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AKT > Rheumatology > Flashcards

Rheumatology Flashcards

1
Q

Causes of scarring alopecia

A 
Trauma, burns
Radiotherapy
Lichen planus
Discoid lupus
Tinea capitis
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2
Q

Causes of non-scarring alopecia

A 
Male pattern baldness
Drugs = cytotoxic, carbimazole, heparin, oral contraeption, colchine
Iron deficiency, zinc deficiency
Alopecia areata
Telogen effluvium
Trichotillomania
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3
Q

How to manage any new synovitis

A

Refer urgently to rheumatology

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4
Q

Main side effect of colchicine

A

Diarrhoea

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5
Q

2nd line treatment for gout

A

febuxostat

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6
Q

Inheritance of McArdle’s disease

A

Autosomal recessive

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7
Q

Features of McArdle’s disease

A

Muscle pain and stiffness after exercise
Muscle cramps
Myoglobinuria
Low lactate levels during exercise

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8
Q

If a patient has undiagnosed primary hyperparathyroidism and is started on vitamin D replacement, what is a possible risk?

A

Severe hypercalcaemia and vitamin D toxicity

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9
Q

Side effects of gold

A

Proteinuria

Corneal opacities

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10
Q

Side effects of penicilliamine

A

Proteinuria

Exacerbation of myasthenia gravis

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11
Q

What test is most specific for SLE?

A

Anti-dsDNA

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12
Q

Supplements to be taken during pregnancy

A

400mcg folic acid pre-conception and until 12 weeks gestation (5mg if high risk for neural tube defect)

10mcg vitamin D throughout entire pregnancy

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13
Q

DEXA scan - what is the Z score adjusted for?

A

Age, gender and ethnic factors

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14
Q

Monitoring for patients on biologic therapy

A

FBC, U+E, LFTs every 3-4 months after starting therapy, then every 6 months one stable

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15
Q

Which blood test is a useful rule out test for SLE?

A

ANA

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16
Q

Ehler-Danlos syndrome inheritance

A

Autosomal dominant

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17
Q

Ehler-Danlos syndrome features

A 
Elastic, fragile skin
Joint hypermobility - multiple dislocations
Easy bruising
Aortic regurg, mitral valve prolapse
Aortic dissection
SAH
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18
Q

HLA B27 associations

A

Ankylosing spondylitis
Reactive arthritis
Acute anterior uveitis

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19
Q

HLA DR3 associations

A

Dermatitis herpetiformis
Sjogren’s syndrome
Primary biliary cirrhosis

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20
Q

DLA DR4 associations

A

T1DM

Rheumatoid arthritis

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21
Q

Secondary causes of Raynaud’s

A 
Connective tissue disorders: scleroderma, RA, SLE
Leukaemia
Type 1 cryoglobulinaemia
Using vibrating tools
Cervical rib
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22
Q

Drug causes of Raynaud’s

A

Oral contaceptive pill

Ergot (used in cluster headaches)

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23
Q

Raynaud’s - factors suggesting underlying connective tissue disorder

A 
Onset over 40
Unilateral
Rashes
Autoantibodies
Digital ulcers
Calcinosis
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24
Q

Raynaud’s - management

A

CCB - nifedipine
IV prostacyclin infusion
Refer all with suspected secondary Raynauld’s

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25
Q

Lateral epicondylitis - what exacerbates the pain?

A

Wrist extension against resistance with elbow extended

Supination of the forearm with elbow extended

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26
Q

Medial epicondylitis - what exacerbates the pain?

A

Wrist flexion and pronation

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27
Q

Blood tests in osteoporosis

A

Calcium normal

Phosphate normal

ALP normal

PTH normal

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28
Q

Blood tests in osteomalacia

A

Calcium decreased

Phosphate decreased

ALP increased

PTH increased

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29
Q

Blood tests in primary hyperparathyroidism

A

Calcium increased

Phosphate decreased

ALP increased

PTH increased

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30
Q

Bone profile blood tests in CKD

A

Calcium decreased

Phosphate increased

ALP increased

PTH increased

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31
Q

Blood tests in Paget’s disease

A

Calcium normal

Phosphate normal

ALP increased

PTH normal

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32
Q

Blood tests in osteopetrosis

A

Calcium normal
Phosphate normal
ALP normal
PTH normal

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33
Q

Causes of dactylitis

A 
Psoriasis
Reactive arthritis
Sickle cell disease
TB
Sarcoidosis
Syphilis
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34
Q

