Clinical Flashcards
(235 cards)
1
Q
what is the normal temperature range?
A
- 36.5 to 37.5 (NICE guidance)
2
Q
how does acute tonsilitis present?
A
- swollen, red tonsils
- (sometimes covered in white bits)
3
Q
what is the causative microorganism for acute tonsilitis?
A
- Streptococcus pyogenes
- (often called group A Streptococcus)
4
Q
how does scarlet fever present?
A
- flu-like symptoms - high temp., sore throat, swollen neck glands
- a rash appears 12-48 hrs later (the rash blanches with gentle pressure - redness disappears and then returns)
- a white coating also appears on the tongue, this peels which leaves it red and swollen (strawberry tongue)
5
Q
is scarlet fever a notifiable disease?
A
- yes
6
Q
name 4 notifiable diseases
A
- COVID-19
- diptheria
- food poisoning
- malaria
- measles
- plague
- rubella
- scarlet fever
- smallpox
- tetanus
- tuberculosis
- whooping cough
- yellow fever
7
Q
what are the majority of sore throats caused by?
A
- viral infections
8
Q
what virus causes glandular fever (infectious mononucleosis)?
A
- Epstein-Barr virus
- (Epstein-Barr virus is one of 8 different types of human herpes viruses) - it can cause many other different diseases too
9
Q
how do we tell the difference between bacterial and viral throat infections?
A
- near-patient testing
- (guesswork)
- (clinical scoring system)
10
Q
give an example of a near-patient testing kit
A
- HCG pregnancy testing kit
- CRP testing kit
- Strep. A antigen test kit
11
Q
how does near-patient testing relate to immunology?
A
- we use antibodies to bind to the substance of interest (such as HCG in pregnancy) and then a marker to show that the binding has taken place
12
Q
why would it be helpful to GPs to be able to tell whether Streptococcus pyogenes is causing a sore throat?
A
- antibiotic stewardship
13
Q
give three reasons for doctors to engage in antibiotic stewardship
A
- to improve patient outcomes by giving the most appropriate antibiotic for the correct length of time
- to reduce microbial resistance
- to decrease the spread of infections caused by multip-drug resistant organisms. both in the community and in the hospital setting
- avoidance of side effects from inappropriate use of antibiotics
14
Q
what would happen if we didn’t have antibiotics?
A
- wouldn’t be able to treat simple infections (eg. lower respiratory tract infection)
- these very treatable infections would become very dangerous and potentially fatal
- also more resistance to anti-viral and anti-fungal treatments
15
Q
what type of crystals are found in gout?
A
- monosodium urate (uric acid)
16
Q
what type of crystals are found in pseudogout?
A
- calcium pyrophosphate
17
Q
apart from the presence of crystals, what else would be different about the characteristics of the synovial fluid in a knee with crystal synovitis and a normal knee?
A
- volume of synovial fluid is higher
- viscosity of synovial fluid is lower
- colour of fluid is straw/opaque (compared to clear in normal)
- WBC is a lot higher
- PMN count (polymorphouclear cells) is higher
18
Q
what is gout?
A
- overproduction of uric acid
- underexcretion of uric acid (abnormal renal handling of urate)
- (both of these lead to hyperuricemia)
19
Q
what are some causes of hyperuricemia (gout)
A
overproduction of urate:
- excess dietary purines (high triglycerides intake)
- high alcohol intake
- myeloproliferative disorder
- lymphoproliferative disorder
under excretion of urate (abnormal renal handling of urate):
- renal disease
- polycystic kidney disease
20
Q
what are some drugs which can cause hyperuricemia?
A
- Cyclosporine (immunosuppressant used for RA and Crohn’s)
- Alcohol
- Nicotinic acid
- Thiazides (diuretic)
- Lasix/frusemide (diuretic used for high BP and oedema)
- Ethambutol (antibiotic against tuberculosis)
- Aspirin (low dose)
- Pyrazinamide (antibiotic against tuberculosis)
21
Q
which groups of people are more at risk of developing gout and what are some predisposing factors?
A
- common in men over 40
- post-menopausal women (loss of uricosuric effect of oestrogen)
predisposing factors:
- immediate post-operative period after major surgery
- myocardial infection (heart attack)
- stroke
- fasting
- alcohol abuse
- large intake of food with high purine content (salty fish, meat)
- local infection
22
Q
which joint is most commonly affected by gout?
A
- MTP joint of the great toe (metatarsophalangeal joint)
23
Q
which lab tests should be done for patients with suspected gout?
A
- joint fluid analysis
- WCC in joint fluid (neutrophils)
- culture to rule out infection
- serum uric acid
- renal function
- urine dipstick (haematuria - gout and kidney stones)
24
Q
what are the differentials for gout?
A
- degree of inflammation (different from RA)
- matched only by other crystal disease (pseudogout) or infection
- 1st MTP joint pain (characteristic of gout)
- (shoulder and hip involvement are rare in gout - could be pseudogout)
25
what is the line of treatment for gout (acute and intercritical)?
acute attack:
- joint rest and ice
- NSAIDs or COX 2 inhibitors
- oral steroids
- local steroid injection
- oral colchicine
intercritical gout (recurrent attacks):
- diet (low purine intake)
- reduce alcohol intake
- weight reduction
- colchicine prophylaxis
- urate lowering drugs (allopurinol or febuxostat)
26
what is pseudogout?
