MSK

Question 1

Sx of OA?

Answer 1

Localised disease (hip/knee): Pain and crepitus on movement with background ache at rest - joints may feel unstable. Symptoms worse with prolonged activity.
Generalized disease (nodal): Bouchard's nodes (PIP) and Heberden's nodes (DIP), reduced range of movement and mild synovitis

Question 2

What is seen on X-ray in OA?

Answer 2

Loss of joint space, Osteophytes, Subchondral cysts and Subarticular sclerosis

Question 3

Tx of OA?

Answer 3

Exercise to improve local muscle strength and weight loss if obese.
Analgesia (regular paracetamol or NSAIDs), intra-articular corticosteroids, joint arthroplasty.

Question 4

Sx of septic arthritis?

Answer 4

Sudden onset severe joint pain and swelling, colour change in the skin around the joints and fever

Question 5

Tx of septic arthritis?

Answer 5

Aspirate the joint and send for microbiological culture

Start antibiotic treatment ASAP.

Question 6

Common causative organisms of septic arthritis? How can you identify them?

Answer 6

Staph. aureus = gram positive catalase positive cocci which is also coagulase positive
Neisseria gonococcus = gram negative diplococci
Streptococcus and Gram -ve bacilli

Question 7

Sx of RA?

Answer 7

Symmetrical swollen, painful and stiff small joints of the hands/feet which is worse in the morning.
Ulnar deviation, Boutonniere deformitiy and Swan-neck deformity
Fever, fatigue, weight loss and pericarditis

Question 8

Dx of RA?

Answer 8

Anti-CCP positive
X-ray = Loss of joint space, Errosions, Soft bones (juxta-articular osteopenia), Soft tissue swelling and joint deformity

Question 9

Tx of RA?

Answer 9

Eary use of DMARDs, steroids, TNF-alpha inhibitors e.g. infliximab. Give NSAIDs for pain

Question 10

Sx of gout?

Answer 10

Sudden onset severe joint pain and swelling (often in the MTP joint of the big toe). Tophi indicate long term high urate levels

Question 11

RFs for gout?

Answer 11

Impaired renal function: hypertension, diuretics, anti-hypertensives, aspirin and DM
High purine diet e.g. red meat, seafood, alcohol etc.
Tumour lyisis syndrome

Question 12

Dx and Tx of gout?

Answer 12

ASPIRATE! Negativley birefringent, needle shaped, monosodium urate crystals seem on microscopy.
High dose NSAIDs/steroids/colchicine. Allopurinol for long term prevention.

Question 13

Dx and Tx of pseudogout?

Answer 13

ASPIRATE! Positivley birefingent phosphate crystals - usually affects the knee.
Intra-articular steroids. NSAIDs and colchicine for long term prevention

Question 14

Name the spondylarthropathies. What do they have in common?

Answer 14

Ankylosing spondylitis, Psoriatic arthritis and Reactive arthritis.
Seronegative (RF -ve), associated with HLA B27, generally asymmetrical, enthesitis, dactylitis and iritis

Question 15

Sx of ankylosing spondylitis?

Answer 15

Young man with gradual onset lower back pain which radiates down the buttocks and is worse at night. Has morning stiffness which is relieved by exercise and progressive loss of spinal movement

Question 16

Tx of ankylosing spondylitis?

Answer 16

Exercise, NSAIDs, local steroid injections and TNF-alpha-blockers e.g. adalimumab

Question 17

Sx of psoriatic arthritis?

Answer 17

Pain, swelling and stiffness in the joints, nail changes e.g. pitting, synovitis => dactylitis and errosive bone changes e.g. pencil-in-cup X-ray deformity

Question 18

Tx of psoriatic arthritis?

Answer 18

NSAIDS, sulfsalazine/methotrexate and anti-TNF agents

Question 19

Sx of reactive arthritis?

Answer 19

Iritis/conjunctivitis, urethritis and pain/joint stiffness = Reiter's triad
Keratoderma blenorrhagica (brown plaques on palms/soles), painless penile ulceration (if chlamydia)

Question 20

Sx and Dx of Sjogren’s syndrome?

Answer 20

Decreased tear production = dry eyes, decreased salivation = dry mouth and parotid swelling
Schirmer’s test, usualy ANA positive

Question 21

Sx of systemic sclerosis?

Answer 21

Thickening of the skin, patchy itchy skin discolouration, Raynaud’s phenomenom.
Limited (aka CREST syndrome) = face, hand and feet invoment only
Diffuse = weight loss, fatigue, joint pain/stiffness, dyspnoea and hypertension

Question 22

Dx of systemic sclerosis?

Answer 22

ANA positive

Question 23

Sx of SLE?

Answer 23

Butterfly rash, photosensitive rash, erythema, Raynaud’s phenomenom, alopecia, oral/nasal ulcers, joint stiffness, seizures and weight loss.
High risk of kidney issues

Question 24

Dx of SLE?

Answer 24

ANA positive, anti-dsDNA antibodies = BEST TEST, raised ESR but normal CRP

Question 25

Tx of SLE?

Answer 25

High factor sun-block, hydroxycholorquine, topical steroids, DMARDs e.g. Azothioprine

Question 26

Sx of anti-phospholipid syndrome?

