Finals > Rheumatology > Flashcards

Rheumatology Flashcards

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1
Q

OA : Joints affected and typical history

A
  • Large weight bearing joints - hip, knee
  • CMC
  • DIP, PIP
  • Joint pain and stiffness following use, improves with rest
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2
Q

Signs of OA in the hands

A
  • Heberden’s nodes (in the DIP joints)
  • Bouchard’s nodes (in the PIP joints)
  • Squaring at the base of the thumb (CMC joint)
  • Weak grip
  • Reduced range of motion
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3
Q

Signs of OA on X-ray

A
  • L : Loss of joint space
  • O : osteophyte formation
  • S : Subchondral cysts
  • S : Subarticular sclerosis
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4
Q

What are the non pharmacological management options for OA?

A
  • Therapeutic exercise to improve strength and function and reduce pain
  • Weight loss
  • Occupational therapy to support activities and function
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5
Q

Pharmacological management options of OA ?

A
  • 1st = Topical NSAIDs (Ibuprofen 5% gel, 3x a day).
  • 2nd = Oral NSAIDs with PPI cover (Ibuprofen 400mg 3x daily).
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6
Q

RA : presentation and typical joints affected

A
  • Symmetrical distal polyarthritis affecting the MCP, PIP, wrist and the MTP
  • Joint pain, swelling and stiffness -> better with use
  • Systemic Sx : fatigue, weight loss, flu-like illness, muscle aches and weakness
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7
Q

what antibodies are tested for in RA?

A
  • First line = rheumatoid factor (RF)
  • Anti-cyclic citrullinated peptide (anti-CCP)
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8
Q

what are hand signs seen in advanced RA disease ?

A
  • Z-shaped deformity to the thumb
  • Swan neck deformity (hyperextended PIP and flexed DIP)
  • Boutonniere deformity (hyperextended DIP and flexed PIP)
  • Ulnar deviation of the fingers at the MCP joints
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9
Q

What X-ray changes are seen in RA?

A
  • Early sign = Periarticular/Juxta-articular osteoporosis and loss of join space
  • Later : periarticular erosions, soft tissue swelling and subluxation
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10
Q

How is a flare or initial presentation of RA managed ?

A

Short term steroids (oral or IM)

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11
Q

what is the stepwise management of RA?

A
  1. Monotherapy with methotrexate, leflunomide or sulfasalazine
  2. Combination treatment with multiple cDMARDs
  3. Biologic therapies (usually alongside methotrexate)
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12
Q

what two cDMARDS are deemed safest for RA management in pregnancy ?

A
  • Hydroxychloroquine : only in mild disease or palindromic disease
  • Sulfasalazine (extra folic acid required)
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13
Q

when are biological therapies considered for RA management and give examples

A
  • Inadequate response to at least 2 DMARDS
  • TNF inhibitors (adalimumab, infliximab, etanercept)
  • Rituximab (anti-CD20 on B cells).
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14
Q

How often is methotrexate given and what is given alongside it on a different day ?

A
  • Once weekly
  • 5mg Folic acid
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15
Q

Give 4 SE of methotrexate

A
  • Mouth ulcers and mucositis
  • Liver toxicity
  • Bone marrow suppression and leukopenia (low white blood cells)
  • Teratogenic (harmful to pregnancy) and needs to be avoided before conception in both women and men
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16
Q

Give 4 SE of sulfasalazine

A
  • Orange urine
  • Oligospermia
  • Heinz body anaemia
  • ILD
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17
Q

Give a SE specific to leflunomide

A
  • Peripheral neuropathy
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18
Q

Give 3 SE of hydroxychloroquine

A
  • Retinal toxicity (reduced visual acuity)
  • Blue-grey skin pigmentation
  • Hair lightening (bleaching)
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19
Q

What is a unique SE of anti-TNF medication ?

A

Reactivation of TB

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20
Q

Give 2 SE of rituximab

A
  • Night sweats
  • Thrombocytopenia
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21
Q

How is response to treatment monitored in RA

A
  • CRP and DAS28 score
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22
Q

what are the typically features of ankylosing spondylitits ?

