Rheumatology Flashcards Preview

CCE > Rheumatology > Flashcards

Flashcards in Rheumatology Deck (89):
1

Name some recognised systemic manifestations of SLE

Alopecia
Vasculitis
Epilepsy
Polyneuritis
Stroke
Chorea
Pleurisy
Atelectasis
Pulmonary fibrosis

2

In a patient presenting with low back pain, what are 3 important factors to ask about in the history?

Neurological symptoms in legs: weakness, numbness, paraesthesia
Urinary/bowel symptoms: incontinence
FH of ankylosing spondylitis

3

What are the Calin criteria for inflammatory back pain?

Age of patient at onset: under 40 (1)
Insidious onset (1)
Morning stiffness (1)
Persistence for months: over 3 (1)
Response to exercise: improves (1)

4

HLA B27 test has 90% sensitivity and 90% specificity in a population with chronic back pain for ank spond. In that population 5% will have ank spond. What are the chances of a patient with chronic back pain and a positive HLAB27 having ank spond?

about 30%
200 people with chronic back pain, 10 will have ank spond
Of those 10, 9 will test positive for HLAB27 (sensitivity)
Of the 190 that don't have it, 10% false positive rate so 19. Out of 200 tests: 9 positives from people with AS, 19 positives from people without AS. So 9/28 chance = around 30%

5

What blood results would make you suspect that a patient has Paget's disease of the bone?

Raised alkaline phosphatase
Plasma calcium, phosphate and aminotransferase all normal

6

What is osgood schlatter disease?

Tension at patella tendon leading to avulsion fracture
Symptoms of pain and swelling over tibial tubercle

7

What is osgood schlatter disease?

Tension at patella tendon leading to avulsion fracture
Symptoms of pain and swelling over tibial tubercle

8

What is an enthesis?

Where tendon inserts into bone, where the collagen fibres are mineralised and integrated into bone tissue

9

What is a bursa?

Fluid filled sac located between a bone and tendon which normally serves to reduce friction between two moving surfaces

10

How can you differentiate between articular and periarticular problems?

Articular: pain all planes, active = passive, capsular swelling/effusion, joint line tenderness, diffuse erythema/heat
Periarticular: pain in plane of tendon, active > passive, linear swelling, localised tenderness, localised erythema/heat

11

What is flexor tenosynovitis?

Inflammation of flexor tendon sheaths
Pain and stiffness in flexor finger/thumb, may extend to wrist
Reduced active flexion, crepitus, thickened tender tendon sheaths
May be associated with nodule – trigger finger
Can be associated with RA, Diabetes

12

What is treatment for flexor tenosynovitis?

Injection hydrocortisone
Surgery

13

What is de Quervains tenosynovitis? How can you test for it?

Inflammation of tendon sheath containing extensor pollicis brevis and abductor pollicis longus tendons
Pain, swelling radial wrist
Localised tenderness, crepitus, pain worse over radial styloid
Positive Finkelstein’s test

14

What is Finklesteins test?

With thumb flexed across the palm of the hand, ask patient to move the wrist into flexion and ulnar deviation
Positive if reproduces pain

15

What is the management for de Quervains tenosynovitis?

Rest from precipitating activity
Splintage
Steroid injection
Surgery

16

What conditions can precipitate carpal tunnel syndrome?

Diabetes
Hypothyroidism
RA
Pregnancy
Acromegaly
Vasculitis
Trauma
Amyloid
Sarcoid

17

What does the median nerve supply in the hand?

Lateral two lumbricals
Opponens pollicis
Abductor pollicis brevis
Flexor pollicis brevis
Sensory: Palmar surface thumb, lateral 2 1/2 digits

18

What are clinical features of carpal tunnel syndrome?

Numbness/parasthesia in median nerve distribution
Pain, can radiate up arm
Worse at night
Hang hand over end of bed
Weakness of thumb (abduction)
Thenar wasting
Positive Tinel’s/Phalen’s

19

What investigation can be done for carpal tunnel syndrome?

Nerve conduction studies show reduced nerve conduction velocities across wrist

20

What is the management for carpal tunnel syndrome?

Avoidance of precipitating activity
Night time splints
Local steroid injection
Surgery – division of flexor retinaculum and decompression of carpal tunnel (80% success)

21

What are tennis and golfers elbows?

