MSK

Question 1

Description of septic arthritis?

Answer 1

• Infection producing inflammation in native/prosthetic joint or more than one joint
• Medical emergency and can destroy joint or develop sepsis <24 hour
• Reaches via bloodstream, adjacent osteomyelitis or external skin puncture wounds

Question 2

Epidemiology of septic arthritis?

Answer 2

• Knee in >50% cases, followed by hip, shoulder, ankle and wrists
• 1-2% incidence

Question 3

Risk Factors of septic arthritis?

Answer 3

o	Age>80
o	Rheumatoid arthritis/Gout
o	DM
o	Immunosuppresion
o	Renal failure
o	Prosthetic joints/Recent surgery
o	IVDU

Question 4

Causative organisms of septic arthritis?

Answer 4

o	S.aureus (most common)
o	Streptococcus
o	N.gonorrhoea
o	TB
o	Salmonella
o	Coagulase neg staph – prosthetic joints

Question 5

Symptoms and signs of septic arthritis?

Answer 5

o Monoarticular
o Red, painful, swollen joint developing acutely
o Pain on active and passive movement and often held in position of most comfort (slightly flexed)
o May be fever, rigors, shaking, vomiting
- Signs may be less marked in elderly, IVDU, immunocompromised

Question 6

Investigations needed in septic arthritis?

Answer 6

• Bloods
  o FBC, ESR, CRP, blood cultures
• Joint aspiration
  o Send for leukocyte count, Gram staining, microscopy and culture, ?AAFB
  o Infectious aspiration – yellow, turbid, purulent, >10000 cells, neutrophils, Gram stain and culture +ve
  o Normal aspiration – colourless/pale yellow, clear, 200-1000 cells, mononuclear cells, Gram stain and culture -ve
• X-rays
  o Normal or soft tissue swelling with displacement of capsular fat planes and swelling of soft tissue
  o Later, bone destruction occurs
• CT/MRI scan reserved for difficult cases

Question 7

Initial Management of septic arthritis? Orthopaedic management after referral?

Answer 7

o Analgesia
o IV Flucloxacillin for 2 weeks then oral switch for 4 weeks
 If penicillin allergic - Clindamycin
 If MRSA – Vancomycin
 If gonococcal – cefotaxime
 Empirical and start after aspiration
o Refer to Orthopaedic team for Joint irrigation/drainage, Analgesia, Splinting (In position of function, once infection under control then mobilisation will promote healing)

Question 8

Management of osteomyelitis/septic arthritis?

Answer 8

• Flucloxacillin for 6 weeks
  o Consider adding fusidic acid or rifampicin for 1st 2 weeks
  o If penicillin allergic – clindamycin
  o If MRSA – vancomycin

Question 9

Prognosis of septic arthritis?

Answer 9

o Mortality is 10-20%

o Around half regain baseline joint function after treatment

Question 10

Description of giant cell arteritis?

Answer 10

• Chronic immune-mediated vasculitis characterised by granulomatous inflammation in walls of medium and large arteries
• Preferentially extracranial branches of carotid artery and branches of ophthalmic artery
• GCA and polymyalgia rheumatica often occur together in 50%

Question 11

Epidemiology of giant cell arteritis?

Answer 11

• Incidence rare before 50 and peaks at 70
• White people 7x more common
• 3x more common in women

Question 12

Symptoms of giant cell arteritis?

Answer 12

Headache
	Unilateral over temporal region
Temporal artery and scalp tenderness
	When combing hair
Jaw claudication
	Pain while eating
Amaurosis fugax
Sudden blindness in eye
Diplopia
Fever, fatigue, anorexia
Other – Neuropathy, morning stiffness

Question 13

Signs of giant cell arteritis?

Answer 13

o Ischaemic disease on fundoscopy
o Temporal arteries – prominent, beaded, tender and pulseless
o Bruits may be heard over carotid

Question 14

Suspect giant cell arteritis if..?

Answer 14

• Suspect if >50 and:
  o New onset localised headache, unilateral in temporal area
  o Temporal artery – tender, thickened, nodular, red, pulseless

Question 15

When to refer people with suspected giant cell arteritis?

Answer 15

• Refer all people for temporal artery biopsy
  o If visual impairment – same-day ophthalmology assessment
  o If no visual impairment – urgent rheumatology assessment (biopsy within 7 days)

Question 16

What bloods tests to order in giant cell arteritis?

Answer 16

o ESR, CRP raised
o FBC – normochromic normocytic anaemia, elevated platelets
o LFT – mildly elevated

Question 17

Initial drug treatment of giant cell arteritis?

Answer 17

Immediate Prednisolone 60mg/d PO
 Assess response over 1st 48 hours – if poor seek specialist advice
 If develop visual symptoms – seek same-day assessment for IV methylprednisolone
 Treatment reduced slowly and required for 1-2 years
Aspirin 75mg OD
Omeprazole 20mg OD

Question 18

Ongoing management of giant cell arteritis?

Answer 18

o If symptoms controlled – reduce dose of prednisolone slowly
 60mg until ESR/CRP normal, then reduce by 10mg every 2 weeks until 20mg daily, then reduce 2.5mg every 2-4 weeks until on 10mg daily, then 1mg evert 1-2 months

o Review a week after dose change and every 3 months for 1st year then 3-6 monthly
 Do ESR, CRP, BP and glucose

o Assess fracture risk and whether need bisphosphonates

Question 19

Managing a relapse of giant cell arteritis?

Answer 19

o If visual disturbance – increase to 60mg prednisolone & same-day assessment with ophthalmologist
o If jaw claudication – increase to 60mg daily &seek specialist advice
o If headaches, or PMR – increase dose and seek specialist advice

Question 20

Prognosis of giant cell arteritis?

Answer 20

o Relapses common – especially when steroid treatment reduced or withdrawn too quickly
o Exacerbations occur in 30-50% of people during first 2 years

Question 21

Complications of giant cell arteritis?

Answer 21

o	Visual Loss – total or partial
o	Aortic aneurysm, aortic dissection, large artery stenosis and aortic regurgitation
o	CVD
o	Peripheral neuropathy
o	Confusion and encephalopathy

Question 22

Description of spinal cord compression?

Answer 22

• Acute spinal cord compression is a neurosurgical emergency
• Cancers leading to MSCC – breast, bronchus, prostate, myeloma/lymphoma but can occur with any tumour
• Caused by tumour or metastases in vertebral body or paraspinal region pressing on spinal cord

Question 23

Epidemiology of spinal cord compression?

Answer 23

• 2/3 in thoracic region

- Occurs in 20% of patients with spinal metastases

Question 24

Aetiology of spinal cord compression?

Answer 24

o Metastases (breast, lung, prostate, thyroid, kidney)
o Cancer
o Trauma
o Cervical disc prolapse

Question 25

Symptoms of spinal cord compression?

Answer 25

o Back pain/nerve root pain  Either unilateral/bilateral, aggravated by movement, coughing or lying flat o Motor weakness – strength changes o Subjective sensory disturbances o Bladder/Bowel dysfunction generally occurs late

Question 26

Signs of spinal cord compression?

Answer 26

o Weakness/Paraparesis/Paraplegia o Changes in sensation below level of compression o Hyperreflexia o Clonus and painless bladder distension o Can lead to paraparesis, paraplegia and incontinence

Question 27

Red flags in spinal cord compression?

Answer 27

``` o Leg Weakness o Sensory Loss o Thoracic back pain o Constant pain o Urinary retention/incontinence o Saddle Anaesthesia & loss of anal tone ```

Question 28

Management if suspected metastatic spinal cord compression?

Answer 28

o Contact MSCC coordinator urgently if:  Pain in thoracic or cervical spine, progressive lumbar spine, severe unremitting lower spinal pain, aggrevated by straining, local tenderness, nocturnal spinal pain o Contact MSCC coordinator immediately if signs of MSCC

Question 29

Initial management of spinal cord compression?

Answer 29

Initial Management  Nurse flat with neutral spine  Offer graduated compression/anti-embolism stockings  Catheterise in bladder incontinent Medical  Urgent dexamethasone 16mg PO daily commenced at suspicion  PPI cover needed Imaging  Urgent Whole Spine MRI

Question 30

Definitive management of spinal cord compression?

Answer 30

```  Surgery • Should have before they cannot walk • Postoperative radiotherapy  Radiotherapy • Urgent if surgery not suitable • Fractionated radiotherapy if epidural tumour without neurological involvement, pain or spinal instability ```

Question 31

Prognosis of spinal cord compression?

Answer 31

- Outcomes correlate with level of function at the time of treatment - If treated within 24 hours, 57% will walk again - Complete paralysis, present for several days, is almost never reversible

Question 32

What diseases have a positive rheumatoid factor?

Answer 32

```  Rheumatoid arthritis  Sjogrens syndrome  Felty’s syndrome  Infection  SLE, sclerosis ```

Question 33

What diseases have a positive anti-CCP antibody?

Answer 33

 Rheumatoid arthritis

Question 34

What diseases have a positive antinuclear antibody?

Answer 34

```  SLE  Autoimmune hepatitis  Sjogren’s syndrome  Systemic sclerosis  Rheumatoid arthritis ```

Question 35

What diseases have a positive anti-double stranded DNA (dsDNA) & positive anti-Sm & positive anti-RNP??

Answer 35

 SLE

Question 36

What diseases have a positive antihistone antibody?

Answer 36

 Drug-induced SLE

Question 37

What diseases have a positive antiphospholipid antibody (anti-cardiolipin)?

Answer 37

 Antiphospholipid syndrome |  SLE

Question 38

What diseases have a positive anti-Ro?

Answer 38

• SLE, Sjogren’s syndrome, systemic sclerosis

Question 39

What diseases have a positive anti-La?

Answer 39

• Sjogren’s syndrome, SLE

Question 40

What diseases have a positive anti-Jo-1 & anti-mi-2?

Answer 40

• Polymyositis, dermatomyositis

Question 41

What diseases have a positive anti-Scl70?

Answer 41

• Diffuse systemic sclerosis

Question 42

What diseases have a positive antimitochondrial antibodies (AMA)?

Answer 42

 Primary biliary cirrhosis  Autoimmune hepatitis  Idiopathic cirrhosis

Question 43

What diseases have a positive anti-smooth muscle antibodies (SMA)?

Answer 43

 Autoimmune hepatitis |  Primary biliary cirrhosis

Question 44

What diseases have a positive gastric parietal antibodies?

Answer 44

 Pernicious anaemia |  Atrophic gastritis

Question 45

What diseases have a positive intrinsic factor antibodies?

Answer 45

 Pernicious anaemia

Question 46

What diseases have a positive anti-tissue transglutaminase & anti-endomysial antibodies?

Answer 46

 Coeliac disease

Question 47

What diseases have a positive thyroid peroxidase antibodies?

Answer 47

 Hashimoto’s thyroiditis |  Graves’ disease

Question 48

What diseases have a positive islet cells Ab & glutamic acid decarboxylase?

Answer 48

 T1DM

Question 49

What diseases have a positive anti-GBM?

