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1
Q

What is osteoarthritis?

A
  • loss of cartilage
  • disordered bone repair
  • most common arthritis
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2
Q

What xray findings do you get with osteoarthritis?

A

LOSS

  • loss of joint space
  • osteophytes formation
  • subchondral sclerosis
  • subchondral cysts
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3
Q

Risk factors for osteoarthritis

A
  • female

- obesity

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4
Q

Presentation of osteoarthritis

A
  • mainly in large weight-bearing joints
  • joint pain, worse with movement
  • stiffness on rest
  • limited joint movement
  • bone swelling in fingers
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5
Q

What are the two types of bone swelling in fingers?

A
  • Heberden = DIP

- Bouchard = PIP

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6
Q

Treatment for osteoarthritis

A

Biological

  • paracetamol → work up analgesics ladder
  • cortisol injections
  • joint replacement

Social

  • weight loss → required before surgery
  • lifestyle advice
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7
Q

What is Rheumatoid Arthritis?

A
  • autoimmune disease
  • symmetrical, deforming, peripheral polyarthritis
  • female 3x > male
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8
Q

What xray findings do you get with RA?

A

JOBS

  • joint space loss
  • osteopenia
  • bone erosion
  • soft tissue swelling
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9
Q

Presentation of RA

A
  • pain in affected joints
  • deformities of hand
  • morning stiffness
  • systemic presentations
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10
Q

Hand deformities in RA

A
  • ulnar deviation
  • swan neck
  • boutonniere deformity
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11
Q

Systemic presentations in RA

A
  • scleritis
  • pleural effusions
  • pericarditis
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12
Q

Diagnostic criteria for RA

A

RF RISES

  • rheumatoid factor positive
  • finger/hand/wrist involvement
  • rheumatoid nodules present
  • involvement of ≥ 3 joints
  • stiffness in the morning for > 1hr
  • erosions seen on xray
  • symmetrical movement

> 4 symptoms for > 6 weeks

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13
Q

Investigations for RA

A

bloods

  • RF = highly sensitive
  • anti-CCP = more specific
  • ESR
  • xray
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14
Q

Treatment for RA

A
  • methotrexate with folate
  • DMARDs
  • steroids
  • biologics
  • NSAIDs/opioids for pain management
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15
Q

What biologics are used to treat RA?

A
  • TNFα blockers = infliximab

- B cell inhibitors = rituximab

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16
Q

What is felty syndrome?

A
  • RA
  • splenomegaly
  • granulocytopenia
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17
Q

What is osteoporosis?

A
  • decreased bone mass/density
  • micro-architectural deterioration
  • increased bone fragility
  • increased susceptibilty to fracture
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18
Q

Causes of osteoporosis

A
  • Cushing’s, PTH
  • myeloma
  • malabsorption
  • steroids
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19
Q

Presentation of osteoporosis

A
  • not clinically apparent until a fracture occurs
  • risk assessment = FRAX and Qfracture
  • DEXA scan → T scan
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20
Q

Treatment for osteoporosis

A
  • bisphosphonates → oral alendronate/IV zoledronate
  • mAbs → denosumab
  • HRT
  • lifestyle advice → quit smoking and alcohol
  • Ca2+ and vitamin D
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21
Q

What is lupus

A
  • Systemic Lupus Erythematosus
  • inflammatory multisystem autoimmune disorder
  • arthralgia and rashes
  • type III hypersensitivity
  • female 9x > male
  • peak in 20-40yrcarditis, pls
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22
Q

Presentation of lupus

A
  • joint pain
  • malar, discoid, photosensitive rash
  • serositis
  • glomerulonephritis with proteinuria
  • depression/psychosis
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23
Q

What serositis can be seen in lupus?

A
  • scleritis
  • pericarditis
  • pleuritis
  • oral ulcers
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24
Q

