MSK Flashcards

Question

What are some signs of rheumatoid arthritis?

Answer 1

- Z shaped deformity to the thumb - Swan neck deformity (flex at DIP) - **Boutonnieres deformity**- due to a tear in the central slip of the extensor components of the finger. This means when they try to straighten their finger it cause it to bend and flex at PIP - Ulnar deviation of the fingers at the knuckles

Answer 2

- **Pulmonary fibrosis** - Anaemia - Cardiovascular disease - Amyloidosis - **Bronchiolitis obliterans** (inflammation causing small airway destruction** - **Felty's syndrome** (RA, neutropenia and splenomegaly) - **Sjogren's syndrome**

Answer 3

- Morning stiffness that lasts longer than 30 mins and improves throughout the day - Fever

Answer 4

- ESR and CRP will be elevated - Rheumatoid factor levels- can be a predictor can have high levels 15 years before the disease - Anti-CCP levels - Joint x-rays

Answer 5

- Comes form the **American college of rheumatology** 1. The joints involved (more and smaller joints score higher) 2. Serology 3. Inflammatory markers 4. Duration of symptoms longer or less than 6 weeks Score is added up and a score of greater than 6 indicates rheumatoid arthritis

Answer 6

- younger onset - Male - Presence of RF and anti-CCG

Answer 7

- Any one of **methotrexate, leflunomide or sulfasalazine**. Hydroxychloroquine can be considered in mild disease and is considered the “mildest” anti rheumatic drug.

Answer 8

Two of methotrexate, leflunomide or sulfasalazine

Answer 9

Methotrexate plus a TNF inhibitor e.g., infliximab

Answer 10

Methotrexate plus rituximab

Answer 11

CRP levels and DAS28

Answer 12

Accelerated atherosclerosis leading to cardiovascular disease

Answer 13

A type of crystal arthritis which is associated with chronically high levels of uric acid. Urate crystals are deposited in the joint causing it to become hot swollen and painful

Answer 14

- Increased cell turnover - Cytotoxic drugs e.g., chemotherapy - Purine rich diet, seafood and alcohol - Obesity - Severe psoriasis

Answer 15

- CKD - Diuretics e.g., thiazide and loop - Pyrazinamide - Lead toxicity - High fructose intake They are the more common cause they account for 90%

Answer 16

- Elderly - Men - Post-menopausal women - Alcohol - Diabetes - IHD - High diet intake of purines

Answer 17

- Uric acid is formed as a breakdown product if purines - Uric acid has a limited solubility in the blood and when there is too much uric acid it can become a urate ion and bind to sodium - This forms urate crystals which deposit in areas with slow blood flow the joints and kidney tubules

Answer 18

- **Gout tophi** are deposits of uric acid - Ears - Base of big toe - Wrists - Base of thumb

Answer 19

- Red, tender, hot and swollen joints - Joint stiffness - Rapid onset of severe pain

Answer 20

Can be made on just clinical presentation but excluding **septic arthritis** is key - **Joint aspiration** will show no bacterial growth, needle shaped crystals, **Negatively birefringent of polarised light**, Monosodium urate crystals - Measure serum urate levels 4-6 weeks after attack as they can be low at time of attack

Answer 21

- Joint space maintained - Lytic lesions - Punched out erosions - Sclerotic borders with overhanging edges

Answer 22

- NSAIDs first line - Colchicine second line- severe diarrhoea is a side effect - Steroids as third line

Answer 23

Lifestyle management and a **Xanthine oxidase inhibitor** - First-line **Allopurinol** - Second-line **Febuxostat**

Answer 24

Is a form of inflammatory arthritis caused by the deposition of **calcium pyrophosphate crystals** in the synovium

Answer 25

- Hyperparathyroidism - Hemochromatosis - Hypomagnesaemia - Hypophosphatemia - Wilson's disease - Acromegaly

Answer 26

Deposition of calcium pyrophosphate triggers synovitis with the **knee, shoulder and wrist most commonly being affected** - Can be acute or chronic

Answer 27

- No bacterial growth - Calcium pyrophosphate crystals - **Rhomboid shaped needles** - **Positive birefringent of polarised light**

Answer 28

Chondrocalcinosis is the classic x-ray change in pseudogout. It appears as a thin white line in the middle of the joint space caused by the calcium deposition. This is pathognomonic (diagnostic) of pseudogout.

Answer 29

An infection of 1 or more joints caused by pathogenic inoculation of microbes.