- deposition of calcium pyrophosphate dihydrate (CPPD)
- chondrocalcinosis - calcified cartilage on x-rays
- presence of CPPD crystals are associated with aggressive, destructive OA
27
what are some of the predisposing factors for pseudogout?
- elderly women > men
- hyperparathyroidism, hypothyroidism
- hemochromatosis (higher levels of iron in body)
- hypomagnesemia (magnesium deficiency)
- hypophosphatasia (low levels of phosphate in body)
- acromegaly (body produces too much growth hormone)
- trauma, infection, OA
28
which joint is most commonly affected by pesudogout?
- knee
- (ankle, wrist, shoulders also commonly affected)
29
what investigations should be done for pseudogout?
- history, clinical examination
- joint fluid analysis (synovial fluid analysis)
- x-ray
- calcium, serum uric acid, Mg, Ferritin, PTH
- negative gram stain and cultures
- CPPD crystals
30
what type of crystals are seen under polarised light for gout?
- (monosodium urate crystals - uric acid)
- negatively birefringent needle shaped crystals
31
what type of crystals are seen under polarised light for pseudogout?
- calcium pyrophosphate dihydrate (CPPD)
- weakly positively birefringent rhomboid shaped crystals
32
what are some x-ray findings that you would see in pseudogout?
- calcium deposition
- subchondral sclerosis
- joint space narrowing
- subchondral cyst formations
- (most common at the radiocarpal articulation - 2nd and 3rd MCP joints)
33
what is the line of management for a patient with pseudogout?
- joint aspiration
- intra-articular steroid injection
- NSAIDs
34
how many bones are there in the human body?
- 306
35
what are the 4 different types of joints?
- fibrous (skull - bones joined to other bones by fibrous tissue)
- primary cartilaginous (ribs - bone joined to hyaline cartilage)
- secondary cartilaginous (pubic bones - bones with hyaline cartilage united by fibrous tissue)
- SYNOVIAL (shoulder, elbow, hip, knee etc.)
36
ligaments vs tendons?
- ligaments join bone to bone
- tendons join muscle to bone
37
does hyaline cartilage have a blood supply?
- no
- hyaline cartilage derives its nutrition from the synovial fluid which is produced by the synovial membrane
- if hyaline cartilage gets damaged then repairs by forming fibrous tissue (not as good as hyaline cartilage)
38
describe the structure of a synovial joint
- bones joined by capsule and strong ligaments hence permitting movement
- bone ends covered with hyaline cartilage (no blood vessels in hyaline cartilage)
- synovial membrane lines the joint, provides synovial fluid (rich in nutrition), provides nutrition to hyaline cartilage
- any inflammation of the synovium in the body such as in RA affects all synovial joints
39
what are some key findings on a knee x-ray for a patient with osteoarthritis?
- loss of joint space
- osteophytes
- cysts
- sclerosis (whitening on x-ray)
40
what damages the hyaline cartilage (leading to OA)?
- normal wear and tear of hyaline cartilage over the years
- inflammatory conditions cause wear that exceeds repair
- mal-alignment of bones can cause excessive wear and tear
- congenital
- severe injuries/fractures of joints and cartilage damage
- tumours
41
why choose a joint replacment (adv vs disadv)?
Advantages:
- almost instant cure of pain relief
- return of mobility
- return to 'normal' life and activities
- majority of joints are long-lasting
Disadvantages:
- operation (comes with level of risk)
- revision surgery potential
- other risks (eg. infection of the joint)
- need to be careful, mobility returned but will never be as goof as a natural joint
42
what do NICE guidelines say about indications for joint replacement?
- refer before there is prolonged and established functional limitation and severe pain
- patient-specific factors (including age, sex, smoking, obesity) should not be barriers to referral for joint surgery
43
what percentage of arthroplasties acquire infection in the UK?
- 1-2%
44
what are some infection preventary measures used in orthopaedic surgery?
- clean, filtered air
- prophylactic antibiotics
- antibiotic-loaded cement
- appropriate PPE used
45
venous thromboembolism is one of the major complications of an arthroplasty, what measures can be taken to reduce the risk of this?
- early mobilisation post-op
- TED stockings
- chemical prophylaxis (warfarin, aspirin)
46
what is osteoarthritis?
- disease of the entire joint (effects the bone, cartilage, synovium, and ligaments)
- breakdown of these tissues causes pain and joint stiffness
47
what does OA most commonly effect?
- knees, hips, and hands
48
what causes OA?
- primary (age is main cause)
- secondary (trauma, infection, inflammatory/RA, Perthes' disease, SUFE, etc.)
49
how does OA affect the hands?
- DIP joints (Heberden's nodes)
- base of thumb (trapeziometacarpal joint)
50
how does OA affect the hands?
- DIP joints (Heberden's nodes)
- base of thumb (trapeziometacarpal joint)
51
what are the 2 surgery options for a patient with OA (after trying all of the conservative measures)?