A
  • Young man (20s), presenting with lower back pain and stiffness of insidious onset
  • Stiffness = worse in AM and improves with exercise
  • Pain at night which improves on getting up
  • Sacroiliac pain
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23
Q

Give 6 conditions associated with ank. spond

A
  • A – Anterior uveitis
  • A – Aortic regurgitation
  • A – Atrioventricular block (heart block)
  • A – Apical lung fibrosis (fibrosis of the upper lobes of the lungs)
  • A – Anaemia of chronic disease
  • A : Achilles tendonitis
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24
Q

what is seen on examination in ank. spond?

A
  • Reduced lateral flexion
  • Reduced forward flexion (<5cm increase on Schober’s test)
  • Reduced chest expansion
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25
what is the most useful investigation for diagnosing ank. spond and what are the most common findings !
- Plain X-ray - Sacroilitis : subchondral erosions, sclerosis - Squaring of lumbar vertebrae - Syndesmophytes
26
If X-ray is negative but suspicion of ank. spond is still high, what can be done ?
- MRI - Shows bone marrow oedema
27
what is the stepwise management of ank. spond ?
REGULAR EXERCISE & physio 1. NSAIDs
28
what are the most common triggers of reactive arthritis ?
- STI = chlamydia - Gastroenteritis
29
How does reactive arthritis present ?
- Develops 4 wks after infection - Arthritis (asymmetrical oligoarthritis). - Urethritis - Eye : conjunctivitis, anterior uveitis - Circinate balanitis - Dactylitis
30
How is reactive arthritis managed ?
- Joint aspiration -> microscopy, culture and sensitivity and crystal examination (exclude septic arthritis) - Symptomatic : analgesia, NSAIDs, intra-articular steroids
31
What are the 5 patterns of arthritis associated with psoriasis ?
- Symmetrical polyarthritis : (>4, similar to RA) - Asymetrical oligoarthritis : (1-4 joints). - Sacrolitis : (spine and sacroiliac joints) - DIP joint disease - Arthritis mutilans : (phalanges - osteolysis leads to telescoping digits).
32
what 5 other signs are seen in psoriatic arthritis ?
- Plaques of psoriasis on the skin - Nail pitting - Onycholysis (separation of the nail from the nail bed) - Dactylitis - Enthesitis
33
what is seen on X-ray in psoriatic arthritis ?
- Periostitis - ' Pencil-in-cup' appearance of digits
34
what is the stepwise management of psoriatic arthritis ?
- NSAIDs - Steroids - DMARDs (e.g., methotrexate, leflunomide or sulfasalazine) - Anti-TNF medications (etanercept, infliximab or adalimumab) - Ustekinumab is a monoclonal antibody that targets interleukin 12 and 23
35
what is SLE ? What kind of hypersensitivty reaction is it ? and who is it more common in ?
- Inflammatory autoimmune connective tissue disorder. - Type 3 - Young to middle aged women - Asian, African, Caribbean and Hispanic ethnicity
36
what antibodies are associated with SLE
- Anti-nuclear antibodies (Highly sensitive, low specificity). - anti-dsDNA (highly specific, less sensitive)
37
what bloods are used to monitor SLE ?
- ESR - Low C3/C4
38
what lifestyle advice is given to people with SLE ?
- Suncream and sun avoidance !! For photosensitive malar rash
39
what are the 3 first line treatment options for SLE?
- Hydroxychloroquine - NSAIDs - Steroids (e.g., prednisolone)
40
what is discoid lupus erythematosus and 3 RF ?
- Autoimmune chronic skin condition - Women, darker skin and smoking
41
What are the features of DLE
- Photosensitive erythematous, raised rash - Common on face, neck, ears and scalp - Can lead to scarring alopecia
42
How is DLE managed ?
- Skin biopsy to confirm - Sun protection - Topical steroids - Hydroxychloroquine if necessary
43
what is systemic sclerosis ?
- Autoimmune connective tissue disease involving inflammation and fibrosis of the connective tissues, skin and internal organs
