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Phase 4 - GR > Rheumatology / orthopaedics > Flashcards

Rheumatology / orthopaedics Flashcards

1
Q

Name a large vessle / medium / small primary vasculitis

A

Large - giant cell / Takayasu
[Giant samurai]

medium
PAN, kawasaki
[Cows are cooked in medium PANS]

small
Henoch-schonlein purpura, Wegner’s granulomatosis, churg strauss, microscopic polyangitis
[German sounding + microscopic obvs]

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2
Q

Secondary causes of vasculitis

A

Aortitis in RA

Autoimmune, malignancy, durgs, infection

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3
Q

Eg of infective / drug / autoimmune causes of secondary vasculitis

A

BBV, strep

penicillin, steroids

RA, SLE, sjorgrens

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4
Q

What are the ANCA associated vasculities?

A

Wegners, microscopic polyangitis, Churg strauss, drug induced

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5
Q

What is ANCA? How are they detected? 2 types and associated antibody?

A

Anti-neutrophil cystoplasmic antibodies

Detected with indirect immunofluorescence microscopy

Cytoplasmic ANCA
Peri-nuclear ANCA

C-ANCA = Proteinase 3 (PR3)
P-ANCA = Myeloperoxidase (MPO)
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6
Q

69 M
Sinus problems, blocked nose with bloody discharge
No improvement with antibiotics and steroid spray
Constitutional symptoms
Hearing problems
Arthralgia
Rash on legs

Nasal tone of voice
Vasculitic rash on legs
Small joint and ankle swelling

Ix
Low Hb
Raised Ur & Cr
CRP 109

A

Wegners

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7
Q

For exams
c-ANCA / PR3 ?
P-ANCA / MPO?

A

c anca - wegners

p anca - churg strauss

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8
Q

Triad of affected areas in wegners

A

lung, kidney, ENT

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9
Q

Usual vasculitis with raised eosinophils

A

Churg Strauss

Often get new / worsening asthma

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10
Q

New name for wegners?

what and Who usually affected?

A

Granulomatosis with polyangitis

Necrotising vasculitis of arterioles, capillaries and post-capillary venules

Typically affects men aged 25-60

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11
Q

Causes of cavitation on lung XR?

A

wegners, malignancy, septic emboli, TB, Klebsiella, Staph aureus, pulmonary infarcts

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12
Q

main 3 affected organs features of Granulomatosis with polyangitis?

A

Upper resp - Sinusitis
Otitis
Nasal crusting & bleeding
Saddle nose deformity

Lungs
Cavitation
haemorrhage

Renal
Glomerularnephritis (haematuria/proteinura)

Also 
Eyes
nervous system 
heart 
Gi
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13
Q 
52 F
Increasing SOB on minimal exertion
Poor appetite
5 stone weight loss in previous 6 months
Rash on legs
PMH
Asthma
Nasal polyps
Psoriasis
Syndrome X
Β thalassaemia trait
DH
Diltiazem
Amitriptyline
Serotide
Salbutamol
Betnovate cream

O/E
Scattered wheeze
Vasculitic rash on legs
No joint swelling

Ix
Low Hb
Raised EO 5.8
CRP 291, ESR 35
CK 654
RF +
cANCA +
MPO +

What is it?
Usual organs and features?

A

Eosinophilic granulomatosis with polyangitis
(Churg Strauss)

Systemic necrotising vasculitis of arterioles, capillaries and post-capillary venules

Lungs
New/worsening asthma
Pulmonary infiltrates
Alveolar haemorrhage

CNS
Mono/polyneuropathy

ENT
Polyps
conductive hearing loss
allergic rhinitis

Skin
Pupura
nodules

Renal disease RARE

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14
Q

Common Ix in wegners/churg strauss

A

Hb, RF, CRP, ESR, CK
Eosinophils (raised in churg)
ANCA
Biopsy if needed

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15
Q

Mx of Churg / Wegners ?

Maintanence of remission?

A

Induction of remission
High dose steroids + Cyclophosphomide or Rituximab

Plasma exchange if life threatening/Cr >500

(if no organ threatening involvement)
High dose steroids + Methotrexate or Mycophenolate

Maintenance of remission
Methotrexate + pred + folic acid
or Azathioprine

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16
Q

Which vasculitis is microscopic polyangitis similar to?

Difference?

A

Churg straus
pANCA +ve

No granuloma formation
Predominantly affects kidneys

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17
Q

Main features of HSP

A 
Children
IgA
Purpuric rash
Arthritis
Abdominal pain
Glomerulonephritis
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18
Q

How to remember main feature of polyarteritis nodosa ?

Other features ?

A

Nodosa means knots (aneurysms)
Medium vessel

Common co-infection with Hep B
Hypertension
Epididymitis
constitutional Sx

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19
Q

Mx of Giant cell arteritis if visual disturbance? W/O disturbance?

What else do you give?

A

Prednisolone 40mg if no visual disturbance
Prednisolone 60mg if visual disturbance

Dramatic response normally seen within 48 hours

May require steroid sparing agents

  • PPI
  • Osteoporosis prophylaxis
  • Aspirin
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20
Q

What condition is linked to temporal arteritis ?

A

Polymyalgia rheumatica

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21
Q

Sx / signs of GCA

A

Headache, severe, sharp dull throbbing, wouldn’t improve without steroids
TA swollen, tender, pulseless
Diplopia, ptosis, ischaemic optic neuropathy (sudden painless monocular visual loss)
Papilloedema, haemorrhages, optic atrophy later

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22
Q

Features of PMR

A

Shoulder / pelvic pain
morning stiffness
Weakness on exertion due to pain (rather than intrinsic muscle disease)

Can start asymmetrically then becomes bilateral

Decreased appetite can lead to weight loss

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23
Q

3 Ix in PMR ? What is this in part for?

mX?

