msk

Question 1

What are the risk factors for SLE and epidemiology

Answer 1

more in women, younger ages (20-40), afrocaribean and asian women

Question 2

presentation of SLE

Answer 2

(thing flaws) low grade fever, VERY FATIGUED, weight loss
and then system specific symptoms, because SLE is a systemic disease it can affect pretty much any organ so difficult to diagnose!

skin: mouth or other ulcers, butterfly rash or other
joints: small> large joint pain and stiffness
renal: haematuria (and proteinuria but that finding- lupus nephritis)
lungs: breathlessness
brain: depression
heart; pericarditis or myocarditis?
lymphadenopathy

Question 3

SLE pathophysiology

Answer 3

autoimmune condition with infiltrates in any system?
HLA, B8 , DR2, DR3 are some immune complexes involved in the infiltration of the organs

Question 4

SLE diagnostics, give one very SENSITIVE and one very SPECIFIC ANTIBODIES

Answer 4

sensitive: ANA (99%)
SPECIFIC: anti-ds DNA but only 70% sensitive

other diagnostic indicators
FBC findings:

anaemia
lymphocytopenia
thrombocytopenia due to immune mediated destruction

Question 5

GIVE a v specific but very poor sensitivity ab for SLE

Answer 5

anti-smith antibody

Question 6

general management of SLE

Answer 6

basics are NSAIDS and sun-block
Hydroxychloroquine is the suggested drug
then if specific organs have porblems consider prednisolone and cyclophosphamide

Question 7

use of ESR and CRP in lupus?

Answer 7

ESR is generally used to monitor disease
during active disease the CRP may be normal - a raised CRP may indicate underlying infection

Question 8

comment on complement and anti ds-DNA levels as a tool to monitor LUPUs

Answer 8

complement (C3 and C4 usually low since they are used up in complexes deposited in the organs

Question 9

polymyalgia rheumatica presentation and demographic

Answer 9

large joint pain and stiffness, mainly shoulders and hips
older patients so 60+
usually RAPID ONSET
also kinda FLAWS- low grade fevers, lethargy, appetite loss, weight, sweats, mild polyarthralgia (think case seen on video with retired man thats just feeling sick all the time)

Question 10

is muscle weakness a feature of polymyalgia rheumatica?

Answer 10

noooooo

Question 11

polymyalgia rheumatica commonly associated condition

Answer 11

giant cell/ temporal arteritis

Question 12

polymyalgia rheumatica management

Answer 12

steroids, patients typically respond dramatically to steroids, failure to do so should prompt consideration of an alternative diagnosis

Question 13

investigations in polymyalgia rheumatica

Answer 13

raised inflammatory markers e.g. ESR > 40 mm/hr
note creatine kinase and EMG normal

Question 14

myasthenia gravis presentation

Answer 14

it is a progressive

Question 15

myasthenia gravis muscle groups commonly affected and consequent symptom produced

Answer 15

extraocular muscles (diplopia)
face muscles (ptosis) ,
neck muscles (dysphagia)
limb griddles - limb weakness

Question 16

associated conditions with myasthenia gravis

Answer 16

• thymoma in 15% of people which is quite high really
• other autoimmune diseases
• thymic hyperplasia in 50-70%

Question 17

investigations for myasthenia gravis

Answer 17

• single fibre electromyography (high sensitivity)
• CT thorax to exclude thymoma
• acetylcholine receptor antibodies present in 85-90% of people
  (of the ones that don’t have these abs 40% have another ab: anti- muscle specific tyrosine kinase abs )

Question 18

long term management of myasthenia gravis first line

Answer 18

• long acting acetylcholinesterase inhibitors

Question 19

what other treatments may be required for management of myasthenia gravis down the line

Answer 19

immunosuppression with prednisolone initially and then maybe azathioprine or some other options

thymectomy

Question 20

myasthenia gravis crisis management

Answer 20

plasmapheresis and IV immunoglobulins

Question 21

Ankylosing spondylitis presentation

Answer 21

Lower back pain and stiffness and sacroiliac pain
Young male in teens or 20s symptom onset> 3 months

Question 24

Pathophysiology of ankylosing spondylitis

Answer 24

HLA b27 associated inflammatory condition causing the SACROILIAC joint and vertebral joints most commonly to merge together! Squaring of the vertebra, bamboo spine late presentation ect

Question 25

What makes ankylosing spondylitis stiffness worse and better

Answer 25

Better by movement worse by rest (worse at night and takes at least 30 mins to improve in morning)

Question 26

Key complication of ankylosing spondyllitis and disease lrogression

Answer 26

Vertebral fractures and progression is not linear with flares and remitting stages

Question 27

What other symptoms and associations with ankylosing spondylitis

Answer 27

Weight loss and fatigue Other things associated u get with it ae chest pain anterior uveitis , IBD, RESTRIctive lung disease, anaemia, enthesitis, dactylitis, pulmonary fibrosis in the upper lobes

Question 28

Describe the schober’s test

Answer 28

Make a mark at L5 and one 10 cm above one 5 below . These points are 15 cm apart and when they bend forward this needs to increase by at least 5 in normal person. If not this supports diagnosis of ankylosing spondylitis

Question 29

first line diagnostic investigation of ankylosing spondylitis

Answer 29

pelvic XRAY

Question 30

ankylosing spondylitis investigation if pelvic xray shows no significant findings

