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Rheum Flashcards

1
Q
  1. A 65 year old builder with gradual onset left hip pain worse with activity and late in the day ?
A
  • Osteoarthritis
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2
Q
  1. What X-ray findings would you see for osteoarthritis ?
A
  • LOSS
  • Loss of joint space
  • Osteophytes
  • Subchondral sclerosis
  • Subchondral cysts
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3
Q
  1. What are the names for the lumps on joints in osteoarthritis ?
A
  • Heberden’s nodes  DIP joints
  • Bouchard’s nodes  PIP joints
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4
Q
  1. What are non-medical options for osteoarthritis ?
A
  • Weight loss (if overweight)
  • Physiotherapy
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5
Q
  1. What are medical/surgical options for osteoarthritis ?
A
  • Analgesia
  • Intra-articular steroid injections
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6
Q
  1. Medical/Surgical options for OA
A
  • Analgesia – topical NSIADs 1st line 2nd line are oral NSIADs + PPO
  • Intra-articular steroid injections
  • Joint replacement surgery
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7
Q
  1. A 43 year old with symmetrical joint pain, swelling and stiffness in the hands, wrists and feet. Symptoms are worst in the morning ?
A
  • Rheumatoid arthritis
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8
Q
  1. What antibodies are associated with RA ?
A
  • Rheumatoid factor antibodies
  • Cyclic citrullinated peptide (CCP) antibodies
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9
Q
  1. What hand deformities are associated with RA ?
A
  • Z-shaped deformity (thumb)
  • Swan neck deformity
  • Boutonnieres deformity
  • Ulnar deviation at the MCP joints
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10
Q
  1. What is the investigation for synovitis ?
A
  • Ultrasound
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11
Q
  1. What scoring system is used for RA ?
A
  • DAS28
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12
Q
  1. What treatment options are available for RA ?
A
  • DMARDs
  • Methotrexate
  • Leflunomide
  • Sulfasalazine
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13
Q
  1. Which DMARDs are used in pregnancy ?
A
  • Hydroxychloroquine
  • Sulfasalazine (extra folic acid)
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14
Q
  1. What type of biological is used to treat RA ?
A
  • Infliximab  TNF inhibitor
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15
Q
  1. A 35 yo presents with asymmetrical pain and stiffness in the fingers and feet. There are skin and nail changes. What is the diagnosis ?
A
  • Psoriatic arthritis
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16
Q
  1. What nail changes occur with psoriatic arthritis ?
A
  • Nail pitting
  • Onycholysis – separation of the nail from the nailbed
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17
Q
  1. What is dactylitis ?
A
  • Inflammation of the entire digit in psoriatic arthritis
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18
Q
  1. What is the most severe form with osteolysis and telescoping of the digits ?
A
  • Arthritis mutilans
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19
Q
  1. What other conditions is psoriatic arthritis associated with ?
A
  • Uveitis
  • IBD
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20
Q
  1. Signs of psoriatic arthritis ?
A
  • Plaques of psoriasis on the skin
  • Nail pitting
  • Onycholysis - (separation of the nail from the nail bed)
  • Dactylitis - (inflammation of the entire finger)
  • Enthesitis - (inflammation of the entheses, which are the points of insertion of tendons into bone)
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21
Q
  1. What X-ray changes are seen for psoriatic arthritis ?
A
  • Periostitis (inflammation of the periosteum, causing a thickened and irregular outline of the bone)
  • Ankylosis (fixation or fusion of the bones at the joint)
  • Osteolysis (destruction of bone)
  • Dactylitis (inflammation of the whole digit, seen as soft tissue swelling)
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22
Q
  1. How is psoriatic arthritis managed ?
A
  • Depends on severity. Usually MDT led
  • NSAIDs
  • Steroids
  • DMARDs e.g. methotrexate
  • Anti-TNF medications (etanercept, infliximab or adalimumab)
  • Ustekinumab is a monoclonal antibody that targets interleukin 12 and 23
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23
Q
  1. A 42 yo presents with knee pain and swelling 2 weeks after having gastroenteritis. What is the most likely diagnosis ?
