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MSK Flashcards

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1
Q

What is Ankylosing spondylitis ?

A

Seronegative spondyloarthopathy and a chronic inflammatory disease of the axial skeleton that leads to partial or complete fusion and rigidity of the spine

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2
Q

Epidemiology of Ankylosing spondylitis? (3)

A

Young males

  • M>F
  • Age 15-40 years old
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3
Q

What gene is Ankylosing spondylitis associated with it?

A

HLA-B27

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4
Q

What are the clinical features of ankylosing spondylitis ? (7)

A
  • Inflammatory back pain- describe it
    • Early morning back stiffness which gets better with activity
    • May experience night pain
  • Anterior uveitis
  • Enthesitis- Inflammation where tendon or ligament attaches to bone (achilles is most common site)
  • Tenderness at sacroiliac joint
  • Reduced spinal mobility
  • Extra-articular features
  • Constitutional symptoms
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5
Q

Anterior uveitis- features? (3)

A
  • Eye pain
    • Redness
    • Photophobia
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6
Q

Extra-articular features (6 A’s) of ankylosing spondylitis

A
  • Apical lung fibrosis
    • Amyloidosis
    • Anterior uveitis
    • Achilles tendinitis
    • Aortic regurgitation
    • AV node block
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7
Q
  • Constitutional symptoms of ankylosing spondylitis - what are they? (4)
A
  • Fatigue
    • Weakness
    • Fever
    • Weight loss
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8
Q

Name an investigation requested in all patients presenting with inflammatory back pain

A

Pelvic X-Ray

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9
Q

What will the pelvic X-Ray show for Ankylosing spondylitis ?

A

Sacroiliitis → Subchondral erosions and sclerosis

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10
Q

What will Lumbar X-Ray show for Ankylosing spondylitis? (2)

A
  • Bamboo spine- Syndesmophytes (ossification of outer fibres of annulus fibrosus) form between adjacent vertebrae
  • Squaring of lumbar vertebrae
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11
Q

List 4 investigations for ankylosing spondylitis

A
  • HLA-B27
  • MRI
  • CXR
  • spirometry
  • Schober’s test
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12
Q

for Ankylosing spondylitis , Schober’s test- showing? (3)

A
  • Reduced lateral flexion <5cm
    • Reduced forward flexion
    • Reduced chest expansion
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13
Q
  • MRI for Ankylosing spondylitis - when do we do it and what will it show?
A
  • If high suspicion for AS but X-ray negative
    • May show enthesitis
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14
Q

-for ankylosing spondylitis
CXR- showing?

A

Apical lung fibrosis

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15
Q

for ankylosing spondylitis
What would spirometry show?

A

Restrictive defect → FEV1/FVC ratio >0.7

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16
Q

What’s 1st line for ankylosing spondylitis?

A

NSAIDs and encourage regular exercise (physiotherapy)

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17
Q

for ankylosing spondylitis, What if there is high disease activity despite conventional treatment (failed on 2 NSAIDs)?

A

Anti-TNF-alpha (infliximab or etanercept)

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18
Q

for ankylosing spondylitis,, What is the treatment if there is peripheral joint involvement?

A

DMARDs (Methotrexate)

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19
Q

List complications of ankylosing spondylitis (4)

A
  • Osteoporosis
  • Cardiac involvement
  • Hip involvement
  • Pulmonary involvement
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20
Q

Describe the prognosis of ankylosing spondylitis (2)

A
  • Patients who do well are those who lead active lifestyles and maintain a disciplined exercise programme
  • Disease progression may ultimately lead to the fusion of the sacroiliac joints and the vertebral column, resulting in bamboo spine
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21
Q

What is gout?

A

Acute inflammatory monoarthritis, caused by percipitation of monosodium urate crystals in joints

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22
Q

Risk factors for crystal arthropathy? (4)

A
  • Male
  • Obesity
  • Alcohol
  • Meat & seafood
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23
Q

What is the strongest risk factor for crystal arthropathy?