Answer 49

 Goodpasture’s disease

Question 50

What diseases have a positive antineutrophil cytoplasmic antibodies (ANCA) - cytoplasmic - specific for serine proteinase 3?

Answer 50

* Granulomatosis with polyangiitis (Wegeners) * Microscopic polyangiitis * Polyarteritis nodosa

Question 51

What diseases have a positive antineutrophil cytoplasmic antibodies (ANCA) - perinuclear - specific for myeloperoxidase?

Answer 51

* Microscopic polyangiitis | * Churg-Strauss disease

Question 52

What diseases also have a positive ANCA?

Answer 52

 ANCA also positive in Crohn’s, UC, sclerosing cholangitis, autoimmune hepatitis, Felty’s, SLE, RA, drugs (antithyroid, allopurinol, ciprofloxacin)

Question 53

What diseases have a positive acetylcholine receptor antibodies?

Answer 53

 Myasthenia gravis

Question 54

What diseases have a positive anti-voltage gated Ca-channel antibodies?

Answer 54

 Lambert Eaton Syndrome

Question 55

Description of osteoarthritis?

Answer 55

Damage to synovial joints leads to repair and structural change o May occur through repeated excessive loading and stress of joint over time, or by injury Progressive loss of cartilage leads to exposed bone being sclerotic and increased vascularity Osteophytes form

Question 56

Epidemiology of osteoarthritis?

Answer 56

- Commonest joint condition - Prevalence increases with age - Females 3>1 Males - Onset >50 years

Question 57

Typical pattern in males and females of osteoarthritis?

Answer 57

- Females – hands and knees | - Males – hips

Question 58

Risk factors of osteoarthritis?

Answer 58

``` o Familial o Age o Obesity o Joint damage or malalignment o Occupation/Sports ```

Question 59

Symptoms in localised disease of osteoarthritis?

Answer 59

``` o Joint pain  Worse on movement  Relieved at rest  Worse at end of day  Joint gelling after 30 minutes of rest ``` o Crepitus, instability, loss of function

Question 60

Symptoms in generalised disease of osteoarthritis?

Answer 60

o DIP, MCP, MTP and weight-bearing hips

Question 61

Signs of osteoarthritis?

Answer 61

``` o Herbeden’s nodes (DIPs) o Bouchard Nodes (PIPs) o Joint tenderness, derangement o Decreased ROM o Mild synovitis o Muscle wasting o Baker’s cyst (OA/RA) ```

Question 62

Diagnosis without imaging of osteoarthritis?

Answer 62

o If >45, has activity-related joint pain and NO morning stiffness or lasts <30 minutes

Question 63

Investigations and their findings in osteoarthritis?

Answer 63

``` - CXR o Loss of joint space o Osteophytes o Subarticular sclerosis o Subchondral cysts - Raised CRP - Test for Rheumatoid if suspected ```

Question 64

General Management of osteoarthritis?

Answer 64

o Leaflet/Arthritis UK website o Exercise to improve local muscle strength and improve aerobic fitness o Weight loss o Appropriate footwear, cold packs, walking aids o Local heat or ice can help

Question 65

Analgesic management of osteoarthritis?

Answer 65

o Topical NSAIDs o If ineffective, short-term oral NSAID (+PPI) o Intraarticular steroid injection for moderate-to-severe pain Refer if conservative measures fail

Question 66

When to refer to surgeon in osteoarthritis? What options are available?

Answer 66

o When?  Joint replacement if impacting on QoL and refractory to non-surgical treatment o Options?  Total joint replacement  Resurfacing  Fusion

Question 67

Complications of osteoarthritis?

Answer 67

o Joint deformity o Functional impairment o Occupational impact o Falls

Question 68

Description of osteoporosis? What are osteoporotic fractures?

Answer 68

- Low bone mass and structural deterioration of bone tissue – leads to increase in bone fragility and susceptibility to fracture - Osteoporotic fracture = fragility fracture occurring as consequence of osteoporosis

Question 69

Definition of osteoporosis?

Answer 69

o Osteoporosis = Bone mineral density (BMD) of 2.5 SD below mean – measured by DEXA applied to femoral neck o Osteopenia = BMD between -1 and -2.5 on DEXA - It may be primary (age related) or secondary (to conditions or drugs)

Question 70

Epidemiology of osteoporosis?

Answer 70

- Women mostly – due to decrease in oestrogen in menopause | - 1 in 3 women and 1 in 5 men will have fragility fracture

Question 71

Risk Factors of osteoporosis - reduced bone mineral density?

Answer 71

```  DM, Hyperthyroidism, hyperparathyroidism  IBD, Coeliac, pancreatitis  CKD  Liver failure  COPD  Menopause  Immobility  BMI<18.5 ```

Question 72

Risk factors of osteoporosis - does not reduce bone mineral density?

Answer 72

```  Age  Oral corticosteroids  Smoking  Alcohol >3 units daily  Previous fragility fractures  RA  Drugs – SSRIs, PPI, Carbamazepine ```

Question 73

Symptoms of osteoporosis?

Answer 73

- Usually asymptomatic unless fragility fracture occurred

Question 74

What are the at risk groups in osteoporosis?

Answer 74

Women >65, Men>75 ``` Over 50 if:  Previous osteoporotic fragility fracture  Use of corticosteroids  History of falls  BMI <18.5  Smoker  Alcohol >14 per week  Secondary cause ``` Under 50 if:  Use of corticosteroids  Untreated premature menopause  Previous fragility fracture Under 40 if:  >7.5mg prednisolone for >3 months  Previous or multiple fragility fracture Consider in:  SSRIs, carbamazepine, GnRH, PPIs, pioglitazone

Question 75

Testing for at risk groups in osteoporosis?

Answer 75

o Online risk calculator (QFracture/FRAX) to predict 10 year risk  If high (>10%) – DEXA scan to measure BMD  If borderline but risk factors – DEXA scan to measure BMD

Question 76

When to test without calculating risk in osteoporosis?

Answer 76

- Dual-energy X-ray absorptiometry (DEXA) scan to measure BMD without calculating risk if: o >50 with Hx of fragility fracture o <40 with major risk factor for fractures

Question 77

Bloods performed in osteoporosis?

Answer 77

o Bone screen - Ca, PO4 and ALP usually normal

Question 78

Management if DEXA >-2.5 or low risk of fractures in osteoporosis? When to reassess?

Answer 78

Lifestyle advice  Regular exercise – walking outdoors, strength training  Eat balanced diet  Stop smoking  Drink within recommended alcohol limits Reassess at minimum 2 years

Question 79

Management if DEXA 2.5 or less in osteoporosis - drug treatment?

Answer 79

 Bisphosphonate (alendronate 10mg OD or 70mg once weekly; risedronate 5mg OD or 35mg once weekly) • Oral - if T-score <2.5 and QFRACTURE >1% • IV - if T-score <2.5 and QFRACTURE >10% and cannot take oral • Postmenopausal women and men >50 • Postmenopausal women alternative: Denosumab  If calcium adequate (>700mg/day) • 400 units of colecalciferol daily  If calcium inadequate: • 400 units of colecalciferol with 1000mg of calcium daily  HRT in women premature menopause (<40 years old)

Question 80

Management if DEXA 2.5 or less in osteoporosis - lifestyle advice?

Answer 80

 Regular exercise – walking outdoors, strength training  Eat balanced diet  Stop smoking  Drink within recommended alcohol limits

Question 81

Management if DEXA 2.5 or less in osteoporosis - follow up?

Answer 81

 Every 3-5 years • If high risk – continue alendronate for 10 years (7 for risedronate) • If not high risk – DEXA o Continue if 2.5 and reassess after 2 years

Question 82

Description of rheumatoid arthritis?

Answer 82

- Chronic systemic inflammatory disease characterised by symmetrical, deforming, peripheral polyarthritis

Question 83

Pathology of rheumatoid arthritis?

Answer 83

- Affects typically small joints of hands and feet but can be at any synovial joint - Synovial fluid inflammation leads to thickening of lining and infiltration by inflammatory cells - Synovium proliferates over cartilage leaving ‘pannus’ – destroys cartilage and bone

Question 84

Epidemiology of rheumatoid arthritis?

Answer 84

- 1% of population - Females 2>1 Males - Incidence increases with age - Peak onset 50-60 years

Question 85

Risk factors of rheumatoid arthritis?

Answer 85

``` o Women o Familial o Genetic  HLA-DR4/DR1 o Smoking ```

Question 86

Symptoms of rheumatoid arthritis?

Answer 86

o Typical  Symmetrical swollen, painful and stiff small joints of hands and feet  Worse in morning (>30 minutes of stiffness) and after activity  Joint instability, subluxation and dislocation  Many joints can be affected o Less Common  Sudden onset, widespread arthritis  Recurring mono/polyarthritis o Systemic Illness  Fatigue, fever, weight loss, pericarditis, pleurisy

Question 87

Signs of rheumatoid arthritis?

Answer 87

``` o Early (inflammation, no joint damage)  Swollen MCP, PIP, wrist, MTP joints ``` ``` o Later (joint damage, deformity)  Ulnar deviation of fingers  Dorsal wrist subluxation  Boutonnaire deformity  Swan-neck deformity  Z-deformity of thumbs  Rupture of extensor hand tendons  Similar foot deformities ```

Question 88

Extra-articular signs of rheumatoid arthritis?

Answer 88

```  Nodules- elbows Lymphadenopathy  Vasculitis/Alveolitis/Bronchiolitis  Pleural/Pericardial Effusions  Reynauds/Carpal tunnel syndrome/Peripheral neuropathy  Splenomegaly  Episcleritis/Scleritis  Osteoporosis  Felty's Syndrome (Splenomegaly, RA, pancytopenia) ```

Question 89

When should you refer person with suspected rheumatoid arthritis?

Answer 89

- All suspected should be referred to early arthritis clinic

Question 90

Bloods performed in rheumatoid arthritis?

Answer 90

``` o FBC – anaemia o CRP, ESR increased o LFTs, U&Es o Rheumatoid Factor  Positive in 60-70% o Anti-Cyclic Citrullinated peptide antibodies (Anti-CCP)  Highly specific o Antinuclear antibodies  Positive in up to 30% of people ```

Question 91

Imaging performed (if needed) in rheumatoid arthritis?

Answer 91

- X-Rays of hands and feet o Soft tissue swelling, osteopenia, decreased joint space o Later bony erosions, subluxation - Other options o USS/MRI o Aspiration  Sterile, high neutrophils

Question 92

Diagnostic criteria of rheumatoid arthritis? When is diagnostic?

Answer 92

o People with >1 joint with definite swelling not explained by other disease o Add total scores ≥6/10 is diagnostic ``` A – Joint Involvement (swelling or tenderness +/- imaging evidence)  1 large joint = 0  2-10 large joints = 1  1-3 small joints = 2  4-10 small joints = 3  >10 joints (≥1 small) = 5 B – Serology  Negative RF & Anti-CCP = 0  Low +ve RF/Anti-CCP = 2  High +ve RF/Anti-CCP = 3 C – Acute phase reactants  Normal CRP/ESR = 0  Abnormal CRP or ESR = 1 D – Duration of symptoms  <6 weeks = 0  > 6 weeks = 1 ```

Question 93

Management in primary care of rheumatoid arthritis?

