A
  1. A connective tissue disorder, due to a mutation in the fibrillin-1 gene
  2. Autosomal dominant
  3. Upward dislocation of lens, downward sloping palpebral fissures, high arched palate, long neck, pectus excavatum / carinatum, mitral valve prolapse, aortic dissection, aortic regurgitation, pneumothoraces, scoliosis >20 degrees, long limbs, arm span:height >1.05, arachnodactyly, pes planus
  4. Regular echocardiogram monitoring, review by ophthalmology, BBs, ACEIs, ARBs, physiotherapy, genetic counselling
  5. Hypermobility exercises to calculate Beighton score, cross thumb across palm & wrap thumb and fingers around wrist for arachnodactyly, check span length wrt height, look for high arched palate, auscultate heart for murmurs
21
Q

BEHCET’S DISEASE

  1. What is it?
  2. What gene is it associated with?
  3. What are the main features of Behcet’s Disease?
  4. What are some of the differentials of oral ulcers?
  5. What is the main investigation?
  6. What is the management?
A
  1. A complex inflammatory multisystem disorder of recurrent oral and genital ulcer
  2. HLA-B51
  3. Oral ulcers (painful, with red halo), genital ulcers, anterior uveitis, DVTs, thrombophlebitis, erythema nodosum
  4. Behcet’s Disease, Simple apthous ulcers, IBD, Coeliacs, B12 / Folate / Iron deficiency, HSV, Hand foot and mouth and SSC
  5. Pathergy test
  6. Steroids
22
Q

VASCULITIS

  1. State the names of 4 small vessel vasculitic conditions
  2. State the names of 3 medium vessel vasculitic conditions
  3. State the names of 2 large vessel vasculitic conditions
  4. pANCA is associated with what vasculitic condition?
  5. cANCA is associated with what vasculitic condition?
  6. What are the features of Henoch-Schonlein purpura?
  7. What is the management of Henoch-Schonlein purpura?
  8. What are the features of Eosinophillic Granulomatosus with Polyangiitis?
  9. What are the features of Microscopic Polyangiitis?
  10. What are the features of Granulomatosis with Polyangiitis?
  11. What are the features of Polyarteritis Nodosa?
  12. What are the features of Kawasaki’s?
  13. What is the management of Kawasaki’s?
A
  1. Henoch-Schonlein Pupura, Granulomatosis with Polyangitis, Eosinophillic Granulomatosis with Polyangiitis, Microscopic Polyangiitis
  2. Eosinophillic Granulomatosis with Polyangiitis, Polyarteritis Nodosa, Kawasaki’s
  3. Takasayu’s arteritis, Giant Cell Arteritis
  4. Eosinophillic Granulomatosis with Polyangiitis (Churg Strauss)
  5. Granulomatosis with Polyangiitis (Wegener’s)
  6. Purpuric rash on buttock, polyarthalgia, abdo pain, nephropathy
  7. Supportive management, i.e. fluids, analgesia, rest
  8. High eosinophils, asthma, paranasal sinisitus
  9. Mainly renal, i.e. haematuria, proteinuria
  10. Sinusitis, Epistaxis, Haemoptysis, Renal Failure, Saddle shaped nose
  11. Livedo Reticularis. Associated with Hep B
  12. High fever, rash, conjunctivitis, strawberry tongue
  13. Aspirin. Screen for coronary artery aneurysms
23
Q

ELBOW PAIN

  1. What is Lateral Epicondylitis also known as?
  2. What are the features of Lateral Epicondylitis?
  3. What is the management of Lateral Epicondylitis?
  4. What is Medial Epicondylitis also known as?
  5. What are the features of Medial Epicondylitis?
  6. What is a good differential for Medial Epicondylitis?
  7. What is a good differential for Lateral Epicondylitis?
  8. What are the features of Cubital Tunnel Syndrome?
  9. What are the features of Radial Tunnel Syndrome?
  10. What is Olecranon Bursitis?
  11. What is the management of Olecranon Bursitis?
  12. What may be other differentials for Elbow Pain?
A
  1. Tennis elbow
  2. Pain and tenderness over the lateral epicondylitis, with pain on wrist extension and forearm supination
  3. NSAIDs and Paracetamol
  4. Golfer’s elbow
  5. Pain and tenderness over the medial epicondylitis, with pain on wrist flexion and forearm pronation. May also have Ulnar nerve involvement (paresthesia of 4th and 5th fingers)
  6. Cubital tunnel syndrome
  7. Radial tunnel syndrome
  8. Compression of ulnar nerve, hence paresthesia of 4th and 5th fingers. May be worse on resting on firm surfaces
  9. Pain 4-5cm distal to the lateral epicondylitis, pain worse on extension and PROnation
  10. Inflammation of the Olecranon Bursae, may have swelling over the elbow and pain when bursa compressed
  11. Elbow pads, changing activity, oral NSAIDs, surgical drainage if infected
  12. Osteoarthritis, rheumatoid arthritis, septic arthritis, reactive arthritis, cellulitis
24
Q

MULTIPLE MYELOMA

  1. What are the features?
  2. What are some blood test investigations?
  3. What are some imaging investigations?
  4. What are special test investigations?
  5. What is the medical and surgical management?
A
  1. CRABBI
    C - Hypercalcaemia (stones, bones, abdominal groans, thrones, psychiatric overtones)
    R - Renal failure due to Bence Jones protein
    A - Anaemia
    B - Bleeding, i.e. thrombocytopenia
    B - Bone pain in back
    I - Infections
  2. FBC: anaemia, LFTs: high ALP, U&Es: high urea, high calcium, Blood film: Rouleaux formation
  3. Whole body MRI: skeletal surgery, Head XR: raindrop skull
  4. Urine electrophoresis: Bence Jones protein, Bone marrow aspirate, Trephine biopsy
  5. Medical: Chemotherapy, bisphosphonates
    Surgical: Stem cell transplantation
25
Q

BACK PAIN

  1. What are some causes of Back Pain?
A

Ankylosing Spondylitis, Cauda Equina, Osteoarthritis, Osteoporosis, Multiple Myeloma, Spinal Stenosis

Rheumatology (1 decks)

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