Aims
Review topics in detail that are likely to play a substantial part in exams
Point you towards topics to concentrate on
Flag up potential pitfalls
Teach some exam technique
Disclaimer!
Approach
Brief revision of History essentials
Clinical cases with periodic MCQs – high yield topics not comprehensive
If time…quick rundown on important facts from range of musculoskeletal conditions
MSK history
Phase 3 History lecture is excellent ‐ has everything you need!
2 types of historys for OSCEAcute monoarthritissubacute – chronic joint pain : RA/OA
Questions are similar – slightly different focusAcute monoarthritis – RFs for gout, haemarthrosis and septic arthritisRA/OA – inflammatory or non‐inflammatory, functional limitation and extra‐articular manifestations
Joint pain ‐ Site
‐Distribution: symmetrical or non‐symmetrical
‐Type of joints: Large joints, small synovial joints, are any joints spared (important in hands)
‐Number of joints – mono, oligo (2‐4), polyarthritis(>4)
‐Any axial involvement – neck, back or buttock pain
MSK History: Stiffness
‐Key in differentiating inflammatory and non‐inflammatory arthritis ‐ Ask which joints!‐Early morning stiffness > 30 minutes indicates inflammatory arthritis‐Relationship to exercise/rest – exercise helps inflammatory arthritis, makes OA worse‐Stiffness is common in OA but usually less than 30 minutes‐Inflammatory arthritis may display diurnal variation
Weight loss
Fever
Night pain
Single joint involvement
Neurological symptoms and signs
Red flags – Arthritis UK
Extremely importantAsk generally about impact on life Then ask specifically about workADLs : cooking, washing, dressingCaring for children if appropriate Any help currently in place?
Drug Hx: Quantify analgesia including herbal and OTC – May be important to ask about contraception specifically
Social History
This patient has presented with pain, stiffness and swelling in the small joints of both hands, predominantly in the MCPS and PIPs. She experiences stiffness first thing in the morning for 45 minutes. She denies axial disease The pain is unresponsive to simple analgesia and is impacting upon her mood and limiting her ability to care for her young child.
Examination
‐ No time to go over everything!‐ Always assess function – if necessary make it the
first thing you do!‐ Always say that you would do a NV exam and
examine the joint above and below at the end‐ May be asked to examine rheumatoid hands –practice an exam touching and not touching the patient
‐ Always think about associated diseases that may support your diagnosis
MCQs
‐ No trick questions
‐ Don’t try and be too clever – presentations in MCQs will be very typical ‘med student’ presentations
‐ If they have a symptom or a sign its there for a reason
Rheumatoid Arthritis
Inflammatory, symmetrical polyarthritis of the small synovial joints of the hand and feet
Young women – 30‐40 peak presentation
Examination – hot, swollen joints, boggy swelling indicative of tenosynovitis, deformity (see later slide), DIPs commonly sparedSystemic features : Fever, weight loss, fatigue, anaemia of chronic disease, dry mouth/eyes, scleritis, episcleritis, nodules, rashes and serositis
IX: CRP, ESR, Rheumatoid factor, Anti‐CCP, USS
Deformities to be able to recognise
Swelling and be able to describe joints readilyBoutonniereSwan neckUlnar deviation of MCPsRadial deviation at the wristZ thumb Piano key sign Muscle wastingRheumatoid nodulesTendon nodulesFeatures of Carpal tunnel and other neuropathysNail Changes ‐ psoriatic, vasculitisALWAYS DO A FUNCTIONAL ASSESSMENT!
You are an F2 in a GP practice and are asked to see a 33 year old woman with painful joints. She describes a 4‐6 week history of painful and stiff joints. Her stiffness is pronounced for up to 60 minutes in the morning and eases throughout the day. She denies a recent sore throat. On Examination, there is no obvious deformity and only mild, boggy swelling of the MCPs and PIPs. She has no nail changes or rashes. She is rheumatoid factor positive. What is the most likely diagnosis?
