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Part 1 > rheum > Flashcards

rheum Flashcards

1
Q

acute Gout

A

NSAIDs
colchicine if renal impairment
3rd line steroids oral
4th intraarticular steroids

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2
Q

DE QUERVEINS Tendosinovitis

A

Features
pain on the radial side of the wrist
tenderness over the radial styloid process
abduction of the thumb against resistance is painful
Finkelstein’s test: with the thumb is flexed across the palm of the hand, pain is reproduced by movement of the wrist into flexion and ulnar deviation

Management
analgesia
steroid injection
immobilisation with a thumb splint (spica) may be effective
surgical treatment is sometimes required
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3
Q

OSteoporosis frax

A 
FRAX:
history of glucocorticoid use
rheumatoid arthritis
alcohol excess
history of parental hip fracture
low body mass index
current smoking
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4
Q

Marfan’s assw what eye condition

A

eyes: upwards lens dislocation (superotemporal ectopia lentis), blue sclera, myopia

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5
Q

rheumatoid arthritis what drugs are safe in pregnancy

A

sulfasalazine

hydroxychloroquine

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6
Q

rheumatoid factor

A

IgM towards one’s own IgG

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7
Q

Marfan’s mutation

A

Mutation of FBN1 that encodes Fibrillin-1

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8
Q

sjogren’s assw with what malignancy

A

lymphoid malignancy

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9
Q

anti-Jo 1:

A

polymyositis

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10
Q

anti centromere antibodies

A

Limited (central) systemic sclerosis = anti-centromere antibodies

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11
Q

Limited cutaneous systemic sclerosis

A

Raynaud’s may be first sign
scleroderma affects face and distal limbs predominately
associated with anti-centromere antibodies
a subtype of limited systemic sclerosis is CREST syndrome: Calcinosis, Raynaud’s phenomenon, oEsophageal dysmotility, Sclerodactyly, Telangiectasia

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12
Q

scl 70 antibodies

A

Diffuse cutaneous systemic sclerosis

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13
Q

Diffuse cutaneous systemic sclerosis

A

scleroderma affects trunk and proximal limbs predominately
associated with scl-70 antibodies
the most common cause of death is now respiratory involvement, which is seen in around 80%: interstitial lung disease (ILD) and pulmonary arterial hypertension (PAH)
other complications include renal disease and hypertension
poor prognosis

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14
Q

Scleroderma

A

(without internal organ involvement)
tightening and fibrosis of skin
may be manifest as plaques (morphoea) or linear

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15
Q

azathioprine

A

metabolised to the active compound mercaptopurine, a purine analogue that inhibits purine synthesis. A thiopurine methyltransferase (TPMT) test may be needed to look for individuals prone to azathioprine toxicity.

Adverse effects include
bone marrow depression
nausea/vomiting
pancreatitis
increased risk of non-melanoma skin cancer
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16
Q

Ankylosing spondylitis - x-ray findings:

A

subchondral erosions, sclerosis
and squaring of lumbar vertebrae

late:
sacroiliitis: subchondral erosions, sclerosis
squaring of lumbar vertebrae
‘bamboo spine’ (late & uncommon)
syndesmophytes: due to ossification of outer fibers of annulus fibrosus
chest x-ray: apical fibrosis

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17
Q

proximal myopathy in combination with mechanic hands

A

anti-synthetase syndrome.

association with interstitial lung disease - particularly non-specific interstitial pneumonia or NSIP.

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18
Q

Mx of Sjogrens

A

artificial saliva and tears

pilocarpine may stimulate saliva production

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19
Q

polyarteritis nodosa

A

fever, malaise, arthralgia
weight loss
hypertension
mononeuritis multiplex, sensorimotor polyneuropathy
testicular pain
livedo reticularis
haematuria, renal failure
perinuclear-antineutrophil cytoplasmic antibodies (ANCA) are found in around 20% of patients with ‘classic’ PAN
hepatitis B serology positive in 30% of patients

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20
Q

Reactive arthritis: features

A

typically develops within 4 weeks of initial infection - symptoms generally last around 4-6 months
arthritis is typically an asymmetrical oligoarthritis of lower limbs
dactylitis
symptoms of urethritis
eye: conjunctivitis (seen in 10-30%), anterior uveitis
skin: circinate balanitis (painless vesicles on the coronal margin of the prepuce), keratoderma blenorrhagica (waxy yellow/brown papules on palms and soles)

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21
Q

biggest cause of gout

A

decrease in renal urate secretion:
drugs*: diuretics
chronic kidney disease
lead toxicity

