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Alice's finals cards > Rheumatology > Flashcards

Rheumatology Flashcards

1
Q

What are the 4 key changes on an X-ray of an osteoarthritic joint?

A

L- Loss of joint space
O- Osteophytes
S- Subchondral sclerosis
S- Subchondral cysts

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2
Q

What is the presentation of oestoarthritis?

A

Joint pain and stiffness which is worsened by activity

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3
Q

What signs of osteoarthritis are found in the hands?

A

Heberden’s nodes (DIP)

Bouchard’s nodes (PIP)

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4
Q

How is osteoarthritis diagnosed?

A

Can be made without any investigations if the pt is >45, has typical activity related pain, stiffness lasting < 30 mins and no morning stiffness

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5
Q

Management of osteoarthritis

A 
Physiotherapy
oral paracetamol and topical NSAID
Add oral NSAID and PPI
?opiates
Intra-articular joint injections
joint replacement
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6
Q

What is the distribution pattern of rheumatoid arthritis?

A

Symmetrical and affecting multiple joints

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7
Q

Which 2 genes is RA often associated with?

A

HLA DR4

HLA DR1

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8
Q

What type of autoantibody is rheumatoid factor (RF)

A

It can be any type but is usually IgM

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9
Q

Which 2 antibodies are associated with RA?

A 
Rheumatoid factor (RF)
Cyclic citrullinated peptide antibodies (anti CCP)
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10
Q

What is the usual presentation of RA?

A

Pain and stiffness of small joint of the hands and feet. . Worse in the morning
Better with activity
Associated with fatigue, wt loss

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11
Q

Which joints are almost never affected by rheumatoid arthritis?

A

DIP joints

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12
Q

What changes can be seen in the hands in RA?

A

Z shaped thumb
Swan neck deformity
Boutonnieres deformity
Ulnar deviation

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13
Q

What is Caplan’s syndrome?

A

Pulmonary fibrosis with pulmonary nodules, secondary to RA

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14
Q

Which investigations should be organised in RA?

A

RF, anti CCP antibodies
CRP, ESR
X-rays of hands and feet

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15
Q

What can be seen on X-ray of a joint in RA?

A

Joint destruction and deformity
Soft tissue swelling
Periarticular osteopenia
Boney erosions

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16
Q

What is the DAS28 score?

A

It is a score used in the monitoring of RA. It assesses 28 joints

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17
Q

What is the management of RA?

A

1st line= monotherapy with methotrexate, lefunomide or sulphasalazine
2nd line= 2 DMARDs in combination
3rd line= methotrexate + biological therapy (usually a TNF inhibitor)
4th line= rituximab

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18
Q

What should be prescribed alongside methotrexate?

A

Folic acid 5mg to be taken on a different day

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19
Q

What are the notable side effects of methotrexate?

A

Pulmonary fibrosis

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20
Q

What are the notable side effects of leflunomide?

A

Hypertension

Peripheral neuropathy

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21
Q

What are the notable side effects of sulfasalazine?

A

Temporary male infertility

Bone marrow supression

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22
Q

What are the notable side effects of hydroxychoroquine?

A

Nightmares

Reduced visual acuity

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23
Q

What is the main side effect of anti-TNF medications?

A

Reactivation of TB and Hep B

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24
Q

What are the main side effects of rituximab?

