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Mike2556
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Give 5 features of a typical presentation of rheumatoid arthritis
- Found in DIP/PIP and MCP joints
- Symmetrical
- Pain and swelling
- Early morning stiffness
- Rheumatoid nodules
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Describe 5 hand deformities seen in rheumatoid arthritis
- Subluxation: MCPs drawn out of sockets, usually radial-dorsal
- Ulnar deviation: MCP deviation
- Boutonniere: PIP flexion and DIP hyperextension
- Swan neck: DIP hyperextension and PIP flexion
- Z-thumb: Fixed flexion and subluxation of MCP, hyperextension of IP
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What 5 features may been seen in a hand x-ray in R.A?
- Loss of joint space
- Subluxation
- Juxta-articular osteopenia
- Bony erosions
- Soft tissue swelling
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Give 4 other systems affected by R.A. and specific manifestations
- Respiratory: Pulmonary fibrosis
- Haematological: Anaemia
- Cardiovascular: MI/CVA risk increased
- Skin: Rheumatoid nodules
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Give a brief description of the diagnostic criteria in R.A
- Number of small joints: 3/4 = 2/3 points
- Number of large joints: 2 = 1 point
- Low/high RF or ACPA = 2/3 points
- 6 weeks or longer = 1 point
- High ESR or CRP = 1 point
- 6 or more means definite R.A
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Give 4 investigations useful in diagnosing rheumatoid arthritis
- Bloods: ESR, CRP and Hb
- Serology: Anti-CCP (80%), RF (70%) and ANA (30%)
- Imaging: X-ray for baseline
- Aspiration: Effusion and rule-out septic arthritis
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Give 6 considerations in the management of R.A
- Analegesia: NSAIDs
- Acute: Intra-articular corticosteroids
- Long term: DMARDs to avoid corticosteroids
- Physiotherapy: Maintain joint movement and muscle stiffness
- Occupational therapy: Help with ADL
- Restoration: Surgical reconstruction
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What are the differential diagnoses for acute joint pain and swelling? Give 5
- Septic arthritis until proven otherwise
- Osteoarthritis
- Reactive arthritis
- Gout
- Pseudogout
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Give 5 risk factors for oestoarthritis
- Obesity
- Female
- Hypermobility
- Trauma
- Occupation
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Give 5 red flags in back pain
- <16 or >50 new onset pain
- Neurological features (anal tone, urinary retention etc)
- Worse at rest
- Malignancy Hx
- Steroid use
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What investigations are available in low back pain?
- Only required if red-flags present or atypical presentation
- Imaging
- Bloods: FBC, ESR, bone profile for underlying condition
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Give 4 radiological features seen in oesteoarthritis
- Narrowing of joint space
- Osteophytes
- Sub-chondral sclerosis
- Sub-chondral cysts
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Give 4 signs and 4 symptoms of osteoarthritis
- Signs:
- - Crepitus
- - Reduced range
- - Effusion
- - Muscle wasting
- Symptoms:
- - Pain
- - Stiffness
- - Instability
- - Loss of function
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Give 4 considerations in the management of osteoarthritis
- Analgesia: NSAIDs
- Lifestyle change: Weight loss
- Physiotherapy: Muscle strength and stability/walking aids
- End-stage: Arthroplasty
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Give 4 investigations used in suspected septic arthritis
- Aspirate: Urgent microscopy, stain and culture
- Blood cultures
- Swab
- Bloods: FBC and inflammatory markers to monitor improvement
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What is the acute management for septic arthritis?
- General resuscitation
- IV flucloxacillin and fucidin (erythro in allergy)
- Analgesia
- Drainage of joint/washout
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What is 'pseudogout'? How is it treated?
- Calcium pyrophosphaste crystals are deposited in joints or extra-articular tissues
- Crystals are rhomboid, unlike gout crystal
- Treated similarly to gout
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What x-ray feature is seen in avascular necrosis of the femoral head?
Well demarcated area of increased bone density in upper pole of femoral head
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Give 5 features of a typical gout presentation
- Sudden onset
- Agonizing pain
- Swelling and redness
- First MTP in 75%
- Precipitated by excess food, alcohol or dehydration
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What investigations should be performed in suspected gout?
- Aspirate: Joint fluid microscopy for crystals (and cultures for DDx)
- Bloods: Serum uric acid, U+Es
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Give 4 medications which may be used in the management of gout
- NSAIDs: Naproxen, diclofenac
- Colchicine: Anti-inflammatory
- Corticosteroids: IM injection
- Allopurinol: Reduce urea
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What is a "seronegative spondyloarthropathy"? Give 3
- An arthropathy without the production of RF
- Ankylosing spondylitis
- Psoriatic arthritis
- Reactive arthritis
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What are the criteria for ankylosing spondylitis?
