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MLA Rheumatology Flashcards

1
Q

Which haplotypes are associated with rheumatoid arthritis?

A

HLA-DR4/DR1

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2
Q

Which modifiable risk factor increases disease severity in rheumatoid arthritis?

A

Smoking - increases citrullination

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3
Q

What is rheumatoid factor?

A

IgM Antibody directed against the Fc region of IgG

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4
Q

When is joint stiffness most prominent in rheumatoid arthritis?

A

In the morning (worse at rest and during periods of inactivity)

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5
Q

What are the most common sites affected by rheumatoid arthritis?

A

Metacarpophalangeal, proximal interphalangeal, metatarsophalangeal joints, followed by the wrists, knees, elbows, ankles, hips and shoulder

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6
Q

Which joints are spared in rheumatoid arthritis?

A

Distal interphalangeal joints

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7
Q

What is a swan-neck deformity?

A

Hyper-extension of the proximal interphalangeal joint (flexion of DIP)

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8
Q

Which rheumatoid deformity is associated with hyperflexion of the PIP joints?

A

Boutonniere deformity

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9
Q

Which syndrome describes a triad of splenomegaly, neutropenia and rheumatoid arthritis?

A

Felty Syndrome

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10
Q

Which serology is positive in RA?

A

Rheumatoid factor
Anti-CCP

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11
Q

Which autoantibody is most specific in RA?

A

Anti-CCP

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12
Q

What are the radiograph features of rheumatoid arthritis?

A

Periarticular erosions
Loss of joint space
Juxta-articular osteoporosis

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13
Q

Which score is used to assess disease severity in rheumatoid arthritis?

A

DAS-28

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14
Q

Prior to surgery in patients with RA, which immediate X-ray should be performed?

A

Ap and lateral cervical spine to screen for atlantoaxial subluxation

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15
Q

What is the first medical management for RA?

A

Disease-modifying drugs e.g., Methotrexate, sulfasalazine and azathioprine

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16
Q

What are the adverse effects associated with methotrexate?

A

Mucositis, myelosuppression, hepatotoxicity, pulmonary toxicity (hypersensitivity pneumonitis).

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17
Q

What should be co-prescribed with methotrexate?

A

Folic acid 5 mg (administered >24 hours since last methotrexate dose)

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18
Q

How long should methotrexate be discontinued for until conception?

A

Minimum 6 months

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19
Q

Which drug can interact with methotrexate and cause marrow aplasia?

A

trimethoprim/co-trimoxazole

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20
Q

What is the medical management for acute RA flares?

A

Short-term bridging with glucocorticoids

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21
Q

What is the preferred medical management until a rheumatoid appointment is available?

A

Low-dose NSAID with PPI cover

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22
Q

What is the indication to start biological DMARDs in RA?

A

inadequate response to >2 DMARDs

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23
Q

What are the preferred biological DMARDs in RA?

A
  • Anakinra – IL-1
  • Anti-TNF-alpha – Etanercept, infliximab, adalimumab
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24
Q

What investigation should be performed prior to starting biological therapy in RA?

A

CXR to screen for latent tuberculosis

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25
Q

What are the pulmonary complications associated with RA?

A

Interstitial lung disease, pleural effusion

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26
Q

What is the affected site associated with Heberden’s nodes?

A

Distal interphalangeal joint

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27
Q

Which node is associated with the proximal interphalangeal joint in osteoarthritis?

A

Bouchard’s nodes

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28
Q

What is the pain presentation associated with osteoarthritis?

A
  • Activity-related joint pain
  • NO morning joint-related stiffness or morning stiffness >30 minutes.
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29
Q

On palpation of joints in patients with osteoarthritis, what is commonly felt?

A

Crepitus

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30
Q

Which hand joints are most commonly affected in osteoarthritis?

A

First carpometacarpal joint at the base of the thumb

and

DIP/PIP

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31
Q

What fixed deformity of the thumb is observed in osteoarthritis?