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22
Q

Rheumatoid arthritis Mx

A

DMARD monotherapy plus bridging steroids

methotrexate is the most widely used DMARD. Monitoring of FBC & LFTs is essential due to the risk of myelosuppression and liver cirrhosis. Other important side-effects include pneumonitis
sulfasalazine
leflunomide
hydroxychloroquine

if 2 dmards fail - can try TNFalpha inhibitor
- infliximab

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23
Q

Paget’s blood and urine

A

raised ALP
normal calcium and phosphate

Raised urine hydroxyproline - bone turnover

24
Q

examination of carpal tunnel syndrome

A

weakness of thumb abduction (abductor pollicis brevis)
wasting of thenar eminence (NOT hypothenar)
Tinel’s sign: tapping causes paraesthesia
Phalen’s sign: flexion of wrist causes symptoms

25
Q

ankylosing spondilitis

A

if using TNF alpha inhibitors

- radiological progression is NOT changed

26
Q

L3 nerve root compression

A

loss of thigh sensation
reduced knee reflex
positive femoral stretch test
weakness of quadriceps

27
Q

L4 nerve root compression

A

Sensory loss anterior aspect of knee
Weak quadriceps
Reduced knee reflex
Positive femoral stretch test

28
Q

L5 Nerve compression

A

Sensory loss dorsum of foot
Weakness in foot and big toe dorsiflexion
Reflexes intact
Positive sciatic nerve stretch test

29
Q

S1 nerve root compression

A

Sensory loss posterolateral aspect of leg and lateral aspect of foot
Weakness in plantar flexion of foot
Reduced ankle reflex
Positive sciatic nerve stretch test

30
Q

pseudogout

A

Features
knee, wrist and shoulders most commonly affected
joint aspiration: weakly-positively birefringent rhomboid-shaped crystals
x-ray: chondrocalcinosis

Management
aspiration of joint fluid, to exclude septic arthritis
NSAIDs or intra-articular, intra-muscular or oral steroids as for gout

RF 
haemochromatosis
hyperparathyroidism
acromegaly
low magnesium, low phosphate
Wilson's disease
31
Q

Symptoms may be reproduced by deep palpation just below the ASIS (pelvic compression) and also by extension of the hip.
There is altered sensation over the upper lateral aspect of the thigh.
There is no motor weakness.

A

? meralgia paraesthetica - lateral cutaneous nerve of thigh compression

Burning, tingling, coldness, or shooting pain
Numbness
Deep muscle ache
Symptoms are usually aggravated by standing, and relieved by sitting
They can be mild and resolve spontaneously or may severely restrict the patient for many years.

32
Q

antiphospholipid syndrome

A 
Features
venous/arterial thrombosis
recurrent fetal loss
livedo reticularis
thrombocytopenia
prolonged APTT
other features: pre-eclampsia, pulmonary hypertension

Associations other than SLE
other autoimmune disorders
lymphoproliferative disorders
phenothiazines (rare)

33
Q

sulfasalazine cautions + adverse effects

A

G6PD deficiency
allergy to aspirin or sulphonamides (cross-sensitivity)

Adverse effects
oligospermia
Stevens-Johnson syndrome
pneumonitis / lung fibrosis
myelosuppression, Heinz body anaemia, megaloblastic anaemia
may colour tears → stained contact lenses

34
Q

which TB drug causes lupus

A

isoniazid

35
Q

weak external rotation of shoulder

A

adhesive capsulitis

36
Q

Anti-ribonuclear protein (anti-RNP)

A

mixed connective tissue disease

37
Q

Rheumatoid arthritis XR changes

A

Early x-ray findings
loss of joint space
juxta-articular osteoporosis
soft-tissue swelling

Late x-ray findings
periarticular erosions
subluxation

38
Q

Rheumatoid arthritis associations

A

respiratory: pulmonary fibrosis, pleural effusion, pulmonary nodules, bronchiolitis obliterans, methotrexate pneumonitis, pleurisy
ocular: keratoconjunctivitis sicca (most common), episcleritis, scleritis, corneal ulceration, keratitis, steroid-induced cataracts, chloroquine retinopathy
osteoporosis
ischaemic heart disease: RA carries a similar risk to type 2 diabetes mellitus
increased risk of infections
depression

Less common
Felty’s syndrome (RA + splenomegaly + low white cell count)
amyloidosis

39
Q

Temporal arteritis features

A

Temporal arteritis is large vessel vasculitis
overlaps with polymyalgia rheumatica (PMR).

