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Flashcards in Rheum Deck (113):
1

What are the features of lupus?

DOPAMINE RASH
- Discoid rash
- oral ulcers
- photosensitivitity
- arthralgia
- Malar rash
- Immunological features - dsDNA, RhF
- Neurological
- ESR increase
- Renal
- ANA
- Serositis
- Haematological

2

What antibodies are seen in drug induced lupus?

Anti - histone antibodies

3

What is the effect of recurrent PEs?

V;Q mismatch leading to decreased transfusion factor and pulmonary hypertension leading to cor pulmonale

4

What is the mechanism of action of Varencilline?

Partial nicotinic receptor agonist

5

What is the mechanism of action of Buproprion?

Norepinepherine and dopamine reuptake inhibitor and partial nicotinic antagonist

6

What are the antibodies seen in coeliac disease?

Alpha gliadin
anti TTG
Antiendomysial antibodies

7

What is seen on XR in a patient with vit D deficiency?

Rickets - growth retardation- knocked knees and bowed legs and deformity at the metaphyseal - epiphyseal junction and large head
Osteomalacia - pathological #

8

Where are the most common sites for septic arthritis?

Hip, knee and shoulder

9

What are the main causes of septic arthritis?

Staph aureus
Staph epidermis
Neisseria Gonorrhea

10

What are the risk factors for SA?

DM
increasing age
IVDU
immmunosuppressed
CKD
prosthetic joints

11

What tests should be done in suspected SA?

FBC, ESR/CRP
U&Es and LFTs
Urate levels
Blood cultures
Joint aspiration - turbid and yellow in colour, decreased viscosity, larger level of WBCs and neutrophils
Joint culture

12

What are the symptoms of SA?

decreased RoM
fatigue and general malaise
inflammed and tender joint
muscle spasm
*all very rapid onset*

13

What is the treatment for SA?

Always involve orthopaedics and micro
Empirical antibiotics after aspiration
Consider washout and debribement
Staph aureus - flucoxacillin
MRSA - vancomycin
Gonnococcal or gram negative - cefotaxime

14

What is the pathophysiology seen in RA?

inflammatory condition affecting the synovial membrane which leads to synovial hypertrophy and then break down. Lead by T cells

15

What are RF for RA?

Family history, smokers, female , 50-60y/o

16

How does RA present?

Polyarthritis - typically symmetrical hand and feet involvement
Morning stiffness
relieved by movement
soft tissue swelling

17

What are the signs of RA on examination?

Boutonneire - flexion of PIP and hyperextension DIP
Swan neck - hyper extension of PIP and flexion of DIP
Tenosynovitis and extensor tendon rupture
Z shaped thumb
Subluxation and ulna deviation of the digits
Soft tissue swelling at the MCP, PIP and wrist.

18

What are found on blood tests in RA?

RhF
Anti CCP
Anaemia of chronic disease
Increased ESR or CRP

19

What are the XR finding in RA?

Loss of joint space
Erosions
juxta articular osteopenia
soft tissue swelling and subluxation

20

What is the managment of RA?

NICE recommends MTX and one other DMARD with short course of corticosteriods
DAS28 used to measure disease activity and indicate when to start biological agents
NSAIDs good for pain
Physio and and OT involvement
Surgery - extensor tendon repair and carpal tunnel release

21

What are sufferers of RA at more risk of?

2-3 fold increased risk of IHD

22

What are the extra articular manifestations of RA?

Nodules
intersititial lung disease
IHD
serositis
carpal tunnel disease
peripheral neuropathy
splenomegaly
episcleritis and kerratoconjuncitivitis sicca
osteoporosis and amyloidosis

23

What are the risk factors for OA?

>60y/o
Obese
may relate to occupation
injury
family history
increased bone density

24

What are the signs of OA?

Periarticular tenderness
crepitus
decreased RoM
muscle wasting
wasting deformity
instability
squaring of the thumb
Bouchard and Heberden nodes

25

Where does OA effect?

Knee
Hip
thumb
cervical spine

26

What are the signs of OA on XR?

Loss of joint space
Osteophytes
Subchondral cysts
Sclerosis

27

What is the management of OA?

Exercise
Weight loss
Physio and OT invovlement
Heat and cold packs
Walking aids and supports
Pharmacological - start with paracetamol and topical NSAID > weak opioid > NSAID and PPI > intra articular corticosteriods
Surgery - arthroscopy and replacement

28

What is the pathophysiology of gout?

