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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

Finger deformity seen in RA where the PIPJ is hyperflexed and DIPJ is hyperextended.

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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. Should encourage annual testing at opticians though.

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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 (xanthine oxidase)

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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 systemic 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

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60
Q

What would characterise a ‘severe flare’ of SLE?

A

Pericarditis/ nephritis/ AIHA/ CNS disease

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61
Q

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

A

Prednisolone + IV cyclophosphamide

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62
Q

What drugs can be used to manage SLE chronically

A

Hydroxychloroquine + DMARDs + low-dose steroids

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63
Q

What is anti-RNP antibody associated with?

A

Mixed connective tissue disease

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64
Q

What valve disease is associated with relapsing polychondritis?

A

Aortic valve disease

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65
Q

What is the triphasic colour change in Raynaud’s?

A

White –> blue –> red

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66
Q

What does CREST stand for?

A

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

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67
Q

Where is skin involvement limited to in CREST syndrome?

A

Face, hands and feet

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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)
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69
Q

Recall some principles of managing Raynaud’s phenomenon

A

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

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70
Q

Recall some signs and symptoms of dermatomyositis and polymyositis

A

Wasting of shoulder and pelvic girdle

Dysphagia, dysphonia, respiratory weakness

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71
Q

Which malignancies can result in polymyositis as a paraneoplastic syndrome?

A

Lung
Pancreas
Ovarian
Bowel

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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

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73
Q

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

A

Very raised CK

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74
Q

How can polymyositis or dermatomyositis be definitively diagnosed?

A

Muscular biopsy

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75
Q

What is the ‘myositis panel’ of antibodies?

A

Anti-Jo1
Anti-Mi2
Anti-SRP

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76
Q

Recall 3 types of ANCA negative small vessel vasculitides

A

Goodpasture’s
Cryoglobulinaemia
Henoch Schonlein Purpura

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77
Q

Which of the vasculitides is associated with polymyalgia rheumatica?

A

Temporal arteritis

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78
Q

Recall some signs/symptoms of temporal arteritis

A

Scalp tenderness
Jaw claudication
Headache
Amaurosis fugax

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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

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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

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81
Q

How should temporal arteritis be managed?

A

40-60mg PO prednisolone

Followed by PPI + alendronate for 2 years

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82
Q

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

A

IV methylprednisolone

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83
Q

How should polymyalgia rheumatica be managed?

A

15mg PO prednisolone

Taper down to 5mg + PPI + alendronate

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84
Q

What are the symptoms of polymyalgia rheumatica?

A

Pain/stiffness in the shoulder, neck and hips

NO weakness

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85
Q

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

A

Weak upper limb pulses, hypertension

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86
Q

Which demographic is polyarteritis nodosa most common in?

A

Young males (less common in UK)

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87
Q

What is the key association of polyarteritis nodosa?

A

Hep B virus

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88
Q

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

A

Renal angiogram

Rosary bead sign

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89
Q

How can polyarteritis nodosa be managed?

A

Prednisolone and ciclophosphamide

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90
Q

Recall 2 examples of medium vessel vasculitides

A

Kawasaki disease

Polyarteritis nodosa

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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

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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
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93
Q

Recall some signs and symptoms of granulomatosis with polyangiitis

A

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

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94
Q

Recall some signs and symptoms of eosinophillic granulomatosis with polyangiitis

A
  • Eosinophilia
  • Asthma
  • Rapidly progressive glomerulonephritis
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95
Q

Recall some signs and symptoms of microscopic polyangiitis

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

What is pANCA directed against?

A

A myeloperoxidase

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97
Q

How should granulomatosis with polyangiitis be managed?

A

Prednisolone + ciclophosphamide OR rituximab

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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

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99
Q

How should henoch schonlein purpura be managed?

A

Regular follow-up with urine dips and BP measurement

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100
Q

How quickly should henoch schonlein purpura usually resolve naturally?

A

4 weeks

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101
Q

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

A

Lung nodules

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102
Q

How should goodpasture’s be managed?

A

Immunosuppression and plasmapheresis

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103
Q

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

A

Simple (20%)

Mixed (80%)

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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

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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

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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
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107
Q

Recall some options for management of fibromyalgia

A

Educate
CBT
Graded exercise programmes
Amitriptyline/ pregabalin/ venlafaxine

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108
Q

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

A

Carbamazepine

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109
Q

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

A

Duloxetine

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110
Q

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

A

Amitriptyline

Pregabalin

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111
Q

What criteria are used to diagnose Still’s disease?

