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Rheumatology Flashcards

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1
Q

What is osteoarthritis?

A

Wear-and-tear of the articular cartilage over time

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2
Q

What is the most common type of arthritis?

A

Osteoarthritis

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3
Q

Which joints are most commonly affected in osteoarthritis (4)?

A

Weight-bearing joints:

  • Hips
  • Knees
  • Spine
  • Hands
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4
Q

Describe the presentation of osteoarthritis (5).

A
  • Joint pain
  • Joint stiffness
  • Bouchard’s nodes
  • Heberden’s nodes
  • Squaring at the base of the thumb
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5
Q

Give one way in which osteoarthritis can be differentiated from inflammatory arthritis.

A

Osteoarthritis - symptoms are worse with activity

Inflammatory arthritis - symptoms improve with activity

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6
Q

How can osteoarthritis be diagnosed?

A

Without investigation if:

  • Patient is over 45
  • Typical activity related joint pain
  • No morning stiffness or stiffness that lasts less than 30 minutes
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7
Q

What can be used to confirm a diagnosis of osteoarthritis? Features?

A

X-ray - LOSS:

  • Loss of joint space
  • Osteophytes
  • Subchondral sclerosis
  • Subchondral cysts
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8
Q

What is the first line management for osteoarthritis (4)?

A

Patient education:

  • Lifestyle advice - diet, weight loss, exercise
  • Physiotherapy to improve joint strength
  • Orthotics
  • Heat and ice
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9
Q

What is the second line management for osteoarthritis (3)?

A

Analgesia - pain control:

  • Step 1 - oral paracetamol + topical NSAIDs
  • Step 2 - oral NSAIDs
  • Step 3 - opiates
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10
Q

How can the most severe cases of osteoarthritis be treated?

A

Joint replacement

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11
Q

What is the most common inflammatory arthritis?

A

Rheumatoid arthritis

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12
Q

Which joints are most commonly affected in rheumatoid arthritis?

A

Small joints of the hands and feet

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13
Q

Name 2 genes associated with rheumatoid arthritis.

A
  • HLA DR4 - often present in RA + patients

- HLA DR1 - occasionally present in RA + patients

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14
Q

Which antibody is most sensitive in diagnosing rheumatoid arthritis?

A

Rheumatoid factor

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15
Q

Which antibody is most specific in diagnosing rheumatoid arthritis?

A

Anti-CCP

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16
Q

Describe the presentation of rheumatoid arthritis (8).

A
  • Symmetrical polyarthritis
  • Joint pain - improves with activity
  • Joint stiffness
  • Joint swelling
  • Ulnar deviation
  • Swan neck deformity
  • Boutennieres deformity
  • Z-shaped deformity of the thumb
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17
Q

Which joints are almost never affected in rheumatoid arthritis?

A

Distal interphalangeal joints

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18
Q

What is the 1st line investigation for rheumatoid arthritis?

A

Bloods - measure RF and anti-CCP

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19
Q

What is the gold standard investigation for rheumatoid arthritis?

A

X-ray of hands and feet - shows erosions

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20
Q

What is the 1st line treatment for rheumatoid arthritis (3)?

A

DMARDs:

  • Methotrexate
  • Hydroxychloroquine
  • Sulfasalazine
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21
Q

Name 3 biologics that can be used to treat rheumatoid arthritis.

A
  • Infliximab
  • Adalimumab
  • Rituximab
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22
Q

Give 2 examples of anti-TNF drugs.

A
  • Infliximab

- Adalimumab

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23
Q

Give an example of an anti-CD20 drug.

A

Rituximab

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24
Q

What is used to monitor the progression of rheumatoid arthritis?