A
  • Reactive arthritis
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24
Q
  1. What is the classic triad of features of reactive arthritis ?
A
  • Arthritis
  • Conjunctivitis
  • Urethritis/balanitis
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25
Q
  1. What are the most common triggers of reactive arthritis ?
A
  • Gastroenteritis
  • Sexually transmitted infection (chlamydia)
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26
Q
  1. What gene is associated with reactive arthritis ?
A
  • HLA B27
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27
Q
  1. What is an important differential for reactive arthritis ?
A
  • Septic arthritis
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28
Q
  1. What investigations would you order to exclude other causes of reactive arthritis ?
A
  • Joint aspiration
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29
Q
  1. How is reactive arthritis management ?
A
  • Abxs may be given until septic arthritis is excluded
  • Treatment of triggering infection e.g. chlamydia
  • NSAIDs
  • Steroid injection into the affecting joints
  • Systemic steroids may be required, particularly where multiple joints are affected
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30
Q
  1. What is a key investigation to differentiate reactive arthritis from other DDs
A
  • Joint aspiration and fluid sent for microscopy, culture, sensitivity and testing for infection and crystal examination for gout and pseudogout
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31
Q
  1. What is the main gene associated with ankylosing spondylitis ?
A
  • HLA B27
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32
Q
  1. What are the main symptoms of ankylosing spondylitis ?
A
  • Pain and stiffness that is worse in the morning and improves over the day
  • Stiffness is in the lower back
  • Sacroiliac pain (buttock region)
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33
Q
  1. What is the name of the test you would ask a patient to do to confirm ankylosing spondylitis ?
A
  • Schober’s test
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34
Q
  1. What X-ray finding would be present in ankylosing spondylitis in late disease ?
A
  • Bamboo spine
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35
Q
  1. What is an MRI finding in early disease in ankylosing spondylitis ?
A
  • Bone marrow oedema
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36
Q
  1. Which joints are mainly affected in ankylosing spondylitis ?
A
  • Sacroiliac joints
  • Vertebral column joints
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37
Q
  1. What additional non-back symptoms might someone with ankylosing spondylitis have ?
A
  • Chest pain related to the costovertebral and sternocostal joints
  • Enthesitis (inflammation of the entheses, where tendons or ligaments insert into bone)
  • Dactylitis (inflammation of the entire finger)
  • Vertebral fractures (presenting with sudden-onset new neck or back pain)
  • Shortness of breath relating to restricted chest wall movement)
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38
Q
  1. What conditions are associated with ankylosing spondylitis ?
A
  • Anterior uveitis
  • Aortic regurgitation
  • Atrioventricular block
  • Apical lung fibrosis (fibrosis of the upper lobes of the lungs)
  • Anaemia of chronic disease
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39
Q
  1. What investigations might one do for ankylosing spondylitis ?
A
  • Inflammatory markers e.g. CRP and ESR
  • HLA B27 genetic testing
  • X-ray of spine and sacrum
  • MRI spine – bone marrow oedema in early disease
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40
Q
  1. How will ankylosing spondylitis appear on x-ray ?
A
  • Squaring of the vertebral bodies
  • Subchondral sclerosis and erosions
  • Syndesmophytes
  • Ossification of the ligaments, discs and joints
  • Fusion of the facet, sacroiliac and costovertebral joints
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41
Q
  1. How is ankylosing spondylitis managed ?
A
  • NSIADs are first line
  • Anti-TNF medications are 2nd line e.g. infliximab
  • Monoclonal antibodies 3rd line e.g. interleukin 17
  • Upadacitinib also 3rd line (JAK inhibitor)