A

Yamaguchi criteria

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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

148
Q

What is a normal anti-CCP titre?

A

<7

149
Q

How should a new diagnosis of rheumatoid arthritis be managed?

A
  • Start on steroids (~40mg) then reduce dose incrementally down to 10mg
  • Wean onto long-term DMARDs
  • Regular bloods and x-rays to monitor disease progress
150
Q

What must be co-prescribed with steroids, especially if on longer courses?

A
  • Stomach protection (e.g. PPI or H2 antagonist)
  • Bone protection if on longer courses (e.g. calcium, vitamin D, bisphosphonates)
151
Q

How is methotrexate taken?

A
  • Once a week
  • Folic acid should be taken once a week alongside it, usually the day after
152
Q

What is the blood monitoring required when starting DMARDs?

A
  • Every 2w for the first 6w
  • Every month for first three months
153
Q

What is the difference between a large and a medium vessel?

A

A vessel becomes ‘medium’ when it penetrates an organ

154
Q

What are some causes of carpal tunnel syndrome?

A
  • Endocrine causes - hypothyroidism, acromegaly, diabetes etc
  • Rheumatoid arthritis
  • Repeated use
  • Idiopathic
  • Pregnancy
155
Q

What type of hypersensitivity reaction is GCA?

A

Type 4

156
Q

What feature of GCA is associated with a poor prognosis?

A

Ischaemic scalp ulcers

157
Q

What are some of the ocular problems you can get in GCA?

A
  • Transient monocular vision loss (amaurosis fugax)
  • Visual field defects
  • Complete vision loss
158
Q

What is the management of GCA?

A
  • High dose prednisolone (40-60mg) over 18-24 months
  • Consider alendronate and vitamin D for bone protection
  • PPIs for stomach protection
  • Urgent ophthalmology review if ocular symptoms present
159
Q

What can be given in relapsing GCA disease?

A

Methotrexate

160
Q

Which interleukin is strongly involved in production of fever?

A

IL-1

161
Q

What is the role of IL-2?

A

T cell differentiation

162
Q

How is Takayasu’s arteritis diagnosed?

A

PET-CT

163
Q

What is a significant eosinophil level?

A

Should be no more than 10% of the total WCC

164
Q

What are some causes of an eosinophilia?

A
  • Atopy and allergies
  • Worms
  • Vasculitis
  • Eosinophilic haematological malignancies
  • EGPA
165
Q

What is the only lung disease to cause an INCREASE in gas transfer on PFTs?

A

GPA (Wegner’s)

166
Q

Can infliximab be used in pregnancy?

A

Don’t use within 6 months of pregnancy

167
Q

Can methotrexate be used in pregnancy?

A

No it is teratogenic - wait 3 months after stopping before getting pregnant

168
Q

Can sulfasalazine be used in pregnancy?

A

It can reduce sperm count so should be advised against in partners of women who want to conceive. However, it is fine to take for the women.

169
Q

What is the pattern of joint involvement in rheumatoid arthritis?

A

Symmetrical, bilateral and proximal (typically DIPJ-sparing)

170
Q

Which antibody related to RA confers a higher risk of joint erosion/worse disease prognosis?

A

Anti-CCP antibodies

171
Q

What is the DAS28 based on?

A
  • 28 joint score
  • CRP/ESR
  • VAS (visual analogue score)
172
Q

What are the different scores for the DAS28?

A

> 5.1 = severe
3.2-5.1 = moderate
2.6-3.2 = mild
<2.6 = in remission

173
Q

What are the different methods of giving steroids and when would each be used?

A
  • Intra-articular - particularly if it is a small number of joints affected (1/2)
  • Oral - usually if it is more than 2 joints
  • IM - for multiple, severe joint involvement
174
Q

What is the steroid used in IM steroid injections?

A

Depomedrone

175
Q

What is an acute complication of methotrexate and what test is done to monitor this?

A

Acute pneumonitis - this is why a baseline CXR is needed before starting therapy

176
Q

What is a rare complication of sulphasalazine?

A

DRESS syndrome

177
Q

Can leflonamide be used in pregnancy?

A

No

178
Q

Can hydroxychloroquine be used in pregnancy?

A

Yes

179
Q

What screening/baseline tests should be done before starting DMARDs?

A
  • LFTs
  • FBC
  • Hep B serology (core and surface)
  • Latent TB (Quantiferon)
  • CXR
  • XR of hands and feet
  • HIV test
180
Q

When can a patient be stepped up to a biological therapy?

