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Phase 2a > Rheumatology > Flashcards

Rheumatology Flashcards

1
Q

what is inflammation

A

reaction of microcirculation
movement of fluid and WBC into extra-vascular tissues
pro-inflammatory cytokines

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2
Q

what are the 4 pillars of inflammation

A 
rubor = red
dolor = painful
calor = heat
tumour = swollen
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3
Q

how may inflammation present

A

4 pillars +
stiffness
poor mobility/function
deformity

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4
Q

how may inflammatory joint pain progress

A

eases with use of joint

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5
Q

how may degenerative pain progress

A

pain increases with use = clicks/clunks

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6
Q

describe the difference in presentation of inflammatory and degenerative joint pain

A
  1. inflammatory = >60 mins vs <30 mins for degenerative
  2. degenerative = not clinically inflamed (hot and red)
  3. inflammatory responds to NSAIDs, degenerative not so much
  4. inflamm = hands and feet, degenerative = CMC, DIP joints (NOT AS A RULE)
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7
Q

what is the demographic for inflammatory pain

A

young
psoriasis
family history

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8
Q

what is the demographic for degenerative joint pain

A

older

prior occupation/sport

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9
Q

what does PRISMS stand for

A 
Pain
Rash/skin lesions
Immune
Stiffness
Malignancy
Swelling/sweats
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10
Q

what acronym can be used for history taking of rheumatological complaint

A

PRISMS

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11
Q

what is dactylitis

A

inflammation of a digit

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12
Q

what is enthesitis

A

inflammation of the entheses = site where tendon or ligament insert into bone

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13
Q

describe how ESR is measured

A
  1. blood sample is centrifuged
  2. time taken for RBC to fall is measured
  3. increased fibrinogen in inflammation = stick to RBC = makes them heavier = fall faster
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14
Q

what is an ESR

A

erythrocyte sedimentation rate = increases in inflammation/infection
takes weeks to change relative to inflammation

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15
Q

what is CRP

A

C-reactive protein
increases in inflammation
rises and falls rapidly = good indicator of current inflammation

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16
Q

what are auto-antibodies

A 
immunoglobulins that bind to self
most commonly looked for:  IgM
IgG
CCP
ANA
anti-dsDNA
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17
Q

what auto-antibodies are found in rheumatoid arthritis

A 
RF = rheumatoid factor
CCP = cyclic citrullinated peptide
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18
Q

what auto-antibodies are found in systemic lupus erythematosus

A 
ANA = antinuclear antibody = binds to antigens in cell nucleus
dsDNA = double stranded DNA
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19
Q

what is spondyloarthritis (SpA)

A 
umbrella term for group of conditions with inflammatory joint changes
1. ankylosing spondylitis AS
2. psoriatic arthritis PsA
3. enteropathic arthritis
4. reactive arthritis
= associated with HLA-B27 gene
= seronegative so no RF
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20
Q

what is HLA B27

A

human leucocyte antigen B27
= a tissue type that plays a role in antigen presenting in immune system
a person is either HLAB27 positive or negative = +ve does not mean you will get AS

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21
Q

where is CRP produced

A

produced by liver in response to IL-6

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22
Q

name the 3 hypothesis of how HLAB27 is linked with disease

A
  1. molecular mimicry
  2. mis-folding theory
  3. HLA B27 heavy chain homodimer hypothesis
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23
Q

SPINEACHE to describe features of SpA

A 
Sausage digit
tabiasis
Inflammatory back pain
NSAID good response
Enthesitis (heel)
Arthritis
Crohns/Colitis/CRP elevated
HLA B27
Eye uveitis
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24
Q

what is particular in diagnosis of alkylosing spondylitis

A

can have normal CRP

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25
Q

what is syndesmophytes

A

new bone formation and vertical growth from anterior vertebral corners

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26
Q

what is sacroiliitis

A 
sclerosis
erosions
loss of space
fusion 
= of sacroiliac joint
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27
Q

what is delayed damage theory

A

once inflammation has occurred = new bone formation is inevitable

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28
Q

what factors would differentiate inflammatory back pain IBP from general back pain

A 
age of onset below 40
insidious onset
improvement with exercise
pain at night
no improvement with rest
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29
Q

how is axial spondyloarthritis diagnosed using the ASAS classification criteria

A
  1. sacroiliitis on imaging plus 1+ SpA feature (SPINAECHE)