Answer 30

- **S.aureus the most common in all age groups** - S.epidermis in prosthetic joints - Streptococcus pyogenes in children under 5 - Gonorrhoeae in young sexually active people **if a young person presents think this**. (Watch out louis) - E.coli in immunosuppressant, elderly and IV drug use

Answer 31

- Underlying joint disease - IV drug use - Immunocompromised - Prosthetic joint/recent joint surgery

Answer 32

- Normally only one joint is affected. Most commonly the knee. - Hot tender and swollen joint - Limited range of movement

Answer 33

- Difficulty weight bearing - Fever

Answer 34

- FBC - Elevated CRP and ESR - Blood cultures - Plain x-ray

Answer 35

Joint aspiration will be yellow and cloudy and show presence of bacteria

Answer 36

**Kocher criteria** a score of 2 suggests 40% likelihood and score of 3 suggest 93%

Answer 37

- **Empirical therapy**: flucloxacillin plus rifampicin is first-line - **Penicillin allergy**: clindamycin - **Suspected or confirmed MRSA**: vancomycin - **Gonococcal arthritis or gram-negative infection**: cefotaxime or ceftriaxone Continue for 3-6 weeks

Answer 38

Mortality from septic arthritis ranges from 10 to 20% with treatment,

Answer 39

An inflammatory condition of the bone caused by an infecting organism most commonly S.aureus.

Answer 40

- Most common in children due to haematogenous spread - Adolescents and adults tend to get it due to an infection secondary to trauma

Answer 41

- **Staphylococcus aureus**: A gram-positive cocci. Includes MRSA (Methicillin Resistant Staphylococcus Aureus) a penicillin resistant organism. MOST COMMON! - Mycobacterium tuberculosis: Acid fast bacilli. May cause osteomyelitis - characteristically in Pott’s disease (TB affecting the spine). - Salmonella spp.: Gram-negative rods. Most commonly seen in patients with sickle cell anaemia. - Polymicrobial: More commonly seen in those with ulcers secondary to vascular disease, neuropathy and diabetes.

Answer 42

- Diabetes - Old age - Peripheral vascular disease - Immunocompromise - Malnutrition - Trauma/ injury

Answer 43

- Can occur when there is breakdown of the protective barriers of the skin e.g., Open fracture, skin ulcer, surgery - Haematogenous spread - Most commonly affects the axial skeleton, primarily the vertebral bones. The next most frequently affected sites are other axial bones like the sternum and pelvis. In children, long-bone osteomyelitis is seen

Answer 44

- Bacteria reach the bone and start to proliferate. This alerts immune cells and they try and fight off the infection. - The immune cells release chemicals that cause local bone destruction and usually this is effective

Answer 45

- If the lesion is not that extensive, and there’s viable bone the osteoblasts and the osteoclasts begin to repair the damage over a period of weeks. However, in some cases, the process turns into a chronic osteomyelitis - lasting months to years.

Answer 46

- Redness - Swelling - Evidence of trauma or surgery - Tenderness - Ulcers/skin breaks

Answer 47

- Fever - Joint pain - Erythema - Muscle aches - Nausea

Answer 48

Blood tests will show raised inflammatory markers (e.g., WBC, CRP and ESR). Blood cultures may be positive for the causative organism. Bone cultures can be performed to establish the causative organism and the antibiotic sensitivities.

Answer 49

MRI- will show bone marrow oedema and abscesses

Answer 50

- 6 weeks of flucloxacillin, possibly with rifampicin or fusidic acid added for the first 2 weeks - Clindamycin if penicillin allergy - Vancomycin in MRSA Chronic requires 3 months of antibiotics

Answer 51

- Septic arthritis - if infection spreads to joints - Growth disturbance in children and adolescents - Amputations

Answer 52

Most patients with acute osteomyelitis recover with no long-term complications if osteomyelitis is diagnosed promptly and treated adequately.

Answer 53

A group of related chronic inflammatory conditions. They tend to affect the axial Skelton adn share similar clinical features.

Answer 54

- Rheumatoid factor negative - **HLA-B27 positive** - louis strongly disagrees (not anymore) - thanks for correcting - Pathology in the spine - Asymmetrical inflammation of an entire joints**Sausage fingers** - Extra-articular manifestations

Answer 55

**S**- Sausage digit **P**- Psoriasis **I**- inflammatory back pain **N**- NSAIDs illicit a good response **E**- Enthesitis inflammation where tendon meets joint (plantar fasciitis) **A**- Arthritis **C**- Crohn's/colitis/CRP **H**- HLA-B27 **E**- eye uveitis

Answer 56

A chronic progressive inflammatory arthropathy. It mainly affects the spine and cause progressive stiffness and pain. Ankylosis= abnormal stiffening and immobility of a joint due to the fusion of a bone

Answer 57

- More common in males - Most commonly presents in teens/20s - Women present later and are underdiagnosed - 90% are HLA-B27 positive

Answer 58

- There is lymphocyte and plasma infiltration with local erosion of bone at the attachments of the intervertebral and other ligaments. - Inflammation of these tendons/ligaments when they heal they heal with new bone formation

Answer 59

- Symptoms tend to occur gradually over **3 months** -**Lower back pain stiffness** and **sacroiliac pain** in the buttock region. - The pain and stiffness is worse with rest and improves with movement it is worse at night and morning and improves throughout the day

Answer 60

- Weight loss and fatigue - Chest pain - Anaemia - **Heart block** - **Pulmonary fibrosis** - Aortitis inflammation of the aorta Note that any of the SPINEACHE symptoms may be present