Diagnosis of lupus

A
  • bloods → ESR raised, CRP normal
  • ANA
  • Anti-dsDNA
  • serum C3 and C4
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25
Treatment for lupus
- steroids - hydroxychloroquine - methotrexate
26
What is hyperuricaemia?
- high levels of uric acid - >420 M, >360 F - asymptomatic - 1 in 5 will develop gout
27
What is pseudogout?
- buildup of calcium pyrophosphate | - birefringent +ve, rhomboid
28
What is gout?
- buildup of monosodium urate | - birefringent -ve, needles
29
How does the buildup of uric acid lead to inflammation?
- uric acid builds up - precipitates as uric acid crystals - crystals deposit in joint spaces - inflammation
30
Stages of gout progression
1. high uric acid levels → builds up in blood → crystals form around joints 2. acute gout → symptoms start → painful gout attack 3. intercritical gout → periods of remission between gout attacks 4. chronic gout → gout pain frequent and tophi form in joints
31
Signs and symptoms of gout
- red hot joint → painful, swollen - acute onset - most common joint = big toe - also affects midfoot, ankle, knee, wrist
32
Investigations for gout
1. bloods - U&E and eGFR for renal function - uric acid levels, now and 4-6 weeks later → confirm hyperuricaemia GOLD STANDARD = joint aspiration to test for urate crystals
33
Management for acute gout
1. NSAIDs or colchicine 2. intra-articular steroid injection lifestyle advice
34
Management of chronic gout
1. allopurinol → inhibits xanthine oxidase 2. febuxostat consider coprescribing clolchicine with allopurinol for 6 months
35
Signs and symptoms of septic arthritis
LIFE THREATENING - red hot swollen joints - cold peripheries - confusion - high temperature
36
Causes and risks of septic arthritis
- IVDU - immunocompromised - intra-articular joints - common bugs
37
What bugs cause septic arthritis?
- S.aureus - Neisseria gonorrhoea - gram -ve bacteria eg E.coli - haemophilius influenza (kids)
38
What is the sepsis 6?
1. give O2 to keep stats above 94% 2. take blood cultures → CSF, urine, sputum 3. give IV antibiotics 4. give a fluid challenge 5. measure lactate 6. measure urine output
39
What antibiotics can be given to treat septic arthritis?
- flucloxacillin - if penicillin allergic → clindamycin - if MRSA → vancomycin - if gonococcal arthritis or gram -ve infection → cefotaxime
40
Treatment for septic arthritis
Sepsis 6
41
What is osteomyelitis?
infection of the bone marrow
42
What are the 3 ways of entry for osteomyelitis?
- hematogenously - open wound - contiguously → skin into blood
43
Risk factors for osteomyelitis
- penetration injury - IVDU - diabetes/CKD - HIV - sickle cell disease - RA - children → URT/varicella infection
44
Presentation of osteomyelitis
- limp or reluctance to weight bear (kids) - non-specific pain at site of infection - low grade fever - malaise and fatigue
45
Investigations for osteomyelitis
- FBC → raised WCC, ESR, CRP - xray - blood cultures
46
Management for osteomyelitis
- antibiotics - supportive care - surgery
47
What are the 3 seronegative spondyloarthropathies?
- ankylosing spondylitis - reactive arthritis - psoriatic arthritis
48
How do seronegative spondyloarthropathies present?
SPINACHEE - sausage digits - psoriasis - inflammatory back pain - NSAIDs (good response) - Arthritis - Crohn's disease - HLA B27 - Eye → uveitis - enthesitis
49
What is ankylosing spondylitis?
- inflammation of sacroiliac joints | - loss of spinal movements
50
Investigations for ankylosing spondylitis
- bloods = HLA B27 | - xray
51
Xray findings for ankylosing spondylitis
- eroded and sclerotic sacroiliac joints - unclear margin between rims - bone spurs aka syndesmophytes - bamboo spine due to fusion
52
Treatment for ankylosing spondylitis
- NSAIDs - physiotherapy - steroid injections - DMARDs → methotrexate, sulfasalazine - TNF inhibitor or mAb → etanercept, infliximab, adalimumab - ustekinumab = last line
53
Signs and symptoms of psoriatic arthritis
- painful swollen stiff joints - psoriatic plaques - dactylis - telescopic fingers → pencil in cup on xray occurs in 10-40% of people with psoriasis
54
Treatment for psoriatic arthritis
same as ankylosing spondylitis
55
What causes reactive arthritis?
- mainly due to infection | - think about if someone has an active sexual history
56
Signs and symptoms of reactive arthritis
- can't see = uveitis - can't pee = urethritis - can't climb a tree = enthesitis - keratoma blennorhagica - circinate balantis
