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General practice > Rheum > Flashcards

Rheum Flashcards

1
Q

What is ankylosing spondylitis(AS)

A

Inflammatory condition mainly affecting the spine that causes progressive stiffness and pain

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2
Q

Conditions associated with HLA B27 gene

A

Seronegative spondyloarthropathy to include reactive arthritis and psoriatic arthritis

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3
Q

Key joints affected in AS

A

Sacroiliac joints

Joints of the vertebral column

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4
Q

Presentation of AS

A

Gradual symptoms
Lower back pain and stiffness and sacroiliac pain
Worse with rest and improves with movement
Worse at night and in the morning

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5
Q

Key complication of AS

A

Vertebral fractures

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6
Q

Conditions associated with AS

A

Systemic symptoms such as weight loss and fatigue
Chest pain(costovertebral joints affected)
Ethesitis
Anaemia
Anterior uveitis
IBD

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7
Q

Test used to support diagnosis of AS

A

Schober’s test

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8
Q

IX for AS

A

CRP and ESR
HLA B27
Spine X-ray and sacrum
MRI

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9
Q

What might MRI of spine show in AS

A

Bone marrow oedema early in the disease

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10
Q

X-ray features of AS

A 
Squaring of vertebral bodies 
Subchondral sclerosis and erosions 
Syndesmophytes 
Joints/ligaments ossification 
Fusion of facet, sacroiliac and costovertebral joints
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11
Q

Mx of AS

A

NSAIDs
Steroids for flares
Anti-TNF meds(etanercept)
Monoclonal antibodies

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12
Q

General mx of AS outside NSAIDs and steroids

A 
Physio 
Exercise 
Smoking cessation 
Bisphosphonates 
Treatment of complications 
Surgery occasionally
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13
Q

What is rheumatoid arthritis(RA)?

A

Rheumatoid arthritis is an autoimmune condition that causes chronic inflammation of the synovial lining of the joints, tendon sheaths and bursa

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14
Q

RA genetic associations

A

HLA DR4

HLA DR1

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15
Q

Antibodies present in RA

A

Rheumatoid factor

Anti-ccp(sensitive to RA)

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16
Q

Presentation of RA

A

Symmetrical distal polyarthropathy

Pain 
Swelling 
Stiffness 
Fatigue 
Weight loss
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17
Q

Joints affected by RA

A

MCP and PIP joints in the hands

Can also present with larger joints affected such as the knees, shoulders and elbows.

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18
Q

What is palindromic rheumatism

A

involves self limiting short episodes of inflammatory arthritis with joint pain, stiffness and swelling typically affecting only a few joints.
The episodes only last 1-2 days and then completely resolve

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19
Q

What is atlantoaxial subluxation

A

The axis (C2) and the odontoid peg shift within the atlas (C1). This is caused by local synovitis and damage to the ligaments and bursa around the odontoid peg of the axis and the atlas.

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20
Q

What can atlantoaxial subluxation lead to

A

SCC

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21
Q

Signs of RA in the arthritis

A

Z shaped deformity to the thumb
Swan neck deformity (hyperextended PIP with flexed DIP)

Boutonnieres deformity (hyperextended DIP with flexed PIP)
Ulnar deviation of the fingers at the knuckle (MCP joints)
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22
Q

What is boutonnieres deformity due to

A

Is due to a tear in the central slip of the extensor components of the fingers

In RA

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23
Q

Extra-articular manifestations of RA

A 
Pulmonary fibrosis 
Bronchiolitis obliterans 
Felty's syndrome 
Secondary sjogren's syndrome 
Anaemia of chronic disease
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24
Q

Wrist syndrome associated with RA

A

Carpel tunnel syndrome

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25
Q

Eye manifestations of RA

A

Episcleritis and scleritis

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26
Q

IX in RA

A

Rf
anti-CCP
CRP and ESR
X-rays

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27
Q

X-ray changes in RA

A

Joint destruction and deformity
Soft tissue swelling
Periarticular osteopenia
Boney erosions

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28
Q

Scoring system used to assess RA

A

DAS28 - swollen joints, tender joints, ESR/CRP result

Useful in monitoring disease activity and response to treatment

Also HAQ questionnaire to assess response to treatment

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29
Q

Factors causing worse prognosis in RA

A 
Younger onset
Male
More joints and organs affected
Presence of RF and anti-CCP
Erosions seen on xray
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30
Q