- arthrodesis (fusion)
- arthroplasty (replacement): excision / hemi / total joint
52
how does arthrodesis benefit a patient with severe OA?
- relieves pain
- durable
- however, sacrifices movement
- (good for DIP joint as movement isn't sacrificed too much)
53
what are the complications of arthroplasty?
IMMEDIATE:
- technical (eg. perioperative fracture)
EARLY:
- infection
- dislcoation
LATE:
- aseptic loosening
- wear of the implant
54
what is a trapezectomy? (when would we do this?)
- excision arthroplasty - bone removed to create effectively a new joint
- very durable
- no foreign material entering body
- can do for base of thumb joint (trapeziometacarpal) because non-weight bearing and can therefore heal
55
what is a trapezectomy? (when would we do this?)
- excision arthroplasty - bone removed to create effectively a new joint
- very durable
- no foreign material entering body
- can do for base of thumb joint (trapeziometacarpal) because non-weight bearing and can therefore heal
- preserves range of motion
- long rehab / recovery
56
which joint is it very rare to see OA affect?
- elbow
- more likely to be RA or synovitis / bursitis
57
if the rotator cuff of a shoulder is completely destroyed, what is the treatment?
- a reverse total arthroplasty
58
what is hallux rigidus?
- OA of the 1st metatarsal phalangeal joint (MTP joint)
59
what is the line of management for hallux rigidus?
- analgesia
- orthosis: stop movement (supportive footwear)
- debridement of osteophytes
- arthrodesis (fusion) or arthroplasty (replacement)
60
what are the NICE guidelines for diagnosing osteoarthritis clinically without investigations?
- 45 yrs or over
- activity-related joint pain
- either no morning joint-related stiffness or morning stiffness that lasts no longer than 30 mins
61
what should your management of OA mainly focus on?
- the patient not the x-ray!
- (each patient has a different experience - x-ray could look bad but patient is fine and vice versa)
62
list some some important viral diseases that are not commonly seen in primary care.
- Norovirus and rotavirus
- Molluscum contagiosum
- hepatits B, C, E
- Dengue
- Measles, mumps, and rubella
- Rabies
- Ebola and Lassa
63
List some commonly seen viral diseases in primary care.
Respiratory:
- adenovirus
- coronavirus
- influenza A, influenza B
- parainfluenza
- respiratory syncytial virus
- rhinovirus
- human metapneumovirus
The rest:
- Human herpes viruses
- Parvovirus B-19
- Coxsackie A-16
- Human Papilloma viruses (HPV)
- Norovirus
- Hepatitis A
- HIV
- Measles, mumps, and rubella
64
describe the range of common viral presentations in primary care
- URTI - sore throat, cough, ear or sinus pain
- viral exanthem (rash caused by virus)
- warts
- diarrhoea / vomiting
- acute viral jaundice
- screening result
- immunocompromised
65
how do we diagnose viruses?
serology (from blood):
- antibodies - IgM (recent/acute), IgG (past)
- antigens - eg. hep B e-antigen
retrospective due to seroconversion and viral loads
nucleic acid amplification tests (secretions, tissue samples, blood):
- reverse transcription polymerase chain reaction (RT-PCR)
- LAMP (loop-mediation isothermal amplification)
- real-time testing enabling immediate clinical decision
66
what type of influenza vaccine is given to patients aged 2-17 years old?
- live attenuated influenza vaccine (LAIV)
67
what type of influenza vaccine is given to patients aged over 65 or over?
- adjuvanted trivalent influenza vaccine (aTIV)
- (adjuvant added to the vaccine to make it more effective in older people)
68
Name some different types of human herpes viruses (HHV).
- Herpes simplex type 1 and 2
- Cytomegalovirus (CMV)
- Varicella zoster virus (chicken pox and shingles)
- Epstein Barr virus (EBV) - most commonly causes glandular fever (aka. infectious mononucleosis)
- Human Herpes virus types 6, 6A, 7, and 8
69
70% of sore throats are caused by what?
- viral infections
70
what can cytomegalovirus cause?
- can cause an infection similar to EBV
- can cause congenital infection, hepatitis, splenomegaly, transverse myelitis, encephalitis
- can cause serious infection in the immunocompromised (eg. interstitial pneumonia in bone marrow transplant and AIDS patients)
71
what condition does this rash associate with?
- Epstein Barr virus (or cytomegalovirus)
72
what is a viral exanthem?
- a widespread rash that is usually accompanied by systemic symtpoms such as fever, malaise, and headache
- usually caused by an infectious condition such as a virus
73
what condition does this rash associate with?
- parvovirus B-19 (slapped cheek)
74
what condition is this rash associated with?
- measles
- (note: rash affects the trunk of the body)
75
what condition is this associated with?
- chicken pox (VZV)
- (note: slightly infected)
76
what condition is this rash associated with?
- rubella
77
what condition is this rash associated with? (with distinct large circular patch, 'herald patch')
- pityriasis rosea
- self-limiting rash
- distinct circular patch, appears lighter on pigmented skin and darker on lighter skin
78
what condition is this associated with?