Answer 93

 Referral needed if RA suspected • Urgently if small joint of hands and feet affected, >1 joint or delay of 3 months or more between symptom onset and seeking medical advice  Analgesia • Paracetamol with/without codeine • If not controlled: o NSAID/Coxib plus PPI

Question 94

Secondary care investigations for diagnosis of rheumatoid arthritis?

Answer 94

* RF * Anti-CCP (if RF negative) * X-ray of hands and feet

Question 95

Secondary care investigations following diagnosis of rheumatoid arthritis?

Answer 95

* Anti-CCP * X-ray in hands and feet * Functional ability (HAQ) for baseline

Question 96

Management of flare up of rheumatoid arthritis?

Answer 96

Analgesia – NSAID, paracetamol, codeine o Offer PPI ``` Corticosteroid injection o IA (methylprednisolone acetate or triamcinolone acetonide) o IM (methylprednisolone acetate or triamcinolone acetonide) ``` Oral prednisolone

Question 97

Lifestyle advice given in rheumatoid arthritis?

Answer 97

* Manage CVD and BP * Mediterranean diet * Stop smoking * Specialist Physiotherapy/OT * Alcohol stop * Pneumococcal and Influenza vaccine

Question 98

Long-term management of rheumatoid arthritis - monitoring treatment response?

Answer 98

o CRP/ESR and disease activity using DAS28 score

Question 99

Long-term management of rheumatoid arthritis - drug management?

Answer 99

1st step o DMARD monotherapy within 3 months onset (1st-line)  Methotrexate, leflunomide or sulfasalazine  Consider hydroxychloroquine as alternative 2nd step o Add another DMARD (oral methotrexate, leflunomide, sulfasalazine or hydroxychloroquine) when remission/low disease activity not achieved 3rd step o Add Biological Agents  Sarilumab + Methotrexate (if severe DAS28)  Others – adalimumab, etanerept, infliximab, certolizumab pegol, golimumab, tocilizumab, abatacept 4th Step o Methotrexate + Rituximab  If severe and no response to other DMARDs, including at least 1 TNF inhibitor

Question 100

Long-term management of rheumatoid arthritis - surgical management?

Answer 100

* Refer - pain, function, deformity or synovitis progressing despite optimal non-surgical management * Refer – imminent or actual tendon rupture, nerve compression, stress fracture

Question 101

Long-term management of rheumatoid arthritis - monitoring?

Answer 101

* 6 months after achieving remission or low disease activity * Annual review – assess HAQ * After 1 year of maintenance without steroids – consider stepping down dose of drug or stopping one DMARD

Question 102

Description of polymyalgia rheumatica?

Answer 102

- Chronic, systemic inflammatory disease – characterised by aching and morning stiffness in the neck, shoulder and pelvic girdle - Usually >50 years old

Question 103

Epidemiology of polymyalgia rheumatica?

Answer 103

- Most common inflammatory rheumatic condition in older people - Same demographics as GCA - Age >50

Question 104

Risk factors of polymyalgia rheumatica?

Answer 104

o Older age - >65 o Females o Northern European o Infection (mycoplasma, chlamydia, parvovirus B19)

Question 105

When to suspect polymyalgia rheumatica?

Answer 105

- Suspect in >50 with >2 week history of core symptoms: o Bilateral shoulder and/or pelvic girdle pain  Worse with movement  Interferes with sleep  May radiate to elbows and knees o Stiffness lasting >45 minutes  After waking or rest  May cause difficulty turning over in bed, rising from chair

Question 106

Other features of polymyalgia rheumatica?

Answer 106

o Low grade fever, fatigue, anorexia and weight loss o Peripheral MSK signs:  Carpal tunnel syndrome, peripheral arthritis, swelling of limbs o NO WEAKNESS

Question 107

Diagnosis of polymyalgia rheumatica?

Answer 107

o Core features o Excluding conditions that mimic PMR  GCA, active infection/cancer, arthritis, thyroid disease, statin-induced, myositis o Positive response to oral corticosteroids

Question 108

Bloods to arrange in polymyalgia rheumatica?

Answer 108

o CRP raised o ESR raised (can be normal) ``` o Arrange in all patients:  TFT  FBC  LFT – raised ALP  Protein electrophoresis  CK levels normal  RF  Dipstick urinalysis ```

Question 109

Tests to order if features of pathology in polymyalgia rheumatica?

Answer 109

 Urine Bence Jones proteins  ANA  Anti-CCP  CXR

Question 110

Management of polymyalgia rheumatica if most likely diagnosis?

Answer 110

- If PMR most likely diagnosis: o Oral prednisolone 15mg OD  Follow up after 1 week to see response o After 3-4 weeks – ESR/CRP and consider reducing dose

Question 111

When to make working diagnosis of polymyalgia rheumatica? And management from there?

Answer 111

- Make working diagnosis of PMR if >70% improvement within 1 week and normalised ESR/CRP in 4 weeks o If less response – increase dose to 20mg o If still no response – refer to rheumatology

Question 112

How to reduce prednisolone when fully controlled symptoms in polymyalgia rheumatica?

Answer 112

``` o 15mg 3-4 weeks o Then 12.5mg for 3 weeks o Then 10mg for 4-6 weeks o Then reduce by 1mg every 4-8 weeks until stopped o Lasts 1-2 years ```

Question 113

General advice in polymyalgia rheumatica?

Answer 113

o Provide blue steroid card | o Immediate medical attention if symptoms of GCA

Question 114

Follow up of polymyalgia rheumatica?

Answer 114

- Follow Up o 1 week after dose change o Every 3 months – BP, glucose - Asses osteoporosis fracture risk

Question 115

When to refer to rheumatologist with atypical PMR with no alternative diagnosis?

Answer 115

o <60 o Red flags – weight loss, night pain, neurological symptoms o Do not have core symptoms o Normal ESR/CRP or very high

Question 116

When to refer polymyalgia rheumatica for specialist management?

Answer 116

o Relapsing when reducing dose o >2 years steroids o Repetitive flares o Lots of adverse effects

Question 117

Complications of polymyalgia rheumatica?

Answer 117

o GCA and its complications - 15-20% | o Complications of long-term steroid use

Question 118

Prognosis of polymyalgia rheumatica?

Answer 118

o Good – symptoms usually resolve within 24-72 hours o 1-2 years of treatment is required o Relapse common – responds to restarting or increasing dose of steroid

Question 119

Description of gout?

Answer 119

- Raised uric acid level in blood and deposition of urate crystals in joints and tissues - Gout tends to attack joints in extremities as temperature in feet low enough to precipitate urate from plasma

Question 120

Pathology of gout?

Answer 120

o Hyperuricaemia results from overproduction of uric acid and renal underexcretion o Urate derived from breakdown of purines (meat, peas, lentils, oats, mushrooms, spinach) o Impaired excretion (Kidney disease, hypertension, Increased PTH, diuretics/aspirin, hypothyroidism) o Increased production (Increased purines, PCV, Leukaemia, Carcinoma)

Question 121

Epidemiology of gout?

Answer 121

- Most common inflammatory arthritis - Men 10x, prevalence increases with age - Prevalence increasing

Question 122

Aetiology of gout?

Answer 122

``` o Cytotoxics o Hereditary o Increased dietary purines o Leukaemia o Diuretics o Alcohol o Associated CVD, HTN, DM, Renal failure ```

Question 123

Symptoms of gout?

Answer 123

o Sudden onset, monoarticular pain, swelling and redness | o Most common MTP big toe, ankle, foot or hands

Question 124

Investigations performed when gout suspected?

Answer 124

- Bloods o FBC, CRP, U&Es, cholesterol, glucose o May be done in primary care to find caused - Joint fluid microscopy and culture o Urate crystals – negatively bifringent o Rule out septic arthritis - X-ray o Soft-tissue swelling, then punched-out lesions in peri-articular bone - Serum Uric Acid o Done 4-6 weeks after acute attack to confirm increased uric acid

Question 125

Management of acute attack of gout?

Answer 125

o General Advice Bed-rest Elevate and ice joint Keep joint in cool environment o Drug Treatment NSAIDs (Diclofenac 75mg bd or if CI colchicine 500mcg bd) Continue until 1-2 days after acute attack resolved Do not alter treatment if patient on long-term gout treatment Oral steroids could be used if NSAIDs CI (prednisolone 15mg od for 5 days) o Follow Up after 4-6 weeks Serum uric acid after 4-6 weeks (Aim <300micromol/L) Measure BP, HbA1c, U&E and lipids

Question 126

Prevention advice of gout?

Answer 126

``` o Lose weight o Regular exercise o Stop smoking o Reduce alcohol intake o Stop diuretics o Diet – reduce cholesterol, avoid sugar-sweetened soft drinks avoid purine rich foods (meats and seafood) ```

Question 127

Drug prevention in gout?

Answer 127

Allopurinol o after 1st attack of gout o Start at 100mg (50 if renal impairment) OD, increased in increments of 100mg every 4 weeks until SUA <360 (<300 if frequent flares or tophi) o Commence after acute attack when not in pain Colchicine cover with starting allopurinol  Alternative – febuxostat 80mg OD, up to 120mg OD

Question 128

When to refer to rheumatologist in gout?

Answer 128

o Diagnosis uncertain or during pregnancy or <30 o Persistent symptoms on maximum anti-inflammatory medication o Intra-articular steroid injection o Person requires urate-lowering therapy but allopurinol and febuxostat CI or not tolerated o Complications present

Question 129

Prognosis of gout?

Answer 129

o Self-limiting – usually resolve within 1-2 weeks | o Around half recur within a year

Question 130

Complications of gout?

Answer 130

o Tophi occurs in 50% with untreated gout – may become inflamed and infected o Urinary stones common in people with gout o Risk factor for chronic kidney disease

Question 131

Description, symptoms, investigations and management of pseudogout?

Answer 131

o Calcium pyrophosphate deposition in hyaline and fibrocartilage o Typically affects knees, wrists, hips of elderly with history of arthritic attacks o Associated with hyperparathyroidism, haemochromatosis, Wilson’s disease, hypothyroidism o X-rays show chondrocalcinosis in joint menisci, tendon insertion, ligament, bursa o Aspiration – weakly positively bifringent crystals on microscopy o Rx – NSAIDs and rest

Question 132

Description of vasculitis?

Answer 132

- Inflammatory disorder of blood vessel walls, causing destruction (aneurysm/rupture) or stenosis - Can be primary (occurring on own) or secondary (SLE, RA, hepatitis B/C, HIV)

Question 133

Classification of vasculitis - large vessel?

Answer 133

 Giant cell arteritis |  Takayasu’s arteritis

Question 134

Classification of vasculitis - medium vessel?

Answer 134

 Polyarteritis Nodosa |  Kawasaki Disease

Question 135

Classification of vasculitis - small vessel?

Answer 135

```  ANCA positive • P-ANCA – microscopic polyangiitis, glomerulonephritis, Churg-Strauss syndrome • C-ANCA – Wegener’s granulomatosis  ANCA negative • Henoch-Schonlein purpura • Goodpasture’s syndrome • Cryoglobulinaemia  Other Causes: • SLA, RA, IBD • Drugs – sulphonamides, Beta-lactams, quinolones, NSAIDs , OCP, thiazides • Neoplasm – hairy cell leukaemia ```

Question 136

Symptoms of vasculitis - large vessel?

