Pathology

Question 1

Osteomyelitis?

Answer 1

Cx - Infection of the bone - Bacteria in blood such as staph aureus, trauma or surgery

Sx - Inflammation, swelling, hot, loss of function in the joint bone

SPx - Humerus or femur in children and vertebral bones in adults

Ix - Blood tests, aspirates, MRI or CT of tissue

Mx - Remove dead tissue, aspirate fluid from joint, Initial IV antibiotics then prescribed - ceftriaxone and/or penicillin antibiotics

Question 2

Osteomalacia?

Answer 2

Cx - Softening of bones by Vit D deficiency that means calcium levels are reduced
***Chrnoic kidney disease

Sx -Often none > fatigue, bone pain, muscle weakness and aches, anorexia?

SPx - Dark skin pigmentation needs longer in sun to produce same amount of vitamin D, stomach surgeries, kidney or liver disease, coeliac

Mx - Vitamin D supplements

Ix - Reduced Ca and PO, ^PTH, ^alkaline phosphate

*Leads to 2nd hyperPT

Question 3

Rickets

Answer 3

• Osteomalacia in kids
• Effects epiphyseal growth plate that hasn’t closed leading to softening and leaking of bones

Sx - Leads to delayed growth, motor skills, pain in pelvis and spine, swollen wrists - due to excessive non mineralised osteoid at growth plate

Ix - Low Ca

Question 4

Padget’s bone disease

Answer 4

Cx - Over active osteoblast and osteoclast

Sx - Bone deformities and pain with areas of varying bone density

Mx - Bisphosphates (knock out osteoclasts)

Ix - Normal Ca and PO, ^^alkaline phosphate, normal PTH

** most common in elderly people in: skull, lower bones, pelvis and spine showing lesions

Question 5

Osteoarthritis

Answer 5

Cx - Wear and tear type that occurs in synovial joints

Sx - Joint pain, stiffness, weakness, worsened by activity,
** loss of joint space, osteophytes (margins of joint), subchondral sclerosis (increased bone density), subchondral cysts,

• Herberns nodes - DIP swelling
• Bouchard nodes - PIP swelling

SPx - Made worse by activity, hands, knees, hips and spine and NO systemic upset, more likely in females

Mx - topical NSAIDs 1st
- oral NSAID with PPI
- steroid injections

Question 6

Rheumatoid arthritis

Answer 6

Cx - Auto immune - IgM antibodies attack IgG antibodies

Sx - chronic inflammation in the joint lining, tendon sheath and bursa, swelling, pain and stiffness

SPx - Tends to be symmetrical, more likely in women, often in hands, fingers, feet, ankle, systemic upset, worse in the morning, cholesterol deposits in nodules
*DIP spared

Mx - DMARDs - methotrexate
- Steroids for flares
Anti TNF

Ix - Elevated rheumatic factor, anti CCP antibodies**, CRP and ESR
- x rays of affected joints showing loss of joint space
- Joint aspirate - high WCC, yellow fluid, no crystals,
**DAS28 for activity

Question 7

Gout

Answer 7

Cx - Deposits of uric acid (needle shaped) - negative bifrinegent crystals/monosodium urate in the synovial of joints

Sx - Swollen, hot, painful joints

SPx - More likely if you’re male, consume alcohol, high purine diet, cardiovascular disease, typically base of big toe, thumb and wrist

Mx - NSAID’s or colchicine 1st
- Allopurinol long term for reducing serum urate (NSAID or diclofenac should be given along side)
Colchicine and allopurinol at same time

Ix - Raised blood uric acid levels, aspirates, x ray off joints (>360 diagnose)
- if during flare, repeat in 2 weeks when sx resolved

Question 8

Osteoporosis

Answer 8

• Reduced bone density leading to increased fracture risk
• Bone and muscle pain/weakness, back pain caused by collapsed vertebrae
• More likely in females, post menopausal, early menopause, long term steroids

Mx- bisphosphates - Alendronic acid and risedronate, denosumab -monoclonal antibody that regulates osteoclasts, teriparatide - synthetic PTH

