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1
Q

If someone present with severe back pain, usually around the thoracic area, and has a fever and respiratory symptoms, what is a likely diagnosis?

A

Pott’s disease of the spine

- secondary to TB infection

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2
Q

If a patient presents with a history of increasing back pain and fever, what should you suspect and how is it diagnosed and treated?

A

Dicitis

Diagnosis:
MRI
CT guided biopsy

Treatment:
6-8 weeks IV Antibiotics
+
Infective endocarditis scan

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3
Q

What back pathology typically presents with worsening of pain:

  • in the morning
  • extension movement
A

Facet Joint Pain

  • straight leg test will be negative.
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4
Q

If a patient presents with fever and severe pain that is getting worse in their:

  • lower back
  • radiating into their thigh and groin

the patient finds the pain is relieved somewhat by lying down and flexing their legs.
What is a likely diagnosis?

A

Psoas Abscess

Primary: haematogenous spread from distant site

Secondary: spread from local sources: crohn’s, diverticulitis, GU infections, endocarditis

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5
Q

If there is a disc prolapse at level 4/5 which sensory root will be affected?

A

Dermatome 5

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6
Q

What is the general Management for lower back pain?

A

Analgesia

  • NSAIDs
  • Paracetamol

Muscle relaxants
- diazepam (if needed)

Early mobilization

Physiotherapy

Cognitive behaviour therapy

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7
Q

Which primary tumour will show a codman’s sign on x-ray?

A

Osteosarcoma

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8
Q

What disease may lead to osteosarcoma?

A

Paget’s disease

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9
Q

How is osteosarcoma diagnosed and what other place should be imaged? and how is it treated?

A

High resolution CT

Image the Chest - the cancer spreads to lungs early

Treatment:

  • 8 weeks chemotherapy
  • amputation
  • continual chemotherapy
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10
Q

Where does osteosarcoma usually present?

A

Metaphysis of long bone

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11
Q

Which tumour may have the onion sign on xray?

A

Ewing’s sarcoma

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12
Q

Why should chondromas be removed?

A

They can become malignant and transform into chondrosarcomas

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13
Q

What is the management for chondrosarcomas?

A

Only surgical

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14
Q

What are some of the complications of Paget’s disease?

A

Pathological fractures

Hypercalcaemia

Nerve compression

Deafness

Osteosarcoma

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15
Q

What are the characteristic findings of the hands with OA?

A

Heberden’s nodes - DIPJ

Bouchard’s Nodes - PIPJ

Squaring of the base of thumb - CMJ

Weakened grip

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16
Q

What is the management for OA?

A

Lifestyle advice + strengthen exercises

physiotherapy

Analgesics:
1st line: Paracetamol + topical NSAIDs

2nd line: Oral NSAIDs + PPI

3rd Line: Opioids + steroid injections

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17
Q

What is the diagnostic criteria for OA?

A 
Diagnosis can be made clinically if: 
>45 years old 
Signs and symptoms 
\+ 
No stiffness over 30mins in morning
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18
Q

What are some extra articular manifestations of RA?

A

Pulmonary fibrosis
Pulmonary nodules
pleurisy

Episcleritis
Scleritis
Corneal ulceration

Vasculitis

Nodules

Felty’s syndrome

Depression

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19
Q

What x-ray changes can be seen in Ankylosing Spondylitis?

A

Squaring of vertebral bodies

Subchondral sclerosis

Syndesmophytes
- ligament calcification

Subchondral erosion

Fusion

  • facet joints
  • sacroiliac joints
  • costovertebral joints
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20
Q

What is the management of ankylosing spondylitis?

A

Physiotherapy
Smoking cessation

1st Line:

  • NSAIDs
  • naproxen
  • steroids for flares

2nd line:
- TNA alpha inhibitors

3rd line:

  • Secukinumab
  • surgery
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21
Q

What is a IL-17 inhibitor used in ankylosing spondylitis?

A

Secukinumab

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22
Q

What are some complications of Ankylosing spondylitis?

A

Bamboo spine

Vertebral fractures

Lung fibrosis
- apex of lungs

Heart block

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23
Q

What is an important clinical test to be done for Ankylosing spondylitis that suggests severe restriction in the lower spine?

A

Schober’s test
This is when the L5 is marked, then 10cm above is marked and 5cm below.
The patient then bends forward.

If the distance between them is <20cm then this shows there is a restrictive movement disorder. Helping support SA.

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24
Q

What are the crystals seen in pseudogout? and how do they appear under microscopy?