A

Hyperuricaemia

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24
Q

What are the causes of hyperuricaemia? (2)

A

Underexcretion of uric acid
Overproduction of uric acid

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25
Underexcretion of uric acid- causes? (2)
- Renal failure (CKD) - Thiazide diuretics
26
Overproduction of uric acid- cause?
Tumour lysis syndrome
27
What is pseudogout?
Deposition of calcium pyrophosphate crystals within the joint space
28
Name a risk factor for pseudogout
Hyperparathyroidism (due to increased serum calcium)
29
Gout clinical features? (7)
- Severe pain - Swollen, red, stiff joint - Asymmetrical joint distribution - Erythema and warmth - Podagra (Painful MTP of big toe) - Tophi - Acute attacks after large meal with purine rich foods e.g. red meat or seafood
30
Tophi- present where? **(3)**
Present over extensor surface joints - Elbows - Knees - Achilles tendons
31
Pseudogout clinical features? (2)
- Pain and swelling, knee most commonly affected - Longer duration of acute attacks than gout
32
Which investigation differentiates between gout and pseudogout?
Arthrocentesis with synovial fluid analysis
33
What does Arthrocentesis with synovial fluid analysis show in gout? (2)
- Needle shaped crystals - Negatively birefringence
34
What does Arthrocentesis with synovial fluid analysis show in pseudogout? (2)
- Rhomboid shaped crystals - Positively birefringent
35
Following an acute episode, what should be checked in gout?
- Once it has settled down, serum urate levels checked 2 weeks later - Uric acid levels may be high, normal or low during the attack
36
What would an X-Ray show in gout?
“Rat bite” erosions
37
What would an X-Ray show in pseudogout?
Chondrocalcinosis (Cartilage calcification)
38
What must you exclude in gout & how?
Septic arthritis by gram stain and cultures
39
What is the management for acute gout?
NSAIDs (Naproxen)
40
What if NSAIDs are contraindicated for management for acute gout?
Colchicine (If patient has e.g. peptic ulcers or CKD)
41
what is the management for recurrent gout?
Allopurinol → Lowers uric acid levels via inhibition of xanthine oxidase Also give NSAID/colchicine when starting on it as a cover
42
What other medication can Allopurinol have a bad interaction with?
Azathioprine as it can cause bone marrow suppression
43
List lifestyle changes for management of gout (3)
- Reduce alcohol - Lose weight - Avoid foods high in purines- such as? **(3)** - Liver - Seafood - Oily fish
44
What is the management for acute pseudogout? (3)
- Intra-articular corticosteroids (dexamethasone) - NSAIDs - Colchicine
45
What do we give therefore for mono/oligoarticular disease? (2)
intra-articular dexamethasone +/- paracetamol
46
What do we give therefore for polyarticular disease? (2)
NSAIDs or colchicine +/- paracetamol
47
What is the management for chronic/recurrent pseudogout?
Joint replacement
48
What is Osteoarthritis?
Joint disease characterised by non-inflammatory degeneration of the joint complex
49
Which joints are most commonly affected inOsteoarthritis (most common to least)? (3)
Knee > hip > hands
50
Risk factors in Osteoarthritis? (6)
- Obesity - Excessive joint loading - Family history - History of joint injury - Female - Age >50
51
What are the Clinical features of OA? (6)
- Pain during or after exertion, relieved by rest - Sparing of the MCP joints but involves PIP & DIPs - Malalignment (Causes valgum and varum deformities) - Crepitus - Asymmetrical joint involvement
52
- Why do Heberden and Bouchard nodes occur?
Due to osteophyte formation
53
Sparing of the MCP joints but involves PIP & DIPs- what does this differentiate?
Differentiates OA from RA which does affect MCP
54
Bony deformities of OA- what are they? **(4)**
- Heberden nodes at DIPs - Bouchard nodes at PIPs - Squaring at base of thumb - Varus deformity
55
What would X-Ray of affected joints in OA show? (4)
**LOSS** - Loss of joint space - Osteophytes - Subchondral sclerosis - Subchondral cysts
56
What would CRP and ESR show for OA?
normal
57
What would rheumatoid factor and anti-CCP show for OA?
Negative
58
Long term OA non-pharmacological management? (2)
- Regular low impact aerobic exercise and muscle strengthening - Weight loss
59
What’s 1st line for OA? (2)
- Paracetamol - Topical NSAIDs (only for knee and hand)
