MLA Rheumatology Flashcards
1
Q
Which haplotypes are associated with rheumatoid arthritis?
A
HLA-DR4/DR1
2
Q
Which modifiable risk factor increases disease severity in rheumatoid arthritis?
A
Smoking - increases citrullination
3
Q
What is rheumatoid factor?
A
IgM Antibody directed against the Fc region of IgG
4
Q
When is joint stiffness most prominent in rheumatoid arthritis?
A
In the morning (worse at rest and during periods of inactivity)
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
6
Q
Which joints are spared in rheumatoid arthritis?
A
Distal interphalangeal joints
7
Q
What is a swan-neck deformity?
A
Hyper-extension of the proximal interphalangeal joint (flexion of DIP)
8
Q
Which rheumatoid deformity is associated with hyperflexion of the PIP joints?
A
Boutonniere deformity
9
Q
Which syndrome describes a triad of splenomegaly, neutropenia and rheumatoid arthritis?
A
Felty Syndrome
10
Q
Which serology is positive in RA?
A
Rheumatoid factor
Anti-CCP
11
Q
Which autoantibody is most specific in RA?
A
Anti-CCP
12
Q
What are the radiograph features of rheumatoid arthritis?
A
Periarticular erosions
Loss of joint space
Juxta-articular osteoporosis
13
Q
Which score is used to assess disease severity in rheumatoid arthritis?
A
DAS-28
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
15
Q
What is the first medical management for RA?
A
Disease-modifying drugs e.g., Methotrexate, sulfasalazine and azathioprine
16
Q
What are the adverse effects associated with methotrexate?
A
Mucositis, myelosuppression, hepatotoxicity, pulmonary toxicity (hypersensitivity pneumonitis).
17
Q
What should be co-prescribed with methotrexate?
A
Folic acid 5 mg (administered >24 hours since last methotrexate dose)
18
Q
How long should methotrexate be discontinued for until conception?
A
Minimum 6 months
19
Q
Which drug can interact with methotrexate and cause marrow aplasia?
A
trimethoprim/co-trimoxazole
20
Q
What is the medical management for acute RA flares?
A
Short-term bridging with glucocorticoids
21
Q
What is the preferred medical management until a rheumatoid appointment is available?
A
Low-dose NSAID with PPI cover
22
Q
What is the indication to start biological DMARDs in RA?
A
inadequate response to >2 DMARDs
23
Q
What are the preferred biological DMARDs in RA?
A
- Anakinra – IL-1
- Anti-TNF-alpha – Etanercept, infliximab, adalimumab
24
Q
What investigation should be performed prior to starting biological therapy in RA?
A
CXR to screen for latent tuberculosis
25
What are the pulmonary complications associated with RA?
Interstitial lung disease, pleural effusion
26
What is the affected site associated with Heberden's nodes?
Distal interphalangeal joint
27
Which node is associated with the proximal interphalangeal joint in osteoarthritis?
Bouchard’s nodes
28
What is the pain presentation associated with osteoarthritis?
* Activity-related joint pain
- NO morning joint-related stiffness or morning stiffness >30 minutes.
29
On palpation of joints in patients with osteoarthritis, what is commonly felt?
Crepitus
30
Which hand joints are most commonly affected in osteoarthritis?
First carpometacarpal joint at the base of the thumb
and
DIP/PIP
31
What fixed deformity of the thumb is observed in osteoarthritis?
Squaring
32
How is the severity if hip arthritis measured?
Oxford Hip Score
33
Which movement is affected in hip arthritis?
Painful restriction of internal rotation with hip flexion.
34
What is the main symptom of knee osteoarthritis?
Locking - inability to straighten the knee
35
What are the four radiological features observed in osteoarthritis?
* Loss of joint space
* Osteophytes
* Subchondral sclerosis
* Subchondral cysts
36
What is the first line medical management for osteoarthritis?
Topical 5% ibuprofen gel applied 3 times a day for knee OA
37
If topical therapy is ineffective in patients with osteoarthritis, what is the next line of management?
Oral NSAIDs e.g., ibuprofen, celecoxib
38
What is the definitive management of an osteoarthritis hip?
Total hip replacement
39
What is the most common reason for a total hip replacement revision?
Aseptic loosening
40
Which dislocation is most commonly associated with anosteoporotic hip?
Posterior dislocation
41
What are the risk factors for ankylosing spondylitis?
HLA-B27
42
Which joint is most affected in Ankylosing Spondylitis ?
Sacroiliac joints
43
What is the characterised stiffness presentation in Ankylosing Spondylitis ?
Prolonged morning back stiffness
44
Which movements are restricted in Ankylosing Spondylitis ?
Limited lumbar spine motion (lateral and forward flexion)
Reduced chest expansion
45
Which test is used to assess for lumbar spine motion in Ankylosing Spondylitis ?