A. Psoriatic arthritis B. Generalised osteoarthritisC. PseudogoutD. GoutE. Rheumatoid Arthritis
You are an F2 in a GP practice and are asked to see a 33 year old woman with painful joints. She describes a 4‐6 week history of painful and stiff joints. Her stiffness is pronounced for up to 60 minutes in the morning and eases throughout the day. She denies a recent sore throat. On Examination, there is no obvious deformity and only mild, boggy swelling of the MCPs and PIPs. She has no nail changes or rashes. She is rheumatoid factor positive.
Alongside offering analgesia what is the most appropriate management plan for this patient?
A. Return in 6 weeks for reassessmentB. Refer routinely for assessment by a rheumatologistC. Check Anti‐CCP, CRP and ESRD. Order a hand x‐rayE. Refer urgently for assessment by a rheumatologist
RA: Management
Early high intensity, disease modifying therapy therapy to prevent debility
2 DMARDS (Methotrexate + 1 more)
Steroids in acute flares (PPI and bone protection)
NSAIDS and Cox‐II inhibitors (+PPI) for symptoms
If DMARDS fail: Biologics ‐mostly anti‐TNF agents
You are asked to see a 53 year old male office worker complaining of bilateral knee pain. The pain has been present for 6‐10 months but is now beginning to stop him from taking his daily walk. He reports EMS for 10 minutes, exacerbation of pain with exercise and occasional ‘giving way’ at the knee joints. He has tried paracetamol but with little relief. He denies trauma. On examination the knee joints do not appear red or swollen. There is some discomfort on knee flexion but full ROM is persevered. Crepitus is present in both knees. Patellar tap test is negative. Ligaments are intact, HIP NAD.
What is the most likely diagnosis?
A. Rheumatoid arthritisB. PseudogoutC. Traumatic pre‐patellar buristisD. OsteoarthritisE. Gout
You suspect osteoarthritis. Which of the following is true regarding the diagnosis of this gentleman’s knee pain?
A. An x‐ray is essential to confirm a diagnosis of osteoarthritis on first presentationB. His early morning stiffness makes osteoarthritis less likelyC. A serum urate would be helpful to exclude goutD. Osteoarthritis typically presents with red, hot, swollen jointsE. Osteoarthritis can be diagnosed based on history and examination alone
OA: Clinical featuresTypically effects large, weight bearing joints** in older individual
Stiffness common but often brought on by exercise and does not occur in the AM for >30 minutes
Examination – typically not hot red or swollen, effusion, crepitus, limited ROM
Investigations – if diagnostic doubt consider:ESR and CRP (normal in OA), X‐ray: LOSS – but mainly useful for excluding other diagnoses
OA: Risk factors
Non‐modifiable : Age, Female, Family history, hxof inflammatory arthritis, SUFE and other childhood hip conditions etc
Modifiable : Weight, previous injuries, muscle weakness, ligament laxity
You diagnose osteoarthritis on clinical grounds. The gentleman wants to know how he can manage his condition. Regarding the management of osteoarthritis, which of the following is true?
A. Education, Exercise and Weight loss are the core therapies for OAB. An X‐ray should be ordered to assess his suitability for joint replacementC. Oral analgesics are the mainstay of osteoarthritis treatmentD. Physiotherapy is not useful in the management of osteoarthritisE. All exercise should be avoided as it is exacerbating his knee pain
OA: Management
OA: Management considerations
Patient preference – therapeutic alliance
Core treatments
Joint surgery is a pain relieving operation –consider age (prosthetic joint life is approx 20 years) and fitness for surgery
Caution with NSAIDS – Asthma, CV risk, GI bleeding, Renal impairment, interaction with ACEIs, Fluid retention
You are the Rheumatology SHO and you are asked to see a man who has been referred from A and E with a hot red swollen right knee. The gentleman is 55 with a PMH of Hypertension (currently controlled on Periondopril, Amlodopine and bendroflumethiazide) and Type 2 diabetes. His pain started in bed late last night and has increased in severity during that time. He noticed it red and swollen early this morning and promptly came to A and E. He denies any temperatures, light headedness or trauma to the knee. He drinks 30 units each weekend, does not smoke and works as a builder. On examination the knee is hot, red and swollen and your examination is limited by pain. No other joints are involved. Temperature 36.7.
