MSK/Rheumatology Flashcards
1
Q
blood test for rheumatoid arthritis?
A
Anti CCP (most sensitive), rheumatoid factor, raised ESR/CRP
2
Q
Management of RA
A
Ibuprofen/NSAIDs
Steroids
Methotrexate (DMARDs)
Rituximab (biologics)
3
Q
Gout
A
intra-articular build up of monosodium urate crystals, associated with hyperuricaemia
4
Q
Gout presentation
A
1st metatarsal and distal interphalangeal joints often inflamed, formation of tophi (lumps of urate salt)
5
Q
Management of gout
A
Lifestyle changes (e.g. eat less red meat), NSAIDs (colchicine), allopurinol (xanthine oxidase inhibitor)
6
Q
Investigations for gout
A
Joint aspiration and polarised light microscopy (needle live negatively birefringent crystals), increased uric acid levels on blood test
7
Q
Pseudogout
A
Calcium pyrophosphate crystals inducing damage to joints
8
Q
Risk factors for pseudogout
A
older females, hyperthyroidism, hyperparathyroidsism
9
Q
presentation of pseudogout
A
hot, swollen, tender joint, often knees
10
Q
Ix for pseudogout?
A
joint aspiration and polarised light microscopy (rhomboid positive birefringent crystals)
11
Q
Mx of pseudogout
A
NSAIDs (colchicine)
12
Q
SLE
A
aNA and aDsDNA antibodies attack soft tissue causing widespread inflammation and damage
13
Q
SLE risk factors
A
young, black, women
14
Q
Presentation of SLE?
A
butterfly rash, weight loss, fever, fatigue, joint pain, mouth ulcers, correctable ulnar deviation
15
Q
Ix for SLE?
A
Bloods - raised ESR, normal CRP, ANA and aDsDNA antibodies present
16
Q
Management of SLE?
A
Ibuprofen, cyclophosphamide, hydroxychloroquine, prednisolone, methotrexate
17
Q
Complications of SLE?
A
cardiac, lung and kidney involvement, widespread inflammation causing damage
18
Q
Inflammation of the kidneys due to SLE?
A
lupus nephritis
19
Q
What is fibromyalgia
A
unknown aetiology, hyperaesthesia (exaggerated perception of pain), allodynia (pain in response to non-painful stimuli)
20
Q
Ix of fibromyalgia
A
11/18 tender points for > 6 months, other investigations to exclude other diseases
21
Q
Mx for fibromyalgia
A
Education of patient and family, TCA (amitriptyline), analgesia, exercise, CBT
22
Q
Symptoms of fibromyalgia
A
Widespread chronic pain, chronic fatigue, memory problems, non-restorative sleep, morning stiffness
23
Q
Risk factors for gout
A
FHx, high alcohol intake, purine rich food, excess fructose intake, drugs (e.g. low dose aspirin)
24
Q
Food group that can help to reduce gout?
A
Dairy
25
Sjogren's syndrome
autoimmune syndrome that affects exocrine glands (e.g. salivary, lacrimal)
26
Presentation of Sjogren's syndrome
Dry mucous membranes i.e. dry mouth, dry eyes, dry vagina
27
Ix for Sjogren's syndrome
Presence of anti-Ro and anti-La antibodies, Schirmer test (tears travelling <10mm)
28
Risk factors for Sjogren's syndrome
Fx, female, >40
29
Managment of Sjogren's syndrome?
Artificial tears and saliva, vaginal lubricants, hydroxychloroquine to halt progression
30
Giant cell arteritis (GCA) pathophysiology
affects aorta and/or its major branches (carotid/vertebral arteries), temporal artery often involved (hence aka temporal arteritis)
31
Risk factors for giant cell arteritis (GCA)
>50, female, Hx of polymyalgia rheumatica
32
Presentation of giant cell arteritis (GCA)
New onset of headache, scalp tenderness (hurts brushing hair), jaw claudication, visual disturbances
33
Ix for giant cell arteritis (GCA)
Raised ESR and/or CRP, temporal artery biopsy (gold standard for diagnosis) shows giant cells and granulomatous inflammation
34
Mx for giant cell arteritis (GCA)
High dose glucocorticoids ASAP (e.g. prednisolone)
35
Presentation of Takayasu's arteritis
'pulseless disease', arm claudication, syncope
36
Mx for Takayasu's arteritis
steroids
37
Treatment for Takayasu's arteritis
Angiography = gold standard, elevated ESR and CRP, granulomatous inflammation on histology
38
Polyarteritis nodosa is associated with...
