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Rheum Flashcards

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1
Q
  1. A 65 year old builder with gradual onset left hip pain worse with activity and late in the day ?
A
  • Osteoarthritis
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2
Q
  1. What X-ray findings would you see for osteoarthritis ?
A
  • LOSS
  • Loss of joint space
  • Osteophytes
  • Subchondral sclerosis
  • Subchondral cysts
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3
Q
  1. What are the names for the lumps on joints in osteoarthritis ?
A
  • Heberden’s nodes  DIP joints
  • Bouchard’s nodes  PIP joints
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4
Q
  1. What are non-medical options for osteoarthritis ?
A
  • Weight loss (if overweight)
  • Physiotherapy
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5
Q
  1. What are medical/surgical options for osteoarthritis ?
A
  • Analgesia
  • Intra-articular steroid injections
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6
Q
  1. Medical/Surgical options for OA
A
  • Analgesia – topical NSIADs 1st line 2nd line are oral NSIADs + PPO
  • Intra-articular steroid injections
  • Joint replacement surgery
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7
Q
  1. A 43 year old with symmetrical joint pain, swelling and stiffness in the hands, wrists and feet. Symptoms are worst in the morning ?
A
  • Rheumatoid arthritis
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8
Q
  1. What antibodies are associated with RA ?
A
  • Rheumatoid factor antibodies
  • Cyclic citrullinated peptide (CCP) antibodies
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9
Q
  1. What hand deformities are associated with RA ?
A
  • Z-shaped deformity (thumb)
  • Swan neck deformity
  • Boutonnieres deformity
  • Ulnar deviation at the MCP joints
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10
Q
  1. What is the investigation for synovitis ?
A
  • Ultrasound
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11
Q
  1. What scoring system is used for RA ?
A
  • DAS28
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12
Q
  1. What treatment options are available for RA ?
A
  • DMARDs
  • Methotrexate
  • Leflunomide
  • Sulfasalazine
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13
Q
  1. Which DMARDs are used in pregnancy ?
A
  • Hydroxychloroquine
  • Sulfasalazine (extra folic acid)
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14
Q
  1. What type of biological is used to treat RA ?
A
  • Infliximab  TNF inhibitor
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15
Q
  1. A 35 yo presents with asymmetrical pain and stiffness in the fingers and feet. There are skin and nail changes. What is the diagnosis ?
A
  • Psoriatic arthritis
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16
Q
  1. What nail changes occur with psoriatic arthritis ?
A
  • Nail pitting
  • Onycholysis – separation of the nail from the nailbed
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17
Q
  1. What is dactylitis ?
A
  • Inflammation of the entire digit in psoriatic arthritis
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18
Q
  1. What is the most severe form with osteolysis and telescoping of the digits ?
A
  • Arthritis mutilans
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19
Q
  1. What other conditions is psoriatic arthritis associated with ?
A
  • Uveitis
  • IBD
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20
Q
  1. Signs of psoriatic arthritis ?
A
  • Plaques of psoriasis on the skin
  • Nail pitting
  • Onycholysis - (separation of the nail from the nail bed)
  • Dactylitis - (inflammation of the entire finger)
  • Enthesitis - (inflammation of the entheses, which are the points of insertion of tendons into bone)
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21
Q
  1. What X-ray changes are seen for psoriatic arthritis ?
A
  • Periostitis (inflammation of the periosteum, causing a thickened and irregular outline of the bone)
  • Ankylosis (fixation or fusion of the bones at the joint)
  • Osteolysis (destruction of bone)
  • Dactylitis (inflammation of the whole digit, seen as soft tissue swelling)
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22
Q
  1. How is psoriatic arthritis managed ?
A
  • Depends on severity. Usually MDT led
  • NSAIDs
  • Steroids
  • DMARDs e.g. methotrexate
  • Anti-TNF medications (etanercept, infliximab or adalimumab)
  • Ustekinumab is a monoclonal antibody that targets interleukin 12 and 23
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23
Q
  1. A 42 yo presents with knee pain and swelling 2 weeks after having gastroenteritis. What is the most likely diagnosis ?
