Rheumatology Flashcards
(143 cards)
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
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
3
Q
Signs of OA on X-ray
A
- L : Loss of joint space
- O : osteophyte formation
- S : Subchondral cysts
- S : Subarticular sclerosis
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
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).
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
7
Q
what antibodies are tested for in RA?
A
- First line = rheumatoid factor (RF)
- Anti-cyclic citrullinated peptide (anti-CCP)
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
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
10
Q
How is a flare or initial presentation of RA managed ?
A
Short term steroids (oral or IM)
11
Q
what is the stepwise management of RA?
A
- Monotherapy with methotrexate, leflunomide or sulfasalazine
- Combination treatment with multiple cDMARDs
- Biologic therapies (usually alongside methotrexate)
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)
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).
14
Q
How often is methotrexate given and what is given alongside it on a different day ?
A
- Once weekly
- 5mg Folic acid
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
16
Q
Give 4 SE of sulfasalazine
A
- Orange urine
- Oligospermia
- Heinz body anaemia
- ILD
17
Q
Give a SE specific to leflunomide
A
- Peripheral neuropathy
18
Q
Give 3 SE of hydroxychloroquine
A
- Retinal toxicity (reduced visual acuity)
- Blue-grey skin pigmentation
- Hair lightening (bleaching)
19
Q
What is a unique SE of anti-TNF medication ?
A
Reactivation of TB
20
Q
Give 2 SE of rituximab
A
- Night sweats
- Thrombocytopenia
21
Q
How is response to treatment monitored in RA
A
- CRP and DAS28 score
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
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
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
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