- hand, foot, and mouth
- Coxsackie A-16 is most common
79
what condition is this associated with?
- Human Papilloma virus (HPV)
80
why should people get the HPV vaccine?
- evidence shows that vaccinated women have a reduced risk of developing cervical cancer
- boys will also be offered the HPV vaccine, it is considered a sexually transmitted disease now
81
how would somebody contract hepatitis A?
- contracted orally, contamination of food or water with faeces containing the virus
- not that common in the UK, more common in travellers
82
what condition is associated with this?
- molluscum contagiosum
- caused by a pox virus, multiple lesions can occur
- mainly in children, no treatment needed
83
what is the SEPSIS SIX?
1. Give oxygen to keep SATS above 94%
2. Take blood cultures
3. Give IV antibiotics
4. Give a fluid challenge
5. Measure lactate
6. Measure urine output
84
what are the 3 P's of first aid?
- Preserve life
- Prevent further harm
- Promote recovery
85
what is SSSABC assessment?
S = Safety (surrounding area)
S = Stimulate the patient
S = Shout for help
A = Airway (assess airway for obstruction, head tilt, chin lift)
B = Breathing (feel for breathing)
C = Circulation
(start CPR if no signs of life and call 999)
86
what is the ratio for chest compressions:mouth breaths in CPR?
30:2
87
what is rheumatoid arthritis?
- an autoimmune, inflammatory polyarthritis (often symmetrical) with extra-articular conditions
88
what scoring system is used to measure disease activity in rheumatoid arthritis?
- DAS-28
- looks at number of joints affected and how badly they have been affected
- looks at blood tests to get a measure of inflammatory response using either CRP or ESR on blood tests
89
what is remission of RA defined as according to DAS-28, and what is moderate disease activity defined as?
- remission = less than 2.6
- moderate = greater than 5.1
90
what are 4 key radiological features of rheumatoid arthritis? (x-ray findings)
- soft tissue swelling
- juxta-articular erosions
- peri-articular osteoporosis
- loss of joint space
91
list some DMARDs used in the management of rheumatoid arthritis
- methotrexate
- sulfasalazine
- leflunomide
- hydroxychloroquine
- (gold, azathioprine, ciclosporin)
92
list some biologics used in the management of rheumatoid arthritis
- anti-TNFs (adalimumab, infliximab, entanercept)
- rituximab (monoclonal antibody against B-cells)
- abatercept
- tociluzimab
93
how often is methotrexate given and what should be prescribed with it?
- once a week
- folic acid should be prescribed with it (but given on a different day)
94
what are some side effects of methotrexate?
- bone marrow suppression
- GI problems
- liver problems
- infections
- rheumatoid nodules can be exacerbated
- NOT SAFE IN PREGNANCY
95
what drug should not be prescribed together with methotrexate? (hint: the drug is commonly used to treat UTIs)
- trimethoprim
96
how often should blood tests be carried out for patients who take methotrexate and why?
- blood tests should be carried out once a month
- because of the bone marrow suppression side effects
97
what are some side effects of sulfasalazine?
- nausea
- rashes
- haematological: low WCC, low platelet count
- (comes as an orange tablet and can cause orange bodily fluids but not harmful)
98
what is the classification criteria for RA?
- morning stiffness > 1hr
- more than 3 joints affected
- hand involvement
- symmetrical
(above four must be for 6 weeks or more)
- nodules
- rheumatoid factor positive
- radiographic erosions
99
what are the 4 essential details on a patient name tag (hospital tag)?
- Full name
- Date of birth (DOB)
- Hospital number
- NHS number
100
what are some safety steps taken in pre-op surgery?
- all syringes are labelled (any without labels are thrown away)
- WHO safety checklist
101
give some examples of 'never events' in surgery (including some drug errors)
- wrong site surgery
- wrong implant
- wrongly prepared high-risk injectable medication
- maladministration of a potassium-containing solution
- intravenous administration of epidural medication
- maladministration of insulin
102
what is the most common type of chronic pain?
- chronic back pain
103
what are the differences between acute pain and chronic pain?
Acute pain...
- clear reason for occurrence
- good likelihood of resolving with healing/recovery
- good response to treatment where available
Chronic pain...
- less clear cause - no ongoing pathology/injury or healing
- often poor response to available treatments
- psychological component needs assessing and if needed, managing
104
what emotions are often linked with chronic pain?
- depression
- anxiety / fear
105
give some characteristics of generalised anxiety disorder
- characterised by excessive anxiety and worry
- for a diagnosis - must be going on for over 6 months
- associated with restlessness, fatigue, sleep disturbance, muscle tension
106
the persistent pain cycle
107
what are some treatment methods for anxiety/depression that accompany chronic pain?
- Education: help the patient understand that chronic pain (if thoroughly investigated) does not indicate any underlying pathology
- Relaxation: mindfulness, deep breathing, realistic goal setting
- CBT: trying to change the mindset (negative thoughts) towards the condition
- Pain management programmes (PMPs)
- exercise, yoga, acupuncture
108
what type of interventions have to be looked at in chronic pain?
- Non-pharmacological / surgical interventions
- need to look at the mindset of the patient and psychological interventions need to be looked at
109
what is the definition of pain?