- <50 years with chronic back pain
- Morning stiffness >30mins
- Improvement of back pain with exercise not rest
- Awakening from back pain in second half of night
- Alternating buttock pain
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Give 3 interventions used in AS
- Analgesia: Slow release NSAIDs ON
- Biologics: Infliximab very effective
- Physio: Morning exercise to improve function and prevent kyphosis/lung restriction
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Give a brief description of the criteria for diagnosing psoriatic arthritis
- Current psoriasis or personal/family history (2)
- Nail changes (1)
- RF negative (1)
- Previous confirmed dactylitis (1)
- X-ray of ossified joint margins (1)
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Where do bony erosions occur in:
Psoriatic arthritis
Rheumatoid arthritis
SLE
- Central in the joint (pencil in cup)
- Juxta-articular
- No erosions, purely synovial
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Give 4 nail changes seen in psoriasis
- Pitting
- Onycholysis
- Discoloration
- Hyperkeratosis
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Give 5 features seen in a reactive arthritis
- Acute onset
- Asymmetrical
- Lower limb
- Post-infection
- Associated features; conjunctivitis, Reiter's
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In ANY rheumatological arthritis, what 5 treatments are always recommended? (Rule of Thumb)
- NSAIDs
- Local corticosteroid injections
- 5-ASA/methotrexate
- TNF-alpha i.e. infliximab
- Physiotherapy for muscle strength/flexibility
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Outline the typical presentation of polymyalgia rheumatica
- >50 yoa
- Sudden onset
- Severe pain and stiffness
- Limb-girdle pattern
- Rheumatology characteristics
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Outline the typical presentation of giant cell arteritis
- >50 years
- Severe headaches
- Scalp/temple tenderness
- Jaw claudication
- Tender/swollen temporal/occipital arteries
- Sudden, painless unilateral vision loss
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What investigations are useful in suspected GCA?
- FBC: Normocytic/chromic anaemia
- ESR/CRP: Raised/Very high
- Temporal artery biopsy from affected side
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Give 3 long-term complications of temporal arteritis
- Permanent unilateral visual loss
- Complications of stroke
- Osteopenia from high dose corticosteroids
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Give 5 systems affected by SLE and how
- MSK: Small joint pain but clinically normal
- Skin: Butterfly erythema, photosensitivity
- Lungs: Bilateral pleurisy/effusion
- CVS: Pericarditis/effusion
- Renal: Lupus nephritis
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Give 3 antibodies that may be present in SLE
- ANA
- Anti-dsDNA
- Anti-phospholipid
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Outline the natural history of SLE and its treatment
- Present with malaise, fatigue and possibly features from the affected systems
- Exacerbations and complete remissions
- Acute attacks require short courses of oral corticosteroids or IM injections if local
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What is the antiphospholipid syndrome?
- Recurrent arterial or venous thrombosis and/or recurrent miscarriages
- Persistent presence of antiphospholipid antibodies; cardiolipin, lupus anticoagulant
- No other possible cause
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How does scleroderma typically present?
- CREST syndrome in 70%
- Calcinosis
- Raynaud's
- Esophageal dysmotility
- Sclerodactyly
- Telangiectasia
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Outline the pathophysiology of Paget's disease
- Altered gene expression in osteoclasts causes bone resorption
- Compensatory deposition of woven bone, which lacks structure
- Eventually formation exceeds resorption
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Outline the typical presentation of Paget's
- Incidental in 60-80%; x-ray or ALP
- Most commonly affects pelvis, L-Spine, femur, T-Spine
- Central bone pain or nerve compression
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What investigations are useful in suspected paget's?
- X-ray: Early lytic lesions (especially skull) and late sclerotic lesions
- Bloods: ALP raised
- Bone profile: Calcium and phosphate normal
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What investigations are typically used in suspected rheumatological disease?
- Joint aspirate (in monoarthropathy)
- Bloods: FBC, U+E (if app), ESR, CRP, ALP
- Bone profile
- Imaging: X-ray of site, CT/MRI if app
- Autoantibodies
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What investigations are typically used in suspected osteomalacia?
- Bone profile: Calcium normal but raised PTH
- LFTs: Raised ALP
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How does osteomalacia typically present?
- Vague features; bone pain or myositis
- Pathological fracture
- "Waddling" gait due to proximal myopathy
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What is the definition of osteoporosis?
- Disease characterised by low bone mass and micro-architectural deterioration, leading to enhanced fragility and fracture risk
- Bone density 2.5 standard deviations below young healthy adult mean value (T score <-2.5)
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Give 5 risk factors for osteoporosis
- Oestrogen deficiency
- Vit D deficiency
- Glucocorticoid use
- Smoking
- Low BMI
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What investigation is used to quantify osteoporosis?
DXA: Bone density of L-Spine/femur to determine T-score
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Give 5 indications for DXA scanning
- Radiographic osteopenia
- BMI <19
- Known BMD-dependent risk factors
- Glucocorticoid therapy (<65yoa)
- Previous pathological fracture
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Give 5 interventions in the primary prevention of osteoporotic fracture
- Pharmacological
- Supplements: Calcium and Vit D
- Exercise: Weight bearing to increase BMD
- Smoking cessation
- PT/OT: Reduce fall likelihood
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Give 3 pharmacological interventions in the primary prevention of osteoporotic fractures
- Bisphosphonates
- Strontium ranelate
- Vitamin supplementation
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