To Review Flashcards
A 50 year old lady attends her GP. She is concerned that she has osteoporosis as her mother has been diagnosed with this. How should her GP proceed initially?
Perform a fracture risk assessment
Refer for a bone density scan
Explain that she is too young for osteoporosis and ask her to return in 5 years
Commence therapy with HRT
Commence calcium and Vitamin D supplements
Perform a fracture risk assessment
Mrs York was diagnosed with rheumatoid arthritis several years ago. She mentions that her eyes have been consistently itchy for the past few weeks and that her husband has commented on her apparent reduced libido. She confesses to you that she feels very upset about it but she just is not enjoying sexual intercourse currently, it has become increasingly uncomfortable. She begins to cry as she reveals how stressful she is finding her situation and you notice that although When she is crying heavily and loudly, very few tears are actually present on her face. Which antibodies would you expect to be present in Mrs York’s results?
Anti-Smith Anti-dsDNA Anti-Ro and Anti-La Anti-Scl-70 Anti-Jo-1
Anti-Ro and Anti-La
Anti-dsDNA associations
SLE
Anti-Jo-1 associations
polymyositis and dermatomyositis.
Anti-Smith antibodies associations
highly specific to SLE.
Anti-Scl-70 associations
diffused cutaneous systemic sclerosis
A 57-year-old male presents with an acutely swollen knee joint. The joint is aspirated and the fluid is sent for analysis. Microscopy reveals rhomboid-shaped crystals with weak positive birefringence under polarised light. Which of the following is the most likely diagnosis?
Rheumatoid arthritis Gout Osteoarthritis Septic arthritis Pseudogout
Pseudogout
- deposition of calcium pyrophosphate dihydrate (CPPD) in the joint tissues
- Rhomboid crystals with weak positive birefringence under polarised light are the typical finding on microscopy.
*Pseudogout also affects the knee more than Gout does. Gout classically presents affecting the 1st MTPJ
Johnny is a 19-year-old male who has presented with fatigue, weight loss and severe lower back pain which keeps him awake at night. He also experiences stiffness in the mornings which normally takes over 40 minutes to loosen up. Investigations show: Raised CRP and ESR levels Presence of the HLA B27 gene, ‘Bamboo spine’ finding on x-ray. You diagnose himwith ankylosing spondylitis. What would you prescribe for Johnny as his first-line treatment?
Secukinumab Bisphosphonates Corticosteroid injections Infliximab Physiotherapy
Physiotherapy
Physiotherapy is a key part of treating AS and subsequently helps enable patients to keep active which can improve their posture and range of spinal movement, along with preventing the spine from becoming stiff and painful.
If patients require pain relief, NSAIDs should be prescribed.
A 30 year old woman presents to the emergency department with an acute exacerbation of asthma. This is her first admission for asthma, which has been poorly controlled in the community. She also complains of sinus issues with blockage and discharge from her ears and nose. First line investigations reveal an eosinophillia and elevated ESR but are otherwise unremarkable. Urinalysis shows blood ++ and protein ++. Chest X-ray shows interstitial nodules. Which of the following is the most likely diagnosis?
Granulomatosis with polyangitis (GPA) (Wegener’s) Churg-Strauss syndrome Helminthic infection Allergic Bronchopulmonary Aspergillosis Microscopic polyangitis
Churg-Strauss syndrome
*Eosinophilia, poorly controlled asthma, CXR findings indicative of granulomatous change along with renal involvement make this the most likely diagnosis.
Mrs Jones lives alone and is currently in remission from breast cancer. She presents to her GP with progressive muscle pain, fatigue and weakness in her shoulders over the past few weeks. Upon examination, you notice periorbital oedema, a purple rash on her eyelids and erythematous patches on her elbows which you suspected to be Gottron lesions. You perform further tests which show elevated creatine kinase. What would be your first-line treatment?
Azathioprine Anti TNF therapy NSAIDS Corticosteroids IV immunoglobulins
Corticosteroids
Mrs Jones is presenting with classic symptoms of dermatomyositis. It shares similar features with polymyositis plus skin involvement. These two conditions can be caused by underlying malignancy (paraneoplastic syndromes), therefore it is critical that Mrs Jones is also assessed for a potential cancer re-occurrence.
Corticosteroids are the first-line treatment for both conditions.
Mr Ahmed presents to your clinic with a loss of function in his hands, when you inspect them you notice shiny, tight skin and a loss of fat pads on the fingers. He states to you sadly that he is not a well man and suffers from hypertension, shortness of breath, difficulties swallowing, a dry cough and is a poorly controlled type II diabetic. What is your primary differential diagnosis?
Lung cancer Osteoarthritis Diffuse cutaneous systemic sclerosis Rheumatoid arthritis Limited cutaneous systemic sclerosis
Diffuse cutaneous systemic sclerosis
This question relates to diffuse cutaneous systemic sclerosis because it has systemic involvement as well as CREST features.
There is no mention of joint involvement therefore the answer cannot be RA or osteoarthritis.