Answer 61

- FBC normocytic anaemia - CRP and ESR elevated - Genetic testing for HLA-B27 - X-ray (MRI if x-ray of the spine is normal may show bone marrow oedema)

Answer 62

- Bamboo spine- calcification of ligaments - Syndesmophytes - areas of boney growth where the ligament normally inserts into the bone. - Ossification - structures such as ligaments turn into bone like tissue - Fusion - seen in facet joints, sacroiliac joints and costovertebral joints

Answer 63

Schober's test

Answer 64

Have the patient stand straight. Find the L5 vertebrae. Mark a point 10cm above and 5cm below this point (15cm apart from each other). Then ask the patient to bend forward as far as they can and measure the distance between the points. If the distance with them bending forwards is less than 20cm, this indicates a restriction in lumbar movement and will help support a diagnosis of ankylosing spondylitis.

Answer 65

- NSAIDs - Steroids - TNF-alpha infliximab - Monoclonal antibodies targeting IL-7 (secukinumab)

Answer 66

- Vertebral fractures - Osteoporosis - Aortitis - Restrictive lung disease - Heart block

Answer 67

An inflammatory arthritis associated with psoriasis. Can vary in severity from mild stiffening and soreness in the joint or the joint can be completely destroyed **arthritis mutilans**

Answer 68

10-20% and it usually occurs within 10 years of developing the skin change

Answer 69

- It has a strong genetic component and although not fully understood the activation of **CD8+ T cells** is thought to play a crucial role

Answer 70

- Joint tenderness and warmth - Dactylitis: swelling of the whole digit (sausage fingers) - Enthesitis: Inflammation of the tendons - Plaques of psoriasis on the skin - Pitting of the nails - Onycholysis (separation of the nail from the nail bed)

Answer 71

- Eye disease - Aortitis - Amyloidosis

Answer 72

The condition does not have a single pattern of affected joints in the same way as osteoarthritis or rheumatoid. There are several recognised patterns: **Symmetrical polyarthritis** presents similarly to rheumatoid arthritis and is more common in women. The hands, wrists, ankles and DIP joints are affected. **Asymmetrical pauciarthritis** affecting mainly the digits (fingers and toes) and feet. Pauciarthritis describes when the arthritis only affects a few joints. Spondylitic pattern is more common in men.

Answer 73

**PEST** screening tool Patients are asked about: joint pain, swelling, nail pitting Can also use the **CASPAR** criteria

Answer 74

- **Periostitis**- thickened and irregular outline of the bone - **Ankylosis**- where bones are joined together - **Pencil-in-cup appearance**- the classic x-ray change to the digits is the “pencil-in-cup appearance”. This is where there are central erosions of the bone beside the joints and this causes the appearance of one bone in the joint being hollow and looking like a cup whilst the other is narrow and sits in the cup.

Answer 75

It refers to synovitis occurring due to a recent infective trigger. This is an autoimmune response to infection elsewhere in the body

Answer 76

- 30-50 fold increase if someone is HLA-B27 positive - Women less commonly affected - Mainly occurs in adults

Answer 77

- **Gastroenteritis**- Salmonella, shigella - **Sexually transmitted disease**- chlamydia, Gonorrhoea

Answer 78

- Immune system is responding to the recent infection. This results in antibodies and inflammation that also affect the joints - It presents a lot like septic arthritis without infection at site of the bone it is somewhere else in the body

Answer 79

- Acute, asymmetrical monoarthritis typically in lower leg (knee). Can also present with triad of: Urethritis, arthritis and conjunctivitis **Can't see, pee or climb a tree**

Answer 80

- **Iritis** - swelling and irritation of eye - **Keratoderma blennorrhagia** - painless, red, raised plaques and pustules - **Circinate balanitis** - dermatitis of the head of the penis - **Mouth ulcers**

Answer 81

- Aspirate joints to rule out septic arthritis/Gout - Infectious serology - Sexual health review/ask about diarrhoea if present do a stool sample

Answer 82

- If patient presents with acute, warm, swollen and painful joint - **Hot joint policy** - presume patient has septic arthritis until its excluded - **Antibiotics** - **Aspirate joint - MCS & crystal examination** NSAIDs Steroid injections into the affected joints Systemic steroids may be required, particularly where multiple joints are affected

Answer 83

Most cases resolve within 6 months

Answer 84

- Is a chronic systemic autoimmune condition (type III hypersensitivity) due to a complex interplay between genetic and environmental factors. - It often takes a relapsing-remitting course. This results in chronic inflammation

Answer 85

It refers to the typical red **malar rash** that occurs across the face. It is more common in women and Asians

Answer 86

- Cardiovascular disease - Infections

Answer 87

- UV light - Smoking - EBV (epstein barr virus) - Sex hormones

Answer 88

- Middle aged - Female gender - HLA associations (**HLA-B8/DR2/DR3**)

Answer 89

- Environmental triggers e.g., UV light causes cell death. Due to genetic factors there is reduced clearance of these cellular debris - Also genetics play a further role as the immune system of these patients do not recognise the cellular debris as self so they attack them forming antibody-antigen complexes which get deposited in different tissues activating the complement pathway (type III hypersensitivity)