- An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage
110
what is the difference between nociceptive and neuropathic pain?
Nociceptive: pain arising from activation of nociceptors following tissue injury
Neuropathic: pain arising from disease or damage to nervous system
111
what is the difference between interoception and exteroception? (and which is pain classed as?)
Interoception: sensing internal body states
Exteroception: sensing the external environment
(pain is interoceptive)
112
what are some examples of chronic diseases?
- dementia (eg. Alzheimer disease)
- arthritis
- asthma
- cancer
- COPD
- Chrohn's disease
- Cystic fibrosis
- diabetes
- epilepsy
- heart disease
- HIV / AIDS
- mood disorders (bipolar and depression)
- multiple sclerosis
- Parkinson disease
113
give an example of an unmodifiable risk factor.
- age
- genetic (inherited) risk
114
give an example of some modifiable risk factors.
- diet
- exercise
- smoking
- alcohol consumption
115
how is chronic back pain diagnosed?
- back pain that persists for more than three months
116
what are the two top causes of days off work?
1. mental health
2. low back pain
117
what team members might be involved in the care of chronic back pain?
- GP or nurse practioner
- community physio
- osteopath or chiropractic practioner
- radiology service
- pain clinic
- orthopaedic surgeon
- rheumatologist
118
describe the three phases seen in chronic low back pain?
119
is comorbidity common in chronic conditions?
Yes
120
What is the pathology of Pagets disease?
- increased bone cell activity
- osteoclasts are bigger than normal (resorbing bone)
- osteoblasts lay down bone in a haphazard way (poor bone architecture)
- therefore see expansion of poor quality bone which is weak
- marrow replaced with fibrous tissue and blood vessels
121
What gene has a defect in Pagets?
- SQSTM1 gene
122
What are the clinical features of Pagets?
- acetabular protrusion
- bone deformity
- bone pain (50%): not localised, night pain
- increased risk of fracture (10-30%)
- spinal stenosis)
- OA in neighbouring joints
- examination: warm, tender, deformity
123
What radiological features are seen in Pagets?
- bones are typically expanded
- cortical thickening
- lytic and sclerotic areas
124
What investigations should be done for suspected Pagets?
- clinical examination and history
- alkaline phosphatase
- plain radiograph
- isotope bone scan (shows extent of disease)
125
What is the treatment for Pagets disease?
- reduce osteoclast function: zolendronate (or zolendronic acid)
- relieve symptoms: analgesia and treat OA
- ensure vitamin D levels are adequate
- physiotherapy
- surgery: fractures, joint replacement, spinal stenosis
126
What is a tumour / neoplasm?
- cells keep dividing when new cells are not required and cause a mass of tissue or tumour
- unregulated clonal division which is irreversible
127
What are some benign tumours of the bone, cartilage, fibrous tissue, and vascular system?
128
What is a classic radiological appearance of osteosarcomas?
- sunburst appearance
129
What is a malignant tumour of the bone cartilage called?
- chondrosarcoma
130
What is a classic radiological appearance of Ewing's sarcoma?
- onion skin on x-ray
- (2nd most common in childhood, from the medullary (long bones) cavity)
131
Where are the most common places for bone tumours to metastasise from?
- breast
- lung
- prostate
- kidney
- thyroid
132
How would you manage a patient with a metastatic bone disease?
- analgesia for pain
- bisphosphonates have a role (might reduce bone turnover)
- orthopaedic surgeon (to stabilise the abnormal bone): intramedullary nails, joint replacement, plates/screws
- (image shows dynamic hip screw to stabilise that area, note that screw has fractured the bone but doesn't matter)
133
Image of plate that has been put in for a patient with a metastatic lesion in their forearm...
- plate stabilises area and relieves pain
134
What is the definition of osteoporosis?
- osteoporosis = a systemic skeletal disease characterised by low bone mass and deterioration of bone tissue, with consequent increase in bone fragility and susceptibility to fracture
135
Where are the most common places for a patient with osteoporosis to fracture?
- spine
- neck of femur
- wrist
- proximal humerus
- pelvis (stress fractures)
136
How is osteoporosis usually diagnosed?
- usually found by accident secondary to another condition (eg. on x-ray for fracture)
137
What is the mortality after a hip fracture?
- 20% of patients die within a year
- also have high risk of future fracture
138
The 3 types of vertebral fracture seen in a patient with osteoporosis...
- note: wedge fracture most common
139
What do multiple vertebral wedge fractures often lead to?
- kyphosis
- (the more vertebral wedge fractures the more kyphotic the patient becomes)
140
What are some non-modifiable risk factors for osteoporosis?
- age (elderly)
- gender (more common in females, or men with low testosterone)
- previous fragility fracture at a characteristic site
- endocrine (eg. early menopause)
- parental history of hip fracture(
141
What are some modifiable risk factors for osteoporosis?
- low BMI
- lifestyle: smoking, alcohol intake
- low bone density
142
Age-related changes in bone mass...
- note: women more likely to enter fracture threshold
143
What is FRAX?
- Fracture Risk Assessment Tool
144
How is bone density measured and what is an issue with this?
