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Musculoskeletal Flashcards

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1
Q

Define amyloidosis.

A

Heterogenous group of diseases characterised by extracellular deposition of amyloid fibrils.

    • Type AA = serum amyloid A protein*
  • -Type AL = Monoclonal immunoglobulin light chains*
    • Type ATTR (familial amyloid polyneuropathy) = Genetic-variant transthyretin*
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2
Q

What are the presenting signs and symptoms of amyloidosis?

A

o Renal = proteinuria, nephrotic syndrome, renal failure

o Cardiac = restrictive cardiomyopathy, heart failure, arrhythmia, angina

o GI = macroglossia (characteristic of AL), hepatosplenomegaly, gut dysmotility, malabsorption, bleeding

o Neurological = sensory and motor neuropathy, autonomic neuropathy, carpal tunnel syndrome

o Skin = waxy skin and easy bruising, purpura around the eyes (characteristic of AL), plaques and nodules

o Joints = painful asymmetrical large joints, enlargement of anterior shoulder

o Haematological = bleeding tendency

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3
Q

What are the appropriate investigations for amyloidosis?

A

o Tissue Biopsy

o Urine = proteinuria, free immunoglobulin light chains (in AL)

o Bloods = CRP/ESR, Rheumatoid factor, Immunoglobulin levels, Serum protein electrophoresis, LFTs, U&Es

o SAP Scan = radiolabelled SAP will localise the deposits of amyloid

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4
Q

Define ankylosing spondylitis.

A

Seronegative inflammatory arthropathy affecting preferentially the axial skeletal and large proximal joints.

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5
Q

What are the risk factors/causes of ankylosing spondylitis?

A

o Unknown cause

  • Linked to HLA-B27 (over 90% of cases)
  • Possible infective triggers and antigen cross-reactivity
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6
Q

What are the presenting symptoms of ankylosing spondylitis?

A

o Lower back and sacroiliac pain

o Disturbed sleep

o Pain pattern -> worse in the morning or with rest but better with activity

o Progressive loss of spinal movement

o Symptoms of asymmetrical peripheral arthritis

o Pleuritic chest pain (due to costovertebral joint involvement)

o Heel pain (due to plantar fasciitis)

o Non-specific symptoms (e.g. malaise, fatigue)

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7
Q

What are the clinical signs of ankylosing spondylitis on examination?

A

o Reduced range of spinal movement (particularly hip rotation)

o Reduced lateral spinal flexion

o Schober’s Test = 2 fingers are placed on the patients back about 10 cm apart -> patient is asked to bend over -> distance between the two fingers should increase by > 5 cm on forward flexion -> reduced movement would suggest ankylosing spondylitis

o Tenderness over the sacroiliac joints

o Later stages = Thoracic kyphosis, Spinal fusion, Question mark posture

o Signs of Extra-Articular Disease = 5 As = Anterior uveitis, Apical lung fibrosis, Achilles tendinitis, Amyloidosis, Aortic regurgitation

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8
Q

What are the appropriate investigations for ankylosing spondylitis?

A

o Bloods = FBC (anaemia of chronic disease, Rheumatoid factor (negative), ESR/CRP (high)

o Radiographs

  • Anteroposterior and lateral radiographs of the spine = Bamboo spine
  • Anteroposterior radiograph of sacroiliac joints = Symmetrical blurring of joint margins
  • Later stages = erosions, sclerosis, sacroiliac joint fusion
  • CXR = check for apical lung fibrosis

o Lung Function Tests = assess mechanical ventilatory impairment due to kyphosis

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9
Q

Define spondylosis.

A

Progressive degenerative process affecting the vertebral bodies and intervertebral discs, and causing compression of the spinal cord and/or nerve roots.

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10
Q

What are the presenting symptoms of spondylosis?

A

o Neck/Back pain/stiffness

o Arm pain (stabbing or dull ache)

o Paraesthesia

o Weakness

o Clumsiness in the hands

o Weak and stiff legs

o Gait disturbance

o Atypical chest pain

o Breast pain

o Pain in the face

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11
Q

What are the clinical signs of spondylosis on examination?