2. HLA B27 plus 2+ SpA features

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30
Q

what is osteoporosis

A

systemic skeletal disease
low bone mass
microarchitectural deterioration of bone tissue
increase in bone fragility and susceptibility to fracture
= bone not weaker, just less of it there

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31
Q

describe the changes in trabecular architecture with ageing

A

decrease trabecular thickness
decrease in connections between horizontal trabeculae
decrease in trabecular strength

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32
Q

why does osteoporosis increase in women

A

menopause = loss of restraining effects of oestrogen on bone turnover
high bone turnover = more resorption than formation
cancellous bone loss
michroarchitectural disruption

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33
Q

what is DEXA

A

dual energy Xray absorptiometry
= low radiation
= measures important fracture sites

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34
Q

what is a T score

A

standard deviation score = compared with gender matched young adult average of peak bone mass (??)

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35
Q

why is Cushing’s syndrome a risk factor for osteoporosis

A

cortisol increases bone resorption and induces osteoblast apoptosis

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36
Q

what is osteomalacia

A

metabolic bone disorder = low mineral bone content and vitamin D deficiency = soft bones but normal amount

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37
Q

what causes osteomalacia

A 
vit D deficiency
resistance to vit D
liver disease
tumour induced
osteodystrophy
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38
Q

what are the signs/symptoms of osteomalacia

A

bone pain
myalgia
pathological fracture

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39
Q

how does osteomalacia present in children

A

= rickets

= bowed legs and knocked knees

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40
Q

how is osteopenia diagnosed

A

DEXA scanning = score of -1 to -2.5 = osteopenia

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41
Q

how is osteoporosis diagnosed

A

DEXA scanning = score -2.5 or worse = osteoporosis

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42
Q

how is osteomalacia treated

A

increase Vit D and calcium dietary intake

Vit D and calcium supplements = cholecalciferol or calcitriol

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43
Q

what is vasculitis

A

inflammation of blood vessel walls with subsequent impaired blood flow =
vessel wall destruction = perforation = haemorrhage into tissues
also causes endothelial injury = thrombosis and ischaemia/infarction of tissues

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44
Q

how is vasculitis classified

A

primary/secondary = if due to pre-existing condition or random
vessel size = small/large
ANCA = positive or negative
target organ affected

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45
Q

what are ANCA

A

anti- nuclear cytoplasmic antibody = specific antibodies for antigens in cytoplasmic granules of neutrophils and monocyte lysosomes

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46
Q

name the main large vessel vasculitis

A

giant cell arteritis (temporal arteritis) = primary
Takayasu’s arteritis = primary
aortitis in RA = secondary

47
Q

name the main small vessel vasculitis

A

granulomatosis with polyangiitis (GPA) = primary
Churg Strauss = primary
microscopic polyangiitis = primary
vasculitis secondary to autoimmune disease = secondary

48
Q

what is the name of vasculitis classification

A

Chapel Hill

49
Q

what is the most common condition affecting the synovial joints

A

osteoarthritis

50
Q

what is osteoarthritis

A

a degenerative arthritis which affects synovial joints and characterised by articular cartilage degeneration

51
Q

what tissues of the joint are involved in osteoarthritis

A

all tissues are involved but articular cartilage is most affected

52
Q

describe the process of osteoarthritis

A 
metabolically active and dynamic process = mediated by cytokines including:
IL1
TNFalpha
NO
as well as driven by mechanical forces
53
Q

what are the main pathological features of osteoarthritis

A

loss of cartilage

disordered bone repair

54
Q

what joints does OA affect

A 
knees = medially spreading laterally through patellofemoral compartment
hips
big toe
spine
hands = DIP, PIP, CMC joints
55
Q

what is an arthroscopy

A

removal of loose bodies = prevents joint locking

56
Q

what is an osteotomy

A

realignment of the knee by removing section of bone

57
Q

what is fusion surgery

A

done in complex joints where replacement cant be done = fuse joints

58
Q

what joints are affected in OA of the hands

A

distal interphalangeal joint
carpometacarpal joint

59
Q

where is the CMC joint

A

connecting trapezium of thumb to first metacarpal of the thumb

60
Q

what compartment of the knee is most affected by osteoarthritis

A

medial

61
Q

what is erosive/inflammatory OA

A

subset of OA
strong inflammatory component
can be treated with DMARDs

62
Q

what is a loose body

A

bone or cartilage fragment leads to locking of joint

63
Q

what is a discoid rash

A

red patches of skin associated with scaling and plugging of hair folicles

64
Q

what is a butterfly rash

A

fixed red patches over cheeks

65
Q

what is marfans syndrome

A

inherited autosomal dominant condition causes lack of fibrillin
caused by mutation in FBN1 gene
not curable = genetic counselling, surgical management

