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Phase 3a > Rheumatology 1 > Flashcards

Rheumatology 1 Flashcards

1
Q

When is the peak incidence of rheumatoid arthritis?

A

40s

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2
Q

What are the risk factors for rheumatoid arthritis?

A

Genetic (HLA DR4 and DR1)
Female
Smokers
RF and anti-CCP

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3
Q

What are the constitutional symptoms of RA?

A

Fatigue
Sweat
Weight loss
Fever

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4
Q

What type of arthritis is RA?

A

Insidious symmetrical polyarthritis

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5
Q

What typical joints are involved in RA?

A 
PIP
MCP
Wrist and ankle
MTP
Elbow and knee
Cervical spine
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6
Q

Name three deformities seen in aggressive or untreated RA?

A 
Ulnar deviation at the wrist
Palmar subluxation at the MCP and wrist
Z Thumb
Boutonniere's
Hammer toe
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7
Q

What is Boutonniere’s deformity?

A

Fixed flexion of digit

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8
Q

What are the signs of active rheumatoid?

A

Heat, redness, swelling, pain, stiffness >30 minutes in the morning

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9
Q

What is the name of the form of RA, where joint inflammation is episodic and resolves with no lasting damage?

A

Palindromic

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10
Q

Name three systemic features of RA?

A 
Secondary Sjogren's syndrome
Episcleritis
Rash
Rheumatoid nodules
Pulmonary fibrosis
Serositis
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11
Q

What is Felty’s syndrome?

A

RF positive RA
Neutropenia
Splenomegaly

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12
Q

Why are RA patients at risk of osteoporosis?

A

Consequence of long term steroids

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13
Q

What are the components of the DAS28 score?

A

CRP/ESR
Global VAS - how has the patient’s RA been over the last week
Number of tender joints
Number of swollen jionts

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14
Q

What is found on FBC and acute phase reactants in a patient with active rheumatoid?

A

Raised ESR and CRP
Normochromic normocytic anaemia
Reactive thrombocytosis
Raised ferritin but low serum iron

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15
Q

What percentage of the normal population have a positive RF?

A

5%

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16
Q

What is anti-CCP and why is it sometimes better to use than RF?

A

Anti-cyclic citrullinated peptide

More specific than RF

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17
Q

What is seen on X-Ray in RA?

A

Soft tissue swelling and synovitis
Periarticular osteopenia
Loss of joint space
Erosions

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18
Q

What is the treatment of a newly diagnosed rheumatoid arthritis patient?

A 
IM depomedrone (tides patient over until methotrexate kicks in)
Methotrexate and another DMARD such as hydroxychloroquine or sulfasalazine
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19
Q

When might methotrexate not be started in a newly diagnosed RA patient?

A

Patient is breastfeeding
Patient is trying to conceive/pregnant
Disease is very mild

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20
Q

Name three anti-TNF biological DMARDs

A

Infliximab
Etanercept
Adalimumab

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21
Q

What is the mechanism of rituximab?

A

Anti-CD20

Binds to B cells and triggers cell apoptosis

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22
Q

What is the main side effect of methotrexate?

A

Nausea (decreased with folic acid)

Abnormal liver function

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23
Q

If a patient is intolerant to methotrexate why can’t they have rituximab?

A

Rituximab must be taken with methotrexate as there is a higher risk with this biologic that antibodies will form against the biologic. Methotrexate decreases the chance of this happening

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24
Q

What is tocilizumab?

A

Anti-IL6

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25
Q

What is abatacept?

A

T-cell co-stimulator modulator

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26
Q

What is baracitinib?

A

JAK inhibitor

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27
Q

What is the DAS28 threshold to signify uncontrolled disease and possibly the changing of medication?

A

DAS28>5.1

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28
Q

What factors convey a poor prognosis in RA?

A

Male
Diagnosed less than 30 years
Large number of joints involved
Extra-articular manifestations

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29
Q

What is SLE?

A

A heterogenous, inflammatory, multi-system autoimmune disease

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30
Q

What are the risk factors for SLE?

A

Female
Afro-Caribbean/SE Asian/Chinese ethnicity
HLA DR2/DR3

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31
Q

What is the most common cause of SLE?

A

Idiopathic

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32
Q

Name three drugs that can induce lupus

A 
Chlopromazine
Methyldopa
Isoniazid
d-penicillamine
Minocycline
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33
Q

What are the signs and symptoms of SLE?

