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Phase 3b > Rheumatology > Flashcards

Rheumatology Flashcards

(153 cards)

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1
Q

What are the X-Ray changes in Osteoporosis?

A 
LOSS
Loss of joint space
Osteophytes
Subchondral/subarticular sclerosis
Subchondral cysts
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2
Q

Risk factors for osteoarthritis

A 
Obesity
Old age
Female
Family history
Occupation
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3
Q

Presentation for osteoarthritis

A 
Pain on movement
Crepitus
Worse at end of day/no morning stiffness
Worsened by exercise/relieved by rest
No systemic features
Stiffness after rest - gelling
Bony swelling & deformity - Heberden's and Bouchard's nodes
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4
Q

Where does Heberden’s node affect?

A

DIP

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5
Q

Where does Bouchard’s node affect?

A

PIP

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6
Q

Management for osteoarthritis

A

Weight loss
Exercises for muscle strength - physiotherapy
Aids and devices/walking stick - occupational therapy

Oral paracetamol and topical NSAIDs
Oral NSAID + PPI e.g. Omeprazole
Intra-articular steroid injections (methylprednisolone)

Joint replacement (hip and knee)

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7
Q

What joint is most commonly affected in septic arthritis?

A

Knee

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8
Q

What is the commonest bacteria causing septic arthritis

A

Staph aureus

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9
Q

What other bacteria cause septic arthritis

A

Step pyogenes
H. influenzae
E. coli
Nesisseria gonorrhoea (in sexually active)

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10
Q

Risk factors for septic arthritis

A 
Prosthetic joint
Rheumatoid arthritis
Diabetes
IV drug abuse
Alcohol
Immunosuppression
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11
Q

Presentation for septic arthritis

A 
Usually only affects ONE joint - the KNEE
Hot
Red
Swollen
Painful
Immobile/restricted
Fever lethargy
Sepsis
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12
Q

Investigations for septic arthritis

A

Joint aspiration for synovial fluid microscopy and culture
WCC
Polarised microscopy (exclude gout = urate crystals & pseudogout = calcium pyrophosphate)
ESR/CRP raised
X-ray

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13
Q

Management for septic arthritis

A

Empirical antibiotics
Flucloxacillin for staph + rifampicin
Vancomycin for MSRA/penicillin allergy

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14
Q

Define rheumatoid arthritis

A

Chronic inflammatory autoimmune disease characterised by synovial joint inflammation leading to joint destruction

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15
Q

What is the pattern of rheumatoid arthritis

A

Symmetrical and affects multiple joints

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16
Q

Genetic associations for rheumatoid arthritis

A

HLA DR4

HLA DR1

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17
Q

Who is more commonly affected in rheumatoid arthritis

A

50 year old woman

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18
Q

Presentation for rheumatoid arthritis

A 
Symmetrical polyarthritis
Joint pain + swelling
Worse after rest/improves with exercise
Morning stiffness
Sudden onset
Fatigue
Weight loss
Fever
Muscle aches and weakness
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19
Q

What joints are affected in rheumatoid arthritis

A 
MCP
MTP
PIP
Wrist and ankle
Cervical spine
Knee, hips, shoulders
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20
Q

Signs on examination for rheumatoid arthritis

A

Z-shaped deformed thumb
Swan neck deformity
Boutonnieres deformity - flexed at PIP and extended at DIP
Ulnar deviation of the fingers

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21
Q

What is palindromic rheumatism?

A

Self-limiting short episodes of inflammatory arthritis. Only lasts 1-2 days then resolves

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22
Q

Extra-articular manifestations of rheumatoid arthritis

A 
Rheumatoid nodules
Lymphadenopathy
Secondary Sjogren's syndrome
Felty's syndrome = RA + splenomegaly + neutropenia
Obliterative bronchiolitis
Caplan's syndrome (pulmonary fibrosis with pulmonary nodules)
Anaemia
Cardiovascular disease
Epscleritis and scleritis
Carpal tunnel syndrome
Amyloidosis
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23
Q

