Muscle Disease, Back Pain and Vasculitis Tutorial

Question 1

useful investiagtions for suspected RA?

Answer 1

FBC
inflammatory markers
anti-CCP
ANA
X rays
US

Question 2

why would you test for ANA antibody in a suspected RA patient?

Answer 2

CT disease is a differential

Question 3

what would you expect on X ray of someone with RA?

Answer 3

peri-articular osteopenia

erosions in MCP joint

Question 4

what blood results suggest anaemia of chronic disease

Answer 4

low Hb but normal MCV

Question 5

can you get seronegative RA?

Answer 5

yes

Question 6

is anaemia of chronic disease common in RA?

Answer 6

yes

Question 7

where does back pain tend to radiate to?

Answer 7

buttocks

Question 8

what would you suspect in a young person (20-40) with a 3 month history of back pain?

Answer 8

ankylosing spondylitis

Question 9

what is the significance of back pain radiating to the buttocks?

Answer 9

suggests involvement of the sacroiliac joint which is common in seronegative arthritis and ank spond

Question 10

cause of a bamboo spine?

Answer 10

too much calcium

Question 11

questions to ask in a history of someone with suspected AS?

Answer 11

stiffness > 30 mins
better with exercise?
pain at night?

Question 12

is ank spond an inflammatory arthritis?

Answer 12

yes

Question 13

define polyarthritis?

Answer 13

> 4 joints affected

Question 14

define oligoarthritis?

Answer 14

1-4 joints affected

Question 15

define monarthritis?

Answer 15

only 1 joint affected

Question 16

name the main 4 types of seronegative arthritis?

Answer 16

psoriatic arthritis
reactive arthritis
enteropathic arthritis
ankylosing spondylitis

Question 17

what is enthesitis?

Answer 17

inflammation at the points where tendons and ligaments attach to bone

Question 18

what is the disease process behind tennis elbow and achilles tendonitis?

Answer 18

enthesitis

Question 19

what causes the spinal involvement in AS?

Answer 19

enthesitis

Question 20

why can you get achilles tendonitis along with AS?

Answer 20

both caused by enthesitis

Question 21

tests for AS?

Answer 21

modified schober’s test
MRI
HLA B27 test

Question 22

why is CRP not that useful in AS?

Answer 22

enthesises are very avascular so inflammation there wont show up

Question 23

what should you do an MRI of and why?

Answer 23

whole spine and sacroiliac region to see enthesitis

Question 24

management for AS?

Answer 24

1. NSAIDs eg diclofenac, naproxen
2. add another NSAID
3. anti-TNF

Question 25

go-to treatment for spinal disease?

Answer 25

NSAIDs

Question 26

treatment for synovitis?

Answer 26

methotrexate | steroids

Question 27

what disease commonly presents with hip and shoulder pain?

Answer 27

polymyalgia rheumatica (PMR)

Question 28

what is polymyalgia rheumatica?

Answer 28

muscle pain because of an inflamed JOINT

Question 29

what is polymyositis?

Answer 29

muscle pain/weakness because of inflamed muscle fibres

Question 30

do you get pain/stiffness in the morning with polymyositis or PMR?

Answer 30

polymyositis

Question 31

do you get muscle wasting in PMR or polymyositis?

Answer 31

polymyositis

Question 32

is there an age group limit on PMR? if so, what is it?

Answer 32

yes, over 50s

Question 33

is there an age group for polymyositis? if so, what is it?

Answer 33

no

Question 34

why would you not include fibromyalgia in a differential of an elderly woman with weight loss, myalgia, pain in hip/shoulder and fatigue?

Answer 34

only affects younger people pain is everywhere, not localised don't get weight loss in fibromyalgia

Question 35

examination in someone with suspected PMR/polymyositis?

Answer 35

muscle power reading | joint/muscle examination

Question 36

what investigation could you do to differentiate between polymyositis and PMR and why?

Answer 36

CK, it is high in polymyositis but normal in PMR

Question 37

treatment for PMR?