Mx of RA

A

Steroids

NSAIDs/COX-2 inhibitors

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31
Q

NICE advice for DMARDs in RA

A

1st - Methotrexate, leflunomide or sulfasalazine

2nd - 2 of above in combo

3rd - Addition of TNF inhibitor(adalimumab)

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32
Q

What is co-prescribed with methotrexate

A

Folic acid 5mg

33
Q

Notable side effects of methotrexate

A 
Mouth ulcers and mucositis 
Liver toxicity 
Pulmonary fibrosis 
Bone marrow suppression and leukopenia 
Teratogenic
34
Q

Notable side effects of leflunomide

A

Peripheral neuropathy
Teratogenic
HTN

35
Q

Notable side effects of sulfasalazine

A

Temporary male infertility (reduced sperm count)

Bone marrow suppression

36
Q

Notable side effects of anti-TNF drugs

A

Vulnerability to severe infections and sepsis

Reactivation of TB and hepatitis B

37
Q

Notable side effects of hydroxychloroquine

A

Nightmares and reduced visual acuity

38
Q

Notable side effects of rituximab

A

Night sweats and thrombocytopenia

39
Q

What type of hypersensitivity reaction is SLE

A

Type 3 hypersensitivity reaction

40
Q

Most common disease course in SLE

A

It often takes a relapsing-remitting course, with flares and periods where symptoms are improved.

41
Q

SLE presentation

A 
Fatigue 
Weight loss 
Arthralgia 
Myalgia 
SOB
Raynaud's phenomenon 
Mouth ulcers
42
Q

Type of rash associated with SLE

A

Photosensitive malar rash. This is a “butterfly” shaped rash across the nose and cheek bones that gets worse with sunlight.

43
Q

IX in SLE

A 
Autoantibodies 
FBC(normocytic anaemia) 
CRP and ESR 
Immunoglobulins 
Urinalysis and urine protein-creatinine ratio
44
Q

Autoantibodies present in SLE

A

Anti-nuclear antibodies(ANA)

Anti-double stranded DNA(anti-dsDNA) - specific

45
Q

Criteria for diagnosis of SLE

A

SLICC Criteria or the ACR Criteria for establishing a diagnosis

involves confirming the presence of antinuclear antibodies and establishing a certain number of clinical features suggestive of SLE

46
Q

CVS complications of SLE

A

Cardiovascular disease - HTN, CAD

Pericarditis

47
Q

Complications of SLE

A 
Infection 
Anaemia of chronic disease 
Interstitial lung disease 
Lupus nephritis 
Recurrent miscarriage 
VTE
48
Q

1st line treatments for SLE

A

NSAIDs
Steroids (prednisolone)
Hydroxychloroquine (first line for mild SLE)
Suncream and sun avoidance for the photosensitive the malar rash

49
Q

Options for SLE mx if first line haven’t worked

A

Rituximab is a monoclonal antibody that targets the CD20 protein on the surface of B cells

Belimumab is a monoclonal antibody that targets B-cell activating factor

50
Q

Most common causes of drug-induced lupus

A

Procainamide

Hydralazine

51
Q

Adverse effects of hydroxycholroquine

A

Bull’s eye retinopathy

52
Q

Crystals present in pseudo gout

A

Crystal arthropathy caused by calcium pyrophosphate crystals - AKA chonedrocalcinosis

53
Q

Presentation of pseudogout

A

Hot swollen stiff painful joint - knee, shoulders, wrists and hips

Can affect multiple joints

Can be asymptomatic

54
Q

What does aspirated fluid show in CPPD

A

No bacterial growth
Calcium pyrophosphate crystals
Rhomboid shaped crystals
Positive birefringent of polarised light

55
Q

How does pseudo gout appear on x-ray

A

Chondrocalcinosis - It appears as a thin white line in the middle of the joint space caused by the calcium deposition

Also LOSS

L – Loss of joint space
O – Osteophytes
S – Subarticular sclerosis
S – Subchondral cysts

56
Q

Mx of CPPD

A 
NSAIDs
Colchicine
Joint aspiration
Steroid injections
Oral steroids

Joint washout(arthrocentesis) in severe cases

57
Q

What is discoid lupus

A

Discoid lupus erythematosus is a non-cancerous chronic skin condition.

