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Flashcards in Diagnosis and Investigations Deck (48):
1

Questions to ask re swollen and painful hands?

When did your symptoms start and have they built up gradually?
Do they vary throughout the day?
When are at they at their worst and how do they respond to activity and time of day?
Do your joints ever feel stiff, for example in the morning?
Any constitutional symptoms i.e. fever, night sweats or weight loss?
Any skin rashes, change in bowel habit or dry or watery eyes?
Do joint problems run in your family?

2

Types of Inflammatory Arthritis

CTD
Vasculitis
Seropositive Spondlyoarthritis
Seronegative Spondlyoarthritis

3

How does IA present?

Insidiously
<30 mins morning stiffness
Improves with exercise and as the day goes on
If multisystem or constitutional sx, expect CTD
If other symptoms such as bowel habit or eye involvement consider Seronegative

4

How does RA present?

As with IA but expect strong family hx
Symmetrical small joint polyarthritis

5

What is non inflammatory arthritis?

Osteoarthritis

6

How does OA present?

No morning stiffness, or morning stiffness lasting <30 mins
Worse with exercise and better with rest
Ageing pt

7

How does Septic Arthritis present?

Asymmetrical monoarthritis
Associated fever and infective sx
Acute hx over hours or days
Pt feels generally unwell

8

What are the types of crystal arthritis?

Gout
Pseudogout

9

How can you differentiate between gout and pseudogout?

Gout: Negatively bifringent needles
Pseudogout: Positively bifringent rhomboids
Gout more likely in pattern - MTP - Ankle - Knee
Pseudogout more likely in larger joint and in patient with underlying OA

10

What are the risk factors for gout?

Male
Age >45
Taking thiazide diuretics
Consume large amount of alcohol
Diet high in purines i.e. meat, oily fish, marmite
High BMI
Family Hx

11

How does crystal arthritis present?

Acute onset
acutely painful and unable to weight bear on affected joint

12

What is Sjogren's Syndrome?

Goes often alongside CTD/RA
Dry eyes and mouth

13

What is reactive arthritis?

Presents after an infection such as food poisoning or STI
Affects younger patients
Asymmetric oligoarthritis

14

What do you do if you suspect someone has RA?

Provide simple analgesia for pain relief
Refer urgently to Rheumatology

15

What investigations would you do in someone who has RA?

Baseline FBC, LFT, U&E
ESR/CRP - markers of inflammation
TFT - if abnormal can present with joint pain
Rheumatoid Factor and anti-CCP - suggest RA
ANA - suggest CTD
X-Rays of hands and feet - may see RA changes

16

What would you see on an X-Ray of a patient with RA?

Soft tissue swelling
Loss of joint space
Intra-articular erosions
Periarticular osteopenia

17

How do you diagnose RA?

Using the American College of Rheumatologist guidelines

18

Which areas are looked at in the diagnosis of RA?

Number of joints involved - at least 1 must be a small joint
Serology - RF or anti-CCP
Acute phase reactants - CRP or ESR
Duration of symptoms >6 weeks

19

How do we monitor disease activity in RA?

Disease Activity Score - DAS
Calculated after looking at number of tender joints, number of swollen joints, global assessment of disease activity from 0-100, and ESR/CRP measurement.

20

When would you use USS in a patient with joint swelling?

If there is clinical suspicion about whether or not swelling is present. USS can identify synovitis and joint effusion as well as bone erosions very sensitively.

21

How common are extra-articular manifestations of RA?

40% of patients with RA have extra-articular manifestations i.e. dry mouth, lung problems, heart problems, vasculitis, Felty's syndrome, eye problems

22

What is Felty's Syndrome?

RA
Splenomegaly
Neutropenia

23

What eye problems do people with RA suffer from?

Scleritis
Episcleritis

24

Differentials for a single hot, swollen joint?

Gout
Pseudogout
Reactive Arthritis
Septic Arthritis
Psoriatic Arthritis
Haemarthrosis

25

What investigations would you do in someone presenting with a hot swollen joint?