A
  • Reactive arthritis
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24
Q
  1. What is the classic triad of features of reactive arthritis ?
A
  • Arthritis
  • Conjunctivitis
  • Urethritis/balanitis
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25
25. What are the most common triggers of reactive arthritis ?
- Gastroenteritis - Sexually transmitted infection (chlamydia)
26
26. What gene is associated with reactive arthritis ?
- HLA B27
27
27. What is an important differential for reactive arthritis ?
- Septic arthritis
28
28. What investigations would you order to exclude other causes of reactive arthritis ?
- Joint aspiration
29
29. How is reactive arthritis management ?
- Abxs may be given until septic arthritis is excluded - Treatment of triggering infection e.g. chlamydia - NSAIDs - Steroid injection into the affecting joints - Systemic steroids may be required, particularly where multiple joints are affected
30
30. What is a key investigation to differentiate reactive arthritis from other DDs
- Joint aspiration and fluid sent for microscopy, culture, sensitivity and testing for infection and crystal examination for gout and pseudogout
31
31. What is the main gene associated with ankylosing spondylitis ?
- HLA B27
32
32. What are the main symptoms of ankylosing spondylitis ?
- Pain and stiffness that is worse in the morning and improves over the day - Stiffness is in the lower back - Sacroiliac pain (buttock region)
33
33. What is the name of the test you would ask a patient to do to confirm ankylosing spondylitis ?
- Schober’s test
34
34. What X-ray finding would be present in ankylosing spondylitis in late disease ?
- Bamboo spine
35
35. What is an MRI finding in early disease in ankylosing spondylitis ?
- Bone marrow oedema
36
36. Which joints are mainly affected in ankylosing spondylitis ?
- Sacroiliac joints - Vertebral column joints
37
37. What additional non-back symptoms might someone with ankylosing spondylitis have ?
- Chest pain related to the costovertebral and sternocostal joints - Enthesitis (inflammation of the entheses, where tendons or ligaments insert into bone) - Dactylitis (inflammation of the entire finger) - Vertebral fractures (presenting with sudden-onset new neck or back pain) - Shortness of breath relating to restricted chest wall movement)
38
38. What conditions are associated with ankylosing spondylitis ?
- Anterior uveitis - Aortic regurgitation - Atrioventricular block - Apical lung fibrosis (fibrosis of the upper lobes of the lungs) - Anaemia of chronic disease
39
39. What investigations might one do for ankylosing spondylitis ?
- Inflammatory markers e.g. CRP and ESR - HLA B27 genetic testing - X-ray of spine and sacrum - MRI spine – bone marrow oedema in early disease
40
40. How will ankylosing spondylitis appear on x-ray ?
- Squaring of the vertebral bodies - Subchondral sclerosis and erosions - Syndesmophytes - Ossification of the ligaments, discs and joints - Fusion of the facet, sacroiliac and costovertebral joints
41
41. How is ankylosing spondylitis managed ?
- NSIADs are first line - Anti-TNF medications are 2nd line e.g. infliximab - Monoclonal antibodies 3rd line e.g. interleukin 17 - Upadacitinib also 3rd line (JAK inhibitor)
42
42. What is additional management of ankylosing spondylitis ?
- Physiotherapy - Exercise and mobilisation - Avoid smoking - Bisphosphonates for osteoporosis - Surgery is occasionally required for severe joint deformity
43
43. How can SLE present ?
- Hair loss - Malar rash - SOB - Splenomegaly - Joint pain - Lymphadenopathy - Myalgia
44
44. What is the initial antibody test for SLE ?
- Anti-nuclear antibodies
45
45. What is the specific antibody test for SLE ?
- Anti-double stranded DNA (anti-DSDNA) - Anti-SMITH
46
46. What is 1st line for mild SLE ?
- Hydroxychloroquine - (NSAIDs and steroids)
47
47. What treatment options are available for SLE in more severe disease ?
- DMARDs e.g. methotrexate - Biological therapies e.g. Rituximab
48
48. What biological medicine that targets B-cells is used to treat SLE ?
- Rituximab
49
49. What demographics are commonly affected by SLE ?
- Women - Asian, African, Caribbean and Hispanic - Young to middle aged adults
50
50. What are complications of SLE ?
- Cardiovascular disease - Infection - Anaemia – chronic disease, medication bone marrow suppression or kidney disease - Pericarditis - Pleuritis - Interstitial lung disease leading to pulmonary fibrosis - Lupus nephritis - Neuropsychiatric SLE - Recurrent miscarriage - VTE and antiphospholipid syndrome
51
51. A 30 yo with skin lesions on her face and patches of hair loss. Symptoms are worse in the sunlight. What is the diagnosis ?