44
what are the features of limited cutaneous systemic sclerosis ?
- C : Calcinosis - R : Raynaud's - E : oEsophageal dysmotility - S : Sclerodactyly - T : Telangiectasia
45
what extra features are associated with diffuse cutaneous systemic sclerosis ?
- Cardiovascular problems (e.g., HTN and coronary artery disease) - Lung problems (e.g., pulmonary hypertension and pulmonary fibrosis) - Kidney problems (e.g., glomerulonephritis and scleroderma renal crisis)
46
what is used to manage Raynaud's and what can make it worse ?
- Keeping hands warm and CCB (nifedipine) - BB can worsen the symptoms
47
What antibodies are seen in systemic sclerosis ?
-> ANA -> Anti-centromere = limited -> Anti-Scl-70 = diffuse
48
what is the common presentation of polymyalgia rheumatica (PMR)
- >60yrs - Rapid onset (<1mnth) - Pain and stiffness of shoulders, pelvic girdle and neck. - Worse : in morning, after rest, interferes with sleep. - Raised ESR
49
What is the management of PMR?
- 15mg prednisolone daily - If no respone = consider alt. diagnosis. Usually respond rapidly and v well to steroids
50
what are the additional management points for patients on long term steroids ?
Don't STOP - Don't abruptly stop - S : Sick day = increase in unwell - T : Treatment card - O : Osteoporosis prevention with bisphosphonates, calcium & vit D - P : PPI
51
what is GCA, who does it more commonly affect and what is it strongly linked too ?
- Systemic vasculitis affecting medium and larger arteries - Older white pts - Linked to PMR
52
How does GCA typically present ?
- Unilateral headache - Jaw claudication - Tender and thickened temporal artery - Blurred / double vision
53
what investigations are done in GCA ?
- ESR (Raised) - Temporal artery biopsy = multinucleated giant cells - Duplex USS = hypoechoic "halo" sign and stenosis of temporal artery
54
how is GCA managed ?
- No vision loss = high-dose pred (40-60mg) - Evolving vision loss = IV methylpred (500-1000mg)
55
what other medications are considered in GCA ?
- Aspirin 75mg daily decreases vision loss and strokes - PPI while on steroids - Bisphosphonates and calcium and vitamin D for bone protection while on steroids
56
- Severe pain in the first MTP joint - Swelling - Erythema
Gout
57
what is seen on aspiration of joint fluid in gout ?
- Needle shaped negatively birefringement crystals of monosodium urate
58
what can be seen in x ray in gout ?
- Maintained joint - Lytic lesions in the bone - Punched out erosions - Erosions can have sclerotic borders with overhanding edges
59
what is the acute management of gout ?
- First : NSAIDs (naproxen) with PPI - 2nd : Colchicine - 3rd : Oral prednisolone (15mg/day) If the pt is already on allopurinol it should be continued
60
When is colchicine given for the acute management of gout over NSAIDs?
- In those with renal impairment or significant heart disease - SE : diarrhoea
61
What is given for gout prophylaxis ?
- Xanthine oxidase inhibitors - Allopurinol -> 100mg of, titrated up to aim for uric acid <300umol/L - Colchicine cover when starting allopurinol
62
What is a typical presentation of pseudogout ?
- Pt >65 y/o with a rapid onset hot, swollen, stiff joint - Usually : knee, shoulder, hip or wrist
63
what is seen on joint aspiration in pseudogout ?
- Rhomboid shaped weakly positively birefringent crystals of calcium pyrophosphate
64
what is commonly seen on X-ray in pseudogout ?
- Chondrocalcinosis
65
what are 4 underlying RF for pseudogout which can cause it to develop at a younger age
- Haemochromatosis - Hyperparathyroidism - Low magnesium, low phosphate - Acromgely, wilson's disease
66
Define osteoporosis
- Significant reduction in bone density = weaker and more fracture prone - Osteopenia = less severe decrease in bone density
67
