MSK: systemic conditions Flashcards
(77 cards)
1
Q
What is the pathophysiology of osteoporosis?
A
more break down of bone than formation of bone causing decrease in bone density
2
Q
what increase osteoclast/ bone resorption and breakdown?
A
PTH-> increase serum calcium-> osteoclast bone resorption
3
Q
what increase osteoblast/ bone formation
A
- calcitonin: produced by C-cells in thyroid, inhibits osteoclast activity and decrease serum calcium
- growth hormone, estrogen, testosterone
- good nutrients: intake of calcium and vitamin D
- strength training
4
Q
what are the 2 main types of osteoporosis and their causes?
A
- type 1/ Post menopausal: decrease in estrogen-> increase bone resorption/ breakdown by osteoclast
- type 2/ Senile/ old age: osteoblast loose ability for bone formation
- secondary: corticosteorids
5
Q
Histological findings of osteoporosis & which change cause increase bone fragility
A
- fewer trabeculae in spongy/ trabecular bone (inside part of the bone)
- Thickening of cortical bone (outside part of bone)
- Widening of the Haversian canals (hollow center space of osteons that makeup the cortical part of bone, have blood supply of innervation of bone cells): this is the reason of increase risk of fracture/ bone fragility
6
Q
What are the risk factors of osteoporosis? Any Conditions or medication?
A
Low estrogen (after menopause)
Low serum calcium
Glucocorticoids (decrease Ca2+ absorption from gut)
Physical inactivity
Cushing’s syndrome, diabetes
Alcohol & smoking
7
Q
What is the investigation and diagnosis for osteoporosis? and who should be investigated?
A
DEXA scan: test bone density T score: less than 2.5 or -2.5= osteoporosis
All Female 65+ and male 75+, if they are younger, screen if they have previous fragility fractures, on oral corticosteroids (ie, glucocorticoids for arterial problems)
8
Q
what are the treatment options for osteoporosis (mode of action)
A
reduce fragility risk
1. Oral Bisphosphonates: analogue of pyrophosphate that inhibits osteoclast (ie, alendronate & risedronate)
2. Hormone replacement therapy for younger post-menopausal women
9
Q
what are the side effects and compensations for prescribing bisphophonate
A
- Side effects: Oesophageal ulcer & reflux, Osteonecrosis of jaw (jaw pain with no scalp tenderness), osteosarcoma (bone pain)
- give vitamin D or calcium if blood test show deficiency
- raised alkaline phosphatase levels
10
Q
What is the main complication of osteoporosis and its presentation? Any other complications?
A
FRACTURES
Vertebral/ compression fracture: back pain, height loss, hunches posture
Femoral neck fracture
Distal radius fracture
11
Q
What is gout? Symptoms, site & causes
A
- inflammatory arthritis that is severely painful, swollen, and red esp at night
- 70% is in the first MTP but can occur in the ankle, wrist, MCP, knee
- Drugs (thiazide, furosemide)- trauma, infection, surgery. haemolytic anaemia
12
Q
What is the test & diagnosis for gout? what other level might also be raised?
A
Test: aspirate for synovial fluid
diagnosis: needle shaped negatively birefringent monosodium urate crystals under polarized light + Uric acid/ urate increase when symptoms settled
13
Q
What are the treatments of gout? Any cautions/ side effects when perscribing?
A
- NSAID (prescribe with PPI, not for patients with peptic ulcer)
- Colchicine (SE: diarrhea)
- allopurinol: Urate lower therapy
14
Q
What is the typical presentation of polymyalgia rheumatica?
A
- Aching and pain with morning stiffness (45 min+) & worse with movement in the proximal limb muscles but no weakness (ie, painful to move but power is there)
- Bilateral shoulder pain radiating to arm & elbow, Bilateral pelvic girdle pain
- Low grade fever, low mood
- Temporal arteritis symptoms
- 60 female, white
15
Q
What is the diagnosis of polymyalgia rheumatica? which levels should be normal
A
- Clinical symptoms + inflammatory marker + response to steroid- Raised ESR, plasma viscosity, CRP
- Dramatic response to steroid should be seen (normal creatinine & anti-CCP)
16
Q
What is the treatment of polymyalgia rheumatica? any side effects? What other medications may be necessary for long term treatment?