Answer 136

```  End-organ (TIA/CVA)  Hypertension  Aneurysms  Dissection  Visual changes, jaw claudication ```

Question 137

Symptoms of vasculitis - medium vessel?

Answer 137

```  Ulcers  Digital infarcts  Nodules  Livedo reticularis  Papulo-necrotic lesions  Hypertension ```

Question 138

Symptoms of vasculitis - small vessel?

Answer 138

```  Palpable purpura 1-3mm  Tiny papules  Spinter haemorrhages  Urticaria  Vesicles  Haematuria ```

Question 139

Specific symptoms depending on organs affected in vasculitis?

Answer 139

o Systemic – fever, malaise, weight loss, arthralgia, myalgia o Skin – purpura, ulcers, livedo reticularis, splinter haemorrhages, digital gangrene o Eyes – episcleritis, slceritis, visual loss o ENT – epistaxis, nasal crusting, stridor o Pulmonary – SOB, haemoptysis o Cardiac – angina, MI, heart failure, pericarditis o GI – pain, malabsorption o Renal – hypertension, haematuria, proteinuria, casts, renal failure o Neuro – TIA/CVA, fits, chorea, psychosis, confusion, altered cognition o GU - orchitis

Question 140

Investigations performed in vasculitis?

Answer 140

``` - Bloods o FBC, U&E, LFT o CRP/ESR o ANCA o RF o Anti-CCP - Urine dip, microscopy and culture - Biopsy - Echocardiogram and blood cultures if murmur ```

Question 141

Management of vasculitis?

Answer 141

- Referral to rheumatologist - Specific Treatments o Large Vessel – Steroids (Azathioprine) + bisphosphonates o Medium/Small Vessels – Steroids and IV cyclophosphamide (Azathioprine) o ANCA positive – Mycophenolate mofetil

Question 142

What is Wegener's granulomatosis?

Answer 142

- Granulomatosis with polyangiitis - Necrotising granulomatous inflammation and vasculitis of small and medium vessels (predilection for lungs, URT, kidneys)

Question 143

Symptoms of Wegener's granulomatosis?

Answer 143

o Nasal obstruction, ulcers, epistaxis, saddle nose deformity o Glomerulonephritis - Proteinuria, haematuria o Cough, haemoptysis o Skin purpura, mononeuritis multiplex, arthritis, keratitis, scleritis, episcleritis

Question 144

Tests performed in Wegener's granulomatosis?

Answer 144

o cANCA o Raised ESR/CRP o Urinalysis – proteinuria, haematuria o CXR – nodules and fluffy infiltrates

Question 145

Management of Wegener's granulomatosis?

Answer 145

o Prednisolone and cyclophosphamide o Azathioprine and methotrexate (steroid sparing) o Co-trimoxazole prophylaxis against PCP

Question 146

Description of Takayasu's arteritis?

Answer 146

- Systemic vasculitis affecting aorta and major branches - Granulomatous inflammation causes stenosis, thrombosis and aneurysm - Rare outside Japan, affects 20-40

Question 147

Symptoms of Takayasu's arteritis?

Answer 147

- Symptoms o Dizziness, visual changes, weak arm pulses, fever, malaise - Complications o Aortic regurgitation, aortic aneurysm, dissection, stroke, IHD

Question 148

Diagnossi of Takayasu's arteritis?

Answer 148

o ESR, CRP raised | o MRI

Question 149

Management of Takayasu's arteritis?

Answer 149

o Prednisolone o Methotrexate or cyclophosphamide if refractory o Angioplasty +/- stenting

Question 150

Description of Kawasaki Disease?

Answer 150

- Systemic vasculitis with coronary arteritis – coronary artery aneurysms - Commonest cause of acquired child heart disease

Question 151

Diagnostic criteria of Kawasaki Disease?

Answer 151

o Fever for 5 days and 4 out of 5 of following:  Conjunctivitis without pus  Cervical lymphadenopathy  Extremity changes – swelling of hands/feet and desquamation  Rash  Lips- red, cracking or strawberry tongue

Question 152

Investigations of Kawasaki Disease?

Answer 152

o Bloods – CRP and ESR raised | o ECG and echo to rule out CV complications

Question 153

Management of Kawasaki Disease?

Answer 153

o High dose IV immunoglobuilin 2g/kg within 10 days o Corticosteroids - prednisolone -if IV-ImmunoGlobulin ineffective o Aspirin 30-50mg continued for atleast 6 weeks

Question 154

Description of Henoch-Schonlein Purpura?

Answer 154

- Acute IgA mediated vasculitis causing medium sized artery inflammation - Occurs between 3-10, boys mostly - Aetiology – infection (group-A strept, mycoplasma, EBV, drugs and allergies

Question 155

Symptoms of Henoch-Schonlein Purpura?

Answer 155

o Preceding URTI in 50-90% cases o Skin Rash Symmetrical, palpable purpura over buttocks, extensor surfaces, arms, legs and ankles Initially uticarial -> becoming maculopapular -> subsequently purpuric Recurs over several weeks o Arthralgia Knees and ankles mainly o Colicky Abdo Pain Intussusception (2/3%) o Renal Nephropathy 80% of cases have micro/macro-scopic haematuria or mild proteinuria Complete recovery is normal but if proteinuria is severe, nephritic syndrome o Scrotal Oedema

Question 156

Investigations of Henoch-Schonlein Purpura?

Answer 156

o Mid-stream urine – protein and haematuria o BP o Bloods – FBC, ESR, U&E, IgA o Imaging – Renal US and biopsy

Question 157

Management of Henoch-Schonlein Purpura?

Answer 157

o Most resolve in <2 months o Usually self-limiting, regular paracetamol and NSAIDs may help joint pain but caution in renal insufficiency o If severe, prednisolone may help resolve abdominal pain o May require admission to hospital for monitoring of abdominal and renal complications

Question 158

Description of Goodpasture's syndrome?

Answer 158

- Acute glomerulonephritis + lung involvement (haemoptysis, diffuse pulmonary haemorrhage) - Caused by anti-GBM antibodies (bind to kidney basement membrane and alveolar)

Question 159

Management of Goodpasture's syndrome?

Answer 159

- Tests – CXR, renal biopsy | - Management – prednisolone and plasmaphoresis

Question 160

Description of low back pain?

Answer 160

- Pain in lumbosacral area of back, between buttocks and bottom of ribs - Specific causes – sciatica, vertebral fracture, intra-abdominal pathologies and rare, ankylosing spondylitis, cancer and infection - Non-specific when no specific cause and may be due to trauma or MSK injury

Question 161

How common is low back pain?

Answer 161

- 60% people have low back pain in their life

Question 162

Risk factors of low back pain?

Answer 162

o Obesity o Physical inactivity o Heavy lifting o Depression

Question 163

Symptoms of non-specific back pain?

Answer 163

o Pain varies with posture and time, exacerbated by movement

Question 164

Red flag symptoms needing investigation in low back pain?

Answer 164

o Cauda equina syndrome – bilateral neurological deficit of legs, urinary retention/incontinence, faecal incontinence, perianal sphincter loss, saddle anaesthesia o Cancer of spine - >50, gradual onset, unremitting pain, remains when supine and aching at night that disturbs sleep, spinal tenderness, unexplained weight loss, Hx of cancer o Spinal fracture due to trauma or osteoporosis – sudden onset, severe central spinal pain, relieved by lying down, history lf major trauma, deformity of spine, tenderness o Spinal infection – fever, TB, diabetes, IVDU, HIV

Question 165

Management of low back pain - if red flag symptoms?

Answer 165

- If red flag symptoms – admit or refer urgently for assessment

Question 166

Management of non-specific back pain?

Answer 166

o Risk stratification STarT Back to identify risk factors o Self-Management Advice  Exercises - leaflets  Local heat  Stay active and resume normal activities and work as soon as possible o Analgesia  NSAIDs (ibuprofen or naproxen)  Codeine 2nd line  If muscle spasm – give diazepam 2mg up to TDS for 5 days o Group exercise programmes o CBT if psychological element

Question 167

Management of low back pain - if initial management not working for patient?

Answer 167

o Radiofrequency denervation if supplied by medial branch nerve o Spinal cord stimulation

Question 168

Follow up in low back pain?

Answer 168

o If worsening or persist after 3-4 weeks, come back to GP

Question 169

Prognosis of low back pain?

Answer 169

- Non-specific back pain resolves within 4 weeks usually | - May have episodes of recurrence

Question 170

Description of prolapsed disc?

Answer 170

- Part of nucleus pulposus herniates through weakness in outer part of disc - Majority L4/5 or L5-S1

Question 171

Pathology of prolapsed disc?

Answer 171

o Usually occur postero-laterally when annulus fibrosis is thin and not supported by longitudinal ligaments o Herniation will impinge on nerves below

Question 172

Epidemiology of prolapsed disc?

Answer 172

- Degeneration of disc - Trauma - General wear and tear - Lifting heavy loads

Question 173

Aetiology of prolapsed disc?

Answer 173

- Degeneration of disc - Trauma - General wear and tear - Lifting heavy loads

Question 174

Symptoms of prolapsed disc?

Answer 174

- Sudden, onset, severe back pain – usually following strenuous exercise - Clearly related to position and aggravated by movement - Radiation depends on nerve impingement: o S1 – buttock to back of foot o L5 – Buttock to lateral leg and dorsal foot o L4 – Lateral aspect of thigh to medial calf - Typically, one sided but can be bilateral if large - Bowel & Bladder incontinence

Question 175

Signs of Cauda Equina Syndrome?

Answer 175

- Bilateral root pain in legs - Saddle anaesthesia - Loss of anal tone PR - Bladder + Bowel incontinence

Question 176

Imaging of prolapsed disc?

Answer 176

- X- rays often normal - Need good examination - MRI diagnostic and can identify for surgery

Question 177

Management of prolapsed disc?