60
What’s 2nd line for OA? (3)
- Oral NSAIDs - Opioids - Intra-articular corticosteroids
61
- What needs to be prescribed along with oral NSAIDs?
PPI
62
What treatment option is left if OA patient is experiencing persistent pain despite multiple treatment modalities?
Arthroplasty → Complete or partial replacement of the joint
63
List complications of OA (3)
- Decline in ADL (Activities of daily living) - Effusion - NSAID related GI bleed
64
Describe the prognosis of OA (2)
- Combo. of treatment can provide adequate pain control and preserve function and QOL for many patients - However, most patients continue to have some degree of pain and functional limitation affecting their desired activities and QOL
65
What is osteomalacia? (2)
Softening of the bones secondary to low vitamin D levels which in turn leads to decreased bone mineral content
66
What is rickets?
Disorder of impaired mineralisation of cartilaginous growth plates (Only in children)
67
Causes of osteomalacia? (3)
- Vitamin D deficiency- caused by? (3) - Reduced exposure to sunlight - Low dietary intake - Reduced intestinal absorption- caused by? **(2)** - Coeliac disease - Chronic pancreatitis - Defective vitamin D metabolism- caused by? **(2)** - Liver cirrhosis - CKD - Drugs (Anticonvulsants)
68
What are the clinical features of osteomalacia? (5)
- Bone pain & tenderness - Pathological fractures, esp at Femoral neck - Proximal myopathy- May lead to waddling gait - Fatigue - Hypocalcaemia symptoms- which are? **(4)** - Convulsions - Arrhythmias - Tetany - Paraesthesia
69
What will be found in bloods for osteomalacia? (4)
- Low vitamin D levels - Low calcium & phosphate - Raised ALP - Raised PTH (Secondary hyperparathyroidism)
70
What may you find on an X-Ray in osteomalacia?
Looser zones (Pseudofractures)
71
What is the main management for osteomalacia? (2)
Vitamin D supplementation - Ergocalciferol + Calcium carbonate (if dietary calcium is inadequate)
72
List complications of osteomalacia (3)
- Pseudofractures - Hypocalcaemia (sometimes normocalcaemia) - Secondary hyperparathyroidism
73
What is prognosis of osteomalacia dependent on? (2)
- On underlying cause - Compliance with therapies
74
What is osteomyelitis?
Inflammatory condition of the bone caused by an infective organism
75
What organisms cause osteomyelitis most? (2)
- Most commonly Staphylococcus aureus - Except in sudden cardiac arrest patients, salmonella species is more common
76
What are the two classifications of osteomyelitis?
Haematogenous osteomyelitis and Non-haematogenous osteomyelitis
77
Haematogenous osteomyelitis- what is it?
Results from bacteraemia and usually monomicrobial → most common in children
78
Risk factors of Haematogenous osteomyelitis? (4)
- Sickle cell anaemia - IV drug use - Immunosuppression - Infective endocarditis
79
Non-haematogenous osteomyelitis- what is it?
Results from contagious spread of infection from adjacent soft tissues to the bone or from direct injury/trauma to the bone and usually polymicrobial
80
Risk factors of Non-haematogenous osteomyelitis? (3)
- Diabetic foot ulcers/pressure sores - DM - Peripheral arterial disease
81
Which of these 2 types of osteomyelitis is most common in adults?
Non-haematogenous osteomyelitis
82
How many bones does osteomyelitis usually involve?
A single bone
83
Risk factors of osteomyelitis? (6)
- Penetrating injury - IV drug use - Diabetes - HIV - Recent surgery - Distant or local infection
84
What are the clinical features of osteomyelitis? (4)
- Limp or reluctancy to weight bear- common presentation in who? Children - Pain at site of infection - Malaise, fatigue, fever, chills - Inflammation, tenderness, erythema or swelling
85
What clinical feature in native vertebral osteomyelitis?
Local back pain with systemic symptoms
86
What is the most definitive imaging modality for osteomyelitis?
Bone MRI
87
What investigation is needed for osteomyelitis before giving Abx?
Bone biopsy
88
What will be raised in bloods for osteomyelitis? (3)
- WCC - ESR - CRP
89
What is the management for osteomyelitis?
Abx therapy for 2-4 weeks → Flucloxacillin (IV)
90
What is the management for osteomyelitis if the patient is allergic to penicillin??
Clindamycin
91
List complications of osteomyelitis (3)
- Drug reactions - Infection recurrence - Fracture
92