Tennis elbow: lateral epicondylitis, inflammation common extensor origin
Golfer’s elbow: medial epicondylitis, inflammation common flexor origin
Pain localised to specific area
Elbow flexion/extension does not cause pain
Pain upon: resisted wrist extension (Tennis)
resisted wrist flexion (Golfer’s)

22

What is management for tennis and golfers elbows?

Rest from precipitating activity
Elbow clasps
Local corticosteroid injection
Physiotherapy – ultrasound and acupuncture
Surgery (often ineffective)

23

What problems can occur with the rotator cuff?

Supraspinatous tendinitis/rupture
Rotator cuff tear
Adhesive capsultitis (frozen shoulder)
Acute calcific supraspinatous tendonitis
Subacromial bursitis
Acromioclavicular joint OA

24

What are the muscles of the rotator cuff and what are their functions?

Supraspinatous - abduction
Infraspinatous – external rotation
Teres minor – external rotation
Subscapularis – internal rotation

25

What is rotator cuff syndrome? And what test can be done for it?

Spectrum from mild supraspinatus tendinitis to complete tendon rupture
Chronic impingement of cuff under acromial arch
Pain often over acromial area extending into deltoid
Painful mid arc
Impingement test – abducted, flexed and internally rotated
Supraspinatus stress

26

How can a rotator cuff problem be investigated?

USS

27

What is the management for rotator cuff syndrome?

Rest, NSAIDs
Local steroid injection around tendon – subacromial space and PT
If chronic/rupture refer to Orthopaedics for surgical opinion

28

What is acute calcific supraspinatus tendonitis?

Calcium hydroxyapatite deposition near supraspinatus enthesis
Young adults, F>M, acute pain over several hours
Normally resolves over few days

29

What is the management for acute calcific supraspinatus tendonitis?

Minor – NSAID
Moderate – consider steroid injection
Severe – consider aspirating calcified material

30

What is adhesive capsulitis (frozen shoulder)?

Progressive pain and stiffness
Global reduction in movement, but particularly external rotation
Three phases: Pain (3-5 months), Adhesive phase (4-12 months), Recovery phase (12-42 months)
Associated with diabetes
Most patients recover by 30 months, but still have reduced movements

31

What is the management for frozen shoulder?

Analgesia, NSAIDs, Physiotherapy, steroid injection
Surgical opinion in difficult cases (manipulation under anaesthesia)

32

What are signs/symptoms of acromoclavicular joint OA?

High arc pain
Local tenderness
Adduction painful
Impingement

33

What is trochanteric bursitis?

Inflammation of superficial and deep bursa that separates gluteus muscles from posterior and lateral side of greater trochanter of the femur
Boring pain over lateral aspect of hip
May radiate down lateral thigh
Worse on walking or lying in bed at night
Localised tenderness upon pressure over greater trochanter

34

What is the management of trochanteric bursitis?

Rest
Analgesia
Steroid injection
Physio

35

What is Achilles' tendonitis?

Inflammation of the achilles tendon
Sometimes at enthesis
Sometimes in middle avascular portion of tendon
Can be seen with seronegatives
Localised pain and swelling of Achilles tendon, with difficulty walking

36

What is a complication of Achilles' tendonitis?

Achilles' tendon rupture

37

How do you investigate Achilles tendonitis?

USS

38

What is the management for Achilles tendonitis?

Rest, NSAIDs, physiotherapy
Local steroid injection under U/S guidance into paratenon can help tenosynovitis – if no evidence of tear

39

What is an Achilles' tendon rupture? How can you test for it?

Acute rupture – sudden calf pain as if being hit on back of leg
Palpable gap in tendon
Some but little plantarflexion
Squeeze calf whilst prone - no plantarflexion in affected leg (Simmond’s)

40

What is the management for Achilles' tendon rupture?

Surgery to repair tendon
Conservative – below knee cast in ankle equinus 6 weeks

41

What is fibromyalgia? What are symptoms?

All over pain
Fatigue
Sleep disturbance
Depression
Anxiety
Irritable bowel
Tender spots
Diagnosis of exclusion

42

Which conditions can mimic fibromyalgia?