A

Night sweats and thrombocytopenia

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25
What are the signs of psoriatic arthritis?
``` Plaques of psorasis Pitting of nails Onycholysis Dactylitis Enthesitis ```
26
How is psoriatic arthritis screened for?
PEST tool
27
What are the changes seen on X-ray in psoriatic arthritis?
``` Periostitis Ankylosis Oestolysis Dactylitis Pencil in a cup appearance ```
28
What is the management for psoriatic arthritis?
NSAIDs DMARDs Anti-TNF Ustekinumab (monoclonal antibody which targets interleukin 12 and 23)
29
What is reactive synovitis?
When synovitis occurs in the joints as a reaction to a recent infective trigger
30
Which infections commonly trigger reactive arthritis?
Gastroenteritis | STI (most often chlamydia)
31
What are the 3 common associated symptoms of reactive arthritis?
Bilateral conjunctivitis Anterior uveitis Circinate balanitis (cant see, cant pee, cant climb a tree)
32
What is the management of reactive arthritis?
Aspirate the joint and send for gram staining, culture and sensitivity NSAIDs Steriod injections
33
Which gene is ankylosing spondylitis related to?
HLA B27
34
Which are the key joints affected in ankylosing spondylitis
Sacroiliac joints and vertebral column
35
What is the classical X-ray finding in ankylosing spondylitis?
Bamboo spine
36
How does ankylosing spondylitis present?
``` Someone in their late teens or twenties Onset > 3months Lower back pain and stiffness Sacroiliac pain Vertebral fractures ```
37
Which test in examination can help to confirm a diagnosis of ankylosing spondylitis?
Schober's test
38
Which investigations should be done for ankylosing spondylitis?
Inflammatory markers HLA b27 test X-ray of the spine and sacrum MRI of the spine
39
What is the management of the ankylosing spondylitis?
NSAIDs Steriods Anti-TNF
40
What is the pathophysiology of SLE?
SLE is characterised by anti-nuclear antibodies. They are antibodies to proteins within a person's own nucleus
41
How does SLE present?
``` Fatigue Weight loss Photosensitive malar rash Myalgia and arthralgia lymphadenopathy Raynaud's ```
42
Which investigations should be done for SLE?
ANA blood test Urine protein: creatinine ratio (looking for lupus nephritis) FBC, CRP, ESR
43
Which autoantibodies are associated with SLE?
ANA | Anti-dsDNA
44
How is SLE diagnosed?
SLICC or ACR criteria. Involves confirming the presence of antinuclear antibodies
45
How is SLE managed?
NSAIDs Steroids Hydroxychloroquine Suncream for rash
46
How does discoid lupus erthyematosus present?
Photosensitive lesions which are inflamed, dry, crusty and scaling
47
How can a diagnosis of discoid erthyematosus be confirmed?
Skin biopsy
48
How is discoid lupus erythematosus managed?
Sun protection Steriods Hydroxychloroquine
49
What is limited cutaneous systemic sclerosis?
``` Used to be called CREST syndrome C-Calcinosis R-Raynaud's phenomenon E-oEsophageal dymotility S-Sclerodactyly T-Telangiesctasia ```
50
What is diffuse cutaneous systemic sclerosis?
Has many features of CREST syndrome but also CV, lung and kidney problems
51
What is scleroderma renal crisis?
Combination of severe hypertension and renal failure
52
How systemic sclerosis diagnosed?
using classification criteria from the american college of rheumatology
53
What are the main treatments for systemic sclerosis?
Steroids and immunosuppressants
54
Which other rheumatological disease has a strong association with polymyalgia rheumatica?
Giant cell arteritis
55
Who does polymyalgia rheumatica usually affect?
Caucasian women 50 years old
56
What are the core features of PMR?
Bilateral shoulder pain which may radiate to the elbow Bilateral pelvic girdle pain Worse with movement Interferes with sleep Stiffness for at least 45 mins in the morning
57
How long do symptoms of PMR have to be present for diagnosis?
at least 2 weeks
58
How is a diagnosis of PMR made?
Clinical presentation and response to steriods
59
What is the management of PMR?
15mg prednisolone. If no response after one week then stop. Continue for 4 weeks if there is a good response and slowly taper.
60
What are the additional steps that should be taken when someone is started on steroid therapy?
DON'T STOP DON'T- make them aware they will be dependent and mustn't stop S-Sick day rules (increase the dose) T- Treatment card O- Osteoporosis prevention P- PPI
61
What is giant cell arteritis?
