Rheumatology Flashcards
(323 cards)
1
Q
Define rheumatology
A
Medical management of musculoskeletal disease
2
Q
Give 3 causes of inflammatory joint pain?
A
- Autoimmune (RA, connective tissue disease, spondyloarthropathy, vasculitis)
- Crystal arthritis
- Infection
3
Q
Give 2 causes of non-inflammatory joint pain?
A
- Degenerative (OA)
2. Non-degenerative (fibromyalgia)
4
Q
What are the 5 main signs of inflammation?
A
- Red (rubor)
- Heat (calor)
- Pain (dolor)
- Swelling (tumour)
- Loss of function
5
Q
How does inflammatory pain differ from degenerative non-inflammatory pain?
A
Inflammatory pain eases with use
Degenerative pain increases with use
6
Q
Are you more likely to see swelling in inflammatory or degenerative pain?
A
In inflammatory pain = synovial swelling
Often no swelling in degenerative
7
Q
What is bone pain?
A
Pain at rest and at night
Can be due to tumour, infection, fracture
8
Q
What is inflammatory joint pain?
A
Pain and stiffness in joints in the morning, at rest and with use
Can be inflammatory or infective
9
Q
Name 2 inflammatory markers that can be detected in blood tests
A
- ESR (erythrocyte sedimentation rate)
2. CRP
10
Q
Explain why ESR levels are raised in someone with inflammatory joint pain
A
Inflammation leads to increased fibrinogen –> RBC’s clump together –> RBC’s fall faster = increased ESR
11
Q
Explain why CRP levels are raised in someone with inflammatory joint pain
A
Inflammation leads to increased IL-6 levels –> CRP produced in response to IL-6 –> CRP raised
12
Q
Describe the ESR and CRP levels in someone with lupus
A
ESR raised
CRP low
13
Q
What else might be seen in blood tests for joint pain?
A
Auto-antibodies = immunoglobulins that bind to self antigens
14
Q
With what tissue type are all spondyloarthropathies conditions associated?
A
HLA B27 tissue type
15
Q
Give 5 conditions that fall under the term spondyloarthritis
A
- Ankylosing spondylitis
- Reactive arthritis
- Psoriatic arthritis
- Enteropathic arthritis
- Juvenile idiopathic arthritis
16
Q
What is the function of HLA B27?
A
Class 1 surface antigen that interacts with MHC and antigen presenting cell
17
Q
Name 3 theories that can explain why HLAB27 is associated with spondyloarthritis
A
- Molecular mimicry
- Mis-folding theory
- HLAB27 heavy chain hypothesis
18
Q
Describe the ‘molecular mimicry’ theory for explaining why HLAB27 is associated with spondyloarthritis
A
Infection –> immune response –> infectious agent has peptides very similar to HLAB27 –> autoimmune response triggered against HLAB27
19
Q
Give the 3 main clinical features of spondyloarthritis
A
- Seronegative and HLAB27 association
- Axial arthritis
- Asymmetrical large joint arthritis
20
Q
Give 6 signs of spondyloarthritis
A
SPINE ACHE
- Sausage digits = dactylics
- Psoriasis
- Inflammatory back pain
- NSAID responsive
- Enthesitis
- Arthritis
- Crohn’s/UC
- HLAB27
- Eye - uveitis
21
Q
What is the general treatment for all spondyloarthritis?
A
Initially DMARDs and then biological agents if DMARDS fail (TNF blockers)
22
Q
Describe the pathophysiology of ankylosing spondylitis
A
Inflammation of spine –> erosive damage –> repair/new bone formation –> irreversible fusion of spine (syndesmophytes)
23
Q
When does ankylosing spondylitis usually present?
A
In young adults (16-30)
24
Q
Give 5 signs and symptoms of ankylosing spondylitis
A
- Syndesmophytes - vertical vertebral bone growth
- Sacroililitis - joint fusion/los of joint space
- Kyphosis - spine curved downwards
- Enthesitis
- Anterior uveitis
- BACK PAIN
25
What investigations might you do in someone who you suspect to have ankylosing spondylitis?
1. X-ray --> sacroilitis and syndesmophytes (bamboo spine)
2. MRI
3. HLAB27 test
26
What is the diagnostic criteria for ankylosing spondylitis?
1. >3 months back pain
2. Aged <45 at onset
3. Plus one of the SPINE ACHE symptoms
27
What is the treatment for ankylosing spondylitis?
Exercise
Long term NSAIDS
TNF inhibitors (infliximab)
Surgery - spinal/hip replacement
28
Give 3 locations that psoriasis commonly occurs at
1. Elbows
2. Knees
3. Fingers
29
Give 4 clinical features of psoriatic arthritis
1. Asymmetrical oligoarthritis (60%)
2. Large joint arthritis (15%)
3. Enthesitis
4. Dactylitis
5. Nail changes (pitting, onycholysis)
30
What investigations might you do in someone you suspect to have psoriatic arthritis?
X-ray = pencil cup deformity (erosion) in IPJs
31
How do you treat psoriatic arthritis?
NSAIDs
DMARDS (methotrexate, sulfasalazine)
TNFa inhibitor (infliximab)
32
What is reactive arthritis?
Sterile inflammation of the synovial membrane, tendons and fascia triggered by an infection at a distant site, usually GI or genital
33
What GI infections are associated with reactive arthritis?
Salmonella
Shigella
Yersinia enterocolitica
34
What GU infections are associated with reactive arthritis?
Chlamydia
| Ureaplasma urealyticum
35
What is the triad of symptoms for reactive arthritis?
1. Arthritis
2. Conjunctivitis
3. Urethritis
36
What investigations might you do in someone you suspect to have reactive arthritis?
Inflammatory markers - ESR and CRP raised
Stool culture
Infectious serology
37
How is reactive arthritis treated?
Antibiotics to treat infections
| NSAIDs and corticosteroids
38
What type of spondyloarthritis occurs in 20% of patients with IBD?
Enteropathic arthritis
39
What is the criteria for making a clinical diagnosis of juvenile idiopathic arthritis?
Joint swelling/stiffness >6 weeks in children <16 and no other cause is identified
40
What is the aetiology of JIA?
Unknown - idiopathic
41
Why is it important to check the eyes in JIA?
Children with JIA are at high risk of developing uveitis
42
Describe the treatment for JIA
1. Steroid joint injections
2. NSAIDs
3. Methotrexate
4. Systemic steroids
43
Psoriatic arthritis commonly involved swelling of what joint?
