Rheum fifth yr Flashcards

Question

Features of fibromyalgia

Answer 1

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

Answer 2

Diagnosis is clinical and sometimes refers to the American College of Rheumatology classification criteria which lists 9 pairs of tender points on the body. If a patient is tender in at least 11 of these 18 points it makes a diagnosis of fibromyalgia more likely Management tailored to individual patient. Psychosocial and MDT approach. Explanation Aerobic exercise CBT Medication - pregabalin, duloxetine, amitriptyline

Answer 3

type of crystal arthropathy and inflammatory arthritis. associated with chronically high blood uric acid levels. Urate crystals are deposited in the joint causing it to become hot, swollen and painful. Gout flares Gouty tophi are subcutaneous deposits of uric acid typically affecting the small joints and connective tissues of the hands, elbows and ears. The DIP joints are most affected in the hands. typically presents with a single acute hot, swollen and painful joint. Typical joints - metatarsophalangeal, wrists, carpometacarpal - also knee and ankle

Answer 4

Male Obesity High purine diet (e.g. meat and seafood) Alcohol Diuretics Existing cardiovascular or kidney disease Family history increased production of uric acid - myeloproliferative, cytotoxic drugs, severe psoriasis Lesch-Nyhan syndrome

Answer 5

diagnosed clinically or by aspiration of fluid from the joint. Excluding septic arthritis is essential as this is a potential joint and life-threatening diagnosis. uric acid - checked once acute episode settled down (2wks later) Aspirated fluid - no bacterial growth, needle shaped, negatively birefringement of polarised light, monosodium urate crystals X-ray - joint space maintained, lytic lesions in bone, punched out erosions with sclerotic borders and overhanging edges

Answer 6

Acute: NSAIDs, colchicine, steroids colchicine - SE diarrhoea Prophylaxis: Allopurinol (xanthine oxidase inhibitor) - reduces uric acid levels Lifestyle changes

Answer 7

form of microcrystal synovitis caused by the deposition of calcium pyrophosphate dihydrate crystals in the synovium Cause hot, swollen, stiff, painful knee - or shoulder, wrist, hip Associated with increasing age. If younger (<60) then usually have underlying risk factor (haemochromatosis, hyperparathyroidism, low Mg, low phosphate, acromegaly, Wilsons)

Answer 8

joint aspiration: weakly-positively birefringent rhomboid-shaped crystals x-ray: chondrocalcinosis in the knee this can be seen as linear calcifications of the meniscus and articular cartilage

Answer 9

aspiration of joint fluid, to exclude septic arthritis NSAIDs or intra-articular, intra-muscular or oral steroids as for gout Joint washout in severe cases

Answer 10

Condition where there is reduction in the density of bones. Osteopenia is less severe reduction than osteoporosis. Means bone is less strong and more prone to fractures Osteoporotic vertebral fracture - loss of height, kyphosis, localised tenderness on palpation of spinous processes at fracture site

Answer 11

Older age Female Reduced mobility and activity Low BMI (<18.5 kg/m2) Rheumatoid arthritis Alcohol and smoking Long term corticosteroids. NICE suggest the risk increases significantly with the equivalent of more than 7.5mg of prednisolone per day for more than 3 months) Other medications such as SSRIs, PPIs, anti-epileptics and anti-oestrogens Post menopausal - as oestrogen is protective against osteoporosis

Answer 12

FRAX assessment on patients at risk: women >65, men >75, Younger patients with risk factors such as a previous fragility fracture, history of falls, low BMI, long term steroids, endocrine disorders and rheumatoid arthritis. FRAX outcome without a BMD result will suggest one of three outcomes: Low risk – reassure Intermediate risk – offer DEXA scan and recalculate the risk with the results High risk – offer treatment FRAX outcome with a BMD result will suggest one of two outcomes: Treat Lifestyle advice and reassure Lab values all normal (calcium, phosphate, ALP, PTH)

