Medicine year 3- EOCP > Frailty- bones > Flashcards

Frailty- bones Flashcards

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1
Q

Rheumatoid arthritis- what is it and risk factors

A

Chronic inflammation of the synovial lining of the joints, tendon sheaths and bursa.
Tends to be symmetrical and affect multiple joints. It is a symmetrical polyarthritis
Risk factors: women, middle age (40-60), family history, smoking, western diet, certain gut bacteria

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2
Q

Rheumatoid arthritis- genetic association

A
  • HLA DR1- present in RA patients
  • HLA DR4- present in RF positive patients
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3
Q

Rheumatoid arthritis- antibodies

A
  • Rheumatoid factor- autoantibody present in 70% of RA patients, targets the FC portion of the IgG antibody. Can be positive in autoimmune inflammatory conditions, hepatitis C, TB, AIDS
  • Cyclic citrullinated peptide antibodies (anti-CCP antibodies)- more specific then rheumatoid factor, can be positive whilst RF is negative
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4
Q

Rheumatoid arthritis- bloods

A
  • U&E’s- NSAID’s can cause renal impairment
  • LFT- treatment can be hepatotoxic
  • FBC- normocytic anaemia due to chronic disease. Treatments can cause bone marrow suppression. Platelets are increased with inflammation.
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5
Q

X-ray: Rheumatoid arthritis

A
  • L- loss of joint space
  • E- erosions
  • S- soft tissue swelling
  • S- soft bones (peri-articular osteopenia, decreased density)
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6
Q

X-ray: Osteoarthritis

A
  • L- loss of joint space
  • O- osteophytes
  • S- subchondral sclerosis
  • S- subchondral cysts
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7
Q

When should you refer urgently with RF (within 3 days)

A
  • Small joints of the hands or feet are affected
  • More than one joint is affected
  • There has been a delay of three months or longer between the onset of symptoms and the person seeking medical advice
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8
Q

Systems of rheumatoid arthritis

A

Presents with symmetrical distal polyarthropathy. Worse after rest, improves with activity
Key symptoms: pain, swelling, stiffness. Tends to affect the small joints of the hand and feet, typically the wrist, ankle, MCM and PIP joints in the hands.
Systemic symptoms: fatigue, weight loss, flu like illness, muscle aches and weakness

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9
Q

Palindromic rheumatism

A

Self limiting short episodes of inflammatory arthritis with joint pain, stiffness and swelling typically affecting only a few joints. The episodes only last 1-2 days and then completely resolve. Having positive antibodies (RF and anti-CCP) may indicate that it will progress to full rheumatoid arthritis

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10
Q

Joints affected in rheumatoid arthritis

A
  • Proximal Interphalangeal Joints (PIP) joints
  • Metacarpophalangeal (MCP) joints
  • Wrist and ankle
  • Metatarsophalangeal joints
  • Cervical spine
  • Large joints can also be affected such as the knee, hips and shoulders
  • DIP is never affected by rheumatoid arthritis as well as the Ips of the toes and the thoracolumbar spine
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11
Q

Atlantoaxial subluxation

A

Occurs in the cervical spine. The axis (C2) and the odontoid peg shift within the atlas (C1). This is caused by local synovitis and damage to the ligaments and bursa around the odontoid peg of the axis and the atlas. Subluxation can cause spinal cord compression and is an emergency. This is particularly important if the patient is having a general anaesthetic and requiring intubation. MRI scans can visualise changes in these areas as part of pre-operative assessment.

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12
Q

Signs of rheumatoid arthritis

A
  • Boggy synovium due to inflammation and swelling
  • Z shaped deformity of the thumb
  • Swan neck deformity- hyperextended PIP and flexed DIP
  • Boutonnieres deformity- hyperextended DIP and flexed PIP
  • Ulnar deviation of the fingers at the knuckle- MCP joint
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13
Q

Extra-articular manifestations of rheumatoid arthritis

A
  • Pulmonary fibrosis with pulmonary nodules (Caplan’s syndrome)
  • Bronchiolitis obliterans (inflammation causing small airway destruction)
  • Felty’s syndrome (RA, neutropenia and splenomegaly)
    *Secondary Sjogren’s Syndrome (AKA sicca syndrome)
  • Anaemia of chronic disease
  • Cardiovascular disease
  • Episcleritis and scleritis
  • Rheumatoid nodules
  • Lymphadenopathy
  • Carpel tunnel syndrome
  • Amyloidosis
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14
Q

Rheumatoid arthritis- Felty’s syndrome and Caplans syndrome

A

Felty’s syndrome: Splenomegaly, Rheumatoid arthritis, Neutropenia. Can cause life threatening infections.