- Discoid lupus erythematosus
52
52. What is the initial investigation for discoid lupus erythematosus ?
- Skin biopsy
53
53. What is the treatment for discoid lupus erythematosus ?
- Sun protection - Topical steroids - Intralesion steroid injections - Hydroxychloroquine
54
54. What cancer could skin lesions become in discoid lupus erythematosus ?
- Squamous cell carcinoma
55
55. What are the 3 stages of Raynard’s Phenomenon ?
- White - Blue - Red
56
56. What % of patients have underlying disease and Raynard’s Phenomenon ?
- 10-20%
57
57. What is the most associated connective tissue disease with Raynard’s ?
- Systemic sclerosis (scleroderma)
58
58. What screening blood test is available with system sclerosis ?
- Anti-nuclear antibodies
59
59. What test can be used to examine the small blood vessels in the fingers ?
- Nailfold capillaroscopy
60
60. What is medical management for Raynaud’s ?
- Nifedipine
61
61. What are secondary causes of Raynaud’s ?
- Connective tissue disorders – scleroderma, RA and SLE - Leukaemia - Using vibrating tools - Drugs e.g. COCP - Cervical rib
62
62. What factors of Raynaud’s suggest underlying connective tissue disease ?
- Onset after 40 years - Unilateral symptoms - Rashes - Presence of autoantibodies - Features which may suggest RA, SLE e.g. arthritis or recurrent miscarriages - Digital ulcers - All with suspected secondary symptoms should be referred to secondary care
63
63. What does CREST stand for in CREST syndrome ?
- C – Calcinosis - R – Raynaud’s phenomenon - O – Oesophageal dysmotility - S - Sclerodactylyl - T – Telangiectasia
64
64. What ABs are checked initially in connective tissue disease ?
- Antinuclear antibodies (ANA)
65
65. What ABs are checked in limited cutaneous systemic sclerosis ?
- Anti-centromere antibodies
66
66. What ABs are checked in diffuse cutaneous systemic sclerosis ?
- Anti-SCL-70 antibodies
67
67. A 65 yo white women with one month of shoulder and pelvic girdle pain and stiffness worse in the pain. What is the diagnosis ?
- Polymyalgia rheumatica
68
68. What abnormal presents in blood tests in polymyalgia rheumatic ?
- Increased CRP, ESR and Plasma viscosity
69
69. What is the treatment for polymyalgia rheumatica ?
- Initially prednisolone 15 mg OD
70
70. What do you need to prescribe in addition to long term steroid treatment ?
- Bisphosphonates - Calcium + vitamin D - PPIs
71
71. What condition is polymyalgia rheumatica closely associated with ?
- Temporal arthritis
72
72. How does polymyalgia rheumatica present ?
- Pain and stiffness in the - Shoulders – potentially radiating to the upper arm and elbow - Pelvic girdle - Neck - Typically in older Caucasian women
73
73. What are the characteristic features of pain and stiffness in polymyalgia rheumatica ?
- Worse in the morning - Worse after rest or inactivity - Interferes with sleep - Takes at least 45 minutes to ease in the morning - Somewhat improves with activity
74
74. What are the associated features of polymyalgia rheumatica ?
- Systemic symptoms e.g. weight loss, fatigue and low grade fever - Muscle tenderness - Carpel tunnel syndrome - Peripheral oedema
75
75. What are DDs of polymyalgia rheumatica ?
- Osteoarthritis - RA - SLE - Fibromyalgia - Lymphoma or leukaemia - Myeloma
76
76. What is the key blood test for temporal arthritis ?
- ESR (usually >50mm/hour)
77
77. What is the initial treatment for temporal arthritis ?
- IV methylprednisolone if evolving visual loss - High dose prednisolone if no visual loss (40-60mg)
78
78. A 56 yo presents with pain and weakness in their thighs, shoulders and upper arms. There is a purplish rash on the eyelids. What is the diagnosis ?
