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Flashcards in CDM possible exam Qs Deck (61):
1

List five things in a joint that can cause pain

- synovium
- periosteum
- joint capsule
- ligaments
- subchondral bone

2

List four pathological disease process of a joint

- Synovitis
- Infection
- Crystal deposition
- Enthesitis
- Structural and mechanical derangement

3

List four event occurring in synovitis

- Neovascularisation
- Infiltration of synovium with lymphocytes, plasma cells and macrophages
- Masses of proliferating syncopates and invading inflame cells leads to panes formation
--> pannus can destroy articular structures
- Synovial cell hyperplasia

4

List four types of crystals

- Monosodium urate (gout)
- Calcium pyrophosphate dihydrate (pseudogout)
- Calcium phosphate (hydroxyapatite)
- Calcium oxalate

5

List the four key events in enthesitis

Inflammation of enthesis results in metaplasia of radially orientated collagen fibres giving rise to fibrous bone formation
->metaplasia: new set of cells developed to replace current set that was unable to handle situation
-> new bone formation (2nd to periostitis)
-> gradual ossification of syndesmosis
-> syndesmophytes formation along outer fibres of vertebral discs

6

List four examples of entheseal sites

- Tendons and bone
- Ligaments and bone
- Cortical bone and periosteum
- Vertebral bodies and annulus fibrosis

7

Compare RA and OA joint stiffness

RA
- stiff upon waking, persists for more than 30-60 mins

OA
- occurs upon waking or following periods of inactivity, but is usually brief <30 mins

8

Compare RA and OA joint pain

RA
- occurs with both rest and with motion
- worse at beginning of movements and improves

OA
- occurs mainly or only during movement
- improves with rest

9

Compare RA and OA joint swelling

RA
- synovial hypertrophy and synovial effusion
- inflammation of periarticular structures
- degree of swelling varies over time

OA
- osteophyte formation and bone swelling
- ST swelling can contribute - cysts, thickening and effusion

10

List six descriptors to help diagnose a painful joint

Onset:
- abrupt
- insidious
Distribution
- Asymmetrical
- Symmetrical
Duration of ssx
- Acute
- Chronic
Joint involvement
- migratory
- additive
- intermittent
Number of joints affected
- mono
- oligo
- poly
Extra-articular manifestations
- systemic ssx
- skin lesions
- ocular lesions

11

List six descriptors for joint pain

- sharp
- achy
- stabbing
- burning
- throbbing
- pulsating

12

List six signs of inflammatory joint disease

- Synovial hypertrophy
- Joint effusion (synovial inflammation; trauma; haemarthrosis)
- Pain with motion
- Limited ROM (capsular pattern)
- Erythema (vasodilation - acute inflammatory arthritis)
- Warmth
- Joint tenderness

13

Define:
monoarthritis:
oligoarthritis:
polyarthritis:

monoarthritis:
when only one joint is affected

oligoarthritis:
between 2-4 joints are affected

polyarthritis: more than 5 joints affected

14

List three categories of joint pain

In true joint pain, three broad categories of joint disease must be differentiated, they may occur concurrently in the same joint;
- Inflammatory arthritides
- Non-inflammatory arthritides
- Arthralgia

15

List three ssx of joint disease

- pain
- swelling
- stiffness
- Loss of ROM
- fatigue
- weakness

16

Joint involvement may be classified as

- migratory
- additive
- intermittent

17

Manifestations of rheumatoid conditions can be arbitrarily divided into

Constitutional
Extra-articular
Articular

18

List four conditions in which typically present with a skin lesion/rash

SLE = malar rash
Dermatomyositis = Gottron's papules
Systemic Sclerosis = dermal induration due to fibrosis
Psoriatic arthritis = psoriasis preceding inflammation

19

List three conditions presenting with ocular lesions

RA = scleritis
AS = anterior uveitis
ReA = conjunctivitis

20

List three conditions that present with systemic manifestations

RA
PsA
PMDM

21

List the signs of degenerative joint disease

- Bony overgrowth (bouchards nodes)
- Limited ROM
- Crepitus (grating sensation)
- Joint deformity

22

Define CRP

C-reactive protein is an inflammatory marker produced by the liver in the presence of inflammatory cytokines (interleukin 1 & 6) when there is tissue damage, autoimmune disease or infection

23

What does CRP tell you that ESR doesn't

- more sensitive than ESR
- rises and falls faster than ESR
- better mirrors extent pf tissue damage than ESR
- Is independent of factors that raise ESR
- correlates better with disease activity

24

Define ANA testing

ANA testing is used to detect pathological antibodies which target specific nuclear antigens. Generally presents in those with autoimmune disorders

25

When would ANA titres be elevated?

- normal people
- in people with autoimmune conditions
- in those with rheumatic conditions

26

Name three diseases in which ANA titres would be elevated

- SLE
- Sjogren's
- Polymyositis
- Mixed connective tissue disorder
- Systemic Sclerosis

27

When would you order ANA tests?