Investigations for rheumatoid arthritis

A

Anti-CCP
Rheumatoid factor
FBC
X-ray

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24
Q

X-ray features seen in rheumatoid arthritis

A 
LESS
Loss of joint space
Bony Erosions
Soft tissue swelling
Softening of bones (osteopenia)
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25
Treatment for rheumatoid arthritis
1st line = DMARDs - Methotrexate 2nd line = two DMARDS - methotrexate + sulfasalazine/hydroxychloroquine/leflunomide 3rd line = Methotrexate + TNF inhibitor - adalimumab 4th line = Methotrexate + rituximab
26
Side effects of methotrexate
Pneumonitis Oral ulcers Hepatotoxicity Teratogenic - harmful to pregnancy - PRESCRIBE WITH FOLIC ACID 5MG
27
Side effects of hydroxychloroquine
Irreversible retinopathy
28
Side effects of sulfasalazine
Reduced sperm count Skin rash Bone marrow suppression
29
Side effects of leflunomide
Teratogenic Oral ulcers Hepatotoxicity Peripheral neuropathy
30
Examples of Anti-TNF drugs
Infliximab Adalimumab Golimumab Etanercept
31
Side effects of Anti-TNF drugs
Reactivation of TB Infection/sepsis Hepatitis B
32
What is rituximab
A monoclonal antibody
33
Side effects of rituximab
Infections/sepsis Night sweats Thrombocytopenia (low platelets)
34
What treatment do you give in an acute exacerbation of rheumatoid arthritis?
Methylprednisolone
35
Risk factors for gout
``` Male Obesity High purine diet (meat and seafood) Alcohol Diuretics Cardiovascular or kidney disease Family history ```
36
Which joints are affected in gout
``` BIG TOE >50% Wrists Thumb Knee Ankle ```
37
Investigations for gout
Joint aspiration and polarised light microscopy of synovial fluid = negative birefringent needles, URATE crystals Serum urate raised X-ray: Soft tissue swelling, 'punched out' erosions, tophi
38
Treatment for gout
1st line = NSAIDs e.g. Ibuprofen/naproxen 2nd line = Colchicine 3rd line = Steroids - in patients with renal failure Rest, elevation, ice
39
Contraindications for NSAIDS
Peptic ulcer | Heart/renal failure
40
Side effects of colchicine
GI upset | Diarrhoea
41
Prophylaxis for gout
Lose weight Reduce alcohol consumption Avoid purine rich meats Allopurinol - xanthine oxidate inhibitor
42
Side effects of allopurinol
Rash Fever Reduced WCC Avoid allopurinol until acute attack has settled
43
How does gout present?
Hot, swollen, painful joint
44
How does pseudogout present?
Hot, swollen, painful More common in elderly Large joints - knee, shoulders, wrist and hips
45
Causes of pseudogout
Hyperparathyroidism Surgery Trauma Illness
46
Investigations for pseudogout
Polarised light microscopy of synovial fluid - positive rhomboid crystals, CALCIUM PYROPHOSPHATE X-ray: Chondrocalcinosis - calcium deposition Exclude septic arthritis
47
Management for pseudogout
NSAIDs + colchicine Joint aspiration Intra-articular steroids Icepacks + rest
48
Define SLE
Inflammatory autoimmune connective tissue disease with antinuclear antibodies "Systemic" because it affects multiple organs
49
What age group and people are typically affected by SLE?
Women of CHILD-BEARING age
50
Symptoms for SLE
``` Fatigue Weight loss Fever Myalgia Lymphadenopathy Alopecia Raynauds ```
51
Criteria for SLE
``` 4 out of 11: Discoid rash Malar butterfly rash Photosensitivity Oral ulcers Non-erosive arthritis Serositis - pleuritis/pericarditis Renal disorder CNS disorder - seizures or psychosis Haematological disorder - leukopenia, thrombocytopenia, lymphopenia Immunological disorder - Anti-dsDNA, Anti-Sm, Antiphospholipid antibodies ANA +ve in >95% ```
52
Investigations for SLE
ESR raised + CRP normal FBC - anaemia, leukopenia, thrombocytopenia Autoantibodies - ANA, Anti-dsDNA, Anti-smith C3 & C4 decreased Proteinuria in lupus nephritis
53
Treatment for SLE
