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Rheumatology Flashcards

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1
Q

What 2 drugs would you avoid prescribing to a patient on methotrexate?

A

Trimethoprim or cotrimoxazole

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2
Q

What is the monitoring of methotrexate?

A

FBC, U+E and LFT before starting, repeated weekly until therapy stabilised, then every 2-3 months.

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3
Q

What is the triad of Felty’s syndrome?

A
  • RA
  • Neutropenia
  • Splenomegaly
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4
Q

What is the acute mx of gout?

A
  • NSAIDs (avoid in warfarin- GI bleed)
  • Colchicine (SE: diarrhoea)
  • Intra-articular steroid injection
  • Oral steroids (pred) if others CI
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5
Q

What are the indications for allopurinol prophylaxis?

A
  • Recurrence
  • Tophi
  • Renal disease
  • Uric acid renal stones
  • If on cytotoxic or diuretics
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6
Q

At what time should allopurinol be prescribed if indicated? Co-prescribe? Dose?

A

2 weeks after an acute attack has settled (may prescip further attack)

Initially 100mg OD, titrate to uric acid <300

NSAID or colchicine cover when starting

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7
Q

What are the red flags for sinister causes of back pain?

A
  • <20yrs or >55
  • Acute onset in elderly people
  • Constant or progressive pain
  • Nocturnal apin
  • Pain worse on being supine
  • Fever, night sweats, weight loss
  • Hx of malignancy
  • Abdo mass
  • Thoracic back pain
  • Morning stiffness
  • Bilateral or alternating leg pain
  • Neurological disturbance (inc sciatica)
  • Sphincter disturbance
  • Immunosuppression
  • Lew claudication or exercise-related leg weakness/numbness (spinal stenosis)
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8
Q

What nerves are tested in the straight leg raise?

A

L4, L5, S1

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9
Q

What nerves are tested on the femoral stretch test?

A

L4 and above

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10
Q

What are the features of acute cauda equina compression?

A

= Neurosurgical emergency

  • Alternating or bilateral root pain in legs, saddle anaesthesia, low of anal tone on PR, bladder +/- bowel incontinence
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11
Q

What are the features of acute cord compression?

A
  • Bilateral pain
  • LMN signs at level of compression
  • UMN and sensory loss below
  • Sphincter disturbance
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12
Q

What pain and weakness would an L2 lesion cause?

A

Pain: across upper thigh.
Weakness: hip flexion and adduction

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13
Q

What pain and weakness would an L3 lesion cause?

A

Pain across lower thigh
Weakness: Hip adduction, knee extension
Dec knee jerk

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14
Q

What pain and weakness would an L4 lesion cause?

A

Pain: across knee to medial malleolus
Weakness: Knee extension, foot inversion and dorsiflexion
Dec knee jerk

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15
Q

What pain and weakness would an L5 lesion cause?

A

Pain: lateral shin to dorsum of foot and great toe
Weakness: hip extension and abduction. Knee flexion. Foot and great toe dorsiflexion.
Dec great toe jerk

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16
Q

What pain and weakness would an S1 lesion cause?

A

Pain: posterior calf to lateral foot and little toe
Weakness: knee flexion. Foot and toes plantar flexion. Foot eversion.
Dec ankle jerk.

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17
Q

What are the signs and symptoms of localised osteoarthritis?

A
  • Localised disease is typically knee or hip
  • Pain on movement and crepitus
  • Worse at end of day
  • Background pain at rest
  • Joint gelling- stiffness after rest up to 30 mins.
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18
Q

What are the signs and symptoms of primary/general osteoarthritis?

A 
- Heberden's nodes (DIPs)
 (+ Bouchard's nodes (PIPs))
- Commonly affected: DIPs, thumb CMJ, knees
- Joint tenderness
- Bony swelling
- Dec ROM
- Mild synovitis
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19
Q

What are the typical findings on plain x-ray in OA?

A

Loss of joint space
Osteophytes
Subarticular sclerosis
Subchondral cysts

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20
Q

What is the most common joint affected by septic arthritis?

A

Knees >50%

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21
Q

What are the RF for septic arthritis?

A
  • Pre-existing joint disease, especially RA
  • DM
  • Immunosuppression
  • CKD
  • Recent joint surgery
  • Prosthetic joints
  • IVDU
  • > 80
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22
Q

What is the most important Ix in suspected septic arthritis?

Study These Flashcards
A

Urgent joint aspiration for micro and culture

23
Q

What empirical abx would you use for septic arthritis?

Study These Flashcards
A
  • Fluclox
  • Clindamycin if allergy
  • Vancy IV if MRSA or hx of
  • Cefotaxime if gonococcal or gram -ve suspected
24
Q

What is the typical presentation in RA?