Define the T / Z score
- DEXA scan = measures bone mineral density - T score = no. of standard deviations pt is from an average healthy young adult - Z score = no. of standard deviations pt is from the average for their age, sex and ethnicity
68
Explain the diagnosis based on T score at femoral neck
- Normal : > -1 - Osteopenia : -1 to -2.5 - Osteoporosis : <-2.5 - Severe osteoporosis : <-2.5 + fracture
69
What are the RF for osteoporosis ?
- Advancing age - Female sex - Histort of glucocorticoid use - RA - Alcohol excess - Hx of parental hip fracture - Low BMI - Current smoking - Post menopausal
70
when should somebody be assessed for a 10 yr risk of major osteoporotic fracture and hip fracture ?
- Anyone on long-term oral corticosteroids or with a previous fragility fracture - Anyone 50 and over with risk factors - All women 65 and over - All men 75 and over
71
What 2 tools are used to osteoporotic fracture risk
- QFracture tool - FRAX tool
72
Based on the QFracture tool, what pts are considered for a DEXA scan ?
Pts >10%
73
what are the 3 steps to managing osteoporosis
1. Address reversible RF : increase exercise, healthy weight, stop smoking, reduce alcohol 2. Calcium (1000mg) and vitamin D (400-800 IU) 3. Treatment : bisphosphonates
74
Give 4 SE of bisphosphonates
- Reflux and oesophageal erosions - Atypical fractures (e.g., atypical femoral fractures) - Osteonecrosis of the jaw (regular dental checkups are recommended before and during treatment) - Osteonecrosis of the external auditory canal
75
How should bisphosphonates be taken ?
- Alendronate (70mg once weekly) - Empty stomach with a full glass of water - Remain upright for 30 mins afterwards)
76
How are patients >=75 yrs following a fragility fracture managed ?
- Presumed to having underlying osteoporosis - Begin alendronate without need for DEXA scan
77
How is a patient <75 yrs following fragility fracture managed ?
- Arrange DEXA
78
what is osteomalacia ?
- Softening of bones secondary to low vitamin D levels = decreased bone mineral content
79
How can osteomalacia present ?
- Fatigue - Bone pain - Muscle weakness - Muscle aches - Pathological or abnormal fractures (especially femoral neck)
80
What is seen on bloods in osteomalacia ?
- Low vit D (serum 25-hydroxyvitamin D of <25 nmol/L = deficiency) - Raised ALP - Low calcium, phosphate
81
What can be seen on x-ray in osteomalacia
- Translucent bands (looser zones or pseudofractures)
82
How is osteomalacia treated ?
- Colecalciferol (vitamin D supplements) - 50,000 IU once weekly for 6 weeks - 4000 IU daily for 10 weeks
83
Following the loading regime (if needed) what is the maintenance dose of vitamin D in osteomalacia treatment ?
800-2000 IU per day
84
What is Paget's disease of bone ?
- Increased, uncontrolled bone turnover
85
where is most commonly affected in Paget's disease ?
- Skull - Spine / pelvis - Long bones of lower extremeties
86
What is seen on bloods in paget's disease of the bone ?
- Isolated raised ALP
87
what are common X-ray findings in paget's ?
- Bone enlargement and deformity - Osteoporosis circumscripta - Cotton wool appearance of the skull (poorly defined patchy areas of increased and decreased density) - V-shaped osteolytic defects in the long bones
88
How is paget's managed and monitored?
- Bisphosphonates (either oral risedronate or IV zoledronate) - Checking serum ALP
89
What are 4 key complicatons of paget's ?
- Hearing loss - Heart failure - Osteosarcoma - Spinal stenosis and spinal cord compression
90
what is antiphospholipid syndrome ?
- Autoimmune disorder where antiphospholipid antibodies bind the cell surface and cause inflammation and increased thrombosis risk - Can occur in isolation or secondary to conditions like SLE
91
what are the key complications of antiphospholipid syndrome ?