Hepatitis B
39
Polyarteritis nodosa is associated with which infection?
Hepatitis B
40
Presentation of polyarteritis nodosa
peripheral neuropathy, HTN, livedo reticularis, unilateral orchitis, generalised abdominal pain
41
Ix for polyarteritis nodosa
Raised ESR/CRP, HBsAg, biopsy
42
Mx for polyarteritis nodosa
If hep B +'ve - antiviral agent, plasma exchange and corticosteroids
If hep B -'ve - corticosteroids
43
Kawasaki disease risk factors
children, males, Japanese
44
Presentation of Kawasaki disease (CREM)
```
C - conjunctivitis
R - rash
E - erythema of hands and feet
M - mucous membrane changes (strawberry tongue)
+ fever
```
45
Kawasaki disease
arteritis associated with mucocutaneous lymph nodes
46
EGPA
eosinophilic granulomatosis with polyangiitis - small and medium vasculitis, most associated with lung and skin problems
47
Henoch-Schonlein purpura
IgA vasculitis, due to IgA deposits in the blood vessels of affected organs such as skin, kidneys, GI tract
48
Presentation of Henoch-Schonlein purpura
Symmetrical purpuric rash affecting lower limbs or buttocks in children, joint pain, abdominal pain, renal involvement
49
Granulomatosis with polyangiitis
Small vessel vasculitis, affects respiratory tracts and kidney
50
Granulomatosis with polyangiitis presentation
SADDLE-SHAPED NOSE, epistaxis, crusty nasal/ear secretions, sinusitis, cough, wheeze, haemoptysis
51
Ix for granulomatosis with polyangiitis
High eosinophils on FBC, presence of c-ANCA
52
Marfan syndrome
Autosomal dominant condition, affects gene involved in creating fibrillin
53
Presentation of Marfan syndrome
Tall, long limbs and fingers, hypermobility, high arch palate
54
Mx of Marfan syndrome
Lifestyle changes - avoid intense exercise and caffeine, beta blockers and ARBs, annual echocardiogram
55
Complications of Marfan syndrome
Mitral/aortic valve prolapse, aortic aneurysms, lens dislocation, pneumothorax
56
Risk factors for Marfan syndrome?
FHx
57
Ehlers-Danlos syndrome
Rare disease, group of inherited connective tissue disorders, caused by faulty collagen
58
Presenation of Ehlers-Danlos syndrome
(varies but typically) joint hypermobility, easily stretched skin, easy bruising, chronic joint pain, re-occurring dislocation
59
Mx for Ehlers-Danlos syndrome
Physiotherapy, psychological support
60
Complications of Ehlers-Danlos syndrome
Prone to hernias, prolapse, aortic root dilation, joint pain, abnormal wound healing
61
Antiphospholipid syndrome
associated with antiphospholipid antibodies where blood becomes prone to clotting (hypercoagulable state), occurs on its own or secondary to an autoimmune disorder (especially SLE)
62
presentation for antiphospholipid syndrome
thrombosis, recurrent miscarriages, livedo reticularis, thrombocytopenia
63
Mx for antiphospholipid syndrome
long-term warfarin, pregnant women (LMWH and aspirin)
64
Presentation of SLE?
malar rash, fatigue, fever, weight loss, oral ulcers, myalgia, Raynaud's, lymphadenopathy
65
Investigations for SLE?
ANA, anti-dsDNA, FBC (anaemia, raised CRP/ESR)
66
Treatment for SLE?