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42
Q
  1. What is additional management of ankylosing spondylitis ?
A
  • Physiotherapy
  • Exercise and mobilisation
  • Avoid smoking
  • Bisphosphonates for osteoporosis
  • Surgery is occasionally required for severe joint deformity
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43
Q
  1. How can SLE present ?
A
  • Hair loss
  • Malar rash
  • SOB
  • Splenomegaly
  • Joint pain
  • Lymphadenopathy
  • Myalgia
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44
Q
  1. What is the initial antibody test for SLE ?
A
  • Anti-nuclear antibodies
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45
Q
  1. What is the specific antibody test for SLE ?
A
  • Anti-double stranded DNA (anti-DSDNA)
  • Anti-SMITH
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46
Q
  1. What is 1st line for mild SLE ?
A
  • Hydroxychloroquine
  • (NSAIDs and steroids)
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47
Q
  1. What treatment options are available for SLE in more severe disease ?
A
  • DMARDs e.g. methotrexate
  • Biological therapies e.g. Rituximab
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48
Q
  1. What biological medicine that targets B-cells is used to treat SLE ?
A
  • Rituximab
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49
Q
  1. What demographics are commonly affected by SLE ?
A
  • Women
  • Asian, African, Caribbean and Hispanic
  • Young to middle aged adults
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50
Q
  1. What are complications of SLE ?
A
  • Cardiovascular disease
  • Infection
  • Anaemia – chronic disease, medication bone marrow suppression or kidney disease
  • Pericarditis
  • Pleuritis
  • Interstitial lung disease leading to pulmonary fibrosis
  • Lupus nephritis
  • Neuropsychiatric SLE
  • Recurrent miscarriage
  • VTE and antiphospholipid syndrome
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51
Q
  1. A 30 yo with skin lesions on her face and patches of hair loss. Symptoms are worse in the sunlight. What is the diagnosis ?
A
  • Discoid lupus erythematosus
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52
Q
  1. What is the initial investigation for discoid lupus erythematosus ?
A
  • Skin biopsy
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53
Q
  1. What is the treatment for discoid lupus erythematosus ?
A
  • Sun protection
  • Topical steroids
  • Intralesion steroid injections
  • Hydroxychloroquine
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54
Q
  1. What cancer could skin lesions become in discoid lupus erythematosus ?
A
  • Squamous cell carcinoma
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55
Q
  1. What are the 3 stages of Raynard’s Phenomenon ?
A
  • White
  • Blue
  • Red
56
Q
  1. What % of patients have underlying disease and Raynard’s Phenomenon ?
57
Q
  1. What is the most associated connective tissue disease with Raynard’s ?
A
  • Systemic sclerosis (scleroderma)
58
Q
  1. What screening blood test is available with system sclerosis ?
A
  • Anti-nuclear antibodies
59
Q
  1. What test can be used to examine the small blood vessels in the fingers ?
A
  • Nailfold capillaroscopy
60
Q
  1. What is medical management for Raynaud’s ?
A
  • Nifedipine
61
Q
  1. What are secondary causes of Raynaud’s ?
A
  • Connective tissue disorders – scleroderma, RA and SLE
  • Leukaemia
  • Using vibrating tools
  • Drugs e.g. COCP
  • Cervical rib
62
Q
  1. What factors of Raynaud’s suggest underlying connective tissue disease ?
A
  • Onset after 40 years
  • Unilateral symptoms
  • Rashes
  • Presence of autoantibodies
  • Features which may suggest RA, SLE e.g. arthritis or recurrent miscarriages
  • Digital ulcers
  • All with suspected secondary symptoms should be referred to secondary care
63
Q
  1. What does CREST stand for in CREST syndrome ?
A
  • C – Calcinosis
  • R – Raynaud’s phenomenon
  • O – Oesophageal dysmotility
  • S - Sclerodactylyl
  • T – Telangiectasia
64
Q
  1. What ABs are checked initially in connective tissue disease ?
A
  • Antinuclear antibodies (ANA)
65
Q
  1. What ABs are checked in limited cutaneous systemic sclerosis ?
A
  • Anti-centromere antibodies
66
Q
  1. What ABs are checked in diffuse cutaneous systemic sclerosis ?
A
  • Anti-SCL-70 antibodies
67
Q
  1. A 65 yo white women with one month of shoulder and pelvic girdle pain and stiffness worse in the pain. What is the diagnosis ?