A 
Inflammatory arthritis
Systemic features
Oral ulcers
Dry eyes and mouth
Alopecia
Malar butterfly rash
Pleurisy and fibrosis
Raynaud's
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34
Q

What is the malar butterfly rash of lupus?

A

Photosensitive
Erythematous, raised, pruritic
Spares the naso-labial folds

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35
Q

What other rashes feature in SLE?

A

Discoid lupus
Livedo reticularis
Alopecia
Vasculitic rashes

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36
Q

How is lupus nephritis diagnosed?

A

Routine monitoring of hypertension, proteinuria, haematuria, raised urea or creatinine

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37
Q

What type of anaemia is common in SLE?

A

Haemolytic

But normochromic normocytic anaemia is common

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38
Q

What antibodies are found in SLE?

A 
Anti-dsDNA
Anti-SM
Antiphospholipid
ANA
Anti-histone if drug induced
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39
Q

How is haemolytic anaemia diagnosed?

A

direct Coombs’ test

Reticulocytes, bilirubin, blood film

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40
Q

What complement levels are seen in SLE?

A

Low C3 and C4

High C3d

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41
Q

What malignancy is associated with SLE?

A

non-Hodgkin’s lymphoma

42
Q

Name some drugs used to treat various symptoms of SLE.

A

Hydroxychloroquine
Mycophenolate mofetil
Azathioprine
Cyclophosphamide

43
Q

Which drug is first line for mild SLE?

A

Hydroxychloroquine

44
Q

Name some risk factors for fibromyalgia

A 
Stress
Chronic fatigue
Women
Depression
PTSD
45
Q

Name some symptoms of fibromyalgia.

A

Chronic widespread pain and stiffness
Fatigue and poor sleep
Poor memory and concentration
Paraesthesias

46
Q

Which conditions may co-exist with fibromyalgia?

A

IBS
Tension headaches
Irritable bladder
TMJ syndrome

47
Q

How many tender points are required to diagnose fibromyalgia?

A

11/18

48
Q

What medications are used to treat the pain of fibromyalgia>

A

Opioids
NSAIDs
Amitriptyline and duloxetine
Pregabalin and gabapentin`

49
Q

Name some large vessel vasculitides.

A

Giant cell arteritis

Takayasu’s arteritis

50
Q

Describe the facial pain of GCA.

A

Recent onset
Temporal/occipital
Scalp tenderness
Jaw claudication

51
Q

What percentage of GCA patients have cerebral, systemic, and both cerebral and systemic involvement?

A

Both - 30%
Systemic only - 5%
Cerebral only - 65%

52
Q

What percentage of RA patients are RF positive, and what percentage of the normal population are RF positive?

A

RF positive RA - 80%

RF positive non-RA - 20%

53
Q

What are the visual symptoms of GCA?

A

Amaurosis fugax
Diplopia
Blurred vision

54
Q

What is the cause of amaurosis fugax?

A

Ischaemic optic neuritis due to vasculitic involvement of the ophthalmic artery.

55
Q

What is the main complication of GCA?

A

Subclinical aortic root involvement leading to aneurysms

56
Q

What is the name of the syndrome where vasculitis affects the aortic arch vessels, causing brain ischaemia?

A

Subclavian steal syndrome

57
Q

Name four consequences of long term steroids

A

Osteoporosis
Steroid myopathy
Bruising
Hypertension

58
Q

What is the different in treatment response between GCA and PMR?

A

PMR is exquisitely sensitive to steroids and does not relapse once in remission
GCA is less sensitive and may relapse

59
Q

How is GCA diagnosed?

A

Pulseless temporal artery
Bruit over carotid, axillary, or brachial arteries
Elevated ESR
Temporal artery biopsy

60
Q

What is seen on temporal artery biopsy in GCA?

A

Vasculitis with skip lesions
Mononuclear cells
Granulomas

61
Q

What are three differentials of GCA?

A

Migraine or tension headache
Trigeminal neuralgia
Takayasu’s arteritis

62
Q

What is the treatment of GCA?

A

Immediate PO prednisolone

63
Q

In what circumstances is IV methylprednisolone given in GCA?

A

If visual symptoms are present

64
Q

What does joint hypermobility mean?