Hydroxychloroquine, NSAIDs, steroids (prednisolone), lifestyle (sun protection, exercise)
67
Antiphospholipid syndrome
Autoimmune disease, body produces antiphospholipid antibodies (aPL) to phospholipid-binding plasma proteins --> hypercoagulable state --> venous and arterial thromboses
Leads to recurrent thrombosis (DVT, PE, stoke, MI), frequency miscarriages, arthralgia
68
Mx for APL syndrome?
warfarin (LMWH and aspirin in pregnancy)
69
Pathophysiology of Sjogren's syndrome
lymphocytic infiltration into lacrimal and salivary glands (--> dry eyes and mouth)
70
Secondary Sjogren's?
secondary to SLE, systemic sclerosis, RA
71
Ix for Sjogren's?
Schirmer's test - see how far tears travel
72
Polymyositis/dermatomyositis
Chronic inflammation of muscles and skin (autoimmune)
73
Pathophysiology of polymyositis/dermatomyositis
Endothelium of endomysial capillaries targeted by antigens --> perifascicular atrophy, capillary loss, B cell infiltration, destruction of muscle fibres
74
Presentation of polymyositis/dermatomyositis
Slow onset proximal muscle weakness, fatigue, weight loss
Dermatomyotisis only - Gottron's papules, photosensitive erythematous rash
75
Ix for polymyositis/dermatomyositis
Increase serum creatinine kinase (enzyme found in muscle cells), muscle biopsy
76
Tx for polymyositis/dermatomyositis
Steroids (prednisolone), sun protection, IV immunoglobulins (severe disease)
77
Systemic sclerosis (scleroderma)
Multisystem autoimmune disease characterised by vascular damage and fibrosis
78
Pathophysiology of scleroderma
Increased fibroblast activity, abnormal growth of connective tissue, excessive collagen production and deposition
79
Presentation of scleroderma?
Skin thickening, sclerodactyly, Raynaud's, GORD, pulmonary HTN
80
Pathophysiology - Marfan's syndrome
Mutations in fibrillin-1 gene --> production of abnormal fibrillin protein --> connective tissue abnormalities
81
Presentation of Marfan's (MARFANS)
Mitral valve prolapse, aortic dissection, retinal detachment, fibrillin-1 mutation, arachnodactyly, near-sightedness, scoliosis
82
Treatment for Marfan's
Beta-blockers, surgical interventions
83
Enhlers-Danlos syndromes
Group of connective tissue disorders - due to a genetic mutation, production of faulty connective tissue proteins (e.g. collagen)
84
Presentation of EDS?
skin elasticity/fragility, hypermobility, fatigue, easy bruising, striae
85
Which type of joints does osteoarthritis always affect?
synovial, weight-bearing joints are most commonly involved (hips, knee, cervical, lumbar spine)
86
How is the joint affected in osteoarthritis?
'Wear and tear', cartilage worn down, subchondral bone and ligaments also
87
Pathophysiology of OA - 2 part process
1. hyaline cartilage degradation
| 2. abnormal chondrocyte homeostasis
88
OA pathophysiology
1. Chondrocytes lose ability to generate and repair cartilage
2. Chondrocytes overexpress proteases and cytokines, cytokines induce inflammation and cartilage breakdown
3. Exposure of underlying subchondral bone results in sclerosis --> reduced joint space
89
OA risk factors
Obesity, genetic predisposition, female, occupation, trauma
90
OA presentation
Joint pain (movement of bone on bone), deep dull ache that is relieved with rest and worsened on activity, morning stiffness lasting <30 minutes, limited mobility, no systemic symptoms, weight bearing joints affected (hips, knees, spine, hands
91
How are the hands commonly affected in OA? (think HOB)
Herberden's nodes, Bouchard's nodes
92
Ix for OA?
X-ray, normal bloods
93
Mx for OA?
Weight loss, avoid physical activity, paracetamol (1st line), intra-articular corticosteroid injections, surgical joint replacement
94
Risk factors for RA?