Answer 90

Anti-nuclear antibodies

Answer 91

- Fatigue - Weight loss - Joint and muscle pain - Fever - **Photosensitive malar rash**. Get's worse with sunlight and is butterfly shaped across the cheeks - Hair loss - Mouth ulcers - Shortness of breath

Answer 92

- Antibodies - FBC will show anaemia of chronic disease - C3 and C4 levels will be low - Increased CRP and ESR - Renal biopsy to asses for lupus nephritis

Answer 93

-**Anti-nuclear antibodies (ANA)**: Around 85% of patients with SLE will be positive for ANA. The initial step in testing for SLE. Antinuclear antibodies can be positive in healthy patients and with other conditions (e.g. hepatitis). A positive result needs to be interpreted in the context of their symptoms. - **Anti-double stranded DNA (anti-dsDNA)**: is specific to SLE, meaning patients without the condition are very unlikely to have these antibodies. Around 70% of patients with SLE will have anti-dsDNA antibodies

Answer 94

-Anti-Smith (highly specific to SLE but not very sensitive) -Anti-centromere antibodies (most associated with limited cutaneous systemic sclerosis) -Anti-Ro and Anti-La (most associated with Sjogren’s syndrome) -Anti-Scl-70 (most associated with diffuse cutaneous systemic sclerosis) -Anti-Jo-1 (most associated with dermatomyositis)

Answer 95

Use the SLICC criteria or the ACR criteria: involves the presence of ANA antibodies and certain number of clinical features

Answer 96

- CVD - Infections - Pericarditis - Lupus nephritis - Recurrent miscarriage

Answer 97

- NSAIDs - Steroids (prednisolone) - **Hydroxychloroquine** first line for mild - Sun cream for malar rash

Answer 98

- Methotrexate - Mycophenolate mofetil - Azathioprine - Tacrolimus - Leflunomide - Ciclosporin

Answer 99

- **Rituximab** targets B cells - **Belimumab** targets B-cell activating factor

Answer 100

A disorder associated with antiphospholipid antibodies where the blood becomes prone to clotting as the patient is in a **hypercoagulable state**. It presents with a variety of clinical features characterised by **thromboses** and **pregnancy related morbidity**

Answer 101

Systemic lupus erythematous in 20-30% of cases

Answer 102

- Antiphospholipid antibodies can cause thrombosis by binding to the phospholipid on the surface of cells such as endothelial cells, platelets and monocytes. - Once they bind to these cells it can result in thrombosis formation and/or miscarriage. They tend to affect cerebral and renal vessels

Answer 103

**C**- Coagulation defects **L**- livedo reticularis - lace-like purplish discolouration of skin **O**- Obstetric issues e.g., miscarriage **T**- Thrombocytopenia (low platelets) CLOT

Answer 104

- Stroke - MI - Renal thrombosis

Answer 105

- Recurrent miscarriage - Still birth - Preeclampsia

Answer 106

Libmann-Sacks endocarditis: is a type of non-bacterial endocarditis where there are growths (vegetations) on the valves of the heart. The mitral valve is most commonly affected. It is associated with SLE and antiphospholipid syndrome.

Answer 107

Diagnosis would be made when there is a history of thrombosis or pregnancy related complications plus the presence of: Lupus anticoagulant antibodies Anticardiolipin antibodies Anti-beta-2 glycoprotein I antibodies **The presence of them needs to be persistent positive test more than 12 weeks apart**

Answer 108

- Long term warfarin with an INR range of 2-3 - Pregnant women are put on low molecular weight heparin plus aspirin

Answer 109

Autoimmune disorders where there is inflammation in the muscles. Polymyositis refers to chronic inflammation of the muscles. Dermatomyositis is a connective tissue disorder where there is chronic inflammation of the skin and muscles

Answer 110

- The **creatine kinase** blood test. It is an enzyme that is found inside muscle. Inflammation of the muscles can lead to the release of it.

Answer 111

- Rhabdomyolysis - Acute kidney injury - Myocardial infarction - Statins - Strenuous exercise

Answer 112

They can be caused by an underlying malignancy. This makes them **paraneoplastic syndromes**

Answer 113

- Lung - Breast - Ovarian - Gastric

Answer 114

- Muscle pain, fatigue and weakness - Occurs bilaterally and typically affects the proximal muscles - Mostly affects the **Shoulder and pelvic girdle** - Develops over weeks

Answer 115

**Polymyositis occurs without skin features** - Gottron lesions - Photosensitive rash on back shoulders and neck - Purple rash on face and eyelids - Periorbital oedema - Subcutaneous calcinosis

Answer 116

Anti-Mi-2 antibodies Anti-nuclear antibodies

Answer 117

- Clinical presentation - Elevated creatine kinase levels - Autoantibodies

Answer 118

Muscle biopsy

Answer 119

- Patients should be assessed for underlying cancer - Corticosteroids are first line - Then immunosuppressants - Then infliximab

