1
Q
management of OA
A
- topical analgesia + lifestyle factors
- Paracetamol
- NSAID plus PPI (eg Naproxen 250-500mg BD)
- Corticosteroid intraarticular injection
- Surgery
2
Q
management of RA
A
- DMARD (Methotrexate)
- Adjunct corticosteroid (Prednisolone) or NSAID (eg Naproxen)
If giving steroid long term, supplement with Vitamin D and calcium) - DMARD Combination therapy e.g. Hydroxychloroquine or Sulfalazine
- Biologic Agent (e.g. TNF alpha inhibitors, etanercept, infliximab, adalimumbab)
3
Q
management of Ank Spond
A
- NSAID plus physiotherapy and stretching and exercise advice
eg Naproxen 500mg BD - TNF alpha inhibitor eg alalimumbab , etanercept
4
Q
Fibromyalgia Management
A
- Lifestyle and relaxation techniques
TCAs eg Amitriptyline
5
Q
what are the features of fibromyaligia?
A
- chronic pain
- diffuse tenderness on examination ( need >11/18 tender points)
- fatigue unrelieved by rest
- sleep and mood disturbance
- abnormal sensations
- sensitivity to bright colours , loud noises and strong odours
- headaches
6
Q
what is the most accurate movement for measuring hip function and hip pain?
A
internal rotation
7
Q
what are red flags in the history of hip pain in a child?
A
- night pain, night sweats, weight loss = Acute lymphoblastic leukaemia
- fever, holding leg ABDUCTED = septic arthritis
- Fever, NON WEIGHT BEARING= osteomyelitis of femur pelvis
- changeable , unclear or unusual history= NON ACCIDENTAL INJURY
8
Q
what are some causes of hip pain in a child?
A
- fracture
- developmental dysplasia of the hip (aka congenital dislocation)
- Girls>Boys, Congenital, skin folds and buttock flattening, Born with it. - Transient synovitis (follows urti)
- juvenile idiopathic arthritis
- Perthes disease (Boys 4-8 yrs) AVN and remodelling of femoral epiphyses
- Slipped upper femoral epiphyseal
9
Q
what are the signs of cauda equina?
A
- bladder/bowel dysfunction
- bilateral sciatica
- saddle anaesthesia
MRI scan these patients
10
Q
back pain red flags
A
- weight loss, fever, systemic illness
- cauda equina symptoms
- severe tearing pain : AAA?also exclude other abdo causes
- immunosuppressed, IVDU , corticosteroid patients
11
Q
what is a pathological fracture? and what are some causes
A
a fracture through abnormal bone
e.g. osteoporosis, osteomalacia, osteopenia, bony mets, infections, bony metabolic diseases, secondary to medications
12
Q
how would you manage an open fracture?
A
- Primary survey (ABCDE)
- Secondary survey (look for further injuries)
- Remove gross contamination
- Photograph the wound
- Place a saline soaked gauze over the wound and put limb in a splint
- give iv prophylactic antibiotics
- list for theatre within 24 hours for debridement and washout and stabilization
Imaging also chest abdo pelvis x ray
13
Q
signs of compartment syndrome
A
Pain, especially on movement (even passive)
Parasthesiae
Pallor may be present
Arterial pulsation may still be felt as the necrosis occurs as a result of microvascular compromise
Paralysis of the muscle group may occur
14
Q
what is compartment syndrome
A
Compartment Syndrome is when the pressure within a fascial compartment exceeds the perfusion pressure within the compartment, causing ischaemia of the tissues within the compartment.
15
Q
what would you do if you suspected compartment syndrome
A
- Review neurovascular status of limb
- review analgesia and release any dressings or casts which might be increasig the pressure
- position limb at level with the heart
- contact senior, as they may need emergency fasciotomy
16
Q
what are some factors which may cause mal union or non union
A
local factors: blood supply, infection, stability, pattern
systemic factors: smoking, diabetes, corticosteroids, HIV, diet, NSAIDs
17
Q
what is the most senstitive clinical sign for diagnosing compartment syndrome
A
pain on passive stretch
18
Q
x ray features of gout
A
- gouty tophi
- punched out lesions
- soft tissue swelling
19
Q
treatment of gout
A
acute: NSAIDs and Colchicine
long term: Allopurinol
20
Q
which compartment of the leg is most commonly affected by compartment syndrome?
A
anterior compartment
21
Q
what is pagets disease of the bone?
A
occurs in people >55 years
focal bone resorption followed by excessive and chaotic bone deposition
affects in order spine, skull, pelvis, femur
ALP raised
abnormal thickened sclerotic bone on x ray
treat with Bisphosphonates
22
Q
Raynauds disease
- who gets it
- what is it
- how to treat it
A
typically presents in females under the age of 30
symmetrical attacks
spasms of arterioles can lead to diminshed blood supply to the affected area causing them to turn white or even blue
typically affects the hands and feet
treated with calcium channel blocker (Nifedipine)
23
Q
Raynauds Phenomenon
secondary to CTD
what features suggest this?
