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ICSM Year 6 > Medicine - Rheumatology > Flashcards

Medicine - Rheumatology Flashcards

1
Q

Recall 5 indications for MRI to investigate back pain

A

Cauda equina

Malignancy

Infection

Fracture

Ankylosing spondylitis

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2
Q

What sort of pain might radiofrequency denervation be useful for?

A

Joint facet pain

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3
Q

Recall 2 groups of people who are at increased risk of rheumatoid arthritis

A

Females

Smokers

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4
Q

Recall some HLA associations with rheumatoid arthritis

A

HLA-DR1

HLA-DR4

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5
Q

Recall some examination findings in the hands in rheumatoid arthritis

A

Radial deviation at wrists

Ulnar deviation at MCP joints

‘Z thumb’

Boutonniere deformity

Swan neck deformity

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6
Q

What is the boutonniere deformity?

A

Rupture of central slip allowing proximal inter-phalangeal joint to to prolapse through ‘buttonhole’

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7
Q

What is the swan neck deformity?

A

Stretching of the volar plate causing proximal inter-phalangeal joint hyperextension –> distal interphalangeal joint flexion

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8
Q

What abnormality might rheumatoid arthritis cause in the neck?

A

Atlanto-axial subluxation

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9
Q

What is Felty’s syndrome?

A

Rare triad of:

Rheumatoid arthritis

Neutropaenia

Splenomegaly

Can be remembered using the mnemonic - SANTA:

Splenomegaly

Anaemia

Neutropaenia

Thrombocytopaenia

Arthritis

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10
Q

Recall some useful investigations for rheumatoid arthritis

A 
Positive 'squeeze test' 
Bloods: 
- Positive RhF in 70% 
- Anti-CCP: 80% sensitive 
- ANA
Imaging: XR, USS (synovitis), MRI
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11
Q

How can rheumatoid arthritis disease activity be monitored?

A

DAS28 (Disease Activity Score 28)

CRP monitoring

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12
Q

What is the 1st line management of rheumatoid arthritis?

A

Conventional DMARD monotherapy

Short bridging course prednisolone

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13
Q

Recall 4 examples of conventional DMARDs

A

Methotrexate
Sulfasalazine
Hydroxychloroquine
Mycofenolate mofetil

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14
Q

What monitoring is required for methotrexate?

A

Regular FBCs and LFTs

Risk of myelosuppression and liver cirrhosis

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15
Q

What monitoring is required for hydroxychloroquine?

A

Annual visual acuity testing after 5 years’ continuous use

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16
Q

What are the 2nd and 3rd line management options for rheumatoid arthritis?

A

2nd line: Conventional DMARD combination therapy

3rd line: conventional DMARD + biological DMARD

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17
Q

Give 4 examples of biologics that can be used to manage rheumatoid arthritis

A
  • Etanercept
  • Infliximab
  • Adalimumab
  • Rituximab
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18
Q

How should flare ups of rheumatoid arthritis be managed?

A

Corticosteroids +/- NSAIDs

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19
Q

How can rheumatoid and osteoarthritis be differentiated using X rays of the hands?

A

Rheumatoid: loss of joint spaces in the proximal joints
Osteoarthritis: loss of joint spaces in the distal joints

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20
Q

Recall the X ray features of osteoarthritis vs rheumatoid arthritis

A 
Osteoarthritis: LOSS
Loss of joint spaces
Osteophytes 
Subchondral cysts 
Subchondral sclerosis 
Rheumatoid arthritis: LESS
Loss of joint spaces
Erosions (periarticular) 
Soft tissue swelling 
Subluxation and deformity
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21
Q

Recall the aetiology of gout

A

Monosodium urate crystals deposited in and around joints

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22
Q

Systematically recall some causes of gout

A

Decreased excretion: primary gout, renal impairment

Increased cell turnover: lymphoma, leukaemia, psoriasis, haemolysis, tumour lysis syndrome

Drugs: diuretics, aspirin, EtOH excess

Purine rich foods

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23
Q

Recall some signs and symptoms of gout other than the monoarthritis

A

Tophi
Radiolucent kidney stone
Interstitial nephritis

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24
Q

What might an X ray show in gout?

A

Punched out erosions

‘Rat bites’

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25
Q

Recall the management of gout

A

Acutely: NSAIDs - or colchicine if history of duodenal ulcer/ renal failure
Intra-articular steroid injections may be used if certain it isn’t septic arthritis
Chronic prevention: conservative, or urate-lowering therapy

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26
Q

What conservative measures might be used to prevent gout?