``` NSAIDs Steroids (prednisolone) Hydroxychloroquine Suncream and sun avoidance Methotrexate Azathioprine Mycophenolate Rituximab + belimumab ```
54
Define ankylosing spondylitis
Inflammatory condition affecting the spine that causes progressive stiffness and pain
55
What is the genetic association with ankylosing spondylitis
HLA B27
56
How does ankylosing spondylitis present?
Young adult male <30 years old Gradual onset of lower back pain >3 months Worse at night and in the morning Pain and stiffness is worse with rest and improves with movement/exercise Pain radiates from the sacroiliac joints to hips/buttocks Loss of spinal movement hence decreased thoracic expansion Kyphosis Neck hyperextension (question mark posture) Spino-cranial ankylosis
57
Associations with ankylosing spondylitis
``` Enthesitis Dactylitis Anterior uveitis Aortitis Anaemia Heart block Restrictive lung disease Pulmonary fibrosis Inflammatory bowel disease ```
58
Investigations for ankylosing spondylitis
Clinical - Schober's test MRI spine - bone marrow oedema CRP & ESR raised X-ray of spine: 'Bamboo spine', subchondral erosions and sclerosis, fusion of the facet, sacroiliac and costovertebral joints, syndesmophytes, ossification
59
Treatment for ankylosing spondylitis
``` Exercise + physiotherapy NSAIDs - ibuprofen + naproxen Local steroids injections Anti-TNF medications - etanercept, inflixiumab Surgery - hip replacement ```
60
Associations with enteric arthropathy
Inflammatory bowel disease GI bypass Coeliac disease Whipple's disease
61
Define psoriatic arthritis
Inflammatory arthritis associated with psoriasis | Occurs in 10-20% of people with psoriasis
62
How does psoriatic arthritis present?
Symmetrical polyarthritis - hands, wrists, ankles, DIP Asymmetrical pauciarthritis - digits (toes and feet), fingers Spondylitic pattern - back stiffness, sacroiliitis, atlanto-axial joint involvement Other areas: spine, achilles tendon, plantar fascia
63
Signs of psoriatic arthritis
Plaques of psoriasis on the skin Pitting of the nails Onycholysis - separation of the nail from the nail bed Dactylitis - inflammation of the digits Enthesitis - inflammation of the points of insertion of tendon into bone
64
Other associations with psoriatic arthritis
``` Eye disease (conjunctivitis and anterior uveitis) Aortitis Amyloidosis ```
65
Investigations for psoriatic arthritis
``` X-ray: "Pencil in cup" appearance Central erosions Osteolysis Dactylitis Ankylosis Periostitis ```
66
Define arthritis mutilans
Occurs in the phalanxes, there is osteolytic destruction of the bones around the joints in the digits. Leads to shortening of the digits "telescopic finger"
67
Treatment for psoriatic arthritis
NSAIDs DMARDs - methotrexate, sulfasalazine Anti-TNF medications - etanercept, infliximab Ustekinumab - last line monoclonal antibody
68
Define reactive arthritis
Where synovitis occurs in the joints as a reaction to a recent infective trigger - affecting the lower limb Typically causes an acute monoarthritis affecting a single joint most often the knee - warm, swollen and painful joint
69
Differential diagnoses for reactive arthritis
Septic arthritis - in reactive arthritis there is no infection in the joint
70
Most common causative organisms which trigger reactive arthritis
Gastroenteritis (campylobacter, salmonella, shigella, Yersinia) Chlamydia
71
What is Reiter's syndrome?
Urethritis Arthritis Conjunctivitis CANT SEE, CANT WEE, CANT CLIMB A TREE
72
Investigations for reactive arthritis
ESR & CRP raised Aspirate joint and send sample for gram staining, culture and sensitivity - EXCLUDE septic arthritis Crystal examination of fluid - rule out gout & pseudogout
73
Treatment for reactive arthritis
NSAIDs Steroid injections DMARDs - methotrexate, sulfasalazine
74
Define Behcet's disease