- VTE (DVT/PE) - Arterial thrombosis (stroke, MI) - Pregnancy related (recurrent moscarriage)
92
what investigations are done in antiphospholipid syndrome ?
- Antibodies : Lupus anticoagulant, Anticardiolipin antibodies, Anti-beta-2 glycoprotein I antibodies - FBC : thrombocytopenia - Clotting : prolonged APTT
93
How is antiphospholipid syndrome managed ?
- No previous thrombosis = low dose aspirin - Previous venous / arterial blood clot = Long term warfarin with INR target of 2-3
94
what rash is associated with antiphospholipid syndrome ?
Livedo reticularis (netlike reddish-blue skin discoloration)
95
What heart condition is associated with anti-phospholipid syndrome ?
- Libmann-Sacks endocarditis - Non bacterial endocarditis - Vegetations on the heart valves
96
what is Sjogren's syndrome ?
- Autoimmune disorder affecting exocrine glands = dry mucosa - Can be primary or secondary to RA / other connective tissue disorders
97
what are the features of sjogren's
- Dry eyes - Dry mouth - Vaginal dryness - Arthralgia - Raynaud's - More common in women, presents in middle age
98
what malignancy does Sjogren's increase the risk of ?
lymphoid
99
what antibodies are seen in Sjogren's
- Anti-SS-A = anti-Ro - Anti-SS-B = anti-La - RF - ANA
100
what test can be done for Sjogren's ?
Schirmer's test <10mm = significant
101
how is Sjogren's managed
- Artifical tears - Pilocarpine = stimulates muscarinic receptors = promoting salivary and lacrimal gland secretion
102
what is Behcet's syndrome and its associations ?
- Complex inflammatory condition - HLA B51 - More common in men, young adults and eastern mediterranean pts
103
What are the classical symptoms of Behcet's ?
1. Oral ulcers (3x a year). 2. Genital ulcers 3. Anterior uveitis AND - Thrombophlebitis and DVT - Arthritis - Erythema nodosum - GI : abdo pain, diarrhoea, colitis
104
what investigation can support the diagnosis of bechet's
- Pathergy test - Erythema and enduration 24-48 hrs after skin pricking
105
what is polymyositis and what can 2 conditions can it be associated with
- Inflammatory disorder causing symmetrical, proximal muscle weakness - Connective tissue disorders - Malignancy
106
How does polymyositis present ?
- Gradual onset symmetrical proximal muscle weakens +/- tenderness - Raynaud's - Resp muscle weakness - Dysphagia, dysphonia
107
what is elevated in polymyositis and dermatomyositis
- Creatinine kinase
108
what antibody is associated with polymyositis ?
- Anti-Jo-1 - More common in a pattern of disease that also involves the lungs, raynaud's and fever
109
What is the first line treatment for polymyositis and dermatomyositis ?
Corticosteroids
110
Along with proximal muscle weakness, what else is seen in dermatomyositis ?
CHARACTERISTIC SKIN LESIONS - Gottron papules on hands (roughened red papules over extensor surfaces of fingers) - Heliotrope rash on eyelids - Periorbital oedema - Photosensitive erythematous rash on the back, shoulders and neck
111
Name 3 small-vessel vasculitis
- Microscopic polyangitis - Granulomatosis with polyangitis (Wegener's granulomatosis) - Eosinophilic granulomatosis with polyangitis (Churg-Strauss)
112
What are the main features of microscopic polyangitis and what is its associated antibodies ?
- p-ANCA - Glomerulonephritis = renal failure - Diffuse alveolar haemorrhage = haemoptysis
113
What are the main features of granulomatosis with polyangitis and what is its associated antibody ?
- URT: epistaxis, sinusitis, saddle shaped nose, nasal crusting - LRT : cough, wheeze, haemoptysis - Kidneys : glomerulonephritis - c-ANCA
114
what are the common findings of eosinophilic granulomatosis with polangitis and what antibody is associated
- Lungs, skin and kidneys - Severe asthma in middle age - Sinusitis and allergic rhinitis - Raised eosinophils - p-ANCA
115
Name 2 medium vessel vasculitis