ANA testing is particularly useful in the diagnosis of SLE
nearly all patients with SLE have positive ANA test (93% sensitivity, 57% specificity)

28

Define Alkaline Phosphatase testing

ALP is a group of isoenzymes produced by the liver cells and bone tissue. When these cells are destroyed serum ALP increases

29

When would ALP be elevated

ALP is elevated in pathological conditions that increase bone turnover or destruction i.e. paget's
Also elevated in non-musculoskeletal cases i.e. obstructive biliary cirrhosis

30

Name three diseases in which ALP is elevated



When would you order ALP tests =?

- Paget's
- Hyperparathyroid
- Rickets
- Osteomalacia

To aid Dx of liver and bone diseases

31

Define Rheumatoid factor testing

Test to detect a group of autoantibodies (usually IgM) that for immune complexes that deposit in the tissues, resulting in complement activation and inflammation

32

When would RF titres be elevated?

In normal people
People with autoimmune diseases
In rheumatic conditions

33

Name three specific disease for RF

- RA
- SLE
- SSC
- PMDM

34

when would you order RF testing

Support clinical diagnosis of RA
- is not pathognomonic

35

Define ESR

Highly sensitive non-specific and inexpensive test for tissue damage and inflammation by a measure of heigh that erythrocytes fall through plasma in a westergren tube over an hour. Falling rate is slowed by acute phase proteins and immunoglobulins in the serum

36

When would ESR be elevated?

- Inflammatory conditions
- If extensive tissue necrosis has occurred

37

Name three specific conditions ESR is associated with

- infection
- cancers
- autoimmune diseases i.e. PMDM

38

When would you order ESR?

to aid diagnosis of a particular disease

39

Name a test that would be used to diagnose the following: (give justification)
OA
RA
Gout
Pseudogout
SLE
Infective Arthritis
PMR

OA
- synovial fluid examination (exclude the presence of inflammatory arthritis or cystalopathy)
RA
- RF titres (80% pt have it but not diagnostic)
Gout
- synovial fluid analysis (negatively bifringent needle shaped crystals)
Pseudogout
- synovial fluid analysis (positively bifingent cuboid shaped crystals)
SLE
- ANA testing (high titres of antinuclear antibodies)
Infective Arthritis
- synovial fluid analysis (positive for presence of immune cells and initiating bacteria)
PMR
- ESR (significantly increased in this condition)

40

List five indications for synovial fluid joint aspiration

- Inflammatory conditions
- Cancer
- Autoimmune disease
- PMR

41

List five conditions which might cause increased CRP

- RA
- SLE
- SSC
- Polymyositis
- Dermatomyositis

42

Define arthography

A test performed using X-rau, CT or MRI to produce a series of images of a joint after administration of a contrast medium

43

Indications of arthography

- Mainly used to diagnose cause of persisitent, unexplained knee or shoulder pain
- To visualise meniscus, cartilage and ligaments on bone
- To visual joint derangement and synovial cysts

44

Define HLA-B27

A test to determine the presence of human leukocyte antigen, which is a surface antigen encoded by the B locus on the major histocompatibility complex on chromosome 6. it presents antigen peptides to T cells to differentaite self from non-self

45

When would HLA-B27 be elevated

- AS
- PsA
- Juvenile AS
- IBD
- Spondylitis
- ReA

46

define creatine kinase

test used to determine the level of creatine kinase in the blood stream, it is most sensitive to mm injury

47

When would CK be elevated?

- crush injury
- Rhabdomyolysis
- muscular dystrophy
- myositis

48

List four ominous radiological findings indicating malignancy

- diffuse hazy invasion of bone
- extensive bone deformity
- diffuse periosteal new bone formation
- extension of tumour into neighbouring ST

49

List four radiolgrahic findings of a giant cell tumour

- radiolucent areas situated in the end on long bones
- lesion is bounded by subchondral bone
- central lesion may have soap bubble appearance
- thinning and ballooning of cortex occurs

50

List four radiographic findings of a simple bone cyst

- well demarcated
- radiolucent
- occurring in metaphysis
- may extend to physeal plate
- cortical thinning and expansion

51

List four lab results that would indicate malignant disease

FBC - anaemia
ESR - elevated in maligancy
Serum protein electrophoresis - elevated IgG
Serum acid phosphatase - elevated

52

Incidence, distribution, pathology, clinical picture, radiological features, diagnostic investigations and treatment of

OSTEOSARCOMA

Incidence:
- rare but highly malignant
- primarily a malignancy of childhood/adolescence
- possible complication of Paget's disease

Distribution
- may affect any bone - usually the metaphysis of long bones esp. the knee or pro humerus

Pathology
- destroys and replaces bone
- results in:
> bone loss
> abnormal new bone esp. periosteal margins
- spreads towards periosteym and surrounding ST
- May cross the epiphyseal plate
- histologically arises from primitive bone forming cells
- METs occur early via blood often to the lung