66
Q

what are the signs/symptoms of marfans

A

aortic aneurism (root)
aortic dissection
coarctation of aorta

tall, long arms
dislocation of lens
high arched pallet

67
Q

what is EDS

A

Ehlers-Danlos syndrome
autosomal dominant condition causes defective type 1 and 2 collagen production
no treatment = manage complications

68
Q

what are the signs/symptoms of EDS

A

hyper elastic skin
hypermobile joints
joint deformities
early onset osteoarthritis

easy bruising
anal prolapse
valvular heart disease

69
Q

what population groups are more commonly affected by SLE

A

afro-Caribbean/asian

70
Q

what test are done to diagnose SLE and which is specific for SLE

A

anti-nuclear antibody

double stranded DNA antibody = specific

71
Q

what diseases can Raynauds be seen as a secondary condition to

A

systemic sclerosis
mixed connective tissue disease
SLE

72
Q

what are the vascular damage causes of raynauds

A

atherosclerosis
frost bite
vibrating tools

73
Q

what is Raynauds phenomenon

A

lack of blood flow in the microvasculature circulation causing cold and cyanosed fingers in the cold and increased blood flow in the warm = red/purple hands

74
Q

what is the difference between scleroderma and systemic sclerosis

A

scleroderma only affects skin/underlying soft issue

systemic sclerosis affects internal organs

75
Q

how is localised scleroderma divided

A 
morphea = discoloured oval patches, itchy and hairless
linear = thick skin along face, scalp, legs, arms
76
Q

how is systemic scleroderma divided

A 
limited = milder form, mostly affecting skin
diffuse = affects whole body/ internal organs
77
Q

what is dermatomyositis

A

inflammation of muscles with a skin rash

more common in women

78
Q

what is polymyositis

A

inflammation of muscles which affects many different muscles particularly shoulders hips and thighs
more common in women

79
Q

what organ can be affected in dermatomyositis/polymyositis

A

lungs = interstitial lung disease

80
Q

what is the treatment of dermatomyositis/polymyositis

A

steroids

immunosuppressant drugs

81
Q

how is osteomalacia diagnosed

A

low calcium
low phosphate
high alkaline phosphatase
biopsy shows incomplete mineralisation

82
Q

what does SHATTERED stand for (Presentation of osteoporosis)

A 
Steroid use >5mg/day
Hyperthyroidism/parathyroidism/calciuria
Alcohol and tobacco
Thin
Testosterone low
Early menopause
Renal/liver failure
Erosive/inflammatory bone disease
Dietary calcium low/DMT1
\+ Family history
83
Q

explain SOAP BRAIN MD in the presentation of SLE

A 
Serositis = pleurisy/pericarditis
Oral ulcers
Arthritis
Photosensitivity
Blood cytopenias
Renal involvement
Antinuclear antibodies
Immunological phenomena (dsDNA)
Neurological = psychosis/seizures
Malar rash
Discoid rash
84
Q

what does CREST stand for and what disease does it describe

A 
systemic sclerosis:
Calcinosis = Ca skin deposits
Raynauds
Esophageal stricture/reflux
Sclerodactyly = thick skin fingers/toes
Telangiectasia = dilated facial spider veins
85
Q

what is the treatment progression for osteoporosis

A

alendronice acid –> denosumab –> teriparatide

denusomab can be used if alendronic acid is CI or not tolerated

86
Q

what drugs can cause osteoporosis

A 
steroids
alcohol
anti-epileptics
lithium
cyclosporin
PPI
87
Q

what DMARDs can precipitate gout

A

methotrexate

sulfasalazine

88
Q

what is polymalgia rheumatica

A

common
old people
muscle stiffness
raised inflamm markers ESR >40mm/hr

89
Q

how does polymyalgia rheumatica present

A

> 60
rapid onset
morning stiffness in proximal limbs
mild polyarthralgia, lethergy, low-grade fever