A

o Arms = atrophy of the forearm and hand muscles, segmental muscle weakness in a nerve root distribution, hyporeflexia, sensory loss (mainly pain and temperature), pseudoathetosis (writhing finger movements when hands are outstretched, fingers spread and eyes closed)

o Legs = increased tone, weakness, hyper-reflexia, extensor plantar response, reduced vibration and joint position sense

o Lhermitte’s Sign = neck flexion causes crepitus (grating sound) and/or paraesthesia down the spine

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12
Q

What are the appropriate investigations for spondylitis?

A

o Spinal X-ray - lateral

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13
Q

Define gout.

A

A disorder of uric acid metabolism causing recurrent bouts of acute arthritis caused by deposition of monosodium urate crystals in joints, soft tissues and kidneys.

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14
Q

What are the causes of gout?

A

o Hyperuricaemia

  • Increased urate intake or production = increased dietary intake, increased nucleic acid turnover (e.g. lymphoma, leukaemia, psoriasis), increased synthesis of urate (e.g. Lesch-Nyhan syndrome)
  • Decreased Renal Excretion = idiopathic, drugs (e.g. ciclosporin, alcohol, loop diuretics), renal dysfunction
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15
Q

What are the presenting signs and symptoms of an acute attack of gout?

A

o Precipitating factors = trauma, infection, alcohol, starvation, introduction or withdrawal of hypouricaemic agents

o Sudden excruciating monoarticular pain - usually affects the metatarsophalangeal joint of the great toe with symptoms peaking at 24 hrs

They resolve over 7-10 days

o Can present with cellulitis, polyarticular or periarticular involvement

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16
Q

What are the presenting signs and symptoms of intercritical gout?

A

o None

  • Intercritical gout = asymptomatic period between acute attacks
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17
Q

What are the presenting signs and symptoms of chronic tophaceous gout?

A

o Follow repeated acute attacks

o Persistent low-grade fever

o Polyarticular pain with painful tophi (urate deposits)

o Best seen on tendons and the pinna of the ear

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18
Q

What are the presenting signs and symptoms of urate urolithiasis?

A

o Renal calculi symptoms

  • Severe pain in the groin and/or side
  • Blood in urine
  • Vomiting and nausea
  • WBCs or pus in the urine
  • Reduced amount of urine excreted
  • Burning sensation during urination
  • Persistent urge to urinate
  • Fever and chills if there is an infection
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19
Q

What are the appropriate investigations for gout?

A

o Synovial Fluid Aspirate = monosodium urate crystals will be seen - needle-shaped, negative birefringence under polarised light microscopy

  • Microscopy and culture will also be performed to exclude septic arthritis

o Bloods = FBC (raised WCC), U&Es, Raised urate, Raised ESR

o AXR/KUB Film = Uric acid renal stones may be seen

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20
Q

Define pseudogout.

A

Arthritis associated with deposition of calcium pyrophosphate dihydrate (CPPD) crystals in the joint cartilage.

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21
Q

What are the risk factors for pseudogout?

A

o Joint damage - osteoarthritis, trauma etc

o Precipitating factors = Intercurrent illness, Surgery, Local trauma

o Rarer conditions = Haemochromatosis, Hyperparathyroidism, Hypomagnesaemia, Hypophosphatasia

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22
Q

What are the presenting symptoms of pseudogout?

A

o Acute Arthritis = Painful, Swollen Joint

o Chronic Arthropathy = Pain, Stiffness, Functional impairment

o Uncommon Presentations = Tendonitis, Tenosynovitis, Bursitis

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23
Q

What are the clinical signs of pseudogout on examination?

A

o Acute Arthritis = Red, Hot, Tender, Restricted range of movement, Fever

o Chronic Arthropathy = Similar to osteoarthritis, Bony swelling, Crepitus, Deformity, Restriction of movement

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24
Q

What are the appropriate investigations for pseudogout?