Clinical picture
- pain is the first symptom
> constant
> worse at night
> gradually increasing in severity
- lump or swelling
- tenderness
- overlying tissues may be inflamed

Radiological features
- hazy, osteolytic areas
- dense osteoblastic areas
- poor definition of endosteal margin
- breaching of cortex
> spread to adjacent tissue
> new bone extending from cortex
> sunburst effect
- reactive new bone formation (periosteal elevation)
- pulmonary METs

Dx investigations
- increased ESR
- +/- increased serum ALP
- blood tests show elevated WBC
- xray
- bone scan = increased uptake by neoplasm

Tx
- surgery
- chemo

53

Incidence, distribution, pathology, clinical picture, radiological features, diagnostic investigations and treatment of

CHONDROSARCOMA

A collective term for a group of malignant mesenchymal tumours that are mainly made up of cartilage cells that produce cartilage matrix

Incidence
- second most common bone malignancy
- M:F = 1.5:1
- age?

Distribution
- most common in the femur, humerus, ribs and pelvis

Pathology
- slow growing tumour
- can become very large
- derived from cartilage
- produces cartilage
- late metastasis

Clinical picture
- local pain (deep dull ache)
- pain at night
- local swelling
- decreased ROM when tumour is near joint
- path F#

pelvic tumour will cause additional ssx incl. -
- urinary frequency or obstruction, high groin mm pain and nerve dysfunction

Radiological findings
Primary
- usually large lesion >5cm
- radiolucent area (due to bone destruction)
- variable amounts of stippled calcification
- globular mass on surface of bone
- periosteal new bone formation
Secondary
- patches of calcification in the cartilage cap of osteochondroma

Tx:
- surgery

Lab investigations:
? Would be same as any malignancy?

54

Fibrosarcoma

A tumour of mesenchymal origin, which is composed of malignant fibroblasts in a collagen matrix

Epidemiology/incidence
- rare in bone (<5% of all primary bone tumours)
- M:F = 1:1
- most common in adults 30-60 yoa

Distribution:
- occurs in the metaphysics or diametaphyseal region of long bone. usually occur in LL, esp. femur and tibia followed by the pelvis

Pathology
Primary
- may originate in bone or invade bone from nearby connective tissue
Secondary
- can be secondary to; Paget's, FD, GCT, bone infarct or chronic osteomyelitis

clinical picture:
- localised painful mass
- Path F#

Radiological features:
- osteolytic
- well-defined or ragged margin
- periosteal reaction is seen with cortical destruction
- extension into ST is common
CT & MRI are primarily used to define extent of tumour

Tx:
- surgery
- pre and post operative radiation

Labs:
?

55

Incidence, distribution, pathology, clinical picture, radiological features, diagnostic investigations and treatment of

Ewing's Sarcoma

A primary malignant bone tumour whose small round tumour cells resemble those of lymphoma or neuroblastoma

epidemiology/incidence
- 10-15% of all bone sarcomas
- bone tumour with youngest predilection
- median age 15 years
- >50% of patients are adolescents
- peak incidence in 2nd decade

Pathology:
?

Clinical Picture:
- localised pain
- palpable mass
- path F#
- asymmetric neuro ssx

Radiological features:
general -
- large
- poorly marginated
- >80% extend into ST
Plain xray:
- variable but usually have aggressive appearance
- common findings incl. permeative, laminated periosteum, sclerosis
MRI & CT are used to examine bone lesions MRI is best for ST

Tx:
- chemo
- surgery

Labs:
blood test -
- increased ALP
- hypercalcemia

56

Define Antiphosphlipid Antibody testing

ALPA are a group of antibodies directed against phospholipid associated proteins such as
- prothrombin
- cardiolipin
- beta 2 glycoprotein 1

57

Who has ALPAs?

- normal people have elevated levels following acute medical illness and infections
- people suffering SLE
- Antiphospholipid antibody syndrome

58

Indications for ALPA testing

• Unexplained thrombotic episodes
• Recurrent miscarriages
• Thrombocytopenia
• Prolonged PTT test
• Symptoms indicative of autoimmune disease

59

Define Cryoglobulin testing

Cryoglobulins are a group of abnormal serum immunoglobulins that precipitate (separate) at low temperatures
Cryoglobulin particles float in the serum & precipitate at the bottom of the test tube at 4 degrees C
Particles dissolve on re-warming of serum to body temperature
Precipitated cryoglobulins can lead to;
Thrombosis → increased blood viscosity slows blood flow
Ischemic necrosis → due to small blood vessel blockage
Vasculitis → cryos activate immune system

60

Who would have elevated cryoglobulins?

Not specific for any conditions, produced in a number of conditions including;
• Autoimmune diseases
• Infections
• Lymphoproliferative diseases
• Vasculitic conditions
• Glomerulonephritis

61

Indications for cryoglobulin testing

Ordered in people with ssx suggestive of cryoglobulinaemia;
• Bruising
• Rashes
• Joint pain
• Weakness
• Raynaud’s phenomenon
NOTE: All these ssx can be due to SLE