DIP joint
44
Describe a psoriatic plaque
Pink, scaling lesion
| Occurs on extensor surfaces of limbs
45
Give 3 differences between RA and psoriatic arthritis
```
Psoriatic = psoriatic lesions, sausage like swelling around DIP joint, pencil in cup erosion on XR, HLAB27 associated.
RA = hands and wrists typically affected, peri-articular erosion on XR, rheumatoid nodules
```
46
Defne osteoporosis
A systemic skeletal disease characterised by low bone mass and micro architectural deterioration of bone tissue
Increase in bone fragility and fracture susceptibility
47
Describe the epidemiology of osteoporosis
50% of women and 20% of men over 50 are affected
48
What 2 factors are important for determining the likelihood of osteoporotic fracture?
1. Propensity to fall --> trauma
| 2. Bone strength
49
Give 4 properties of bone that contribute to bone strength
1. Bone mineral density
2. Bone size
3. Bone turnover
4. Bone mice-architecture
5. Mineralisation
6. Geometry
50
Name a hormone that can control osteoclast action and so bone turnover
Oestrogen
51
Why are so many women over 50 affected by osteoporosis?
Likely to post-menopausal --> less oestrogen --> osteoclast action isn't inhibited
High rate of bone turnover --> bone loss and deterioration --> increased fracture risk
52
What happens to bone micro-architecture as we get older that leads to a reduction intone strength?
Trabecular thickness decreases and horizontal connection decrease --> lowers trabecular strength --> increase risk of fracture
53
Why can RA cause osteoporosis?
RA is an inflammatory disease
| High levels of IL-6 and TNF --> increase bone resorption
54
What is the affect of high cortisol levels on bone turnover?
Cortisol increases bone turnover --> increase bone resorption and induces osteoblast apoptosis
55
Give 5 risk factors for osteoporosis
1. Age
2. Women
3. Previous fracture
4. Family history of osteoporosis or fracture
5. Alcohol
6. Smoking
7. Medications
8. Immobility
56
Name 3 endocrine disease that can be responsible for causing osteoporosis
1. Hyperthyroidism and primary hyperparathyroidism - TH and PTH increase bone turnover
2. Cushing's syndrome - cortisol leads to increase bone resorption and osteoblast apoptosis
3. Early menopause, male hypogonadism - less oestrogen/testosterone to control bone turnover
57
Name 2 medications that can cause osteoporosis
1. Glucocorticoids
2. Depo-povera
3. GnRH analogues
4. Androgen deprivation
58
Give the clinical presentation of osteoporosis
1. Asymptomatic development
2. Fragile bones
3. Pathological fractures (femur neck)
59
What investigations might you do in someone who you suspect to have osteoporosis
DEXA scan = bone mineral density scan - gives you a T score
60
Name 2 areas of the skeleton commonly affected by osteoporosis that the DEXA scan focuses on
1. Lumbar spine
| 2. Hip
61
What is a T score?
Is a standard deviation that is compared to a gender-matched young adult mean
62
What is a normal T score?
> -1.0
63
What T score signifies that a patient has osteopenia?
-2.5 < t < -1
64
What T score signifies that a patient has osteoporosis?
T < -2.5
65
What tool can be used to assess someones risk of osteoporotic fracture?
FRAX = predicts 10 year fracture chance
66
Give 2 examples of anti-resorptive treatments used in the management of osteoporosis
Decrease osteoclast activity and bone turnover
1. Bisphosphonates - alendronate, risedronate
2. HRT - oestrogen
3. Denosumab
67
Give an example of an anabolic treatment used in the management of osteoporosis
Increase osteoblast activity and bone formation
| 1. Teriparatide = PTH analogue
68
Give 3 advantages of HRT
1. Reduces fracture risk
2. Stops bone loss
3. Prevent menopausal symptoms
69
Give 3 disadvantages of HRT
1. Increased risk of breast cancer
2. Increased risk of stroke and CV disease
3. Increased risk of thrombo-embolism
70
How do bisphosphonates work?
Inhibit cholesterol formation --> osteoclast apoptosis
71
Define osteopenia
Pre-cursor to osteoporosis characterised by low bone density
72
Define osteomalacia
Poor bone mineralisation leading to soft bone due to lack of Ca2+
73
What is vasculitis?
Inflammation and necrosis of blood vessel walls with subsequent inspired blood flow
74
What cells might you see on a histological slide taken form someone with vasculitis?
Neutrophils
| Giant cells
75
Describe the pathophysiology of of vasculitis
Vessel wall destruction --> perforation and haemorrhage
| Endothelial injury --> thrombosis and infarction
76
Give an example of large vessel vasculitis
Giant cell arteritis
77
Give an example of medium/small vessel vasculitis
Wegner's granulomatosis (Granulomatosis polyangitis)
78
What is Giant cell arteritis?
Granulomatous inflammation of large cerebral arteries as well as other large vessels (aorta) which occurs in association with Polymyalgia rheumatica
79
Describe the epidemiology of giant cell arteritis
Affects those > 50 years old
Incidence increase age
Twice as common in women
80
Describe the pathophysiology of giant cell arteritis
Arteries become inflamed, thicken and can obstruct blood flow
81
Give 5 symptoms of giant cell arteritis
1. Headache
2. Temporal artery/scalp tenderness
3. Jaw claudication
4. Visual symptoms - vision loss
5. Systemic symptoms - fever, malaise
82
How does giant cell arteritis present in a medical emergency?
Stroke and blindness
83
What might you find on clinical investigation in someone with giant cell arteritis?
1. Palpable and tender temporal arteries with reduced pulsation
2. Sudden monocular visual loss, optic disc is pale and swollen
3. High ESR
84
What is the diagnostic criteria for giant cell arteritis?
1. Age >50
2. New headache
3. Temporal artery tenderness
4. Abnormal artery biopsies
85
What investigations might you do in someone who you suspect has giant cell arteritis?
1. Bloods - high ESR, CRP
| 2. Temporal artery biopsy
86
Describe the treatment for giant cell arteritis
1. Corticosteroids - prednisolone
2. DMARDs - methotrexate (sometimes)
3. Osteoporosis prophylaxis is important
87
Give 2 complications of giant cell arteritis
1. Increased CVA risk
| 2. Visual loss
88
What does ANCA stand for?
Anti-neutrophil cytoplasmic antibodies
89
What is the pathophysiology of Wegener's granulomatosis?
Necrotising granulomatous vasculitis affecting arterioles and venules
ANCAs can activate primed circulating neutrophils which leads to fibrin deposition in vessel walls and deposition of destructive inflammatory mediators
90
What organ systems can be affected Wegener's granulomatosis?