A

CRP - ESR takes longer to change so not as good

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25
What is crystal arthritis?
Arthritis caused by the accumulation of crystals in the joint
26
What are the 2 types of crystal arthritis?
- Gout | - Pseudogout
27
What type of crystal arthritis causes a more severe presentation?
Gout
28
What are the risk factors for gout (7)?
- Male - Middle-aged - Family history - Existing cardiovascular/renal disease - Obesity - High purine diet - meat, seafood - Alcohol - high in fructose
29
Which joint is usually affected in gout?
Base of the big toe (metatarso-phalangeal joint)
30
What is it important to exclude in the case of a hot, painful and swollen joint?
Septic arthritis
31
Describe the presentation of gout (2).
- 1 joint which is hot, painful and swollen | - Gouty tophi
32
How is gout diagnosed? Results?
Aspiration of the synovial fluid from the joint: - No bacterial growth - Monosodium urate crystals - Needle-shaped crystals - Negatively bifringent of polarised light
33
How is a gout flare up managed (3)?
1st line - NSAIDs (not aspirin) 2nd line - colchicine (those who cannot tolerate NSAIDs e.g renal impairment) 3rd line - steroids
34
What drugs can be given for gout prophylaxis (2)?
1st line - allopurinol (given a month after gout attack) | 2nd line - febuxostat
35
What can someone do to reduce the risk of gout (5)?
- Weight loss - Stay hydrated - Reduce alcohol intake - Reduce consumption of purine-rich foods e.g red meat, seafood
36
Who is more likely to be affected by pseudogout?
Elderly
37
Which joint is most commonly affected by pseudogout?
Knee
38
How is pseudogout diagnosed? Results?
Aspiration of the synovial fluid from the joint: - No bacterial growth - Calcium pyrophosphate crystals - Rhomboid-shaped crystals - Positively bifringent under polarised light
39
What is osteoporosis?
A condition where there is a reduction in bone density
40
What is osteopenia?
A less severe reduction in bone density as seen in osteoporosis
41
What are the risk factors for osteoporosis?
SHATTEREDD: - Steroid use - Hyperthyroidism/hyperparathyroidism - Alcohol and smoking - Thin - low BMI - Testosterone low - Early menopause - Renal or liver failure - Erosive/inflammatory bone disease - Dietary calcium decreased - Diabetes mellitus type 1
42
Name a key group where osteoporosis should be considered. Why?
Post-menopausal women: - Lower levels of oestrogen - Oestrogen is protective against osteoporosis as it inhibits osteoclasts
43
What can be given to post-menopausal women to prevent osteoporosis?
Hormone replacement therapy (HRT)
44
What is the 1st line investigation for osteoporosis?
FRAX tool - measures the risk of a fragility fracture over the next 10 years
45
What information is inputted into the FRAX tool (9)?
- Age - Sex - BMI - Co-morbidities - Smoking - Alcohol - Previous fractures - Glucocorticoid use - Bone mineral density from DEXA scan
46
What is the gold standard investigation for osteoporosis?
DEXA scan - measures bone mineral density | - Gives a T score at the person's hip
47
What is a T score?
The number of standard deviations below the mean for a healthy young adult their bone mineral density is
48
What is a normal T score?
T score > -1
49
What T score suggests osteopenia?
T score -1 - -2.5
50
What T score suggests osteoporosis?
T score < -2.5
51
What T score suggests severe osteoporosis?
T score < -2.5 and pathological fracture present
52
What is the 1st line treatment for osteoporosis?
Bisphosphanates e.g alendronate and AdCal
53
What is a common side effect of bisphosphonates? What can be done to prevent this?
Reflux: - Taken on an empty stomach first thing in the morning - Remain upright for at least an hour after taking
54
What is 2nd line treatment for osteoporosis? How does it work?
Denosumab - inhibits osteoclast activity
55
What lifestyle changes can be made to manage osteoporosis?
- Exercise - Maintain a healthy weight - Smoking cessation - Reduce alcohol consumption - Adequate vitamin D and calcium
56
What are the 4 features of spondyloarthropathies?
- Axial inflammation - spine and sacro-iliac joints - Asymmetrical peripheral arthritis - Seronegative - absence of rheumatoid factor - Strong association with HLA-B27
57
Name 4 spondyloarthropathies.
- Ankylosing spondylitis - Psoriatic arthritis - Reactive arthritis (Reiters syndrome) - Enteropathic arthritis