- DEXA scan (Dual-Energy X-ray Absorptiometry)
- based on female reference ranges
145
What are the T score ranges for normal, osteopenic, and osteoporotic?
- normal = T > -1.0
- osteopenia = T -1.0 to -2.5
- osteoporosis = T < -2.5
- (T score measures bone density against a young healthy person)
146
What is the difference between T score and Z score?
- T score measures bone density against a healthy young person
- Z score takes into account age and gender
147
What is the pathophysiology of osteoporosis?
- osteoblast function decreases
- therefore osteoclast function is higher than osteoblast function so bone loss occurs
148
Scanning Electron Microscopy (SEM) of normal bone and osteoporotic bone...
- as you can see, osteoporotic bone more likely to fracture
149
What investigations should be done for a patient with osteoporosis (mainly to rule out other causes)?
- FBC
- ESR / CRP
- serum calcium (albumin adjusted)
- 25-hydroxyvitamin D
- liver tests
- PTH
- liver tests
- alkaline phosphatase
- markers of bone turnover
- thyroid
- myeloma screen
- plain radiography / MRI / isotope bone scan / DEXA
150
What is the management for osteoporosis?
- diet: protein, calcium, vitamin D
- exercise
- lifestyle
- treat underlying diseases
- drug treatment
- falls intervention (medical, OT, physio)
151
What are the main drugs used in treatment for osteoporosis?
- bisphosphonates (alendronate, zolendronic acid)
- calcium and vitamin D
- denosumab
152
What is osteogenesis imperfecta?
- syndrome of bone fragility due to mutations in type 1 collagen gene (most cases of OI are caused by a dominant genetic defect)
- often called 'brittle bones'
153
What is the line of management for osteogenesis imperfecta?
- treatment is aimed at preventing or controlling the symptoms
- trying to increase muscle mass and developing optimal bone mass
- extensive surgical and dental procedures
- physio and use of mobility aids (wheelchairs, braces) are common
154
What is the most common type of osteogenesis imperfecta and what is the most severe type of osteogenesis imperfecta?
- type 1 most common
- type 2 most severe (babies usually don't survive)
- (there are 7 types)
155
What are the clinical features of osteogenesis imperfecta?
- frequency of fractures
- stature / bone deformity / scoliosis
- coloured sclera (eyes)
- laxity of muscles and joints (hypermobility)
- brittle teeth
- respiratory failure
156
What is osteomalacia?
- osteomalacia = "soft bones"
- outside bone normal, inside of bone is impaired (osteoid has impaired mineralisation)
- usually as a result from disturbance of vitamin D and phosphate metabolism
- (osteoid = bone protein matrix, mostly type 1 collagen)
157
What are the 4 main actions of 1,25-dihydroxyvitamin-D?
- facilitates calcium (duodenal) and phosphate (small intestine) absorption from the gut
- triggers osteoblast RANK-L which activates osteoclasts to resorb bone, releasing calcium into the circulation
- triggers osteoblast production of a number of mediators resulting in laying down bone osteoid
- decreases PTH synthesis and secretion
158
What are some risk factors for osteomalacia (vit D deficiency)?
- dark-skinned individuals and their breast-fed babies
- elderly and people who cannot mobilise well
- chronic liver / kidney disease or failure (cannot metabolise vit D well)
- poor intestinal malabsorption
- anticonvulsant medication
- diet
159
Rickets x-ray...
- in Rickets, growth plate formation is abnormal and becomes wide and irregular
- affects children
160
What are some radiological features of osteomalacia?
- bone softening / deformity: bowing of long bones
- increased fractures: biconcave vertebral bodies
- pseudofractures: small radiolucent lines through bone cortices
- osteopenia which can mimic osteoporosis
- (image shows pseudofracture - on right)
161
What is the treatment of osteomalacia?
- treat underlying condition
- vitamin D supplements: cholecalciferol (vitamin D3) as a high loading dose and then lower maintenance dose
162
What does alkaline phosphatase (ALP) measure?
- bone turnover (osteoblast activity)
- key feature is isolated ALP (other blood tests are normal)
163
What is the basic structure of a clinical physical examination?
- LOOK: for deformity/signs of injury
- FEEL: for tenderness, swelling
- MOVE: to assess range of movement
- SPECIAL TESTS: tests stability and power
164
What investigations should be considered for soft tissue injuries (after physical examination has been done)?
- ultrasound scan
- MRI scan
- (x-ray / CT: to investigate associated fractures, or if don't think it's a soft tissue injury)
165
What is the treatment for a soft tissue injury?
- analgesia
- RICE (Rest, Ice, Compression, Elevate)
- immobilise
- (splint, sling, brace)
- phsiotherapy
- surgical repair
- education/information
166
What is the treatment for a soft tissue injury?
- analgesia
- RICE (Rest, Ice, Compression, Elevate)
- immobilise
- (splint, sling, brace)
- physiotherapy
- surgical repair
- education/information
167
Biceps tendon rupture...
- investigations: hook test, but use MRI (or ultrasound) to confirm if unsure
- treatment: surgical repair and sling
168
MRI of torn ACL ligament and normal ACL ligament...