It is also known as temporal arteritis. It is a systemic vasculitis of the medium and large arteries
62
What is the key complication of GCA?
Vision loss
63
What are the symptoms of GCA?
``` Severe unilateral headache Scalp tenderness Jaw claudication Blurred or double vision Irreversible painless complete sight loss ```
64
What are the diagnostic criteria for GCA?
Clinical presentation Raised ESR (>50mm/hour) Temporal artery biopsy
65
What is found on temporal artery biopsy in GCA?
Multinucleated giant cells
66
What is seen on duplex ultrasound of temporal artery in GCA?
Hypoechoic halo
67
What is the management of GCA?
Steroids (prednisiolone 40-60mg) Aspirin PPI
68
What is a LATE complication of GCA?
Aortitis leading to aortic aneurysm and aortic dissection
69
What is polymyositis?
Inflammation in the muscles
70
What is dermatomyositis?
Connective tissue disorder where there is chronic inflammation in the skin and muscles
71
What is the key investigation for myositis?
Creatinine kinase blood test. CK should be less than 300U/L, in myositis the result is usually in the thousands
72
What can cause polymyositis or dermatomyositis?
It can be a paraneoplastic syndrome caused by lung, breast, ovarian or gastric cancers
73
How does polymyositis and dermatomyositis present?
Muscle pain, fatigue, weakness Bilaterally Mostly affects shoulder and pelvic girdle develops over weeks
74
What are the skin features of dermatomyositis?
``` Gottron lesions (knuckles, elbows and knees) Photosensitive erythematous rash ```
75
Which autoantibodies are present in dermomyositis and myositis?
Anti-Jo-1 antibodies: polymyositis (but often present in dermatomyositis) Anti-Mi-2 antibodies: dermatomyositis. Anti-nuclear antibodies: dermatomyositis.
76
What is the definitive diagnostic test for dermomyositis?
Muscle biopsy
77
What is the first line treatment for dermomyositis and myositis?
Corticosteriods
78
What is antiphospholipid syndrome?
A disorder associated with antiphospholipid antibodies where the patient is in a hypercoagulable state
79
What are the main associations of antiphospholipid syndrome?
Thrombosis, pregnancy complications and recurrent miscarriage
80
What are the antiphospholipid antibodies associated with antiphospholipid syndrome?
Lupus anticoagulant Anticardiolipin antibodies Anti-beta-2 glycoprotein I antibodies
81
What is livedo reticularis?
A purple lace like rash which is seen in antiphospholipid syndrome
82
How is a diagnosis of antiphospholipid syndrome made?
When there is a history of thrombosis or pregnancy plus persistent antibodies
83
What is the management of antiphospholipid syndrome?
long term warfarin unless pregnant when women are started on LMWH (enoxaparin) plus aspirin
84
What is Sjogren's syndrome?
An autoimmune condition which affects the exocrine glands. It leads to the symptoms of dry mucus membranes (mouth, eyes, vagina)
85
What is the difference between primary and secondary sjogren's?
Primary is when the condition occurs in isolation, secondary is when it occurs related to SLE or RA
86
Which autoantibodies are associated with Sjogren's?
anti-Ro and anti-La
87
Which test is used to diagnose sjogrens and how is it conducted?
Schirmer's test. Involves inserting a folded piece of filter paper under the lower eyelid with a strip hanging out. Leave for 5 mins and see how far the tears travel along the strip. Should be 15mm
88
What is the management of Sjogren's?
Artificial tears Artificial saliva Vaginal lubricants Hydroxychloriquine is used to halt the progression of the disease
89
What are the general symptoms of vasculitis?
``` Purpura joint and muscle pain Peripheral neuropathy Renal impairment HTN ```
90
Which tests should be done to test for vasculitis?
Inflammatory markers (CRP and ESR) ANCA is the antibody present in vasculitis!! p-ANCA (MPO antibodies): Microscopic polyangiitis and Churg-Strauss syndrome c-ANCA (PR3 antibodies): Wegener’s granulomatosis
91
How should vasculitis be managed?
Steroids and immunosuppressants
92
What type of vasculitis is henoch-schonlein purpura?
IgA vasculitis. Inflammation occurs due to immunoglobulin A deposits in the blood vessels
93
What are the 4 classic features of henoch-scholein purpura?
Pupura Joint pain Abdo pain Renal involvement
94
What is the management of HSP?
Analgesia, fluids, rest. Should resolve in 4-6 weeks
95
What is eosinophillic granulomatosis with polyangiitis?