A
- Prednisolone 15mg (usually a dramatic respond by 3-4 weeks with normal inflammatory marker, if not give another diagnosis)
- Reduce dosage gradually- SE: avascular necrosis of hip
- give bisphosphonate w/or calcium, vitamin D to reduce osteoporosis risk caused by steroid
- Give PPI for gastric protection
17
Q
What are some related conditions to polymyalgia rheumatica? MSK/systemic symptoms?
A
Commonly associated with giant cell/ temporal arteritis (headache & tender at temple, jaw pain)
Carpal tunnel
Pitting edema
18
Q
what is the pathophysiology of rheumatoid arthritis
A
- Genetically predisposed individual have immune system that mistakes self-antigens (ie citrullinated protein) as foreign, and immune cells (B and T cells) produce autoantibodies that bind to these self- antigens and triggers a immune response
- Immune response attacks synovial membrane and recruits more immune cells causing inflammation and destruction
19
Q
what are the symptoms of rheumatoid arthritis?
A
- Joint swelling, pain, w/ morning stiffness for 30 min +
- effects MCP and PIP
- Gradually worsen as larger joints are involved
20
Q
what clinical exam is positive and deformity is present in rheumatoid arthritis
A
- positive squeeze test
- swan neck & boutonniere deformity
21
Q
What are the diagnostic tests for Rheumatoid arthritis?
A
- Rheumatoid factor
- anti-CCP: more specific, if rheumatoid factor is negative do this
- X-ray of hands and feet
22
Q
what is rheumatoid factor
A
circulating antibody (igM or igA) that react to Fc portion of igG
23
Q
what is Anti-CCP
A
anti-cyclic citrullinated peptide antibodies
- formed during a self-citrulllination process in genetically predisposed individual where positively charged arginine amino acid turns into neutral citrulline and body developed Anti-CCP
24
Q
what is considered bad prognosis for rheumatoid arthritis?
A
Positive rheumatoid factor, anti-CCP & erosions on x-ray in 2 years means poor prognosis
25
what criteria is used to measure disease activity?
DAS 28
- assess 28 joints for swelling and tenderness in combination with inflammatory markers
26
what is the X-ray finding of rheumatoid arthritis, who should get it?
LESS
L: loss of joint space
E: periarticular Erosion
S: soft tissue swelling
S: soft bones/ osteopenia
27
What are the steps of management for rheumatoid arthritis treatment?
1. Monotherapy of oral methotrexate +/- short term corticosteroids: prednisolone for flare ups (oral or intramuscular)
2. If methotrexate is not suitable or severe SE-> sulfasalazine, leflunomide, hydroxychloroquine is used
28
when is TNF inhibitor used when treating rheumatoid arthritist
If patient have tried 2 DMRAD and still inadequate response
29
What is the first line main rheumatoid arthritis treatments, its side effects/ monitoring when prescribed?
- Methotrexate, Once per week
- prescribed w/ folic acid to be taken a day after due to myelosuppression (bone marrow)
- hepatotoxicity, methotrexate pneumonitis
- Monitor FBC, U&E, LFT
30
what is the mode of action of methotrexate
inhibit dihydrofolate reductase (enzyme for synthesis of purines & pyrimidines)
31
what should be avoided when prescribing methotrexate
- Avoid trimethoprim or co-trimoxazole, and aspirin
- avoid pregnancy for 6 months after stopping drug
32
what are the pros and cons of hydroxychloroquine?
- Bull’s eye retinopathy- visions loss, need annual eye screening
- Can be used in pregnant woman
33
what are some examples of TNF inhibitors, any side effects?