A
typically occuring secondary to CTDs features which indicate raynauds from CTD: -presenting >40 yrs -systemic features -asymmetry -rashes -auto antibodies
24
Q
what are the small vessel vasculitides
A
Granulomatosis Polyangiitias
Eosinophillic Granulomatosis Polyangiitis
Microscopic polyangiitis
Henoch Schonlein purpura (IgA mediated)
25
medium vessel vasculitides
```
Kawasaki disease (paediatrics, strawberry tongue, treat with aspirin)
Polyarteritis nodosa (necrotising inflammation, associated with hep b and livedo reticularis)
```
26
large vessel vasculitides
Takayasu
| Giant Cell Arteritis
27
microscopic polyangiitis
Microscopic polyangiitis is a small-vessel ANCA vasculitis
Features
renal impairment: raised creatinine, haematuria, proteinuria
fever
other systemic symptoms: lethargy, myalgia, weight loss
rash: palpable purpura
cough, dyspnoea, haemoptysis
mononeuritis multiplex
28
what is nephrotic syndrome
```
hypoalbuminaemia,
oedema,
heavy proteinuria (>3-5g/24hrs),
hyperlipidaemia,
lipiduria
```
29
what is nephritic syndrome?
```
haematuria,
oliguria,
hypertension,
proteinuria (>2g/24hrs),
oedema
ureamia
```
30
symptoms of SLE
- raynauds
- mouth ulcers
- rash on cheeks
- weight loss
- low grade fever
- fatigue
- joint pain and swlling
- oedema
- pleural effusion
- pericarditis/pericadial effusion
- loss of appetite
- photosensitivity
31
what is the antibody for SLE
Anti-ds DNA , Smith , nRNP
32
what is the antibody for Sjorgens syndrome?
Ro(SSA) La (SSB)
33
what is the antibody for subacute cutaneous lupus erythematosus (SCLE)
Ro (SSA) La(SSB)
34
what is the antibody associated with dermatomyositis
Anti Jo
35
what is the antibody associated with progressive systemic sclerosis? (diffuse systemic sclerosis)
Anti Sci 70
36
what is the antibody associated with CREST syndrome? (limited systemic sclerosis)
anti-centromere antibody
37
3 patterns of sclerosis
- diffuse systemic sclerosis
- limited systemic sclerosis (CREST)
- scleroderma
38
what are the symptoms of CREST syndrome
```
C-calcinosis
R-raynauds
E-eosophageal strictures
S-sclerodactylitiy (thickening of skin)
T-telagniectasia
```
39
what are the features of De Quevrains tenosynovitis
```
-commonest in females 30-50
pain at the radial side of the wrist
-tenderness at radial styloid process
-abduction of the thumb against resistance is painful
-Finkelsteins test produces pain
```
40
what is plantar fasciitis
most common cause of heel pain in adults
| worse over medial calcaneal tuberosity
41
which blood tests would you order in someone with suspected SLE?
- FBC,WCC, U&Es, LFTs(albumin), ANAs (anti nuclear antigens), ENAs (extractable nuclear antigens- will only be present if ANA is positive!)
- Urine dip- look for proteinuria /haematuria
- CRP and ESR
- compliment levels (activity marker in SLE, low=active)
- MSU look for casts
- protein:creatine ratio of urine
42
what would CRP and ESR show in SLE?
CRP is usually normal or near normal
ESR is raised in active disease
(if CRP is high you need to exclude infection)
43
what is ANA and what does it mean
ANA means anti nuclear antibody
if negative it means that a CTD or SLE is very unlikely
ANA positve suggests a rheumatological or CTD disease (but 5% of the healthy population has ANA )
44
what are the considerations of pregnancy and SLE
- pregnancy should be planned to ensure stability of the disease (no flare ups)
- ensure immunosuppressants being used are safe for the baby
- check Anti RO and anti La antibodies (these can cross the placenta and cause neonatal lupus)
- check for anti-phospholipid syndrome (increased risk of miscarriage)
45
what are the features of neonatal lupus?
- Lupus rash
- complete heart block
- blood abnormalities (including cytopenias)
46
treatment of lupus
Induction of remission: Corticosteroids
or
cyclophosphamide/mycopentolate if Lupus nephritis
maintaining remission: NSAIDs may be sufficient if no
then lowest dose corticosteroid/immunosuppressive therapy (hydroxychloroquine,methotrexate)
47
treatment of raynauds?
-nifedipine (calcium channel blocker)
48
which drug should you ask specifically about if you suspect gout?
thiazide diuretics
49
what type of hypersensitivity reaction takes place in lupus nephritis?
Type 3
50
how can you diagnose Lupus nephritis?
with a biopsy
urine sample and serology may help
(haematuria, proteinuria)
51
what would a biopsy of a kindey with lupus nephritis show?