Ix - DEXA scan used to determine bone density, bloods - Ca, PO, ALP, PTH normal
- T score for young individuals of same sex
- Z score for individuals of same age and sex

** Frax tool for assessing need for dexa scan

Question 9

Curare paralysis

Answer 9

• Competitive antagonist of nicotinic cholinergic receptors causing paralysis

Question 10

Botox toxins

Answer 10

• Inhibit exocytosis, Ach unable to cross synaptic cleft and bind in junctional folds

Question 11

Carpal tunnel syndrome

Answer 11

Cx - Compression on the median nerve caused by inflammation

Sx - Tingling, numbness or pain in 3.5 digits (thumb, index, middle and half of ring)

Mx - Cut flexor retinaculum to release pressure, steroid injection to relive inflammation

Question 12

Rigor mortis

Answer 12

• Where after an AP has occurred and no ATP is synthesised, can’t break the cross bridge between actin and myosin
• Muscles become rigid 4 hrs after death around the limbs

Question 13

Psoriasis

Answer 13

• Too many keratinocytes

Sx - itching and patchy skin, red and pink dry skin with slivery/white scales

Ix - Skin biopsy

Mx - topical steroids (creams and ointments)

Question 14

Ankylosing spondylitis

Answer 14

*Typically in a young man with lower back pain worse in the mornings and night
* Associated with HLA B27 gene

Cx - inflammation in lower axial skeleton
- sacroiliac joints and vertebral column

Sx - lower back pain that radiates to the bum, often stiffness or pain in the mornings, can be woken at night, better on exercise , swimming helps
- restrictive lung defect

** reduced chest expansion, lateral flexion and forward flexion - schobers<5

Ix - CRP and ESR
* - HLA B27 genetic test
* - X ray of sacroiliac joints
- MRI of spine to show bone marrow oedema

Mx - NSAIDS and exercise regime first line
- steroids
- additional physio

*more common in men

Question 15

Marfan’s syndrome

Answer 15

• A dominant inherited disorder that affects CT
• commonly affecting heart, eyes, blood vessels and skeleton
• Can affect the aorta causing dissections and aneurysm that can be life threatening

Cx - mutation in fibrillar 1 protein

Sx - tall and slender builds
- high arched palate and crowded teeth
- heart murmurs
- extreme near sightedness
- flat feet and a curved spine
- protruding or sunken breast bone

Ix - genetic testing

*Recurrent pneumothoraces common

Question 16

Psoriatic arthritis

Answer 16

*Inflammatory arthritis associated with psoriasis
- asymmetrical

Sx - plaques of psoriasis on the skin
- pitting of the nails
- oncholysis
- dactalysis
**Eye disease, aortitis, amyloidosis
- worse in mornings, improves with use
***Affects hands and feet

Ix - PEST screening tool -those with psoriasis
X ray - periostitis, ankylosis, osteolysis, dactylitis,

Mx - NSAIDS if mild
- Methotrexate mod to severe
- Anti TNF meds

Question 17

Reactive arthritis

Answer 17

• Where synovitis occurs as a reaction to a recent tigger - can affect multiple joints and can take 4 weeks post infection
• often single joint in lower limb (knee)
  **no infection in the joint

Cx - gastroenteritis, chlamydia (STI),

Axs - bilateral conjunctivtis, anterior uveitis, circinate balanitis
**(can’t see, pee or climb and tree)

Sx - hot, swollen, painful joint

Ix - ESR, CRP, ANA, rheumatoid factor
- no infection in the joint itself

Mx (when septic arthritis is excluded)
- NSAID
- steroid injections
- recurrent cases may rewire DMARDS

Question 18

lupus erythematosus

Answer 18

*Inflammatory autoimmune CT disease
*More common in women and Asias around middle age
*systemic so affects multiple organs
** Can be drug induced by hydrazine

Sx - non specific symptoms
- fatigue, weightloss, joint and muscle pain, fever, photosensitive malaria rash (across face), mouth ulcers, SOB, raynauds, hair loss, clots

Ix - Anti nuclear antibodies (99%)
- anti double stranded DNA antibodies (most specific to SLE)
- CRP typically normal but ESR raised
- nephritis
- C3 and C4 reduced - auto immune acute disease
- lupus anticoagulant and anti phospholipid antibodies (increase clotting risk)