- etanercept, infliximab
- Risk of reactivation tuberculosis (chest x-ray & TB test first)
34
what are the respiratory and cardiovascular manifestations of rheumatoid arthritis
- resp: pulmonary fibrosis, pleural effusion, bronchiectasis
- Ischemic heart disease
35
what are the MSK manifestations of rheumatoid arthritis
MSK: osteoporosis, Carpal tunnel syndrome, De-quervain's
36
what is the triad for felty's syndrome?
rheumatoid arthirist + splenomegaly + low white cell count
37
what are the histological changes in osteoarthritist
- Progressive damage to a synovial joint causing structure changes and pain
- Loss of cartilage at the ends of bones
- osteophytes (bone growth to compensate for the lost cartilage)
38
what are the risk factors of osteoarthrisit
genetic factors
age, female
obesity
previous trauma
39
What is a synovial joint? What does it consist of?
- Joint that allows movement
- enclosed by articular cartilage (end of bones) and synovial membrane on the side forms a joint cavity filled by synovial fluid
- protected on the outside by a joint/ articular capsule.
40
What are the symptoms of osteoarthritis?
- Swelling of Carpometacarpal (CMC, squaring of thumb), and DIP (heberden's nodes)
- Bilateral Knee and hip pain
- Joint pain on movement, relieved by resting, Morning stiffness that only last few minutes
41
What is the investigation for osteoarthritis? What are the results?
X-ray
- Loss of Joint space
- Osteophytes (new bone formed to compensate cartilage loss)
- Subchondral sclerosis (dense bone formed in cartilage loss)
- Subchondral cysts (cyst formed beneath cartilage when it's degenerating)
42
What is the management and treatment for osteoarthritis?
- Weight Loss, muscle strengthening exercise
- Paracetamol, topical NSAIDs/ COX-2 inhibitors (avoid if patient takes aspirin, topical NSAID only for hand and knee)
- add codeine
43
What is the management for osteoarthritis of the hip?
Oral analgesia
Intra-articular injections
Total hip replacement (aseptic loosening is common)
44
What is the cause of ankylosing spondylitis?
- Having the HLA-B27 gene causing inflammation for sacroiliac joint (sacrum= below vertebrae attaching it to pelvis, ilium= pelvis)
45
what is the typial patient profile and presentation of ankylosing spondylisit
- Male 20-30 years of age + lower back pain/stiffness that is worse in the morning & improve with exercise
- Pain at night that’s relieved when getting up
46
What are the investigations and treatment for ankylosing spondylitis?
- X-ray, clinical examinations, HLA-B27 gene (90%), raised inflammatory markers
- Exercise like swimming, NSAID, physiotherapy
47
What are the X-ray symptoms of ankylosing spondylitis?
- Sacroiliitis: loss of joint space & denser bones in sacroiliac joint
- Squaring of lumbar vertebrae
- Syndesmophytes: bony outgrowth in edge of vertebrae
48
What are the clinical examinations done for ankylosing spondylitis? What are the results?
Lumbar exam: reduced lateral flexion
Schober’s test: reduced forward flexion
Reduced chest expansion
49
what are the ocular, MSK, and hematological manifestations of ankylosing spondylitis
- Anterior uveitis: inflammation of front eye
- Achilles tendonitis: inflammation of tendon that connects calf muscle and heel bone
- Amyloidosis: build up of protein amyloid in organs and tissues
50
what are the respiraotry and cardiovascular manifestations of ankylosing spondylitis
- Apical fibrosis: scarring of apex of lung
- Aortic regurgitation: aortic valve cant close properly
- AV node block: delayed electrical signal at av node
51
What is vasculitis? What are the 2 main types?
Inflammation of the blood vessels
- Primary vasculitis: inflammatory response that targets the vessel walls and has no known cause
- Secondary vasculitis: infection, drug, toxin and may occur as part of another inflammatory disorder or cancer
52
What does vasculitis cause? What are some general symptoms?
- Inflammation -> thickening of vessel wall-> stenosis & ischemia
- Palpable purpura (raised, non-blanching when pressed)
53
What are the symptoms & typical presentation of temporal arteritis/ giant cell arteritis?