- Polyarteritis nodosa - Kawasaki disease
116
what are the typical features of polyarteritis nodosa
- Renal impairment - Hypertension - Tender, erythematous skin nodules (similar to erythema nodosum) - Myocardial infarction - Stroke - Mesenteric arteritis causing intestinal symptoms
117
Name 2 large vessel vasculitis
- GCA - Takayasu's arteritis
118
Where does takayasu's arteritis affecrt and how does it present ?
- Aorta + branches - Pulmonary arteries - <40 yrs - Claudication symptoms - Non specific : fever, malaise, muscle aches
119
what is the approach to diagnosing vasculitis ?
- Urinalysis for haematuria and proteinuria - Bloods: urea and creatinine for renal impairment, full blood count: normocytic anaemia and thrombocytosis may be seen - CRP: raised - ANCA testing - Chest x-ray: nodular, fibrotic or infiltrative lesions may be seen
120
what antibodies are seen in those with drug induceded lupus
Anti-histone antibodies
121
what is seen on arthrocentesis in RA ?
- High WBC count - Predominantly polymorphonuclear neutrophil predominance - Appearance is yellow and cloudy
122
Exam questiin presentation of osteomalacia
Bone pain, tenderness and proximal myopathy (-> waddling gait).
123
what should NEVER be prescribed alongside methotrexate
- Trimethoprim : can cause fatal pancytopenia - Co-trimoxazole also contains trimethoprim !
124
what is antisynthetase syndrome, what causes it and how does it present
- Subtype of dermatomyositis caused by anti-Jo-1 antibodies 1. Myositis 2. Interstitial lung disease 3. Thickened and cracked skin of the hands (mechanic's hands) 4. Raynaud's phenomenon
125
- Red, hot swollen joint - Aspiration = gram +ve cocci in clusters that are coagulase positive - Likely organism
Staphylococcus aureus
126
- Red, hot swollen joint - Aspiration = gram +ve cocci in clusters that are coagulase positive - Flucloxacillin resistant - Likely organism
MRSA (methicillin-resistant S.aureus)
127
Management of septic arthritis caused by MRSA
Vancomycin teicoplanin and linezolid could also be used
128
What antibodies are seen in antiphospholipid syndrome
Anti-cardiolipin
129
IV antibiotic for septic arthritis
Flucloxacillin Clindamycin if pen allergic 4-6 wks (switched to oral after 2)
130
what blood results are seen in osteoporosis ?
all normal !
131
Presentation of SLE
- Young female - Fatigue, fever, mouth ulcers - Skin : malar rash - MSK : arthralgia - CVD : pericarditis, myocarditis - Resp : pleurisy - Renal : proteinuria - Neuro : anxiety, depression, psychosis
132
Presentation of primary Raynaud's disease
Young women Bilateral symptoms
133
6 secondary causes of Raynaud's phenomenon
- Connective tissue - Leukaemia - Type 1 cryoglobulinaemia - Use of vibrating tools - Drug : COCP - Cervical rib
134
2 common causes of drug induced lupus
Procainamide Hydralazine
135
Inheritance of EDS and what is affected
- AD - Connective tissue disorder affecting type III collagen
136
6 features / complications of EDS
- Elastic, fragile skin - Joint hypermobility: recurrent joint dislocation - Easy bruising - Aortic regurgitation, mitral valve prolapse and aortic dissection - Subarachnoid haemorrhage - Angioid retinal streaks
137
How many points does a pt need to be tender in for a diagnosis of fibromyalgia
11 out of 18
138
Inheritance and effect of Marfan's
AD : chromosome 15 Defect in protein filbrillin-1 Connective tissue disorder
139
6 general features of marfan's
Tall statue with wide arm span Arachnodactyly Pes planus Pectus excavatum Scoliosis High arched palate
140
Effect of marfans on heart
- Mitral valve prolapse - Dilation of aortic sinus : AAA, dissection, aortic regurg
141
Effect of marfan's on lungs
Repeated pneumothoraces
142
Effect of marfan's on eyes
Upward lens dislocation
143
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