Genetic predisposition (HLA-DR4), female, smoking, FHx
95
Pathophysiology of RA
Complex autoimmune attack against synovium of joint (synovitis), this synovium thickens and grows out of the surface of the cartilage (forming a Pannus). Pannus destroys the articular cartilage and subchondral bone (bone erosion). Antibodies incite this inflammation
96
RA presentation
SYMMETRICAL joint pain and swelling (also at rest), morning stiffness >30 mins that improves upon activity, joint deformities (Swan neck, Boutonniere, ulnar deviation)
97
Which joints does RA commonly affect?
MCP joints (toes), PIP joints, wrist, knee
98
Joint deformities often seen in RA?
Swan neck, Boutonniere, ulnar deviation
99
SPINEACHE - presentation of spondylarthropathies
sausage digit, psoriasis, inflammatory back pain, NSAID good response), enthesitis, arthritis, Crohn's/colitis, HLA-B27, eyes (uveitis)
100
Diagnosis of RA
FBC - ESR, CRP raised
Serum antibodies - RF, anti-citrullinated peptide antibodies (most sensitive)
X-rays - show soft tissue swelling and joint narrowings
Sterile synovial fluid with high neutrophil count
101
DMARDs used in RA
sulfasalanzine - 1st line for most
| methotrexate - in more advanced disease (CI in pregnancy)
102
Presentation of septic arthritis
Medical emergency, acute onset, most commonly in knee, hot, red, swollen, painful joint, fever
103
Diagnosis of septic arthritis
Joint aspiration - purulent synovial fluid, very high WCC
| Elevated ESR/CRP
104
Septic arthritis - treatment
antibiotics (flucloxacillin, fusidic acid)
105
Crystals in gout?
monosodium urate crystals, needle shaped negatively birefringent
106
Pseudogout crystals?
calcium pyrophosphate crystals, rhomboid shaped positively birefringent
107
pathophysiology of gout?
purines metabolised into hypoxanthine --> xanthine --> uric acid by xanthine oxidase enzymes. Build up of uric acid --> monosodium urate crystals
Intra-articular deposition of crystals, neutrophils detect as abnormal --> inflammatory response
108
Gout presentation
Sudden onset pain, swelling and redness of 1st MTP (big toe)
Pain, erythema, swelling, tenderness, warmth
109
Dx gout
joint aspiration and synovial fluid analysis - needle shaped negatively birefringent crystals, raised serum uric acid
110
Tx for gout
Lifestyle - reduce alcohol, red meat
NSAIDs
If NSAIDs CI --> Colchicine
Long-term management - allopurinol to reduce uric acid levels
111
Pseudogout risk factors
Age, DM, OA, joint trauma
112
Pseudogout presentation
Often incidental finding, commonly affects knees and wrists, painful attacks that last longer than gout
113
Diagnosis of pseudogout
Joint aspiration - positively birefringent rhomboid shaped crystals
114
Tx for pseudogout
NSAIDs, colchicine
115
Osteoporosis - SHATTERED
```
Steroid use
Hyperpara/thyroidism
Alcohol/smoking
Thin
Testosterone reduced
Early menopause
Renal/liver failure
Erosive bone disease
Dietary calcium low
```
116
Clinical presentation of osteoporosis
FRACTURES, typically occur at thoracic and lumbar vertebrae, proximal femur
117
Diagnosis of osteoporosis
DEXA scan
118
1st line medication for osteoporosis
Bisphosphonates - inhibit osteoclasts and increased bone mass at hip and spine sites
119
Pathophysiology of osteoporosis
increased bone breakdown by osteoclasts and decreased bone formation by osteoblasts
120
Spondyloarthropathies
Group of chronic inflammatory arthritic conditions that affect the vertebral column
121
Common spondyloarthropathies
Ankylosing spondylitis, psoriatic arthritis, reactive arthritis
122
Common features of spondyloarthropathies
Slow arthritis, sacroiliac joints affected, morning stiffness and pain - improves upon movement, enthesitis
123
Ankylosing spondylitis