A
  • Polymyalgia rheumatica
68
Q
  1. What abnormal presents in blood tests in polymyalgia rheumatic ?
A
  • Increased CRP, ESR and Plasma viscosity
69
Q
  1. What is the treatment for polymyalgia rheumatica ?
A
  • Initially prednisolone 15 mg OD
70
Q
  1. What do you need to prescribe in addition to long term steroid treatment ?
A
  • Bisphosphonates
  • Calcium + vitamin D
  • PPIs
71
Q
  1. What condition is polymyalgia rheumatica closely associated with ?
A
  • Temporal arthritis
72
Q
  1. How does polymyalgia rheumatica present ?
A
  • Pain and stiffness in the
  • Shoulders – potentially radiating to the upper arm and elbow
  • Pelvic girdle
  • Neck
  • Typically in older Caucasian women
73
Q
  1. What are the characteristic features of pain and stiffness in polymyalgia rheumatica ?
A
  • Worse in the morning
  • Worse after rest or inactivity
  • Interferes with sleep
  • Takes at least 45 minutes to ease in the morning
  • Somewhat improves with activity
74
Q
  1. What are the associated features of polymyalgia rheumatica ?
A
  • Systemic symptoms e.g. weight loss, fatigue and low grade fever
  • Muscle tenderness
  • Carpel tunnel syndrome
  • Peripheral oedema
75
Q
  1. What are DDs of polymyalgia rheumatica ?
A
  • Osteoarthritis
  • RA
  • SLE
  • Fibromyalgia
  • Lymphoma or leukaemia
  • Myeloma
76
Q
  1. What is the key blood test for temporal arthritis ?
A
  • ESR (usually >50mm/hour)
77
Q
  1. What is the initial treatment for temporal arthritis ?
A
  • IV methylprednisolone if evolving visual loss
  • High dose prednisolone if no visual loss (40-60mg)
78
Q
  1. A 56 yo presents with pain and weakness in their thighs, shoulders and upper arms. There is a purplish rash on the eyelids. What is the diagnosis ?
A
  • Dermatomyositis
79
Q
  1. How does dermatomyositis differ from polymyositis ?
A
  • Polymyositis presents with pain and weakness in the joints but without the rash on the eyelids
80
Q
  1. What are the skin changes seen on the hands in dermatomyositis ?
A
  • Gottron lesions
81
Q
  1. What is the initial blood test for dermatomyositis ?
A
  • Creatine kinase
82
Q
  1. What antibodies are associated with dermatomyositis ?
A
  • Anti-Jo-1
  • Anti-Mi-2
  • Anti-nuclear antibodies
83
Q
  1. What is the definitive investigation for dermatomyositis ?
A
  • Muscle biopsy
84
Q
  1. What should one consider in new cases of dermatomyositis ?
A
  • Possible underlying cancer
85
Q
  1. What is first line treatment for dermatomyositis ?
A
  • Corticosteroids
86
Q
  1. A 45 yo female presents with dry eyes, mouth and vagina ?
A
  • Sjogren’s syndrome
87
Q
  1. What are the affected structures in Sjorgren’s syndrome ?
A
  • Exocrine glands
  • Notably the lacrimal and salivary glands (hence the dryness)