Answer 13

Lifestyle - activity and exercise, healthy weight, adequate calcium and vitamin D, avoid falls, stop smoking, reduce alcohol consumption calcium supplementation with vitamin D in patients at risk of fragility fractures with an inadequate intake of calcium - e.g., calcichew D3. If adequate calcium intake but lack sun exposure - vit D supplementation Bisphosphonates - reduce osteoclast activity and preventing the reabsorption of bone. E.g., alendronate, risedronate, zoledronic acid. SE - reflux, oesophageal erosions, atypical fractures, osteonecrosis of jaw and external auditory canal Denosumab is a monoclonal antibody that works by blocking the activity of osteoclasts. Strontium ranelate is a similar element to calcium that stimulates osteoblasts and blocks osteoclasts but increases the risk of DVT, PE and myocardial infarction. Raloxifene is used as secondary prevention only. It is a selective oestrogen receptor modulator that stimulates oestrogen receptors on bone but blocks them in the breasts and uterus. Hormone replacement therapy should be considered in women that go through menopause early. Follow up for low risk patients, and pt's on bisphosphonates should have repeat FRAX and DEXA scan after 3-5 years. Consider treatment holiday if BMD improved and no fractures.

Answer 14

Gives prediction of the risk of a fragility fracture over the next 10 hears Input information (age, BMI, co-morbidities, smoking, alcohol, FHX, and also BMD if available). Gives percentage risk of 10 year probability of major osteoporotic fracture and hip fracture in patients 40-90 QFracture tool - pts 30-90, larger group of RFs included

Answer 15

BMD measured using DEXA (dual energy X-ray absorptiometry) Reading at hip used for classification and management of osteoporosis Bone density can be represented as a Z score or T score. Z scores represent the number of standard deviations the patients bone density falls below the mean for their age. T scores represent the number of standard deviations below the mean for a healthy young adult their bone density is. WHO classification - T score > -1 is normal, -1 to -2.5 is osteopenia, less than -25 is osteoporosis, less than -2.5 plus fracture is severe osteoporosis

Answer 16

Blood cell count, sedimentation rate or C-reactive protein, serum calcium, albumin, creatinine, phosphate, alkaline phosphatase and liver transaminases Thyroid function tests Bone densitometry ( DXA) Other procedures, if indicated: Lateral radiographs of lumbar and thoracic spine/DXA-based vertebral imaging Protein immunoelectrophoresis and urinary Bence-Jones proteins 25OHD PTH Serum testosterone, SHBG, FSH, LH (in men), Serum prolactin 24 hour urinary cortisol/dexamethasone suppression test Endomysial and/or tissue transglutaminase antibodies (coeliac disease) Isotope bone scan Markers of bone turnover, when available Urinary calcium excretion

Answer 17

a condition where there is defective bone mineralisation causing “soft” bones. Results from insufficient vitamin D. Vitamin D is essential in calcium and phosphate absorption from the intestines and kidneys. Vitamin D is also responsible for regulating bone turnover and promoting bone reabsorption to boost the serum calcium level. Causes low Ca and phosphate and hence defective bone mineralisation. Low Ca causes secondary hyperparathyroidism, so more PTH and increased reabsorption from bones.

Answer 18

May be asymptomatic Fatigue Bone pain Muscle weakness - proximal myopathy > waddling gait Muscle aches Pathological or abnormal fractures - especially femoral neck Looser zones

Answer 19

Serum 25-hydroxyvitamin D is the laboratory investigation for vitamin D. The interpretation of the results is as follows: <25 nmol/L – vitamin D deficiency 25 – 50 nmol/L – vitamin D insufficiency 75 nmol/L or above is optimal Low Ca, low phosphate, increased ALP, increased PTH X-rays - osteopenia (more radiolucent) DEXA - low BMD

Answer 20

Darker skin Low exposure to sunlight Live in colder climates Spend a lot of time indoors CKD Drug induced - anticonvulsants Inherited - hypophosphatemic rickets Liver disease - cirrhosis Coeliac disease

Answer 21

supplementary vitamin D (colecalciferol) - several regimes 50,000 IU once weekly for 6 weeks, 20,000 IU twice weekly for 7 weeks, 4000 IU daily for 10 weeks maintenance supplementary dose for of 800 IU or more per day should be continued for life after the initial treatment