Describe the prognosis if osteomyelitis is diagnosed promptly and treated adequately
For most patients with acute osteomyelitis recover with no long-term complications
93
What is osteoporosis?
- Skeletal disease characterised by low bone density and micro-architectural defects in bone tissue - This leads to increased bone fragility and susceptibility to fractures
94
What is the most common type of osteoporosis?
Primary osteoporosis
95
List causes of primary osteoporosis (3)
- Post menopausal osteoporosis- - Senile osteoporosis- - RA
96
Post menopausal osteoporosis- what happens?
Decreased oestrogen, leads to increased bone resorption due to increased osteoclast activity and decreased osteoblast activity
97
- Senile osteoporosis- what happens?
Gradual loss of bone mass as patients age
98
List causes of secondary osteoporosis (5)
- Drug induced- which ones? **(2)** - Long term corticosteroid therapy - PPIs - Cushing’s syndrome - Hyperthyroidism - Hyperparathyroidism - Hypogonadism
99
Risk factors of osteoporosis? (2)
- Tobacco smoking - Malnutrition → Low calcium and vitamin D
100
Clinical features of osteoporosis? (2)
- Fragility fractures → Pathological fractures caused by everyday activities or minor trauma - Back pain → Vertebral fracture is most common
101
What is the gold standard investigation for measuring bone density?
DEXA scan
102
What is a T-score?
- Bone density as a standard deviation compared to reference population of healthy young adults - i.e. -2.5 = 2.5 SD’s below that of an average healthy young adult
103
What t score result indicates osteoporosis?
T-score ≤ -2.5
104
What t score result indicates osteopenia?
-1 to -2.5
105
What is a Z score?
Adjusts for age, sex, ethnicity
106
In which patient is a DEXA scan not necessary in diagnosing osteoporosis?
Following a fragility fracture in women ≥ 75 years
107
What is 1st line investigation for suspected osteoporotic vertebral fracture?
X-Ray of the spine (not an MRI)
108
What is FRAX?
Estimates 10 year risk of fragility fracture
109
What will bone profile and bloods show for osteoporosis?
Normal - ALP - Ca - PO4 - PTH
110
What do always check in a man with osteoporosis?
Testosterone
111
What’s 1st line management for osteoporosis?
bisphosphonates (alendronate) → Inhibit osteoclasts leading to reduced bone resorption
112
What other conditions can we use bisphosphonates for? (3)
- hypercalcaemia - Paget’s disease - Pain from bone metastases
113
Side effects of bisphosphonates? (3)
- Oesophagitis/oesophageal ulcer- how to avoid? patients should take tablet on empty stomach 30 mins before brekky with lots of water and remain upright for 30 mins to reduce mucosal irritation - Osteonecrosis of the jaw - Atypical stress fractures, esp of proximal femoral shaft
114
What can you give if patients can’t tolerate side effects of oledronates?
Risedronate
115
What is 2nd line for postmenopausal women with osteoporosis?
Denosumab
116
List other management based on cause of osteoporosis (3)
- Calcium and vitamin D supplementation (ergocalciferol)- if needed then give before alendronate - Teriparatide (PTH analogue) - Avoid or minimise use of glucocorticoids
117
What is a complication of osteoporosis?
Fractures - Hip - Rib - Wrist
118
What is septic arthritis?
Infection of the joint space
119
List two routes of spread for septic arthirtis
Haematogenous- Direct contamination-
120
Haematogenous- meaning?
Spread from a distant site - Abscess - Wound infection - Septicaemia
121
Direct contamination in septic arthritis- from?
Iatrogenic from arthrocentesis or trauma leading to open wounds around joints
122
what is the most common causative organism for septic arthritis in adults and children >2 years?
Staphylococcus aureus (gram +ve)
123
what is the most common causative organism in young adults for septic arthritis who are sexually active?
Neisseria gonorrhoeae (gram -ve diplococci)
124
what is the most common causative organismfor septic arthritis in a prosthetic joint?
Staph epidermidis
125
Risk factors of septic arthritis? (6)
- underlying joint disease (OA/RA) - prosthetic joint - age >80 - immunosuppression - diabetes - IV drug use
126
What are the clinical features for septic arthritis? (4)
- Acute onset- Symptoms present for <2 weeks - Unilateral hot, swollen, painful, restricted joint - Fever - Most commonly affected joint is the knee joint (followed by hip, wrist, shoulder, ankle)