A systemic inflammatory disorder of unknown cause Characteristically presents with recurrent oral and genital ulcers Link with HLA-B5 gene
75
Features of Behcet's disease
``` Mouth ulcers - at least 3 a year Genital ulcers Skin - erythema nodosum, papules & pustules Eyes - Anterior or posterior uveitis, retinal haemorrhage MSK - morning stiffness, arthralgia GI - inflammation and ulcers CNS - Meningitis, migraines Veins - Budd-Chari syndrome, DVT ```
76
Investigations for Behcet's disease
Clinical diagnosis | Pathergy test - needle prick leads to papule formation
77
Treatment for Behcet's disease
``` Topical steroids for mouth ulcers Systemic steroids - oral prednisolone Colchicine Immunosuppressants - azathioprine Infliximab ```
78
Define Polymyalgia Rheumatica
Inflammatory condition that causes pain and stiffness in the shoulders, pelvic girdle and neck Strong association to giant cell arteritis
79
Features of Polymyalgia Rheumatica
``` Age >50 years, more common in female caucasians Subacute onset <2 weeks Bilateral shoulder pain radiating to elbows Bilateral pelvic girdle pain Worse with movement Morning stiffness >45 minutes Carpal tunnel syndrome Weight loss, fever, fatigue ```
80
Investigations for Polymyalgia Rheumatica
Clinical diagnosis + response to steroids ESR & CRP elevated Creatine kinase levels are normal
81
Treatment for Polymyalgia Rheumatica
Prednisolone 15mg Consider other diagnosis if no response after 1 week Risk of adrenal crisis if steroids stopped abruptly
82
Define Giant Cell Arteritis
Systemic vasculitis of the medium and large arteries | Strong link with polymyalgia rheumatica
83
Symptoms of Giant Cell Arteritis
Headache - severe unilateral Scalp tenderness Jaw claudication Amaurosis fugax - sudden blindness in one eye
84
Investigations for Giant Cell Arteritis
``` Clinical presentation Raised ESR >50 Raised CRP Temporal artery biopsy Raised alkaline phosphatase ```
85
Treatment for Giant Cell Arteritis
Prednisolone 60mg/day Aspirin PPI - Omeprazole for gastric prevention whilst on steroids Bisphosphonates for osteoporosis prevent
86
Define polymyositis
Condition of chronic inflammation of muscles
87
Define dermatomyositis
Connective tissue disorder where there is chronic inflammation of the skin and muscles
88
What is the key investigation for diagnosing polymyositis and dermatomyositis
Creatine kinase blood test = >1,000
89
What are the causes of a raised creatine kinase level
``` Polymyositis and dermatomyositis Rhabdomyolysis Acute kidney injury MI Stains/colchicine Strenuous exercise HIV ```
90
Presentation for polymyositis and dermatomyositis
Muscle pain, fatigue and weakness | Occurs bilaterally and affects proximal muscles - affecting shoulders and pelvic girdle
91
What skin involvement is there in dermatomyositis
``` Gottren's lesions - patches on knuckles Macular rash Purple rash on face and eyelids Preorbital oedema Subcutaneous calcinosis ```
92
Investigations for polymyositis and dermatomyositis
``` Clinical presentation Elevated creatine kinase >1,000 Electromyography Muscle biopsy Autoantibodies - Anti-Jo-1 = Polymyositis, Anti-Mi-2 = Dermatomyositis, ANA = Dermatomyositis ```
93
What autoantibody is present in polymyositis?
Anti-Jo-1
94
What autoantibody is present in dermatomyositis?
Anti-Mi-2 | ANA
95
Treatment for polymyositis and dermatomyositis
Prednisolone | Immunosuppressants - azathioprine
96
Define osteoporosis
Reduction in the density of the bones
97
Define osteopenia
Less severe reduction in bone density than osteoporosis
98
Risk factors for osteoporosis
``` SHATTERED Steroid use Hyperthyroidism, hyperparathyroidism, hypercalciuria Alcohol and smoking Thin (BMI<22) Testosterone low Early menopause - low oestrogen Renal or liver failure Erosive/inflammatory bone disease (myeloma/RA) Dietary low calcium/malabsorption ```
99