- Dermatomyositis
79
79. How does dermatomyositis differ from polymyositis ?
- Polymyositis presents with pain and weakness in the joints but without the rash on the eyelids
80
80. What are the skin changes seen on the hands in dermatomyositis ?
- Gottron lesions
81
81. What is the initial blood test for dermatomyositis ?
- Creatine kinase
82
82. What antibodies are associated with dermatomyositis ?
- Anti-Jo-1 - Anti-Mi-2 - Anti-nuclear antibodies
83
83. What is the definitive investigation for dermatomyositis ?
- Muscle biopsy
84
84. What should one consider in new cases of dermatomyositis ?
- Possible underlying cancer
85
85. What is first line treatment for dermatomyositis ?
- Corticosteroids
86
86. A 45 yo female presents with dry eyes, mouth and vagina ?
- Sjogren’s syndrome
87
87. What are the affected structures in Sjorgren’s syndrome ?
- Exocrine glands - Notably the lacrimal and salivary glands (hence the dryness)
88
88. What are conditions could Sjorgren’s syndrome be secondary to ?
- SLE - RA
89
89. What are the associated antibodies with Sjorgren’s syndrome ?
- Anti-Ro - Anti-La
90
90. What is the test for dry eyes in Sjorgren’s syndrome ?
- Schirmer test
91
91. What is the treatment that can halt Sjorgren’s syndrome progression ?
- Hydroxychloroquine
92
92. How is Sjorgren’s syndrome managed ?
- Hydroxychloroquine – mainly in patients with joint pain - Artificial tears - Artificial saliva - Vaginal lubricants - Pilocarpine – can stimulate teat and saliva
93
94. How does granulomatosis with polyangiitis present ?
- Sinusitis - Nose bleeds - Saddle shaped nose - Cough, wheeze and haemoptysis - Glomerulonephritis
94
95. What type of disease is granulomatosis with polyangiitis ?
- Vasculitis
95
93. What are complications of Sjogren’s syndrome ?
- Eye – corneal ulcers - Oral – dental cavities and candida infections - Vaginal – candida and sexual dysfunction
96
96. What is the blood test for granulomatosis with polyangiitis ?
- Anti-neutrophil cytoplasmic antibodies
97
97. What are the treatments for granulomatosis with polyangiitis ?
- Steroids - Cyclophosphamide (90% response) - Plasma exchange - Median survival = 8-9 years
98
98. What blood test is raised in gout ?
- Uric acid
99
99. What is seen on aspirated fluid ?
- Monosodium urate crystals - Needle shaped negatively birefringent of polarised light
100
100. What is first line for an acute flair of gout ?
- NSIADs e.g. ibuprofen or naproxen
101
101. What is 1st line for acute gout with renal impairment and what is its main side effect ?
- Colchicine - Diarrhoea
102
102. What is given prophylactically for gout ?
- Allopurinol
103
103. What are RFs for gout ?
- Male - Fhx - Obesity, high purine diet and alcohol - Diuretics - CVD and CKD
104
104. What joints are typically affected in gout ?
- Base of the big toe – metatarsophalangeal joint - Base of the thumb – carpometacarpal joint - Wrist - Larger joints knee or ankle
105
105. What DD is important to rule out in gout ?
- Septic arthritis
106
106. What are pseudogout crystals made from ?
- Calcium pyrophosphate crystals
107
107. What will appear on joint fluid microscopy for pseudogout ?
- Rhomboid shaped crystals that are positively birefringent of polarised lights
108
108. What is 1st line medication for pseudogout ?
- NSAIDS
109
109. How does pseudogout present ?
- Many patients are asymptomatic and are picked up on X-ray - A typical acute presentation is a 65 yo pt with rapid onset hot, swollen, stiff and painful knee - Other affected joints include the shoulders, hips and wrists
110
110. How is pseudogout managed ?
- 1st line = NSAIDs e.g. naproxen with PPI cover - Colchicine - Intra-articular steroid injections (septic arthritis must be first excluded) - Oral steroids
111
111. A 75 year old women on long term steroids for polymyalgia rheumatica presents. She drinks 35 units of alcohol per week and is sedentary. What is the most likely diagnosis ?