It is more common in women and usually presents in young adults between ages 20 to 40.

58
Q

Populations in which discoid lupus is more likely

A

It is more common in darker-skinned patients and smokers.

59
Q

What is discoid lupus associated with

A

It is associated with an increased risk of developing systemic lupus erythematosus, however this risk is still below 5%.

Rarely the lesions can progress to squamous cell carcinoma (SCC) of the skin.

60
Q

Presentation of discoid lupus

A

The lesions typically occur on the face, ears and scalp. They are photosensitive, meaning that they are made worse by exposure to sunlight.

They are associated with scarring alopecia (hair loss in affected areas that does not grow back) and hyper-pigmented or hypo-pigmented scars.

61
Q

Appearance of discoid lupus

A 
Inflamed
Dry
Erythematous
Patchy
Crusty and scaling
62
Q

Diagnosis of discoid lupus

A

Skin biopsy to confirm diagnosis

63
Q

Mx of discoid lupus

A

Sun protection
Topical steroids
Intralesional steroid injections
Hydroxychloroquine

64
Q

Patterns of psoriatic arthritis

A

Symmetrical polyarthritis
Asymmetrical pauciarthritis
Spondylitic pattern

65
Q

Signs of psoriatic arthritis

A

Plaques of psoriasis on the skin
Pitting of the nails
Onycholysis (separation of the nail from the nail bed)
Dactylitis (inflammation of the full finger)
Enthesitis

66
Q

Psoriatic arthritis associations

A 
Eye disease (conjunctivitis and anterior uveitis)
Aortitis (inflammation of the aorta)
Amyloidosis
67
Q

Screening tool for psoriatic arthritis

A

PEST tool - high score –> rheum referral

68
Q

xray changes in psoriatic arthritis x-rays

A 
Periostitis 
Anklyosis 
Osteolysis 
Dactylitis 
Pencil-in-cup appearance
69
Q

What is arthritis mutilans

A

most severe form of psoriatic arthritis. This occurs in the phalanxes. There is osteolysis (destruction) of the bones around the joints in the digits. This leads to progressive shortening of the digit. The skin then folds as the digit shortens giving an appearance that is often called a “telescopic finger”.

70
Q

Mx of arthritis arthritis mutilans

A

NSAIDs for pain
DMARDS (methotrexate, leflunomide or sulfasalazine)
Anti-TNF medications (etanercept, infliximab or adalimumab)
Ustekinumab is last line (after anti-TNF medications) and is a monoclonal antibody that targets interleukin 12 and 23

71
Q

Most common cause of reactive arthritis

A

Chalmydia

Gonorrhea commonly causes gonococcal septic arthritis

72
Q

Reactive arthritis associations

A

Bilateral conjunctivitis (non-infective)
Anterior uveitis
Circinate balanitis is dermatitis of the head of the penis

Can’t see, pee or climb a tree

73
Q

Mx of reactive arthritis

A

NSAIDs
Steroid injections into the affected joints
Systemic steroids may be required, particularly where multiple joints are affected

DMARDs or anti-TNF meds for recurrent cases

74
Q

Auto-antibodies present in systemic sclerosis

A

ANA
Anti-centromere in limited cutaneous systemic sclerosis

Anti-scl-70 antibodies in diffuse cutaneous systemic sclerosis

75
Q

Specific examination technique for systemic sclerosis

A

Nailfold capillaroscopy

76
Q

Mx of systemic sclerosis

A

MDT
Steroids
Immunosuppressants

77
Q

Non-med mx of systemic sclerosis

A

Avoid smoking
Gentle skin stretching to maintain the range of motion
Regular emollients
Avoiding cold triggers for Raynaud’s
Physiotherapy to maintain healthy joints
Occupational therapy for adaptations to daily living to cope with limitations

78
Q

Medical mx of systemic sclerosis

A

Nifedipine can be used to treat symptoms of Raynaud’s phenomenon
Anti acid medications (e.g. PPIs) and pro-motility medications (e.g. metoclopramide) for gastrointestinal symptoms
Analgesia
Antibiotics
Antihypertensives
Treatment of pulmonary artery hypertension
Supportive management of pulmonary fibrosis

General practice (26 decks)

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