1. URT
2. Lungs
3. Kidneys
4. Skin
5. Eyes
91
What is the affect of Wegener's granulomatosis on the URT?
1. Sinusitis
2. Otitis
3. Cough
4. Haemoptysis
5. Saddle nose deformity
92
What is the affect of Wegener's granulomatosis on the lungs?
1. Pulmonary haemorrhage/nodules
| 2. Inflammatory infiltrates are seen on X-ray
93
What is the affect of Wegener's granulomatosis on the Kidney?
Glomerulonephritis --> haem/proteinuria
94
What is the affect of Wegener's granulomatosis on the skin?
Ulcers
| Pulpura
95
What is the affect of Wegener's granulomatosis on the eyes?
Uveitits
Scleritis
Episcleritis
96
What investigations might you do in someone you suspect to have Wegener's Granulomatosis?
ANCA testing
Tissue biopsy - (renal biopsy best)
CT - assessment of organ involvement
97
What is the treatment for Wegener's Granulomatosis?
Glucocorticoids (prednisolone) AND Immunosuppresive drugs (cyclophosphamide OR rituximab) AND plasma exchange for specific complications
98
Define osteoarthritis
A non-inflammatory degenerative disorder of moveable joints characterised by the deterioration of articular cartilage and the formation of new bone
99
Why does the prevalence of OA increase with age?
Due to the cumulative effect of trauma and a decrease in neuromuscular function
100
Give 5 risk factors for developing OA
1. Genetic predisposition - females, FHx
2. Trauma
3. Abnormal biomechanics (e.g. hypermobility)
4. Occupation (e..g manual labor)
5. Obesity = pro-inflammatory state
6. Old age
101
What are the most important cells responsible for OA?
Chondrocytes
102
Describe the pathophysiology of osteoarthritis
Mechanical stress --> cytokine mediated TNF/IL/NO involved
103
Name the 2 main pathological features of osteoarthritis
1. Cartilage loss
| 2. Disordered bone repair
104
Name the 3 joints of the hand that are commonly affected in osteoarthritis
1. Distal interphalangeal joint
2. Proximal interphalangeal joint
3. Carpal metacarpal joint
105
Which surface of the knee is most commonly affected by OA?
Medial surface
106
Give 5 symptoms of OA
1. Morning stiffness (<30 minutes)
2. Pain - aggravated by activity
3. Tendernes
4. Walking and ADLs affected
5. Joint swelling and bony enlargement
6. Deformities
7. Crepitus
7. Synovitis and effusion
107
What is the primary investigation used to make a diagnosis of OA?
X-ray
108
Give 5 radiological features associated with OA
LOSS
1. Loss of joint space - articular cartilage destruction
2. Osteophyte formation - calcified cartilaginous destruction
3. Subarticular sclerosis - exposed
4. Subchondral cysts
5. Abnormalities of bone contour
109
Describe the non-medical management of osteoarthritis
1. Eduction
2. Weight loss
3. Activity and exercise
4. Physiotherapy and occupational therapy
5. Walking aids/podiatry
110
Describe the pharmacological management of OA
1. Pain relief - paracetamol and NSAIDs --> opioids if needed
2. Intra-articular steroid injections
3. DMARDs - in inflammatory OA
111
Describe the surgical management for OA
Arthroscopy for loose bodies
Osteotomy (changing bone length)
Arthroplasty (joint replacement)
Fusion (ankle/foot)
112
Give 3 indications for surgery in OA
1. Significant limitation of function
2. Uncontrolled pain
3. Waking at night from pain
113
A patient complains of 'locking', what is the most likely cause?
A loose body - bone or cartilage fragment
114
Nodal osteoarthritis can affect the DIP and PIP joints. What are the 2 terms sued for nodes on these joints?
1. PIP = Bouchard's nodes
| 2. DIP = Heberden's nodes
115
Give an example of an inherited connective tissue disease
1. Marfan's syndrome = abnormal fibrillar production
| 2. Ehler Dnalos syndrome = abnormal collagen production
116
Give 3 features of Marfan's syndrome
1. Long limbs
2. Lens dislocation
3. Abnormal sternum (pectus excavatum)
4. Aortic root enlargement
5. Arachnodactyly - long fingers
117
Give 2 features of Ehler Danlos syndrome
1. Stretchy skin
| 2. Joint hypermobility
118
Give an example of an autoimmune connective tissue disease
1. SLE
2. Systemic sclerosis (scleroderma)
3. Sjogren's syndrome
4. Dermatomyositis/Polymyositis
119
What is SLE?
Systemic lupus erythematous = inflammatory multi-system disease characterised by the presence of serum anti-nuclear antibodies (ANA)
120
Describe the epidemiology of SLE
1. 90% of cases are in young women
2. More common in afro-caribbean
3. Genetic association
121
Describe the pathogenesis of SLE
Type 3 hypersensitivity reaction = immune complex mediated
| Autoantibodies to a variety of auto antigens result in formation and deposition of immune complexes
122
What can cause thrombosis in SLE?
The presence of antiphospholipid antibodies
123
What autoantibody is specific to SLE?
Anti-double stranded DNA
124
Give 5 symptoms of SLE
1. Rash - photosensitive vs diced vs malar (butterfly rash)
2. Mouth ulcers
3. Raynaud's phenomenon
4. General - fever, malaise, fatigue
5. Depression
6. Lupus nephritis --> proteinuria, renal failure and renal hypertension
7. Arthritis - symmetrical
8. Serositis - pleurisy/pleural effusion
125
What investigations might you do in someone who you suspect has SLE?
1. Blood tests = anaemia, neutropenia, thrombocytopenia, RAISED ESR and NORMAL CRP
2. Serum autoantibodies - ANA, anti-dsDNA
126
Describe the non medical treatment for SLE
Patient eduction and support
UV protection
Screening for end organ damage
Reduce CV risk factors - smoking cessation
127
Describe the pharmacological treatment for SLE
Corticosteroids
NSAIDs
Antimalarials
Immumnosuppresives/DMARDs
Anticoagulants (for those with antiphospholipid antibodies)
Biological therapy targeting B cells - rituximab
128
What is systemic sclerosis (scleroderma)?
A multi system disease characterised by excess production and accumulation of collagen --> inflammation and vasculopathy
129
Describe the pathophysiology of scleroderma
Various factors cause endothelial lesion and vasculopathy
| Excessive collagen deposition --> inflammation and auto-antibody production
130
Give 5 signs of limited scleroderma
CREST
1. Calcinosis - skin calcium deposits
2. Raynauds
3. Esophageal reflux/stricture
4. Sclerodactyly - thick tight skin on fingers/toes
5. Telangiectasia - dilated facial spider veins
6. Pulmonary arterial hypertension
131
Give 4 signs of diffuse scleroderma
1. Proximal scleroderma
2. Pulmonary fibrosis
3. Bowel involvement
4. Myositis
5. Renal crisis
132
What is a diagnostic test for scleroderma?