A 
ESR/CRP - THESE WILL BE HIGH
RhF/ACCP
ANA
CK - THIS WILL BE NORMAL AS MUSCLES ARE ACTUALLY SPARED. THIS DISTINGUISHES IT FROM OTHER MUSCLE PATHOLOGIES SUCH AS polymyositis.
TFT
Myeloma screen
CXR

(ruling out other conditions that can present similary
RA, SLE, polymyositis, hypo/hyperthyroid, myeloma

Pred 15mg
Bone protection
PPI

The main complication is steroid induced osteoporosis

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24
Q

Is GCA only in temporal?

name 2 Constitutional sx

A

Leading question - Obvs not

15% - carotid, subclavian, axillary

Arm claudication
Paraesthesia
Digital ischaemia
Raynaud’s
Absent pulses
Aortic aneurysm & dissection
Aortic insufficiency
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25
Q

What are the aspects of the vasculitic screen? - Name 4

A

[FUEL Breaks Cars]

FBC
Normochromic normocytic anaemia
Leucocytosis
Thrombocytosis
Eosinophilia
Urine
PCR
Urine dip
Blood
Protein

LFT
Clotting

ESR/CRP

ANCA

CXR

Biopsy

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26
Q

Post vasculitic screen what further Ix might you do?

A

[EM…III]

Imaging
MRA
PET

Infection screen
General septic screen
Serology Eg HepB in PAN

Immunology
RF/ACCP
ANA
ENA
dsDNA

Myeloma screen

EMG - if neuropathy

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27
Q

What 5 things would you use when describing a fracture

A

Complexity
- Simple = closed, compound = open

Type
-FIG-TACOS
Fissure, impaction, greenstick, transverse, avulsion, comminuted, oblique, spir

Comminution
-Number of pieces broken into

location
-distal, radial shaft

displacement
-Translation (sideways), angle, shortening

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28
Q

What is the FRAX score for?

Name 3 things on it

A

Estimate 10 year risk of fracture with BMD

Age, sex, BMI

Previous fracture, parent hip fracture, low femoral neck BMD

Alcohol, smoking, glucocorticoids

RA, secondary osteoporosis

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29
Q

Which 2 fractures can lead to avascular necrosis

A

femoral head

scaphoid

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30
Q

What is a colles fracture

A

distal radius with dorsal displacement fragments

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31
Q

Mx of wrist frac

A

Reduction via manipulation with *anaesthesia

*Immobilisation -initially avoid full cast as swelling may impede circulati

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32
Q

Sign of scaphoid frac?

A

tenderness in anatomical snuff box

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33
Q

What runs through anatomical snuff box?

A

radial sensory branch

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34
Q

Comp of colles

A

median nerve damage (/ulnar)

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35
Q

Fall backwards - opposite of collies is what? Apperance?

A

smiths fracture
[distal fracture of radius with volar]

garden spade deformity

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36
Q

Seen on lateral Xray of colles

A

dinner fork sign

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37
Q

How does a NOF frac present

A

Affected leg shortened, adducted and externally rotated

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38
Q

2 main sub types of NOF

A

intracapsular

extra-capsular

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39
Q

Which is worse and why - intra vs extra capsular

A

intra

(medial and lateral circumflex artery)

-> May disrupt blood supply to femoral head - avascular necrosis

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40
Q

General Ix in NOF

A

AP and lateral XR (Shenton’s line)
[MRI if # suspected but not obvious on XR]

FBC, cross-match, renal, glucose, ECG

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41
Q

Mx of intracapsular

A

analgesia - no NSAIDS

Surgery within 1 day

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42
Q

Mx of displaced vs undisplaced NOF

A

Undisplaced - internal fixation with screws

*Displaced - hemiarthroplasty (replace head)

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43
Q

When do you xray an ankle - name 3 points

A

Ottawa ankle rules

> 55

Inability to wt bear (4 steps) now and at time of injury

Bone tenderness at posterior edge or tip of lateral malleolus (6cm)

Bone tenderness at posterior edge or inf tip medial malleolus

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44
Q

Mx of ankle frac if dislocation

A

If neurovascular compromise or dislocation (obvious deformity) then reduce immediately (before XR, under sedation or analgesia)

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45
Q

When do you xray ankle frac for monitor

A

reduction, 48 hours, 7 days, then 2 weekly

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46
Q

Main worry comp with #

A

Compartment syndrome

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47
Q

Signs of compartment syndrome

A

Pain out of proportion: 6Ps, pain, parasthesia, pallor, paralysis, perishingly col

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48
Q

Mx of compartment

A

Prompt fasciotomy

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49
Q

Comp post fasciotomy for compartment syndrome ? Mx?

A

Myoglobinuria -> renal failure

Aggressive IV fluids

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50
Q

Stages of # healing

A

Haematoma formation *hours
MP and inflamm leukocytes

callus formation (soft callus) *days
Inflammation leads to angiogenesis and increased number of chondrocytes.

Bony callus formation *weeks
ossification and direct bone formation. Soft callus replaced by woven bone

Bone remodelling *months
Woven bone replaced by organised cortical bone. Continually remodelled therefore no scarring

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51
Q

What is frozen shoulder - main sx? when does it occur?

A

Thickening and contraction of glenohumeral joint capsule ± formation of adhesions

pain and loss of function

spont or post rotator cuff injury

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52
Q

Key movement lost in frozen shoulder

A

external rotation

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53
Q

Define osteoperosis

A

by low bone mass and micro-architectural deterioration leading to increasing fragility and fracture risk

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54
Q

DEXA results for osteoperosis /penia

A

T-score < -2.5 (s.d. below young healthy adult mean)

-2.5 < T

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55
Q

What is the pathogenesis of osteoperosis

A

Increased breakdown by osteoclasts

Decreased bone formation by osteoblasts

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56
Q

Common locations for osteoperotic #

A

Spine (vertebral crush), wrist (distal radius), hip (proximal femur), pelvis

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57
Q

Name 3 secondary risk factors for osteoperosis

A

SHATTERED

S - steroids + Cushing’s (>7.5mg for 3 months)
H - hyperTh, hyperPTh, hypercalciuria
A - alcohol and tobacco
T - thin (BMI<19) or AN
T - testosterone decreased - primary hypogonadism, or anti-androgens @ PrCa
E - early menopause (<45)
R - renal/liver function - renal osteodystrophy in CKD, chronic liver disease
E - erosive/inflammatory disease: RA, multiple myeloma, metastasis
D - dietary Ca/T1DM - malabsorption, malnutrition

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58
Q

name 2 ways steroids increase risk of osteoperosis

A

Decrease Ca absorption from gut

Increase osteoclast activity

Decrease muscle mass

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59
Q

Why are XRAYS often normal in OP ? Name 1 thing you might you see

A

nothing seen till lose 30% BMD

Radiolucency, cortical thinning, biconcave vertebrae

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60
Q

Key DDx in OP?