- wire loop lesions
- crescent shaped swelling
- thickening of capillary loops
52
diagnostic criteria for SLE
Any >4 of the following
1. malar rash
2. discoid rash
3. oral ulcers
4. photosensitivity
5. arthitis
6. serositis (pericarditis, pleuritis)
7. renal disorder
8. neurological disorder (seizures/psychosis
9. haematological disorder (haemolytic anaemia, thrombocytopenia, lymphopenia, leukopenia
10. immunological disorder (Anti Ds Dna, anti smith)
11. antinuclear antibody
53
what is onycholysis?and when may it be seen?
lifting of nail bed
| seen in psoriasis
54
nailfold infarcts are a sign of...
SLE
| Vasculitis
55
what is feltys syndrome?
splenomegaly
neutropenia
RA
56
what is Bechets disease? (features)
RARE disease characterised by blood vessel formation throughout body
- mouth ulcers
- uveitis
- IBD
- genital sores
- arthritis
57
what is osteogenesis imperfecta?
```
autosomal dominant collagen disease
results in brittle bones which are prone to fractures
-ask blue sclera
-deafness (otosclerosis)
-Family hx
```
58
what may help identify Non accidental injury in achild
- unclear hx /changeable hx
- known to social services
- poor parent-child relationship
- injuries inkeeping with developmental age
59
what is important to check with any fracture?
-neurovascular integrity
60
management of a supracondylar fracture (in kids)
- analgesia
- list for theatre
- reduction
- fixation with K wires
- plaster cast
K wires and cast removed at clinic in 4 weeks
61
which structures may be damaged in a supracondylar fracture?
- brachial artery
- ulnar nerve
- median nerve
62
how long do childhood fractures take to heal?
-4-6 weeks upper limb
-6-8 weeks lower limb
generally quicker than adults
63
what are some common childhood fractures
- supracondylar
- clavicle
- wrist
- buckle (bone buckles in on itself as opposed to breaking)
64
what is a greenstick fracture and why does it occur?
it is a fracture commonly seen in children where it is a crack and not a complete fracture
happens because childhood bone is softer than adult bone
65
main differences between childhood fractures and adult fractures
- childhood fractures heal faster
| - childhood fractures remodel with growth hence minor deformity is more accepted
66
how can you check the median nerve function?
get the patient to make an O shape with their thumb and index finger
67
fractures associated with osteoporosis
- Colles fracture (FOOSH)
- wedge fracture of vertebra
- NOF fracture
68
name some tools/stuff which can be used to secure a fracture
- wires
- plates
- moulded plaster
- elastic nails
69
hip pain may be referred from?
- spine
- knee
- abdomen (including hernial orifices)
- testicles
70
most likely cause of hip pain in a child?
transient synovitis of hip
71
transient synovitis of hip featues
boys>girls
4-8yrs
acute onset limp
preceeded by URTI or other viral illness eg gastroenteritis
72
what is perthes disease?
degenerative condition affecting the hip joints in children. AVN femoral head
most respond to conservative management (bracing of femoral head in acetabulum)
73
blood supply to femoral head?
most comes from the retinacular arteries originating from the
LATERAL CIRCUMFLEX FEMORAL ARTERY
74
red flags for hip pain in a child
-night pain
-weight loss
-weight loss, night pain, night sweats = Acute lymphoblastic leukaemia
-fever
-
75
what is slipped upper femoral epiphysis and what are risk factors
- displacement of the femoral epiphyseal head postero inferiorly
- risk factors: male , overweight, hypothyroidism, >10 yrs
76
DDH signs/features
more common in girls
picked up in newborns
leg length discrepencies / unequal skin folds
77
juvenile idiopathic arthritis features
- most are pauciarticular (less than 4 joints)
- medium sized joints (knee, ankle, elbows
- associated with anterior uveitis
- ANA may be positive
- limp
78
Langhams triad of EGPA
- asthma
- eosinophilia
- multi organ involvement
79
what should you do if you find blood in the urine on au urine dip?
send off for red cell casts - this may be a nephritis
80
cresenteric glomerulonephritis is a serious complication of...
ANCA associated vasculitides
| treat with high dose immunosuppression (steroids)
81
treatment of a small vessel vasculitis
induction: steroid and either rituximab or cyclophosphamide
maintenance: taper steroid and continue either azathiorpine, rituximab, methotrexate,
82
when starting patients on high dose steroids what do you need to consider?
- gastro protection
- bone protection
- screen for diabetes
- check weight and blood pressure
83
what drug is associated with worsening asthma symptoms in EGPA?
Montelukast
84
differentials of fibromyalgia
```
rheumatoid
-SLE
-polymyalgia rheumatica
endocrine
-addisons
-hyperparathyroid
-hypothyroid
-vit D deficiency
infection
malignancy
```
Year 4 M&M OSCE
flashcards
Decks in class (10)
# Cards