Centromere autoantibody = diagnostic
133
Describe the management of scleroderma
1. Raynauds = physical protection and vasodilators (nifedipine -CCB)
2. GORD = PPI (omeprazole) for life
3. Annual echo and pulmonary function tests to monitor arterial pulmonary pressure
4. ACEi to prevent renal crisi
134
What is the pathophysiology of sjögren's syndrome?
Lymphatic infiltration of exocrine glands - especially lacrimal and salivary
135
What does sjögren's syndrome often occur secondary to?
Other autoimmune disease --> SLE, RA, scleroderma, primary biliary cirrhosis
136
Give 5 symptoms of sjögren's syndrome
1. Dry eyes and dry mouth
2. Inflammatory arthritis
3. Rash
4. Neuropathies
5. Vasculitis
137
Why does someone with sjögren's syndrome have dry eyes and a dry mouth?
There is immunologically mediated destruction of epithelial exocrine glands meaning the lacrimal and salivary glands produce fewer secretions
138
What investigations might you do in someone who you suspect to have sjögren's syndrome?
Serum auto-antibodies --> anti-RO, RF, ANA
Raised immunoglobulins and ESR
Schirmer's test - ability for eyes to self-hydrate
139
What is the treatment for sjögren's syndrome?
Tear and saliva replacement
| Immunosuppression/corticosteroids for systemic complications
140
What is dermatomyositis?
A rare disorder of unknown aetiology
| Inflammation and necrosis of skeletal muscle fibres and skin
141
Give 3 symptoms of dermatomyositis
1. Rash
2. Muscle weakness
3. Lungs are often affected too (e.g. interstitial lung disease)
142
What investigations might you do in someone who you suspect has dermatomyositis?
1. Muscle enzymes raised
2. Electromyography (EMG)
3. Muscle/skin biopsy
4. Screen for malignancy
5. CXR
143
What is the treatment for dermatomyositis?
Steroids - prednisolone
| Immunosuppressants
144
What is the name given to inflammation of an entire digit?
Dactylitis
145
What class of drugs can cause Raynaud's?
Beta blockers
146
What are the 3 phases of Raynaud's?
White (vasoconstriction) --> Blue (tissue hypoxia) --> red (vasodilation)
147
What class of drugs does Nifedipine fall into and why can is be used to treat Raynaud's?
Nifedipine - CCB
| Relaxes blood vessels and stops vasospasm
148
Describe the pathophysiology of septic arthritis
Infection produces inflammation in joints
| Knee > Hip > Shoulder
149
Give 3 causes of septic arthritis
1. Staphylococcus aureus
2. Streptococci
3. Neisseria Gonorrhoea
4. Gram negative = E. coli, pseudomonas aeruginosa
150
Give 5 risk factors for septic arthritis
1. Prosthetic joints
2. Old age
3. IVDU
4. Immunocompromised
5. Rheumatoid arthritis
6. DM
151
Give 4 symptoms of septic arthritis
1. Painful
2. Red
3. Swollen
4. Hot
5. Fever
152
What investigation would you do to someone you suspect has septic arthritis?
Joint fluid aspiration --> culture and microbiology
153
Describe the treatment for septic arthritis
```
Antibiotics guided by aspirate cultures
Joint aspiration/drainage
Splinting and physiotherapy
Analgesia
Prosthetic joints - debridement --> arthroplasty
```
154
Define osteomyelitis
Bone inflammation secondary to infection
155
Describe the epidemiology of osteomyelitis
Increasing incidence of chronic OM
| Bimodal age distribution (children and elderly)
156
What can cause osteomyelitis?
1. Staph. aureus
2. Coagulase negative staph (s. epidermidis)
3. Aerobic gram negate bacilli (salmonella)
4. Mycobacterium TB
157
Name 2 predisposing conditions for osteomyelitis
1. Diabetes
| 2. PVD
158
Osteomyelitis: Describe the 3 routes of infection into bone
1. Direct inoculation of infection to bone (trauma, surgery)
2. Contagious spread of infection from adjacent tissues to bone
3. Hematogenous seeding (e.g. due to cannula infection)
159
Osteomyelitis: Who is most likely to be effected by contagious spread of infection?
Affects older adults, those with DM, chronic ulcers, vascular disease, arthroplasties
160
What bones are likely to be affected by hematogenous seeding in adults?
Vertebrae
161
What bones are likely to be affected by hematogenous seeding in children?
Long bones
162
Why do vertebrae tend to be affected by hematogenous seeding in adults?
With age, the vertebrae become more vascular meaning bacterial seeding is more likely
163
Why do long bones tend to be affected by hematogenous seeding in children?
In children the metaphysis of long bones has a high but slow blood flow and basement membrane are absent meaning bacteria can move from the blood to bone
164
Name a group of people who are at risk of hematogenous osteomyelitis
IVDU and other groups at risk from bacteraemia
165
Give 4 host factors that affect the pathogenesis of osteomyelitis
1. Behavioural (risk of trauma)
2. Vascular supply (arterial disease, DM)
3. Pre-existing bone/joint problems (RA)
4. Immune deficiency
166
Acute osteomyelitis: what changes to bone might you see histologically?
1. Inflammatory cells
2. Oedema
3. Vascular congestion
4. Small vessel thrombosis
167
Chronic osteomyelitis: what changes to bone might you see histologically?
1. Necrotic bone - 'squestra'
2. New bone formation 'involucrum'
3. Neutrophil exudates
4. Lymphocytes and histiocytes
168
Why does chronic osteomyelitis lead to sequestra and new bone formation?
Inflammation in BM increase intramedullary pressure --> exudate into bone cortex --> rupture through periosteum --> interruption of periosteum blood supply --> necrosis --> sequestra --> new bone forms
169
What is acute osteomyelitis associated with?
Associated with inflammatory bone changes caused by pathogenic bacteria
170
What is chronic osteomyelitis associated with?
Involves bone necrosis
171
Give 3 symptoms of osteomyelitis
1. Slow onset
2. Dull pain at OM site, aggravated by movement
3. Systemic = fever, rigors, sweating, malaise
172
Give 3 signs of acute osteomyelitis
1. Tender
2. Warm
3. Red swollen area around OM
173
Give 3 signs of chronic osteomyelitis
1. Acute OM signs
2. Draining sinus tract
3. Non-healing ulcers/fracture
174
What is the differential diagnosis of osteomyelitis?