Other presentations?

Study These Flashcards
A
  • Symmetrical swollen, painful and stiff small joins of hands and feet, worse in the morning
  • Less commonly: sudden onset, widespread arthritis
  • Palindromic RA = recurring arthritis of various joints
  • Systemic illness with fever, weight loss, pericarditis and pleurisy, with few joint symptoms initially.
25
What antibodies are most specific for RA?
Anti-CCP
26
What scale is used to measure disease activity in RA? What is the target score?
DAS28 | <3
27
What is the first-line treatment in RA?
DMARDs - should be started within 3 months of persistent symptoms. Can take 6-12 weeks for symptomatic benefit.
28
What is typically the best combination of DMARDs in RA?
Methotrexate, sulphasalazine and hydroxychloroquine
29
What are the potential SE of methotrexate?
Immunosuppression -> pancytopenia, neutropenic sepsis (monitor FBCs) - Pneumonitis - Oral ulcers - Hepatotoxicity
30
What are the potential SE of sulfasalazine?
- Rash - Dec sperm count - Oral ulcers
31
What are the potential SE of leflunamide?
- Teratogenic (M and F) - Oral ulcers - HTN - Hepatoxicity
32
What is the potential SE of hydroxychloroquine?
Irreversible retinopathy (annual opthal review)
33
What is the first-line agent for active RA after failure to respond to 2 DMARDs and with a DAS28 >5.1?
TNF-alpha inhibitors (Infliximab, etanercept etc) Can also be used as mono therapy if methotrexate CI - used adalimumab or etanercept.
34
What is the agent of choice in severe, active RA where DMARDs and a TNF-alpha have failed/ CI? What would you use if this is ineffective or CI?
B cell depletion - Rituximab then IL-1 and IL-6 inhib: Tocilizumab in combo with methotrexate.
35
What are the SE of biologics?
- Serious infection, inc reactivation of TB and hep B - Worsening heart failure - Hypersensitivity - Injection site-reactions - Blood disorders - ANA and reversible SLI-type illness
36
What antibody is associated with diffuse cutaneous systemic sclerosis?
Scl-70
37
What antibody is associated with limited cutaneous systemic sclerosis?
Anti-centromere
38
What are the skin features of dermatomyositis?
- Photosensitive - Macular rash over back and shoulder - Heliotrope rash in periorbital region - Gottron's papules - roughened red papules over extensor surfaces of fingers - Nail fold capillary dilatation
39
What are the common antibodies in dermatomyositis?
Majority are ANA positive | 25% anti-Mi-2 positive
40
What is the triad of Reiter's syndrome?
- Urethritis - Conjunctivitis - Arthritis (Reactive arthritis)
41
What is HLA-B27 associated with?
Reactive arthritis | Ankylosing spondylitis
42
What antibody is commonly associated with antiphospholipid syndrome?
Anti-Cardiolipin antibody
43
What is anti-DsDNA highly specific for?
SLE
44
What is anti-mitochondrial antibody associated with?
Primary biliary cirrhosis
45
What is chondrocalcinosis? | What does this suggest?
Loss of joint space, with linear calcification of the articular cartilage Pseudogout.
46
What would you see on joint aspiration in pseudo gout?
Weakly-positively birefringent rhomboid shaped crystals
47
When would you start bone protection in a patient with PMR?
Straight away, as it is likely that they will be on a significant dose of pred for >3 months. Give Vit D, calcium supplements and oral bisphosphonates (alendronate)
48
In general what would you do as a result of the following T-scores? - >0 - Between 0 and -1.5 - Less than -1.5
- >0: Reassure - Between 0 and -1.5: Repeat scan in 1-3 years - Less than -1.5: Offer bone protection
49
What is the first-line drug treatment for Raynauds?
Nifedipine
50
What antibody is fairly specific to polymyositis?
Anti-Jo1
51
What is Takyasu's arteritis? | Symptoms?
An inflammatory, obliterative arteritis affecting the aorta and branches - Upper limb claudication - Diminshed/absent pulses - Raised ESR - F>M
52
What is Buergers disease? | Signs and symptoms?
Segmental, thrombotic occlusions of the small and medium sized lower limb vessels. Commonest in young, male smokers. - Proximal pulses present, loss of pedal pulses. - Tortuous, corkscrew shaped collateral vessels may be seen on angiography.
53
In what condition and what two allergies might you be cautious of prescribing sulfasalazines?
GP6D deficiency | Allergy: aspirin or sulphonamides
54
Give 2 common and 3 less common causes of drug-induced lupus?
- Procainamide - Hydralazine Less common: - Isoniazid - Minocycline - Phenytoin

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