A

o Bloods = High WCC in acute attacks, High ESR

o Blood culture = exclude septic arthritis

o Joint Aspiration = Rhomboid, brick-shaped crystals, positive birefringence, culture/gram-staining to exclude septic arthritis

o Plain Radiograph of the Joint = Chondrocalcinosis

  • Signs of osteoarthritis = Loss of joint space, Osteophytes, Subchondral cysts, Sclerosis
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25
Define giant cell arteritis.
Granulomatous inflammation of large arteries, particularly branches of the external carotid artery, most commonly the temporal artery.
26
What are the risk factors for giant cell arteritis?
o Age o Some infections o Associated with HLA-DR4 and HLA-DRB1
27
What are the presenting symptoms of giant cell arteritis?
o Subacute onset (usually over a few weeks) o Headache o Scalp tenderness o Jaw claudication o Blurred vision o Sudden blindness in one eye o Systemic = malaise, low-grade fever, lethargy, weight loss, depression o Symptoms of polymyalgia rheumatica = early morning pain and stiffness of muscles of the shoulder and pelvic girdle
28
What are the clinical signs of giant cell arteritis on examination?
o Swelling and erythema overlying the temporal artery o Scalp and temporal tenderness o Thickened non-pulsatile temporal artery o Reduced visual acuity
29
What are the appropriate investigations for giant cell arteritis?
o Bloods = High ESR, FBC (normocytic anaemia of chronic disease) o Temporal Artery Biopsy = Performed within 48 hrs of starting corticosteroids - negative biopsy doesn't necessarily rule out GCA
30
What is the management plan for giant cell arteritis?
o High dose oral prednisolone immediately to prevent visual loss - reduce the dose of prednisolone gradually over time o Many patients need to be kept on a maintenance dose of prednisolone for 1-2 yrs o Low dose aspirin (with PPIs and gastroprotection) - reduces risk of visual loss, TIAs and stroke o Annual CXR for up to 10 yrs to look for thoracic aortic aneurysms
31
What are the possible complications of giant cell arteritis?
o Carotid artery aneurysms o Aortic aneurysms o Thrombosis o Embolism to the ophthalmic artery leading to visual disturbance and loss of vision
32
Define osteoarthritis.
Age-related degenerative joint disease when cartilage destruction exceeds repair, causing pain and disability.
33
What are the risk factors for osteoarthritis?
o Obesity o Developmental abnormalities (e.g. hip dysplasia) o Trauma (e.g. previous fractures) o Inflammatory (e.g. rheumatoid arthritis, gout, septic arthritis) o Metabolic (e.g. haemochromatosis, acromegaly)
34
What are the presenting symptoms of osteoarthritis?
o Joint pain and discomfort o Use-related o Stiffness or gelling after inactivity o Difficulty with certain movements o Feelings of instability o Restriction walking, climbing stairs and doing manual tasks o Systemic features are usually absent
35
What are the clinical signs of osteoarthritis on examination?
oLocal joint tenderness o Bony swellings along joint margins - Heberden's Nodes - dista interphalangeal joint - Bouchard's Nodes - proximal interphalangeal joint o Crepitus and pain during joint movement o Joint effusion o Restriction of range of joint movement
36
What are the appropriate investigations for osteoarthritis?
o Joint X-Ray of the affected joint will show FOUR classic features: - Loss/narrowing of joint space - Osteophytes - Subchondral cysts - Subchondral sclerosis
37
Define osteomyelitis.
Infection of the bone leading to inflammation, necrosis and new bone formation. Can be acute, subacute or chronic. *o Causative organisms = Staphylococcus aureus, Group A Streptococcus*
38
What are the risk factors for osteomyelitis?
o Diabetes o Immunosuppression o IV drug use o Prostheses o Sickle-cell anaemia
39
What are the presenting symptoms of osteomyelitis?
o Pain in the affected area - may not show in infants o Fever o Malaise o Rigors o History of preceding skin lesion, sore throat, trauma or operation
40