Used to be known as Churg-Strauss syndrome. It is a small and medium vessel vasculitis which is most associated with lung and skin problems.. Can present with severe asthma and elevated eosinophil levels
96
What is wegener's granulomatosis?
Small vessel vasculitis which affects the respiratory tract and kidneys
97
What are the features of wegners granulomatosis?
``` Nose bleeds Crusty nose secretions (ew) hearing loss Saddle shaped nose Cough, wheeze haemoptysis Glomerulonephritis ```
98
What does Behçet’s disease present with?
Recurrent oral and genital ulcers
99
Which gene is Behçet’s disease linked with?
HLA B51
100
What do the ulcers in Behçet’s disease look like?
Painful and sharply circumscribed with a red halo
101
What are skin findings in Behçet’s disease?
Erethema nodosum Papules and pustules Vasculitic types rashes
102
What are they investigations for Behçet’s disease?
The pathergy test.
103
What is the management of Behçet’s disease?
Topical and systemic steroids Colchicone immunosupressiants
104
What causes gout?
High blood urate. This leads to urate crystals being deposited in the joint
105
What are gouty tophi?
Subcutaneous deposits of uric acid
106
Which are the classic joints affected by gout?
Base of the big toe Wrists Base of thumb
107
How is gout diagnosed?
Apirate the joint. the fluid will show needle shaped crystals which are negatively bifringent of polarised light
108
what is seen on X-ray of a gouty joint?
Lytic lesions, punched out erosions, sclerotic borders and overhanging edges
109
How should a flare of gout be managed?
NSAIDs | Colchicine
110
What is a notable side effect of colchicine?
diarrhoea
111
How should gout be prevented?
Allopurinol (xanthine oxidase inhibitor) and lifestyle changes
112
When should gout prophylaxis be initiated?
After the acute attack
113
What is pseudogout?
a crystal arthropathy caused by calcium pyrophosphate crystals
114
What does pseudogout aspirate show?
Rhomboid crystals which are positively birefringent of light
115
What is the classic xray change seen in pseudogout?
Chondrocalcinosis. A thin white line in the joint space which is caused by calcium deposition
116
What are the management options for pseudogout?
NSAIDs Colchicine Joint aspiration Steroid injections
117
What does the FRAX score predict?
A person's risk of a fragility fracture in the next 10 years
118
What factors are considered in a FRAX score?
age, BMI, co-morbidities, smoking, alcohol, bone mineral density and FHx
119
Which joint is the T score measured at in osteoporosis?
The hip
120
What is the range of T scores suggestive of osteopenia?
-1 to -2.5
121
What is the T score indicative of osteoporosis?
Less than -2.5
122
What is the management of osteoporosis?
Bisphosphonates (alendronate 70mg once weekly) | Calcium and vitamin D
123
What is the potential side effect of bisphosphonates and how is this managed?
Reflux and oesophageal erosions
124
What is osteomalacia?
there is defective bone mineralisation which results in soft bones Due to insufficient vitamin D
125
What are the symptoms of vitamin D deficiency?
``` Fatigue Bone pain Muscle weakness Muscle aches Pathological fractures looser zones ```
126
What is the investigation for osteomalacia?
Serum 25-hydroxyvitamin D
127
What is the treatment and dosing for osteomalacia?
Supplementary vitamin D (colecalciferol) 50,000 IU one weekly for 6 weeks 20,000 IU twice weekly for 7 weeks 4000 IU daily for 10 weeks
128
What is Paget's disease of bone?
Excessive bone turnover. This is due to excessive activity of osteoblasts and osteoclasts
129
Why is there increased risk of pathological fractures in paget's disease?
There is areas of high and low density bone which results in large and mishapen bones
130
What does paget's disease present with?
Bone pain Bone deformity Fractures Hearing loss
131
What are the key x-ray findings in paget's disease?
bone enlargment Osteoporosis circumscripta Cotton wool appearance of the skull V shaped defects in the long bones
132
What is seen on blood tests in paget's disease?
Raised ALP | Normal calcium and phosphate
133
What is the management of paget's disease?
Bisphosphonates NSAIDs Calcium and vit D
134
What are the 2 key complications of paget's disease?
Osteogenic sarcoma | Spinal stenosis and cord compression

Alice's finals cards (21 decks)

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