Uric acid precipitant on articular cartilage, tendons and surrounding tissue due to increased uric acid levels due to impaired renal excretion and over production of uric acid and over consumption of purine rich food.

29

What are the risk factors for gout?

HTN, CKD, alcohol, thiazide duiretics, trauma, infection and dehydration

30

What are the signs and symptoms of gout?

often big toe joint
Burning pain that came on over night
low grade fever
may have tophi

31

What investigations are done in suspected gout?

Cultures - rule out SA
Polarised light microscopy - negative needles
urine analysis and serum urate which may be raised or normal

32

What are the XR finding in Gout?

Normal joint space
soft tissue swelling
peri articular erosions

33

What is the management of gout?

high dose NSAID or colchicine
Rest and elevation
Lose weight and stop precipitating factor

Prevention -- allopurinol - started 3 weeks post attack in greater than 1 attack in a year, tophi or renal stones
should be continued in acute attack if already on

34

What is psuedogout?

Ca pyrophosphate dehydrate depositon in the joints

35

What are the risk factors for psuedogout?

Hyperparathyroidism
Haemochromatosis
Hypophosphataemia
OA and DM
Wilsons disease
CKD

36

How does psuedogout present?

Acute monoarthropathy of large joints in the elderly
Wrist, hip and knee

37

What investigations should be done in suspected pseudogout?

Cultures to rule out SA
Polarised light microscopy - weakly positive rhomboids

38

What is seen on XR in psuedogout?

Chondrocalcinosis

39

What is the management of psuedogout?

Rest, cold packs, aspiration and intra articular steriods
NSAIDs and colchine may help
Chronic - MTX and hydrochloroquinine

40

What are the common features of the spondyloarthropathies?

affect the axial skeleton
seronegative - no RhF
HLA B27 positive
Asymmetrical large joint oligo or monoarthritis
Extra articular manifestations - anterior uveitis, oral ulcers, valve incompetance , dactylitis and enthelitis

41

What is AS?

Inflammation of the SI joints followed by involvement of the surounding tissue leading to
- subchondral granulation tissue
- calcification of annular fibrosis

42

Explain the presentation of AS?

Gradula onset back pain, worse at night
spinal morning stiffness that eases with movement
Pain radiates into the hip and buttock

43

What are the signs of AS?

Kyphosis
Neck hyper extension leading to ? posture
Reduced schober <5cm
Reduced chest expansion
Costochondritis
Positive Sacroiliac stretch

44

What is found on investigation of AS

normocytic anaemia
increased ESR/CRP
CXR may show fibrosis in the apex
Osteoporosis on DEXA

45

What is found on XR of AS?

Early - bony erosions, widening of SI joints and vertebral bodies appear square with shiny corners
Late - ossification of longitudinal ligements of spine and bamboo appearance

46

What is the management of AS?

Exercise and intense physio
NSAIDs to reduce pain
Anti TNF blockers in severe disease
Local steriod injections
Bisphosphonates

47

What are the associated As in AS?

Aortic valve incompetance
Apical lung fibrosis
Anterior uveitis
Achilles tendonitis
AV block
Amyloidosis

48

What are some indications of poor prognosis in AS?

ESR >30
onset <16
Early hip invovlement
poor response to NSAIDs

49

What is enteropathic arthritis?

Arthritis associated with bowel pathology
IBD, GI bypass, whipples disease and coeliac

50

How does enteropathic arthritis present?

Asymmtrical large joint oligoarhritis mainly affecting the lower limbs

51

How is enteropathic arthritis managed?

Treat IBD
NSAIDs or intra articular steriods for arthritis
*NSAIDs may worsen crohns*

52

What is psoartic arthritis?

Pathophysiology involves the release of T cells and chemo/cytokines
Affects 10-40% with skin changes
can present before skin changes

53

How can Psoaratic arthritis present?

DRAMA
-DIP
-RA like
-AS like
-Mutilans
-Asymetrical oligo or polyarthritis

54

What are the best predictor that a patient may develop psoaratic arthritis in those with skin disease?

Nail changes - pitting, onchylolysis and hyperkeratosis

55

What is the management of psoatic arthritis?

CASPAR scoring tool
Intra articular steriods
In progressive peripheral joint disease MTX first line

56

What is seen on XR in Psoriatic arthritis?