What are the clinical signs of osteomyelitis on examination?
o Localised erythema o Tenderness o Swelling o Warmth o Painful/limited movement of affected limb o Seropurulent discharge from an associated wound or ulcer
41
What are the appropriate investigations for osteomyelitis?
o Bloods = FBC, ESR, CRP o Blood culture o Swabs of wound or discharge o Radiographs o Radioisotope bone scan = shows areas of increased activity
42
Define polymyalgia rheumatica.
An inflammatory condition of unknown cause, which is characterised by severe bilateral pain and morning stiffness of the shoulder, neck and pelvic girdle.
43
What are the risk factors for polymyalgia?
o Unknown - linked to genetics and environmental factors o Associated with giant cell arteritis
44
What are the presenting signs and symptoms of polymyalgia rheumatica?
o Tend to be relatively non-specific o Usual inclusion criteria for polymyalgia rheumatica = Age \> 50 yrs, Duration of symptoms \> 2 weeks, Bilateral shoulder or pelvic girdle aching (or both), Morning stiffness lasting \> 45 mins, High ESR/CRP o Characteristic clinical picture of polymyalgia rheumatica = bilateral shoulder pain and stiffness of acute or subacute onset with bilateral arm tenderness o No weakness o Symptoms are worst when walking o Morning stiffness may be so bad that they find it difficult to get out of bed, or raise their arms enough to brush their hair o May be flu-like symptoms at onset
45
What are the appropriate investigations for polymyalgia?
o Bloods = ESR/CRP (raised), FBC, U&Es, LFTs, TFTs, Creatine kinase o Bone profile o Protein electrophoresis o Others = urinary Bence Jones proteins, autoantibodies (e.g. anti-CCP antibodies)
46
What is the management plan for polymyalgia rheumatica?
o Corticosteroids are the main treatment o Steroid-sparing agents (e.g. methotrexate) are sometimes used o Physiotherapy and occupational therapy o Monitor for adverse effects of steroids (e.g. osteoporosis)
47
What are the possible complications of polymyalgia rheumatica?
o Temporal arteritis o Relapse of disease o Complications of steroid use (e.g. fracture risk)
48
Define reactive arthritis.
Characterised by a sterile arthritis occurring after an extra-articular infection (commonly GI or urogenital).
49
Define Reiter's syndrome.
Triad of reactive arthritis, urethritis and conjunctivitis
50
What are the risk factors for reactive arthritis?
Associated with infections - GI = Salmonella, Shigella, Yersinia, Campylobacter - Urogenital = Chlamydia trachomatis o HLA-B27
51
What are the presenting symptoms of reactive arthritis?
o Symptoms can develop 3-30 days after infection o Burning or stinging when passing urine (due to urethritis) o Arthritis o Low back pain (due to sacroiliitis) o Painful heels (due to enthesitis and plantar fasciitis) o Conjunctivitis
52
What are the clinical signs of reactive arthritis on examination?
o Signs of Arthritis = asymmetrical oligoarthritis, often affects the lower extremities, sausage-shaped digits o Signs of Conjunctivitis = anterior uveitis - painful red eye o Oral Ulceration o Circinate Balanitis = scaling red patches on the glans o Keratoderma Blenorrhagica = brownish-red macules, vesicopustules, yellowish-brown scales, found on the soles and palms o Others = nail dystrophy, hyperkeratosis, onycholysis
53
What are the appropriate investigations for reactive arthritis?
o Bloods = FBC, High ESR and CRP o Genetics = HLA-B27 testing o Stool or Urethral Swabs and Cultures - likely to be negative by the time the arthritis develops (because the arthritis occurs post-infection) o Urine = screen for chlamydia trachomatis o Plain X-Rays = useful in chronic cases - erosions seen at the entheses (insertion of tendons into bone) o Joint Aspiration = exclude septic or crystal arthritis
54
Define rheumatoid arthritis.
Chronic inflammatory systemic disease characterised by symmetrical deforming polyarthritis and extra-articular manifestations.
55
What are the risk factors for rheumatoid arthritis?