What is the tool to measure the risk of a fracture in the next 10 years?
FRAX | Uses age, BMI, co-morbidities, smoking, alcohol, family history to calculate
100
How is bone mineral density measured?
DEXA scan
101
What is a T-score and what scores indicate what diagnosis?
The T-score gives you the number of standard deviations below the mean for a healthy young adult. >-1 = normal -1 - -2.5 = osteopenia
102
Lifestyle treatment for osteoporosis
``` Weight-bearing exercise Stop smoking Reduce alcohol consumption Calcium & Vitamin D rich diet Avoid falls ```
103
Pharmacological treatment for osteoporosis
Bisphosphonates - 1st line Alendronate, risedronate, zolendronic acid Calcium with Vitamin D supplements Denosumab - monoclonal antibody Strontium ranelate Raloxifene
104
How do bisphosphonates work?
Reduce osteoclastic activity, preventing reabsorption
105
Side effects of bisphosphonates
Reflux Oesophageal ulcers - sit upright Jaw osteonecrosis Photosensitivity
106
Define osteomalacia
Normal amount of bone but it is soft (low mineral content). Results from insufficient vitamin D The result if it occurs after the fusion of the epiphyses
107
What is Rickets?
Rickets is the result of osteomalacia is this occurs during the period of bone growth in children
108
Causes of osteomalacia
``` Vitamin D deficiency - due to malabsorption, poor diet or lack of sunlight Renal osteodystrophy Vitamin D resistance Drug induced - anticonvulsants Liver disease ```
109
Symptoms of Rickets
Growth retardation Hypotonia Knock-kneed Bow-legged
110
Symptoms of osteomalacia
Bone pain Fractures Muscle weakness Fatigue
111
Investigations for osteomalacia
``` Serum-25-hydroxyvitamin D <25nmol/L Serum calcium low Serum phosphate low Alkaline phosphate may be high PTH high (secondary hyperparathyroidism) X-ray=osteopenia ```
112
Treatment for osteomalacia
Vitamin D
113
Define Paget's disease
Disorder of bone turnover. Increased bone turnover due to increased numbers of osteoblasts and osteoclasts. Results in remodelling, bone enlargement, deformity and weakness
114
Symptoms of Paget's disease
Bone pain Bone deformity Fractures Hearing loss if bones of the ear are affected
115
Complications of Paget's disease
Osteoarthritis Increased calcium Nerve compression due to bone overgrowth in spine Osteosarcoma
116
Investigations in Paget's disease
X-ray - Bone enlargement and deformity 'Cotton wool' appearance of skull 'V-shaped' defects in the long bones Osteoporosis circumscripta - osteolytic lesions Raised alkaline phosphatase Normal calcium Normal phosphate
117
Treatment for Paget's disease
Bisphosphonates - Alendronate | NSAIDs for bone pain
118
Define systemic sclerosis
An autoimmune inflammatory and fibrotic connective tissue disorder Scleroderma is hardening of the skin Two types - limited and diffuse cutaneous systemic sclerosis
119
What antibodies are present in diffuse cutaneous systemic sclerosis?
``` Anti-Scl-70 antibodies Antinuclear antibodies (ANA) ```
120
Features of diffuse cutaneous systemic sclerosis
Includes features of CREST Cardiovascular problems - hypertension, coronary artery disease Lung problems - pulmonary hypertension, pulmonary fibrosis Kidney problems - glomerulonephritis
121
Features of limited cutaneous systemic sclerosis
Calcinosis - calcium deposits under the skin - fingertips Raynaud's phenomenon - Fingertips go white -> blue due to cold Oesophageal dysmotility - swallowing difficulties Sclerodactyly - swollen, tight digits Telangiectasia - dilated small blood vessels in the skin
122
What is Raynaud's phenomenon
Fingertips go white -> blue due to cold
123
What causes Raynaud's phenomenon
``` SLE RA Dermato/polymyositis Vibrating tools Beta-blockers Hypothyroidism Thrombocytosis ```
124
Treatment for Raynaud's phenomenon
Keep warm Stop smoking Nifedipine, sildenafil
125