Side effects of denosumab

A 
Dyspnoea
Diarrhoea
URTI
Hypocalcaemia
Atypical femoral fractures
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35
Q

Causes of drug induced lupus

A

Procainamide

Hydralazine

Phenytoin

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36
Q

Fibromyalgia - management

A

Explanation
Aerobic exercise
CBT
Pregabalin, duloextine, amitriptyline

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37
Q

Fibromyalgia - diagnosis

A

Clinical

Tender in 11/18 ‘tender points’

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38
Q

Fibromyalgia - features

A 
Chronic pain at multiple sites
Lethargy
"Brain fog"
sleep disturbance
Headaches
Dizziness
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39
Q

What is the minimum steroid intake a patient should be taking before they are offered osteoporosis prophylaxis?

A

7.5mg prednisolone or more each day for 3 months

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40
Q

Which rheumatoid drug causes retinopathy?

A

Hydroxychloroquine

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41
Q

T score > -1.0

A

Normal

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42
Q

T score -1.0 to -2.5

A

Osteopenia

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43
Q

T score < -2.5

A

Osteoporosis

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44
Q

Risk of calcium supplements

A

Increased MI

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45
Q

Which drugs cannot be prescribed with methotrexate and why?

A

Trimethoprim and cotrimoxazole - increase risk of marrow aplasia

High dose aspirin - increased risk of methotrexate toxicity

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46
Q

How to alter the colchicine dose in renal failure

A

reduce dose by 50% if creatinine clearance is less than 50

Avoid if less than 10

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47
Q

Features of transient idiopathic osteoporosis

A

Third trimester of pregnancy
Groin pain with limited range of movement
Unable to weight bear
Raised ESR

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48
Q

Age <75 and had a previous fragility fracture?

A

DEXA scan

then FRAX assessment

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49
Q

Age >75 and previous fragility fracture?

A

No need to DEXA, start treatment

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50
Q

Blood test findings in antiphospholipid syndrome

A

Prolonged APTT

Low platelets

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51
Q

Scoring system used to assessed for hypermobility

A

Beighton score

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52
Q

What is ANCA?

A

anti-neutrophil cytoplasmic antibody

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53
Q

Conditions associated with pANCA

A

UC
Crohn’s

Primary sclerosing cholangiits

Eosinophilic granulomatosis polyangiitis
Anti-GBM disease

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54
Q

Conditions associated with cANCA

A

granulomatosis with polyangiitis

microscopic polyangiitis

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55
Q

ANCA associated vasculitis - investigations

A

Urinalysis for proteinuria and haematuria
U+E
FBC
CRP raised
ANCA
CXR: nodular, fibrotic or infiltrative lesions

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56
Q

ANCA associated vasculitis - features

A

Renal = proteinuria, haematuria, creatinine rise

Respiratory = dysphoea, haemoptysis

Fatigue, weight loss, fever

Vasculitic rash

Sinusitis

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57
Q

Types of malignant bone tumours

A

Osteosarcoma
Chondrosarcoma
Ewing’s sarcoma

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58
Q

Osteosarcoma - predisposing factors

A

Rb gene (associated with retinoblastoma)
Paget’s disease
Radiotherapy

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59
Q

Osteosarcoma - main location

A

Long bones prior to epiphyseal closure

Femur, tibia, humerus

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60
Q

Osteosarcoma - xray findings

A

Codman’s triangle (due to periosteal elevation)

Sunburst pattern

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61
Q

What is chondrosarcoma?

A

Malignant tumour of cartilage

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62
Q

Chondrosarcoma - main location

A

axial skeleton

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63
Q

Ewing’s sarcoma - age of presentation

A

Children and adolescence

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64
Q

Ewing’s sarcoma - main location

A

Pelvis and long bone

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65
Q

Ewing’s sarcoma - presentation

A

Severe pain

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66
Q

Ewing’s sarcoma - xray findings

A

‘onion skin’ appearance

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67
Q

Types of benign bone tumours

A

Osteoma

Osteochondroma

Giant cell tumour

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68
Q

Osteoma - associations

A

Gardner’s syndrome

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69
Q

What is osteoma?