Answer 177

``` Symptomatic relief - NSAIDs, paracetamol, codeine, bed rest Steroid injection Physio & Exercise Surgery (if worsening, not settled in 6 weeks) ```

Question 178

Description of sciatica?

Answer 178

- Sciatic nerve L4-S3 | - Symptoms arise from impingement of lumbosacral nerve roots and felt in sciatic dermatome

Question 179

Epidemiology of sciatica?

Answer 179

- Around 15-40% of patients experience sciatica at some point during lifetime - Incidence related to age, peaking in 5th decade - Rarely seen before 20

Question 180

Risk factors of sciatica?

Answer 180

- Strenuous physical activity - Whole body vibration - Smoking, obesity, occupational factors

Question 181

Causes of sciatica?

Answer 181

- Slipped disc (90% of cases) - Spondylolisthesis – proximal vertebra moves forward relative to distal vertebra - Spinal stenosis o Narrowing of spinal canal – pain relived by forward flexion and worsened on extension - Infection and Cancer (rare)

Question 182

Symptoms of sciatica?

Answer 182

- Affect hamstrings and all muscles below knee (foot drop), with loss of sensation below knee laterally - Unilateral leg pain radiating below the knee to the foot or toes - Low back pain – not too severe - Numbness, tingling (paresthesia) and muscle weakness in dermatome

Question 183

Red flags in back pain of sciatica?

Answer 183

- Cauda equina syndrome - Spinal fracture o Sudden onset relieved by lying down o Hx of trauma, strenuous lifting, osteoporosis o Point tenderness over vertebral body - Cancer o >50, gradual onset of symptoms o Severe, unremitting pain – aching at night, unexplained weight loss - Infection (discitis, vertebral osteomyelitis, spinal epidural abscess) o Fever, TB, diabetes, Hx of IVDU, HIV

Question 184

When to refer sciatica?

Answer 184

- Urgent referral if red flag suspicion

Question 185

General advice in sciatica?

Answer 185

- Use STarT Back to identify risk factors - Self-management advice o Information – symptoms usually settle in 4-6 weeks o Local heat may help o Small firm cushion between knees while sleeping o Leaflets o Encourage active, normal daily activities

Question 186

Analgesia in sciatica?

Answer 186

``` o NSAIDs (ibuprofen, naproxen) +/- paracetamol o Add amitriptyline, duloxetine, gabapentin, pregabalin o Benzodiazepines (diazepam 2mg TDS up to 5 days) for muscle spasm ```

Question 187

Follow up of sciatica?

Answer 187

- Seek follow-up if worsening or not improving after 2-3 weeks

Question 188

Management options in certain groups of patients for sciatica?

Answer 188

- Group exercise programme (biomechanical, aerobic) - Physiotherapist - CBT if they have psychosocial obstacles to recovery

Question 189

Complications of sciatica?

Answer 189

- Permanent nerve damage with possible sensory deficits and motor weakness, such as foot drop - Anxiety, depression and psychosocial impact - Time off work, loss of employment

Question 190

Prognosis of sciatica?

Answer 190

- Usually transient with improvements seen within weeks or a few months - Poorer prognosis seen in women, more severe sciatica - May have recurrence of symptoms

Question 191

Definition of spondyloarthritis?

Answer 191

o Group of inflammatory rheumatologic conditions o Can be axial (affecting sacroiliac joints and spine) or peripheral (psoriatic arthritis, reactive arthritis, enteropathic spondyloarthritis)

Question 192

Description of ankylosing spondylitis?

Answer 192

- Ankylosing Spondylitis (radiographic axial spondyloarthritis) o Inflammatory axial spondyloarthritis with sacroilitis on x-ray is characteristic

Question 193

Epidemiology of ankylosing spondylitis?

Answer 193

- Prevalence 0.25-1% - 3x more common in men and present earlier than women - Present between 20-30

Question 194

Aetiology of ankylosing spondylitis?

Answer 194

- Unknown aetiology | - 90% HLA B27 positive

Question 195

Symptoms of ankylosing spondylitis?

Answer 195

- Gradual onset, recurrent low back pain and stiffness o Worse at night with spinal morning stiffness (>30 minutes) o Relieved by exercise - Pain radiates from sacroiliac joint to hips and buttocks - Loss of spinal movement due to new bone formation (SI ankylosis and syndesmophytes (bony growths in intervertebral joint ligaments) - Fatigue

Question 196

Signs of ankylosing spondylitis?

Answer 196

- Kyphosis and neck hyperextension - Dactylitis (swelling of fingers and toes) - Arthritis - Enthesitis – inflammation of site of tendon/ligament insertion (costchondritis, plantar fasciitis, Achilles tendonitis) - Acute anterior uveitis

Question 197

Blood tests & imaging to perform in patient suspected of ankylosing spondylitis?

Answer 197

- Bloods in primary care o ESR, CRP, FBC (normocytic anaemia) - Local guidelines on X-ray (sacroiliitis), MRI, USS o Sacroiliitis, sclerosis, erosions, total or partial ankylosis (fusion of joints)

Question 198

Management if ankylosing spondylitis suspected?

Answer 198

o Refer to rheumatologist

Question 199

Diagnostic criteria of ankylosing spondylitis?

Answer 199

o Modified New York Criteria | o ASAS classification criteria

Question 200

Criteria of Modified New York Criteria in diagnosing ankylosing spondylitis?

Answer 200

o Modified New York Criteria  Diagnosed if • At least 1 clinical criteria + radiological criteria • All 3 clinical criteria without radiological evidence  Clinical • Low back pain - >3 months, improved by exercise but not relieved by rest • Limitation of lumbar spine movement in sagittal and frontal planes • Limitation of chest expansion  Radiological criteria • Sacroiliitis on XR

Question 201

Criteria for ASAS classification criteria in diagnosing ankylosing spondylitis?

Answer 201

o ASAS classification criteria (for people with back pain for 3 months or more who were <45 at onset)  Sacroiliitis on imaging plus 1 or more feature of spondyloarthritis OR  HLA-B27 plus 2 or more features of spondyloarthritis • Features = inflammatory back pain, arthritis, enthesitis, uveitis, dactylitis, psoriasis, IBD, response to NSAIDs, FHx, high CRP

Question 202

Imaging performed in ankylosing spondylitis?

Answer 202

o XR of sacroiliac joints

Question 203

when can you diagnose ankylosing spondylitis?

Answer 203

XR shows sacroiliitis with New York criteria bilateral grade 2-4 or unilateral 3-4

Question 204

Imaging if XR does not show sacroilitis but high NY score?

Answer 204

Unenhanced MRI

Question 205

General advice in suspected ankylosing spondylitis?

Answer 205

o Chronic condition and no cure – need referral for confirmation o Exercise – maintain posture and mobility o If chest wall restriction – influenza and pneumococcal vaccine

Question 206

Anaglesia in suspected ankylosing spondylitis?

Answer 206

o NSAIDs with PPI o Add paracetamol and codeine if NSAIDs CI o Corticosteroid injection for sacroiliitis/enthesitis

Question 207

When to refer to rheumatologist in ankylosing spondylitis?

Answer 207

- Referral to rheumatologist if low back pain starting before 45 and lasting >3 months, plus 4 or more of the following: o Low back pain starting before 35 o Symptoms wake during second half of night o Buttock pain o Improvement when moving o Improvement within 48 hours of NSAIDs o 1st degree relative with spondyloarthritis o Current or past arthritis o Current or past enthesitis o Current or past psoriasis - If 3 are present – perform HLA-B27 test – if positive, refer to rheumatologist

Question 208

Management of confirmed ankylosing spondylitis in primary care?

Answer 208

o Analgesia  NSAIDs with PPI  Add paracetamol and codeine if NSAIDs CI o Flare Management  Referral to secondary care – if recurrent flare ups, taking DMARDs, or comorbidities o 2-yearly osteoporosis DEXA scan o Manage modifiable risk factors  CVD, hypertension, lipid modification, obesity, smoking cessation o Referral  Ophthalmology if anterior uveitis suspected  Rheumatology if symptoms not controlled

Question 209

Management of confirmed ankylosing spondylitis in secondary care - non-pharmacological?

Answer 209

- Specialist physiotherapy o Stretching, strengthening, postural exercises, deep breathing, range of motions - Consider hydrotherapy

Question 210

Management of confirmed ankylosing spondylitis in secondary care - pharmacological?

Answer 210

- NSAIDs (at lowest effective dose) + PPI o If taken for 2-4 weeks and not adequate – switch NSAIDs - Biological DMARDs (assess after 12 weeks) o TNF-alpha inhibitors (adalimumab, etanercept, golimumab, infliximab) – severe and not responding to NSAIDs o Secukinumab – if not responded to NSAIDs or TNF-alpha inhibitors

Question 211

Management of confirmed ankylosing spondylitis in secondary care - surgical?

Answer 211

o Refer when spinal deformity significantly affecting ADLs and severe or progressive despite optimal treatment

Question 212

Managing flare ups of ankylosing spondylitis?

Answer 212

o Flare management plan with access to care, self-care advice, pain management and changes to medications

Question 213

Prognosis of ankylosing spondylitis?

Answer 213

- 70-90% of those affected remain fully independent or minimally disabled long term - Spinal deformities may occur usually after 10 years - Worse prognosis in ESR >30, onset <16 and early hip involvement

Question 214

COmplications of ankylosing spondylitis?

Answer 214

- Aortic regurgitation - Anterior uveitis - AV node block - Achilles’ tendon rupture - Spinal fractures - Fixed and flexed posture - Osteoporosis - Cauda equina syndrome

Question 215

Definition of reactive arthritis?

Answer 215

- Seronegative spondyloarthritis, typically affecting lower limbs 1-4 weeks after urethritis (chlamydia ureaplasma) or dysentery (Campylobacter, salmonella, shigella, Yersinia)

Question 216

What is Reiter's syndrome?

Answer 216

- Reiter’s syndrome – triad of urethritis, arthritis and conjunctivitis

Question 217

Epidemiology of reactive arthritis?

Answer 217

- Young white adults | - Associated with HLA-B27

Question 218

Risk factors of reactive arthritis?

Answer 218

- Post-venereal – Chlamydia, HIV | - Post-enteric – Campylobacter, Salmonella, Shigella

Question 219

Symptoms of reactive arthritis?

Answer 219

- Symptoms 2-4 weeks after GU or GI infection o Acute malaise, fatigue and fever o Asymmetrical lower limb oligoarthritis o Low back pain o Enthesitis o May be iritis, keratoderma blenorrhagica (brown, raised plaques on soles and palms), circinate balanitis (painless penile ulceration), mouth ulcers

Question 220

Investigations of reactive arthritis?

Answer 220

- Bloods o Raised ESR/CRP o FBC – normocytic, normochromic anaemia, mild leucocytosis and thrombocytosis o HLA-B27 positive - Joint aspiration to rule out septic arthritis o High WBC count (polymorphonuclear leukocytes) - Culture of stools, throat and urogenital tract to identify causative organism

Question 221

Management of reactive arthritis?

Answer 221

- Immobilise affected joints - NSAIDs - Prednisolone – oral/intra-articular/topical - If symptoms >6 months – DMARD - sulfasalazine or methotrexate

Question 222

Prognosis of reactive arthritis?

Answer 222

o Usually self-limiting with resolution in 3-12 months, may persist

Question 223

Complications of reactive arthritis?

Answer 223

o Osteoarthritis | o Iritis/Uveitis

Question 224

Description of polyarteritis nodosa?

Answer 224

Necrotising vasculitis causing aneurysms and thrombosis of medium-sized arteries, leading to infarction in organs (renal) with systemic symptoms

Question 225

Epidemiology of polyarteritis nodosa?

Answer 225

Women 2x

Question 226

Associated conditions of polyarteritis nodosa?

Answer 226

Hep B

Question 227

Symptoms of polyarteritis nodosa?