A

Weight loss
No EtOH excess
Avoid prolonged fasting

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27
Q

Recall the 1st and 2nd line xanthine oxidase drugs that can be used as a urate-lowering therapy

A

1st: allopurinol
2nd: febuxostat

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28
Q

Recall some seronegative spondyloarthropathies

A

PEAR

Psoriatic arthritis
Enteropathic arthritis
Ankylosing spondylitis
Reactive arthritis

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29
Q

Recall some associations of the seronegative spondyloarthropathies

A

HEADS

HLA-B27
Enthesitis
Axial, asymmetircal oligoarthritis 
Dactylitis
Seronegative
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30
Q

What is the key difference in signs and symptoms between psoriatic arthritis and ankylosing spondylitis?

A

No signs or symptoms in the hands in ankylosing spondylitis

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31
Q

Recall some associated signs and symptoms of anklosing spondylitis

A 
All the 'A's 
Anterior uveitis 
Apical lung fibrosis 
Aortic regurgitation 
AV node block 
Achilles tendonitis
Amyloidosis
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32
Q

What is Schober’s test used to diagnose, and what would a positive test be?

A

Ankylosing spondylitis

  • Mark L5
  • 1 finger 5cm above and 1 5cm below
  • <5cm increase when bending over = positive
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33
Q

What is a syndesmophyte?

A

Bony growth originating inside a ligament

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34
Q

Recall 3 signs that might be seen on X ray of the lumbar spine in ankylosing spondylitis

A
  1. Bamboo spine (squaring of lumbar vertebrae)
  2. Dagger sign (supraspinous tendon ossification)
  3. Syndesmophytes
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35
Q

What options for medical management are there in ankylosing spondylitis?

A

NSAIDs
Anti-TNF
Secukinumab

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36
Q

What condition is the ‘pencil in cup deformity’ most associated with?

A

Psoriatic arthritis

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37
Q

How can psoriatic arthritis be managed?

A

NO STEROIDS (can cause flares of psoriasis when tapered)
NSAIDs are first line
–> methotrexate, ciclosporin, sulfasalazine

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38
Q

What is the eponymous name for reactive arthritis?

A

Reiter’s arthritis

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39
Q

What is reactive arthritis?

A

Sterile arthritis that develops 1-4 weeks after either urethritis or dysentry

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40
Q

What are the symptoms of reactive arthritis?

A 
"Can't see, can't pee, can't climb a tree"
- Conjunctivitis 
- Urethritis 
- Lower limb oligoarthritis 
Also: skin issues --> 
- keratoderma blenorrhagicum 
- Circinate balantis 
- Enthesitis
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41
Q

How should enteropathic arthritis be managed?

A

Treat underlying IBD
NSAIDs
Local steroids

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42
Q

What condition does RhF have an 100% sensitivity for?

A

Felty’s syndrome

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43
Q

Which autoimmune connective tissue disorder is associated with anti-dsDNA?

A

SLE

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44
Q

Which autoimmune connective tissue disorder is associated with anti-CCP?

A

Rheumatoid arthritis

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45
Q

Which autoimmune connective tissue disorder is associated with anti-histone?

A

Drug-induced SLE

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46
Q

Which autoimmune connective tissue disorder is associated with anti-centromere?

A

CREST syndrome

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47
Q

Which autoimmune connective tissue disorder is associated with anti-Jo-1?

A

Polymyositis

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48
Q

Which autoimmune connective tissue disorder is associated with anti-topoisomerase?

A

Diffuse stsremic sclerosis

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49
Q

How should Behcet’s disease be managed (broadly)?

A

Immunosuppression

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50
Q

Recall some symptoms of sjogren’s syndrome

A

Keratoconjunctivitis sicca
Xerostomia
Dyspareunia
Bilateral parotid swelling

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51
Q

How can eye dryness be tested for in suspected Sjogren’s syndrome?

A

Schirmer’s test (uses filter paper in the eye)

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52
Q

What is the main danger of sjogren’s in pregnancy?

A

Antibodies can cross placenta and cause foetal heart block

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53
Q

Recall some symptoms of SLE

A 
SOAP BRAIN MD
Serositis 
Oral ulcers
Arthritis 
Photosensitivity
Blood (pancytopaenia)
Renal (proteinuria, haematuria)
ANA
Immunology (anti-dsDNA, AIHA) 
Neurological (eg seizures)

Malar rash
Discoid rash

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54
Q

Which drugs can precipitate ‘drug-induced lupus’?