Schober's test
46
What type of respiratory dysfunction is associated with Ankylosing Spondylitis ?
Restrictive defect
47
What planar complication is associated with Ankylosing Spondylitis ?
Enthesitis (heel, plantar)
Tenderness at tendon insertion sites e.g., Achilles tendon and plantar fascia
48
What are the extra-articular complications associated with Ankylosing Spondylitis ?
* Apical fibrosis – detected on CXR.
* Anterior uveitis
* Aortic regurgitation and AV node block
* Achilles tenonitis
* Amyloidosis
* Peripheral arthritis
* Cauda equina syndrome
49
Which is the most useful investigation in patients with suspected Ankylosing spondylitis?
Plain X-ray of sacroiliac joins to assess for sacroillitis
50
What is a late and uncommon radiograph finding in Ankylosing spondylitis?
Bamboo spine
51
Which investigation is indicated to assess for respiratory complications in Ankylosing Spondylitis?
Spirometry
52
What is the first line management for Ankylosing spondylitis?
NSAIDs (lowest effective dose)
53
When are DMARDs indicated for ankylosing spondylitis?
For peripheral joint involvement
54
Which haplotype associated with psoriatic arthritis?
HLA-B27
55
What deformity is associated with psoriatic arthritis?
Mutilans - telescoping fingers
56
What is the characteristic radiograph finding observed in psoriatic arrthritis?
Pencil in cup deformity
57
What is the immediate management for suspected psoriatic arthritis?
Urgent referral to the rheumatologist - prescribe NSAIDs at the lowest effective dose
58
What is used to manage acute flares of psoriatic arthritis?
Steroids e.g., prednisolone
59
Which monoclonal antibodies are indicated for the management of psoriatic arthritis?
Ustekinumab and secukinumab (targets IL-17)
60
What is the triad of symptoms associated with reactive arthritis?
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.
61
What are the commonest causes of reactive arthritis?
: 1-4 weeks following an enteric infection (e.g., Campylobacter, Salmonella, Shigella, Yersinia), a venereal infection (e.g., chlamydia) or a streptococcal sore throat.
62
What investigations are indicated for reactive arthritis?
* Bloods:
- CRP/ESR – raised
- WCC – raised
- Antibody testing – negative
* Joint aspiration – negative for crystals and bacteria.
63
What is the first line management for reactive arthritis?
NSAIDs, intra-articular steroids
64
Which autoantibodies are associated with Sjogren's syndrome?
Anti-Ro and Anti-La
65
What are the characteristic features associated with Sjogren's syndrome?
Dry mouth and dry eyes
66
Which sex is most affected in Sjogren's syndrome?
Female:male predominance (9:1)
67
Which test is used to assess for wetting in Sjogren's disease?
Schirmer's test (,5 mm wetting per minute)
68
What is the serology testing in patients with Sjogren's syndrome?
Anti-Ro and Anti-La
ANA
RF
69
What is the first line conservative management for Sjogren's syndrome?
Artificial tears
Saliva substitute
Mouth Rinse
Pilocarpine
70
Which auto-antibody is associated with polymyositis?
Anti-Jo-1
71
What is the main clinical presentation of polymyositis?
Symmetric involvement of proximal girdle muscles (shoulder and pelvic muscles)
72
What respiratory complication is associated with polymyositis?
Interstitial lung disease
73
Which blood tests are raised in polymyositis?
Creatine kinase
ESR
LDH
74
What is the diagnostic investigation for polymyositis?
EMG-guided biopsy
75
What screen should be performed in polymyositis?
Malignancy screen - tumour markers, CXR, mammography
76
What is the first line management for polymyositis?
High-dose oral steroids
77
What is indicated for the management of refractory polymyositis?
IV IG
78
Which viruses can precipitated dermatomyositis?
Coxsackie B virus, parvovirus, and enterovirus
79
Which drugs can worsen dermatomyositis?
hydroxyurea, cyclophosphamide, penicillin, sulphonamides and NSAIDs
80
Which two skin manifestations are associated with dermatomyositis?
Heliotrope rash
Gottron's papules
81
Which blood markers are raised in dermatomyositis?
ESR and serum CK levels
82
Which investigations are used to diagnose dermatomyositis?
EMG-guided biopsy
83
What is the most common composition of gout?
Monosodium urate crystal
84
Which drugs can precipitate gout?
Thiazide diuretics, low dose salicylates, ACEi and beta-blockers
85
What are the risk factors for gout?
Tumour lysis syndrome
Obesity
Alcohol excess
86
Which joint is most affected by gout?
1st MTP joint
87
What are the features of chronic tophaceous gout?
Polyarticular arthritis
Tophi deposits in ear lobes, fingers and elbows
Urate kidney stones
88
What is the first line investigation for gout?