Systemic lupus erythematosus (SLE)
Hypothyroidism
Polymyalgia rheumatica
Malignancy
Myopathy
Metabolic bone disease

43

What is the management for fibromyalgia?

Patient education: About condition, Reassure that no serious pathology, No harm in exercising
Cognitive behavioural therapy (CBT)
Low dose amitriptyline
Graded aerobic exercise regime

44

What are the criteria for the classification of RA?

Morning stiffness >1 hour >6 weeks
Arthritis of 3 or more joints >6 weeks
Arthritis of hand joints: wrist, PIP, MCP >6 weeks
Symmetric arthritis
Rheumatoid nodules
Positive rheumatoid factor
Radiographic changes
4 present - refer

45

What baseline investigations are useful in RA?

ESR/PV/CRP
FBC
U&E/LFT
RhF
Anti CCP
ANA
Urine dip
Radiology

46

What deformities occur in the hand in RA?

Swan neck and boutonnière
Z shaped thumb
Ulnar deviation (MCP)
Volar subluxation (wrist)

47

What deformities happen in the foot in RA?

Hammer, overlapping and claw toes
Splay foot, valgus deviation (MTP)
MTP head subluxation
Pes planus, valgus hind foot

48

What deformity can happen in the spine in RA?

Atlantoaxial subluxation

49

What are extra articular features of RA?

Systemic: weight loss, fever, lymphadenopathy, fatigue
Ocular: keratoconjunctivitis sicca, scleritis, episcleritis
Pulmonary: alveolitis, fibrosis, nodules, pleural effusions,
Cardiac: carditis, conduction disturbance, coronary arteritis
Vasculitis: ischaemia and infarction
Feltys syndrome
Amyloidosis: nephrotic syndrome, cardiac, malabsorption
Anaemia
Osteoporosis

50

Who might be involved in the management of a patient with RA?

GP
Rheumatologist
Nurse specialist
Physio
Occupational therapist
Podiatrist
Orthotist
Surgeons

51

What surgery can be done for a patient with RA?

Joint arthroplasty
Tendon repair
Synovectomy
C spine stabilisation

52

What toxic effects can DMARDs have?

Bone marrow toxicity: thrombocytopenia, leucopenia, pancytopenia
Liver toxicity: >2x increase AST or ALT or lowered albumin
Renal toxicity and hypertension: >1+ blood and or protein, >30% rise creatinine
Pulmonary: dry cough and dyspnoea

53

What risks do TNF alpha biologics have?

Infections esp TB
Malignancy
MS
CCF

54

Which inflammatory cells are found in sacroiliac joints of patients with ankylosing spondylitis?

CD4 and CD8 T cells and macrophages

55

What is the diagnostic criteria for ankylosing spondylitis?

Radiologic criteria: sacroiliitis grade 2 bilaterally or 3-4 unilaterally
Clinical criteria: LBP and stiffness >3 months improved with exercise and not relieved by rest, limitation of L spine motion in frontal and saggital planes, limitation of chest expansion
Diagnosis requires radiologic criteria and at least one clinical

56

What is schobers test?

Mark level L5
Mark 5cm below and 10cm above this point
Patient touch toes while keeping knees straight
If distance between two points doesn't increase by 5cm, sign of restriction in lumbar flexion - ankylosing spondylitis

57

What are axial features of ankylosing spondylitis?

Early: Romanus lesion
Advanced: bony ankylosis

58

What are peripheral features of ankylosing spondylitis?

Hip and shoulder disease
Peripheral enthesopathy

59

What are possible complications of ankylosing spondylitis?

Fracture: C5/6, C6/7, C7/T1
Spondylodiscitis

60

What are extra articular features of ankylosing spondylitis?

Uveitis
Psoriasis
Inflammatory bowel
Aortic regurgitation
Conduction defects
Upper lobe fibrosis
Neurological: fracture dislocation - cauda equina syndrome, Atlanto-axial disease
Renal: amyloidosis, IgA nephropathy

61

What investigations should be done for a patient with ankylosing spondylitis?

L spine and sacroiliac joint X-ray
CRP and ESR
HLA B27

62

What are treatment options for ankylosing spondylitis?

Physio
NSAIDs
DMARDs and steroids
TNF alpha blockers
Surgery

63

What is the peak age of onset for psoriatic arthritis?

