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Rheum/MSK > Rheum 1 > Flashcards

Rheum 1 Flashcards

1
Q

What are some risk factors for osteoarthritis?

A 
joint hypermobility
insufficient joint repair
diabetes
increasing age
female
obesity - proinflamm state
occupation - manual labour, farming and football
local trauma
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2
Q

How does osteoarthritis present?

A
  • Affects many joints
  • Symptoms are usually gradual in onset and progressive
  • Joint pain - made worse by movement and relieved by rest
  • Joint stiffness after rest (gelling)
  • less than 30 mins morning stiffness

BOUCHARD’s - proximal interphalangeal joints
HEBERDEN’s - distal interphalangeal joints

*b before h, bouchard’s more proximal

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3
Q

How would you investigate osteoarthritis?

A

X-ray - LOSS (loss of joint space, osteophytes, subarticular sclerosis, subchondral cysts)

Bloods - CRP, ESR = normal
Rule out rheumatoid - Rh factor, anti-CCP

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4
Q

How would you treat osteoarthritis?

A

Local analgesia - capsaicin, then paracetamol then NSAID

Exercise therapy

Methylprednisolone intrarticular injection

Sodium hyaluronate

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5
Q

What are risk factors for rheumatoid arthritis?

A

Women - premenopause
Fam hx
Genetic factors - HLA-DR4 & HLA- DRB1
Smoking

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6
Q

How does RA present?

A
  • slowly progressive, symmetrical swollen, painful and stiff
  • MCP and PIP of hands, MTP of feet
  • DIPS are spared
  • wrists, elbows, shoulders, knees and ankles
  • joints usually warm and tender
  • symptoms worse in the morning and in the cold
  • morning stiffness lasting more than 30 minutes

Ulnar deviation, Swan neck/.Z-thumb, Boutonniere

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7
Q

How does RA present in the Lungs, Heart and eyes?

A

Pleural effusions, interstitial lung disease

Pericarditis, Pericardial rub

Dry eyes, episcleritis

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8
Q

How does RA present in neurologically and in the skin?

A

Peripheral sensory neuropathies, Cord compression

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9
Q

How would you investigate Rheumatoid arthritis?

A

Rheumatoid factor - positive in 60-70%

anti-CCP - positive in 70%

elevated CRP and ESR

radiographs - erosions

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10
Q

How would you treat Rheumatoid arthritis?

A

DMARDs - MTX, Sulfasalazine, Hydrochloroquine started within 3 months of persistent symptoms

Prednisolone

Ibuprofen

Etanercept

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11
Q

How can you define osteoporosis, osteopenia and osteomalacia?

A

Osteoporosis - BMD >2.5 SD below the young adult mean value

Osteopenia BMD between 1-2.5 SD below the young adult mean valu

Osteomalacia - poor bone mineralisation leading to soft bone due to lack of Ca2+

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12
Q

What are some causes/risk factors for osteoporosis?

A

SHATTERED

  • steroids
  • hyperthyroid & hyperparathyroid
  • alcohol & tobacco
  • thin
  • testosterone
  • early menopause
  • renal or liver failure
  • erosive/inflamm bone disease
  • dietary calcium decrease/malabsorption
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13
Q

What are common presentations of osteoporosis?

A

Vertebral crush fracture : sudden onset of severe pain in the spine

Colles’ fracture of the wrist

Fracture of the proximal femur usually in older individuals falling on their side or back

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14
Q

How would you investigate osteoporosis?

A

DEXA
USS of heel
X-ray
biochem markers of bone absorp and resorp - deoxypyridinoline and N-telopeptides
bloods - calcium, albumin, creatinine, phosphate, parathyroid hormone

TFTs

urinary free cortisol

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15
Q

How would you treat osteoporosis?

A

bisphos - alendronic acid (men with low test add test) (reassess after 5 years with updated FRAX and dexa)

calcium and vit D supplementation

raloxifene or denosumab

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16
Q

What is SLE?

A

Systemic Lupus Erythematosus

Inflammatory, multisystem autoimmune disorder with arthralgia and rashes as the most common clinical features
- cerebral and renal disease as the most serious problems

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17
Q

What are causes/risk factors for SLE?

A
  • pre-menopausal women most affected
  • African-carribeans and Asians
  • HLA genes linked
  • Drugs - hydralazine, isoniazid, procainamide, penicillamine
  • UV light
  • Epstein-barr
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18
Q

Pneumonic for SLE presentation?