Although persistent shortness of breath, a persistent dry cough and dysphagia are red flag symptoms for cancer, it is not the most likely diagnosis, especially considering his hand signs.
A 43-year-old female presents with a 3-week history of worsening weakness in her upper arms and legs. As a result, she is struggling to stand up from a chair and brush her hair. However, she still has good fine motor skills in her hands. The GP is concerned that she may have developed polymyositis and wants to send blood tests. Which of the following tests is most likely to be significantly raised?
Creatine kinase Alkaline phosphatase (ALP) Fibrinogen Creatinine Haemoglobin
Creatine kinase
Creatine kinase is always raised in inflammatory myopathic disorders like polymyositis and dermatomyositis. It is not unusual for it to be up to 50 times the upper limit of normal in active disease.
A 23 year student sees his GP with a several year history back pain and stiffness. The pain is worse at night, first thing in the morning and if he has been sitting for long periods studying. He is otherwise well apart from a previous episode of a red, painful eye for which he received some steroid eye drops. On examination he has a reduced Schober’s test and is tender over his right sacroiliac joint. Which investigation would be most helpful in reaching a diagnosis?
CRP HLA B27 MRI whole spine Anti-CCP antibody Trial of non-steroidal anti-inflammatory medication
MRI whole spine
A 30 year old woman presents to her GP with a four week history of worsening pain and stiffness in her hands.Her past medical history includes a five year history of Raynaud’s phenomenon which she manages conservatively with gloves and hot water bottles in cold weather. She also was recently started on omeprazole for difficult to manage gastroesophageal reflux. On examination you note sclerodactyly bilaterally with a small ulcer on the tip of the fourth finger on the right. On the face there are diffuse telangiectasia and microstomia. She is otherwise systemically well. What is the single most likely diagnosis?
Diffuse cutaneous systemic sclerosis Raynaud's disease Omeprazole-induced vasospasm Limited cutaneous systemic sclerosis Cardioembolic ischaemia
Limited cutaneous systemic sclerosis
54-year-old male presents to the GP with severe pain in one of his toes which started yesterday. He has no significant past medical history and has not experienced anything like this in the past. On examination, there is erythema and exquisite tenderness over the right first metatarsophalangeal joint (MTP). Vital signs are all within normal limits and there is nothing else to note on examination. Given the likely diagnosis, which of the following would be the most appropriate first-line treatment?
NSAIDs Intra-articular corticosteroids Canakinumab Oral corticosteroids Colchicine
NSAIDs
NSAIDs are the first line for Gout.
Colchicine is used in patients that are inappropriate for NSAIDs, such as those with renal impairment or significant heart disease. A notable side effect is gastrointestinal upset.
Gottrons papules
Dermatomyositis
+purple rash on eyes
Which of the following DEXA scan results are diagnostic of osteoporosis?
-2.0
2
- 2.4
- 1
- 2.6
-2.6
DEXA scan results < -2.5 are diagnostic of Osteoporosis
A 5 year old boy comes to the GP with his mother, complaining of pain in his right hip. The child is otherwise well; however, the mother mentions that he was unwell with a cold two weeks ago.His temperature is 36.5 and all the other observations are normal.When asking him to walk, he demonstrates a right antalgic gait. On inspection, there is no erythema or swelling over the hip joint and the right hip is slightly flexed and in external rotation.Internal rotation of the right hip is reduced. The neurovascular examination is normal. What is the most likely diagnosis?
Slipped capital femoral epiphysis Developmental dysplasia of the hip Juvenile idiopathic arthritis Septic arthritis of the hip Transient synovitis of the hip
Transient synovitis of the hip
The antalgic gait, the findings on inspection and the recent history of respiratory infection point towards a diagnosis of transient synovitis of the hip.
A 76 year old woman is brought to A&E by ambulance after falling in the supermarket. She reports slipping on washing up liquid, which had been spilt on the floor. She had no loss of consciousness or head injuries. She complains of pain in her right hip. She usually takes 2 mile walks every day. She is a member of a table tennis club and enjoys dancing. She has a past medical history of hypothyroidism and takes levothyroxine. On examination, she has a shortened, abducted and externally rotated right leg. She is unable to weight bear or straight leg raise with the right hip. Cardiovascular, respiratory and neurological examinations are normal. X-rays of her hip reveal an intertrochanteric fracture on the right side. Her case is discussed at the orthopaedic trauma meeting. What definitive management is most likely to be recommended?
Conservative management with bed rest Hemiarthroplasty Dynamic hip screw Intramedullary nail Total hip replacement
Dynamic hip screw
Intertrochanteric fractures are extracapsular. They occur between the greater and lesser trochanter. These are treated with a dynamic hip screw (AKA sliding hip screw).
Intra-capsular fractures involve a break in the femoral neck, within the capsule of the hip joint. This affects the area proximal to the intertrochanteric line.
Non-displaced intra-capsular fractures may have an intact blood supply to the femoral head, meaning it may be possible to preserve the femoral head without avascular necrosis occurring. They can be treated with internal fixation (e.g., with screws) to hold the femoral head in place while the fracture heals.