Mx
- hydroxycloroquine - treatment of choice 1st
- NSAIDs and suncream
Azithroprine

Question 19

Sciatica

Answer 19

Cx - L5-S1 disc herniation compressing spine

Sx - Pain, numbness, tingling, weakness of glutes, bad, of legs, calves, foot and toes, possible urinary incontinence
***Unilateral

Ix - MRI
- positive leg raise test

Mx - Usually heals on its own,
- NSAIDS and steroids

Question 20

Cauda equina

Answer 20

Cx - Ruptured disc, stenosis, tumour….

Sx - Faecal and urinary incontinence
- reduced power in limbs
- reduced sensation to pain and temperature
***Bilateral symptoms

• Urinary incontinence a late symptom and irreversible sign

Ix - MRI

Mx - surgical decompression

Question 21

Pseudogout

Answer 21

• Older adult with hot, swollen, painful knee
• Haemachomatosis a RF

Cx - depositis of calcium pyrophosphate crystals

Sx - typically milder presentation than gout and septic arthritis

Ix - exclude septic arthritis
- Aspirate joint fluid showing: no bacterial growth, calcium pyrophosphate crystals, rhomboid shaped crystals, positive infringement of polarised light
- chonedrocalcinosis (thin white line in middle of joint due to calcium deposition) (LOSS)

Mx - aspirate to exclude septic arthritis
- NSAIDS, steroids

Question 22

Adhesive capsulitis

Answer 22

*Also known as frozen shoulder

Sx - problems with active and passive movements
- last 6months -2years
- worse on external rotation

Mx - NSAID, physio, roads

Question 23

Compartment syndrome

Answer 23

• Complication that may occur following surgery or ischaemia reperfusion
• Raised pressure in a compartment compromises tissue perfusion, leading to necrosis
• Most common in supracondylar humerus and tibial shaft fractures

Sx - pain on active and passive extension of fingers
- parasthesia
- pallor
- pulse may still be felt
- Paralysis of muscles

Consistent medication use points to compartment syndrome

Ix - pressure in compartment above 40mmHg is diagnostic

Mx - fasiotomy

Question 24

Cubital tunnel syndrome

Answer 24

*Ulna nerve is compressed inside the cubital tunnel

Cx - person bends elbow, lifting, reaching and pulling motions
- arthritis, previous fractures

Sx - funny bone pain, numbness in ring or little finger, weak grip, drops things, claw hand

Mx - NSAIDs and steroids

Question 25

Giant cell arteritis/ temporal arteritis

Answer 25

Vasculitis of medium and large arteries - typically temporal arteries * Associated with poly myalgia rheumatica * Higher risk if white females over 50 Sx - Severe unilateral headache around temporal area, scalp tenderness, jaw claudication, blurred or double vision, painless sight loss - Other common systemic features Ix - giant cells found on temporal artery biopsy, ESR raised, CRP raised - reduced Hb, thrombocytosis, Mx - first line high dose pred - if evolving vision loss - IV methylpred

Question 26

Fibromyalgia

Answer 26

* Widespread pain in Body most common around 30-50 * 5x more common in women Cx - Unknown Sx - widespread pain at multiple sites or all over - cognitive impairment - lethargy - sleep disturbance and headaches Mx - aerobic exercise Antidepressants - duloxetine...

Question 27

polymyalgia rheumatica

Answer 27

* Usually affects Asian women more often * Associated with giant cell arteritis * Older adults affected Cx - Sx - pain and stiffness in neck, arms, shoulders and pelvic girdle but can be everywhere, affects sleep, worse in the morning, worse when moving, weight loss and fever - rapid onset **no weakness** Ix - ESR raised CRP raised, CK normal, Mx - Prednisolone 15mg - should respond quick - Anti TNF when failure to respond