A

Calcium pyrophosphate crystals

Positively bifiregent and rhomboid

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25
What are the crystals in gout and how do they appear?
Monosodium urate crystals Negatively bifiregent, needle shaped
26
What is the long term treatment of gout?
Allopurinol - start 3 weeks after attack - increased every 4 weeks until the target level of urate acid is reached Febuxostat - if allopurinol not tolerated Uricosuric agents - promote excretion of urate acid stop use of predisposing factor - thiazides - losartan
27
When investigating gout what additional tests should be done beyond the joint aspiration?
Biochemical screen - Renal function - Lipid profile - glucose levels - uric acid level These should be done because of the association between metabolic syndrome and gout.
28
What should the patient be warned off when starting urate lowering drugs such as allopurinol?
That increased bouts of gout may occur initially and to continue with the treatment. Therefore should be on NSAIDs as well to cover.
29
What additional management outwith medication should be done for patients suffering with gout?
Lifestyle factors - loose weight - reduce alcohol intake - especially beer - maintain good hydration - avoid high purine diets - seafood, red meats - stop thiazides - swap for ACE inhibitors
30
What blood markers are typically elevated in acute gout?
ESR CRP Neutrophils
31
What clinical findings may be seen on a knee with OA?
Varus deformity Joint line/ periarticular tenderness Weakness and wasting of quadriceps Restricted movement Bony swellings around joint
32
What is the most sensitive sign for hip OA?
Pain and restriction of internal rotation of the hip when flexed
33
What are some risk factors towards septic arthritis?
Immunocompromised Prosthetic joint Damaged joint - RA - Previous Septic arthritis IVDU Diabetes Localised ulceration
34
What features of septic arthritis would point towards the infection being a disseminated STI?
``` Sexually active young person History of STI Migratory arthralgia Polyarthralgia Low grade fever Painful pustular skin lesions ```
35
What is the general management for Septic arthritis:
Following investigations, Joint aspiration, bloods. Sepsis 6: - IV antibiotics. - 2 weeks IV, 4 weeks oral Daily aspiration of joint or surgical drainage If prosthetic then orthopaedics are needed for DIAR or removal Physiotherapy early on - passive movement of joint
36
What is the triad of symptoms seen in reactive arthritis? | what is the management?
Reiter's syndrome - urethritis - arthritis - conjunctivitis NSAIDs/ intra articular injections consider methotrexate if > 6 months
37
What are two major complications of bisphosphonates?
Acid reflux - should be avoided in achalasia or strictures due to ulceration affect Osteonecrosis of the Jaw - should be withheld during dental work Atypical Bone fractures - especially of the hip
38
What pharmacological management is available for osteoporosis?
Vit D and Calcium supplements Bisphosphonates Denosumab Teriparatide - PTH recombinant HRT
39
What are the T scores ranges?
- 1.5 to -2.5: Osteopenia | - 2.5> : osteoporosis
40
Where does the DEXA scan usually look at?
Lumbar spin | Hip
41
Outwith DEXA scan what additional tests do you want to perform in osteoporosis?
* FBC * TFTs * Vitamin D * PTH levels • Coeliac screen - Can affect calcium reabsorption • Gonadotrophins If early onset, especially in males Good history of previous fractures, and risk factors
42
what medication is allopurinol contraindicated with?
azathioprine cause bone marrow suppression
43
How is Paget disease treated?
Bisphosphonates Calcitonin
44
How is Paget's disease investigated?
Bloods: - ALP - C- Telopeptide (bone turnover) X-ray - slcerotic bone Isotope uptake scan
45
What are the associated symptoms of Ankylosing spondylitis?
A's - Apical fibrosis in lungs - Anterior uveitis - Aortic regurgitation - Achilles tendonitis - AV node block - Amyloidosis
46
Outwith Reiter's syndrome what other clinical finding may point towards reactive arthritis?
dactylitis
47
What are the red flags of back pain?
<20 years of age, >50 years worse at night and morning Associated with systemic illness/ Fever Weight loss Previous/ active malignancy Associated with neurological symptoms
48
What are the risk factors for recurrence of back pain?
``` Female Increasing age Pre-existing chronic pain Psychological factors - distress Unemployment ```
49
What treatment can be done into vertebral crush fractures?
Vertoplasty - cement Kyphoplasty - balloon
50
Name some differentials into a swollen joint in a child:
Hemarthrosis Septic Juvenile idiopathic arthritis Reactive arthritis
51
What Examination do you want to do into a swollen joint?
``` Assess temperature Look for erythema Check ROM Compare against other knee Look at patient systemically - are they well ```
52
What are clinically findings of hands in rheumatoid disease?
Symmetrical Z deformity of thumb Prominent ulnar Swelling of PIPJs and MCPJs
53
Why might a RA patient have clubbing of fingers?
Interstitial lung disease methotrexate use
54
What are some complications of hip joints?
loosening of joint Septic arthritis Dislocation
55
What is a common cardiac manifestation of RA?
Pericarditis
56
What are the differentials for septic arthritis?
Gout Haemarthrosis Cellulitis Psoriatic arthritis
57
The fluid aspirated from an infected joint should be sent away for what?
Crystal Microscopy Gram staining Cultures Sensitivities
58
What is the management of septic arthritis?
IV Flucloxacillin +/- IV Gentamicin or IV Vancomycin if MRSA or allergic 2 weeks IV, 4 weeks PO Surgical: - irragation - wash out
59
What are some of the risk factors for OA?
Family history Obesity Occupation Hyperflexibility Trauma
60
What are some of the secondary causes of OA?
Intra-articular fracture Avascular ncesosis Paget's disease Haemochromatosis
61
What are the surgical interventions that can be done for OA?
Osteotomy - removal Arthroplasty - joint replacement Arthrodesis - fixation
62
What are some non medical interventions into OA?
Lifestyle changes - weight loss Insoles - cushioning Walking aids Knee braces TENs machine Physiotherapy
63
What is the definition of osteoporosis
Low bone mass Micro-architectural deterioration increased risk of fragility fracture
64
How is osteoporosis differentiated from osteomalacia?
Osteoporosis has normal mineralisation whereas osteomalacia does not
65
What are the risk factors for osteoporosis:
Menopause Low calcium Alcohol Smoking Steroid use Physical inactivity Hypogonadism in men
66
What is a screening method prior to DEXA scan for osteoporosis?
Quantitative Ultrasound
67
What does the T and Z score stand for in Osteoporosis?
T score - Bone density compared against a healthy 30 year old of same gender Z score - Bone density compared against some of the same age, gender and ethnicity
68
How many NSAIDs need to be used before TNF alpha is started in the management of Ankylosing spondylitis?
2 NSAID trials. then move to TNF alphas

Phase 4 (49 decks)

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