o Other autoimmune disease o HLA-DR1 and HLA-DR4
56
What are the presenting symptoms of rheumatoid arthritis?
o Gradual onset of joint pain and swelling o Morning stiffness o Impaired function o Usually affects peripheral joints symmetrically o Systemic Symptoms = fever, fatigue, weight loss
57
What are the clinical signs of rheumatoid arthritis on examination?
o Early Signs = spindling of fingers, swelling of MCP and PIP joints, warm and tender joints, reduction in range of movement o Late Signs = symmetrical deforming arthropathy, ulnar deviation of fingers as a result of subluxation (partial dislocation) of the MCP joints, radial deviation of the wrist, Swan neck deformity, Boutonniere deformity, Z deformity of the thumb, trigger finger (inability to straighten the finger, tendon nodule palpable), tendon rupture, wasting of small muscles of the hand, palmar erythema o Rheumatoid Nodules = firm subcutaneous nodules (usually found on the elbows, ulnar margin, palms and over extensor tendons) o Signs of complications
58
What are the appropriate investigations for rheumatoid arthritis?
o Bloods = FBC (low Hb, high platelets), High ESR and CRP o Antiboidies = Rheumatoid factor (found in 70% of RhA patients), Antinuclear antibodies (30%) o Joint Aspiration = acute setting to rule out septic arthritis o Joint X-Ray = deformity, osteopaenia, narrowing of joint space, soft tissue swelling
59
Define sarcoidosis.
Multisystem granulomatous inflammatory disorder.
60
What are the risk factors for sarcoidosis?
o Transmissible agents = viruses o Environmental triggers o Genetic factors
61
What are the presenting signs and symptoms of sarcoidosis?
o General = Fever, Malaise, Weight loss, Bilateral parotid swelling, Lymphadenopathy, Hepatosplenomegaly o Pulmonary = Breathlessness, Dry cough, Chest discomfort, Minimal clinical signs o Musculoskeletal =Bone cysts, Polyarthralgia, Myopathy o Eye = Keratoconjunctivitis sicca, Uveitis, Papilloedema o Skin = Lupus pernio (red-blue infiltrations of the nose, cheeks, ears and terminal phalanges), Erythema nodosum, Maculopapular eruptions o Neurological = Lymphocytic meningitis, Space-occupying lesions, Pituitary infiltration, Cerebellar ataxia, Cranial nerve palsies, Peripheral neuropathy o Cardiac = Arrhythmia, Bundle branch block, Pericarditis, Cardiomyopathy, Congestive cardiac failure
62
What are the appropriate investigations for sarcoidosis?
o Bloods = High serum ACE, High calcium, High ESR, FBC (WCC may be low due to lymphocyte sequestration in the lungs), Immunoglobulins (polyclonal hyperglobulinaemia), LFTs (high ALP + GGT) o 24 hr Urine Collection = Hypercalciuria o CXR - Stage 0 = may be clear, Stage 1 = bilateral hilar lymphadenopathy, Stage 2 = stage 1 with pulmonary infiltration and paratracheal node enlargement, Stage 3 = pulmonary infiltration and fibrosis o High-Resolution CT Scan = check for diffuse lung involvement o Gallium Scan = shows areas of inflammation o Pulmonary Function Tests = Low FEV1, FVC shows restrictive picture o Bronchoscopy and Bronchoalveolar Lavage = High lymphocytes, High CD4: CD8 ratio o Transbronchial Lung/Lymph Node Biopsy = Non-caseating granulomas consisting of Epithelioid cells (activated macrophages), Multinucleate Langerhans cells, Mononuclear cells (lymphocytes)
63
Define spetic arthritis.
Joint inflammation resulting from intra-articular infection.
64
What are the causative agents for septic arthritis?
o Bacteria - All ages = Staphylococcus aureus, TB - \< 4 yrs = Streptococcus pneumoniae, Streptococcus pyogenes, Neisseria meningitidis, Gram-negative rods - 16-40 yrs = Neisseria gonorrhoeae o Viruses = Rubella, Mumps, Hepatitis B, Parvovirus B19 o Fungi = Candida
65
What are the risk factors for septic arthritis?
o Recent orthopaedic procedures o Osteomyelitis o Diabetes o Immunosuppression o Alcoholism
66
What are the presenting symptoms of septic arthritis?