A

Joints easily move beyond their normal expected range

65
Q

What is the main risk factor for benign joint hypermobility?

A

Family history

66
Q

Why does hypermobility sometimes lead to exercise related pain?

A

When the body is deconditioned, tissue laxity leads to soft tissue injury. Exercise avoidance means a worsening spiral is set up.

67
Q

What are some other symptoms of hypermobility?

A

Hand writing pain
Fatiguability
Generalised tiredness
Posture related muscle pains

68
Q

Is stiffness present in hypermobility syndrome?

A

Yes, after activity

Often for several days

69
Q

What other conditions is hypermobility associated with?

A

Postural orthostatic tachycardia syndrome (POTS)
Hernias
Uterine or rectal prolapse
Joint dislocation

70
Q

How is POTS diagnosed?

A

Tilt table test

71
Q

What criteria scores hypermobility?

A

Beighton

72
Q

What are the components of the Beighton scores?

A

Little fingers - passive dorsiflexion beyond 90
Thumbs: passive dorsiflexion to forearm
Elbows: hyperextension beyond 10
Knees: hyperextension beyond 10
Trunk: palms on the floor with knees fully extended

73
Q

What Beighton score corresponds to hypermobility?

A

4-6

Young adult

74
Q

What are the differentials of hypermobility?

A

Type 3 Ehlers Danlos
JIA/RA
Fibromyalgia
AS

75
Q

How is hypermobility managed?

A

Physio - strengthening muscle groups

Progressive resisted exercise programme

76
Q

What is the cause of gout?

A

Deposition of monosodium urate crystals within joints causing acute inflammation and eventual tissue damage

77
Q

What is the typical threshold of serum uric acid for recurrent attacks of gout?

A

> 360umol/L

78
Q

What are the risk factors of gout?

A 
Male
Meat/seafood/alcohol
Diuretics
Obesity
Hypertension
79
Q

Name 3 protective factors for gout

A

Dairy products
Coffee
Vitamin C

80
Q

What are the symptoms of gout?

A 
Acute pain
Swelling
Tender
Erythema
Fever
Inability to bear touch/walk
81
Q

What is the most common joint to be affected by gout?

A

First MTP

82
Q

Name three differentials of uric acid gout?

A

Septic arthritis
Calcium pyrophosphate deposition disease
Chronic tophaceous RA

83
Q

What investigations are required in gout?

A

Joint aspiration
Serum uric acid (in an asymptomatic period)
X-Ray
Fasting glucose and lipids

84
Q

What is seen in joint aspiration in gout?>

A

Negatively birefringent needle shaped crystals

85
Q

What are the X-Ray findings in chronic gout?

A

Punched out lesions
Sclerosis
Tophia

86
Q

Why is it important to do fasting glucose and lipids?

A

Gout is commonly associated with metabolic syndrome

87
Q

What is the treatment of an acute attack of gout?

A

Elevation and ice
NSAIDs
Colchicine

88
Q

What is the prophylactic treatment of gout?

A

Allopurinol

Febuxistat

89
Q

When is gout prophylaxis indicated?

A

> 1 attack per 12 months

90
Q

Which foods are high in purines and therefore intake should be reduced?

A

Red meat
Liver and kidneys
Herring, sardines, and mussels

91
Q

Which drugs can cause hyperuricaemia?

A

Diuretics
Aspirin
Ciclosporin
Chemotherapy

92
Q

What type of drug is allopurinol?

A

Xanthase oxidase inhibitor that lowers urate

93
Q

When should gout prophylaxis be initiated?

A

1-2 weeks after an acute attack

94
Q

What crystals are associated with pseudogout?

A

Calcium pyrophosphate dihydrate

95
Q

Attacks of pseudogout can be precipitated by…

A

Dehydration
Illness
Surgery or trauma
RF: haemochromatosis

96
Q

What is the most common joint affected in pseudogout?

A

Knee and wrist

97
Q

How do the symptoms of pseudogout compare with uric acid gout?

A

Similar but milder

98
Q

What does aspiration of a pseudogouty joint show?

A

Intracellular and extracellular weakly positive birefringent rhomboid crystals

99
Q

What is the treatment of gout?

A

Symptomatic

Ice packs, NSAIDs, therapeutic aspiration

100
Q

What are the causes of drug-induced lupus?

A

Procainamide
Hydralazine
Isoniazid

Phase 3a (18 decks)

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