127
What is the triad of clinical features in septic arthritis?
- Fever - Joint pain - Restricted ROM
128
What is arthrocentesis?
Joint aspiration- procedure in which synovial fluid is aspirated from a joint using a sterile needle
129
What is important to do before prescribing antibiotics to septic arthritis patients? (2)
Joint aspiration & culture
130
What does a synovial fluid analysis show in septic arthritis? (2)
- Appearance often yellow-green and turbid - Increased WCC (>90% neutrophils)
131
What else can be done with the synovial fluid in septic arthritis?
Gram stain
132
What type of bacteria is s.aureus? (2)
- Gram positive cocci - Coagulase positive
133
List two other investigations for septic arthritis? (2)
- Blood cultures - Increased CRP & ESR
134
What is the management plan for septic arthritis? (2)
Joint drainage (Therapeutic arthrocentesis)
135
IV antibiotics which cover gram-positive cocci- which one?
Flucloxacillin
136
What if the septic arthritis patient is penicillin allergic?
Clindamycin
137
How long shd clindamycin coursebe
4-6 weeks
138
Describe the prognosis of septic arthritis
Delayed treatment can lead to irreversible joint destruction and subsequent disability
139
What is Reactive arthritis?
Sterile arthritis that occurs after a bacterial infection of the gastrointestinal or urinary tract
140
Name the bacteria causing post-STI reactive arthritis
Chlamydia trachomatis- this form of arthritis is much more common in men
141
What is reactive arthritis categorised as & why? (3)
Seronegative spondyloarthropathy - Negative for rheumatoid factor - Strong genetic association with HLA-B27
142
Who does reactive arthritis commonly affect?
Young men
143
What are the clinical features of reactive arthritis ? (7)
**Can’t see, can’t pee, can’t climb a tree** - Arthritis developing 1-4 weeks after onset of infection (usually asymmetric and affects larger joints in lower extremity) → leads to painful, warm, swollen, red and stiff joints - Lower back pain - Conjunctivitis or Uveitis - symptoms from preceding infection → Diarrhoea, dysuria, urethritis - Dactylitis (Inflammation and swelling of digit) - Fever, fatigue, weight loss - Skin changes
144
reactive arthritis-- Skin changes- such as? **(2)**
- circinate balanitis (painless vesicles on the coronal margin of the prepuce- head of penis) - keratoderma blenorrhagica (waxy yellow/brown papules on palms and soles)
145
What can help differentiate reactive arthritis from septic arthritis symptomatically?
Normal ROM in reactive arthritis
146
ESR & CRP in reactive arthritis
Elevated
147
HLA-B27in reactive arthritis
positive
148
ANA & rheumatoid factor in reactive arthritis
Negative, rule out other conditions
149
Arthrocentesis (synovial fluid analysis) in reactive arthritis(4)
- Cloudy yellow colour - Culture negative - Normal WBC - No crystals
150
What’s 1st line for reactive arthritis?
NSAIDs - Naproxen - Ibuprofen - Diclofenac
151
What if NSAID’s don’t work in reactive arthritis?
Corticosteroids (Prednisolone)
152
What medication do we not use in reactive arthritis?
Antibiotics
153
What must cases of reactive arthritis be in order to be characterised as chronic?
Refractory to both NSAIDs and corticosteroids
154
How do we treat chronic cases of reactive arthritis ?
DMARDs (Sulfasalazine)
155
Describe the prognosis of reactive arthritis
Resolves spontaneously within a year, high rate of recurrence
156
What is Rheumatoid arthritis?
A chronic, systemic, inflammatory autoimmune disorder that primarily affects the joints
157
Who does rheumatoid arthritis usually affect? (2)
- Females - 40-60 year olds
158
Risk factors of rheumatoid arthritis? (2)
- Genetic predisposition- which genes? **(2)** - HLA-DR1 - HLA-DR4 - Smoking
159
What are the clinical features of rheumatoid arthritis? (11)
- Symmetrical pain and swelling- in which joints? **(3)** - MCP - PIP - MTP - Morning stiffness >30 min that improves with activity - Rheumatoid nodules (non-tender, firm, subcutaneous nodules on skin) - Hand deformities- which ones? **(3)** - Ulnar deviation - swan neck deformity (MCP flexion, PIP extension, DIP flexion) - Boutonniere finger deformity (PIP flexion, DIP extension - like pushing a button) - Episcleritis, scleritis - Pleural effusions - Carpal tunnel syndrome - Anaemia of chronic disease - Constitutional symptoms → fever, fatigue, malaise, weight loss - Pleuritic chest pain → pleuritis or pericarditis can occur - Pyoderma gangrenosum