57
Investigations for reactive arthritis
- bloods = inflammatory markers | - imaging to determine extent of damage from enthesitis
58
What inflammatory markers can you see in reactive arthritis bloods?
- ESR - CRP - ANA - rheumatoid factor
59
Treatment for reactive arthritis
- NSAIDs - corticosteroids - DMARDs → chronic arthritis
60
What is vasculitis?
group of autoimmune diseases that cause inflammation of the blood vessel walls
61
General constitutional symptoms of vasculitis
- malaise - fatigue - weight loss - low grade fever
62
What is giant cell arteritis
- large vessel vasculitis | - affects aorta and/or its major branches eg carotid and vertebral arteries
63
Risk factors for giant cell arteritis
- almost exclusive in >50yrs - North European - females 2-3x > males - history of polymyalgia rheumatica
64
Presentation of giant cell arteritis
- headache → new onset, typically unilateral over temporal area - scalp tenderness - jaw claudication - visual disturbances
65
Investigations for giant cell arteritis
- increased ESR and/or CRP - halo sign on US of temporal/axillary artery GOLD STANDARD = temporal artery biopsy → giant cells, granulomatous inflammation
66
Management of giant cell arteritis
high dose glucocorticoids ASAP → prednisolone
67
Complications of giant cell arteritis
- blindess | - irreversible neuropathy
68
What are the common primary bone tumours?
- chondrosarcoma - osteosarcoma - Ewing sarcoma
69
Risk factors of primary bone tumours
- previous radiotherapy - previous cancer - Paget's disease - benign bone lesions - male>female
70
Presentation of primary bone tumours
- common sites → long bones - bone pain - atypical bony or soft tissue swelling/masses - pathological fractures - easy brusiing - mobility issues → unexplained limp, joint stiffness, reduced ROM - inflammation and tenderness over bone - systemic symptoms
71
What is bone pain like in primary bone tumours?
- worse at night - constant or intermittent - resistant to analgesia - may increase in intensity
72
Investigations for primary bone tumours
1. xray GOLD STANDARD = biopsy bloods - FBC - ESR - ALP - lactate dehydrogenase - Ca2+ - U&E CT chest/abdomen/pelvis
73
Management of primary bone tumours
- chemo - radiotherapy - surgery → limb sparing/amputation
74
What is multiple myeloma?
neoplastic proliferation of bone marrow plasma cells
75
Pathophysiology of multiple myeloma
- malignant plasma cells produce excess immunoglobulin - multiple organ dysfunction esp kidneys - 2/3 IgG, 1/3 IgA
76
Presentation of multiple myeloma
OLD CRAB - old age - calcium elevated → bones, stones, groans, moans - renal impairment - anaemia - bone lytic lesions → bone/back pain
77
Investigations for multiple myeloma
- FBC → normocytic normochromic anaemia - films → rouleaux formation (RBC aggregations) - U&Es → raised Ca, urea, creatinine - haematinics → raised ESR - xray → pepper-pot skull, vertebral collapse, fractures - serum/urine electrophoresis → bence jones protein band - bone marrow biopsy → raised plasma cells
78
Diagnostic criteria for multiple myeloma
1. monoclonal protein band in serum/urine 2. raised plasma cells on BM biopsy 3. end organ damage → hypercalcaemia, renal failure, anaemia 4. bone lesions on skeletal survey
79
Treatment for multiple myeloma
- analgesia → bone pain - bisphosphonates → reduce fractures and bone pain - local radiotherapy → reduce focal disease - transfusion → correct anaemia - fluids/dialysis → renal failure - Abs for infections - chemo
80
What is osteomalacia?
- poor bone mineralisation leads to soft bones | - lack of Ca2+ in adults
81
What is rickets?
inadequate mineralisation of the bone and epiphyseal cartilage in growing skeleton of children
82
Pathophysiology of osteomalacia/rickets
- Ca2+ deficiency | - usually due to vitD deficiency
83
Presentation of osteomalacia
- widespread bone pain and tenderness → dull ache, worse on weight bearing - fractures → NOF - muscle weakness → waddling gait, difficulty with stairs - gradual onset, persistent fatigue
84
Presentation of rickets
- knock-kneed, bow-legged - tender swollen joints - growth retardation - bone and joint pain - dental deformities - enlargement of end of ribs → rachitic rosary
85
Diagnosis of osteomalacia/rickets
- xray → loss of cortical bone → defective mineralisation - bloods → low Ca2+ and phosphate - bone biopsies → incomplete mineralisation