Features
typically patient > 60 years old
usually rapid onset (e.g. < 1 month)
headache (found in 85%)
jaw claudication (65%)
visual disturbances secondary to anterior ischemic optic neuropathy
tender, palpable temporal artery
around 50% have features of PMR: aching, morning stiffness in proximal limb muscles (not weakness)
also lethargy, depression, low-grade fever, anorexia, night sweats

40
Q

Temporal arteritis Ix Rx

A

Investigations
raised inflammatory markers: ESR > 50 mm/hr (note ESR < 30 in 10% of patients). CRP may also be elevated
temporal artery biopsy: skip lesions may be present
note creatine kinase and EMG normal

Treatment
high-dose prednisolone - there should be a dramatic response, if not the diagnosis should be reconsidered
urgent ophthalmology review. Patients with visual symptoms should be seen the same-day by an ophthalmologist. Visual damage is often irreversible

41
Q

Usually gradual onset
Unilateral or bilateral leg pain (with or without back pain), numbness, and weakness which is worse on walking. Resolves when sits down. Pain may be described as ‘aching’, ‘crawling’.
Relieved by sitting down, leaning forwards and crouching down
Clinical examination is often normal
Requires MRI to confirm diagnosis

A

Spinal stenosis

42
Q

bone protection in long term steroids

A

T score Management
Greater than 0 Reassure
Between 0 and -1.5 Repeat bone density scan in 1-3 years
Less than -1.5 Offer bone protection

43
Q

initially intermittent tingling in the 4th and 5th finger
may be worse when the elbow is resting on a firm surface or flexed for extended periods
later numbness in the 4th and 5th finger with associated weakness

A

Cubital tunnel syndrome

Due to the compression of the ulnar nerve.

44
Q

chronic pain: at multiple site, sometimes ‘pain all over’
lethargy
cognitive impairment: ‘fibro fog’
sleep disturbance, headaches, dizziness are common

A

fibromyalgia

polymyalgia rheumatica presents similar but with fevers and weight loss

45
Q

low: calcium, phosphate
raised: alkaline phosphatase

A

osteomalacia

46
Q

The classic laboratory finding is a raised creatinine kinase (CK) and the Anti-Jo-1 antibody

A

The hallmark of polymyositis is weakness and/or loss of muscle mass in the proximal musculature, and absent skin involvement.

proximal muscle weakness +/- tenderness
Raynaud's
respiratory muscle weakness
interstitial lung disease: e.g. fibrosing alveolitis or organising pneumonia
dysphagia, dysphonia
47
Q

anti ro

A

assw congenital heart block

assw SLE and sjogrens

48
Q

Osteoarthritis

A
  • paracetamol + topical NSAIDs (if knee/hand) first-line
49
Q

Repeated cramping and myoglobinuria after short bouts of exercise

A

McArdle’s disease

Overview
autosomal recessive type V glycogen storage disease
caused by myophosphorylase deficiency
this causes decreased muscle glycogenolysis

Features
muscle pain and stiffness following exercise
muscle cramps
myoglobinuria
low lactate levels during exercise
50
Q

Pseudoxanthoma elasticum

A

inherited condition (usually autosomal recessive*) characterised by an abnormality in elastic fibres

Features
retinal angioid streaks
‘plucked chicken skin’ appearance - small yellow papules on the neck, antecubital fossa and axillae
cardiac: mitral valve prolapse, increased risk of ischaemic heart disease
gastrointestinal haemorrhage

51
Q

negatively birefringent crystals in joint aspiration

A

gout

52
Q

Oral ulcers + genital ulcers + anterior uveitis

A

Behcet’s

assw DVT 
aseptic meningitis 
arthritis 
abdo pain/diarrhoea/colitis
erythema nodosum
53
Q

DIP involvement arthritis

A

psoriatic

54
Q

hydroxychloroquine SE

A

retinopathy

55
Q

bone pain, typically in the skull or proximal femur
cutaneous nodules
recurrent otitis media/mastoiditis
tennis racket-shaped Birbeck granules on electromicroscopy

A

Langerhans cell histiocytosis is a rare condition associated with the abnormal proliferation of histiocytes. It typically presents in childhood with bony lesions.

56
Q

erythematous, raised rash, sometimes scaly
may be photosensitive
more common on face, neck, ears and scalp
lesions heal with atrophy, scarring (may cause scarring alopecia), and pigmentation

A

Discoid lupus erythematosus

benign disorder younger females.

rarely progresses to systemic lupus erythematosus (in less than 5% of cases).

Discoid lupus erythematosus is characterised by follicular keratin plugs and is thought
to be autoimmune in aetiology

Management
topical steroid cream
oral antimalarials may be used second-line e.g. hydroxychloroquine
avoid sun exposure

Part 1 (10 decks)

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