A

SOAP BRAIN MD

serositis
oral ulcers
arthritis
photosensitivity

blood (all low - anaemia, leukopenia and thrombocytopenia)
renal (protein)
ANA
Immunologic (DS DNA)
Neurologic (psych, seizures)
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19
Q

How does SLE present?

A

Joint - similar to RA
Skin - erythema in butterfly distribution, photosensitive rash

Lung - recurren pleural effusions

Heart - pericarditis, arrhythmias

Kidneys - glomerulonephritis with proteinuria

CNS - seizure and psychosis

Eyes - conjunctivitis, Sjogren’s

GI - mouth ulcers

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20
Q

How would you investigate SLE?

A

FBC - anaemia, leukopenia, thrombocytopenia

Activated PTT - may be prolonged in patients with antiphospholipid antibodies

Urea and Electrolyes

Antinuclear antibodies (ANA - best diagnostic test), dsDNA, Smith antigen (both these highly specific for SLE) - positive

Urinalysis
CXR

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21
Q

How would you treat SLE?

A

Joint and Serositis - hydroxychloroquine, NSAIDs, corticosteroids

Mucocutaneous - sunscreen, oral care, chlorhexidine, artificial saliva

neuropsychiatric - cyclophosphamide, IVIG, plasmapheresis

22
Q

What is Sjogren’s? What are the types?

A

Chronic inflammatory autoimmune disorder - destruction of epithelial exocrine glands, especially the lacrimal and salivary glands

Primary - syndrome of dry eyes in the absence of RA or any autoimmune diseases

Secondary - assoc with connective tissue disease (RA, SLE and systemic sclerosis)

23
Q

How does Sjogren’s present?

A 
dry eyes
dry mouth
salivary and parotid gland enlargement
dryness of skin and vagina
arthralgia, Raynaud's, dysphagia
24
Q

How would you investigate Sjogren’s

A

Schrimer’s - filter paper in the lower conjunctival sac - positive if = less than 5mm paper is wet after 5 minutes

Anti-RO & Anti-LA - positive

Sialometry - measure salivary flow

25
Q

How would you treat Sjogren’s?

A

Artificial tears

Opthalmic ciclosporin drops

Salivary substitutes - pilocarpine

MSK - paracetamol & NSAIDs

vasculitis - prednisolone

26
Q

What is systemic sclerosis? What are the two different types of presentation?

A

Multisystem diseases with involvement of skin and Raynaud’s

Limited Cutaneous Scleroderma/CREST (70%)

Diffuse Cutaneous Scleroderma (30%)

27
Q

How does limited cutaneous scleroderma/CREST present?

A

Raynaud’s
Skin involvement limited to - hands, feet, face and forearms

Flexion deformities of fingers

Beak-like nose and small mouth

Painful digital ulcers and telangiectasia

GI - oesophageal dysmotility or strictures

CREST = calcinosis, Raynaud’s, oesophageal dysmotility, sclerodactyly, telangiectasia

28
Q

How does diffuse cutaneous scleroderma present?

A
  • skin changes more rapidly and widespread
  • early involvement of other organs

GI - dilation and atony (heartburn and dysphagia), malabsorp, pseudoobstruction

Renal - AKI & CKD, acute hypertensive crisi

Lung - fibrosis

Myocardial fibrosis - arrhythmias and conduction

29
Q

How would you investigate systemic sclerosis?

A

FBC - anaemia
Creatinine
Antinuclear antibody - 90% have positive ANA
Extractable nuclear antigens
ESR
Echo - done at onset and yearly (RV or LV diastolic dysfunction, pulm hypertension)
Pulmonary function tests

30
Q

How would you manage systemic sclerosis?

A

Smoking cessation, exercise and physio

Immunosuppresant - MTX

Vasodilator - iloprost

CCB/ACEi

renal crisis - ACEi, nifidepine

Raynaud’s - pentoxifylline

31
Q

What is polymyositis? What is dermatomyositis?

A

Rare muscle disorder of unknown aetiology - inflammation and necrosis of skeletal muscle

Dermatomyositis - when skin is involved

32
Q

How does polymyositis present?

A

Symmetrical progressive muscle weakness - affecting PROXIMAL muscles of shoulder and pelvic girdle

Difficult squatting, up stairs , rising from chair

pain and tenderness are UNCOMMON

pharyngeal, laryngeal and respiratory muscles = dysphagia, dysphonia and resp. failure

DERMATOMYOSITIS - heliotrope (purple) discolouration of eyelids

  • scaly erythematous plaques over the knuckles (Gottron’s papules)
33
Q

How would you investigate polymyositis?