- torn ACL: no black line, it's empty
- treatment: surgical repair
169
Clavicle dislocation...
treatment: sling for 6 weeks, physio, surgery in some cases
170
What is a tension pneumothorax?
- lung gets punctured leading to collapse of the lung
- air continues to leak into chest (or thoracic) cavity, eventually the heart cannot function properly due to restricted venous return and difficulty pumping blood out from the heart
- treatment: insertion of a cannula in the chest, followed by a chest drain
171
What does ISS stand for?
- Injury Severity Score
172
Explain Advanced Trauma Life Support (ABCDE).
- Airway (with cervical spine control): clear any obstructions in the airway, also safeguard the neck in case there is a neck injury
- Breathing (with ventilation): make sure they are breathing, otherwise assist with breathing (ventilation)
- Control of haemorrhage: stop bleeding (tourniquet) and replace blood
- Disability (and brain protection): maintain oxygenated blood to the brain to protect it (100% oxygen always given to prevent secondary brain damage)
- Exposure: remove all clothing and inspect whole body for injury (careful with children and elderly may get cold rapidly)
173
What is the terrible triad in ATLS?
- Acidosis: too much acid in the body (liver and kidneys can't maintain the pH balance)
- Coagulopathy: no blood clotting and therefore risk of excessive bleeding
- Hypothermia: drop in body temp. below 35 degrees
174
Principles for Damage Control Orthopaedics (DCO).
- control of bleeding: 4 major places (chest, abdomen, pelvis, long bone fractures and open wounds)
- arterial repair, decompressing tension pneumothorax, and fasciotomy for compartment syndrome
- provisional fracture stability with external fixation
175
External fixation for femur fracture...
176
What is the definition of compartment syndrome?
- rise of pressure within a closed space resulting in ischaemia of the components
177
What is acute respiratory distress syndrome (ARDS)?
- severe lung disease (shock lung)
- fat globules lodging in small vessels leads to local inflammation
- this leads to impaired gas exchange, hypoxia, and can lead to multiple organ failure
- note: intramedullary nails in long bones can precipitate ARDS by pushing a lot of marrow fat into the circulation
178
What is the exact definition of a fracture?
- a break in one cortex which exists from the opposite cortex
179
If a patient has an injury severity score of more than 15, what does this mean?
- considered a major trauma and has a 10% risk of death
180
Which compartment is used to measure compartment pressure?
- usually the anterior compartment
- note: diagnosis of acute compartment syndrome is based on clinical features (eg. severe pain on passive movement)
181
Why is there some controversy with long bone fixation?
- stabilisation of long bone fractures is best by insertion of nails in the intramedullary canal
- this results in displacement of bone marrow fat which is squeezed into the vessels around the bones and finds its way as fat globules into the lung where it is deposited and where it causes an inflammatory response (ARDS)
182
What type of force gives a spiral/oblique, transverse (often with a bending wedge), and a comminuted fracture with lots of fragments?
- spiral/oblique fracture: twisting force
- transverse fracture (often with a bending wedge): bending force
- comminuted fracture: high energy force
183
Spiral / oblique fracture on x-ray...
184
Transverse fracture on x-ray...
185
Comminuted fracture on x-ray...
186
What is debridement?
- orthopaedic surgeons cut out all dead and damaged tissues (except nerves and major blood vessels)
- the bone is cleaned, and any loose bone fragments removed
- the wound is then cleaned with saline (wash out)
187
What two views do you want for an x-ray?
- AP (antero-posterior) and lateral (90) view
188
Is a CT scan of the pelvis useful?
- very useful: a plain x-ray of the pelvis does not show the sacrum and sacro-iliac joints very well
- as is well known, the pelvis has a ring structure (like a polo mint) so will always break in more than one place
189
How is an intertrochanteric extra-capsular hip fracture managed?
- blood supply (femoral artery) remains intact
- so the fracture is reduced in theatre and fixed with a dynamic hip screw
190
How is an undisplaced VS a displaced sub-capital (intra-capsular) hip fracture managed?
- the retinacular vessels are damaged depriving the femoral head of a blood supply
- in undisplaced and minimally displaced sub-capital fractures there is some damage to the retinacular vessels, but enough blood runs in the retinacular vessels and in most cases the femoral head survives (therefore these fractures are fixed in situ without reducing them)
- in displaced sub-capital fractures, the femoral head is discarded and replaced with a metal ball (hemiarthroplasty) or in fit patients the whole hip is replaced (total hip replacement)
191
What is a greenstick fracture?
- in children the bone is malleable and when injured the whole bone bends
- it is still a fracture as the bone trabeculae breaks (it is like a green twig bending, healing with new bone formation takes place over the next few weeks
192
Labelled diagram of the pelvis...
193
Why are pelvic fractures high risk injuries and potentially life-threatening?
- if pelvic floor is torn this is bad, there is large amount of bleeding which tracks down to the buttocks and thighs and upwards into the pelvis and lower abdomen, this bleeding accounts for a high death-rate in pelvic fractures
- pelvic floor consists of a thick layer of muscles, these are very vascular and many large blood vessels are found in this layer
194
Closed vs open fracture?