A

myeloma

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61
Q

Name 3 Ix in OP

A

FBC, ESR, CRP

Bony profile: Ca, PO4, ALP, PTH
-All normal at OP

U+E, LFT, TFT, serum Ca
Testosterone/gonadotrophins (in men)
Serum Ig, paraproteins,

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62
Q

3 lifestyle Mx for OP

A

smoking, alcohol, wt bearing exercise, balance (fall risk), calcium + vit D rich diet, fall prevention

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63
Q

3 Meds for OP

A

Bisphosphonates + Ca + vit D supplements

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64
Q

Method of fall prevention in OP

A

Try and avoid polypharmacy

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65
Q

Intollerant to bisphosphonates can give?

A

denosumab (monoclonal aB to RANKL)

[denos u mad, why dont you like bisphos]

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66
Q

How do bisphosphonates work?

A

Inhibit osteoclastic bone resorption

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67
Q

Name 2 SEs of bisphosphonates

A

Difficulty swallowing, oesophagitis, gastric ulcers

Osteonecrosis of the jaw

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68
Q

What is osteomalacia ? rickets?

Cause ?

A

Disorder of mineralisation of bone matrix (osteoid) after fusion of epiphyses

Rickets is before fusion

Vit D deficiency

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69
Q

What does Vit D do ?

A

To bone: increases Ca mobilisation, increases osteoclast function

To intestine: increases Ca absorption, increases PO4 absorption

decreases PTH

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70
Q

PTH mech Ca/PO4?

A

To bone -> increase osteoclast function -> increase Ca

To kidney -> increases 1,25vD3, + decreases Ca excretion + increases PO4 excretion

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71
Q

Low levels of what stimulate PTH

A

Ca

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72
Q

RFs / causes of vit D deficiency

Name 3

A

Lack of sunlight, lack of adequate diet, dark skin, alcohol, fam Hx

Malabsorbsion
Renal disease
Liver disease
-(+anticonvulsants, rifampicin )

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73
Q

Name 2 points on pres of rickets

A

leg bowing, knock knees

softening of skull, frontal bossing

delayed walk / waddling

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74
Q

Osteomalacia name 2 key Sx

A

Widespread bone pain + tenderness (low back pain and hips)

Proximal muscle weakness - waddling gait (if severe)

Fatigue

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75
Q

Often get low phosphate in osteomalacia - what sx?

A

Muscle weakness, parasthesia

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76
Q

Name 3 ix in osteomalacia

A

Vit D - Low

Renal, LFT, FBC

Ca - low
PO4- low
PTH - high
ALP - v high

Urinary Ca (low), PO4(high)

XR

DEXA

Iliac crest biopsy - failed mineralisation

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77
Q

Mx of vit D deficiency

A

vit D + Ca

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78
Q

What happens in paget

A

increased turnover of bone

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79
Q

2 parts of the increased turn over in pagets

A

Lytic phase - increased bone resorption by osteoclasts

Sclerotic phase - *Rapid bone formation by osteoblasts - > deformed

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80
Q

Where is affected by Pagets

A

Axial skeleton: lumbosacral spine, pelvis, skull, femur, tibia

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81
Q

2 key Sx in pagets

A

bone pain

deformity

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82
Q

Name 2 comps of pagets

A

pathological # - + lots of bleeding as V vascular

Deafness / tinnitus - Compression of CN8

Deformity

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83
Q

Name 3 Ix in Pagets

A

ALP - HIGH
[Ca, PO4, PTH normal]

Isotope bone scans

XR

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84
Q

Seen on XR of pagets

A

Osteolysis and osteosclerosis (lytic and scleortic lesions)

*Blade of grass lesion between healthy and sclerotic long bone

Cotton wool pattern of multifocal sclerosis in skull

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85
Q

Mx pagets

A

pain and prevent progression

NSAIDS/ para

Bisphosphonates

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86
Q

Basic inflam vs degenerative arthritis

A

Inflam:
Ease on use, worse in morning (>60 mins), hot and red (r/d/c/t/LoF), responds to NSAIDs, swelling *synovial and bony, young/psoriasis/fam Hx

Denerative:
Worse with use, morning (<30 mins), mainly evening, prior occ, sport, *no swelling, not inflamed

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87
Q

Name the key tings stimulating inflamation

A

IL1, IL6, TNF

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88
Q

Key joints in OA

A

Knees, hips, small joints hands, spine

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89
Q

Name 3 signs of OA

A

Joint swelling/synovitis - warmth + effusion

Reduced ROM

Crepitus

Pain on movement

Bony swelling and deformity - osteophytes: DIP (Heberden’s) + PIP (Bouchard’s)

No systemic features

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90
Q

XR of OA

A 
LOSS
Loss of joint space
Osteophytes
Subchondral/subarticular sclerosis
Subchondral cysts
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91
Q

3 Non med Mx of OA

A 
Patient education, 
weight loss, 
screen depression, 
*exercise for muscle strength, 
aids and devices (walking sticks, tap turners)
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92
Q

2 Med Mx of OA? If acute exacerbation?

A

Local analgesia: capsaicin or topical NSAID (first line)
+ Paracetamol
+ NSAIDs ± PPI

Intra-articular steroid injections - mPred

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93
Q

Surgical Mx of OA

A

Replacement (arthroplasty), fusion (arthrodesis)

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94
Q

RA XR?