What is the most likely diagnosis?
A. Septic arthritisB. Acute monoarticular gout C. PseudogoutD. HaemarthrosisE. Osteoarthritis flare
You are the Rheumatology SHO and you are asked to see a man who has been referred from A and E with a hot red swollen right knee. The gentleman is 55 with a PMH of Hypertension (currently controlled on Periondopril, Amlodopine and bendroflumethiazide) and Type 2 diabetes. His pain started in bed late last night and has increased in severity during that time. He noticed it red and swollen early this morning and promptly came to A and E. He denies any temperatures, light headedness or trauma to the knee. He drinks 30 units each weekend, does not smoke and works as a builder. On examination the knee is hot, red and swollen and your examination is limited by pain. No other joints are involved. Temperature 36.7.
Which investigations must you arrange to make a diagnosis?
A. FBC (to include WCC) and CRPB. Serum UrateC. Knee X‐rayD. Knee aspiration: Gram stain, synovial fluid culture and sensitivities, polarized light microscopy, cell count and differentialE. Clinical impression is sufficient
Hot red swollen joint: key points
Differential : Septic arthritis, gout, pseudogout, haemarthrosis …….inflammatory arthritis flare
Clinical features cannot reliably differentiate between gout and septic arthritis – aspiration with synovial fluid analysis and blood cultures are mandatory
Gout crystals are strongly negatively bifringent, needle shaped crystals
Septic arthritis: IV antibiotics (fluclox and benpen) with regular joint aspiration/lavage. Rest, ice Thromboprophylaxis and analgesia
Acute monoarthritis: key points
Finding gout crystals does not rule out septic arthritis
Do not aspirate prosthetic joints – call orthopaedics
Do not aspirate if you suspect cellulitis clinically
FBC, U and E, CRP, ESR, X‐ray +/‐ USS, MRI
Rehydration orally or IV is appropriate regardless of diagnosis
Hold nephrotoxics in this patient
Joint fluid analysis finds strong negatively bifringent crystals and cultures do not exhibit any growth after 4 days. You diagnose acute monoarticular gout.Which of these medication regimens is most appropriate for immediate management of acute gout?
A. Diclofenac, Allopurinol and OmeprazoleB. ParacetamolC. ColchicineD. Diclofenac and omeprazoleE. Heat pack
Acute Gout: Management
NSAIDs with appropriate PPI cover is first line therapy
Colchicine if NSAID unsuitable eg Asthma, Heart Failure, AKI, on anticoagulation
Colchicine utility limited by poor compliance
Allopurinol indicated for recurrent gout, renal damage, tophi and x‐ray changes – NSAID/Colchicine cover
Do not start Allopurinol or other uric‐acid lowering agents during acute attack
Keep patient on allopurinol if on allopurinol at onset
Gout: key points
Wide range of disease: asymptomatic to polyarticularflares to chronic tophaceous gout
Dietary advice and uricosuric agents
Cardiovascular risk management
Education regarding, risk reduction, recognition and treatment of acute attack
Medications review – consider stopping thiazide and loop diuretics (increase uric acid levels), consider substituting ACEI for Losartan
Look over!Seronegative arthritides
‐ Know that HLA‐B27 can rule out these if negative, but is of little value if positive‐ Be aware of characteristic description of Ank Spond lumbar spine X‐ray
Osteoporosis‐Know T‐Score, who needs bisphosphonates and AE of Bisphosphonates
SLE‐ Know classical clinical features ‐ If ANA is negative ‐ SLE very unlikely‐ DS‐DNA+ makes SLE likely, ‐ve of little value
Scleroderma‐ Know CREST acronym for recognition of symptoms
Dermatomyositis‐ Associated with cancer ‐ needs work up‐ Purple heliotrope rash on eyelids and muscle pain, high CK
Polymyalgia Rheumatica‐ Elderly‐ Girdle pain‐ Prolonged course of Steroids‐ Associated with temporal arteritis ‐ Know Mx of TA!