Answer 22

inflammatory arthritis associated with psoriasis that is within the seronegative spondyloarthropathy group. Often precedes the development of skin lesions. It occurs in 10-20% of patients with psoriasis and usually occurs within 10 years of developing the skin changes. It typically affects people in middle age but can occur at any age. Associations Eye disease (conjunctivitis and anterior uveitis) Aortitis (inflammation of the aorta) Amyloidosis

Answer 23

Not a single pattern of affected joints: symmetrical poly arthritis - similar to RA, more common in women, hands, wrists, ankles, DIP, MCP less commonly (unlike RA) asymmetrical pauciarthritis - mainly digits and feet, only few joints spondylitic pattern - more common in men, back stiffness, sacroilitis, atlanto-axial joint involvement also: spine, achilles tendon, plantar fascia Plaques of psoriasis Pitting of nails Onycholysis Dactylitis Enthesitis - points of insertion of tendon to bone Arthritis mutilans - most severe form of psoriatic arthritis occurring in phalanxes - 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”.

Answer 24

PEST tool - nvolves several questions asking about joint pain, swelling, a history of arthritis and nail pitting. A high score triggers a referral to a rheumatologist. X-ray: Periostitis is inflammation of the periosteum causing a thickened and irregular outline of the bone Ankylosis is where bones joining together causing joint stiffening Osteolysis is destruction of bone Dactylitis is inflammation of the whole digit and appears on the xray as soft tissue swelling Pencil-in-cup appearance - central erosions of the bone beside the joints

Answer 25

Similar to RA - coordinated between dermatologists and rheumatologists. NSAIDs DMARDs Anti-TNF (etanercept, infliximab, adalimumab) Ustekinumab - last line - monoclonal antibody that targets interleukin 12 and 23

Answer 26

AD CTD Mostly affects type III collagen Tissue more elastic than normal - causing joint hyper mobility and increased elasticity of the skin Features - elastic, fragile skin joint hypermobility: recurrent joint dislocation easy bruising aortic regurgitation, mitral valve prolapse and aortic dissection subarachnoid haemorrhage angioid retinal streaks mild can be managed in GP MDT - PT, CBT, symptom relief, genetic counselling, celiprolol to prevent Aortic dissection, care with wound healing

Answer 27

AD CTD Defect in FBN1 gene on chromosome 15 that codes for protein fibrillar-1 1 in 3000 people Features tall stature high arched palate arachnodactyly Pectus excavatum pes planus scoliosis of >20 degrees heart - dilation of aortic sinuses (aortic aneurysm, aortic dissection, aortic regurgitation), MV prolapse lungs - repeated pneumothoraces eyes - upwards lens dislocation, blue sclera, myopia dural ectasia Ghent criteria Thumb and wrist sign regular ECHO beta-blocker and ACEi therapy aortic dissection and CVD problems are leading cause of death

Answer 28

characterised by an exaggerated vasoconstrictive response of the digital arteries and cutaneous arteriole to the cold or emotional stress. It may be primary (Raynaud's disease) or secondary (Raynaud's phenomenon). Raynaud's disease typically presents in young women (e.g. 30 years old) with bilateral symptoms. Secondary causes = CTD (scleroderma, RA, SLE), leukaemia, type 1 cryoglobulinaemia, cold agglutinins, use of vibrating tools, drugs (OCP, ergot), cervical rib Management - if suspected secondary then referral to secondary care first-line - calcium channel blocker (nifedipine) IV prostacyclin (epoprostenol) infusions: effects may last several weeks/months

Answer 29

an acquired disorder characterised by a predisposition to both venous and arterial thromboses, recurrent fetal loss and thrombocytopenia. Primary or secondary, commonly from SLE. Also other AI disorders, lymphoproliferative disorders, phenothiazines Causes paradoxical rise in APTT - due to an ex-vivo reaction of the lupus anticoagulant autoantibodies with phospholipids involved in the coagulation cascade

Answer 30

venous/arterial thrombosis recurrent fetal loss livedo reticularis other features: pre-eclampsia, pulmonary hypertension Libmann-Sacks endocarditis is a type of non-bacterial endocarditis where there are growths (vegetations) on the valves of the heart. The mitral valve is most commonly affected.