A

Squaring

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32
Q

How is the severity if hip arthritis measured?

A

Oxford Hip Score

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33
Q

Which movement is affected in hip arthritis?

A

Painful restriction of internal rotation with hip flexion.

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34
Q

What is the main symptom of knee osteoarthritis?

A

Locking - inability to straighten the knee

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35
Q

What are the four radiological features observed in osteoarthritis?

A
  • Loss of joint space
  • Osteophytes
  • Subchondral sclerosis
  • Subchondral cysts
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36
Q

What is the first line medical management for osteoarthritis?

A

Topical 5% ibuprofen gel applied 3 times a day for knee OA

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37
Q

If topical therapy is ineffective in patients with osteoarthritis, what is the next line of management?

A

Oral NSAIDs e.g., ibuprofen, celecoxib

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38
Q

What is the definitive management of an osteoarthritis hip?

A

Total hip replacement

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39
Q

What is the most common reason for a total hip replacement revision?

A

Aseptic loosening

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40
Q

Which dislocation is most commonly associated with anosteoporotic hip?

A

Posterior dislocation

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41
Q

What are the risk factors for ankylosing spondylitis?

A

HLA-B27

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42
Q

Which joint is most affected in Ankylosing Spondylitis ?

A

Sacroiliac joints

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43
Q

What is the characterised stiffness presentation in Ankylosing Spondylitis ?

A

Prolonged morning back stiffness

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44
Q

Which movements are restricted in Ankylosing Spondylitis ?

A

Limited lumbar spine motion (lateral and forward flexion)

Reduced chest expansion

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45
Q

Which test is used to assess for lumbar spine motion in Ankylosing Spondylitis ?

A

Schober’s test

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46
Q

What type of respiratory dysfunction is associated with Ankylosing Spondylitis ?

A

Restrictive defect

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47
Q

What planar complication is associated with Ankylosing Spondylitis ?

A

Enthesitis (heel, plantar)

Tenderness at tendon insertion sites e.g., Achilles tendon and plantar fascia

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48
Q

What are the extra-articular complications associated with Ankylosing Spondylitis ?

A
  • Apical fibrosis – detected on CXR.
  • Anterior uveitis
  • Aortic regurgitation and AV node block
  • Achilles tenonitis
  • Amyloidosis
  • Peripheral arthritis
  • Cauda equina syndrome
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49
Q

Which is the most useful investigation in patients with suspected Ankylosing spondylitis?

A

Plain X-ray of sacroiliac joins to assess for sacroillitis

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50
Q

What is a late and uncommon radiograph finding in Ankylosing spondylitis?

A

Bamboo spine

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51
Q

Which investigation is indicated to assess for respiratory complications in Ankylosing Spondylitis?

A

Spirometry

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52
Q

What is the first line management for Ankylosing spondylitis?

A

NSAIDs (lowest effective dose)

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53
Q

When are DMARDs indicated for ankylosing spondylitis?

A

For peripheral joint involvement

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54
Q

Which haplotype associated with psoriatic arthritis?

A

HLA-B27

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55
Q

What deformity is associated with psoriatic arthritis?

A

Mutilans - telescoping fingers

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56
Q

What is the characteristic radiograph finding observed in psoriatic arrthritis?

A

Pencil in cup deformity

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57
Q

What is the immediate management for suspected psoriatic arthritis?

A

Urgent referral to the rheumatologist - prescribe NSAIDs at the lowest effective dose

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58
Q

What is used to manage acute flares of psoriatic arthritis?

A

Steroids e.g., prednisolone

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59
Q

Which monoclonal antibodies are indicated for the management of psoriatic arthritis?

A

Ustekinumab and secukinumab (targets IL-17)

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60
Q

What is the triad of symptoms associated with reactive arthritis?