A
  • When they have tried 2x previous DMARDs for 6 months with no success
  • DAS28 should also be more than 3.2 (moderate or above)
181
Q

What does Rituximab target?

A

CD20

182
Q

What does Toculizumab target?

A

IL-6

183
Q

Who should not be given JAK2 inhibitors?

A

Elderly due to worries over immunosuppression and cancer

184
Q

Aside from joint and nail changes, what other features are seen in psoriatic arthritis?

A
  • Enthesitis
  • Tendonitis
  • Dactylitis
185
Q

Is psoriatic arthritis a symmetrical or asymmetrical arthritis?

A

Asymmetrical typically

186
Q

How is the severity of psoriatic arthritis measured?

A

PSARC66 (involves 66 joints as well as clinician and patient score)

187
Q

What are the serum urate level targets for gout patents?

A

Within 1 year of therapy = <300
1 year + = <360

188
Q

How should allopurinol be handled during an acute gout attack?

A
  • Do not start during an acute attack
  • If already taking, continue to take alongside colcichine
189
Q

When starting allopurinol, what should be co-prescribed?

A

Colcichine for at least 2 months as there may be a paradoxical effect in first few months of therapy

190
Q

When is CRP and ESR naturally raised?

A

Obese individuals

191
Q

What marker is almost always raised in vasculitis?

A

CRP

192
Q

What is the predominant demographic of a GCA patient?

A

Caucasian, female and >55yo

193
Q

How is ILD secondary to systemic sclerosis managed?

A

Immunosuppression, usually with mycophenalate mofetil and hydroxychloroquine.

194
Q

What is a rare GI complication of systemic sclerosis?

A

Bacterial overgrowth in small bowel - due to poor peristaltic function of the bowel, resulting in bacteria building up in the gut

195
Q

When would pain be worse in disc prolapse?

A

On flexion

196
Q

When would pain be worse in joint facet pain?

A

On extension

197
Q

How does spinal stenosis typically present?

A

Bilateral calf pain, with the symptoms being alleviated by leaning forwards or on something

198
Q

What is anterior uveitis?

A

An acutely red, painful eye with a dilated pupil

199
Q

What is Apremilast?

A

PD4 inhibitor (weak immunosuppressant) - good for patients where immunosuppression is a worry e.g. elderly patients, lymphoma/myeloma patients

  • Doesn’t need much monitoring
  • Tablet form
200
Q

Why can ankylosing spondylitis cause T2 respiratory failure?

A

Due to costo-vertebral fusion of the ribs

201
Q

What can ankylosing spondylitis cause in the heart?

A

AV node heart block due to fibrosis of the conduction pathway

202
Q

What would be seen on examination of an ankylosing spondylitis patient?

A
  • Reduced chest expansion (<3cm)
  • Loss of lumbar lordosis
  • Increased thoracic kyphosis
  • Stooped posture
  • Positive Schobers test
203
Q

What are Romanis lesions and when are they seen?

A

Vertebral endplate sclerosis seen in ankylosing spondylitis

204
Q

What scoring system can be used to determine severity of ankylosing spondylitis?

A

BASDAI

205
Q

What is the management of ankylosing spondylitis?

A
  • Stretching/physiotherapy
  • NSAIDs
  • Biologics
206
Q

When would someone be stepped up to biological therapy in ankylosing spondylitis?

A

4/10 BASDAI + 4/10 pain + 2x failed NSAIDs (1 month) –> biologics

207
Q

What is the evidence base for physiotherapy and NSAIDs as first line for ankylosing spondylitis?

A

Both have been shown to slow progression as well as regular NSAIDs resulting in radiographic regression

208
Q

How is zolendronate given?

A

As a yearly IV infusion

209
Q

Are PPIs required alongside zolendronate?

A

No as it is an IV infusion so it does not damage the stomach lining

210
Q

How is Denosumab given?

A

6-monthly subcutaneous injections

211
Q

What does Denosumab target?

A

RANKL

212
Q

What bone marker can be used to measure response to anti-restorative/anabolic therapies in osteoporosis?

A

PINP (pro-collagen type 1 N-terminal propeptide)

213
Q

What is the P1NP target for post-menopausal women (not on HRT)?

A

20-76mg/dl

214
Q

What part of the joint is affected first in osteoarthritis and rheumatoid arthritis respectively?

A

Osteoarthritis = medial
RA = lateral

215
Q

Is osteoarthritis a distal or proximal disease?

A

Distal

216
Q

Is rheumatoid arthritis a distal or proximal disease?

A

Proximal (classically DIPJ-sparing)

217
Q

What condition is a ‘gull-wing’ appearance seen in the metacarpals?