86
Management of osteomalacia/rickets
vitamin D supplements - rapid mineralisation of bone - resolution of symptoms - malabsorption → IM calcitrol - renal disease → alfacalcidol
87
What is Paget's disease?
disorder of bone turnover
88
Pathophysiology of Paget's disease
- excessive bone turnover (formation and resorption) - due to excessive osteoblast and osteoclast activity - leads to patchy areas os high density (sclerosis) and low density (lysis) - enlarged and misshapen bones → risk of fracture
89
Presentation of Paget's disease
- bone pain - bone deformity - fractures - hearing loss → if bones of ear affected
90
Investigations for Paget's disease
xray - bone enlargement and deformity - osteoporosis circumscripta → well defined osteolytic lesions - cotton wool appearance of skull → poorly defined areas of sclerosis and lysis - v-shaped defects in long bones bloods - raised ALP - normal Ca2+ and phosphate
91
Management of Paget's disease
- bisphosphonates - NSAIDs for bone pain - Ca2+ and vitD supplements
92
Complications of Paget's disease
- osteosarcoma | - spinal stenosis and cord compression
93
Causes of osteomalacia
- malnutrition - drug induced - defective 1-alpha hydroxylation - liver disease
94
Osteosarcoma
- primary bone malignancy - common in kids - metaphysis of long bones - associated with Paget's disease
95
Ewing sarcoma
- v rare - from mesenchymal cells - originate from long bones
96
Osteochondroma
- bening - very common in males under 25 - overproduction of bone → deposits on metaphysis
97
What are common sites of secondary bone tumours?
LEAD KETTLE PBKTL - prostate - breast - kidneys - thyroid - lungs
98
Investigations for secondary bone tumour
bloods - FBC - U&E - ALP - PSA imaging - xray → lytic lesions - CT scans → metastases
99
Management of secondary bone tumours
- pain management - bisphosphonates - radiotherapy - chemo
100
What is fibromyalgia?
- chronic pain syndrome - widespread over body → 11 out of 18 points - >3 months - non-nociceptive pain - no organic cause
101
Pathophysiology of fibromyalgia
- unknown | - possibly pain perception or hyper excitability of pain fibres
102
Presentation of fibromyalgia
- fatigue - brain fog - pain - morning stiffness
103
Investigations for fibromyalgia
exclude all other differential with bloods and imaging
104
Management of fibromyalgia
- exercise - relaxation - neuropathic pain relief → TCA, gabapentin, pregabalin - opiates - CBT
105
Complications of fibromyalgia
- can really affect QoL - anxiety, depression, insomnia - opiate addiction
106
Pathophysiology of Sjogren's syndrome
- chronic inflammatory autoimmune disorder | - destruction of epithelial exocrine glands esp lacrimal and salivary glands
107
Signs and symptoms of Sjogren's
- dry eyes, mouth, vagina (mucous membranes) - parotid gland enlargement - joint pain - Raynauds - systemic features
108
What conditions is Sjogren's associated with?
- RA - SLE - PBC - scleroderma
109
Risk factors of Sjogren's
- 1st degree relative = 7x increased risk - female - >40
110
Investigations for Sjogren's
Schirmer tear test - tears travelling <10mm is significant Rose bengal staining and slit lamp exam RFs, ANA, anti-Ro, anti-La
111
Management of Sjogren's
- artificial tears/saliva, vaginal lubricant - humidifier, eye drops, mouth wash - NSAIDs, hydroxychloroquine (halts progression) - M3 agonist → pilocarpine
112
Complications of Sjogren's
- conjunctivitis - corneal ulcers - dental cavities - candida infections - vaginal candidasis - sexual dysfunction
113
What is Raynauds phenomenon
- intermittent spasm in arteries supplying fingers and toes - usually precipitated by cold and relieved by heat - can also be caused by vibrational tools, smoking, beta blockers - associated with SLE, RA, systemic sclerosis, dermatomyositis
114
Treatment for Raynauds phenomenon
- protect hands - stop smoking - CCBs
115
What is systemic sclerosis?
- multisystem autoimmune disease - increased fibroblast activity - abnormal growth of connective tissue - 2 types → limited and diffuse
116
Signs and symptoms of limited systemic sclerosis
- skin involvement limited to hands, face, feet and forearms - characteristic beak like nose and small mouth - microstomia
117
Signs and symptoms of diffuse systemic sclerosis
- skin changes develop more rapidly and widespread - Raynaud's phenomenon coincident with skin involvement - GI, renal, lung involvement
118