FBC and CRP - infection
U&E - any renal disease
LFT - alcohol damage
Blood cultures - sepsis
Joint aspirate and send for culture, microscopy and gram stain
Basic observations - systemically well or unwell
X Ray joint - look for classical changes

26

What are the differences on microscopy between gout and pseudogout?

Gout - negatively biferingent needles of monosodium urate
Pseudogout - positively biferingent rhomboids of calcium pyrophosphate

27

What are differentials for an acute exacerbation of knee pain?

Septic Arthritis
Crystal Arthritis
Mechanical disruption I.e. ligaments, meniscus, bursa
Rapidly progressive OA
Osteonecrosis

28

What are the risk factors for OA?

BMI - the main modifiable risk factor
Age
Female
Previous joint injury
Intense sporting activity
Occupation
Muscle strength around the joint
Genetic
Deformities or malalignment

29

What are the causes of secondary OA?

Gout
Wilson’s Disease
Haemochromatosis
Haemoglobinopathies
Joint injury or surgery
SUFE
Perthe’s Disease
DDH
Hypermobility syndromes
Diabetes
IA or Septic Arthritis

30

Red flags for hip pain in a child?

Constitutional symptoms - ALL
Fever, systemically unwell, hot swollen joint - Septic Arthritis
Changeable history, unusual history regarding mechanism of injury - Non accidental Injury
High fever, non weight bearing - Osteomyelitis

31

What areas would you want to examine in a child presenting with hip pain?

Perform a hip exam - may be pain on internal rotation
Abdomen including testicles and hernial orifices
Knee

32

Differential Diagnoses for hip pain in a child?

Transient Synovitis
Perthes Disease
Osteosarcoma
Lymphoma
SUFE
JIA
Non accidental Injury
Septic Arthritis
Fracture/Trauma
DDH
Non MSK causes i.e. testicular torsion

33

Red flags for back pain

Age <20 or >50
Night or rest pain
Trauma or fracture possibility
Thoracic pain
Bladder/bowel incontinence or retention
Fever, night sweats, weight loss, anorexia
IVDU
Weakness or numbness in the legs
History of Ca

34

What are the most common causes of sciatica pain by age?

<50 - disc prolapse
>50 - spinal stenosis

35

What investigations should you do in someone presenting with multisystem disease?

Observations and examinations
Urine dipstick - send it for casts if abnormal
FBC, U&E, LFT, CRP, TFT
RF, anti-CCP, ANA, ANCA
X-ray of any areas which appear abnormal

36

What does a positive p-ANCA indicate?

EGPA

37

What does a positive c-ANCA indicate?

GPA
Microscopic Polyangiitis

38

What is the diagnostic criteria for EGPA?

Asthma
Eosinophilia
Multi-system involvement (>2 organs affected)

39

What would a CXR show in vasculitis?

GPA - cavities in the lung

40

What is the most common type of glomerulonephritis associated with vasculitis?

Cresenteric Glomerulonephritis - can present with nephrotic or nephritic syndrome clinically

41

What are the features of nephrotic syndrome?

Proteinuria, hypoalbuminaemia and oedema

42

What are the features of nephritic syndrome?

Haematuria, proteinuria, hypertension, oedema, oliguria, uraemia

43

What is the pattern of inflammatory markers seen in SLE?

ESR raised
CRP normal

44

What is the significance of extra nuclear antibodies in pregnancy?

Some, such as Ro and La are able to cross the placenta and cause neonatal lupus
May be associated with antiphospholipid syndrome

45

Which antibodies are associated with SLE?

dsDNA
Sm
Ro

46

What is the diagnostic criteria for Fibromyalgia?

Sx (pain) last >3 months
On both sides of the body and above and below the waist
Along the axial spine
Difficulty sleeping and poor concentration/memory

47

Differentials for Fibromyalgia?

SLE
Lymphoma or infection
Hypothyroidism
Addison's Disease

48

What investigations should you do if you are suspecting fibromyalgia?

History and exam including trigger points
Widespread pain index score
TFTs
Vitamin D
B12 and Iron studies
ESR/CRP
Magnesium