A

OA

218
Q

What is the classical pattern of joint involvement in RA?

A

Bilateral and symmetrical

219
Q

What condition are ‘opera glass hands’ appearance seen in the metacarpals?

A

Psoriatic arthritis - although very uncommon nowadays due to improved treatments

220
Q

What is acro-osteolysis?

A

Shortening and resorption of bone at the distal end of a finger/toe

221
Q

Where does ankylosing spondylitis typically affect first?

A

Sacro-iliac joints

222
Q

What are some x-ray features seen in ankylosing spondylitis?

A
  • Bamboo cervical spine
  • Fused sacra-iliac joint
  • Dagger sign
223
Q

What are some MRI features seen in ankylosing spondylitis?

A
  • Shiny corners (on T2 weighted images)
  • Fused SIJs
224
Q

What are ankylosing spondylitis patients particularly at risk of?

A

Severe spinal fractures (even when minor trauma involved)

225
Q

What causes the ‘bamboo spine’ in AS?

A

Ossification of the anterior and posterior longitudinal ligaments

226
Q

What causes the ‘dagger sign’ in AS?

A

Ossification of the interspinous ligament

227
Q

What is DISH?

A

Diffuse idiopathic skeletal hyperostosis is a condition characterised by continuous ossification of ligaments and enthuses, mainly in the axial skeletal but can also occur in peripheral joints

228
Q

How is DISH diagnosed?

A

When at least four thoracic vertebrae have developed osteophytes

229
Q

Which part of the skeleton is mainly affected by DISH?

A

Thoracic vertebra

230
Q

What is the incidence of DISH?

A

Quite common - around 10%, incidence increases with age (but usually found incidentally)

231
Q

What age is required for a diagnosis of JIA to be made?

A

Must be present before age of 16

232
Q

Which area of the body is typically spared from ossifications in DISH?

A

Areas near the aorta due to pulsatile effect so most ossifications will be right-sided

233
Q

What is the adult form of JIA known as?

A

Stills disease

234
Q

Below what eGFR are bisphosphonates contraindicated?

A

<35

235
Q

How long should symptoms have been present before a diagnosis of chronic fatigue syndrome can be made?

A

3 months

236
Q

Is azathioprine safe to use in pregnancy?

A

Yes

237
Q

What are some EARLY x-ray findings in RA?

A
  • Juxta-articular osteopenia
  • Loss of joint space
  • Soft tissue swelling
238
Q

What drug cannot be co-prescribed alongside allopurinol?

A

Azathioprine - it can cause bone marrow suppression

239
Q

What initial investigation can be used to confirm a diagnosis of ankylosing spondylitis?

A

Pelvic XR

240
Q

What other drug can methotrexate not be used alongside?

A

Trimethoprim (and co-trimoxazole) - can cause bone marrow suppression and severe/fatal pancytopenia

241
Q

What form of NSAIDs are first line for knee osteoarthritis?

A

Topical

242
Q

How are the renal complications of systemic sclerosis managed?

A

ACE inhibitors

243
Q

If a man is found to have osteoporosis, what should be checked?

A

Testosterone

244
Q

What ongoing Mx should be given to patients aged > 75 who suffer a fragility fracture?

A

Bisphosphonates started immediately (no need for DEXA scan)

245
Q

What should be considered in an elderly patient presenting with dermatomyositis?

A

Underlying malignancy as it can be a paraneoplastic syndrome (ovarian/breast/lung tumours)

246
Q

How might acute pneumonitis present?

A

New onset dyspnoea, low grade fever, cough and scattered crepitations

247
Q

How long is antibiotic therapy required for septic arthritis?

A

4-6 weeks (2 weeks IV, 2-4 weeks PO)

248
Q

When is monitoring vs bone protection offered in relation to DEXA T scores?

A
249
Q

How long do you need to wait after stopping methotrexate before attempting to conceive?

A

6 months (male and female)

250
Q

What is the typical biochemistry of osteomalacia?

A

Low Ca
Low phosphate
High ALP
High PTH

251
Q

What protein is affected in Marfan’s syndrome?

A

Fibrillin

252
Q

What movement typically makes lateral epicondylitis pain worse?

A

Worse on resisted wrist extension/suppination whilst elbow extended

253
Q

What would be a typical joint aspirate in RA?

A

Yellow fluid
No crystals
No culture growth but high WBC

254
Q

What needs to be corrected before starting bisphosphonates?