Erosive changes with pencil cupping

57

What is reactive arthritis?

Sterile arthritis following a GI or GU infection.
Causes include Camplylobacter, salmonella, shingella, ureaplasma and chlamydia

58

Where is mainly affected in reactive arthritis?

Knee

59

What are the extra articular manifestations of reactive arthritis?

Irisitis
Keratoderma blenoorhagia- brown raised plaques on sole and palms
Circinate Balanitis- painless penile ulceration secondary to chalmydia

60

What is the management for Reactive arthritis?

No specific management - splint acutely
NSAIDs or local steriod injections
Sulfasalazine or MTX if last >6 months

61

What is systemic sclerosis?

Caused by over production of collagen due to T cell cytokine release

62

What are the features of limited systemic sclerosis?

CREST
Calcinosis
Raynaurds
oEsophegeal dysmoility
Sclerodacyly
Telangectasia

63

What may been seen on examination of a patients face with limited system sclerosis?

Beak nose and microstomia

64

What investigations should be done with someone with limited systemic sclerosis?

Anticentromere antibodies
RhF
Anti Ro
Barium swallow

65

What is the management of a patient with limited systemic sclerosis?

Treat raynaurds as protocol
PPI and prokinetics such as metaclopramide

66

What may be a life threatening complication of limited systemic sclerosis and how is it managed?

Pulmonary hypertension- treated with sidenafil and bosentan

67

What is systemic diffuse sclerosis?

Affects the whole body
Lungs - fibrosis
Heart - arrhythymias and conduction disorder
Renal - acute hypertensive crisis

68

What are the antibodies in systemic diffuse sclerosis?

SCL -70 antibodies
Anti - RNA polymerase antibodies

69

What other investigations are done in systemic diffuse sclerosis apart from antibodies?

CXR - bibasal fibrosis and cardiomegaly
ECG and ECHO- signs of pulmonary hypertension
Urine dip - protein and haematuria

70

What is the management of systemic diffuse sclerosis?

BP control with ACEi
NO CURE - immunosuppression - consider cyclophosphamide

71

What is SLE?

Relapsing and remitting type 3 autoimmuine connective tissue affecting the entirety of the body

72

Who does SLE present in?

Women of child bearing age
Afro carribean/Asians
FH

73

What are the investigations and blood tests done in SLE?

ANA
dsDNA
Anti Smith
RhF
Decreased WCC and platelets
Arthralgia - non erosive peripheral joints and Jaccoud's - reducible deforming arthropathy

74

What is the management of SLE?

Specialist management
Acute flares - pred and IV cyclophosphamide
Cutaneous symptoms - topical steriods and sun cream
Maintainence - NSAIDs, hydroxychloroquinine and low dose steriods

75

What can be monitored during a flare to check response to treatment?

C3/C4
Anti dsDNA and ESR

76

What do patients with SLE have an increased risk of developing?

Atherosclerosis
HTN
Dyslipidaemia
DM
osteoporosis
AVN
Permenant neurological damage
lymphoma

77

What are the features of antiphospholipid syndrome?

CLOT
- Coagulation defects
- Livedo reticularis - pink/blue mottling of the skin caused by capillary dilation and stasis in the venules
-Obstetric complications
- Thrombocytopenia

78

What is found on investigation in patients with antiphospholipid syndrome?

Prolonged APTT
Anti-cardolipin and lupus anticoagulant antibodies

79

What is the management of anti-phospholipid antibodies?

Anticoagulation - low dose warfarin or aspirin

80

What drugs may lead to drug induced lupus?

Isoniazid, hydralazine, procainamide, phenytoin

81

What is polymyositis?

Lymphocytic inflammation - mainly cytotoxic T8 lymphocytes

82

How does polymyositis present?

Progressive proximal muscle wasting and weakness of striated muscle due to inflammation
May also have dysphagia, dysphonia, respiratory weakness

83

What investigations should be done in patients with patients polymyositis?

Anti Mi2 and anti Jo1
Muscle enzymes will also be increased in serum - ALT, AST LDH and CK

84

How is polymyositis managed?

Prednisolone
immunosuppressant and cytotoxic drugs in resistant cases

85

What should be done in a patient with polymyositis?