A
  1. Can’t pee: Urethritis, UTIs, STIs, circinate balanitis.
  2. Can’t see: Conjunctivitis, iritis, uveitis.
  3. Can’t bend my knee: Axial arthritis, asymmetrical oligoarthritis
  4. Can’t stand on my feet: Keratoderma blennorrhagica.
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61
Q

What are the commonest causes of reactive arthritis?

A

: 1-4 weeks following an enteric infection (e.g., Campylobacter, Salmonella, Shigella, Yersinia), a venereal infection (e.g., chlamydia) or a streptococcal sore throat.

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62
Q

What investigations are indicated for reactive arthritis?

A
  • Bloods:
  • CRP/ESR – raised
  • WCC – raised
  • Antibody testing – negative
  • Joint aspiration – negative for crystals and bacteria.
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63
Q

What is the first line management for reactive arthritis?

A

NSAIDs, intra-articular steroids

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64
Q

Which autoantibodies are associated with Sjogren’s syndrome?

A

Anti-Ro and Anti-La

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65
Q

What are the characteristic features associated with Sjogren’s syndrome?

A

Dry mouth and dry eyes

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66
Q

Which sex is most affected in Sjogren’s syndrome?

A

Female:male predominance (9:1)

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67
Q

Which test is used to assess for wetting in Sjogren’s disease?

A

Schirmer’s test (,5 mm wetting per minute)

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68
Q

What is the serology testing in patients with Sjogren’s syndrome?

A

Anti-Ro and Anti-La
ANA
RF

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69
Q

What is the first line conservative management for Sjogren’s syndrome?

A

Artificial tears
Saliva substitute
Mouth Rinse
Pilocarpine

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70
Q

Which auto-antibody is associated with polymyositis?

A

Anti-Jo-1

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71
Q

What is the main clinical presentation of polymyositis?

A

Symmetric involvement of proximal girdle muscles (shoulder and pelvic muscles)

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72
Q

What respiratory complication is associated with polymyositis?

A

Interstitial lung disease

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73
Q

Which blood tests are raised in polymyositis?

A

Creatine kinase

ESR

LDH

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74
Q

What is the diagnostic investigation for polymyositis?

A

EMG-guided biopsy

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75
Q

What screen should be performed in polymyositis?

A

Malignancy screen - tumour markers, CXR, mammography

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76
Q

What is the first line management for polymyositis?

A

High-dose oral steroids

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77
Q

What is indicated for the management of refractory polymyositis?

78
Q

Which viruses can precipitated dermatomyositis?

A

Coxsackie B virus, parvovirus, and enterovirus

79
Q

Which drugs can worsen dermatomyositis?

A

hydroxyurea, cyclophosphamide, penicillin, sulphonamides and NSAIDs

80
Q

Which two skin manifestations are associated with dermatomyositis?

A

Heliotrope rash
Gottron’s papules

81
Q

Which blood markers are raised in dermatomyositis?

A

ESR and serum CK levels

82
Q

Which investigations are used to diagnose dermatomyositis?

A

EMG-guided biopsy

83
Q

What is the most common composition of gout?

A

Monosodium urate crystal

84
Q

Which drugs can precipitate gout?

A

Thiazide diuretics, low dose salicylates, ACEi and beta-blockers

85
Q

What are the risk factors for gout?

A

Tumour lysis syndrome
Obesity
Alcohol excess

86
Q

Which joint is most affected by gout?

A

1st MTP joint

87
Q

What are the features of chronic tophaceous gout?

A

Polyarticular arthritis
Tophi deposits in ear lobes, fingers and elbows
Urate kidney stones

88
Q

What is the first line investigation for gout?

A

Serum urate

89
Q

What is the definitive investigation for gout?

A

Joint aspiration and polarised microscopy

90
Q

Needle-shaped crystals with strong negative birefringence is associated with what?

91
Q

What is the first line management of an acute gout flare?