88
Q
  1. What are conditions could Sjorgren’s syndrome be secondary to ?
89
Q
  1. What are the associated antibodies with Sjorgren’s syndrome ?
A
  • Anti-Ro
  • Anti-La
90
Q
  1. What is the test for dry eyes in Sjorgren’s syndrome ?
A
  • Schirmer test
91
Q
  1. What is the treatment that can halt Sjorgren’s syndrome progression ?
A
  • Hydroxychloroquine
92
Q
  1. How is Sjorgren’s syndrome managed ?
A
  • Hydroxychloroquine – mainly in patients with joint pain
  • Artificial tears
  • Artificial saliva
  • Vaginal lubricants
  • Pilocarpine – can stimulate teat and saliva
93
Q
  1. How does granulomatosis with polyangiitis present ?
A
  • Sinusitis
  • Nose bleeds
  • Saddle shaped nose
  • Cough, wheeze and haemoptysis
  • Glomerulonephritis
94
Q
  1. What type of disease is granulomatosis with polyangiitis ?
A
  • Vasculitis
95
Q
  1. What are complications of Sjogren’s syndrome ?
A
  • Eye – corneal ulcers
  • Oral – dental cavities and candida infections
  • Vaginal – candida and sexual dysfunction
96
Q
  1. What is the blood test for granulomatosis with polyangiitis ?
A
  • Anti-neutrophil cytoplasmic antibodies
97
Q
  1. What are the treatments for granulomatosis with polyangiitis ?
A
  • Steroids
  • Cyclophosphamide (90% response)
  • Plasma exchange
  • Median survival = 8-9 years
98
Q
  1. What blood test is raised in gout ?
99
Q
  1. What is seen on aspirated fluid ?
A
  • Monosodium urate crystals
  • Needle shaped negatively birefringent of polarised light
100
Q
  1. What is first line for an acute flair of gout ?
A
  • NSIADs e.g. ibuprofen or naproxen
101
Q
  1. What is 1st line for acute gout with renal impairment and what is its main side effect ?
A
  • Colchicine
  • Diarrhoea
102
Q
  1. What is given prophylactically for gout ?
A
  • Allopurinol
103
Q
  1. What are RFs for gout ?
A
  • Male
  • Fhx
  • Obesity, high purine diet and alcohol
  • Diuretics
  • CVD and CKD
104
Q
  1. What joints are typically affected in gout ?
A
  • Base of the big toe – metatarsophalangeal joint
  • Base of the thumb – carpometacarpal joint
  • Wrist
  • Larger joints knee or ankle
105
Q
  1. What DD is important to rule out in gout ?
A
  • Septic arthritis
106
Q
  1. What are pseudogout crystals made from ?
A
  • Calcium pyrophosphate crystals
107
Q
  1. What will appear on joint fluid microscopy for pseudogout ?
A
  • Rhomboid shaped crystals that are positively birefringent of polarised lights
108
Q
  1. What is 1st line medication for pseudogout ?
109
Q
  1. How does pseudogout present ?
A
  • Many patients are asymptomatic and are picked up on X-ray
  • A typical acute presentation is a 65 yo pt with rapid onset hot, swollen, stiff and painful knee
  • Other affected joints include the shoulders, hips and wrists
110
Q
  1. How is pseudogout managed ?
A
  • 1st line = NSAIDs e.g. naproxen with PPI cover
  • Colchicine
  • Intra-articular steroid injections (septic arthritis must be first excluded)
  • Oral steroids
111
Q
  1. A 75 year old women on long term steroids for polymyalgia rheumatica presents. She drinks 35 units of alcohol per week and is sedentary. What is the most likely diagnosis ?