Chronic inflammatory disease of the axial skeleton that leads to partial/complete fusion and rigidity of the spine
124
Gene association with spondyloarthropathies
HLA-B27
125
Presentation of ankylosing spondylitis
episodic inflammation of sacroiliac joints, pain in 1 or 2 buttocks, limited lumbar spine mobility, enthesitis, uveitis, progressive loss of spinal movement
126
ankylosing spondylitis diagnosis
imaging of lumbar spine and pelvis (joint fusion, etc.), elevated ESR due to inflammation, NO AUTOANTIBODIES
127
Tx for ankylosing spondylitis
exercises, NSAIDs at night, TNF-alpha blocking drugs
128
Reactive arthritis
asymmetric inflammatory oligoarthritis of lower extremities following infection
129
Causes of reactive arthritis
GI infections - salmonella, shigella
| STIs - urethritis
130
Presentation of reactive arthritis
Acute, asymmetrical, LOWER LIMB arthritis (days-->weeks after GI or GU infection), fatigue, malaise, weight loss, sacroilitis, conjunctivitis
131
Dx of reactive arthritis
Synovial fluid analysis (sterile - to rule out infection/crystals), raised ESR
132
Tx for reactive arthritis
NSAIDs and local corticosteroid injections
133
Psoriatic arthritis
inflammation of joints (mostly hands, feet spine) that may occur with psoriasis
134
Clinical presentation of psoriatic arthritis
oligoarthritis (asymmetric involvement of both distal and proximal IP joints), spinal involvement, psoriasis, sausage digit, nail pitting
135
Tx for psoriatic arthritis
Analgesia and NSAIDs
136
Methotrexate is CI in ?
pregnancy
137
Methotrexate can cause a drop in ?
WCC/ platelet count
138
Action of methotrexate
Inhibits the enzyme dihydrofolate reductase, essential for the synthesis of purines and pyrimidines
139
Which antibody is most specific to the suspected diagnosis of SLE?
Anti- ds DNA antibody
140
Mechanism of bisphosphonates?
Reduce bone turnover by inhibiting osteoclasts and promoting their apoptosis. Net effect is reduction in bone loss and improvements in bone mass
141
First line bisphosphonate for patients at risk of osteoporosis
Alendronate
142
Indications for bisphosphonates? (MOPS)
Myeloma (reduce pathological fractures
Osteoporosis
Paget's disease of bone to reduce bone turnover
Severe hypercalcaemia
143
Indications for calcium/vitamin D medication
Osteoporosis
CKD - prevent secondary hyperparathyroidism
Calcium to prevent severe hyperkalaemia (arrhythmias)
Osteomalacia
144
Example of xanthine oxidase inhibitor?
Allopurinol
145
Indications for xanthine oxidase inhibitors?
gout
146
Example of an anti-gout agent?
colchicine
147
What is osteoporosis?
systemic skeletal disease define as bone mineral density > 2.5 standard deviations below the young adult mean
148
Risk factors of osteoporosis? (SHATTERED)
```
Steroid use
Hyperparathyroidism/thyroidism
Alcohol/smoking
Thin
Testosterone reduced
Early menopause
Renal/liver failure
Erosive bone disease
Dietary Ca2+ low
```
149
Clinical presentation of osteoporosis
FRACTURES
150
Gold standard diagnosis for Osteoporosis
DEXA scan
151
First line Tx for osteoporosis
Bisphosphonates
152
Main pathological features of OA?
loss of cartilage, disordered bone repair (osteophytes)
153
Clinical presentation of OA?
affects many joints, mechanical pain, loss of movement, morning stiffness <30 mins, commonly affects 1st MTP, DIP joints, Herbeden's nodes and Bouchard's nodes
154
What to look for on XRs for OA?- LOSS
Loss of joint space
Osteophytes
Subarticular sclerosis
Subchondral cysts
155
Treatment for OA
Lifestyle changes
Physical aids
Analgesia - paracetamol, NSAIDs
156
Extra-articular manifestations of RA?
```
Systemic - fever, weight loss
Eyes - dry eyes, scleritis
Neurological - carpal tunnel, cord compression
Skin - subcutaneous nodules
Pulmonary - pleural effusion
```
157
Most sensitive test for RA?