Answer 37

start on low dose prednisolone 15mg daily

Question 38

when should the patient's symptoms stop when taking meds for PMR?

Answer 38

1 week

Question 39

if the patient didnt take medication for PMR, how long woudl it take for their symptoms to go away?

Answer 39

2 years

Question 40

what should be done if a diagnosed PMR patient doesn't respond to low dose steroids?

Answer 40

reconsider diagnosis

Question 41

complications of steroids?

Answer 41

``` osteoporosis cataracts diabetes skin thinning muscle atrophy diabetes peptic ulcers CVD risk ```

Question 42

what should do to protect a patient from osteoporosis if they're on steroids?

Answer 42

give: bisphosphonates calcium vit d

Question 43

common complication of PMR?

Answer 43

giant cell arteritis

Question 44

where does giant cell arteritis get to the temporal artery?

Answer 44

vasculitis of large vessels -> aorta -> external carotid artery -> temporal artery

Question 45

what clinical symptom do you get from facial artery vasculitis?

Answer 45

jaw claudication

Question 46

is the pronounced artery in giant cell arteritis pulsatile or not?

Answer 46

no

Question 47

treatment for giant cell arteritis?

Answer 47

1. temporal artery biopsy 2. increase steroid dose to 1mg/kg 3. check CRP and PV

Question 48

investigations for suspected fibromyalgia?

Answer 48

``` fibromyalgia tender points exclude CT disease by checking: ANA ENA CK CRP PV ```

Question 49

treatment for fibromyalgia?

Answer 49

gabapentin pregabalin antidepressants cognitive behavioural therapy

Question 50

what is dermatomyositis?

Answer 50

polymyositis with skin features

Question 51

what skin features can be present in dermatomyositis

Answer 51

heliotrope rash

Question 52

what investigations should you do for suspected PMR or polymyositis?

Answer 52

``` PV/CRP FBC U+E LFT CK Anti-Jo-1 ```

Question 53

what monitoring should be done for a patient on steroids?

Answer 53

blood glucose for diabetes CV monitoring give bone protection

Question 54

why should you be worried about weight loss in dermatomyositis?

Answer 54

it is associated with malignancy

Question 55

investigations for someone with weight loss and dermatomyositis?

Answer 55

colonoscopy endoscopy CT chest/abdo/pelvis mammogram

Question 56

investigation for dermatomyositis?

Answer 56

``` CK ANA Anti-Jo-1 EMG test for electrical activity MRI ```

Question 57

what would you expect to see on MRI of someone with dermatomyositis?

Answer 57

white muscle from oedema | damaged muscle -> get fat and fibrous tissue forming

Question 58

treatment for dermatomyositis?

Answer 58

1. steroid + azathioprine long term bone protection 2. long term immunosuppression

Question 59

at what times is the risk of cancer in dermatomyositis highest?

Answer 59

2 years before and after diagnosis

Question 60

what should you suspect in someone who has joint pain and ENT involvement?

Answer 60

granulomatosis with polyangiitis

Question 61

tests for someone with suspected vasculitis?

Answer 61

``` 1. urinalysis FBC U+E LFT ANCA PR3 MPO urinalysis CT chest biopsy of rash or lung lesion ```

Question 62

what could you see on CXR of someone with GPA?

Answer 62

necrotising granulomatous cavities in the lower lung fields

Question 63

is GPA ANCA+ve or -ve?

Answer 63

positive

Question 64

what does a vasculitic rash look like?

Answer 64

purpuric inflamed leaky capillaries non blanching

Question 65

what inflammatory marker results would you expect to see in vascultis?

Answer 65

increased CRP and PV | decreased C3/4

Question 66

what urinalysis result would prompt you to do a renal biopsy?

Answer 66

>500mg in urine over 24 hours

Question 67

treatment for severe vasculitis?

Answer 67

high dose steroid + cyclophosphamide

Question 68

treatment for mild/moderate vascultis?

Answer 68

methotrexate oral steroids bone protection