- Osteoporosis
112
112. What risk assessment tool is used in osteoporosis ?
- FRAX tool
113
113. What investigations are done for osteoporosis ?
- DEXA scan
114
114. What T score is diagnostic and what joint does it measure ?
- Less than -2.5 - Femoral neck
115
115. What is a normal T score and what is osteopenic ?
- Normal = more than -1 - Osteopenia = -1 to -2.5
116
116. What are the guidelines for deciding whether to treat osteoporosis ?
- NOGG guidelines
117
117. What is first line treatment for osteoporosis ?
- Bisphosphonates
118
118. What monoclonal-antibody can be used for severe osteoporosis ?
- Denosumab
119
119. What is osteopenia ?
- A less severe decrease in bone density than osteoporosis
120
120. What is the difference between a T and Z score ?
- Z = number of standard deviations the patient is from their age, sex and ethnicity average - T = number of standard deviations the patient is from a healthy young adult
121
121. What are RFs for osteoporosis ?
- Older age - Post-menopausal women - Reduced mobility and activity - Low BMI - Low calcium and vitamin D intake - Alcohol and smoko - Personal or fhx of fractures - Chronic disease e.g. CKD or RA - Long term corticosteroids e.g. 7.5mg or more prednisolone daily for longer than 3 months - Certain medications e.g. SSRIs, PPIs, anti-epileptics and anti-oestrogens
122
122. How does NICE recommend assessing for osteoporosis ?
- 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
123
123. How is the 10 year risk of major osteoporotic fracture and a hip fracture calculated ?
- QFracture tool (preferred by NICE) - FRAX tool (NICE says this may underestimate the risk in some patients)
124
124. How is osteoporosis managed ?
- Address risk factors e.g. physical activity, maintain healthy weight, stop smoking and reduce alcohol consumption - Adress intake of calcium (at least 1000mg) and inadequate vitamin D (400-800 IU) - Bisphosphonates are 1st line (taken on an empty stomach with a full glass of water)
125
125. What are side effects of bisphosphonates ?
- Reflux and oesophageal erosions - Atypical fractures - Osteonecrosis of the jaw - Osteonecrosis of the external auditory canal
126
126. How should bisphosphonates be taken ?
- Empty stomach - Full glass of water - Pts should after sit up for 30 minutes before moving or eating to reduce the risk of reflux and oesophageal erosions
127
128. A 74 yo housebound South-Asian lady presents with fatigue, muscle weakness and bone pain. X-ray shows an abnormal fracture. What is the diagnosis ?
- Osteomalacia
128
127. Given examples of bisphosphonates ?
- Alendronate - Risedronate - Zoledronic acid
129
What are looser zones in the context Osteomalacia and what is the cause ?
- Fragility fractures that go partially through the bone - Vitamin D deficiency
130
130. What electrolytes will be abnormal in Osteomalacia ?
- Low serum calcium - Low serum phosphate
131
131. What LFT and hormone will be abnormal in Osteomalacia ?
- Raised ALP - Raised PTH
132
132. What is the treatment for Osteomalacia ?
- Treatment dose vitamin D - 50,000 IU once weekly for 6 weeks - 4000 IU daily for 10 weeks
133
133. A 68 yo with bone pain and deformity and pathological fractures and hearing loss presents. What is the diagnosis ?
- Paget’s disease of the bone
134
134. What is the name for well defined osteolytic lesions seen in X-ray in Paget’s ?
- Osteoporosis circumscripta
135
135. What is the classic skull X-ray appearance in Paget’s disease ?
- Cotton wool appearance
136
136. What blood test is abnormal in Paget’s ?
- Raised alkaline phosphates
137
137. What is the main treatment for Paget’s ?
- Bisphosphonates

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