o Fever o Excruciating joint pain o Joint redness, swelling and loss of joint function o Usually a monoarthropathy (usually affecting one large joint) - may cause a polyarthropathy in the immunosuppressed o Tuberculous arthritis develops more slowly and is more chronic
67
What are clinical signs of septic arthritis on examination?
o Painful, hot, swollen o Immobile joint o Erythema o Severe pain prevents passive movement o Pyrexia o Look for signs of aetiology
68
What are the appropriate investigations for septic arthritis?
o Joint Aspiration = grossly purulent, send synovial fluid for MC&S, microscopy (rule out crystal arthritis), PCR may be used if a viral cause is suspected o Bloods = FBC (high WCC, high neutrophils), High CRP and ESR, Blood cultures (MC&S), Viral serology may be useful o Plain Joint Radiographs = Can show signs of damage following the infection o MRI Scan = Useful for detecting osteomyelitis
69
Define Sjögren's syndrome.
Characterised by inflammation and destruction of exocrine glands (usually salivary and lacrimal glands).
70
What are the risk factors for Sjögren's syndrome?
o Genetic association = HLA-B8 and HLA-DR3 o Other autoimmune disease
71
What are the presenting symptoms of Sjögren's syndrome?
o Fatigue o Fever o Weight loss o Depression o Dry eyes (keratoconjunctivitis sicca) = gritty and sore o Dry mouth - leads to secondary dysphagia o Dry upper airways = dry cough and recurrent sinusitis o Dry skin or hair o Dry vagina = may cause dyspareunia o Reduced GI mucus secretions leads to reflux oesophagitis, gastritis and constipation
72
What are the clinical signs of Sjögren's syndrome on examination?
o Parotid or salivary gland enlargement o Dry eyes o Dry mouth or tongue o Signs of associated conditions
73
What are the appropriate investigations for Sjögren's syndrome?
o Bloods = High ESR, High amylase (if salivary glands involved) o Autoantibodies = Rheumatoid factor, ANA, Anti-ENA o Schirmer's Test = A strip of filter paper is placed under the eyelid - positive for Sjogren's syndrome if \< 10 mm of the strip is wet after 5 mins o Fluorescein/Rose Bengal Stains = May show punctate or filamentary keratitis o Other Investigations = reduced parotid salivary flow rate, reduced uptake or clearance on isotope scan o Biopsy of salivary or labial glands
74
Define SLE.
Multi-system inflammatory autoimmune disorder. o 4/11 of the diagnostic criteria for SLE - SOAP BRAIN MD - Serositis - Oral ulcers - Arthritis (non-erosive) - Photosensitivity - Bloods (haemolytic anaemia/leukopaenia/thrombocytopaenia) - Renal disease (urine casts/proteinuria) - ANA - Immunological disorder (anti-dsDNA/anti-Sm/anti-phospholipid) - Neurological disease (psychosis/seizures) - Malar rash - Discoid rash
75
What are the presenting signs and symptoms of SLE?
o General = Fever, Fatigue, Weight loss, Lymphadenopathy, Splenomegaly o Raynaud's phenomenon o Oral ulcers o Skin Rash = Malar rash, Discoid lupus, Atypical rashes o Systemic Involvement - Musculoskeletal = arthritis, tendonitis, myopathy o Heart = pericarditis, myocarditis, arrhythmias, Libman-Sacks endocarditis o Lung = pleurisy, pleural effusion, basal atelectasis, restrictive lung defects o Neurological = headache, stroke, cranial nerve palsies, confusion, chorea o Psychiatric = depression, psychosis o Renal = glomerulonephritis
76
What are the appropriate investigations for SLE?
o Bloods = FBC, U&E, LFT, Raised ESR, Normal CRP, Clotting, Complement o Autoantibodies = Anti-dsDNA (60%), Rheumatoid factor (30-50%), Anti-ENA, Anti-RNP, Anti-SM, Anti-Ro, Anti-La, Anti-histone, Anti-cardiolipin o Urine = Haematuria, Proteinuria, Red cell casts o Joints = Plain radiographs o Heart and Lungs = CXR, ECG, Echocardiogram, CT o Kidneys = Renal biopsy (if glomerulonephritis suspected) o CNS = MRI scan, Lumbar puncture
77
Define systemic sclerosis.
Rare connective tissue disease characterised by widespread small blood vessel damage and fibrosis in skin and internal organs.
78
What are the presenting signs and symptoms of systemic sclerosis?