Answer 227

Systemic features - fever, weight loss, headache, myalgia Neuro - mononeuritis multiplex Skin - livedo reticularis rash and punched out ulcers Renal - ischaemia Cardiac, GU and GI involvementt

Question 228

Tests of polyarteritis nodosa?

Answer 228

Bloods - raised WCC, mild eosinophilia, anaemia, high Hep B surface antigien positive 30% ESR/CRP ANCA negative Renal/abdominal angiography - diagnostic of multiple aneurysms

Question 229

Management of polyarteritis nodosa?

Answer 229

Control BP | Steroids and azathioprine/cyclophosphamide

Question 230

Definition of Churg-Strauss Syndrome?

Answer 230

ANCA positive vasculitis affecting small arteries Triad of adult-onset asthma, eosinophilia and vasculitis affecting lungs (pulmonary infiltrates), skin, nerves (mononeuritis multiplex) and heart

Question 231

Symptoms of Churg-Strauss Syndrome?

Answer 231

Systemic - fever, joint pain, muscle pain, weight loss, chest pain Pulmonary - asthma, pneumonitis URTI - sinusitis, rhinitis Heart - HF, myocarditis, MI Skin - purpura, skin nodules, livedo reticularis Renal - CKD, hypertension, glomerulonephritis Nerves - mononeuritis multiplex

Question 232

Investigations of Churg-Strauss Syndrome?

Answer 232

ANCA - pANCA positive in 30% FBC - eosinophilia, high ESR/CRP U&E - high creatinine CXR - pulmonary opacities

Question 233

Management of Churg-Strauss Syndrome?

Answer 233

Steroids Cyclophosphamide if severe Rituximab if refractory disease

Question 234

Definition of Microscopic polyangiitis?

Answer 234

Necrotizing vasculitis affecting small and medium sized vessels

Question 235

Symptoms of Microscopic polyangiitis?

Answer 235

Rapidly progressing glomerulonephritis | Pulmonary haemorrhage

Question 236

Investigations of Microscopic polyangiitis?

Answer 236

pANCA positive

Question 237

Management of Microscopic polyangiitis?

Answer 237

Control BP | Steroids and azathioprine/cyclophosphamide

Question 238

Definition of Behcet's disease?

Answer 238

Systemic inflammatory disease with recurrent oral ulcers, associated with HLA-B5

Question 239

Epidemiology of Behcet's disease?

Answer 239

Most common along old Silk Road - Mediterranean to China Age 20-30

Question 240

Symptoms of Behcet's disease?

Answer 240

Recurrent oral and genital ulceration Uveitis Skin (erythema nodosum, papulopustular lesions) Arthritis (non-erosive large joint oligoarthritis) Vasculitis Pathergy - exaggerated skin injury occuring after minor trauma Myo/pericarditis Colitis CNS - memory impairment, pyramidal signs

Question 241

Diagnosis of Behcet's disease?

Answer 241

Clinical Pathergy test - needle prick leads to papule formation within 48 hours

Question 242

Management of Behcet's disease?

Answer 242

Topical steroids for oral/genital ulcers Azathioprine/Cyclophosphamide for systemic disease Infliximab

Question 243

Definition of Buerger's Disease?

Answer 243

Called thromboangiitis obliterans Non-atherosclerotic smoking-related inflammation and thrombosis of veins and middle-sized arteries causing thrombophlebitis and ischaemia (ulcers and gangrene) Men aged 20-45

Question 244

Aetiology of Buerger's Disease?

Answer 244

Unknown but smoking leads to development/progression of disease

Question 245

Symptoms of Buerger's Disease?

Answer 245

Claudications in feet/hands or pain at rest Begins in extremities and may radiate centrally Discolouration of limbs, symptoms worsen with cold or stress, numbness or tingling, Raynauds' phenomenon, skin ulcers, digital gangrene

Question 246

Investigations of Buerger's Disease?

Answer 246

To rule out other vasculitis - FBC, LFTs, U&E, glucose, ESR, CRP, autoantibodies Imaging - angiography - corkscrew appearance of arteries

Question 247

Management of Buerger's Disease?

Answer 247

Stop smoking!! Avoid cold, sitting or standing in one position for long Avoid tight clothing Aspirin/Iloprost

Question 248

Description of seronegative arthritis?

Answer 248

- Group of conditions that present with inflammatory arthritis without a positive RF - Include Ankylosing spondylitis, Reiter’s syndrome, psoriatic arthritis, Behcet’s disease, JIA

Question 249

Risk factors of seronegative arthritis?

Answer 249

o HLAB27 | o FHx

Question 250

Mean onset and symptoms of seronegative arthritis?

Answer 250

``` - Mean onset 20-40 o Back pain o Sacroilitis o Peripheral arthritis o Enthesitis o Dactylitis o Non-gonococcal urethritis o Psoriasis o Anterior Uveitis o IBD ```

Question 251

What is psoriatic arthritis?

Answer 251

o 35-45, any joints o Psoriasis, enthesitis, dactylitis o Occasional uveitis, aortic regurgitation

Question 252

What is enteropathic arthritis?

Answer 252

o Any age o Asymmetrical lower extremities and symmetrical sacriliitis o Erythema nodosum, pyoderma gangrenosum o Aortic regurgitation

Question 253

Investigations in seronegative arthritis?

Answer 253

- Bloods o ESR and CRP raised o Urate, RF, ANA normal - X-ray

Question 254

Management of seronegative arthritis?

Answer 254

- Treat the type of spondylopathy - Exercise, physiotherapy - NSAIDs - DMARDs - Surgery – joint replacements

Question 255

Physiology of vitamin D?

Answer 255

- Vitamin D is fat soluable vitamin that regulates calcium and phosphate homeostasis - Promotes absorption of calcium and phosphorus from bowel to mineralise newly formed osteoid bone tissue

Question 256

Forms of vitamin D?

Answer 256

o Vitamin D3 (cholecalciferol) – synthesised from 7-dehydrocholesterol in skin by UVB radiation (sunlight) o Both D3 and D2 (ergocalciferol) are obtained from foods  Cod liver oil, oily fish and fortified cereals/spreads o D2 and D3 are inactive – converted to 25-hydroxyvitamin D in liver and then to 1, 25(OH)2D in kidneys

Question 257

Regulation of vitamin D?

Answer 257

o Production regulated by PTH on kidneys

Question 258

Definition of osteomalacia and Ricket's?

Answer 258

- Osteomalacia – normal bone amount but mineral content low, occurs after fusion of epiphysis - Rickets = if this process occurs during period of growth

Question 259

Causes of osteomalacia?

Answer 259

o Insufficient sunlight exposure  Depends on latitude, season and habit of dressing  Age  Darker skin need more sunlight o Inadequate dietary intake o Intestinal malabsorption – coeliac, CF, Crohn’s o Obesity o Liver failure o CKD o Drugs – antiepileptics, corticosteroids, rifampicin, HAART

Question 260

Risk factors of osteomalacia?

Answer 260

``` o Muslim women o Housebound patients o Dark skin (African, Afro-Caribbean, Asian) o Vegans o Pregnancy o >65 o Obese o FHx ```

Question 261

Symptoms of Ricket's?

Answer 261

o Growth retardation o Hypotonia o Apathy o Once walking: knock knee, bow legs, rachitic rosary o Painful wrist swelling o Craniotabes (skull softening with frontal bossing o Delayed tooth eruption

Question 262

Symptoms of osteomalacia?

Answer 262

o Bone pain – lower back, pelvis o Fractures (esp femoral neck) o Muscles aches o Proximal myopathy (waddling gait)

Question 263

Investigations in child with suspected Ricket's?

Answer 263

``` o XR of long bone – cupping, splaying, fraying of metaphysis (champagne glass wrist) o Bone profile  Vitamin D if low calcium o U&E o LFT o TFT o PTH o FBC, ferritin o RA o CRP/ESR ```

Question 264

Investigations must be done in osteomalacia?

Answer 264

o Test serum 25(OH)D levels if present with symptoms  Diagnosis if <25nmol/L  25-50 may be inadequate for some people

Question 265

Investigations considered if underlying cause suspected in osteomalacia?

Answer 265

```  Bone profile  U&E  LFT  TFT  PTH  FBC, ferritin  RA  CRP/ESR ```

Question 266

Prevention management of osteomalacia?

Answer 266

o Take daily 400IU (10mcg) supplement daily throughout year  If pregnant – can get free Healthy Start vitamins (has vitamin D, 400mcg folic acid and 70mg VitC)  If <1 years old – 340-400IU of vitamin D o Advise to intake 700mg of calcium a day  If unable – combined calcium supplementation (Calcichew D3) • Check Ca levels 1 months after  If child, recommended levels are different o Lifestyle advice  Sun exposure – safely  Diet – supplements, cod liver oil, oily fish, egg yolk, meat

Question 267

Management of osteomalacia - who to treat?

Answer 267

 Serum 25(OH)D <25  Serum 25(OH)D 25-50 if: • Fragility fracture, osteoporosis, on antiresorptive drug treatment, symptoms, raised PTH, CKD, coeliac, Crohn’s

Question 268

Management of osteomalacia - how to treat?

Answer 268

 Refer if cancer, Crohn’s to specialist Drug treatment  Vitamin D2 – for strict vegans (from plant sources)  Vitamin D3 (cholecalciferol) for everyone else • Loading dose of 300000 IU (50,000 IU once a week for 6 weeks) then daily 800IU maintenance

Question 269

Management of osteomalacia - follow up?

Answer 269

 1 month of high-dose Vitamin D treatment • Serum calcium levels  3-6 months of high-dose Vitamin D treatment • Serum 25(OH)D levels: o IF <50 – refer to secondary care o IF >50 and no symptoms of hypercalcaemia – maintenance dose of 800IU daily

Question 270

Management of child with Ricket's?

Answer 270

o Refer is underlying cause o Refer to paediatrician if symptoms of Ricket’s o Drug Treatment  Age 1-6 months – 3,000 IU daily for 8-12 weeks  Age 6 months-12 years – 6,000IU daily for 8-12 weeks  Age 12-18 years – 10,000IU daily for 8-12 weeks

Question 271

Prognosis of osteomalacia?

Answer 271

o Correct management – restores levels and reduces risks

Question 272

Complications of osteomalacia?