1. Cellulitis
2. Charcot's joints (sensation loss --> degeneration)
3. Gout
4. Fracture
5. Malignancy
6. Avascular bone necrosis
175
What investigations might you do on someone who you suspect may have osteomyelitis?
1. Bloods - raised inflammatory markers (CRP, ESR) and WCC
2. X-rays (cortical erosion, sequestra, sclerosis) and MRI (delineates inflammatory layers, marrow oedema)
3. Bone biopsy
4. Blood cultures
176
Describe the usual treatment for osteomyelitis
Large dose IV antibiotics tailored to culture findings (S. aureus = flucloxacillin)
Surgical treatment = debridement +/- arthroplasty of joint involved
177
How is the stopping of antibiotics determined in osteomyelitis?
Guided by ESR and CRP
178
Give 4 ways in which TB osteomyelitis is different to other osteomyelitis
1. Slower onset
2. Epidemiology is different
3. Biopsy is essential - caseating granuloma
4. Longer Treatment = 12 months
179
Why is osteomyelitis difficult to treat?
Antibiotics struggle to penetrate bone and bone has a poor blood supply
180
What is bacteraemia?
Bacteria in the blood
181
What is debridement?
The removal of damaged tissue
182
What is the most serious complication of arthroplasty surgery?
Prosthetic joint infection
183
Give 2 ways in which prosthetic joint infections can be prevented
1. Aseptic environment and laminar air flow
| 2. Systemic prophylactic antibiotics
184
What investigations might you do on someone who you suspect might have a prosthetic joint infection?
1. Aspirate --> microbiology
2. Bloods for inflammatory markers and FBC
3. X-rays
185
What must you never do before aspirating a joint?
Never give antibiotics before aspiration
| For at least 2 weeks
186
What are the 3 aims of treatment for prosthetic joint infections?
1. Eradicate sepsis
2. Relieve pain
3. Restore function
187
What treatment you choose for a patient who has a prosthetic joint infection that is unfit for surgery?
Antibiotic suppression
188
What is the gold standard treatment for prosthetic joint infections?
Exchange arthroplasty
- radical debridement of all infected and dead tissue
- systemic and local antibiotic cover
- sufficient joint and soft tissue reconstruction
189
What condition must always be rules out in an acutely inflamed joint?
Septic arthritis --> aspirate the joint
190
What is rheumatoid arthritis?
An auto-inflammatory synovial joint disease
191
Name 3 risk factors of RA
1. Smoking
2. Women
3. Other AI conditions
192
Describe the pathophysiology of RA
1. Chronic inflammation - B/T cells and neutrophils infiltrate
2. Proliferation --> pannus formation (synovium grows out and over cartilage)
3. Pro-inflammatory cytokines --> proteinases --> cartilage destruction
193
Give 5 symptoms of RA
1. Early morning stiffness (>60 mins)
2. Pain eases with use
3. Swelling
4. General fatigue, malaise
5. Extra-articular involvment
194
Give 4 signs of RA
1. Symmetrical polyarthorpathy
2. Deforming --> ulnar deviation, swan neck
3. Erosion on X-ray
4. 80% = RF positive
195
RA extra-articular involvement: describe the effect on soft tissues
Nodules
Bursitis
Muscle wasting
196
RA extra-articular involvement: describe the effect on the eyes
Dry eyes
Scleritis
Episcleritis
197
RA extra-articular involvement: describe the neurological effects
Sensory peripheral neuropathy
Entrapment neuropathies (carpal tunnel syndrome)
Instability of cervical spine
198
RA extra-articular involvement: describe the haematological effects
Felty's syndrome (RA + splenomegaly + neutropenia)
| Anaemia
199
RA extra-articular involvement: describe the pulmonary effects
Pleural effusion
| Fibrosing alveolitis
200
RA extra-articular involvement: describe the effects on the heart
Pericardial rub
| Pericardial effusion
201
RA extra-articular involvement: describe the effects on the kidney
Amyloidosis
202
RA extra-articular involvement: describe the effects on the skin
Vasculitis - infarcts in nail bed
203
What investigations might you do in someone you suspect has rheumatoid arthritis?
Blood for inflammatory markers - ESR and CRP raised
Test for anaemia
Test for RF and Anti-CCP
X-ray
204
What is rheumatoid factor?
An antibody against the Fc portion of IgG
205
What is seen on an X-ray of someone with RA?
LESS:
- Loss of joint space (due to cartilage loss)
- Erosion
- Soft tissue swelling
- Soft bones = osteopenia
206
Describe the treatment for rheumatoid arthritis
- NSAIDS and paracetamol
- Corticosteroids - intra-articular glucocorticoid injections
- DMARDs (methotrexate)
- Biological agents (TNF inhibitor - infliximab)
- Physio and OT
- Synovectomy
207
What joints tend to be affects in RA?
MCP
PIP
Wrist
(DIP often spared)
208
What is gout?
Crystal arthritis
209
Describe the epidemiology of gout?
Gout is most common in men over 75
| Rise in post-menopausal women
210
What joint does gout most commonly affect?
Big toe metatarsophalangeal joint
211
Describe the pathophysiology of gout
Purine --> (by xanthine oxidase) xanthine --> uric acid --> monosodium rate crystals OR excreted by kidneys
Urate blood/tissue imbalance --> rate crystal formation --> inflammatory response through phagocytic activation
212
Give 3 causes of gout
= Hyperuricaemia
1. Impaired excretion - CKD, diuretics, hypertension
2. Increased production - hyperlipidaemia
3. Increased intake - high purine diet = red meat, seafood, fructose, alcohol
213
Name 3 common precipitants of a gout attack
1. Aggressive introduction of hypouricaemic therapy
2. Alcohol or shellfish binges
3. Sepsis, MI, acute severe illness
4. Trauma
214
Name 4 diseases that someone with gout might have an increased risk of developing
1. Hypertension
2. CV disease - e.g. stroke
3. Renal disease
4. Type 2 diabetes
215
Give a symptom of gout
Very red, hot, swollen, tender joint (shiny/taut skin)
Tophi
Urate renal stone formation
216
What are tophi?
Onion like aggregates of urate crystals with inflammatory cells. Proteolytic enzymes are released --> erosion
217
What investigations might you do in a patient you think has gout?
Joint fluid aspirate and microscopy = -ve birefringent needle rate crystals
X-ray = rat bite erosions
218
What is the aim of treatment for gout?
To get urate levels < 300 mol/L
219
How would you treat acute gout?