35-50 years

64

What are the 5 clinical subgroups of psoriatic arthritis?

Symmetrical polyarthritis
Asymmetrical oligoarthritis
DIP disease
Spondylitis
Arthritis mutilans

65

What is treatment for psoriatic arthritis?

NSAIDs
DMARDs
Steroids
TNF alpha
OT/physio
Surgery
Dermatology

66

Who gets reactive arthritis?

Young adults, equal sex
Post urethritis/cervicitis or infectious diarrhoea

67

What are sero positive features of reactive arthritis?

Conjunctivitis
Balanitis
Oral ulcers
Pustular psoriasis

68

What are treatments for reactive arthritis?

NSAIDs
Steroids - intra articular
Antibiotics - chlamydia
DMARDs

69

What cultures might you take from a patient with reactive arthritis?

Throat
Urine
Stool
Urethra/cervix

70

What can reiters syndrome be precipitated by?

Chlamydia
Salmonella
Campylobacter
Shigella
Yersinia

71

What criteria are required for diagnosis of Behçet's disease?

Oral ulceration plus two of:
Genital ulcers
Defined eye lesions
Defined skin lesions
Positive skin pathergy test

72

What conditions are associated with pseudogout?

Haemochromatosis
Hyperparathryoidism
Hypomagnesaemia
Hypophosphatasia
Hypothyroid
Familial hypocalciuric hypercalcaemia

73

What pathogens usually precipitate a reactive arthritis?

Chlamydia trachomatis
Yersinia
Salmonella
Shigella
Campylobacter
C diff
Chlamydia pneumoniae

74

What factors predict a poor prognosis for progression in early RA?

Age
Female
Symmetrical small joint involvement
Morning stiffness over 30 mins
More than 4 swollen joints
CRP >20
Positive RF and anti CCP

75

What are some complications of RA?

Ruptured tendons
Ruptured joints (bakers cysts)
Joint infection
Spinal cord compression
Amyloidosis

76

What deformities of the feet might be seen in RA?

Foot broadens and a hammer toe develops
Exposure of metatarsal heads to pressure by forward migration of protective fibrofatty pad causes pain
Ulcers or calluses may develop under metatarsal head and dorsum of toes
Flat medial arch and loss of flexibility of foot
Valgus deformity of ankle

77

Give some non articular manifestations of RA

Scleritis
Sjögren's syndrome
Lymphadenopathy
Pericarditis
Bursitis
Nodules
Tendon sheath swelling
Tenosynovitis
Amyloidosis
Sensorimotor polyneuropathy
Pleural effusion
Fibrosing alveolitis
Anaemia
Carpal tunnel syndrome
Nail fold lesions of vasculitis
Splenomegaly (feltys syndrome)
Leg ulcers
Ankle oedema

78

What are risk factors for developing carpal tunnel syndrome?

Obesity
Repetitive wrist work
Pregnancy
RA

79

What is the mechanism of action of azathioprine?

Cytotoxic agent
Metabolised to mercaptopurine
Acts as purine analogue to inhibit DNA synthesis

80

What are serious complications of azathioprine therapy?

Renal failure
Bone marrow suppression

81

What enzyme activity needs to be checked before commencing a patient on azathioprine therapy?

TPMT - thiopurine methyltransferase

82

What are features of Behçet's disease?

Oral ulcers
Genital ulcers
Erythema nodosum
Uveitis
Inflammatory reaction when skin is pricked with a fine needle

83

What are treatment options for acute gout?

NSAIDs
Colchicine
Systemic glucocorticoids
Intra articular glucocorticoids

84

Which antibody is present in polyarteritis nodosa?

pANCA

85

What are features of polyarteritis nodosa?

Malaise
Weight loss
Anaemia
Fever
Non specific pains
Acute renal failure
Livedo reticularis

86

What is polyarteritis nodosa?

Medium sized artery vasculitis with a predominance for renal vasculature

87

Which antibody is associated with primary biliary cirrhosis?

Anti mitochondrial antibody

88

In which conditions might ANA antibodies be present?

SLE
Autoimmune hepatitis
Post infection
Inflammatory bowel disease

89

What is the treatment for acute gout?

NSAIDs: indomethacin
Colchicine