Answer 120

An autoimmune inflammatory and fibrotic connective tissue disease. It affects the skin in all areas and also the internal organs

Answer 121

Limited cutaneous systemic sclerosis Diffuse cutaneous systemic sclerosis

Answer 122

Used to be called CREST syndrome. **C**- calcinosis **R**- Raynaud's phenomenon **E**- oEsophageal dysmotility (i hate this one) **S**- Sclerodactyly **T**- Telangiectasia

Answer 123

Includes the CREST symptoms but also has systemic features - Cardiovascular e.g., CAD and hypertension- - Lung problems e.g., pulmonary hypertension and fibrosis - Kidney problems causes glomerulonephritis and a condition called scleroderma renal crisis C- calcinosis R- Raynaud’s phenomenon E- oEsophageal dysmotility (i hate this one) S- Sclerodactyly T- Telangiectasia

Answer 124

- Scleroderma refers to the hardening of the skin. It gives the appearance of shiny tight skin without normal folds -Sclerodactyly describes skin changes in the hand where the skin tightens around the joints and restricts movement

Answer 125

Telangiectasia are dilated small blood vessels in the skin. They are tiny veins that have dilated. They have a fine, thready appearance.

Answer 126

Oesophageal dysmotility is caused by connective tissue dysfunction in the oesophagus. This is commonly associated with swallowing difficulties, acid reflux and oesophagitis

Answer 127

An acute condition where there is a combination of severe hypertension and renal failure.

Answer 128

- Antinuclear antibodies (ANA) are positive in most patients with systemic sclerosis. - **Anti-centromere antibodies** are most associated with **limited cutaneous systemic sclerosis**. - **Anti-Scl-70 antibodies** are most associated with **diffuse cutaneous systemic sclerosis**. They are associated with more severe disease.

Answer 129

- Nailfold capillaroscopy- examines the health of the peripheral capillaries. micro-haemorrhages indicate systemic sclerosis

Answer 130

Nifedipine

Answer 131

Osteoporosis is a condition where there is a reduction in the density of the bones. Osteopenia refers to a less severe reduction in bone density than osteoporosis. Reduced bone density makes bone less strong and more prone to fractures.

Answer 132

- Primary disease - Malignancy - Endocrine dysfunction - COPD - IBD - CLD - CKD

Answer 133

**S**- Steroid use **H**- Hyperthyroidism, hyperparathyroidism **A**- Alcohol and tobacco use **T**- Thin **T**- Testosterone decrease **E**- early menopause- oestrogen is protective **R**- renal or liver failure **E**- Erosive/inflammatory bone disease **D**- dietary e.g., reduced Ca2+, malabsorption, diabetes

Answer 134

- Osteoclasts are responsible for the breakdown of bone and osteoblasts are responsible for the formation. As we age osteoclast activity is increased however this is not matched by osteoblast activity - The **peak mass we reach as young adults is key** a higher peak bone mass can be protective

Answer 135

- Oestrogen deficiency leads to an increased rate of bone loss. It is key yo the activity of bone cell receptors found on osteoblasts, osteocytes, and osteoclasts. - It is thought that osteoclasts survive longer in the absence of oestrogen and there is an arrest of osteoblastic synthetic architecture

Answer 136

They cause an increased turnover of bone. Prolonged use can result in reduced turnover state however the synthesis is affected resulting in bine mass reduction

Answer 137

There is an increased frequency of fractures. The most common ones include, **vertebral crush fracture**, and those of the **distal wrist (Colles' fracture)** and **proximal femur**

Answer 138

It gives a prediction of the risk of a **fragility fracture** over the next **10 years** It involves the inputting of information such as age, BMI, co-morbidities, smoking, family history and if done you can enter a **bone mineral score from a DEXA scan**

Answer 139

It gives the result as a percentage probability of a: - Major osteoporotic fracture - Hip fracture

Answer 140

It stands for dual-energy x-ray absorptiometry. It assess how much radiation is absorbed by the bones indicating how dense the bone is. The measurement is usually taken from the **Hip**

Answer 141

T-score: represents the number of standard deviations below the mean for a **healthy young adult** Z-score: represents the number of standard deviations the bone density falls **below a person for their age** T-score is more relevant

Answer 142

More than -1: Normal -1 to -2.5: Osteopenia Less than -2.5: Osteoporosis Less than -2.5 plus a fracture: Severe Osteoporosis

Answer 143

Low risk- reassure Medium risk- offer DEXA scan and recalculate the risk with the results High risk: offer treatment

Answer 144

- Activty and exercise - Weight control - Reduce alcohol/stop smoking NICE recommend calcium supplementation with vitamin D in patients at risk of fragility fractures with an inadequate intake of calcium. An example of this would be Calcichew-D3, which contains 1000mg of calcium and 800 units of vitamin D (colecalciferol). Patients with an adequate calcium intake but lacking sun exposure should have vitamin D supplementation.