90
Q

how is polymyalgia rheumatica managed

A

prednisolon 15mg/OD
usually dramatic response

91
Q

what is polyarteritis nodosa (PAN)

A

vasculitis
affects medium arteries
necrotising inflammation leading to aneursym formation

92
Q

what are the features of polyarteritis nodosa

A

middle age men + hep B
fever, malaise, WL
hypertension
testicular pain
haematuria
ANCA in 20%
hep B +ve in 30%

93
Q

what is systemic sclerosis

A

unknown aetiology
4x more in females
hardened sclerotic skin and other connective tissues
3 patterns:
1. limited cutaneous systemic sclerosis (incl CREST)
2. diffuse cutaneous systemic sclerosis
3. scleroderma

94
Q

describe limited cutaneous systemic sclerosis

A

raynauds
scleroderma affecting face + distal limbs
anti-centromere antibodies
CREST is a subtype

95
Q

describe diffuse cutaneous systemic sclerosis

A

scleroderma affecting trunk + proximal limbs
anti-scl-70 antibodies
interstitial lung disease + pulmonary hypertension = mortality +++
renal disease
poor prognosis

96
Q

describe the antibodies found in systemic scleroderma

A

ANA Ab in 90%
RF +ve in 30%
antiscl-70 in diffuse
anticentromere in limited

97
Q

describe the findings of joint aspiration in gout

A

monosodium needle shaped crystals
negatively befringent

98
Q

what is raised in gout and what is first line and second line treatment

A

uric acid
1. nsaids
2. colchicine (in renal impairment)

99
Q

what is the treatment for polymyalgia rheumatica and what should you co-prescribe

A

15mg prednisolone OD
+ PPI
+ bisphosphonates
+ Ca + VitD

100
Q

triad of reactive arthritis

A
  1. conjunctivitis
  2. urethritis
  3. arthritis
101
Q

describe the management for SLE + what can discoid LE rarely progress to

A

sun protection
hydroxychloroquine
topical steroids
injected steroids

squamous cell carcinoma

102
Q

what is the management of GCA

A

40-60mg OD prednisolone
500-1000mg OD methylprednisolone if vision loss or jaw claudication

103
Q

what is henoch schonlein purpura caused by and what are the 4 main features

A

IgA immunoglobulin
1. joint pain
2. abdo pain
3. renal involvement
4. purpura

104
Q

55 year old with pain and weakness in thighs, shoulders, upper arms
purplish rash on eyelids
rash over interphalangeal joints on hands

A

dermatomyositis
raised creatinine kinase
anti MI 2 + ANA antibodies
muscle biopsy is definitive
treat with corticosteroids

105
Q

what is behcets disease?
how does it present?
what gene is it associated with?
how is it treated?

A

oral and genital ulcers
joint pain and swelling
HLA B51
treat with topical steroids

106
Q

medicine to treat raynauds

A

prophylactic nifedipine

107
Q

what is the problem in sjogrens?
what conditions can it be secondary to?
what antibodies?
treatment?

A

exocrine glands
RA and SLE
anti RO + anti LA
hydroxychloroquine can halt progression

108
Q

what investigations for synovitis and what is the scoring system for RA

A

USS
DAS28

109
Q

first line treatments for RA

A

methotrexate
sulfasalazine
leflunamide
(with a bridging dose prednisolone)

  1. TNF inhibitors
110
Q

what investigations must you do when starting a TNF inhibitor and why

A

chest XR
can reactivate TB

111
Q

what cancers cause erythema nodosum EN?
what infections cause EN?
what medications cause EN?

A

leukemia
lymphoma

strep throat
TB
mycoplasma pneumonia
GE

COCP
NSAIDs

112
Q

what is the screening tool for psoriasis and what is an extreme form

A

psoriasis epidemiological screening tool
arthritis mutilans

113
Q

what is buergers disease

A

thromboangiitis obliterans
smoker with blue fingers
= ulcers, gangrene, amputation
corkscrew collaterals on angiography
STOP SMOKING COMPLETELY

Phase 2a (15 decks)

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