Answer 272

``` o Hypocalcaemia o 20 hyperparathyroidism o Bone loss o Muscle weakness o Fragility fractures ```

Question 273

Description of Paget's disease of the bone?

Answer 273

- Also called osteitis deformans - Increased bone turnover, increased osteoblasts and osteoclasts which results in: o Remodelling o Bone Enlargement o Deformity o Weakness

Question 274

Epidemiology of Paget's disease of the bone?

Answer 274

- Incidence rises with age | - Commoner in temperate climates = England, USA

Question 275

Risk factors of Paget's disease of the bone?

Answer 275

- Risk Factors - FHx - Paramyxoviruses - Male

Question 276

Symptoms of Paget's disease of the bone?

Answer 276

- Aymptomatic 70% - Deep, boring pain - Bony deformity and enlargement – typically pelvis, lumbar spine, skull, femur and tibia (classical bowed sabre tibia)

Question 277

X-ray findings of Paget's disease of the bone - Skull?

Answer 277

o Enlargement of bone o Patchy cortical thickening with sclerosis, osteolysis and deformity (osteoporosis circumscripta of skull)  Osteoporosis circumscripta – large, well-defined lytic lesions  Cotton wool appearance – mixed lytic and sclerotic lesions  Tam o-shanter sign – frontal bone enlargement

Question 278

X-ray findings of Paget's disease of the bone - spine?

Answer 278

 Picture frame sign – cortical thickening and sclerosis encasing margins

Question 279

X-ray findings of Paget's disease of the bone - long bone?

Answer 279

 Blade of grass/candle flame – advancing tip of V-shaped osteolysis to diaphysis

Question 280

Other tests to perform in Paget's disease of the bone?

Answer 280

- Bone scintigraphy o Hot spots of bone - Bloods o Ca and PO4 normal o ALP markedly raised

Question 281

Management of Paget's disease of the bone?

Answer 281

- Analgesia – NSAIDs + paracetamol - Bisphosphonates o Salmon Calcitonin 2nd line - Monitor Ca & Vitmain D levels - Surgery – deformity, osteoarthritis, nerve compression

Question 282

Complications of Paget's disease of the bone?

Answer 282

``` o Pathological fractures o Osteoarthritis o High Calcium o Nerve compression o Osteosarcoma ```

Question 283

Types of bone tumours - benign?

Answer 283

```  Osteoid osteoma  Chondroma, osteochondroma  Fibroma  Haemangioma  Giant cell tumour ```

Question 284

Types of bone tumours - malignant?

Answer 284

```  Osteosarcoma  Chondrosarcoma  Fibrosarcoma  Ewing’s sarcoma, myeloma  Angiosarcoma ```

Question 285

Description and management of osteoid osteoma?

Answer 285

o Usually <1cm in diameter and surrounded by dense osteoid o Young adults o Most common sites – tibia, femur, vertebrae o Present with pain, worse at night, and relieved by NSAIDs o X-ray – radiolucency surrounded by dense bone o Management – local excision

Question 286

Description and management of osteochondroma?

Answer 286

o Sessile or pedunculated lesions arising from cortex of long bone adjacent to epiphyseal plate o Often present in adolescence as cartilaginous overgrowth at epiphyseal plate o Symptoms – painless lump, joint pain o Management – excision

Question 287

Description and management of chondroma?

Answer 287

o Appears in tubular bones of hands and feet o X-ray – well-defined osteopenic area in medulla o Management – excision and bone graft

Question 288

Description and management of giant cell tumour?

Answer 288

o Aggressive, locally recurrent tumour with low metastatic potential o Sub-articular cancellous region of lone bone – mostly in closed epiphyses around knee and distal radius o Symptoms – 20-40 females o X-ray – asymmetric rarefied area at end of long bone o Management – wide excision and joint replacement, amputation if malignant or recurrent

Question 289

Description and management of chondroblastoma?

Answer 289

o Rare, in epiphysis of long bones o Symptoms – joint pain, muscle atrophy, tenderness o Management – curettage and bone grafting

Question 290

Description and management of osteoblastoma?

Answer 290

o Locally destructive progressive lesion found in vertebrae o Presents with dull aching pain o Needs biopsy to exclude malignancy o Management – curettage/bone graft

Question 291

Description and management of osteosarcoma?

Answer 291

o Most common bone malignancy in children o Occurs in metaphyses of long bone, around knee or proximal humerus o Symptoms – painless mass, destroys bone and rapidly metastasises to lung o X-ray – bone destruction and formation, soft-tissue calcification produces ‘sun-burst’ appearance o Management – Surgical excision and mifamurtide and chemo

Question 292

Description, symptoms, investigations, staging and management of Ewing's sarcoma?

Answer 292

Common in white Caucasian <25, usually males Symptoms – mass or swelling in long bones of arms, legs, pelvis, chest, pain in area, redness, anorexia, malaise, weight loss, paralysis, numbness, tingling if nerve affected Investigations  X-ray – Bone destruction with overlying onion-skin layers of periosteal bone formation  Biopsy needed for diagnosis  FBC and LDH prognostic markers  CT/MRI Management  Chemotherapy (Vincristine, ifosfamide, doxorubicin, etoposide)  Radiotherapy  Surgery to remove tumour (limb saving or amputation)

Question 293

Symptoms of bone tumours?

Answer 293

- Pain, swelling and localised tenderness | - Rapid growth and erythema suggest malignancy

Question 294

Referral from primary care if suspected bone sarcoma?

Answer 294

2-week (48 hours if child) X-ray if unexplained bone swelling or pain, then 2-week (48 hours if child) appointment if X-ray suggest possibility

Question 295

Referral from primary care if suspected soft tissue sarcoma?

Answer 295

urgent US (48 hours if child) if unexplained lump increasing in size, then 2-week (48 hours if child) appointment if US suggestive of soft tissue sarcoma

Question 296

Description of SLE?

Answer 296

- Multisystem autoimmune disease where autoantibodies are made against a variety of autoantigens (e.g. ANA) - Polyclonal B-cell secretion of autoantibodies causing tissue damage via immune complexes, deposition and complement activation

Question 297

Epidemiology of SLE?

Answer 297

- Women 9x, typically of child-bearing age | - More common in Afro-Caribbean, Asians

Question 298

Risk factors of SLE?

Answer 298

``` o HLA- DR3/2 o EBV o Drugs  Isoniazid, hydralazine, procainamide, quinidine, chlorpromazine, minocycline, phenytoin  Disease remits if drugs stopped ```

Question 299

Symptoms of SLE?

Answer 299

- Remitting and relapsing pattern o Non-Specific - Malaise, fatigue, myalgia, fever, lymphadenopathy, weight loss, alopecia, non-infective endocarditis, Raynaud’s, migraine, stroke

Question 300

Criteria for diagnosis of SLE?

Answer 300

``` o If 4 or more/11 criteria: Malar Rash (butterfly rash) - Fixed, erythema, flat or raised over malar eminences sparing nasolabial folds ``` Discoid Rash - Erythematous raised patches with keratotic scales and follicular plugging +/- atrophic scarring - Affects ears, cheeks, scalp, forehead Photosensitivity - On exposed skin, may also cause disease to flare Oral Ulcers Serositis - Pleuritis OR Pericarditis Non-Erosive Arthritis - Involving 2 or more peripheral joints, reversible deforming arthropathy may occur due to capsular laxity (Jaccoud’s arthropathy) - Joint and muscle pain – early morning stiffness - Non-erosive Renal Disorder - Persistent proteinuria OR Cellular casts CNS disorders - Seizures OR Psychosis Haematological disorders - Haemolytic Anaemias with reticulocytosis OR Leukopenia OR lymphopenia OR thrombocytopenia Immunological disorders - Anti-dsDNA OR anti-Sm OR antiphospholipid antibody positive Antinuclear antibody (ANA)

Question 301

Screening tests used in SLE?

Answer 301

o FBC o ESR o Plasma viscosity o ANA

Question 302

Further tests performed in SLE?

Answer 302

``` Antibodies  ANA  Anti-dsDNA  Anti-Sm  Anti-SSA/SSB  Antiphospholipid syndrome Complement – low C3 and C4 ESR raised BP Urinalysis and urine M, C & S FBC (normochromic, normocytic anaemia), U&E, LFT, CRP ```

Question 303

Management of SLE - flare ups?

Answer 303

o IV cyclophosphamide + high-dose prednisolone

Question 304

Management of SLE - maintenance - general measures?

Answer 304

 Smoking Cessation  Sun protection  Exercise

Question 305

Management of SLE - maintenance - joint symptoms?

Answer 305

 NSAIDs and hydroxychloroquine  Low-dose prednisolone  Steroid sparing - Azathioprine, methotrexate and mycophenolate  Cyclophosphamide reserved for life-threatening disease

Question 306

Management of SLE - maintenance - mucocutaneous disease?

Answer 306

 Sun protection  Chlorhexadine, basic oral hygiene and dental appointments  Artificial saliva preparations for dry mouth  Hypromellose eye drops  Hydroxychloroquine  Low-dose prednisolone  Steroid sparing - Azathioprine, methotrexate and mycophenolate

Question 307

Management of SLE - maintenance - lupus nephritis?

Answer 307

 Induction phase - prednisolone, cyclophosphamide or hydroxychloroquine  Maintenance – azathioprine/mycophenolate + prednisolone  BP control - ACEi, A-blockers or CCB  Renal replacement therapy if disease progresses

Question 308

Management of SLE - maintenance - B-cell depletion?

Answer 308

 Belimumab if autoantibody positive SLE

Question 309

Prognosis of SLE?

Answer 309

o 5-year survival 95%

Question 310

Complications of SLE?

Answer 310

``` o Anaemia o Leucopenia o Thrombocytopenia o Steroid-related problems o Amenorrhoea or infertility due to cyclophosphamide o Pericarditis o Myocarditis o Endocarditis o Pleuritis o Pleural Effusion ```

Question 311

Description of systemic sclerosis?

Answer 311

- Systemic sclerosis is multisystem autoimmune disease where there is increased fibroblast activity resulting in abnormal growth of connective tissue o Causes vascular damage and fibrosis in skin, GI, heart, lungs, other organs o Vascular manifestations unclude secondary Raynaud’s phenomenon, ischaemia of extremities, pulmonary arterial hypertension and renal disease

Question 312

Description of scleroderma?

Answer 312

o Scleroderma refers to dermatological component of systemic sclerosis o Localised scleroderma called morphoea – excessive collagen deposition leading to thickening of dermis

Question 313

Symptoms of scleroderma?

Answer 313

 Plaques thickened, usually oval patches  Mauve colour then change to ivory white in middles with lilac edges  Surface is smooth and shiny

Question 314

Investigations of scleroderma?

Answer 314

 Deep punch biopsy

Question 315

Management of scleroderma?

Answer 315

 UVB phototherapy  UVA phototherapy  Methotrexate +/- prednisolone  Topical tacrolimus, imiquimod

Question 316

Peak age for systemic sclerosis?

Answer 316

40-50

Question 317

Risk factors of systemic sclerosis?

Answer 317

o FHx o CMV, parvovirus B19, HepB, EBV, Toxoplasma, H.pylori, chlamydia o Pesticides, hair dye, silica o Cocaine, bleomycin, penicillamine, vitamin K o Vitamin D deficiency

Question 318

Types of systemic sclerosis?

Answer 318

o Limited cutaneous systemic sclerosis  Areas of skin affected include only face, hands and feet  Older term is CREST (calcinosis, Raynaud’s, oesophageal and gut dysmotility, sclerodactyly and telangiectasia)  Associated with anticentromere antibodies o Diffuse cutaneous systemic sclerosis  Whole body and early organ fibrosis (lung, GI, cardiac and renal)  Antitopoisomerase-1 & anti-RNA polymerase antibodies

Question 319

Symptoms of systemic sclerosis - the two types?