Question 28

Sjögren's syndrome

Answer 28

* Autoimmune condition affecting exocrine glands causing dryness and itching * Much more common in females Cx - autoimmune Sx - dry eyes and mouth, vaginal dryness, joint pain, raynauds, Ix - RF positive, ANA, ****anti Ro, anti La * SCHIRMERS TEST - lymphocytic infiltration on histology - lymphoid malignancy risk Mx - artificial replacement of saliva and tears - pilocarpine for dry mouth -

Question 29

Septic arthritis

Answer 29

* Haematgenous spread most common Cx * staph aureus * unless sickle cell anaemia =salmonella * Adults sexually active =neisseria gonorrhoea (gram negative diplococci) - direct penetration or surface infection, surgery * Can spread from a distal infection point via blood Sx - Acutely pain, hot, swollen joint (most common at knee) - problems with function, fever, hot joint Ix - Synovial fluid sampling - x ray, blood cultures Mx - IV antibiotics - flucloxacilin or clydamycin if penicillin allergy - needle aspiration for decompression

Question 30

Raynauds

Answer 30

Cx - Vasospasm of smaller arteries that supply fingers Cx - disease of arteries, CT disease, disease of arteries, smoking Sx - cold fingers or toes, skin turn white the blue, numb tingly feeling or pain upon warming or stress relief *cold or emotional stress* Ix - ANA, ESR Mx - CCB - nifedipine - rapid onset - vasodilators

Question 31

Paracetamol overdose

Answer 31

Sx - abdominal pain, nausea, yellowing of skin and eyes, headache, confusion or drowsiness Mx - IV N-acetylcysteine - activated charcoal if <4hrs Vit K if INR/PT increased * check levels 4-15hrs after (don't give treatment too early - treatment line)

Question 32

Tricyclic antidepressant overdose

Answer 32

Sx - Dilated pupils and tachycardia, seizures, arrhythmia (QRS>100ms) Mx - activated charcoal<1hr - benzodiazepines for seizures - IV Na bicarb

Question 33

Aspirin overdose

Answer 33

Sx - tachypneoic and tachycardia - pulmonary oedema - sweating, tinnitus**, bleeding, drowsiness, Mx - Na bicarb for acid (aspirin is an acid) - activated charcoal - correct electrolytes

Question 34

Beta blockers overdose

Answer 34

Sx - bradycardia, confusion, hypotension Mx - IV atropine, IV glucagon, pacing if not responsive

Question 35

Opioid overdose

Answer 35

Sx - Pin point pupils, reduced rest, reduced GCS, rest acidosis Mx - IV naloxone

Question 36

Digoxin overdose

Answer 36

Sx - yellow halls, hypotension, drowsiness, nausea, anorexia Mx - IV digibind - treat hypokalaemia

Question 37

Benzodiazepines overdose

Answer 37

Sx - drowsiness, dilated pupils, reduced resp rate Mx - flumazemil

Question 38

Iron overdose

Answer 38

Sx - GI and liver problems Mx - gastric lavage - IV Deferoxamine

Question 39

* Haemarthrosis

Answer 39

*Bleeding into the joint space (most commonly knee) Cx - Aneursym, trauma, haemophilia, arthritis, vit K deficiency, ligament tears Sx - pain, swelling and inflammation, trouble moving, bruising, hot joint Ix - X ray, arthrocentesis, Mx - pain and swelling

Question 40

Antiphospholipid syndrome

Answer 40

* 30% have SLE Sx - recurrent thromboses Ix - anti cardiolipin, anti beta 2 glycoprotein, lupus anti coag, thrombocytopenia, prolonged APTT Mx - aspirin primary event - lifelong warfarin

Question 41

Osteogenesis imperfecta

Answer 41

*Brittles bone disease Cx - Autosomal dominant, abnormality in type 1 collagen Sx - multiple bone fractures, blue sclera, deafness due to otosclerosis, dental imperfections Ix - Ca, Po, ALP, PTH all normal

Question 42

Still's disease

Answer 42

Sx - joint pain, rash (salmon pink or macropapular), pyrexia, lymphadenopathy, Ix - raised ferritin and leukocytes * Diagnosis of exclusion - RF and ANA negative Mx - NSAIDs - steroids can be added for sx