Caplans syndrome: Pulmonary fibrosis/lung nodules and rheumatoid arthritis. Normally due to exposure with coal

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15
Q

Rheumatoid arthritis- investigations

A
  • Check rheumatoid factor
  • If RF negative, check anti-CCP antibodies
  • Bloods- Inflammatory markers such as CRP and ESR (non-specific), antibodies
  • X-ray of hands and feet
  • Ultrasound scan- to confirm synovitis
  • Bedside- urine dip
  • Joint aspiration if presenting with monoarthropathy
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16
Q

Non inflammatory causes of raised ESR

A

Pregnancy, diabetes, ESRF, ageing, obesity and anaemia

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17
Q

X-ray changes in rheumatoid arthritis

A
  • Joint destruction and deformity
  • Soft tissue swelling
  • Periarticular osteopenia
  • Bony erosions
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18
Q

Diagnosis of rheumatoid arthritis- points are scored based on

A
  • The joints that are involved (more and smaller joints score higher)
  • Serology (rheumatoid factor and anti-CCP)
  • Inflammatory markers (ESR and CRP)
  • Duration of symptoms (more or less than 6 weeks)
  • Scores are added up and a score greater than or equal to 6 indicates a diagnosis of rheumatoid arthritis.
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19
Q

DAS28 score

A

Based on the assessment of 28 joints and points are given for swollen joints, tender joints, ESR/CRP score

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20
Q

Rheumatoid arthritis- worse prognosis with:

A
  • Younger age
  • Male
  • More joints and organs affected
  • Prescence of RF and anti-CCP
  • Erosions on x-ray
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21
Q

Rheumatoid arthritis- management

A
  • Steroids- for flare ups
  • NSAID’s/ COX-2 inhibitors- risk GI bleeding so are co-prescribed with a PPI
  • Use minimal effective dose
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22
Q

Disease modifying anti-rheumatic drugs (DMARD’s)

A
  • First line is monotherapy with methotrexate, leflunomide or sulfasalazine. Hydroxychloroquine can be considered in mild disease and is considered the “mildest” anti rheumatic drug.
  • Second line is 2 of these used in combination.
  • Third line is methotrexate plus a biological therapy, usually a TNF inhibitor.
  • Fourth line is methotrexate plus rituximab
  • Sulfasalazine and hydroxychloroquine are DMARDs in pregnancy
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23
Q

Biological therapy

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A
  • Anti-TNF (adalimumab, infliximab, etanercept, golimumab and certolizumab pegol)
  • Anti-CD20 (rituximab)
  • Anti-IL6 (sarilumab)
  • Anti-IL6 receptor (tocilizumab)
  • JAK inhibitors (tofacitinib and baricitinib)
24
Q