A

NSAIDs
Colchicine

92
Q

When should a follow-up appointment be scheduled for gout?

A

4-6 weeks following gout flare

93
Q

What is the prophylactic management for gout?

A

Allopurinol

94
Q

What is the mechanism of action for allopurinol?

A

Xanthine oxidase inhibitor

95
Q

What is the alternative drug to allopurinol for urate-lowering therapy in gout?

A

Febuxostat

96
Q

Which drug increases urate excretion in gout management?

A

Probenecid

97
Q

Which drugs should be avoided in patients with gout?

A

Azathioprine

98
Q

What is the crystal composition for pseudogout?

A

Calcium pyrophosphate dehydrate crystals

99
Q

What is the radiological finding observed in pseudogout?

A

Chondrocalcinosis

100
Q

What are the risk factors associated with pseudogout?

A
  • Hyperparathyroidism
  • Hypophosphatemia, hypomagnesaemia
  • Metabolic – DM, hypothyroid
  • Wilson’s disease
  • Haemochromatosis
101
Q

Which joints are affected by pseudogout?

A

Knees, hips and shoulders

102
Q

What are the polarised light microscopy findings in pseudogout?

A

Positively birefringent rhomboid shaped

103
Q

What is the medical management for pseudogout?

A

NSAIDs or intra-articular steroids

104
Q

What i the inheritance pattern to Marfan’s syndrome?

A

Autosomal dominant

105
Q

Which gene is affected in Marfan Syndrome?

106
Q

Which aortic complication is associated with Marfan syndrome?

A

Aortic root dilation

107
Q

Which annual screening investigation is indicated in patients with Marfan syndrome?

A

Echocardiography

108
Q

What lifestyle advice is provided to patients with Marfan Syndrome?

A

Avoid intense exercise and contact sports

109
Q

What is the prophylactic medical management in Marfan syndrome?

A

Beta-blockers

110
Q

Which disorder is associated with pulseless disease with unequal blood pressures in the upper limbs?

A

Takayasu’s Arteritis

111
Q

Which artery is most commonly affected in Takayasu Arteritis?

A

Subclavian arteries

112
Q

What is the clinical presentation of Takayasu Arteritis?

A
  • Limb claudication with exertion
  • Chest pain
  • Systemic features: Weight loss, fatigue, malaise, and headache
  • Vascular bruits
  • Unequal blood pressure in the upper limbs
  • Absent or weak peripheral pulses
  • Hypertension (due to renal artery stenosis).
113
Q

What are the CT angiography findings associated with Takayasu arteritis?

A

Segmental narrowing

114
Q

What is the first-line management for Takayasu arteritis?

115
Q

What is the prophylactic drug indicated in Takayasu’s Arteritis ?

116
Q

Which virus is associated with polyarteritis nodosa?

A

Hepatitis B

117
Q

Which type of vasculitis is associated with livedo reticularis?

A

Polyarteritis Nodosa

118
Q

Intestinal angina and testicular pain is associated with which type of vasculitis?

A

Polyarteritis Nodosa

119
Q

What are the angiography findings associated with Polyarteritis Nodosa ?

A

Strings of pearl/rosary bead appearance

120
Q

Saddle nose deformity, sinusitis and pulmonary haemorrhage is associated with which type of vasculitis?

A

Granulomatosis with Polyangiitis (Wegener’)

121
Q

What auto-antibody is raised in Granulomatosis with Polyangiitis (Wegener’)?

122
Q

What is the target of c-ANCA?

A

Proteinase-3

123
Q

What is the 1st line management for inducing remission in patients with Granulomatosis with Polyangiitis (Wegener’)?

A

Corticosteroids and DMARDs

124
Q

Which drug is indicated for inducing remission in severe Granulomatosis with Polyangiitis (Wegener’)?

A

Cyclophosphamide

125
Q

Which autoantibody is raised in microscopic polyangiitis?

126
Q

What syndrome is associated with microscopic polyangiitis?

