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Musculoskeletal Flashcards

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
Q

Define giant cell arteritis.

A

Granulomatous inflammation of large arteries, particularly branches of the external carotid artery, most commonly the temporal artery.

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26
Q

What are the risk factors for giant cell arteritis?

A

o Age

o Some infections

o Associated with HLA-DR4 and HLA-DRB1

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27
Q

What are the presenting symptoms of giant cell arteritis?

A

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

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28
Q

What are the clinical signs of giant cell arteritis on examination?

A

o Swelling and erythema overlying the temporal artery

o Scalp and temporal tenderness

o Thickened non-pulsatile temporal artery

o Reduced visual acuity

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29
Q

What are the appropriate investigations for giant cell arteritis?

A

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

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30
Q

What is the management plan for giant cell arteritis?

A

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

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31
Q

What are the possible complications of giant cell arteritis?

A

o Carotid artery aneurysms

o Aortic aneurysms

o Thrombosis

o Embolism to the ophthalmic artery leading to visual disturbance and loss of vision

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32
Q

Define osteoarthritis.

A

Age-related degenerative joint disease when cartilage destruction exceeds repair, causing pain and disability.

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33
Q

What are the risk factors for osteoarthritis?

A

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)

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34
Q

What are the presenting symptoms of osteoarthritis?

A

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

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35
Q

What are the clinical signs of osteoarthritis on examination?

A

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

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36
Q

What are the appropriate investigations for osteoarthritis?

A

o Joint X-Ray of the affected joint will show FOUR classic features:

  • Loss/narrowing of joint space
  • Osteophytes
  • Subchondral cysts
  • Subchondral sclerosis
37
Q

Define osteomyelitis.

A

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
Q

What are the risk factors for osteomyelitis?

A

o Diabetes

o Immunosuppression

o IV drug use

o Prostheses

o Sickle-cell anaemia

39
Q

What are the presenting symptoms of osteomyelitis?

A

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
Q

What are the clinical signs of osteomyelitis on examination?

A

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
Q

What are the appropriate investigations for osteomyelitis?

A

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
Q

Define polymyalgia rheumatica.

A

An inflammatory condition of unknown cause, which is characterised by severe bilateral pain and morning stiffness of the shoulder, neck and pelvic girdle.

43
Q

What are the risk factors for polymyalgia?

A

o Unknown - linked to genetics and environmental factors

o Associated with giant cell arteritis

44
Q

What are the presenting signs and symptoms of polymyalgia rheumatica?

A

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
Q

What are the appropriate investigations for polymyalgia?

A

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
Q

What is the management plan for polymyalgia rheumatica?

A

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
Q

What are the possible complications of polymyalgia rheumatica?

A

o Temporal arteritis

o Relapse of disease

o Complications of steroid use (e.g. fracture risk)

48
Q

Define reactive arthritis.

A

Characterised by a sterile arthritis occurring after an extra-articular infection (commonly GI or urogenital).

49
Q

Define Reiter’s syndrome.

A

Triad of reactive arthritis, urethritis and conjunctivitis

50
Q

What are the risk factors for reactive arthritis?

A

Associated with infections - GI = Salmonella, Shigella, Yersinia, Campylobacter

  • Urogenital = Chlamydia trachomatis

o HLA-B27

51
Q

What are the presenting symptoms of reactive arthritis?

A

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
Q

What are the clinical signs of reactive arthritis on examination?

A

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
Q

What are the appropriate investigations for reactive arthritis?

A

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
Q

Define rheumatoid arthritis.

A

Chronic inflammatory systemic disease characterised by symmetrical deforming polyarthritis and extra-articular manifestations.

55
Q

What are the risk factors for rheumatoid arthritis?

A

o Other autoimmune disease

o HLA-DR1 and HLA-DR4

56
Q

What are the presenting symptoms of rheumatoid arthritis?

A

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
Q

What are the clinical signs of rheumatoid arthritis on examination?

A

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
Q

What are the appropriate investigations for rheumatoid arthritis?

A

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
Q

Define sarcoidosis.

A

Multisystem granulomatous inflammatory disorder.

60
Q

What are the risk factors for sarcoidosis?

A

o Transmissible agents = viruses

o Environmental triggers

o Genetic factors

61
Q

What are the presenting signs and symptoms of sarcoidosis?

A

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
Q

What are the appropriate investigations for sarcoidosis?

A

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
Q

Define spetic arthritis.

A

Joint inflammation resulting from intra-articular infection.

64
Q

What are the causative agents for septic arthritis?

A

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
Q

What are the risk factors for septic arthritis?

A

o Recent orthopaedic procedures

o Osteomyelitis

o Diabetes

o Immunosuppression

o Alcoholism

66
Q

What are the presenting symptoms of septic arthritis?

A

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
Q

What are clinical signs of septic arthritis on examination?

A

o Painful, hot, swollen

o Immobile joint

o Erythema

o Severe pain prevents passive movement

o Pyrexia

o Look for signs of aetiology

68
Q

What are the appropriate investigations for septic arthritis?

A

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
Q

Define Sjögren’s syndrome.

A

Characterised by inflammation and destruction of exocrine glands (usually salivary and lacrimal glands).

70
Q

What are the risk factors for Sjögren’s syndrome?

A

o Genetic association = HLA-B8 and HLA-DR3

o Other autoimmune disease

71
Q

What are the presenting symptoms of Sjögren’s syndrome?

A

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
Q

What are the clinical signs of Sjögren’s syndrome on examination?

A

o Parotid or salivary gland enlargement

o Dry eyes

o Dry mouth or tongue

o Signs of associated conditions

73
Q

What are the appropriate investigations for Sjögren’s syndrome?

A

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
Q

Define SLE.

A

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
Q

What are the presenting signs and symptoms of SLE?

A

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
Q

What are the appropriate investigations for SLE?

A

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
Q

Define systemic sclerosis.

A

Rare connective tissue disease characterised by widespread small blood vessel damage and fibrosis in skin and internal organs.

78
Q

What are the presenting signs and symptoms of systemic sclerosis?

A

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
Q

What are the appropriate investigations for systemic sclerosis?

A

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
Q

Define vasculitides.

A

Vasculitis is the inflammation and necrosis of blood vessels.

81
Q

What are the risk factors for vasculitides?

A

o Hepatitis B = polyarteritis nodosa

o Hepatitis C = mixed essential cryoglobulinaemia

o pANCA = microscopic polyangiitis + Churg-Strauss

o c-ANCA = Wegner’s granulomatosis

82
Q

What are the presenting sugns and symptoms of vasculitides?

A

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
Q

What are the appropriate investigations for vascultides?

A

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
Q

Define carpel tunnel syndrome.

A

Symptom complex brought on by compression of the median nerve in the carpal tunnel.

85
Q

What are the causes of carpel tunnel syndrome?

A

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
Q

What are the presenting symptoms of carpel tunnel syndrome?

A

o Tingling and pain in the hand and fingers

o Weakness and clumsiness of the hand

87
Q

What are the clinical signs of carpel tunnel syndrome on examination?

A

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
Q

What are the appropriate investigations for carpel tunnel syndrome?

A

o Bloods = TFTs, ESR

o Nerve Conduction Study (not usually necessary) = impaired median nerve conduction across the carpal tunnel

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