Pathophysiology of rheumatoid arthritis

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A
  • Autoimmune reaction
  • Body recognises own antigens on collagen as foreign
  • T cells, B cells and macrophages activated
  • T cells produce IFN‐γ (interferon gamma) and IL-17
  • Macrophages produce TNF alpha, IL-1 and IL-6
  • Inflammation causes proliferation of synovial cells
  • CARTILAGE DAMAGE, BONY DESTRUCTION AND DEFORMITY
25
Back pain causes
* Bone: malignancy, ankolysing spondylitis, vertebral osteomyelitis, disc herniation, spinal stensosis * Nerve: cauda equina syndrome * Muscle/skin: strain/zoster * Thoracic: PE, Dissection * Lumbar: AAA, cholecystitis, pancreatitis, pyelonephritis * Pelvic- PVD, endometriosis
26
Pathophysiology of ankylosing spondylitis
* Chronic autoimmune inflammation * Inflammation causes destruction of intervertebral joints and sacroiliac joint * Fibrous bands are formed around spinal joints causing reduced mobility * Syndesmophytes are formed causing reduced movement of the vertebrae and fusion of the vertebrae
27
Spondyloarthropathies
Negative for rheumatoid factor * Ankylosing spondylitis * Psoriatic arthritis * Enteropathic arthritis * Reactive arthritis * Juvenile apondylarthropathies * There is an association between HLA B27 with all these conditions
28
Extra-articular features of spondylarthropathies
* Anterior uveitis * Apical lung fibrosis * IgA nephropathy amyloidosis * Aortic insufficiency/AV block/IHD * Autoimmune bowel disease * (Achilles tendon)- Enthesitis
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Investigations for ankolysing apondylitis
* Bedside: urine dip, faecal calprotectin, ECG * Bloods: CRP, ESR, HLA-B27 * Imaging: x-rays, MRI, joint US * Special: visual assessment, Echo, lung function, flexi sig
30
X-ray for ankolysing spondylitis
* Sclerosis of bone around the joint space * Widening of joint space * Bamboo spine: formation of syndesmophytes between vertebral bodies, appearance of completing bridging across vertebrae * Dagger sign: a single central radiodense line due to ossification of the supraspinous and interspinous ligaments secondary to enthesitis
31
Management of ankolysing spondylitis
* Conservative: patient education, specialist MDT management, Specialist nurses, Physiotherapy, Occupation therapy, adjustments to the home, ice packs * Medical: management if comorbidities, NSAIDS (often continuous), DMARDS (sulfasalazine), Biologics (anti-TNFalpha, infliximab/adalimumab) * Surgical: joint replacement
32
Presentation of a vertebral fractures
- Back pain with or without history of injury - Worse in mobilisation - Usually sudden onset
33
Examination of vertebral fracture
- Pin point bony tenderness over the vertebrae - Normal neurological exam
34
Risk factors for osteoporosis
Age Female Smoking Early menopause Steroid use Rheumatoid arthritis Family history
35
Investigations into vertebral fracture
* X-rays * CT and MRI is indicated if neurological compromise * DEXA
36
Management of vetebral fracture
* Bone health * Vitamin D and calcium * Bisphonates * Consider surgical options
37
Spinal abscess- presentation
* Fever, generally unwell * Localised back pain- worse on moving * Radiating pain if nerve route affected * Leg weakness or bladder symptoms if spinal cord is compressed
38
Examination of spinal abscess
* Pyrexial * Possibly septic * Leg weakness * Reduced anal tone on PR
39
Risk factors for spinal abscess
* IVDU * Immunocompromised i.e. HIV or medication * Diabetes * Long term steroid use
40
Investigations and management into spinal abscess
Investigations- raised CRP and WCC, CT and MRI Management- long term antibiotic treatment, possible drainage
41
Cauda equina syndrome- symptoms
* Back pain- chronic or acute * Saddle anaethesia * Urinary incontinence or retention * Bowel incontinence * Bilateral sciatica * Leg weakness
42
Causes of cauda equina syndrome
* Disc herniation * Vertebral fracture * Spinal abscess * Malignant metastasis * Spinal stenosis
43
Examination and investigations of cauda equina syndrome
- Leg weakness - Urinary retention - Reduced anal tone and saddle anaesthesia on PR Investigations: urgent MRI
44
Management of Cauda equina syndrome
- Urgent neurosurgical referral for surgical decompression - If malignant metastasis: steroids
45
Myelopathy
Injury to the spinal cord due to compression. Degeneration of the cervical vertebrae can cause compression of the cervical spine
46
Presentation of degenerative cervical myelopathy
* Severe neck pain * Pain shooting down both arms * Hand weakness * Loss of fine motor function * Pins and needles in hands
47
Examination and investigations of degenerative cervical myelopathy
* Reduced flexion/extension and rotation at the neck * Reduced power in the hands * Reduced hand sensation * Muscle wasting * Hyperreflexia Investigations: X-ray, CT or MRI
48
Management of cervical myelopathy
- Bone health - Analgesia: NSAID's, neuropathic agents - Surgical options
49
Myelopathy and Radiculopathy
Myelopathy: spinal cord compression, weakness, paraesthesia/numbness, Hoffman/Babincki sign, bladder disturbance Radiculopathy: Nerve root compression, myotomal weakness, reduced sensation dermatomal
50
X-ray osteoarthritis of the knee
* Osteophyte formation * Subchrondrial sclerosis * Joint narrowing of compartment space * No soft tissue swelling
51
Osteoarthritis pathology
'Wear and tear' of the joints, non-inflammatory. Occurs in synovial joints and due to genetics, overuse and injury Due to an imbalance between the cartilage being worn down and the chondrocytes repairing it leading to structural issues in the joint
52
Symptoms of osteoarthritis and joints affected
Joint pain and stiffness- worsened by activity Commonly affected joints- hips, knees, sacro-iliac joint, DIPs, CMC joint at the base of the thumb, wrist, cervical spine
53
Osteoarthritis- signs in the hands
Heberden’s nodes (in the DIP joints) Bouchard’s nodes (in the PIP joints) Squaring at the base of the thumb at the carpo-metacarpal joint Weak grip Reduced range of motion
54
Osteoarthritis- analgesia
1) Oral paracetamol and topical NSAIDs or topical capsaicin (chilli pepper extract). 2) Add oral NSAIDs and consider also prescribing a proton pump inhibitor (PPI) to protect their stomach such as omeprazole. They are better used intermittently rather than continuously. 3) Consider opiates such as codeine and morphine. These should be used cautiously as they can have significant side effects and patients can develop dependence and withdrawal. They also don’t work for chronic pain and result in patients becoming depending without benefitting from pain relief.
55
Other treatment for osteoarthritis
Intra-articular steroid injections provide a temporary reduction in inflammation and improve symptoms. Joint replacement can be used in severe cases. The hip and knee are the most commonly replaced joints.
Medicine year 3- EOCP
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