A 
'Hydralazine PIMP'
Hydralazine
Procainamide
Isoniazid
Minocycline
Phenytoin
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55
Q

In anti-phospholipid syndrome, why would the APTT be falsely prolonged?

A

The antibodies in the patient’s serum react with the phospholipids in the lab reagent so the patient’s blood does not clot

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56
Q

Recall some signs and symptoms of antiphospholipid syndrome

A 
CLOT
Coagulation (venous AND arterial thromboembolism) 
Livedo reticularis
Obstetric complications
Thrombocytopaenia
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57
Q

How should antiphospholipid syndrome be managed?

A

If no previous VTE: low-dose aspirin

If previous VTE: warfarin

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58
Q

Which antibodies should you screen for in SLE?

A

ANA
Anti-dsDNA
Anti-Smith

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59
Q

How can SLE disease activity be monitored?

A

Anti-dsDNA titres
C4 and C3 levels (C3 only reduced in extremely severe disease)
ESR

60
Q

What would characterise a ‘severe flare’ of SLE?

A

Pericarditis/ nephritis/ AIHA/ CNS disease

61
Q

How can a severe flare-up of SLE be managed?

A

Prednisolone + IV cyclophosphamide

62
Q

What drugs can be used to manage SLE chronically

A

Hydroxychloroquine + DMARDs + low-dose steroids

63
Q

What is anti-RNP antibody associated with?

A

Mixed connective tissue disease

64
Q

What valve disease is associated with relapsing polychondritis?

A

Aortic valve disease

65
Q

What is the triphasic colour change in Raynaud’s?

A

White –> blue –> red

66
Q

What does CREST stand for?

A

Calcinosis, raynaud’s, oesophageal dysmotility, sclerodactyly, telangiectasia

67
Q

Where is skin involvement limited to in CREST syndrome?

A

Face, hands and feet

68
Q

What organ involvement is possible in diffuse systemic sclerosis?

A

Fibrosis of:

  • GIT (causing incontinence, GORD, dysphagia)
  • Lung (in 80%)
  • Cardiac
  • Renal (causing acute hypertensive crisis)
69
Q

Recall some principles of managing Raynaud’s phenomenon

A

Conservative (gloves etc)
Nifedipine
PDEV inhibitors (eg sildenafil)
IV iloprost

70
Q

Recall some signs and symptoms of dermatomyositis and polymyositis

A

Wasting of shoulder and pelvic girdle

Dysphagia, dysphonia, respiratory weakness

71
Q

Which malignancies can result in polymyositis as a paraneoplastic syndrome?

A

Lung
Pancreas
Ovarian
Bowel

72
Q

Recall some of the dermatological signs of dermatomyositis

A

Periorbital heliotrope rash
Gottron’s papules
Mechanic’s hands
Macular rash in ‘shawl’ distribution

73
Q

Which marker in the blood is strongly indicative of polymyositis or dermatomyositis?

A

Very raised CK

74
Q

How can polymyositis or dermatomyositis be definitively diagnosed?

A

Muscular biopsy

75
Q

What is the ‘myositis panel’ of antibodies?

A

Anti-Jo1
Anti-Mi2
Anti-SRP

76
Q

Recall 3 types of ANCA negative small vessel vasculitides

A

Goodpasture’s
Cryoglobulinaemia
Henoch Schonlein Purpura

77
Q

Which of the vasculitides is associated with polymyalgia rheumatica?

A

Temporal arteritis

78
Q

Recall some signs/symptoms of temporal arteritis

A

Scalp tenderness
Jaw claudication
Headache
Amaurosis fugax

79
Q

What is the most useful imaging to investigate temporal arteritis, and what characteristic sign does it show when positive?

A

USS temporal artery

Halo sign

80
Q

If imaging is negative but temporal arteritis is still suspected, what more invasive test can be used to make a diagnosis?

A

Temporal artery biopsy

81
Q

How should temporal arteritis be managed?

A

40-60mg PO prednisolone

Followed by PPI + alendronate for 2 years

82
Q

How should temporal arteritis be managed if there are visual symptoms?

A

IV methylprednisolone

83
Q

How should polymyalgia rheumatica be managed?

A

15mg PO prednisolone

Taper down to 5mg + PPI + alendronate

84
Q

What are the symptoms of polymyalgia rheumatica?

A

Pain/stiffness in the shoulder, neck and hips

NO weakness

85
Q

What are the signs and symptoms of Takasayu’s arteritis?

A

Weak upper limb pulses, hypertension

86
Q

Which demographic is polyarteritis nodosa most common in?