- fracture = soft tissue envelope in which there happens to be a bone that is broken
- closed: intact skin
- open: skin torn (high risk of infection + non-union of bone)
195
How to read an x-ray?
- read name of patient
- look at patient wristband and confirm date of birth
- read hospital number
- find out date of x-ray
- note part of region, right or left
- look at view of x-ray
- look for whether standing/weight bearing
196
How would you read this x-ray?
- antero-posterior (AP) x-ray of the humerus
- shows clearly proximal shaft and head of humerus
- distal humerus not shown
- there is a transverse fracture of the mid-shaft
197
How would you describe this x-ray/fracture?
- antero-posterior (AP) x-ray of left humerus
- showing humeral ehad and elbow
- there is a displaced short oblique fracture of mid-shaft
- with varus angulation and 50% cortical width displacement
198
Valgus deformity...
- distal limb away from the midline
199
Varus deformity...
- distal limb towards midline
200
Types of ankle fracture (Weber classification)...
- type A: treated non-op in plaster
- type B and C: treated operatively
- A: below syndesmosis
- B: at syndesmosis
- C: above syndesmosis
201
Intertrochanteric hip fracture on x-ray...
202
Sub-capital / intracapsular hip fracture...
203
Classification of hip fractures...
204
Salter-Harris classification of fractures (paediatric fractures)...
205
Benign vs malignant mass?
- benign = a mass of cells that grows in an uncontrolled manner but does not have the ability to invade local structures or spread to other parts of the body
(-oma)
- malignant = a mass of cells that grows in an uncontrolled manner that has the ability to invade local structures and has the ability to spread to other parts of the body. Also has the ability to kill the host if growth and spread is not controlled (cancer)
(-carcinoma, -sarcoma)
206
What are the 6 S's for examination of lumps and bumps?
- Site
- Size
- Shape
- Surface
- Substance (consistency, soft, firm, hard)
- Surrounding structures (local tissue, lymph nodes, nerves, blood vessels, other organs)
207
What are typical history of benign lump?
- slow rate of growth
- other long term masses
- painless
- local pressure effects
208
What are typical history of malignant lump?
- fast rate of growth
- other new masses / lesions
- painful
- local invasive effects
- associated lumps
- associated symptoms of metastasis / systemic spread
209
What are typical clinical findings on examination of benign lumps?
- well defined
- mobile
- smooth
- soft
- no associated masses
210
What are typical clinical findings on examination of malignant lumps?
- ill defined
- immobile
- irregular
- hard
- associated masses
- associated organomegaly (abnormal enlargement of organs)
- associated reduced function of muscle, nerve
211
What investigations should you do for a lump (benign or malignant?
- MRI
- ultrasound
- biopsy
212
What are the 3 main causes of a lump/bump?
- infective (rubor, calor, tumor, dolor)
- inflammatory (eg. rheumatoid nodules
- neoplasmic (new growth)
213
Skin tag picture...
214
Sebaceous cyst picture...
215
Squamous cell carcinoma picture...
216
Lipoma picture...
217
Trochanteric bursitis diagram...
- clinical findings: tenderness over the greater trochanter
218
Prepatellar bursitis diagram...
219
What is enthesitis?
- enthesitis = inflammation of the entheses (the sites where tendons or ligaments insert into the bone)
220
Varicose veins photo...
221
Ankle sprains grading...
222
Sciatica diagram...
223
Nerve entrapment (eg. meralgia paraesthetica) diagram...
- nerve gets trapped in inguinal ligament
224
Peripheral neuropathy diagram...
- gloves and socks distribution
- caused by some sort of nerve toxin
225
Normal x-ray VS osteoarthritis x-ray (hip)...
226
Lymphoedema (diagram, symptoms)...
- symptoms: swelling of limbs (patient may struggle to fit into clothes)
227
Structure of a nerve...
228
What is the role of the myelin sheath?
- acts as an insulator
- speeds up nerve conduction (more saltatory conduction)
229
Which condition is caused by compression of the median nerve at the wrist and what are the symptoms?
- carpal tunnel syndrome
- symptoms: pain, numbness, and tingling in the median nerve distribution (often night symptoms)
230
Which condition is caused by compression of the ulnar nerve at the elbow?
- cubital tunnel syndrome
231
What are some risk factors for carpal tunnel syndrome?
- majority of cases are idiopathic
- trauma (post wrist fracture)
- pregnancy
- rheumatoid arthritis (synovitis)
232
What special tests are used in clinical examination for carpal tunnel sydrome?
- Tinel test
- Phalen test
233
What is the treatment / management for carpal tunnel syndrome?
- wrist splint
- corticosteroid injection
- surgical decompression
234
What is the management for Raynaud's phenomenon?
- keep warm (especially abdomen)
- stop smoking
- calcium channel blockers (eg. nifedipine): causes muscle relaxation and increases blood flow
- iloprost (can only be given IV): causes muscle relaxation and increases blood flow
- sildenafil (aka. viagra)
235
What is SLE and does it affect males or females more?
- SLE = systemic lupus erythematosus
- 90% of affect patients are female