Screen for underlying malignancy
Tumour markers, CXR, mammogram, pelvis/abdo US and CT

86

What are the differentials for polymyositis?

drug induced myopathy - statins
Mixed connective tissue disease
hereditary neuromuscular disorder
SLE

87

What is dermamyositis?

Polymyositis with dermatological signs
- Macular rash - over back and shoulders in shawl sign
- Heliotropic rash - liliac purple rash on eye lids with oedema
- nail fold erythema- dilated capilary loops
- Gottrons papules - roughened red papules over knuckles

88

What is relapsing polychondritis?

Inflammation of elastic cartilage leading to destruction

89

What are the signs of relapsing polychondritis?

Floppy ears
Recurrent chest infections
Noisy breathing

90

How is diagnosis made and what is the management of relapsing polychonritis?

Diagnosis is clincial
Management - steriod and DMARDs
consider CPAP for those with resp invovlement

91

What is sjrogens?

Autoimmune destruction of exocrine glands
primary -females and more common in 40-50 y/o
secondary - to RA, SLE and SS

92

What are the signs and symptoms of sjrogens?

Dry eyes - keratoconjunctivitis sicca
Xerostomia
Dysparenuria
Polyarthritis
Raynaurds
Bilateral parotid gland swelling

93

What is the management of sjrogen'?

Artificial tears
Saliva replacement
NSAIDs and hydroxychloroquinine for arthralgia
pilocarpine may help with saliva production
Immunosuppresion for systemic disease

94

Who is behcets disease associated with?

Turkish, mediterreans and japanease men
Young 20-40y/o

95

What are the clinical features of Behcets disease?

1) recurrent genital and oral ulceration
2) uveitis
erythema nodosum, vasculitis, non erosive large joint arthropathy

96

What is the management of Behcets?

immunosuppresion

97

What is the management of raynaurds?

Wear gloves
CCB - nifedipine or sidenafil
ACE i
IV prostacyclin

98

What is polymyalgia rheumatica?

inflammatory condition that results in muscle pain - usually occuring in females over 65

99

What are the clinical features of polymyalgia rheumatica?

bilateral shoulder and thigh muscle pain lasting greater than 1 month
morning stiffness greater than 1 hour
systemic feature - WL and fever
*always screen for GCA*

100

What is the management of polymyalgia rheumatica?

Corticosteriod - will have prompt response- consider bone and stomach protection
Myeloma and thyroid screen

101

What is fibromyalgia?

Chronic pain and presence of hyperalgesic points and allodynia

102

How does fibromyalgia present?

Women 20-50y/o
Associated with stress, anxiety and PTSD
FIBRO
- fatigue
- Insomnia/ IBS/ Irrritable bladder
- Blues - anxiety and depression
- Rigidity - muscle and joint morning stiffness
-Ow - Pain

Need 11/18 points based on digital palpation

103

What is the management of fibromyalgia?

1) MDT
2) heat treatment, exercise programme and CBT
3) tramadol, moderate pain relief and antidepressants

104

What are the signs and symptoms of anterior uveitis?

Symptoms - occular eye pain, photophobia and blurry visision
Signs - red eye adjacent to iris
need slit lamp to see WBC and protein precipitates

105

What is the treatment of anterior uveitis?

Steriods in non infective causes

106

What is osteoporosis?

t

107

What are the risk factors for osteoporosis?

Steriod and smoking
Hypothyroid and hyperparathyroid
Alcohol and AGe >50
Thin and decreased testosterone
Early menopause
Renal or liver failure
Deficiency of Ca or vit D

108

What should be done in the management of oestoporosis?

Full bone profile and DEXA scan - use FRAX tool
Treatments include
- Bisphosphonates
- Denosumab - monoclonal antibody against RANK -L
- Stronuim renelate
- Teriparatide (PTH analogue)
Raloxefine, HRT and calcitonin

109

Where does paget's disease most commonly affect?

Pelvis, spine, skull, fibula and tibia

110

What are the phases of pagets disease?

Lytic > mixed > sclerotic

111

How does pagets present?

Usually asymptomatic - >55y/o males with increased isolated ALP
Increased temp over area, secondary OA, cranial nerve pathologies from compression

112

What is seen on XR in patients with pagets?

Localised enlargement, patchy cortical thinning with sclerosis, osteolysis and deformitity, advanced lytic lesions in long bones

113

What is the treatment for pagets?

Bisphosphonates and pain relief