Ice packs and rest
NSAIDS
Colchicine = anti-gout medication
Corticosteroids - IM or IA
220
Name 3 treatment options for gout
1. Lifestyle modifications - diet, weight loss, reduce alcohol
2. Allopurinol (xanthine oxidase inhibitor)
3. Colchicine or NSAIDs
221
You see a patient with gout who is taking bendroflumethiazide. What drug might you replace this with to help treat their gout?
You would switch bendroflumethiazide to cosartan as bendroflumethiazide is a diuretic and so impairs urate excretion
222
Name 6 factors that can cause an acute attack of gout
1. Sudden overload
2. Cold
3. Trauma
4. Sepsis
5. Dehydration
6. Drugs
223
A patient presents with an acute mono-arthropathy of their big toe. What are the two main differential diagnoses?
1. Gout
| 2. Septic arthritis
224
A patient presents with an acute mono-arthropathy of their big toe. What investigations might you do?
Joint aspirate
If septic arthritis - high WCC and neutrophilia and bacteria on gram stain
If gout - urate crystals
225
Describe the pathophysiology of pseudogout
Calcium pyrophosphate crystals are deposited on joint surfaces
Crystals elicit an acute inflammatory response
226
What can cause pseudogout?
1. Hypo/hyperthyroidism
2. Haemochromatosis
3. Diabetes
4. Magnesium levels
227
Give a symptom of pseudogout
Acute, hot and swollen joints
| Typically the wrists and knees
228
What investigations might you do in someone you suspect might have pseudogout?
Aspiration --> fluid for crystals and blood cultures = positive birefringent rhomboid crystals
X-rays --> can show chondrocalcinosis
229
What is the most likely differential diagnosis for pseudogout?
Infection
230
Describe the treatment for pseudogout
Colchicine - anti-gout
Aspiration, intra-articular steroid injections
Methotrexate - for inflammation
Surgery if really bad - synovectomy
231
How can you distinguish OA from pseudogout?
Pattern of involvement --> Pseudo = wrists, shoulders, ankle, elbows
Marked inflammatory component --> Elevated CRP and ESR
Superimposition of acute attacks
232
What kind of crystals do you see in pseudogout?
Positive birefringent calcium pyrophosphate rhomboid crystals
233
What kind of crystals do you see in gout?
Monosodium urate crystals = negatively birefringent
234
What kind of crystals fo you see in pseudogout?
Calcium pyrophosphate crystals = positively birefringent
235
What is the diagnostic criteria for fibromyalgia?
Chronic widespread pain lasting for > 3 months with other causes excluded
Pain is at 11/18 tender point sites
236
Name 4 diseases that fibromyalgia is commonly associated with
1. Depression
2. Choric fatigue
3. IBS
4. Chronic headache
237
Give 4 symptoms of fibromyalgia
1. Neck and back pain
2. Pain is aggravated by stress, cold and activity
3. Generalised morning stiffness
4. Paraesthesia of hands and feet
5. Profound fatigue
6. Unrefreshing sleep
238
Give 3 disease that might be included in the differential diagnosis for fibromyalgia
1. Hypothyroidism
2. SLE
3. Low vitamin D
239
How is fibromyalgia diagnosed?
Everything seems normal
11/18 trigger points
Exclude other diagnoses
240
Describe the management of fibromyalgia
```
Educate the patient and family
CBT and exercise programmes
Acupuncture
Analgesics
Low dose antidepressants (amitriptyline) and anticonvulsants (pregabalin)
```
241
What is mechanical back pain?
Back pain resulting from physical wear and tear
242
Name 3 causes of mechanical back pain
1. Disc herniation
2. Cauda equina syndrome
3. Osteoarhtritis
4. Fibromyalgia
5. Osteomyelitis
243
Name 3 risk factors of mechanical back pain
1. Psychological distress
2. Smoking
3. Dissatisfaction with work
244
Give 3 symptoms of mechanical back pain
1. Lumbosacral pain
2. Muscle spasm
3. Cauda equina syndrome --> sharp localised pain with paraesthesia and related bladder/bowel dysfunction
245
Describe the management of mechanical back pain
Prevention = education, exercise
Analgesic ladder = paracetamol --> NSAIDS --> codeine --> low dose amitriptyline
Adjuvant procedures --> physio, acupuncture, CBT
246
Define fracture
Soft tissue injury with discontinuity of the bone
247
Describe the 3 initial steps in the management of fractures
1. Reduce the fracture --> restore length, alignment and rotation
2. Immobilisation
3. Rehabilitation
248
What are the 4 main stages of fractures healing?
1. Haematoma formation
2. Fibrocatilaganeous callus formation
3. Bony callus formation
4. Bone remodelling
249
Name 4 types of fracture
1. Transverse
2. Linear
3. Oblique, non-displaced
4. Oblique, displaced
5. Spiral
6. Greenstick (specific to children)
7. Comminuted
250
Give 5 potential complications of fractures
1. Contamination (infection)
2. Compartment syndrome
3. Damage to surrounding structures
4. Mal union = bone heals wit deformity
5. Non union = bone fails to heal
6. Avascular necrosis
7. Crush syndrome
8. Cast problems
251
Why is a neck of femur fracture considered so bad?
Cuts off the blood supply to the head of the femur = avascular necrosis of head of femur
252
How does a NOF fracture present?
Fall
Groin pain
Inability to weight bare
Externally rotated and short leg (on side of fracture)
253
What is the treatment for a NOF fracture?
```
ANALGESIA = morphine and regional nerve block
Intracapsular = Total hip replacement or hemi arthroplasty
Extracapsular = DHS or cannulated hip screws
```
254
How are ankle fracture classified?
By Weber classification
A = fracture below syndesmosis
B = fracture at level of syndesmosis
C = fracture above level of syndesmosis (worst)
255
What is the treatment for an ankle sprain?
```
Analgesia
Ice
Elevation
Early mobilisation
Build up strength around anklet to prevent recurrence
```
256
How do you treat an open fracture?
```
Tetanus vaccination
Antibiotic s
Cover with saline soaked gauge
Stabilise
Debridement
Surgery as soon as X-ray has been done
```
257
What is compartment syndrome?
Increase in intra-compartmental pressure due to build up of fluid --> pressure on veins causing collapse --> collapse of nerves --> pressure on arteries
258
How does compartment syndrome present?
Tense compartment with pain disproportionate to injury and the 5 P's
1. Pain
2. Pallor
3. Perishingly cold
4. Pulselessness
5. Paraesthesia
259
What is the treatment of compartment syndrome?
Fasciotomy = relieves pressure
260
Why is the ACL so important?