Antibodies present in limited cutaneous systemic sclerosis
``` Anti-centromere antibodies Antinuclear antibodies (ANA) ```
126
Investigations for systemic sclerosis
Clinical features Antibodies Nailfold capillaroscopy
127
Treatment for systemic sclerosis
Immunosuppressants: IV cyclophosphamide in diffuse disease Avoid smoking Regular emollients
128
Define osteomyelitis
Infection of the bone
129
Common organisms causing osteomyelitis
Staphylococcus aureus Pseudomonas E.coli Streptococci
130
Risk factors for osteomyelitis
``` Diabetes Vascular disease Impaired immunity Sickle cell disease Open fractures ```
131
Clinical features of osteomyelitis
Cancellous bone affected in adults - vertebrae = IV drug users, feet = diabetic Vascular bone affected in children - distal femur, upper tibia Infection leads to cortex erosion, with holes Gradual onset pain Tenderness, warmth, erythema
132
Investigations in osteomyelitis
``` ESR increased CRP increased Blood culture positive in 60% Bone biopsy and culture - gold standard X-ray after 14 days = haziness, loss of density ```
133
Treatment for osteomyelitis
6 weeks of antibiotics: Vancomycin & Cefotaxime | Ciprofloxacin for pseudomonas
134
Complications of osteomyelitis
Septic arthritis Fractures Deformity Chronic osteomyelitis
135
Define compartment syndrome
Occurs when swelling of tissues in an anatomic compartment occludes the vascular supply leading to necrosis and hypoxia
136
Features of compartment syndrome
Pain, especially on movement Paraesthesia Pallor Paralysis of the muscle group
137
Investigations for compartment syndrome
Intracompartmental pressure: >20mmHg = abnormal | >30mmHg = critical
138
Treatment for compartment syndrome
Prompt fasciotomy | IV fluids in renal failure due to myoglobinuria following fasciotomy
139
Define cauda equina syndrome
Compression of the cauda equina | Caused by large herniation or prolapses of lumbar discs, but may be from cord tumours or spondylosis
140
Features of cauda equina syndrome
``` Poor anal tone Severe back pain - sudden onset Saddle area (perianal) sensation loss Incontinence/retention of faeces or urine Paralysis +/- sensory loss ```
141
Investigations for cauda equina syndrome
MRI within 4 hours
142
Define carpal tunnel syndrome
Due to compression of the median nerve
143
Symptoms of carpal tunnel syndrome
Tingling or pain in the thumb, index and middle fingers Pain is relieved by dangling the hand over the edge of the bed and shaking it 'wake and shake' Sensory loss and weakness of abductor pollicis brevis Wasting of the thenar eminence
144
Investigations for carpal tunnel syndrome
Phalen's test Tilen's test
145
What is Phalen's test?
Wrist hyperflexed for 1 minute -> reverse prayer sign
146
What is Tinel's test?
Tapping over the nerve induces tingling
147
Treatment for carpal tunnel syndrome
Splinting Corticosteroid injections Carpal tunnel decompression
148
Associations with carpal tunnel syndrome
``` Hypothyroidism Diabetes Obesity RA Acromegaly Amyloidosis Pregnancy Gout Psuedogout ```
149
What inheritance pattern is Marfan's syndrome?
Autosomal dominant
150
What causes Marfan's syndrome
Defect in the FBN1 gene on chromosome 15 that codes for the protein fibrillin-1
151
Features of Marfan's syndrome
``` Tall stature Long neck Long limbs Long fingers (arachnodactyly) High arch palate Hypermobility Pectus excavatum ```
152
Associated conditions with Marfan's syndrome
Lens dislocation in the eye Joint dislocations and pain due to hypermobility Scoliosis of the spine Pneumothorax GORD Mitral valve prolapse (with regurgitation) Aortic valve prolapse (with regurgitation) Aortic anuerysms
153
Treatment for Marfan's syndrome
Biggest risk = aortic dissection - treatment with beta blockers Echocardiogram

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