58
What is a useful mnemonic for spondyloarthropathies?
SPINE ACHE: - Sausage digits - dactylitis - Psoriasis - Inflammatory back pain - NSAIDs good response - Enthesitis - heel - Arthritis - Crohn's, UC - HLA-B27 - Eyes - uveitis, iritis
59
What is ankylosing spondylitis?
An inflammatory condition which mainly affects the spine causing progressive pain and stiffness
60
Which joints are typically affected in ankylosing spondylitis (2)?
- Joints of the vertebral column | - Sacroiliac joints
61
Describe the presentation of ankylosing spondylitis.
- Gradual onset of symptoms - Lower back pain - worse on rest, better with movement - Pain is worse in the morning and at night - Pain wakes them from their sleep - Lower back stiffness
62
What is a complication of ankylosing spondylitis?
Vertebral fracture
63
Name a test which can be used in the examination of ankylosing spondylitis.
Schober's test
64
How is Schober's test done?
- Patient stands straight - Find L5 vertebrae - Mark a point 10 cm above and 5 cm above - Patient bends forward - If the distance between the 2 points is less than 20 cm, suspect ankylosing spondylitis
65
How is ankylosing spondylitis diagnosed?
No single test: - CRP/ESR - elevated - HLA-B27 genetic testing - X-ray
66
Describe the X-ray changes seen in ankylosing spondylitis (3).
- Bamboo spine - Squaring of the vertebral bodies - Subchondral sclerosis and erosions
67
What can be used to treat flare-ups in ankylosing spondylitis?
Steroids
68
Name other conditions which ankylosing spondylitis can result in (5).
5 As: - Anterior uveitis - Autoimmune bowel disease - Apical lung fibrosis - Aortic regurgitation - Amyloidosis
69
What is psoriatic arthritis?
Inflammatory arthritis associated with psoriasis
70
Describe the presentation of psoriatic arthritis.
- Psoriasis - seen in patient or 1st degree relative - Joint pain - Joint stiffness - Dactylitis - Onycholysis - Pitting of the nails
71
How can psoriatic arthritis be differentiated from rheumatoid arthritis?
- Psoriatic arthritis - asymmetrical pattern of joints affected - Rheumatoid arthritis - symmetrical pattern of joints affected
72
Name the screening test used for psoriatic arthritis.
PEST tool
73
What is used to diagnose psoriatic arthritis?
CASPAR criteria
74
Name a classic X-ray finding of psoriatic arthritis.
Pencil-in-cup appearance
75
Name the most severe form of psoriatic arthritis. How does it present?
Arthritis mutilans - short, telescopic finger
76
What is enteropathic arthritis?
Inflammatory arthritis associated with GI pathologies e.g IBD
77
What is reactive arthritis?
Inflammation of a joint that occurs as a reaction to a recent infective trigger
78
What is the most common cause of reactive arthritis?
STIs e.g chlamydia
79
What is it important to exclude when reactive arthritis is suspected?
Septic arthritis
80
Describe the presentation of reactive arthritis (3).
- Recent infection - Single joint affected - Joint is hot, swollen and painful
81
What is associated with reactive arthritis?
'Can't see, pee or climb a tree' - Conjunctivitis - Urethritis - Arthritis
82
How is reactive arthritis diagnosed?
Joint aspiration - exclude septic arthritis and crystal arthritis
83
What is septic arthritis?
An infection that occurs within a joint
84
What type of joints can septic arthritis affect?
- Native joints | - Joint replacements
85
What is the most common causative organism of septic arthritis in native jpints?
Staphylococcus aureus
86
What is the most common causative organism of septic arthritis in joint replacements?
Staphylococcus epidermidis
87
What is the most common causative organism of septic arthritis in IVDUs, immunocompromised and extremes of age?
E. coli or pseudomonas
88
Which joint is most commonly affected in septic arthritis?
Knee
89
Describe the presentation of septic arthritis (2).
- 1 joint which is hot, red, swollen and painful | - Systemic symptoms - fever, lethargy
90
How is septic arthritis diagnosed?
Joint aspiration
91
How is septic arthritis treated?
- Antibiotics for 3 - 6 weeks | - Sepsis 6
92
What are the risk factors for septic arthritis?
- Older age - Open fracture - Pre-existing joint disease - Prosthetic joint - Recent joint surgery - Recent steroid injection into the joint - Immunosuppression - Diabetes

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