A

Young males (less common in UK)

87
Q

What is the key association of polyarteritis nodosa?

A

Hep B virus

88
Q

What imaging is most useful for investigating polyarteritis nodosa and what sign does it classically produce?

A

Renal angiogram

Rosary bead sign

89
Q

How can polyarteritis nodosa be managed?

A

Prednisolone and ciclophosphamide

90
Q

Recall 2 examples of medium vessel vasculitides

A

Kawasaki disease

Polyarteritis nodosa

91
Q

What are the proper names for Wegener’s and Churg Strauss?

A

Wegener’s: granulomatosis with polyangiitis

Churg-Strauss: eosinophillic granulomatosis with polyangiitis

92
Q

Recall the type of ANCA associated with:

  • Granulomatosis with polyangiitis
  • Eosinophillic granulomatosis with polyangiitis
  • Microscopic polyangiitis
A
  • Granulomatosis with polyangiitis: cANCA
  • Eosinophillic granulomatosis with polyangiitis: pANCA
  • Microscopic polyangiitis: pANCA
93
Q

Recall some signs and symptoms of granulomatosis with polyangiitis

A

URT: rhinitis, saddle-nose
LRT: haemoptysis and cough
Renal: rapidly progressive glomerulonephritis

94
Q

Recall some signs and symptoms of eosinophillic granulomatosis with polyangiitis

A
  • Eosinophilia
  • Asthma
  • Rapidly progressive glomerulonephritis
95
Q

Recall some signs and symptoms of microscopic polyangiitis

A
  • Palpable purpura
  • Rapidly progressive glomerulonephritis
  • Haemoptysis
96
Q

What is pANCA directed against?

A

A myeloperoxidase

97
Q

How should granulomatosis with polyangiitis be managed?

A

Prednisolone + ciclophosphamide OR rituximab

98
Q

Recall some signs and symptoms of henoch schonlein purpura

A

Purpuric rash (100%)
Arthralgia with periarticular oedema (70%)
Colicky abdominal pain (60%)
Glomerulonephritis

99
Q

How should henoch schonlein purpura be managed?

A

Regular follow-up with urine dips and BP measurement

100
Q

How quickly should henoch schonlein purpura usually resolve naturally?

A

4 weeks

101
Q

What might be seen on a CXR in granulomatosis with polyangiitis?

A

Lung nodules

102
Q

How should goodpasture’s be managed?

A

Immunosuppression and plasmapheresis

103
Q

What are the 2 types of cryoglobulinaemia, and what is there relative prevalence?

A

Simple (20%)

Mixed (80%)

104
Q

Describe the key differences in the aetiologies of simple vs mixed cryoglobulinaemia

A

Simple: monoclonal IgM secondary to myeloma/ CLL/ Waldenstrom’s macroglobulinaemia –> hyperviscosity

Mixed: polyclonal IgM secondary to SLE/ Sjogren’s/ hep C/ mycoplasma –> immune complex-mediated disease

105
Q

Describe the key differences in the symptoms of simple vs mixed cryoglobulinaemia

A

Simple: visual disturbances, thrombosis, headaches
Mixed: glomerulonephritis, arthralgia, palpable purpura

106
Q

Recall some signs and symptoms of fibromyalgia

A 
Chronic, widespread musculoskeletal pain and tenderness 
Fatigue
Sleep disturbance
Morning stiffness
Poor concentration
Low mood
107
Q

Recall some options for management of fibromyalgia

A

Educate
CBT
Graded exercise programmes
Amitriptyline/ pregabalin/ venlafaxine

108
Q

What is the first line drug used to manage pain in trigeminal neuralgia?

A

Carbamazepine

109
Q

What is the first line drug used to manage pain in diabetic neuropathy?

A

Duloxetine

110
Q

What are the 2 first line drugs used to manage pain in neuropathic pain?

A

Amitriptyline

Pregabalin

111
Q

What criteria are used to diagnose Still’s disease?

A

Yamaguchi criteria

112
Q

What might be raised in the blood in Still’s disease?

A

Ferritin

113
Q

Recall some signs and symptoms of Still’s disease

A

Arthralgia
Salmon-pink rash
Pyrexia (rises alongside arthralgia in the late evening)

114
Q

What is the first line in managing Still’s disease?

A

NSAIDs, after 1 week –> steroids

115
Q

What type of crystal is involved in pseudogout?