A
  • Osteoporosis
112
Q
  1. What risk assessment tool is used in osteoporosis ?
113
Q
  1. What investigations are done for osteoporosis ?
114
Q
  1. What T score is diagnostic and what joint does it measure ?
A
  • Less than -2.5
  • Femoral neck
115
Q
  1. What is a normal T score and what is osteopenic ?
A
  • Normal = more than -1
  • Osteopenia = -1 to -2.5
116
Q
  1. What are the guidelines for deciding whether to treat osteoporosis ?
A
  • NOGG guidelines
117
Q
  1. What is first line treatment for osteoporosis ?
A
  • Bisphosphonates
118
Q
  1. What monoclonal-antibody can be used for severe osteoporosis ?
119
Q
  1. What is osteopenia ?
A
  • A less severe decrease in bone density than osteoporosis
120
Q
  1. What is the difference between a T and Z score ?
A
  • Z = number of standard deviations the patient is from their age, sex and ethnicity average
  • T = number of standard deviations the patient is from a healthy young adult
121
Q
  1. What are RFs for osteoporosis ?
A
  • Older age
  • Post-menopausal women
  • Reduced mobility and activity
  • Low BMI
  • Low calcium and vitamin D intake
  • Alcohol and smoko
  • Personal or fhx of fractures
  • Chronic disease e.g. CKD or RA
  • Long term corticosteroids e.g. 7.5mg or more prednisolone daily for longer than 3 months
  • Certain medications e.g. SSRIs, PPIs, anti-epileptics and anti-oestrogens
122
Q
  1. How does NICE recommend assessing for osteoporosis ?
A
  • Anyone on long-term oral corticosteroids or with a previous fragility fracture
  • Anyone 50 and over with risk factors
  • All women 65 and over
  • All men 75 and over
123
Q
  1. How is the 10 year risk of major osteoporotic fracture and a hip fracture calculated ?
A
  • QFracture tool (preferred by NICE)
  • FRAX tool (NICE says this may underestimate the risk in some patients)
124
Q
  1. How is osteoporosis managed ?
A
  • Address risk factors e.g. physical activity, maintain healthy weight, stop smoking and reduce alcohol consumption
  • Adress intake of calcium (at least 1000mg) and inadequate vitamin D (400-800 IU)
  • Bisphosphonates are 1st line (taken on an empty stomach with a full glass of water)
125
Q
  1. What are side effects of bisphosphonates ?
A
  • Reflux and oesophageal erosions
  • Atypical fractures
  • Osteonecrosis of the jaw
  • Osteonecrosis of the external auditory canal
126
Q
  1. How should bisphosphonates be taken ?
A
  • Empty stomach
  • Full glass of water
  • Pts should after sit up for 30 minutes before moving or eating to reduce the risk of reflux and oesophageal erosions
127
Q
  1. A 74 yo housebound South-Asian lady presents with fatigue, muscle weakness and bone pain. X-ray shows an abnormal fracture. What is the diagnosis ?
A
  • Osteomalacia
128
Q
  1. Given examples of bisphosphonates ?
A
  • Alendronate
  • Risedronate
  • Zoledronic acid
129
Q

What are looser zones in the context Osteomalacia and what is the cause ?

A
  • Fragility fractures that go partially through the bone
  • Vitamin D deficiency
130
Q
  1. What electrolytes will be abnormal in Osteomalacia ?
A
  • Low serum calcium
  • Low serum phosphate
131
Q
  1. What LFT and hormone will be abnormal in Osteomalacia ?
A
  • Raised ALP
  • Raised PTH
132
Q
  1. What is the treatment for Osteomalacia ?
A
  • Treatment dose vitamin D
  • 50,000 IU once weekly for 6 weeks
  • 4000 IU daily for 10 weeks
133
Q
  1. A 68 yo with bone pain and deformity and pathological fractures and hearing loss presents. What is the diagnosis ?
A
  • Paget’s disease of the bone
134
Q
  1. What is the name for well defined osteolytic lesions seen in X-ray in Paget’s ?
A
  • Osteoporosis circumscripta
135
Q
  1. What is the classic skull X-ray appearance in Paget’s disease ?
A
  • Cotton wool appearance
136
Q
  1. What blood test is abnormal in Paget’s ?
A
  • Raised alkaline phosphates
137
Q
  1. What is the main treatment for Paget’s ?
A
  • Bisphosphonates

Phase 4 (17 decks)

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