160
Which joints are spared in RA?
DIP
161
- Episcleritis, scleritis- what’s the difference between the 2?
Episcleritis is erythema only, whereas scleritis is erythema and pain
162
What is Felty’s syndrome? (3)
Rheumatoid arthritis + splenomegaly + low white cell count
163
What’s 1st line investigation for Rheumatoid arthritis?
Rheumatoid factor- Positive in 60-70% of patients- more sensitive
164
What’s a more specific test for Rheumatoid arthritis?
Anti-CCP
165
What scan do we have to do in all patients with suspected RA?
X-ray of hands and feet
166
What would x ray of hand and feet show if positive RA? (3)
- Loss of joint space - Juxta-articular osteoporosis/penia - Soft-tissue swelling
167
What would ultrasonography show for Rheumatoid arthritis?
Synovitis of wrist and fingers
168
What would joint aspiration show in Rheumatoid arthritis?
High WCC
169
Which white cell predominantly shows in RA?
Polymorphonuclear neutrophils
170
Describe the appearance of the RA joint aspiration (2)
- Turbid, yellow - Absence of crystals
171
What scoring system is used to follow RA disease activity?
DAS28
172
How is RA managed? (2)
- DMARDS to slow disease progression- which ones? **(2)** - Methotrexate +/- prednisolone (at initial diagnosis) or - Hydroxychloroquine (or sulfasalazine) - NSAIDS- which ones are there? **(3)** - Ibuprofen - Naproxen - Diclofenac
173
What are other side effects of methotrexate? **(4)**
- Pneumonitis (cough, SOB, fever) - Mucositis - Pulmonary fibrosis - Liver fibrosis
174
what needs to be co-prescribed with methotrexate?
Folate- methotrexate is an anti-folate so co-prescribe folate to reduce the risk of myelosuppression
175
What can be prescribed if there is an inadequate response to at least 2 DMARDs in RA?
Infliximab (TNF-alpha inhibitor)
176
- What is an adverse effect of TNF-alpha inhibitors?
May reactive TB
177
Diclofenac- what diseases is this contraindicated in?
Any form of CVD e.g. IHD, PAD, c)erebrovascular disease, congestive heart failure
178
How are RA flares managed?
Corticosteroids- Prednisolone
179
Describe the prognosis of RA
Patients treated aggressively and early have a good prognosis with most patients achieving good disease control
180
What is Polymyalgia rheumatica?
inflammatory rheumatological syndrome that is relatively common
181
Epidemiology of Polymyalgia rheumatica? (2)
- Females - Typically over 60 years of age
182
What are the causes of Polymyalgia rheumatica? (2)
- Genetic predisposition - Associated with giant cell arteritis- features of temporal arteritis
183
features of temporal arteritis? (5)
- Unilateral vision loss - Headache - Jaw claudication - Scalp tenderness - Tender, palpable temporal artery
184
- Investigations of temporal arteritis? **(3)**
- 1st line- raised ESR (first investigation) - Temporal artery biopsy should be done (may show skip lesions so if negative but still high suspicion, continue pred and redo within 7 days) - Fundoscopy for the vision loss-
185
Fundoscopy for the vision loss in temporal arteritis- what’s found?
Swollen pale optic disc with blurred margins
186
- Treatment of temporal arteritis? **(2)**
- high dose steroids (IV methylprednisolone - given before biopsy done) - urgent ophthalmology review (same day)
187
What steroid do we give if vision loss vs no vision loss in temporal arteritis?
- Vision loss = IV methylprednisolone - No visual loss = high dose oral prednisolone
188
- What do we give if on steroids for long time?
Give bisphosphonates to protect bones
189
What are the clinical features of Polymyalgia rheumatica? (6)
- Shoulder/hip girdle stiffness and pain- describe it Bilateral morning stiffness and pain for >1 hour in these regions - Worse at night - Acute onset - Systemic symptoms → fever, weight loss, malaise, depression - Symptoms of giant cell arteritis - Rapid response to steroids
190
What symptom do we not get in Polymyalgia rheumatica?
Weakness- any weakness felt is due to muscle pain
191
- What are the main investigations in Polymyalgia rheumatica and their findings? **(4)**