Answer 31

Antibodies = anticardiolipin, ant-beta2 glycoprotein, lupus anticoagulant Thrombocytopenia Prolonged APTT

Answer 32

Primary thromboprophylaxis = low-dose aspirin Secondary thromboprophylaxis = initial venous thromboembolic events: lifelong warfarin with a target INR of 2-3 recurrent venous thromboembolic events: lifelong warfarin; if occurred whilst taking warfarin then consider adding low-dose aspirin, increase target INR to 3-4 arterial thrombosis should be treated with lifelong warfarin with target INR 2-3 Pregnancy - LMWH plus aspirin. Warfarin CI'ed in pregnancy

Answer 33

complex inflammatory condition. presumed autoimmune-mediated inflammation of the arteries and veins It characteristically presents with recurrent oral and genital ulcers. It can also cause inflammation in a number of other areas such as the skin, gastrointestinal tract, lungs, blood vessels, musculoskeletal system and central nervous system. There is a link with the HLA B51 gene. This is a prognostic indicator of severe disease. relapsing remitting condition more common in eastern Mediterranean (Turkey) and men

Answer 34

Simple aphthous ulcers are very common Inflammatory bowel disease (particularly Crohn’s disease) Coeliac disease Vitamin deficiency (B12, folate or iron) Herpes simplex ulcers Hand, foot and mouth disease (coxsackie A virus) Squamous cell carcinoma

Answer 35

Triad - mouth ulcers, genital ulcers, anterior uveitis Mouth ulcers - at least 3 episodes, painful, red halo, oral mucosa, heal over 2-4 weeks Genital ulcers - similar appearance to oral ulcers, 'kissing ulcers' Skin - Erythema nodosum, Papules and pustules (similar to acne), Vasculitic type rashes Eyes - need emergency review by ophthalmology - Anterior or posterior uveitis, Retinal vasculitis, Retinal haemorrhage MSK - morning stiffness, arthralgia, oligoarthritis (knee/ankle) GI system - inflammation and ulceration CNS - Memory impairment, Headaches and migraines, Aseptic meningitis, Meningoencephalitis Veins - inflamed veins causing vein thrombosis - Budd Chiari, DVT, PE, cerebral venous sinus thrombosis Lungs - pulmonary artery aneurysms

Answer 36

Clinical diagnosis Pathergy test - abrasion on forearm, creates weal - positive in Behcets, Sweets syndrome and pyoderma gangrenosum Tx: Topical steroids to mouth ulcers (e.g. soluble betamethasone tablets) Systemic steroids (i.e. oral prednisolone) Colchicine is usually effective as an anti-inflammatory to treat symptoms Topical anaesthetics for genital ulcers (e.g. lidocaine ointment) Immunosuppressants such as azathioprine Biologic therapy such as infliximab

Answer 37

HLA-B27 associated spondyloarthropathy M>F (3:1) aged 20-30

Answer 38

Young man with lower back pain Stiffness of insidious onset Stiffness worse in AM - improves with exercise Pain at night - improves on getting up

Answer 39

Reduced lateral flexion Reduced forward flexion - Schober's test Reduced chest expansion

Answer 40

Apical fibrosis Anterior uveitis Aortic regurgitation Achilles tendonitis AV node block Amyloidosis and cauda equina syndrome peripheral arthritis (25%, more common if female)

Answer 41

Inflammatory markers raised HLA-B27 - little use in Dx Plain X-ray of sacroiliac joints: sacroilitis - subchondral erosions, sclerosis squaring of lumbar vertebrae bamboo spine - late, uncommon syndesmophytes - due to ossification of outer fibres of annulus fibrosus CXR - apical fibrosis If still suspicion and -ve X-ray - MRI - shows bone marrow oedema Spirometry - restrictive defect - pulmonary fibrosis, kyphosis and ankylosis of costovertebral joints

Answer 42

Lifestyle - encourage regular exercise, NSAIDs, physiotherapy, avoid smoking, bisphosphonates if osteoporosis, treatment of complications Steroids in flares DMARDs - e.g., sulphasalazine - only useful if peripheral joint involvement Anti-TNF therapy is persistently high disease activity despite conventional treatments - etanercept, MAB's (infliximab, adalimumab) Surgery - deformities of spine/joints