Answer 30

MRI

Question 31

ankylosing spondylitis xray findings

Answer 31

osteophytes, squaring of the vertebra syndesmophytes subchondral errosions ossification subchondral sclerosis and fusion of joints

Question 32

first line management of ankylosing spondylitis

Answer 32

1) NSAIDS - ibuprofen and naproxen you can try switching i not wokring 2) steroids during flares 3) next step is targeting TNF so anti-TNF medications like entanercept adalimumab, certolizumab if none of these work there is a new monoclonal antibody against Il 7 CALED secukinumab - new showing promising results

Question 33

other than female gender and age what are some other important risk factors for osteoporosis

Answer 33

low BMI smoking corticosteroid use alcohol family history

Question 34

what is the definition of osteoporosis

Answer 34

low mineral bone density specifically less than 2.5 standard deviations below the young adult mean density (which can be calculated from a DEXA scan)

Question 35

which patients need to be risk assessed for osteoporosis?

Answer 35

all women > 65 and all men >75 younger patients in the presence of risk factors!!!

Question 36

what are causes of SECONDARY osteoporosis

Answer 36

-hypogonadism in either sex including low testosterone in men and premature menopause in women -endocrine conditions, including diabetes mellitus, Cushing's disease, hyperthyroidism -conditions associated with malabsorption, including inflammatory bowel disease, coeliac disease, and chronic pancreatitis. -rheumatoid arthritis and other inflammatory arthropathies.

Question 37

what is the method of risk assessment for osteoporosis

Answer 37

first exclude secondary causes that may need tratment then fragility rusk score such as FRAX or Qfracture

Question 38

based off os the risk score calculations from risk score calculation tools, when should a dexa scan be offered

Answer 38

QFracture if the 10-year fracture risk is ≥ 10% then a DEXA scan should be arranged FRAX a colour 'risk' is given by the calculator - green, orange or red patients in the orange zone should have a DEXA scan if not already done to further refine their 10-year risk patients in the red zone should also have a DEXA scan if not already done to act as a baseline and guide drug treatment

Question 39

when should a DEXA scan be offered without calculating fragility risk score?

Answer 39

> 50 years of age with a history of fragility fracture < 40 years of age who have a major risk factor for fragility fracture - these patients should be referred to a specialist depending on the T-score before starting treatments that may have a rapid adverse effect on bone density (for example, sex hormone deprivation for treatment for breast or prostate cancer)

Question 40

Postmenopausal women, and men age ≥50, who are treated with oral glucocorticoids: if starting ≥7.5 mg/day prednisolone or equivalent for the next 3 months, what to do?

Answer 40

start bone protective treatment at the same time general osteoporosis management as above don't wait for a DEXA scan before starting treatment oral bisphosphonates are used first-line e.g. alendronate or risedronate

Question 41

other than pharmacological management what are the other aspoects of management important in osteoporosis

Answer 41

balanced diet calcium and vitamin d intake and supplementation should be offerred to all unless gp is certain that its fine weight bearing and muscle strengthening secondary causes of osteoporosis should be considered and treated e.g. hypogonadism in women or men e.g. hormone replacement therapy for premature menopause

Question 42

first line pharmacological treatment of osteoporosis and how are they taken

Answer 42

bisphosphonates are the first-line drug treatment for patients at risk of fragility fractures oral bisphosphonates such as alendronate and risedronate are typically first-line. These are often taken weekly are need taking in a particular way to minimise the risk of oesophageal side-effects

Question 43

when is an exception to the rule of bisphosphonates first line and what is given instead

Answer 43

if following hip fracture give IV zolendronate given yearly

Question 44

second line osteoporosis pharmacological management

Answer 44

denosumab

Question 45

what bones in the body does a DEXA SCAN LOOK AT

Answer 45

hips and pelvis

Question 46

most common locations of pathological fractures

Answer 46

wrist (coles fracture), hips, vertebral (presents with kyphosis, decrease in height, painless or painful ect)

Question 47

pathological fracture causes

Answer 47

primary malignancies metastatic malignancies local benign conditions: chronic osteomyelitis, solitary bone cyst bone disease: pagets, osteoporosis, metabolic bone disease, osteogenesis imperfecta

Question 48

osteomalacia causes

Answer 48

vitamin D deficiency ----malabsorption ----lack of sunlight ----diet chronic kidney disease drug induced e.g. anticonvulsants inherited: hypophosphatemic rickets (previously called vitamin D-resistant rickets) liver disease: e.g. cirrhosis coeliac disease

Question 49

presentation of osteomalacia

Answer 49

bone pain bone/muscle tenderness fractures: especially femoral neck proximal myopathy: may lead to a waddling gait

Question 50

investigation for osteomalacia

Answer 50

bloods low vitamin D levels low calcium, phosphate (in around 30%) raised alkaline phosphatase (in 95-100% of patients) x-ray translucent bands (Looser's zones or pseudofractures)

Question 51

treatment of osteomalacia

Answer 51

vitamin D supplmentation ---- a loading dose is often needed initially calcium supplementation if dietary calcium is inadequate

Question 52

Gottron's papules what are they and what condition are they present in

Answer 52

roughened red papules over extensor surfaces of fingers- dermatomyositis