Serum urate
89
What is the definitive investigation for gout?
Joint aspiration and polarised microscopy
90
Needle-shaped crystals with strong negative birefringence is associated with what?
Gout
91
What is the first line management of an acute gout flare?
NSAIDs
Colchicine
92
When should a follow-up appointment be scheduled for gout?
4-6 weeks following gout flare
93
What is the prophylactic management for gout?
Allopurinol
94
What is the mechanism of action for allopurinol?
Xanthine oxidase inhibitor
95
What is the alternative drug to allopurinol for urate-lowering therapy in gout?
Febuxostat
96
Which drug increases urate excretion in gout management?
Probenecid
97
Which drugs should be avoided in patients with gout?
Azathioprine
98
What is the crystal composition for pseudogout?
Calcium pyrophosphate dehydrate crystals
99
What is the radiological finding observed in pseudogout?
Chondrocalcinosis
100
What are the risk factors associated with pseudogout?
* Hyperparathyroidism
* Hypophosphatemia, hypomagnesaemia
* Metabolic – DM, hypothyroid
* Wilson’s disease
* Haemochromatosis
101
Which joints are affected by pseudogout?
Knees, hips and shoulders
102
What are the polarised light microscopy findings in pseudogout?
Positively birefringent rhomboid shaped
103
What is the medical management for pseudogout?
NSAIDs or intra-articular steroids
104
What i the inheritance pattern to Marfan's syndrome?
Autosomal dominant
105
Which gene is affected in Marfan Syndrome?
FBN1
106
Which aortic complication is associated with Marfan syndrome?
Aortic root dilation
107
Which annual screening investigation is indicated in patients with Marfan syndrome?
Echocardiography
108
What lifestyle advice is provided to patients with Marfan Syndrome?
Avoid intense exercise and contact sports
109
What is the prophylactic medical management in Marfan syndrome?
Beta-blockers
110
Which disorder is associated with pulseless disease with unequal blood pressures in the upper limbs?
Takayasu’s Arteritis
111
Which artery is most commonly affected in Takayasu Arteritis?
Subclavian arteries
112
What is the clinical presentation of Takayasu Arteritis?
* 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
What are the CT angiography findings associated with Takayasu arteritis?
Segmental narrowing
114
What is the first-line management for Takayasu arteritis?
Steroids
115
What is the prophylactic drug indicated in Takayasu’s Arteritis ?
Aspirin
116
Which virus is associated with polyarteritis nodosa?
Hepatitis B
117
Which type of vasculitis is associated with livedo reticularis?
Polyarteritis Nodosa
118
Intestinal angina and testicular pain is associated with which type of vasculitis?
Polyarteritis Nodosa
119
What are the angiography findings associated with Polyarteritis Nodosa ?
Strings of pearl/rosary bead appearance
120
Saddle nose deformity, sinusitis and pulmonary haemorrhage is associated with which type of vasculitis?
Granulomatosis with Polyangiitis (Wegener’)
121
What auto-antibody is raised in Granulomatosis with Polyangiitis (Wegener’)?
c-ANCA
122
What is the target of c-ANCA?
Proteinase-3
123
What is the 1st line management for inducing remission in patients with Granulomatosis with Polyangiitis (Wegener’)?
Corticosteroids and DMARDs
124
Which drug is indicated for inducing remission in severe Granulomatosis with Polyangiitis (Wegener’)?
Cyclophosphamide
125
Which autoantibody is raised in microscopic polyangiitis?
pANCA
126
What syndrome is associated with microscopic polyangiitis?
* Pulmonary Renal Syndrome:
- Pulmonary haemorrhage – diffuse alveolar haemorrhage.
- Renal – Rapidly progressive glomerulonephritis
127
What is the clinical presentation associated with Eosinophilic Granulomatosis with polyangiitis?
Asthma
Eosinophilia
Myocarditis
128
Which autoantibody is raised in Eosinophilic Granulomatosis with polyangiitis?
pANCA
129
What is the target for pANCA?
Myeloperoxidase
130
Which investigations are indicated for monitoring in HSP?
Blood pressure and urinalysis
131
Which haplotype is associated with Behcet's disease?
HLA-B51
132
What is the characteristic clinical manifestations of Behcet's disease?
Recurrent and painful mucocutaneous ulcers
Anterior uveiits
133
Which test is indicated in Behcet's disease?
Pathergy test
134
What is the first line management for Behcet's disease?
Topical corticosteroid for oral and genital ulcers
135
Which autoantibody is associated with limited scleroderma?
Anti-centromere
136
What constellation of symptoms are associated with limited scleroderma?