Diagnosis of systemic sclerosis
- ANAs - anaemia if renal involvement - limited → ACAs - diffuse → topoisomerase, anti-scl 70
119
Treatment for systemic sclerosis
- avoid smoking - handwarmers - GI → PPIs, Abs - renal → ACEi - pulmonary fibrosis → cyclophosphamide
120
What is polymyositis?
- muscle disorder of unknown aetiology | - inflammation and necrosis of skeletal muscle fibres
121
What is dermatomyositis?
polymyositis and skin involvement
122
Signs and symptoms of polymyositis
- symmetrical progressive muscle weakness and wasting | - affect proximal muscles of shoulder and pelvic girdle
123
Signs and symptoms of dermatomyositis
- heliotrope discolouration of eyelids - scaly erythematous plaques over knuckles - arthralgia, dysphagia - Raynaud's
124
Diagnosis of poly/dermato myositis
muscle biopsy bloods → raised - serum creatine kinase - aminotransferases - lactate dehydrogenase - aldolase immunology - ANA - anti jo1 - anti mi2
125
Treatment of poly/dermato myositis
- oral prednisolone - stronger immunosuppressants - symptomatic treatment of skin disease
126
What is antiphospholipid syndrome?
antibody mediated acquired thrombophilia
127
Risk factors for antiphospholipid syndrome
- diabetes - female - HTN - obesity - SLE - oestrogen therapy for menopause
128
Presentation of antiphospholipid syndrome
- thrombosis - recurrent miscarriages - Livedo reticularis - thrombocytopaenia
129
Investigations for anitphospholipid syndrome
- history of thrombosis/pregnancy complications | - antibody screen
130
Treatment of antiphospholipid syndrome
- long term warfarin - LMW heparin and aspirin if pregnant - lifestyles changes to avoid CVS issues
131
Complications
- VTE - arterial thrombosis - pregnancy complications
132
What is the most common type of back pain?
mechanical
133
Differential diagnoses for back pain
- congenital - iatrogenic - infection → osteomyelitis - trauma → fracture - malignancy → multiple myeloma, metastases - lifestyle → posture/overuse - inflammatoin
134
What types of inflammation can cause back pain
- HLA B27 - osteoporosis - osteoarthritis - pyelonephritis
135
What are the red flags for lower back pain
- cauda equina syndrome - cancer of the spine - spinal fracture → trauma/osteoporotic collapse - spinal infection
136
Investigations for back pain
bloods - inflammatory markers - FBC → anaemia, WBC - ALP levels imaging - DEXA scan - MRI
137
Treatment for mechanical back pain
- analgesia ladder - lifestyle advice - physiotherapy
138
What is the analgesia ladder?
1. PCM 2. NSAIDs 3. weak opiates 4. strong opiates 5. neuropathic pain treatment → gabapentin/tricyclic
139
Pathophysiology of granulomatosis with polyangiitis
- small vessel vasculitis - affects respiratory tracts and kidney - common in late teenage years/early adulthood
140
Presentation of granulomatosis with polyangiitis
- saddle-shaped nose - epistaxis - crusty nasal/ear secretions → hearing loss - sinusitis - cough, wheeze, haemoptysis
141
Investigations for granulomatosis with polyangiitis
- high eosinophils - histology → granulomas - presence of c-ANCA
142
Management of granulomatosis with polyangiitis
- nasal corticosteroid - cyclophosphamide complications of granulomatosis → glomerulonephritis
143
Pathophysiology of Marfan syndrome
- autosomal dominant | - affects gene involved in creating fibrillin
144
Presentation of Marfan syndrome
- tall stature - long limbs - long fingers - hypermobility - high arch palate - pectus carinatum
145
Investigations for Marfan syndrome
- physical exam | - Ghent criteria
146
Management of Marfan syndrome
- avoid intense exercise/caffeine - beta blockers/ARBs - annual echo
147
Complications of Marfan sybdrome
- mitral/aortic valve prolapse with regurgitation - aortic aneurysms - lens dislocations
148
Pathophysiology of Ehlers-Danlos syndrome
- group of inherited connective tissue disorders - faulty collagen - varied presentation
149
Presentation of Ehlers-Danlos
- joint hypermobility - easily stretched skin - easy bruising - chronic joint pain - reoccurring dislocations
150
Investigations for Ehlers-Danlos
Beighton score → assesses hypermobility
151
Management of Ehlers-Danlos
- physiotherapy - OT - psychological support → chronic condition, pain
152
Complications of Ehlers-Danlos
- hernias - prolapse - aortic root dilation - joint pain - abnormal wound healing

Phase 2a Resits (10 decks)

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