o Skin = Raynaud's phenomenon o Hands = Initially swollen painful fingers then thickened, tight, shiny and bound to underlying structures, Changes in pigmentation, Finger ulcers o Face = Microstomia (puckering of the skin around the mouth), Telangiectasia o Lung = Pulmonary fibrosis therefore patient develop Pulmonary hypertension o Heart = Pericarditis, Pericardial effusion, Myocardial fibrosis, Heart failure, Arrhythmias o GI = Dry mouth, Oesophageal dysmotility, Reflux oesophagitis, Gastric paresis o Kidneys = Hypertensive renal crisis, Chronic renal failure o Neuromuscular = Trigeminal neuralgia, Muscular wasting, Weakness o Others = Hypothyroidism, Impotence
79
What are the appropriate investigations for systemic sclerosis?
o Autoantibodies = Antinuclear, Anti-centromere (70% of limited cutaneous systemic sclerosis cases), Anti-topoisomerase II (anti-Scl-70), Anti-nucleolar, Anti-RNA polymerase o Lungs = CXR, pulmonary function tests, CT scan o Heart = ECG, echocardiography o GI = endoscopy, barium studies o Kidneys = U&Es, creatinine clearance o Neuromuscular = electromyography, biopsy o Joints = radiography o Skin = biopsy (rarely needed)
80
Define vasculitides.
Vasculitis is the inflammation and necrosis of blood vessels.
81
What are the risk factors for vasculitides?
o Hepatitis B = polyarteritis nodosa o Hepatitis C = mixed essential cryoglobulinaemia o pANCA = microscopic polyangiitis + Churg-Strauss o c-ANCA = Wegner's granulomatosis
82
What are the presenting sugns and symptoms of vasculitides?
o General = fever, malaise, night sweats, weight loss o Skin = rash o Joint = arthralgia, arthritis o GI = abdominal pain, haemorrhage, diarrhoea o Kidneys = glomerulonephritis, renal failure o Lungs = dyspnoea, cough ,chest pain, haemoptysis, haemorrhage o CVS = pericarditis, coronary arteritis, myocarditis o CNS = mononeuritis multiplex, infarctions o Eyes = retinal haemorrhage, cotton wool spots o GCA specific = loss of vision, jaw claudication, headache, scalp tenderness o Polyarteritis Nodosa specific = microaneurysms, thrombosis, infarctions, hypertension, testicular pain o Henoch-Schonlein Purpura specific = purpura, arthritis, gut symptoms, glomerulonephritis, IgA deposition o Wegner's Granulomatosis specific = granulomatous vasculitis of upper and lower respiratory tract, nasal discharge, ulceration and deformity, haemoptysis, sinusitis, glomerulonephritis, saddle nose
83
What are the appropriate investigations for vascultides?
o Bloods = FBC (normocytic anaemia, high platelets, high neutrophils), High ESR/CRP o Autoantibodies = cANCA in Wegner's o Urine = haematuria, proteinuria, red cell casts (if glomerulonephritis) o CXR = diffuse, nodular or flitting shadows, atelectasis o Biopsy = renal, lung, temporal artery (in GCA) o Angiography = to identify aneurysms (in PAN)
84
Define carpel tunnel syndrome.
Symptom complex brought on by compression of the median nerve in the carpal tunnel.
85
What are the causes of carpel tunnel syndrome?
o Usually idiopathic o Secondary to: - Tenosynovitis (e.g. in rheumatoid arthritis) - Infiltrative diseases of the canal/increased soft tissue (e.g. amyloidosis, acromegaly) - Bone involvement in the wrist (e.g. osteoarthritis, fracture) - Fluid retention states (e.g. pregnancy, nephrotic syndrome) Other (e.g. obesity , menopause, diabetes)
86
What are the presenting symptoms of carpel tunnel syndrome?
o Tingling and pain in the hand and fingers o Weakness and clumsiness of the hand
87
What are the clinical signs of carpel tunnel syndrome on examination?
o Sensory impairment in the median nerve distribution o Weakness and wasting of thenar eminence o Tinel's Sign = tapping the carpal tunnel causes symptoms o Phalen's Test = flexion of the wrist for 1 min may cause symptoms o Look out for signs of the underlying cause (e.g. acromegaly, hypothyroidism)
88
What are the appropriate investigations for carpel tunnel syndrome?
o Bloods = TFTs, ESR o Nerve Conduction Study (not usually necessary) = impaired median nerve conduction across the carpal tunnel

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