A

Vitamin D and calcium levels (as bisphosphonates can worsen calcium levels)

255
Q

What type of fracture do bisphosphonates increase the risk of?

A

Atypical stress fractures - typically in the proximal femoral shaft

256
Q

What is the maximum steroid dose advised in the Mx of poly myalgia rheumatica?

A

20mg - if no improvement with this, should be referred to a specialist to consider alternate diagnoses

257
Q

What is the classic triad seen in Behcet’s disease?

A
  • Oral ulceration
  • Genital ulcers
  • Anterior uveitis
258
Q

Aside from the classical triad, what other symptoms are seen in Behcet’s disease?

A
  • Thrombophlebitis
  • DVT
  • Arthritis
  • Erythema nodosum
  • GI symptoms - abdo pain, diarrhoea, colitis
259
Q

Which HLA allele is Behcet’s associated with?

A

HLA B51

260
Q

What is the epidemiology of Behcet’s disease?

A
  • More common in men
  • More common in eastern Mediterranean populations (e.g. Turkey)
  • Tends to affect younger people
  • 30% will have a positive FHx
261
Q

How should bisphosphonates be taken and why?

A

First thing in the morning on an empty stomach with plenty of water.

This is to prevent an oesophageal reaction due to retention as the bisphosphonates can react with the oesophageal lining if retained, resulting in oesophagitis.

262
Q

Pain and stiffness around the base of the thumb points towards which rheumatological condition?

A

Osteoarthritis

263
Q

What further investigation should be ordered for an elderly patient presenting with symptoms of dermatomyositis/polymyositis?

A

Malignancy screen

264
Q

What are the four rotator cuff muscles and what do they do?

A
  • Subscapularis - positioned anteriorly on your chest, helps with internal rotation of shoulder

*Supraspinatus - positioned on top of your shoulder and runs parallel to your deltoid. Needed for the first 20° of shoulder abduction, then the rest of abduction is done by the deltoid

*Infraspinatus - positioned posteriorly on the superior aspect of your back, helps with external rotation of shoulder

*Teres minor - positioned posteriorly on the superior aspect of your back, helps with external rotation of shoulder

265
Q

What should be checked before starting a patient of sulfasalazine?

A

If they are sensitive to aspirin and patients who are allergic to aspirin may also react to sulfasalazine due to cross reactivity in their similar structures

266
Q

What is greater trochanteric pain syndrome?

A

Hip pain (pain and tenderness over the lateral side of thigh) due to repeated movement of the fibroelastic iliotibial band

267
Q

Who is greater trochanteric pain syndrome most commonly seen in?

A

Most common in women aged 50-70 years

268
Q

What is anotehr name for greater trochanteric pain syndrome?

A

Trochanteric bursitis (old name)

269
Q

What antibody is dermatomyositis associated with?

A

Anti-Jo-1

270
Q

What is typically seen on fundoscopy in GCA?

A

Engorged and pale optic disc with blurred margins due to oedema

271
Q

What factors does a Z score take into account?

A

Age, gender and ethnicity

272
Q

What is the treatment for methotrexate toxicity?

A

Folinic acid

273
Q

When should bisphosphonate treatment be re-evaluated?

A

After 5 years of bisphosphonate therapy, treatment should be re-assessed for ongoing treatment depending on their risk (high or low), with an updated FRAX score and DEXA scan.

274
Q

What are some features that would put a patient into the high-risk group requiring bisphosphonate therapy?

A

Age >75
Glucocorticoid therapy
Previous hip/vertebral fractures
Further fractures on treatment
High risk on FRAX scoring
T score <-2.5 after treatment

275
Q

If an osteoporosis patient is deemed low risk after their 5-year reevaluation, what should be done next?

A

If any of the high risk criteria apply, treatment should be continued indefinitely, or until the criteria no longer apply. If they are in the low risk group however, treatment may be discontinued and re-assessed after two years, or if a further fracture occurs.

276
Q

What is one of the most serious comorbidities associated with RA?

A

IHD

277
Q

What is the difference between Gottron’s papule and Gottron’s sign?

A

Gottrons papules - these are small violaceous papules, often seen on the proximal interphalangeal and metacarpophalangeal joints.

Gottron’s sign - this refers to violaceous macules, sometimes with associated oedema, over the knees and elbows.

Both are seen in dermatomyositis.

278
Q

A positive result of which test would suggest referred pain from the lumbar spine resulting in hip pain?

A

Femoral nerve stretch test

279
Q

What are the typical biochemistry results seen in osteogenesis imperfecta?

A

Usually all normal

ICSM Year 6 (21 decks)

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