Important stabiliser of the knee joint, limits anterior translation of the tibia and also contributes to knee rotational starbility
261
How does cauda equina syndrome present?
Bilateral sciatica
Severe or progressive bilateral neurological deficit of legs
Bowel/bladder dysfunction
262
How can you treat cauda equina syndrome?
Decompression and discectomy
263
Name the 4 rotator cuff muscles
Subscapularis
Supraspinatus
Infraspinatus
Teres minor
264
Define sarcoma
A rare tumour of mesenchymal origin
| A malignant connective tissue neoplasm
265
What are the red flag symptoms for bone malignancy?
```
Rest pain
Night pain
Loss of function
Neurological problems
Weight loss
Growing lump
Deformity
```
266
Who are primary bone tumours seen in?
Only seen in the young - rare
267
Give 3 primary bone tumours
1. Osteosarcoma
2. Fibrosarcoma
3. Chondromas
4. Ewings tumour
268
What are secondary bone tumours?
Metastases from:
1. Lungs
2. Breast
3. Prostate
4. Thyroid
5. Kidney
269
What investigations might you do in someone you suspect has bone cancer?
```
Bloods --> FBC, U/E's, Hypercalcaemia, raised alkaline phosphate
X-ray --> bone-lesion interaction
MRI --> soft tissue/bone marrow change
CT --> bone quality and staging
PET
Bone scan --> skeletal masses
USS --> Soft tissue masses
Biopsy
Skeletal isotope scan
```
270
What might you seen on an X-ray of someone with bone cancer?
Onion skin/sunburst appearance = Ewings
| Colman's triangle = osteosarcoma, Ewings, GCT, Osteomyelitis, metastasis
271
What staging is used for bone cancers?
Enneking grading
272
How are malignant bone cancers staged using Enneking grading?
```
G1 = Histologically benign
G2 = Low grade
G3 = High grade
A = intracompartmental
B = extracompartmental
```
273
How are benign bone cancers staged using Enneking grading?
```
G1 = Latent
G2 = Active
G3 = Agressive
```
274
How are bone cancers treated?
MDT management
Benign = NSAIDS
Bisphosphonates (alendronate) - symptomatic help
Malignancy = surgical excision --> radio/chemotherapy
275
Give 4 local complications with surgery for bone cancers
1. Haematoma
2. Loss of function
3. Infection
4. Local recurrence
276
Where do osteosarcomas usually present?
Knee - distal femur, proximal tibia
277
What is an osteosarcoma?
Malignant tumour of bone
| Spindle cell neoplasm that produce osteoid
278
Give 3 features of osteosarcoma
1. Fast growing
2. Aggressive
3. Typically affects 15-19 year olds
279
What is a chondrosarcoma?
A malignant neoplasm of cartilage
280
Where does a chondrosarcoma usually present?
Pelvis
281
Name a boney sarcoma that responds well to chemotherapy
Ewings sarcoma
282
Where does Ewings sarcoma arise from?
Neural crest cells
283
Boney sarcomas make up what percentage of overall sarcomas?
```
20% = boney
80% = soft tissue
```
284
Name 3 soft tissue sarcomas
1. Liposarcoma = malignant neoplasm of adipose tissue
2. Leiomyosarcoma = malignant neoplasm of smooth muscle
3. Rhabdomyosarcoma = malignant neoplasm of skeletal muscle
285
If it not possible to get a wide margin when resecting a sarcoma what might you do?
Give adjuvant radiotherapy
286
Name 2 NSAIDs
1. Ibuprofen
| 2. Naproxen
287
Give 3 side effects of NSAIDs
1. Peptic ulcer disease
2. Renal failure
3. Increased risk of MI and CV disease
288
What can you do to reduce the risk of gastric ulcers and bleeding in someone taking NSAIDs?
1. Co-prescribe PPI
| 2. Prescribe low doses and short courses
289
Give 5 potential side effects of steroids
1. Diabetes
2. Muscle wasting
3. Osteoporosis
4. Fat redistribution
5. Skin atrophy
6. Hypertension
7. Acne
8. Infection risk
290
How do DMARDs work?
Non-specific inhibition of inflammatory cytokines cascade = reduces joint pain, stiffness and swelling
291
Give an example of a DMARD
Methotrexate = gold standard
Hydroxycholoquine
Sulfasalazine
292
How often should methotrexate be taken?
Once weekly
293
Give 3 potential side effects of methotrexate
1. Bone marrow suppression
2. Abnormal liver enzymes
3. Nausea
4. Diarrhoea
5. Teratogenic
294
What can be co-prescribed with methotrexate to reduce the risk of side effects?
Folic acid
295
What are cytokines?
Short acting hormones
296
Name a TNF blocker
Infliximab
| Adalimumab
297
Name a monoclonal antibody that binds to CD20 on B cells
Rituximab - binds to CD 20 --> B cell depletion
298
Describe the mechanism of action of infliximab
Inhibits T cell activation
299
How does alendronate work?
Reduces bone turnover by inhibiting osteoclast mediated bone resorption
300
What class of drug is alendronate?
Bisphosphonate
301
Name 2 drugs that act on the HMGcoA pathway
1. Bisphosphonates - alendronate
| 2. Statins - simvistatin
302
Which of the following is a typical clinical feature of osteoarthritis?
a. 60 minutes of early morning stiffness
b. Painful, swelling across the metacarpophalangeal joints and PIP joints
c. Pain in 1st carpometacarpal joints
d. Mobile subcutaneous nodules and points of pressure
e. Alternating buttock pain
c. Pain in 1st carpometacarpal joints
Morning stiffness is only 15 mins ish in OA
OA = CMC and DIP joints
303
Which of the following is an extra-articular manifestation of rheumatoid arthritis?
a. Subcutaneous nodules
b. Episcleritis
c. Peripheral sensory neuropathy
d. Pericardial effusion
e. All of the above
e. All of the above
304
Which of the following is a classical feature of rheumatoid arthritis on X-ray?
a. Peri-articular sclerosis
b. Sub-chondral cysts
c. Osteophytes
d. Peri-articular erosions
e. New bone formation
d. Peri-articular erosions Inflammatory cytokines causing lysis of bone causing joint damage
Peri-articular sclerosis = OA
Sub-chondral cysts = OA
Osteophytes = OA
New bone formation = SpAs)
305
A 53-year-old man presents to you with a 3-day history of pain in his lower ache. The pain started spontaneously, and he first noticed it at work. He works as a builder and has been unable to go to work for the last 3 days and is keen to have a sick note. Physical examination reveals him to be slightly overweight with a BMI of 29, but there are no neurological deficits or spinal deformity and the pain is not easily localised on examination. Which of the following describe the best management?