Answer 145

**Bisphosphonates**- they interfere with osteoclast activity reducing their activity. eg: **Alendronate** 70mg once weekly **Riseronate** 35mg once weekly **Zoledronic acid** 5 mg once yearly (intravenous)

Answer 146

- Reflux and oesophageal erosions. - Osteonecrosis of the jaw and external auditory canal **They are taken on an empty stomach and person should sit upright for 30 minutes before taking**

Answer 147

**Denosumab** is a monoclonal antibody that works by blocking the activity of osteoclasts. **Teriparatide** anabolic treatment - increases bone density and improves trabecullae structure **Hormone replacement therapy** should be considered in women that go through menopause early. **Strontium ranelate** is a similar element to calcium that stimulates osteoblasts and blocks osteoclasts but increases the risk of DVT, PE and myocardial infarction. **Raloxifene** is used as secondary prevention only. It is a selective oestrogen receptor modulator that stimulates oestrogen receptors on bone but blocks them in the breasts and uterus.

Answer 148

- Activty and exercise - Weight control - Reduce alcohol/stop smoking NICE recommend calcium supplementation with vitamin D in patients at risk of fragility fractures with an inadequate intake of calcium. An example of this would be Calcichew-D3, which contains 1000mg of calcium and 800 units of vitamin D (colecalciferol). Patients with an adequate calcium intake but lacking sun exposure should have vitamin D supplementation.

Answer 149

- Reflux and oesophageal erosions. They are taken 30 minuets before food to prevent this - Osteonecrosis of the jaw and external auditory canal

Answer 150

- Low risk patients should have a follow up within 5 years - Patients being treated should have a repeat FRAX and DEXA after 3-5 years and a **treatment holiday** if BMD has improved (this is 18months to 3 years of treatment before a repeat assessment)

Answer 151

Widespread chronic pain

Answer 152

- female - Middle age - Genetics - Environmental e.g., child abuse, low household income divorced

Answer 153

- It is a problem with how the brain receives pain signals. Most patients have low levels of serotonin which is involved in inhibiting pain signals and elevated levels of substance P which increase pain signals - This together is though to paly a role in the hypersensitivity towards pain. Therefore the patient may perceive pain more readily compared to other people. The pain can be affected by lots of things e.g., sleep and emotions

Answer 154

**Allodynia**- pain in response to non-painful stimuli **Hyperaesthesia**- exaggerated perception of pain to mild stimuli

Answer 155

- Widespread pain that is aggravated by stress, cold and activity - Extreme tiredness - Sleep disturbance - Low mood - Poor concentration and headaches

Answer 156

- Chronic pain that has been present for at least 3 months - Widespread pain - involved left and right sides, above and below waist, and the axial skeleton. - Palpate tender point sites - severe pain in 3 to 6 different areas of your body, or you have milder pain in 7 or more different areas - No other reason for symptoms has been found **ALL INVESTIGATIONS WILL BE NORMAL**

Answer 157

- Rheumatoid arthritis - Chronic fatigue - Hypothyroidism - SLE - Polymyalgia rheumatica (PMR) - High calcium - Low vitamin D - Inflammatory arthritis

Answer 158

- **Amitriptyline** - tricyclic antidepressant - **Serotonin-norepinephrine reuptake inhibitors (SNRIs)** e.g. duloxetine Help by elevating serotonin and norepinephrine levels. - **Anticonvulsants** like pregabalin and gabapentin which slow nerve impulses can help with sleep problems.

Answer 159

An autoimmune condition that affects the **exocrine glands**. It leads to symptoms such as dry mouth, eyes and vagina

Answer 160

Primary SS: where the condition occurs in isolation Secondary SS; where the condition occurs with SLE or rheumatoid arthritis

Answer 161

- Hepatitis - PBC - Graves' disease - Antiphospholipid syndrome normally is SLE or RA

Answer 162

Anti-Ro Anti-La

Answer 163

- Involves inserting a folded piece of filter paper under the lower eyelid with a strip hanging out over the eyelid - This is left for 5 minuets and the distance travelled along the strip is measured. Anything less than 10mm is significant

Answer 164

- Eye infections - Oral problems such as cavities and candida infections - Vaginal problems such as candidiasis and sexual dysfunction

Answer 165

- Pneumonia and bronchiectasis - Non-Hodgkin's lymphoma - Peripheral neuropathy - Vasculitis - Renal impairment

Answer 166

- Artificial tears - Artificial saliva - Vaginal lubricants - Hydroxychloroquine is used to halt the progression of the disease.