A
  • Pulmonary Renal Syndrome:
  • Pulmonary haemorrhage – diffuse alveolar haemorrhage.
  • Renal – Rapidly progressive glomerulonephritis
127
Q

What is the clinical presentation associated with Eosinophilic Granulomatosis with polyangiitis?

A

Asthma

Eosinophilia

Myocarditis

128
Q

Which autoantibody is raised in Eosinophilic Granulomatosis with polyangiitis?

129
Q

What is the target for pANCA?

A

Myeloperoxidase

130
Q

Which investigations are indicated for monitoring in HSP?

A

Blood pressure and urinalysis

131
Q

Which haplotype is associated with Behcet’s disease?

132
Q

What is the characteristic clinical manifestations of Behcet’s disease?

A

Recurrent and painful mucocutaneous ulcers

Anterior uveiits

133
Q

Which test is indicated in Behcet’s disease?

A

Pathergy test

134
Q

What is the first line management for Behcet’s disease?

A

Topical corticosteroid for oral and genital ulcers

135
Q

Which autoantibody is associated with limited scleroderma?

A

Anti-centromere

136
Q

What constellation of symptoms are associated with limited scleroderma?

A
  • Calcinosis (calcium deposit on tip of thumb)
  • Raynaud’s phenomenon (white  blue  red)
  • Oesophageal dysmotility
  • Sclerodactyly
  • Telangiectasia
137
Q

What drug is indicated for the management of Raynaud’s?

A

Nifedipine

138
Q

Which autoantibody is associated with diffuse scleroderma?

A

Anti-Scl70 antibody

139
Q

Which vasculitic disease is associated male smokers with a heavy smoking history?

A

Berger’s disease

140
Q

What contrast angiography finding is characteristic of Berger’s disease?

A

Corkscrew appearance

141
Q

Which auto-antibody is most sensitive regarding SLE?

142
Q

Which is the mot specific autoantibody associated with SLE?

A

Anti-dsDNA

143
Q

What markers are low during active SLE?

144
Q

What is the first line management for SLE?

A

Hydroxychloroquine

145
Q

Which monitoring is required for hydroxychloroquine?

A

Annual monitoring (including fundus autofluorescence and spectral domain OCT) is recommended by the Royal College of Ophthalmologists in all patients who have taken hydroxychloroquine for longer than 5 years, to screen for retinopathy.

146
Q

What T-score is consistent with osteoporosis?

147
Q

What scan is used to assess fracture risk?

148
Q

What are the indications for offering a DXA scan in patients?

A

> 50 years + fragility fracture history

<40 years + major risk factor for fragility fracture

149
Q

What does the QFracture/FRAX assess for?

A

The 10-year risk for developing a fracture

150
Q

A Q fracture of >% indicates a DEXA scan?

151
Q

What parameters are adjusted for in a Z-score?

A

Age, ethnicity, and Sex

152
Q

What is the first line medical management for osteoporosis?

A

1st line: Alendronate 10 mg OD or 70 mg OW
* Consider prescribing bisphosphonates to patients taking high doses of oral corticosteroids (>7.5 mg prednisolone daily for 3 months or longer).

153
Q

What is the mechanism of bisphosphonates?

A

Inhibits osteoclast activity

154
Q

What are the upper gastrointestinal adverse effects associated with bisphosphonates?

A

Oesophageal reactions including oesophagitis and ulcers

155
Q

What is the maximum period of time to take alendronic acid?

156
Q

Maximum duration of risedronate therapy?

157
Q

What is the main cause of osteomalacia?

A

Vitamin D deficiency

158
Q

Which drugs cause osteomalacia?

A

anticonvulsants (e.g., carbamazepine, phenobarbital, and phenytoin), corticosteroids and antacids.

159
Q

What type of gait is observed in osteomalacia?