A 
LESS
Loss of jt space
Erosions
Softening of bones (osteopenia)
Soft tissue swelling
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95
Q

Whats formed in prolifferation in RA?

A

Pannus

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96
Q

Name 3 extra articular pres of RA

A

Rheumatoid nodules @ extensor surface of tendons and *lungs

Vasculitic lesions - commonly skin rashes, leg ulcers

Pleuritic chest pain - pleuritis or pericarditis

Eye problems: secondary Sjogren’s

Neurological: peripheral nerve entrapment, mononeuritis multiplex, atlanto-axial subluxation (C1,C2) - soft tissue swelling within rigid tunnel

Respiratory system: rheumatoid nodules, Caplan’s syndrome, pulmonary fibrosis

Anaemia of chronic disease

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97
Q

Triad in fetty syndrome

A

[RANS fatty]

RA
Neutropenia -
Splenomegaly

[Also - Leg ulcers and brown pigmentation of legs
Lymphadenopathy ]

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98
Q

3 key Ix in RA

A

1) RF (70%)
2) Anti-CCP (cyclic citrullinated peptide)
3) XR hands and feet

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99
Q

What is RF?

A

Antibody against Fc portion of IgG

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100
Q

Mx in RA - Non med / 1/2 line?

A

Physiotherapy, OR, psych services (depression), podiatry

1st line
DMARD (sulphasalazine) + methotrexate

Adjunct - corticosterid +NSAID - lowest effective dose

2ND LINE - Biologicals

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101
Q

how often is methotrexate given?

A

weekly

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102
Q

SE of methotrexate

A

Bone marrow suppression, mucosal damage - mouth ulcers

Long term -
PULM FIBROSIS
[cirrhosis / Renal failure]

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103
Q

monitoring in methotrexate

A

CXR, FBC, LFT, U+E

[ before starting, then 2 weekly till established (6 weeks post dose increase), then 3 monthly ]

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104
Q

Eg of a biologic in RA

A

Anti-TNF-alpha

infliximab, adalimumab, enteracept

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105
Q

When can you give a biologic for RA?

A

Failure to respond to 2 DMARDS after 2 trials of 6 months

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106
Q

Name 3 RFs for gout

A 
Alcohol (beer highest),
 purine rich foods (red meat/sea food), 
fructose (sugary drinks/cakes), 
diuretics, 
DM, CKD, CHD, HTN, hyperlipidaemia
107
Q

3 Ix in gout

A

Serum urate
Joint aspiration
XR

108
Q

Seen on joint aspiration in gout

A

Negatively birefringent needles of mono sodium urate

109
Q

Seen on early vs late gout

A

early - tissue swelling

late - punched out lesions

110
Q

Mx of acute gout

A

NSAID - naproxen

If poorly tolerated - > colchicine

111
Q

Prophylaxis of more gout

A

Lifestyle modification + manage RFs Eg diuretics

allopurinol or febuxostat

112
Q

Crystal in pseudo gout ? most common where?

A

Calcium pyrophosphate

Knee / wrist

113
Q

Mx pseudogout

A

Sx Mx

Ice packs, elevation, aspiration of joint, NSAIDs, IA steroid injection

114
Q

ABs in SLE ?

A

Antinuclear antibodies

115
Q

Genetics in SLE

A

HLA DR2/DR3

116
Q

Most common pres of SLE

A

Raynauds

117
Q

Main drug mx of SLE

A

Hydroxychloroquine

118
Q

Name 3 signs of SLE

A

Oral ulcers - usually painless

Photosensitive rash - skin rash from sunlight

Arthritis - non erosive 2 or more peripheral joints

Malar rash

seizures or psychosis

ESR raised (*not CRP)
Renal disorder - proteinuria > 0.5g/day or +++,

Pleuritis / pericarditis

119
Q

ESR / CRP in SLE

A

CRP normal

ESR raised

120
Q

Name 3 Ix in SLE

A

Autoantibodies: ANA (95%), antidsDNA (60%), antiSmith (30%)

Complement levels: low C4 and C3

[ESR/CRP - ESR raised, CRP normal
FBC - anaemia, leukopenia, thrombocytopenia
Urinalysis: haematuria, casts, proteinuria
U+E (renal disease)
CXR: pleural effusions, cardiomegaly
ECG: pericarditis]

121
Q

Mx of joints SLE?

Kidney / neuro?

A

NSAID ± hydroxychloroquine ± steroids

Cyclophosphamide

122
Q

Key AB in antiphospholipid syndrome

A

Anticardiolipin

123
Q

Pres of antiphospholipid

A

Thrombosis, DVT, pregnancy loss, pre-eclampsia, thrombocytopenia, livedo reticularis: violaceous lace like on trunk, stroke

124
Q

Mx antiphospholipid

A

Warfarin: target 2-3

Avoid clotting lifestyle: smoking, contraceptive pill, healthy diet, low alcohol

125
Q

Seen on clotting studies of Antiphosphplipid

A

Paradoxically low platelets and prolonged APTT

126
Q

Gene in sjogrens

A

HLA DR 3

127
Q

Complex in sjogrens? ->?

A

Sicca complex diminished lacrimal and salivary glands:

dry eyes, dry mouth, enlarged parotid gland

128
Q

Ix in sjogrens

A

Schirmer tear test - filter paper

Autoantibodies

sialography

Biopsy salivary gland - mononuclear cell infiltrate (B and T cells)

129
Q

Mx in sjogrens dryness?

Joint pain?