Answer 167

Inflammation of a blood vessel. It is characterised by the presence of an inflammatory infiltrate and destruction of vessel walls

Answer 168

- Giant cell arteritis - Takayasu's arteritis

Answer 169

- Polyarteritis nodosa - Kawasaki disease

Answer 170

- Microscopic polyangiitis - Granulomatosis with polyangiitis (Wegener's granulomatosis) ((nazi)) - Eosinophilic Granulomatosis with Polyangiitis (Churg-Strauss syndrome)

Answer 171

Henoch-schonlein purpura

Answer 172

Anti neutrophil cytoplasmic antibodies (ANCA) There are two types of blood test p-ANCA (anti-MPO) and c-ANCA (anti-PR3). p-ANCA are positive in: Microscopic polyangiitis and Churg-Strauss syndrome c-ANCA are positive in Granulomatosis with polyangiitis

Answer 173

It is vasculitis of the medium and large arteries. It is the most common form of systemic vasculitis that affects and adults. It usually affects branches of the carotid artery

Answer 174

- Age usually over 50 - Female - Caucasians - Polymyalgia rheumatica associated in 50% of cases

Answer 175

It is a granulomatous vasculitis. Arteries become inflamed and thickened and there is a narrowed vascular lumen and can obstruct blood flow. Cerebral arteries are particularly affected.: **Superficial temporal**: headache and scalp tenderness **Mandibular**: Jaw claudication **Ophthalmic artery**: visual loss due to retinal ischaemia

Answer 176

- Superficial temporal artery tenderness - Absent temporal pulse - Reduced visual activity

Answer 177

- Main symptom is headache that us unilateral and around forehead and temple. - Irreversible painless complete sight loss - Jaw claudication - Scalp tenderness may be noticed when brushing hair

Answer 178

- **Fever** - **Muscle aches** - **Fatigue** - **Weight loss** - **Loss of appetite** - **Peripheral oedema**

Answer 179

- ESR a value of greater than 50mm/h makes up 1 of the 5 criteria - **Definitive diagnosis**- is made doing a temporal artery biopsy: will show the presence of **Multinucleated giant cells**. (negative results don't rule out GCA due to presence of skip lesions)

Answer 180

≥ 3 criteria should be met for a positive diagnosis of GCA

Answer 181

- Corticosteroids 40-60mg IV methylprednisolone - Oral aspirin to prevent ischaemic cranial complications

Answer 182

- Aortic aneurysms - Glucocorticoid toxicity - Vision loss - Cerebrovascular accident

Answer 183

Once the diagnosis is confirmed they will need to continue high dose steroids (40-60mg) until the symptoms have resolved. They then need to slowly wean off the steroids. This can take several years. This is a similar process to managing polymyalgia rheumatica.

Answer 184

A multi-system disorder of unknown cause characterised by necrotising granulomatous inflammation

Answer 185

- B-cells mistakenly target their antibodies to granules made by a person's own neutrophils. - These are 'cytoplasmic anti-neutrophilic cytoplasmic antibodies' or c-ANCAs. Once they are bound to the neutrophil it causes free radical release which damages nearby cells

Answer 186

It affects the respiratory tract and the kidneys. - Nose bleeds - Sinusitis - Crusty nail secretions - Saddle shaped nose - Cough - Wheeze - Haemoptysis - glomerulonephritis

Answer 187

- Steroids combined with cyclophosphamide - Methotrexate and azathioprine usually used for maintenance

Answer 188

Polyarteritis nodosa (PAN) is a medium vessel vasculitis. It is most associated with hepatitis B but can also occur without a clear cause or with hepatitis C and HIV. It affects the medium sized vessels in locations such as the skin, gastrointestinal tract, kidneys and heart. This can cause renal impairment, strokes and myocardial infarction. It is associated with a rash called livedo reticularis. This is a mottled, purplish, lace like rash.

Answer 189

Eosinophilic granulomatosis with polyangiitis used to be called Churg-Strauss syndrome and is still often referred to by this name. It is a **small and medium vessel vasculitis**. It is most associated with lung and skin problems, but can affect other organs such as kidneys. It often presents with severe asthma in late teenage years or adulthood. A characteristic finding is elevated eosinophil levels on the full blood count.

Answer 190

Loads and loads of bone remodelling - Excessive bone resorption and growth Will lead to deformities and potential fractures

Answer 191

Osteoblasts release RANKL, that binds to receptors on osteoclasts, activating them Osteoblasts also release a substance call Osteoprotegerin, which blocks RANKL receptors on osteoclasts, so RANKL can't bind to them and therefore prevents too much bone resorption

Answer 192

- Can be triggered by infections e.g. measles virus - Linked to genetic mutations e.g. SQSTM1

Answer 193

- Typically affects older people (rare in under-40s) - Commoner in temperate climates and anglo-saxons - UK has highest prevalence in the world

Answer 194

Phase 1 - lytic phase - Osteoclasts which have up to 100 nuclei aggressively demineralise the bone (x20 more than normal). Phase 2 - mixed phase (lytic and blastic)- rapid, disorganised proliferation of new bone tissue by a large number of osteoblasts. Collagen deposited in a haphazard way. Phase 3 - sclerotic phase - New bone formation exceeds bone resorption. The bone is structurally disorganised and weak. - Osteoblastic activity slows down leading to dormant phase - 'burned out state'

Answer 195

Misshapen bone, that can impinge on nerves = pain Overgrowth of bone, can lead to Hearing and vision loss Can lead to osteosarcoma - Paget Sarcoma Can lead to bony deformities, like **Kyphosis** Bow legs pelvic asymmetry Arthritis, joint inflammation, Easy fractures