- ESR/CRP Elevated → ESR markedly raised - CK Normal - RF Negative - Autoantibodies Negative
192
What’s 1st line for Polymyalgia rheumatica?
Prednisolone (corticosteroids)
193
What if patients don’t respond to steroids in Polymyalgia rheumatica?
Alternative diagnosis should be considered
194
What do we do if patient is treatment-resistant or relapsed in Polymyalgia rheumatica?
Increase dose
195
What do we give to deal with a potential complication of corticosteroid treatment in Polymyalgia rheumatica?
Corticosteroid-Induced Osteoporosis Prophylaxis → Alendronate (Bisphosphonate). Also ensure calcium and vitamin D levels are good
196
Complications of Polymyalgia rheumatica?
Corticosteroid related issues (e.g. Avascular necrosis of the femoral head)
197
Define Necrotising fasciitis
Life-threatening subcutaneous soft tissue infection that requires a high index of suspicion for diagnosis
198
What is type I necrotising fasciitis?
polymicrobial infection caused by mixed aerobes and anaerobes
199
Who does type I necrotising fasciitis occur more commonly in?
post-surgery in diabetics
200
What is type II necrotising fasciitis?
monomicrobial infection caused by Streptococcus pyogenes
201
Risk factors of Necrotising fasciitis? (5)
- Immunosuppression (diabetes) - IVDU (intravenous drug users) - Cutaneous trauma - Surgery - Varicella zoster infections
202
What is the most commonly affected site of Necrotising fasciitis?
Perineum → called Fournier’s Gangrene
203
What is a risk factor for Fournier’s Gangrene?
use of an SGLT-2 inhibitor (-flozins) in type 2 diabetics Inhibits SGLT-2 co-transporter in PCT, increasing urinary excretion of glucose, hence increases chance of developing a urinary and genital infection, including necrotising fasciitis
204
What are the clinical features of Necrotising fasciitis? (5)
- Acute onset - Anaesthesia or severe pain over site of infection - Oedema (swelling) and erythema - Systemic signs of infection - Delirium and crepitus (advanced cases)
205
what does Necrotising fasciitis often present as?
Rapidly worsening cellulitis with pain out of keeping with physical features
206
Systemic signs of infection- which are? **(7)**
- Fever - Palpitations - Tachycardia - Tachypnoea - Hypotension - Lightheadedness - Nausea and vomiting
207
What is the main set of tests we do for Necrotising fasciitis?What do we do before these?
blood and tissue cultures Surgical exploration
208
What is the main surgical interventionfor Necrotising fasciitis?
Urgent surgical debridement repeated until patient has no necrotic tissue
209
What else do we give for Necrotising fasciitis?
IV Abx → start as empirical until you have obtained blood cultures, then tailor to causative organism
210
Complications of Necrotising fasciitis? (3)
- Mortality - Skin loss - Scarring
211
Prognosis of Necrotising fasciitis?
mortality is higher in patients who develop shock and end-organ damage, approaching 50% to 70%
212
Define pathological fracture
A spontaneous fracture following mild physical exertion or minor trauma due to abnormal weakness of the bone that is caused by an underlying condition
213
What are the 2 types of causes of pathological fracture?
Disorders affecting bone metabolism- Masses
214
Disorders affecting bone metabolism- such as? (5)
- Osteoporosis - Paget disease - Osteopetrosis - Osteomalacia - Osteogenesis imperfecta
215
Osteopetrosis- what’s this?
Rare disease that causes bones to grow abnormally and become overly dense and brittle
216
cause of pathological fracture -Masses- such as? (4)
- Malignant bone tumours- such as? **(3)** - Osteosarcoma (sunburst pattern on X-ray) - Chondrosarcoma - Ewing’s tumour (onion skin appearance on X-ray) - Bone metastases - Benign bone tumours - Multiple myeloma
217
What are the common locations of pathological fractures? (3)
- Spine - Hip - Wrist
218
What finding will make you suspicious of Paget disease?
Isolated ALP elevation
219
How would you treat Paget disease?
Bisphosphonates (alendronate)
220
What is the initial test for suspected malignant bone tumours?
Plain radiograph
221
What investigation is done to confirm radiological diagnosis?
Biopsy
222
What will be raised in bone metastases? (2)
- Calcium - ALP
223
X ray findings of pathological fracture? (2)
- Sclerotic lesions - Osteolytic lesions
Year 3
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