A

Artificial tears
Artificial saliva, drink plenty
Oral pilocarpine

Joint - NSAID + hydroxychloroquine + steroid

130
Q

Key sx of limited sclerosis

A

CREST

Calcium deposists in skin

Raynauds 100%

OEsophageal dysfunction

Sclerodactlyly

Telangiectasia

[fatigue, wt loss]

131
Q

GI / pulm / renal features of systemic sclerosis

A

Heartburn + reflux oesophagitis + watermelon stomach (gastric antral vascular ectasia - bleeding

Pulm
Pulm fibrosis / HTN

Renal
ANCA glomerulonephritis
*Scleroderma renal crisis: accelerated HTN

132
Q

Most important features of systemic sclerosis

A

Pulm HTN - leading cause of death
GI bleed
Renal crisis

133
Q

Name 3 Ix in Systemic Sclerosis

A

LuFT

CXR

Autoantibodies - ANA (most common one)

ECG

FBC

U+E

Barium swallow if oesophageal disorder

134
Q

drug for raynauds

A

nifedipine

135
Q

Mx of pulm HTN / Fibrosis in Systemic sclerosis

A

sildenafil (PA HTN )

Cyclophosphamide (fibrosis)

136
Q

monitoring in systemic sclerosis

A

Monitor and record BP weekly

Yearly LuFT (spirometry, lung volumes and DLCO) + echo for interstitial lung disease and PAH

137
Q

What is this
Not painful
Progressive symmetrical proximal muscle weakness - pelvic girdle
Difficulty rising from chair, climbing stairs, combing hair
Pharyngeal weakness - dysphagia
Interstitial lung disease and AV nodal disease

A

Polymyositis

138
Q

polymyosistis Ix?

A

CK elevated x 50

AAb - anti Jo-1 (poor prognosis - lung disease) in ⅓

Elevated muscle enzymes: LDH, aldolase
*EMG and muscle biopsy - for Dx and confirmation

139
Q

Whats the worry with polymyositis and what Ix do you do ?

A

Can be paraneoplastic cause (lung, ovarian, bowel)

ca125, Ca19-9, CEA

CXR

[Consider CT-TAP]

140
Q

What does this describe and 3 IX?

Rash: (may be UV related)
Heliotrope violaceous eyelid
Gottron’s papules - purple scaly patches on extensors
Nailfold erythema
Shawl sign - macular rash

Systemic upset: fever, arthralgia, malaise, weight loss
AV conduction defects
Interstitial lung disease 50%
GI ulcers

A

Dermatomyositis

CK elevation, LDH, aldolase

AAb: anti-Jo1 (more common in poly), anti-Mi2 (specific), ANA

EMG + muscle biopsy

CXR, LuFT

141
Q

Mx of Polymyositis + dermatomyositis? If lungs involved?

A

Steroids

If fail - immunosuppressives

For lung disease
cyclophosphamide

142
Q

Name 3 features of Ehler danlos

A

mitral valve prolapse, aortic root dilatation
pes planus (flat feet)
Increased elasticity + fragility of skin

Hyper mobile / lax joints

143
Q

mx of elher danlos

A

Physiotherapy, regular gentle exercise, genetic counselling

Periodic echo for floppy mitral valve or aortic root dilatation

144
Q

Gene in marfans

A

AD fibrillin gene FBN1

145
Q

Usual cause of death in marfans

A

Aortic root dilatation and aortic dissection

146
Q

Name 3 features of marfans

A

CV: aortic dilatation, dissection, mitral regurgitation

Lungs: pleural rupture - pneumothorax

Eyes: lens dislocation, closed angle glaucoma

Skeleton: arachnodactyly (Long arms / legs ), hypermobility, pectus excavatum

Facial: high arched palate

147
Q

Monitoring in marfans

A

Annual ECHO - aortic root width

CV MRI - every 5 years

148
Q

Prophylactic med in marfans

A

propanolol

149
Q

What is meant by sero neg arthropathies? What do they affect?

A

RF -ve

1) axial skeleton,
2) peripheral joints,
3) enthesitis (tendons and ligaments) and dactylitis

Anterior uveitis, IBD (similar to Crohn’s)

150
Q

Common gene in seronegative arthropathies

A

HLA B27

151
Q

Eg 3 sero neg arthropathy

A

Ankylosing spondylitis, Reiter’s syndrome, enteropathic arthritis, psoriatic arthritis, Behcet’s disease, JIA
OA

OA AS PA

152
Q

Ankylosing spondylitis age? Features?

A

<40 onset

Inflammatory back pain + enthesitis

Tenderness at sacroiliac region (felt in buttocks) or limited spinal motion

Peripheral enthesitis (50%): Achilles and plantar fascia

Peripheral arthritis (50%): asymmetrical

153
Q

Name 2 extra articular sx of ank spond

A

Eyes: acute anterior uveitis

CV: aortitits and *dissection of the aorta and aortic regurgitation

Lung - apical fibrosis

154
Q

Seen OE for ank spond

A

Reduced chest expansion <5cm

Schober’s test: reduced forward flexion <5cm + loss of lumbar lordosis
Reduced lateral flexion

155
Q

3 Ix in ank spond and what you expect

A

HLA B27: +ve

XR of whole spine: *Bamboo spine

LuFT

Pelvic XR - sacroiliitis

156
Q

Name 3 associations with ank spond

A

The A’s

Apical fibrosis
Anterior uveitis
Aortic regurg
Achilles tendonitis
AV node block
Amyloidosis
157
Q

General Mx for ank spond

A

Physiotherapy + rehabilitation + exercise
First line: NSAIDs (± analgesics - paracetamol)

[will also give corticosteroids / sulfasalazine for tendon/joint involvement ]

158
Q

Mx of enthesitis in ank spond? Peripheral arthritis ?

A

Enthesitis-
intra-articular corticosteroid injection

Arthritis -
DMARD: sulfasalazine

159
Q

Most common joint in PA

A

dip

[Think of nail changes]

160
Q

2 things seen in PA xray

2 other Ix

A 
Plain film XR feet and hands:
-Erosion in DIP
-Pencil in cup deformity 
-[Periarticular new bone formation
Osteolysis]

Anti CCP (-ve)

ESR/CRP (normal or elevated)
RF (+ve or -ve) *+ve in 2-10%

161
Q

Mx of limited PA ? More progressive?