a. Given his age, he should be referred to a specialist
b. He should be sent for an x-ray to look for any pathological changes in his spine
c. He should not be given a sick note, and advised to return to work straight away
d. He should be reassured and advised to take simple analgesics and return to normal activity as soon as he can manage
e. He should be advised to seek other employment
d. He should be reassured and advised to take simple analgesics and return to normal activity as soon as he can manage
306
For a lytic tumour to be visible on X-ray, it must have lost:
a. Greater than 6% bone density
b. Greater than 16% bone density
c. Greater than 60% bone density
d. Greater than 90% bone density
e. 100% bone density
c. Greater than 60% bone density
307
A 57-year-old man presents with a 3-day history of a painful 1st MTP joint. ON examination the area is red and very warm. He has a BMI of 32 and hypertension and has had identical episodes before. Which of the following dietary changes would reduce his risk of future similar episodes?
a. Diet with a high red meat content
b. A diet rich in dairy products
c. Drinking >5 cans of non-diet fizzy drinks per day
d. A diet rich in sugary foodstuffs
e. Switching form drinking beer to drinking larger
b. A diet rich in dairy products
= GOUT
308
Which of the following is not an autoimmune connective tissue disease?
a. Systemic lupus erythematosus
b. Ehler Danlos syndrome
c. Primary Sjogren’s syndrome
d. Systemic sclerosis
e. Dermatomyositis
b. Ehler Danlos syndrome (inherited connective tissue disease)
309
A 23-year-old woman presents with mouth ulcers, fever, painful white fingers and pleuritic chest pain. She is antinuclear antibody (ANA) positive, her ESR is 52 (0-15), and her WCC is low (leucopenic). Which of the following features would you not expect to be associate with her illness?
a. Deforming arthritis
b. Photosensitive rash
c. Seizures
d. Pulmonary embolism
e. Thrombocytosis
e. Thrombocytosis
= SLE so would be thrombocytopenia
310
Which of the following is used in the treatment of SLE?
a. Anti-TNF
b. Anti-malarials
c. Ustekinumab (IL12/23 blocker)
d. Sulfasalazine
e. Allopurinol
b. Anti-malarials (hydroxycloroquinine)
Others
Ustekinumab (IL12/23 blocker) = SpAs
Sulfasalazine = RA
Allopurinol = Gout
311
An adult male present with a 6-week history of right sided headache. General malaise, early morning stiffness, and pain in his jaw when eating. His CRP is 63 (0-5), ESR 78 (0-15). Which of the following is true about his underlying disease?
a. It is associated with ANCA positivity
b. It typically affects those between 50 and 60 years old
c. It can present with acute sight loss
d. It rarely responds to corticosteroids
e. It is a vasculitis affecting small blood vessels
c. It can present with acute sight loss
GIANT CELL ARTERITIS (VASCULITIS)
ANCA = small vessel vasculitis
Giant cell arteritis = patients 70-75 years old
312
Which of the following is now a rare cause for joint infections in infants, due to the standard childhood immunisation schedule in the UK?
a. Staphylococcus Aureus
b. Gp A (B haemolytic) streptococcus
c. Varicella Zoster
d. Rubella
e. Haemophilus Influenzae
e. Haemophilus Influenzae
313
A 64-year-old women with T2DM has been struggling with cellulitis of her right forefoot for 4 weeks. After making no progress with oral antibiotics, she has now had 14 days of IV flucloxacillin and co-amoxiclavulanic acid but then pain and erythema persist, and her CRP has only fallen to 47 from its peak of 91. What is the next most appropriate investigation?
a. Blood cultures
b. MRI right forefoot
c. Plain x-ray right forefoot
d. Skin biopsy of right forefoot
e. USS of right forefoot
c. Plain x-ray right forefoot
314
Which of the following is a non-inflammatory cause of joint pain?
a. RA
b. Septic arthritis
c. SpAs
d. Fibromyalgia
e. Gout
d. Fibromyalgia
315
Which of these is not a feature of RA?
a. NSAIDs help
b. Pain eases with use
c. Effects the DIP joints
d. Pain lasts for an hour or so in the morning
e. Ulnar deviation
c. Effects the DIP joints
| Symptom of OA
316
Alendronic acid is a bisphosphate used in treatment of osteoporosis. What is the MOA?
a. Cause increased bone deposition
b. Cause reactivation of the metaphysis and epiphysis
c. Inhibit osteoclast activity and cause osteoclast apoptosis
d. Reduce the signalling pathway between osteoblasts and clasts by increasing RANK ligand
e. Increase removal of calcium into the haversian canal within bone
c. Inhibit osteoclast activity and cause osteoclast apoptosis
317
Pain big toe = gout. Joint aspiration – what is seen to confirm diagnosis?
a. Tophi
b. Needle shaped crystals which are +ve birefringent
c. Needle shaped crystals which are -ve birefringent
d. Rhomboid shaped crystals which are +ve birefringent
e. Rhomboid shaped crystals which are -ve birefringent
c. Needle shaped crystals which are -ve birefringent = Gout
PSEUDOGOUT = Rhomboid shaped crystals which are +ve birefringent
318
3 weeks stiff and painful knee, urethritis and conjunctivitis. What is the most likely cause?
a. Staphylococcus aureus
b. E. coli
c. Streptococcus pneumonia
d. Haemophilus influenzae
e. Chlamydia
e. Chlamydia
Reactive arthritis symptoms --> often caused by STI
319
Aching hand arm and pins and needles in thumb, index and middle fingers. Shaking his hand seems to help. What is it?
a. Cervical spine fracture
b. Compression of median
c. Compression of radial
d. C8-T1 lesion
e. Compression of ulnar
b. Compression of median = Carpal tunnel syndrome
320
Ankylosing spondylitis, what tissue type is associate with this condition?
a. HLA DQ2
b. HLA B27
c. HLA DR3
d. HLA DR2
e. HLA AD6
b. HLA B27
321
Which is most common cause of osteomyelitis?
a. Strep pneumonia
b. Staph aureus
c. Strep pyogens
d. Mycobacterium TB
e. Haemophilus influenzae
b. Staph aureus
322
Lupus --> blood test reveal what?
a. Anti-DsRNA positive
b. Raised ESR and CRP
c. Raised ESR but normal CRP
d. ANCA positive
e. ANA negative
c. Raised ESR but normal CRP
323
DEXA scan with T score -1.6, what does this mean?
a. Normal
b. Osteopenia
c. Osteoporosis
d. Severe osteoporosis
e. Paget’s disease
b. Osteopenia