A

Calcium pyrophosphate dehydrate

116
Q

Recall 4 associations of pseudogout

A

Hypothyroidism
Chondrocalcinosis
Haemochromatosis
Hyperparathyroidism

117
Q

Recall 4 possible complications of steroid use

A

Cataracts
Avascular necrosis
Osteoporosis
Diabetes mellitus

118
Q

Recall 6 causes of erythema nodosum

A 
Sarcoidosis 
Post-streptococcal infection
TB
IBD
COCP 
Idiopathic
119
Q

How should erythema nodosum be treated?

A
  • Can be managed symptomatically with NSAIDs

- If in setting of sarcoidosis with lung changes –> prednisolone

120
Q

Recall 5 associations of axial spondyloarthropathy

A 
Aortic regurgitation 
Cauda equina 
Psoriasis 
IBD 
Anterior uveitis
121
Q

Recall 3 side effects of ciclosporin

A

Hypertension
Tremulousness
Gingival hypertrophy

122
Q

Describe the broad mechanism of synovitis development in rheumatoid arthritis

A
  • Cellular immune activation of T lymphocytes
  • Plasma cell production of RF, anti-CCP (not necessarily required for development of RA)
  • Macrophage production of inflammatory cytokines and chemokines: eg TNF, IL1 and IL6
  • Cartilage and bone destruction by MMPs and osteoclasts
123
Q

How long does morning stiffness need to last in order to be a significant history for inflammatory arthritis?

A

> 30 mins

124
Q

What needs to be done before DMARDs are started to check for contraindications?

A

Comprehensive metabolic panel + hep B and C serology

125
Q

Recall 4 DMARDs that can be used in rheumatoid arthritis treatment

A

Methotrexate
Leflunamide
Sulphasalazine
Hydroxychloroquine

126
Q

What shoud be done prior to starting any biologic treatment?

A

Test for latent TB

127
Q

Recall 3 common symptoms of septic arthritis

A

Joint effusion
Joint pain
Decreased ROM

128
Q

What is the most commonly implicated pathogen in septic arthritis?

A

Staphylococcus aureus

129
Q

How should septic arthritis be managed?

A

Timely joint aspiration coupled with IV abx

130
Q

What is the most likely comorbidity in a person who has pseudogout?

A

Osteoarthritis

131
Q

Recall 4 drugs/drug classes that increase serum uric acid

A

Thiazides
Furosemide
Low-dose aspirin
Cyclosporine

132
Q

How would synovial fluid examination differ between acute and chronic gout?

A

Acute: intracellular crystals
Chronic: extracellular crystals

133
Q

Which cytokine is most associated with acute flares of gout?

A

IL 1

134
Q

Recall 3 uricosuric agents that may be used as urate-lowering therapies in patients with chronic gout

A

Probenecid
Losartan (useful in patients with HTN)
Fenofibrate (useful in patients with hyperlipidaemia)

135
Q

What is the difference between Heberden’s and Bouchard’s nodes?

A

Heberden’s: DIP

Bouchard’s: PIP

136
Q

What is anti-RPP (ribosomal P protein) highly specific for?

A

SLE with neuropsychiatric manifestations

137
Q

What is Jaccoud arthropathy?

A

Appears similar to swan neck deformity on examination, but is actually a reversible sign of SLE that results from joint capsule and ligament laxity

138
Q

Does lupus nephritis produce the nephrotic or nephritic syndrome when symptomatic?

A

The nephrotic syndrome

139
Q

What are the most a)concerning and b) common pulmonary sequelae of SLE?

A

a) Diffuse alveolar haemorrhage

b) Pleuritis

140
Q

What is the most common cardiac manifestation of SLE?

A

Pericarditis

141
Q

Recall some important lifestyle changes for SLE patients

A

Always wear sunscreen
Stop oestrogen-containing medication
Avoid smoking
Start exercise programme

142
Q

Which DMARD has the best evidence base for treating SLE?

A

Hydroxychloroquine

143
Q

How should lupus nephritis be treated?

A

Induction with high dose methylprednisolone and a steroid-sparing agent (eg cyclophosphamide or MMF)

Follow with steroid-sparing maintenance therapy

144
Q

How should an acute inflammation of gout be treated in patients with CKD that contraindicates NSAIDs?

A

Oral prednisolone

145
Q

3 blood tests for monitoring SLE activity:

A

ESR
dsDNA
C3 + C4

146
Q

What is lupus pernio and what causes it?

A

Disfiguring purple facial rash (not painful)

Caused by sarcoidosis (not lupus, despite the name)

147
Q

Following an acute asthma attack, what PEF is required for safe discharge?

A

> 75% of predicted

ICSM Year 6 (20 decks)

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