Question 43

Discoid lupus

Answer 43

* Auto immune chronic skin condition, more common in women between 20-50 * Dark skin patients * Increase risk of SLE Px - lesion on scalp, face and ears - Photosensitive - Axs with scarring causing alopecia - Ix - skin biopsy Mx - Topical steroid cream - Sun protection

Question 44

Systemic sclerosis

Answer 44

* Auto immune CT disease involving inflammation and fibrosis of CT and organs Cx - unknown Limited cutaneous/crest syndrome - Calcinosis, raynauds phenomenon, oesophageal dismotility, sclerodactaly, Telangiectasis +scleroderma Ix - ANA and Anti centromere Diffuse cutaneous - Includes CREST^ plus: CV, resp and kidney problems Ix - ANA, anti Scl-70 Mx - DMARDs and biologics in diffuse

Question 45

Polymyositis

Answer 45

* Autoimmune condition causing muscle inflammation and proximal muscle weakness Sx - Gradual onset, symmetrical, proximal muscle weakness - difficulties standing, overhead pressing, walking up stairs - muscle pain can sometimes be present Ix - CK elevated, Anti Jo 1, - urgent malignancy screen Mx - steroids first line

Question 46

Dermatomyositis

Answer 46

^ Polymyositis plus skin changes Sx - Gottron papules (back of hands) and heliotrope rash on eye lids, periorbital oedema, photosensitive rash on torso Ix - CK elevated, Anti Jo 1 - urgent malignancy screen Mx - Steroids

Question 47

Small vessel vasculitis

Answer 47

* Henoch-Schonlein Purpura * Microscopic Polyangiitis (ANCA) * Granulomatosis with Polyangiitis (ANCA) * Eosinophilic Granulomatosis with Polyangiitis (ANCA)

Question 48

Medium vessels vasculitis

Answer 48

* Polyarteritis Nodosa * Kawasaki Disease

Question 49

Large cell vasculitis

Answer 49

* Giant Cell arteritis * Takayasu’s Arteritis

Question 50

Henoch-Schonlein Purpura

Answer 50

* IgA nephritis - affects kids u10 - IgA deposits In vessels Px - lower leg and buttocks purpuric rash - joint pain, abdo pain, renal involvement Mx - conservative - analgesia, rest and good hydration

Question 51

Microscopic Polyangiitis (ANCA)

Answer 51

* Small vessels vasculitis Px - Renal failure due to glomerulonephritis - Hameoptysis Ix - P-ANCA positive - MPO - can be C- ANCA - PR3 Mx - steroids

Question 52

Granulomatosis with Polyangitis

Answer 52

* Small vessel vasculitis Px - affects resp tract - nose bleeds, hearing loss, sinusitis - wheeze, haemoptysis * SADDLE SHPAED NOSE - nasal bridge collapse - rapidly progressing glomerulonephritis Ix - C-ANCA positive Mx - Steroids

Question 53

Eosinophilic Granulomatosis with Polyangitis

Answer 53

* Small vessel vasculitis * Primarily affects lungs and the skin Px - Severe asthma - sinusitis, allergic rhinitis - can affect kidneys Ix - eosinophilia, P-ANCA positive Mx - steroids**Chaurg strauss

Question 54

Behcets disease

Answer 54

* Inflammatory condition of vessels causing recurrent oral and genital ulcers - can affect multiple organs Px - oral ulcers 3x per year - painful, red halo, sharp borders - genital ulcers the same - Ant uveitis - heal in 2-4 weeks and may leave scars - erythema nodusum Ix - Pathergy test - needle to skin ** - HLA B51 gene Mx - Topical and oral steroids - ...

Question 55

Ehlers-danlos syndrome

Answer 55

* Group of genetic conditions involving collagen defects Px - hyper mobility In joints and abnormalities in CT Ix - Beighton score for hypermobilty

Question 56

Perthe's Disease

Answer 56

* Childhood condition where too little blood gets to the femoral head and bone begins to die RF - age 4-10 and male Cx - unknown Sx - Limping, pain, stiffness, worse with activity, limited range of motion Ix - X ray - may not show changes initially - shows increased joint space and loss of smooth shape of femoral head Mx - Surgery