A

muscle biopsy - endomysial inflammatory infiltrates, muscle necrosis, atrophy

muscle enzyme (CK, aminotransferase, LDH, aldolase) = elevated

ANA positive in DM

Rh Factors - +ve

Myositis-specific antibodies

34
Q

How would you treat polymyositis?

A

Oral pred
IVIG
creatine

35
Q

What is Raynaud’s? Disease and phenomenon?

A

Intermittent spasm in thr arteries supplying the fingers and toes - precipitated by cold and relieved by heat

Disease - no underlying cause

Phenomenon - underlying disease

36
Q

How does Raynaud’s present?

A

vasoconstriction (white)
cyanosis (blue)
hyperaemia (red)
duration varies - can last hours

numbness, burning sensation and severe pain occur when fingers warm up

infarction and digital loss can occur

37
Q

How can you investigate Raynaud’s?

A 
Clinical
ANA
FBC
Creatinine
Urinalysis

all should be normal

38
Q

How can you treat Raynaud’s?

A

Keep warm, smoking cessation

Paracetamol, Ibuprofen

CCB

IF SEVERE - prostacyclin (iloprost), atorvastatin, analgesia, aspirin

39
Q

What are some shared features of seronegative spondyloarthropathies/spondyloarthritis?

A
  • Axial inflammation - spine and sacroiliac joints
  • asymmetrical peripheral arthritis
  • absence of rheumatoid factor = seronegative
  • strong association with HLA-B27
40
Q

What mnemonic for spondyloarthropathies?

A

SPINEACHE

Sausage digit (dactylitis)
Psoriasis
Inflammatory back pain
NSAID good response
Enthesitis (heel-plantar fasciitis)
Arthritis
Crohn's/colitis/elevated CRP
HLA-B27
Eye (uveitis)
41
Q

How does ankylosing spondylitis present?

A
  • Man <30 y/o
  • gradual onset of low back pain
  • worse at night
  • spinal morning stiffness that is relieved by exercise (bamboo spine)
  • episodic inflammation of sacroiliac joints
  • pain improves towards end of the day
  • asymmetrical joint pain
  • loss of lumbar lordosis
  • increased kyphosis
  • anterior uveitis

restrictive lung disease, pulm fibrosis

42
Q

How would you investigate ankylosing spondylitis?

A

Pelvic X-ray - sacroillitis
MRI - bone marrow oedema

Schober#s test - restriction in lumbar movement

HLA-B27 - 90-95% of patients

43
Q

How would you treat ankylosing spondylitis?

A

NSAIDs + codeine/paracetamol
Intra-articular corticosteroid
TNF-alpha inhibitor

44
Q

How does Psoriatic Arthritis present?

A

10-40% can present before skin changes

  • asymm oligoarthritis
  • spondylitis - uni/bilateral sacrolitis and early cervical spine involvement
  • distal interphalangeal arthritis
  • psoriasis - behind ear/inside ear, scalp, pitting in nails or onokylosis
45
Q

How would you investigate psoriatic arthritis?

A

X-ray of hands and feet - erosion in DIP, osteolysis and pencil-in-cup deformity

ESR and CRP - normal, elevated assoc. with polyarticular and progressive arthritis

Lipid profile, fasting blood glucose, uric acid level - increased risk of met syndrome in psoriatic disease - appropriate metabolic screening

Rh factor - normally negative

46
Q

How would you treat psoriatic arthritis?

A

NSAIDs

Intra-articular corticosteroid - methyl pred

DMARDs - MTX

TNF - alpha inhibitor - etanercept

47
Q

What is reactive arthritis? What are the usual organisms responsible?

A

Sterile inflammation of the synovial membrane, tendons and fascia triggered by an infection at a distant site, usually GI or genital

i) GI - salmonella, shigella
ii) Sexually acquired - urethritis (chlamydia), urea plasma urealyticum

48
Q

How would reactive arthritis present?

A
  • arthritis - acute, asymm and lower-limb
  • few days to a couple weeks after the infection
  • can’t see (acute anterior uveitis)
  • can’t wee (painless ulceration of the penis)
  • can’t climb a tree (plantar fasciitis, achilles tendon enthesitis)

*last 3 = reiter’s syndrome

49
Q

How would you investigate reactive arthritis?

A 
ESR and CRP raised
Infectious serology
Sexual health review
ANA
Rh factor
50
Q

How would you treat reactive arthritis?

A

NSAIDs
Local steroid injection
Sulfasalazine/MTX if symptoms >6 months

51
Q

DEXA scan what is the difference between T and Z score?

A

T-score - bone density compared to healthy 30 year old

Z-score - adjusted for age, gender and ethnic factors

Rheum/MSK (5 decks)

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