- Old female 60+ have rapid onset unilateral headache, jaw pain
- Blurring, double vision
- Scalp tenderness and pain esp when brushing hair
- Patient might have polymyalgia rheumatica
54
What are the investigations for temporal arteritis
- Temporal artery biopsy (skip lesions is possible showing normal result)
- Raised ESR
55
what are the treatments for temporal arteritis
- Urgent high dose prednisolone for no visual loss in suspected patients
- IV methylprednisolone for evolving visual loss
- Urgent refer to ophthalmology
56
What is a major complication of temporal arteritis? What test should be done
- Anterior ischemic optic neuropathy: occlusion of posterior ciliary artery (branch of ophthalmic artery) causing ischemia of optic nerve head
- Fundoscopy: swollen pale disc and blurred margins
57
What is the typical presentation of kawasaki disease
- child with high grade fever for 5+ day and not responding to antipyretics
- conjunctival injection ( red inside eyelid),
- bright red and cracked lips with
- strawberry tongue
(Clinical diagnosis can be made with above symptoms)
58
What are the management and complications of kawasaki disease?
- High dose aspirin (rare instance its used in children)
- Intravenous immunoglobulin
- Coronary artery aneurysm
59
what is ANCA associated vasculitis?
autoimmune condition affecting small blood vessels caused by ANCA (anti-neutrophilic cytoplasmic autoantibodies)
60
what are the 2 types of ANCA vasculitis?
1. pANCA: targets myloperoxidase protein
2. cANCA: targets proteinase 3
61
what are examples of ANCA associated vasculitis
- granulomatosis w/ polyangiitis
- eosinophilic granulomatosis w. Polyangiitis
- microscopic polyangiitis
62
what are the symptoms of ANCA vasculitist?
- Renal impairment
- resp symptoms
- systemic
- vasculitic rash
63
what are the investigations necessary for ANCA vasculitist
- Urinalysis for hematuria & proteinuria
- U&E for renal
- ANCA testing
- CXR
64
what is the treatment for ANCA vasculitis
- Steroids
- cyclophosphamide
65
What are the symptoms, investigation and treatment of wegener’s granulomatosis (granulomatosis with polyangiitis)
- Renal failure, epistaxis/ haemoptysis (nose bleed & coughing up blood)
66
what are the investigations of wegener’s granulomatosis (granulomatosis with polyangiitis)
- Bloods (cANCA), CXR (lesions), renal biopsy (cluster of inflammatory cells/ granulomas)
67
What are the symptoms, investigation and treatment of churg-strauss syndrome (eosinophilic granulomatosis with polyangiitis)
- Bizarre asthma is adult
- paranasal sinusitis
68
What are the investigations of churg-strauss syndrome (eosinophilic granulomatosis with polyangiitis)
- Bloods: P-ANCA with eosinophilia
- Biopsy: granulomatous and necrotizing vasculitis
69
What is polyarteritis nodosa? Describe the typical presentation
- Vasculitis in medium sized arteries
- Common in middle age men with hepatitis B
- Systemic nerve damage, abdominal pain, testicular pain
70
What are the investigation for polyarteritis nodosa?
- Angiogram, tissue biopsy
- hepB serology might be found
71
What are the treatment of polyarteritist nodosa
- Corticosteroids
- cyclophosphamide
72
What is the pathophysiology of systemic lupus erythematosus?
- Type 3 hypersensitivity
- Immune system dysregulation leading immune complex deposition in variety of organs
73
What are the cutaneous/ dermatological symptoms of systemic lupus erythema?
- Malar rash in nasolabial folds-> butterfly rash
- Raynaud’s phenomenon (fingers turn white or blue)
- Mouth ulcers
74
What are the MSK manifestations of systemic lupus erythematosus?
- Arthritis: synovitis or tenderness at 2+ joints with 30 min morning stiffness (deformities are reducible and should not affect joint function, ie, patient can make fist)
- Arthralgia, myalgia
75
How are the investigations and monitoring used in systemic lupus erythematosus?
- Antibodies: ANA and anti-dsDNA
- Inflammatory marker (high means underlying infection)
- Complement level C3 and C4 are low during active disease
76
What are the antibodies associated with systemic lupus erythematosus?
- Highly specific and sensitive: anti-dsDNA
- anti-smith but has lower sensitivity
- Highly sensitive: ANA (used to exclude lupus but not very specific)
77
What are the treatments of systemic lupus erythematosus?
- NSAID, sun block
- Hydroxychloroquine
- Prednisolone if internal organ involvement