Answer 26

CLOT = Coagulation defects, Livedo reticularis, Obstetric issues and Thrombocytopenia OFTEN SEEN IN SLE PATIENTS

Question 27

Name the types of blood vessels affected by vasculitis, give an example for each?

Answer 27

``` Large = GCA Medium = Polyarteritis nodosa Small = ANCA associated e.g. Wegener's granulomatosis or immune compex associated e.g. Goodpasture's syndrome ```

Question 28

Sx of GCA?

Answer 28

Headache, scalp tenderness, tongue/jaw claudication, amaurosis fugax. Malaise, weight loss, dyspnoea and morning stiffness

Question 29

Dx and Tx of GCA?

Answer 29

Temporal artery biopsy, very raised ESR and CRP | Oral prednisolone or IV methylprednisolone (if vision loss)

Question 30

Sx of Polymyalgia Rheumatica (PMR)

Answer 30

Sub-acute (<2 weeks) bilateral aching, tenderness and morning stiffness of the shoulders/hips/proximal muscles. Fatigue, fever, weight loss and depression. Associated with GCA

Question 31

Tx of PMR?

Answer 31

Prednisolone

Question 32

What is fibromyalgia?

Answer 32

``` Chronic pain (>3 months) that is widesperad (left and right sided, above and below the waist and involving the axial skeleton) for which no organic cause can be found. Sx: Un-refreshing/disturbed sleep, fatigue/pain with small amounts of exertion and morning stiffenss ```

Question 33

Tx of fibromyalgia?

Answer 33

Low dose amitriptyline

Question 34

Sx of cauda equina syndrome?

Answer 34

Back pain. Bilateral leg pain, saddle (perianal) anaesthesia, loss of anal tone on PR, bladder incontience, bowel incontinence

Question 35

Sx of acute spinal cord compression?

Answer 35

Bilateral pain, LMN signs at the level of compression, UMN signs below the level of compression. May be sphincter disturbance

Question 36

What is osteomyelitis? What causes it?

Answer 36

Infection of the bone either from direct innoculation, contiguous spread from adjacent tissues or haematogenously e.g. from pneumonia/UTI via the blood. Most common casue = staphylococcus aureus

Question 37

Sx of osteomyelitis?

Answer 37

Malaise, fever and fatiuge. Swelling, redness and pain over the infection area

Question 38

What is mechanical back pain?

Answer 38

Any type of back pain caused by placing abnormal stress and strain on muscles of the vertebral column. RF = poor posture, poor lifting technique, frequent bending/stooping and whole body vibrations

Question 39

What are the most common discs affected in vertebral disc disease?

Answer 39

S1 (ankle jerk reflex lost), L4 (knee jerk reflex lost) and L5

Question 40

Where do secondary bone tumours metastasize from?

Answer 40

Breast, thyroid, lung, kidney and prostate.

Question 41

What are the red flags for bone tumours?

Answer 41

History of cancer, weight loss, night sweats, unremitting pain, pain which is worse at night, pain in children

Question 42

What is the most common primary bone cancer?

Answer 42

Multiple myeloma - most common | Osteosarcoma - most common in children

Question 43

Sx of multiple myeloma?

Answer 43

Oesteolytic bone lesions = bone/back pain, pathological fractures and vertebral collapse Hypercalcaemia = bone pain, renal stones, nausea/vomiting, constipation, abdominal pain, polyuria/polydypsia, weakness and confusion/depression Pancytopenia and renal impairment

Question 44

Dx of multiple myeloma?

Answer 44

Monoclonal protein bands on electrophoresis, increased plasma cells on BM biopsy, evidence of end-organ damage (hypercalcaemia/renal insuffisiency/anaemia) and bone lesions seen on x-ray - commonly spine/skull/pelvis

Question 45

Tx of multiple myeloma?

Answer 45

Analgesia for bone pain (not NSAIDs due to renal impairment), bisphosphonates e.g. zolendronate, transfusions, local radiotherapy, chemotherapy and stem cell transplant

Question 46

Which bone types are most often affected in osteoporosis?

Answer 46

Trabecular bone = vertebral crush fractures | Cortical bone = NOF

Question 47

How is the risk of osteoporosis assessed?

Answer 47

FRAX (measures the 10 year oesteoporotic fracture risk)

Question 48

How do DEXA scans assess osteoporosis? | How do you treat it?

Answer 48

The T-score = number of SDs the bone mineral density is from the youthful gender matched average -1 to -2.5 = osteopenia -2.5 or worse = osteoporosis Alendronic acid alongside calcium and vitamin D supplements

Question 49

Sx of osteomalacia?

Answer 49

In children it causes rickets = growth retardation, knock-knees or bow legs In adults = bone pain/tenderness, increased fractures and waddling gait

Question 50

What is Wegener's granulomatosis?

Answer 50

Now known as granulomatosis with polyangiitis. It is necrotizing granulomatous inflammation and vasculitis of the small and medium vessels

Question 51

Sx of Wegener's granulomatosis (GPA)?

Answer 51

Upper airway disease (nasal obstruction, ulcers, epistaxis and saddle-nose deformity) Renal disease = haematuria and proteinuria Pulmonary disease = haemoptysis Skin purpura. ANCA positive!