Answer 43

Synovitis due to a recent infective trigger Acute mono arthritis - usually knee. No infection in joint Link with HLA B27 Part of seronegative spondyloarthropathy

Answer 44

Gastroenteritis - shigella, salmonella, campylobacter STI - chlamydia

Answer 45

Acute mono arthritis - within 4 weeks of initial infection Bilateral conjunctivitis Anterior uveitis Circinate balanitis Keratoderma blenorrhagica

Answer 46

ABx until septic arthritis excluded NSAIDs Steroid injections Systemic steroids - if multiple joints Most resolve within 6 months and don't recur. Recurrent cases may require DMARDs or anti-TNF medications

Answer 47

Aspirate joint - gram staining, C&S, crystal examination

Answer 48

Obesity ^ age Occupation Trauma Female FHx Hypermobility

Answer 49

Disease of 'wear and tear' Causes - genetic, overuse, injury Synovial joints Imbalance between cartilage being worn down and chondrocytes repairing it - causing structural issues in joint

Answer 50

CMC + DIP joint Squaring of thumb base Episodic joint pain - worse with movement, relieved by rest Stiffness - few mins in AM Painless nodes - Bouchards and Heberdens Commonly affected joints - hips, knees, sacro-iliac joints, DIP, CMC, wrist, cervical spine

Answer 51

If typical features = clinical Dx (over 45 and no stiffness) Plain X-rays - LOSS Loss of joint space Osteophytes Subchondral sclerosis Subchondral cysts X-ray changes don't correlate with Sx Oxford Hip score

Answer 52

Patient education Lifestyle changes - WL, local muscle strenghening exercises, aerobic fitness PT, OT, orthotics Stepwise analgesia: 1 - paracetamol + topical NSAID (knee/hand) 2 - oral NSAID (+PPI) 3 - opiates (codeine/morphine) Intra-articular steroid injections Supports/braces TENS Shockin absorbing soles and shoes Joint replacement - if severe

Answer 53

Autoimmune condition causing chronic inflammation of synovial lining of joints, tendon sheaths and bursa Inflammatory and symmetrical polyarthritis

Answer 54

F>M Middle age FHx Genetic associations - HLA DR4, HLA DR1

Answer 55

Symmetrical distal polyarthropathy - PIP, MCP, wrist/ankle, MTP, cervical spine, large joints Pain, swelling, stiffness (>1 in AM Z-shaped thumb Ulnar deviation of fingers at knuckle +ve squeeze test Swan neck + boutonniere Systemic Sx - fatigue, WL, flu-like illness, muscle aches Palindromic RA - self-limiting short episodes, affecting few joints Atlantoaxial subluxation - can cause SCC - emergency

Answer 56

Pulmonary fibrosis w/ pulmonary nodules (Caplan's) Bronchiolitis obliterans - small airway obstruction Felty's (RA, neutropenia, splenomegaly) Secondary Sjogrens Anaemia of chronic disease CVD Episcleritis + scleritis Rheumatoid nodules Lymphadenopathy CTS Amyloidosis

Answer 57

Clinical American College of Rheum Criteria - joints involved, serology, inflammatory markers, duration

Answer 58

RF Anti-CCP Inflammatory markers X-rays of hand: Loss of joint space Erosions (periarticular) Subluxation Soft tissue swelling Juxta-articular osteoporosis HAQ - functional ability of pt NICE referral - persistent synovitis even if -ve serology, urgent if >3m

Answer 59

Initial - DMARD +/- short course of bridging prednisolone Flares - corticosteroids (oral + IM) Surgery - if significant problems DMARDS - methotrexate (monitor FBC + LFT), sulfasalazine, leflunomide, hydroxychloroquine TNF-i - etanercept, infliximab, adalimumab - if inadequate response to 2 DMARDs Abatacept - causes decreased T-cell proliferation and cytokine production Monitoring Tx response - CRP and disease activity - DAS28

Answer 60

RF +ve, anti-CCP +ve Poor function at presentation X-ray early erosions <2 years HLA DR4 Insidious onset Extra-articular features Female