* Calcinosis (calcium deposit on tip of thumb)
* Raynaud’s phenomenon (white blue red)
* Oesophageal dysmotility
* Sclerodactyly
* Telangiectasia
137
What drug is indicated for the management of Raynaud's?
Nifedipine
138
Which autoantibody is associated with diffuse scleroderma?
Anti-Scl70 antibody
139
Which vasculitic disease is associated male smokers with a heavy smoking history?
Berger's disease
140
What contrast angiography finding is characteristic of Berger's disease?
Corkscrew appearance
141
Which auto-antibody is most sensitive regarding SLE?
ANA
142
Which is the mot specific autoantibody associated with SLE?
Anti-dsDNA
143
What markers are low during active SLE?
C3 and C4
144
What is the first line management for SLE?
Hydroxychloroquine
145
Which monitoring is required for hydroxychloroquine?
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
What T-score is consistent with osteoporosis?
<-2.5
147
What scan is used to assess fracture risk?
DEXA scan
148
What are the indications for offering a DXA scan in patients?
>50 years + fragility fracture history
<40 years + major risk factor for fragility fracture
149
What does the QFracture/FRAX assess for?
The 10-year risk for developing a fracture
150
A Q fracture of >% indicates a DEXA scan?
>10%
151
What parameters are adjusted for in a Z-score?
Age, ethnicity, and Sex
152
What is the first line medical management for osteoporosis?
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
What is the mechanism of bisphosphonates?
Inhibits osteoclast activity
154
What are the upper gastrointestinal adverse effects associated with bisphosphonates?
Oesophageal reactions including oesophagitis and ulcers
155
What is the maximum period of time to take alendronic acid?
10 years
156
Maximum duration of risedronate therapy?
7 years
157
What is the main cause of osteomalacia?
Vitamin D deficiency
158
Which drugs cause osteomalacia?
anticonvulsants (e.g., carbamazepine, phenobarbital, and phenytoin), corticosteroids and antacids.
159
What type of gait is observed in osteomalacia?
Waddling gait
160
Diagnosis for the following:
* Bone profile: Calcium (LOW), phosphate (LOW), ALP (Raised), PTH (Raised).
* Serum 25-hydroxyvitamin D level – Low
Osteomalacia
161
What are the X-ray findings observed in osteomalacia?
oss of cortical bones, Looser’s zones (pseudofractures), cupped metaphysis in rickets
162
What is the first line management for osteomalacia?
1st line: Vitamin D3 supplements with an oral antiresorptive agent, maintenance therapy (800-2000 IU daily).
163
What is Paget's disease?
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
What marker is raised in Paget's disease?
Isolated raised ALP
165
A blade of grass lesions and 'cotton wool' skull pattern is associated with what disease?
Paget's disease
166
What is the management for Paget's disease?
* Zoledronic acid IV 5 mg
167
What is the first line management for Paget's disease?
Analgesia with NSAIDs and paracetamol.
168
How tender points are required for a diagnosis of fibromyalgia?
At least 11 of the 18 points
169
Minimum duration for fibromyalgia diagnosis?
3 months
170
What two factors are associated with the pathogenesis of cervical spondylosis?
Osteophyte formation
Facet joint arthropathy
171
Clumsiness in the hands, radicular pain and paraesthesia/weakness in the upper limbs is consistent with what diagnosis?
Cervical spondylosis
172
What is the gold-standard imaging for the diagnosis of cervical spondylosis?
MRI
173
What is the first-line imaging for cervical spondylosis?
X-ray
174
What is the first line medical management for cervical spondylosis?
Analgesia (NSAID)
Cervical collar
175
What is preserved in PMR?
Muscle strength
176
What is the classic presentation of PMR?
Bilateral shoulder and/or pelvic girdle pain
177
How long does stiffness persist for in PMR and when?
* Stiffness >45 minutes upon waking or periods of prolonged rest.
178
What disease is associated with PMR?
Giant Cell arteritis
179
What is the first line investigation for suspected PMR?
ESR (>40 mm/h)
180
What is the first line management for PMR?
Oral prednisolone (15 mg OD) - continue treatment for 3-4 weeks once remission is achieved
181
Joint deformity associated with a neuropathic joint is consistent with what diagnosis?
Charcot joint
182
Which rule is used to assess for cervical spine injury?
Canadian C-spine rule
183
What three high-risk features for cervical spine injury?
- 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
What is the first line management for cervical spine injury?
In-spine immobilisation
185
What is the first line pain relief for spinal injury?
IV morphine
186
What is a flail chest?
2 or more rib fractures along 3 consecutive ribs
187
What is the management for flail chest?
Invasive ventilation and surgical fixation
188
What is the first line pain management for rib fractures?
Analgesia
189
What is the 2nd line pain management for rib fractures?
Nerve blocks
190
What three screening questions should be asked during a GALS examination?
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?