A

NSAID + physio ± joint injection

If high ESR/CRP -> DMARD (methotrexate)

162
Q

When does reactive arthritis occur? common bugs?

A

1-4 weeks post exposure to GI and GU infections
chlamydia
Campylobacter/salmonella/shigella

163
Q

Famous sx with reactive ?

A

Can’t see, can’t wee, can’t bend your knee (typically lower limb)

Conjunctivitis, non-gonococcal urethritis + post-infectious arthritis

164
Q

Name 3 Ix in Reactive A

A

ESR/CRP very high, FBC - WCC

Joint aspiration - rule out septic or crystal arthropathies

Culture: stool, throat UG tract - for causative organism

Serology chlamydia: PCR or NAAT and contract tracing

165
Q

Mx reactive A

A

NSAID + rest ± intra-articular steroids ± ABX chlamydia (azithromycin)

166
Q

What is Enteropathic arthritis? mx?

A

Arthritis associated with IBD (CD or UC), coeliac

sulfasalazine (bowel and rheumatic)

167
Q

What happens in behcet’s disease?
association ?
mx?

A

Recurrent oral ulcers
joints - non-erosive arthritis (lower limb)

HLA B51

Topical corticosteroids, systemic steroids

168
Q

Key arteries in GCA

A

granulomatous disease of aorta and large cerebral

169
Q

Eye feature in GCA

A

anterior ischaemic optic neuritis

170
Q

QUE ES?

Recent onset temporal headache + scalp tenderness + transient visual symptoms (diplopia) + jaw claudication (on chewing)

A

GCA

171
Q

What can happen to aorta in GCA

A

thoracic aneurysm

172
Q

Ix in GCA

A

ESR > 50mm/hr + temporal artery tenderness + *temporal artery biopsy

Consider - aortic arch angiography

173
Q

2 things Seen on biopsy GCA

A

Granulomatous inflammation, multinucleated giant cells, intimal hypertrophy and inflammation

174
Q

Mx GCA ? What might you try and prevent?

What if it is refractory?

A

High dose oral prednisolone 1mg/kg/day for 4 weeks then taper
+ Aspirin (lower visual problems)

Osteoporosis prevention - Ca + Vit D + bisphosphonate

If refractory - methotrexate

175
Q

que es?

Severe bilateral pain and morning stiffness: shoulders, neck, pelvic girdle (>2 weeks)
with systemic features at onset (malaise, fever, fatigue)

key association?

A

Polymyalalgia rheumatica

GCA

176
Q

What is takyasu’s also called? who does it affect and how?

A

Pulseless disease
young women 20-40 / Japanese

Chronic, progressive, inflammatory, occlusive disease of aorta and branches

177
Q

2 stages of takyasus

A

Systemic: fever, fatigue, wt loss, arthralgia, tenderness on arteries

Occlusive:
Limb claudication 
TIA 
HTN 
Angina
[+ other features of occlusion]
178
Q

Name 2 things seen OE of takyasus

A

Difference in SBP of >10mmHg between arms

Impalpable peripheral pulse

High BP - renal artery stenosis

Arterial bruits on all arteries and
aortic regurgitation

179
Q

2 Ix in takyasus

A

ESR > 50 CRP elevated with active disease

Aortic angiography: (CT/MRI) of aorta and main branches and pulmonary arteries

180
Q

Mx takyasus? 2nd line?

A

Glucocorticoids + aspirin + bone protection

TNF alpha antagonist

181
Q

If you treat with a TNF alpha antagonist what should you consider

A

Vaccine
influenza + pneumococcal as immunosuppressed

Reactivation of TB

182
Q

polyarteritis nodosa key association

A

HBV

183
Q

How to differentiate polyarteritis nodosa from other small /medium vessle?

A

No ANCA

184
Q

Seen on angiography for PAN

A

Microaneurysms and focal narrowing - rosary sign

185
Q

Define PAN

A

Necrotising inflammation of medium sized or small arteries

Spares lung

186
Q

Pres of PAN

A

Nerves and skin most common

Nerves: *mononeuritis multiplex

Skin:
Livedo reticularis, purpura, nodules, necrotic ulcers

GI
Pain post eating from ischemia

Renal - HTN

187
Q

What does livedo reticularis look like

A

mottled

-cyanotic discolouration surrounds pale central skin

188
Q

Name 3 Ix in PAN

A

[P(L)AN B - Hep B and Beads]

HBsAg - 30%

p-ANCA - negative

Acute phase response: leukocytosis/neutrophilia, ESR

Complement - reduced C3/C4

*Arteriography: microaneurysms in small and medium sized arteries (looks like ROSARY beads)

Small artery biopsy: necrotising inflammation

Urinalysis: proteinuria

189
Q

Mx of PAN ? If key association also?

A

Prednisolone ± DMARD (cyclophosphamide)

If active Hep B: antivirals and plasma exchange

190
Q

Key Comp of PAN

A

Renal failure

Due to micro aneurysms -> accelerated HTN

191
Q

Who gets kawasaki? classic features?

A

Children 6M - 5Y (mainly asian)

CRASH and BURN
Conjunctivitis (bilateral + non-purulent)
Rash - non vesicular
Adenopathy (cervical + unilateral)
Strawberry tongue + inflammation of lips and mouth (cracked lips)
Hands/feet - palmar erythema/swelling/desquamation (2-5 days after onset)

Fever > 5 days (burn)

192
Q

Don’t forget what Ix in Kawasaki

A

Coronary artery aneurysm and dilatation - echo

193
Q

Mx Kawasaki

A

First line IVIg + high dose aspirin

194
Q

Why are kids not normally given aspirin ?