Displaced intra-capsular fractures (grade III and IV) disrupt the blood supply to the head of the femur. Therefore, the femoral head needs to be removed and replaced by hemiarthroplasty.
A 23 year old football player comes to the Emergency Department with his friend. He complains of pain and tenderness in his knee after being tackled. He mentions he felt his knee giving way before going to the ground and he is not able to step on it. On examination, the knee is swollen with reduced range of motion. Patient complains of pain when trying to extend the knee. What is the most useful investigation to diagnose the underlying pathology?
MRI scan Knee X-ray CT scan Knee aspiration Ultrasound scan
MRI scan
A 68 year old lady is worried about her risk of osteoporosis. She recently started prednisolone as a treatment for polymyalgia rheumatica, and has read that treatment with steroids can increase the risk of fractures. Her mother suffered a hip fracture in her 70s and never made a full recovery. She tries to live a healthy lifestyle, with a balanced diet, regular walks and avoiding alcohol and smoking. She weighs 58 kg and is 168 cm tall.Using the FRAX tool, her ten-year probability of fracture a major osteoporotic fracture is 28%. The NOGG guidelines recommend starting treatment. Her GP discusses starting treatment with alendronic acid. Which of the following is recommended before starting treatment?
X-rays of the hips and ankles Ankle-brachial pressure index Routine eye check with an optometrist Baseline audiology assessment Routine dental check-up
Routine dental check-up
This is due to the small risk of osteonecrosis of the jaw w/ bisphosphonates
+ other oral sfx
An 82 year old man presents with a two-week history of left shoulder pain. It started after a fall while playing rugby with his great-grandson. Immediately after the fall, it felt sore but he did not feel he needed to attend A&E. He put his arm in a sling and kept it immobilised. Over the following days, it seemed to get more painful, and he noticed weakness when trying to lift his arm out to the side. He finds it difficult to get comfortable at night and the pain is affecting his sleep. He has noticed some improvement in the pain since the injury, but he says the weakness is still present. On examination, there is slightly less muscle bulk around his left shoulder in comparison to the right. There is no tenderness or swelling of the bones or joints on palpation. Shoulder movements are painful. He can internally and externally rotate the shoulder against some resistance. There is more significant weakness and pain on abduction of the shoulder. He can hold his left arm against gravity at 90 degrees of shoulder abduction. The tendon of which muscle is most likely to be affected?
Infraspinatus Deltoid Teres minor Supraspinatus Subscapularis
Supraspinatus
S – Supraspinatus – abducts the arm
I – Infraspinatus – externally rotates the arm
T – Teres minor – externally rotates the arm
S – Subscapularis – internally rotates the arm
Rotator cuff tears may present either with an acute onset of symptoms after an acute injury, or with a gradual onset of symptoms. Patients typically present with:
Shoulder pain
Weakness and pain with specific movements relating to the site of the tear (e.g., abduction with a supraspinatus tear)
**The most common site of a rotator cuff tear is the supraspinatus tendon. **
Which of the following options most accurately describes a positive Trendelenburg’s sign?
A patient with pathology of the left hip stands on their right leg and their right hip is observed to drop.
A patient with pathology of the right hip stands on their right leg and their left hip is observed to drop.
A patient with pathology of the left hip stands on their left leg and their left hip is observed to drop.
A patient with pathology of the right hip stands on their right leg and their right hip is observed to drop.
A patient with pathology of the right hip stands on their left leg and their right hip is observed to drop.
A patient with pathology of the right hip stands on their right leg and their left hip is observed to drop.
A positive Trendelenburg’s sign involves a drop in the pelvis on the unsupported side (the side with the leg off the ground). This suggests a weakness in the Gluteus Medius muscle on the side opposite to where the pelvic drop has occurred.
A 33 year old man is being seen in the orthopaedic clinic after a right knee injury. The injury happened two months ago whilst playing competitive basketball. It occurred while he was changing direction with his knee twisted in an awkward position. He felt a sudden “pop” sensation and the knee locked up. The knee quickly became swollen, painful and stiff. He attended A&E, where he had an x-ray to rule out a fracture and was given crutches and a knee brace. Since the initial swelling and pain have subsided, he is left with a feeling of instability and episodes where the knee locks. The range of motion in the knee is slightly restricted. He still has some pain and swelling. The last time he was seen in the clinic, an MRI scan was arranged. The report suggests a meniscal tear. What is the most appropriate next step in management?
Platelet-rich plasma injection Physiotherapy Partial joint resurfacing Knee arthroscopy Rest, ice and NSAIDs and review again in 2 months
Knee arthroscopy
Two months after a meniscal tear, this patient is having symptoms of pain, swelling, instability and locking. The next step is a knee arthroscopy, which will allow the surgeon to visualise the meniscus, assess the extent of the damage and repair or remove damaged sections, with the aim of improving the function and symptoms. If his symptoms were all improving and he retained good function in the knee, conservative management may be more appropriate.