Answer 196

high levels of ALP Lytic lesions and thickened bone cortices on xray Bone biopsy to exclude malignancies

Answer 197

- pain relief - NSAIDs - Anti-resorptive medication - Biphosphonates e.g. **alendronic acid** - Along with calcium and vit D supplementation - Surgery - - Correct bone deformities - Decompress impinged nerve - Decrease fracture risk

Answer 198

**Autosomal dominant condition** affecting the **FB1 gene** which results in abnormal fibrillin production and therefore a reduced connective tissue strength

Answer 199

- **Osteosarcoma** - Arise from osteoblasts - **Chondrosarcoma** - Arises from the chondrocytes which are cartilage-producing cells. - **Ewing sarcoma** - Thought to arise from neuroectodermal cells

Answer 200

- **Osteochondroma** - mutations in EXT1 + EXT2 arises from the growth plate, and it typically results in a lateral bony projection (exostosis) that has a cap, made mostly of hyaline cartilage. - **Giant cell tumour** - Risk factor: bony trauma e.g. fracture or radiation exposure - The tumor cells arises from osteoclasts cells, that develop into cells that have numerous nuclei - typically over 50 nuclei. - **Osteoblastomas** - large Nidus - Arise from osteoblasts - **Osteoid osteomas**- Small nidus - Arise from osteoblasts

Answer 201

BLT KP: Breast Lung Thyroid Kidney Prostate

Answer 202

Breast and lung Osteolytic = Causing the breakdown of bone

Answer 203

Prostate Thyroid RCC Abnormal hardening of bone and an elevation in bone density

Answer 204

Local persistent severe pain often worse at night Systemic: Weight loss, fatigue, fever, malaise Primary bone cancers only seen in the young

Answer 205

Surgical resection - often limb amputation Adjuvant Chemo/radiotherapy Bisphosphonates

Answer 206

Defective bone mineralisation that has occurred after fusion of the epiphyseal growth plates therefore only occurs in adults.

Answer 207

Disorder of defective bone mineralisation that has occurred prior to fusion of the epiphyseal growth plates and therefore occurs in children

Answer 208

Commonly Vitamin D deficiency leading to reduced calcium and phosphate absorption from the GI tract. Therefore there is inadequate production of Calcium Hydroxyapatite to mineralise bone

Answer 209

Vitamin D deficiency: Malabsorption, Low intake, poor sunlight CKD - low vitamin D activation cannot produce 1,25-hydroxyvit D) Liver failure - Low reaction of Vit D pathway Hyperparathyroidism - secondary to Vit D deficiency

Answer 210

Increase CYP450 metabolism of vitamin D leading to deficiency and hence subsequent osteomalacia

Answer 211

Generalised Bone Pain Fractures of bone - **most commonly femoral neck** Proximal weakness Difficulty bearing weight

Answer 212

Skeletal deformities Knocked knees and Bowed Legs Wide Epiphyses

Answer 213

Correct initial Vit D and then maintenance: Vitamin D replacement - Calcitriol Increase dietary intake of Vit D (D3 tablets/eggs) Treat underlying cause

Answer 214

Many causes, including - Strain - Heavy manual handling - Stooping and twisting whilst lifting - Pregnancy - Trauma - Lumbar disc prolapse - Spondylolisthesis (one vertebrae slips out of place causing back pain) - Osteoarthritis - Fractures - Exposure to whole body vibration

Answer 215

Heavy manual handling (>20kg) Lifting above shoulder height Lifting from below knee height Incorrect manual handling technique Forceful movements Fast repetitive work, poor postures, poor grip

Answer 216

Prolapse of the vertebral disc causing acute pain. Vertebral disc degeneration

Answer 217

Sudden onset of severe back pain often following a strenuous activity Pain is often clearly related to position and is aggravated by movement Muscle spasm leads to a sideways tilt when standing Lower 3 discs L4 - lateral thigh to medial calf L5 - Buttock to lateral leg and top foot S1 - Buttock down back of thigh to ankle/foot

Answer 218

Red flags – TUNAFISH T – trauma, TB U – unexplained weight loss and night sweats N – neurological deficits, bowel and bladder incontinence A – age less than 20, or over 55 F - fever I – IV drug user S - steroid use or immunosuppressed H – history of cancer, early morning stiffness

Answer 219

Anti-Smith (highly specific to SLE but not very sensitive) Anti-centromere antibodies (most associated with limited cutaneous systemic sclerosis) Anti-Ro and Anti-La (most associated with Sjogren’s syndrome) Anti-Scl-70 (most associated with systemic sclerosis) Anti-Jo-1 (most associated with dermatomyositis)

Answer 220

- Anti-centromere antibodies (most associated with limited cutaneous systemic sclerosis). - Anti-Scl-70 (most associated with systemic sclerosis)

Answer 221

Anti-Ro and Anti-La (most associated with Sjogren’s syndrome)

Answer 222

Anti-Jo-1 (most associated with dermatomyositis)