A

Risk of reyes

195
Q

2 catergoris of small vessle vasculitis

A

ANCA associated: microscopic polyangiitis, GPA (granulomatosis with polyangiitis) - Wegener’s,
EGPA (eosinophilic) - Churg Strauss

Immune complex mediated:IgA vasculitis
HSP, Anti GBM

196
Q

2 types of ANCA and thier antigens

A

C-ANCA - cytoplasmic major antigen proteinase-3

P-ANCA - perinuclear major antigen myeloperoxidase

197
Q

Glassic triad in GPA - Wegners

A

ELK disease (ENT, lungs, kidneys)

Upper respiratory tract involvement
Lower respiratory tract involvement
Glomerulonephritis

198
Q

Name 3 parts of pres of wegners /GPA

A

Upper resp
Saddle nose deformity, nasal septal perforation (due to chronic rhinosinusitis)

Lower resp
SOB, cough, pain, haemoptysis…

Renal
oedema, HTN, haematuria (later)

[Eyes
visual blurring marked bilateral periorbital oedema from kidney…

Skin
: palpable purpura or petechia

MSK
Myalgia / arthralgia

Neuro
Numb / weak ]

199
Q

Name 3 Ix in GPA /wegners

A

Kidney: urinalysis and microscopy + renal biopsy
Haematuria, proteinuria, RBC casts

Lung
CT chest - lung nodules (cavitating)

ANCA by immunofluorescense
c-ANCA (anti-PR3)

FBC - anaemia, ESR - raised

200
Q

Mx of GPA/wegeners if serious organ involvement?

Non - life threatening?

A

IV methylpred (3d) + pred oral + cyclophosphamide

IV methylpred (3d) + oral prednisolone + methotrexate

201
Q

How to reamin remission in GPA/wegeners

A

oral pred + methotrexate + folic acid

202
Q

2 Main worries in GPA/wegeners

A

aki

resp failure

203
Q

When would you be very suspicous something might be EGPA -Churg strauss

A

Adult onset asthma

204
Q

Name 3 organs and features of churg strauss

A

[ENT, Resp, Nerves]

***ENT - allergic rhinitis, paranasal sinusitis, nasal polyposis

Lower RT - pneumonitis, haemoptysis

Renal - glomerulonephritis - HTN

*Peripheral neuropathy - mononeuritis multiplex

Skin - purpura, skin nodules

205
Q

Name 3 Ix in churg strauss

A

p-ANCA (antimyeloperoxidase Ab) - 40%

FBC - eosinophilia + anaemia, elevated ESR/CRP

CXR - pulmonary infiltrates

Pulmonary CT - peripheral consolidation - ground-glass attenuation

Biopsy small necrotising granulomas and necrotising vasculitis

206
Q

Mx churg strauss ? severe?

A

IV Mpred -> oral pred

If severe -> cyclophosphamide

+Asthma management

207
Q

When do you suspect mcroscopic polyangitis ? Which key seen on Ix?
Mx?

A

Rapidly progressive glomerulonephritis and pulmonary haemorrhage

p-ANCA

Pred and cyclophosphamide

208
Q

HSP also called? Who gets it?

A

IgA vasculiitis

Young man with previous URTI - Gp A strep (pyogenes)

209
Q

Pres of IgA vasculitis /HSP

A

abdominal pain and vomiting, purpuric rash on buttocks and extensor, joint pain
low grade fever

210
Q

Triad of HSP /IgA

A

Arthralgia, abdo pain, rash

211
Q

Other than triad what organ commonly affected in IgA vasculitis?

A

kidney - 40% nephrotic syndrome

212
Q

key single Ix in IgA vasculitis

A

Urinalysis: proteinuria, RBC, casts, 24 hour urine protein

213
Q

Mx HSP

A

Pain relief

Kidney - steroids

214
Q

Anti GBM disease called? affects what?

A

Goodpastures
Lung / kidney

glomerulonephritis and pulmonary haemorrhage -> haemoptysis and renal failure

215
Q

2 Ix in AntiGBM

A

Renal function: abnormal

Renal biopsy: crescentic glomerulonephritis - perform *urgently

Anti-GBM - positive

216
Q

Mx anti GBM

A

oral prednisolone + cyclophosphamide + plasmapheresis

217
Q

Name 3 things that woudl CI a renal biopsy

A 
Sole native kidney
ESRD
Neoplasm
Bleeding disease
Uncontrolled severe HTN
Acute pyelonephritis
218
Q

Vasuculitis screen

A

Haem
FBC, ESR, clotting screen

Biochem
U+E + Cr - renal function
LFT: PAN and cryo assoc HBV and HCV
CRP

Immunology
Immunoglobulins and protein electrophoresis
ANCA, RF, complement (C3/C4), anti-cardiolipin, cryoglobulins

Microbiology
HBV and HCV serology
Urine microscopy and culture

Radiology
CXR

219
Q

usual suspects in septic A

A

S.aureus / GBS

gonococcal in sexually active

220
Q

Rfs for septic A

A

Prothetic joint

IVDU, diabetes, skin infection, immunosuppression….

221
Q

3 key Ix in Septic A

A

Urgent joint aspiration - synovial fluid Gram stain and culture, WCC, polarised microscopy (exclude gout)

Blood culture x2 ± gonococcal cultures (rectal, urethral, pharyngeal)

Acute phase markers: ESR, CRP, WCC raised

222
Q

XR in septic A is of limited value - what can be seen early / late ?

A

Early: Oedema, swelling and effusion - join space widening

Late: Joint space narrowing / bone loss and cartilage destruction

223
Q

Best way of assessing perarticular abscess / osteomyelitis in septic A

A

MRI /CT

224
Q

Mx Septic A

A

Surgical drainage and lavage (wash) + high dose IV abx

225
Q

Septic A which Abx…
Gon
Staph
MRSA

A

vancomycin / Ceftriaxone

fluclox

vancomycin

226
Q

2 key comps in septic A

A

osteomyelitis

joint destruction

227
Q

Mx of septic A if prothesis

A

*Remove joint and fill with antibiotic impregnated spacer

228
Q

2 main mechs of osteomyelitis cause

A

haematogenous - Commonly associated with *children

Direct - ie post surgery / trauma

229
Q

Most common org in osteomyeleitis

A

staph A / MRSA

230
Q

Most common locations haematogenous osteomyelitis in children / adults?