Anti-CCP antibody
158
3 key clinical features of spondylarthropathies
1. axial inflammation
3. asymmetrical peripheral arthritis
3. strong association with HLA-B27
159
bacteria risk factor for ankylosing spondylitis
salmonella, shigella
160
Clinical presentation of reactive arthritis - can't see, can't wee, can't climb a tree
acute anterior uveitis
circinate balanitis (painless ulceration of the penis)
enthesitis
161
Most common cause of septic arthritis?
Staphylococcus aureus
162
Osteomyelitis
Bone marrow inflammation --> localised bone infection
163
Presentation of osteomyelitis?
Onset over several days, dull pain at site of infection, aggravated by movement, fever, rigors, malaise
164
5 B's - cancers that commonly metastasise to bone
Breast, brostate, bronchi, bhyroid, bidneys
165
Red flags for bone cancer
rest pain, night pain, lump, loss of function, weight loss
166
Test for APL syndrome?
Anticardiolipin test
167
Osteomalacia
Inadequate bone mineralisation (after the fusion of the epiphyeses
168
Causes of osteomalacia
Hyperparathyroidism, vitamin D deficiency, renal disease (inadequate conversion of active vit D), drug induced, liver disease
169
Presentation of osteomalacia
Muscle weakness - characteristic waddling gait, difficulty climbing stairs
Widespread bone pain
Fractures
170
Paget's disease of bone
focal disorder of bone remodelling, increased bone resorption, abnormal osteoclast activity, followed by increased rapid bone formation, forming more disorganised, weaker bone
171
What part of the skeleton is affected by Pagets disease of bone in particular?
Axial skeleton
172
Px of Paget's disease of bone
pain in bone/nearby joint, can be asymptomatic, deformities (skull enlargement, bowing of tibia)
173
osteomyelitis
inflammatory condition of bone caused by infecting organism, most commonly staph aureus
174
Presentation of osteomyelitis
limp/reluctance to weight-bear, pain at site of infection, fever, malaise, fatigue
175
Ix for osteomyelitis
FBC - raised WCC
Raised ESR and CRP
X-ray
Blood culture
176
Mx for osteomyelitis
Antibiotics, supportive care, surgery, debridement
177
Px of primary bone tumours
Bone pain worse at night, constant/intermittent, resistant to analgesia, bony/soft tissue swellings, pathological fractures
178
Ix for primary bone tumours
1st line - X-ray
Gold standard - biopsy
Bloods - FBC, ESR, ALP
179
Multiple myeloma
Neoplastic proliferation of bone marrow plasma cells, produce excess IgG and IgA
180
Px of multiple myeloma (OLD CRAB)
OLD age
Calcium elevated (think stones, bones, groans and moans)
Renal impairment
Anaemia
Bone lytic lesions (high suspicion if bone or back pain)
181
Diagnostic criteria for multiple myeloma
1. Monoclonal protein band in serum/urine
2. Raised plasma cells on BM biopsy
3. End organ damage (hypercalcaemia, renal failure)
4. Bone lesions on skeletal survey
182
Tx for multiple myeloma
```
Analgesia - bone pain
Bisphosphonates - reduce fractures
Local radiotherapy
Transfusion to correct anaemia
Fluids/dialysis - renal failure
```
183
Osteomalacia
Poor mineralisation lead ing to soft bones due to lack of Ca2+
184
Px of osteomalacia
Bone pain and tenderness, dull ache that is worse on weight-bearing, muscle weakness, fractures
185
Dx of osteomalacia
X-ray - loss of cortical bone
Bloods - low Ca2+ and PO43-
Bone biopsies - incomplete mineralisation
186
Mx for osteomalacia
Vitamin D supplements
187
Paget's disease of bone
Excessive bone turnover (formation and resorption) due to increased osteoclastic and blastic activity. Newly formed bone is weaker
188
Px of Paget's disease
bone pain, bone deformity, fractures
189
Mx for Paget's disease
Bisphosphonates, NSAIDs for pain, calcium and vit D supplements
190
Ix for Paget's disease
X-ray - bone enlargement and deformity, V-shaped defected in long bones
Bloods - raised ALP, normal calcium and phosphate