Answer 319

- LcSSc o Milder disease, slow onset and slow progression - DcSSc o Rapid onset, skin thickening and Raynaud’s phenomenon occurring together and skin changes spread rapidly o Symptoms worse in first 3-5 years

Question 320

General features of systemic sclerosis?

Answer 320

o Fatigue | o Weight Loss

Question 321

Skin features of systemic sclerosis?

Answer 321

``` o Swelling of fingers and toes – sclerodactyly o Skin hard and thickened o Raynaud’s phenomenon o Calcinosis – nodules or lumps of chalky material o Tight facial skin and tight lips o Telangiectasia o Salt and Pepper appearance of skin o Dry skin ```

Question 322

MSK features of systemic sclerosis?

Answer 322

o Joint pain and swelling o Myalgia o Restricted joint movements

Question 323

GI features of systemic sclerosis?

Answer 323

``` o GORD o Oesophageal scarring o Fullness after meals o Reduced bowel motility o Constipation ```

Question 324

Pulmonary features of systemic sclerosis?

Answer 324

``` o Fibrosis (ILD) – exertional SOB, cough and crackles o Pulmonary arterial hypertension – exertional SOB, syncope, RV strain ```

Question 325

Cardiac features of systemic sclerosis?

Answer 325

``` o Microvascular CAD o Myocardial fibrosis o LV failure o Pericarditis o Arrhythmias ```

Question 326

Renal features of systemic sclerosis?

Answer 326

o Glomerulonephritis | o Reduced renal function

Question 327

GU features of systemic sclerosis?

Answer 327

o Erectile dysfunction | o Dysparenunia

Question 328

Investigations done in systemic sclerosis?

Answer 328

``` - Bloods o FBC o ESR and CRP o U&E - Antibodies o Anti-topoisomerase 1 (anti-Scl 70) o Anti-centromere antibody (ACA) o Anti-RNA polymerase 3 antibody - Urine protein ```

Question 329

Management of acute systemic sclerosis?

Answer 329

Scleroderma Renal Crisis  BP control – ACEi or CCB  Renal dialysis or transplant

Question 330

Chronic management of systemic sclerosis - non-pharmacological?

Answer 330

```  Physiotherapy  Exercise  Stop smoking  Emollients for skin dryness  Maintain healthy weight ```

Question 331

Chronic management of systemic sclerosis - Pharmacological?

Answer 331

 Methotrexate, mycophenolate or cyclophosphamide

Question 332

Chronic management of systemic sclerosis - Raynaud's Phenomenon?

Answer 332

 Avoid cold weather, stop smoking  CCB (nifedipine)  Aspirin  If ulcers – PDE-5 inhibitors

Question 333

Chronic management of systemic sclerosis - skin?

Answer 333

 Topical emollient  Topical/Oral prednisolone  Antihistamine  If thickening - Methotrexate, mycophenolate or cyclophosphamide

Question 334

Chronic management of systemic sclerosis - GI involvement?

Answer 334

 GORD – PPI |  Gastroparesis – Prokinetic agents (erythromycin, domperidone)

Question 335

Chronic management of systemic sclerosis - ILD?

Answer 335

 Prednisolone  Azathioprine  Continuous Oxygen therapy  Lung transplant

Question 336

Chronic management of systemic sclerosis - pulmonary arterial hypertension?

Answer 336

 PDE-5 inhibitor  Oxygen  Lung transplant

Question 337

Monitoring in systemic sclerosis?

Answer 337

o Annual LFTs, Echos | o Monitor U&Es and BP closely

Question 338

Description of rotator cuff disorders?

Answer 338

o Subacromial pain which is felt in top and lateral side of shoulder o Most common cause of shoulder pain, typically 35-75 and history of repetitive movements at shoulder height or heavy lifting o Include:  Tendinopathy • Shoulder impingement – between acromion and rotator cuff tendons  Partial rotator cuff tears

Question 339

Diagnosis of rotator cuff injury?

Answer 339

 Pain in top and lateral side of shoulder made worse by lifting arm or overhead activities  Night pain  Painful and restricted active movements  Painful passive movements  Painful arc syndrome – 70-120o of abduction

Question 340

Description of frozen shoulder?

Answer 340

o Stiffness and disability of shoulder o Progressive restriction of both active and passive shoulder movement o Typically 40-60, women o Primary or secondary (trauma, rotator cuff tear, CVD, hemiparesis, diabetes, thyroid disease)

Question 341

Phases of frozen shoulder?

Answer 341

 Painful phase – lasts 2-9 months, pain on movement, severe and can disturb sleep  Stiffness phase – lasts 4-12 months, less severe and reduced ROM  Resolution phase – lases 12-42 months, improvement gradually

Question 342

Diagnosis of frozen shoulder?

Answer 342

 Gradual onset pain in deltoid region, worsening shoulder stiffness  Restricted active and passive external rotation

Question 343

Description of shoulder instability?

Answer 343

o Abnormal movement of head of humerus o Typically, <35 years, shoulder feeling out of joint or moves o Causes pain, subluxation or dislocation

Question 344

Diagnosis of shoulder instability?

Answer 344

 Shoulder moves partly or feeling out of joint  Ache or clicking  Arm weakness, tingling  Shoulder dislocation • Anterior – fall onto outstretched hand, <20 years have 90% of further dislocation • Posterior

Question 345

When to XR shoulder?

Answer 345

- Anteroposterior and lateral shoulder XR: o History of trauma o Person not improving with conservative treatments o Movement restricted o Severe pain o Arthritis suspected

Question 346

Management of shoulder pain - when to refer urgently?

Answer 346

```  Trauma, pain and weakness, or sudden loss of ability to actively raise the arm  Any shoulder mass or swelling  Red skin, painful joint, fever  Trauma leading to abnormal shape  New inflammatory symptoms  Systemic symptoms  Acute rotator cuff tear ```

Question 347

Management of shoulder pain - initial management?

Answer 347

```  Analgesia • Paracetamol 1st line • Oral NSAIDs or codeine added on  Encourage carrying out normal daily activities if they are able  Refer to physiotherapy ```

Question 348

Management of shoulder pain - when to refer to secondary care?

Answer 348

 Recurrent shoudler instability  Post-traumatic pain  Not improving after 3 months

Question 349

Management of rotator cuff disorders - general management?

Answer 349

o Rest in acute phase – avoid reaching overhead o Resume normal activities when feel able to do so o Analgesia  Paracetamol 1st line  Oral NSAIDs or codeine added on o Exercises/Physio (6 weeks) o Corticosteroid injection  Give another after 6 weeks if improvement

Question 350

Management of rotator cuff disorders - referral?

Answer 350

 Not benefitted after 6 weeks of non-surgical treatment

Question 351

Management of rotator cuff disorders - surgery?

Answer 351

 Arthroscopic rotator cuff tendon repair if large

Question 352

Management of frozen shoulder?

Answer 352

``` o Avoid movements that worsen pain but continue to use to avoid stiffness o Heat packs o In bed, support arm with pillow o Analgesia • Paracetamol 1st line • Oral NSAIDs or codeine added on o Physiotherapy (6 weeks) o Referral to secondary care:  Pain or stiffness for 3 months and not benefitting from conservative measures ```

Question 353

Description of lateral epicondylitis (Tennis Elbow)?

Answer 353

- Tendonosis affects attachment of tendons of extensor muscles of forearm to lateral epicondyle of humerus

Question 354

Epidemiology of lateral epicondylitis (Tennis Elbow)?

Answer 354

- Prevalence of 1-3%, peak 35-55 years - Most commonly affected muscle is extensor carpi radialis brevis - Dominant arms in 75%

Question 355

Causes of lateral epicondylitis (Tennis Elbow)?

Answer 355

o Minor trauma – repetitive overuse causes micro-tears near origin of common extensor tendon which initiates degenerative process

Question 356

Activities associated of lateral epicondylitis (Tennis Elbow)?

Answer 356

o Tennis o Plumbing o Grip-tensive activities involving repetitive forceful elbow movements

Question 357

Symptoms of lateral epicondylitis (Tennis Elbow)?

Answer 357

- Pain in lateral elbow, with wrist extension and reduced grip strength o Radiates down extensor aspect of forearm o Worsened by excessive and repetitive use of extensor muscles of forearm (strong gripping, repetitive wrist movements) o Occupations using vibratory machines worsen symptoms - Impacts on ADLs

Question 358

What is Mill's Test?

Answer 358

o Straighten patients arm and palpate lateral epicondyle o Fully flex wrist o Pronate patients’ forearm o If painful – positive test

Question 359

What is Cozen's Test?

Answer 359

o Elbow 90 degree of flexion, patient makes a fist and deviates wrist radially with forearm pronated o Resisted extension of wrist o Pain in lateral epicondyle is positive result

Question 360

General management of lateral epicondylitis (Tennis Elbow)?

Answer 360

o Avoid heavy lifting, forceful gripping or twisting actions that may aggravate it o Discuss with OH if work-related  May mix work patterns, take more rest breaks, change handling procedures

Question 361

Further management of lateral epicondylitis (Tennis Elbow)?

Answer 361

- Analgesia o Paracetamol and Ibuprofen gel 1st line o Oral if symptoms ongoing o Corticosteroid injection (may be repeated 2-3 times at 3-6 months intervals) - Physiotherapy

Question 362

When to refer to orthopaedics in lateral epicondylitis (Tennis Elbow)?

Answer 362

o Uncertain diagnosis o Refractory pain o Pain >12 months despite optimal treatment

Question 363

Prognosis of lateral epicondylitis (Tennis Elbow)?

Answer 363

Self-limiting and improves in about 80% of cases over 1-2 years

Question 364

Description of medial epicondylitis (Golfer's elbow)?

Answer 364

- Tendonosis of flexor forearm muscles which insert into medial epicondyle, causing medial elbow pain

Question 365

Causes of medial epicondylitis (Golfer's elbow)?

Answer 365

``` o Golf and other sports o DIY o Computer use o Climbing o Use of vibrating tools ```

Question 366

Symptoms of medial epicondylitis (Golfer's elbow)?

Answer 366

- Pain and tenderness over medial epicondyle, radiating into forearm o Aggravated by wrist flexion and pronation o Gradual onset

Question 367

Tests done in medial epicondylitis (Golfer's elbow)?

Answer 367

- Golfer’s elbow test o Pronate and flex wrist and forearm at same time o Pain over medial epicondyle is positive test

Question 368

General measures of medial epicondylitis (Golfer's elbow)?

Answer 368

o Avoid heavy lifting, forceful gripping or twisting actions that may aggravate it o Discuss with OH if work-related  May mix work patterns, take more rest breaks, change handling procedures

Question 369

Further management of medial epicondylitis (Golfer's elbow)?

Answer 369

- Analgesia o Paracetamol and Ibuprofen gel 1st line o Oral if symptoms ongoing o Corticosteroid injection (may be repeated 2-3 times at 3-6 months intervals) - Physiotherapy

Question 370

Referral to orthopaedics in medial epicondylitis (Golfer's elbow)?

Answer 370

o Uncertain diagnosis o Refractory pain o Pain >12 months despite optimal treatment