A

Waddling gait

160
Q

Diagnosis for the following:

  • Bone profile: Calcium (LOW), phosphate (LOW), ALP (Raised), PTH (Raised).
  • Serum 25-hydroxyvitamin D level – Low
A

Osteomalacia

161
Q

What are the X-ray findings observed in osteomalacia?

A

oss of cortical bones, Looser’s zones (pseudofractures), cupped metaphysis in rickets

162
Q

What is the first line management for osteomalacia?

A

1st line: Vitamin D3 supplements with an oral antiresorptive agent, maintenance therapy (800-2000 IU daily).

163
Q

What is Paget’s disease?

A

Paget’s disease is characterised as a localised disorder of bone marked by uncontrolled bone turnover (excessive osteoclastic resorption and increased osteoblastic activity)  expanded, weakened bone with sclerotic and lytic areas.

164
Q

What marker is raised in Paget’s disease?

A

Isolated raised ALP

165
Q

A blade of grass lesions and ‘cotton wool’ skull pattern is associated with what disease?

A

Paget’s disease

166
Q

What is the management for Paget’s disease?

A
  • Zoledronic acid IV 5 mg
167
Q

What is the first line management for Paget’s disease?

A

Analgesia with NSAIDs and paracetamol.

168
Q

How tender points are required for a diagnosis of fibromyalgia?

A

At least 11 of the 18 points

169
Q

Minimum duration for fibromyalgia diagnosis?

170
Q

What two factors are associated with the pathogenesis of cervical spondylosis?

A

Osteophyte formation

Facet joint arthropathy

171
Q

Clumsiness in the hands, radicular pain and paraesthesia/weakness in the upper limbs is consistent with what diagnosis?

A

Cervical spondylosis

172
Q

What is the gold-standard imaging for the diagnosis of cervical spondylosis?

173
Q

What is the first-line imaging for cervical spondylosis?

174
Q

What is the first line medical management for cervical spondylosis?

A

Analgesia (NSAID)

Cervical collar

175
Q

What is preserved in PMR?

A

Muscle strength

176
Q

What is the classic presentation of PMR?

A

Bilateral shoulder and/or pelvic girdle pain

177
Q

How long does stiffness persist for in PMR and when?

A
  • Stiffness >45 minutes upon waking or periods of prolonged rest.
178
Q

What disease is associated with PMR?

A

Giant Cell arteritis

179
Q

What is the first line investigation for suspected PMR?

A

ESR (>40 mm/h)

180
Q

What is the first line management for PMR?

A

Oral prednisolone (15 mg OD) - continue treatment for 3-4 weeks once remission is achieved

181
Q

Joint deformity associated with a neuropathic joint is consistent with what diagnosis?

A

Charcot joint

182
Q

Which rule is used to assess for cervical spine injury?

A

Canadian C-spine rule

183
Q

What three high-risk features for cervical spine injury?

A
  • Age 65 years or older,
  • Dangerous mechanism of injury (fall from a height >1 m or 5 steps, axial load to the head e.g., diving, high-speed motor vehicle collision, ejection from motor vehicle, horse riding accidents, bicycle collision.
  • Paraesthesia in the upper or lower limbs.
184
Q

What is the first line management for cervical spine injury?

A

In-spine immobilisation

185
Q

What is the first line pain relief for spinal injury?

A

IV morphine

186
Q

What is a flail chest?

A

2 or more rib fractures along 3 consecutive ribs

187
Q

What is the management for flail chest?

A

Invasive ventilation and surgical fixation

188
Q

What is the first line pain management for rib fractures?

189
Q

What is the 2nd line pain management for rib fractures?

A

Nerve blocks

190
Q

What three screening questions should be asked during a GALS examination?

A
  1. Do you have any pain, swelling, or stiffness in your muscles, joints or back?
  2. Can you dress yourself completely without any difficulty?
  3. Can you walk up and down the stairs without any difficulty?

MLA Flashcards (19 decks)

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