A

Children - metaphysis of long bones

Adults - vertebral bodies

231
Q

What is potts disease

A

vertebral osteomyelitis from haematogenous spread of TB

-> abscess

232
Q

Ix osteomyelitis

A 
Plain radiograph
FBC (WCC)
Blood cultures (+ve)
Acute phase markers: ESR + CRP + WCC
Culture from debrided bone
233
Q

2 things Seen on XR of osteomyelitis

A

dark, soft tissue swelling, periosteal thickening , patchy osteopenia

234
Q

Mx of osteomyelitis

A

Bone / soft tissue debridement

Stabailise + immobilise

IV aBX

[Reconstruction)]

235
Q

Dx of fibromyalgia

A

4 quadrant pain at 11/18 tender points for >3 months

[4 quads - Front and back, left and right, above and below diaphram]

236
Q

Mx of firbromyalgia ?

A

First line: amitriptyline + CBT

[2nd gabapentin / pregabalin]

237
Q

Name 4 red flags of back pain

A

TUNA FISH

Trauma

Unexplained weight loss, loss of appetite - cancer/myeloma

Neurological symptoms including bowel bladder dysfunction - cauda equina

Age > 50 or < 20

Fever and night sweats - osteomyelitis/cancer

IVDU/immunosuppression - osteomyelitis

Steroid use - immunocompromise + osteoporotic fracture

History of cancer (prostate, breast, lung, renal)

238
Q

What are your main worries in back pain

A

Cauda equina
Multiple myeloma
Metastatic cancer
Psoas abscess

239
Q

Usual cause of cervical back pain

A

Cervical spondylosis

chronic disk degenertion

240
Q

How does cervical spondylosis present?

A

Simple neck pain
+ radiculopathy (pain, numbness, tingling, weakness in upper limbs)
+ myelopathy (spinal cord)

241
Q

Ix cervical spondylosis

A

Plain XR - osteophytes, narrowing of disc space, encroachment of intervertebral foramen

Neuropathy -> MRI

242
Q

Pres of disk prolapse

A

Pain localised to spine + relevant radiculopathy, sensory disturbance in dermatomal distribution

243
Q

Issue with disk prolapse

A

significant restrictions and exclusion of domestic, leisure, educational activities

244
Q

Differentiate spinal fracture and Ca / infection

A

Spinal fracture: sudden onset pain relieved by lying down, structural deformity e.g. step

Cancer or infection (e.g. discitis) - PAIN REMAINS ON LYING DOWN, night pain>50 or <20, recent infx, IVDU etc….

245
Q

Mx of herniation disk

A

Keep active + give analgesia

Analgesics: NSAIDs + acupuncture

Lumbar discectomy *only if severe nerve compression

246
Q

What psychosocial factors prevent people getting better with chornic back pain ? What do you need to do as a healthcare professional

A 
Beliefs that activity is harmful
sickness behaviour
withdrawal
dissatisfaction at work
depression

manage expectations

247
Q 
Osteoid osteoma 
Size? 
who? 
XR findings? 
Mx?
A

<1cm, surrounded by dense osteoid
[small dense name / oid sounds sore]

Young adults

Radiolucency surrounded by
dense bone

Pain with NSAIDs, local excision = curative

248
Q

Osteochondroma
Who
Where
Pres

A

[long benign = painless name]
Most common benign
Young adults

Next to epiphyseal plate

Painless lump or joint pain, nerve compression = spur on XR

249
Q

Chondroma\
Where
Rx

A

Single or multiple lesions

Hands or feet, tubular bones

Excise lesion + graft bone

250
Q 
Osteosarcoma
Who?
assocciation 
where? 
pres?
what happens next?
A

Most common malignant in children (15-19)

Paget’s

In epiphyses of long bones - knee (75%) or proximal humerus

Painless

Destroys bone and spreads locally, rapidly *mets to lung

251
Q

Seen on XR of osteosarcoma

A

soft tissue calcification = sunburst/hair on end + Codman’s triangle

252
Q

Ewing’s sarcoma
Who?
Pres?

A

Primitive neuroectodermal tumour

15 yo boy

Mass or swelling, long bones, pain

253
Q

Ewings on XR

A

Bone destruction with onion skin layers of periosteal bone formation + Codman’s triangle

254
Q

Mets to bone, usual cause of lytic lesions? scleroitic?

both?

A

Lytic - Myeloma - pepperpot skull, lung, renal (bisphosphonates)

Sclerotic - Prostate

Both - Breast

255
Q

Thromboangitis obliterans also called?
What does it cause?
In who?
Mx

A

Buerger disease
Distal thrombosis of fingers (go necrotic)
Men 30-50 who smoke

STOP SMOKING

256
Q

Which vasculitis can present similarly to HSP
Eg haematuria, palapble purpura, arthralgia,
Key sx differences
Cause?
Mx?

A

Cryglobulinemic vasculitis
No GI pain / doesn’t classically follow URTI

Hep C

Mx of hep c

257
Q

3 complications of compartment syndrome

A

rhabdomyolysis / renal failure
weakness/paralysis
amputation

258
Q

Name 3 causes of cauda equina

A

degenerative - disk herniation / spinal stenosis

inflam - Ank spond

Infective - TB / abscess

Traumatic - fractures / haematomas [eg post spinal anaesthetic]

Tumours

259
Q

NOF parts of Mx

A

ABCDE
Analgesia + nerve block
VTE prophylaxis
Early surgery [36 hours]

260
Q

Benefits of surgery over bed rest for NOF

A

Less bed time = less VTE
less likely Hospital infection
pressure sores
Improved outcomes

261
Q

3 post op mx NOF

A

mobilise day 1
PT/OT
bone protection
optimise meds / address polypharmacy

262
Q

3 comps of NOF

A 
Avascular necrosis 
dislocation 
non-union 
infections 
reduced mobility 
increased social care needs
263
Q

What do you always give with steroids (unless v short term)

A

PPI

Bone protection - bisphos

Phase 4 - GR (22 decks)

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