A

Benign ‘overgrowth’

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70
Q

Osteoma - main location

A

Skull

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71
Q

What is osteochondroma?

A

Cartilage capped bony projection on external surface of bone

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72
Q

Osteochondroma - who is affected

A

Males

Under 20

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73
Q

Giant cell tumour - xray findings

A

Double bubble or soap bubble sign

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74
Q

What is temporal arteritis?

A

A large vessel vasculitis

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75
Q

Temporal arteritis - features

A 
Age >60
Headache
Jaw claudication
Visual changes - blurring, amaurosis fugas, double
Tender, palpable temporal artery
PMR symptoms
Lethargy, low grade fever, night sweats
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76
Q

Temporal arteritis - investigations

A

Raised ESR >50
Raised CRP
Temporal artery biopsy = skip lesions
CK and EMG normal

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77
Q

Temporal arteritis - management

A

High dose steroids

  • oral if no visual changes
  • IV methylpred if visual loss

Will also need bone protection

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78
Q

Antibodies in systemic lupus erythematous

A 
ANA in 90%
Rheumatoid factor in 20%
Anti-dsDNA - highly specific
Anti-smith
Raised ESR
normal CRP
Low C3 and Low C4 during active disease
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79
Q

SLE - which antibody as a screening test?

A

ANA

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80
Q

SLE - which antibody is the most specific?

A

anti-dsDNA

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81
Q

SLE - MSK features

A

arthraglia

non-erosive arthritis

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82
Q

SLE - cardiovascular features

A

pericarditis

myocarditis

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83
Q

SLE - respiratory features

A

pleurisy

fibrosing alveolitis

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84
Q

SLE - renal features

A

proteinuria

glomerulonephritis

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85
Q

SLE - neuro features

A

anxiety, depression
psychosis
seizures

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86
Q

SLE - skin features

A 
malar rash
discoid rash
photosensitive
Raynaud's
Livedo reticularis
non-scarring allopecia
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87
Q

What is a discoid rash?

A

scaly, red, well demarcated patches

sun-exposed places

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88
Q

How to monitor SLE disease activity

A

ESR

anti-dsDNA

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89
Q

Which ethnic group is most at risk of SLE?

A

Afro-caribbean

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90
Q

SLE - management

A

NSAIDS
corticosteroids
hydroxychloroquine
belimumab

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91
Q

What is Sjogren’s syndrome?

A

Autoimmune disorder affecting exocrine glands resulting in dry mucous membranes

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92
Q

What can Sjogren’s syndrome be secondary to?

A

Connective tissue diseases

Rheumatoid arthritis

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93
Q

Sjogren’s syndrome - features

A

Dry eyes and mouth
Vaginal dryness

Arthralgia, myalgia

Raynauld’s

Sensory polyneuropathy

Renal tubular acidosis

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94
Q

Sjogren’s syndrome - antibodies

A

Rheumatoid factor
ANA

anti-Ro antibodies in 70%
anti-La antibodies in 30%

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95
Q

Sjogren’s syndrome - investigations

A

antibodies

Schirmer’s test = filter paper near conjuctival sca to measure tear formation

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96
Q

What malignancy are people with Sjogren’s syndrome at risk of?

A

40-60 fold increase risk of lymphoid malignancy

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97
Q

Sjogren’s syndrome - management

A

Artificial tears and saliva

Pilocarpine may stimulate saliva

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98
Q

What is reactive arthritis?

A

HLA-B27 associated seronegative arthropathy

99
Q

Reactive arthritis - causes

A

STI - chlamydia

GI infection

100
Q

Reactive arthritis - features

A

Arthritis - asymmetrical, lower limbs
Dactylitis

Urethritis
Conjunctivitis
Anterior uveitis

Skin = circinate balanitis, keratoderma blenorrhagica

101
Q

Reactive arthritis - skin findings

A

Keratoderma blenorrhagica

102
Q

Reactive arthritis - management

A

Analgesia, NSAIDs
Intraarticular steroids
In persistent disease: sulfasalazine, methotrexate

103
Q

Reactive arthritis - prognosis

A

Symptoms generally last 4-6 months, in most people resolve within 12 months

25% have recurrent episodes
10% have chronic disease

104
Q

What percentage of people with psoriasis develop psoriatic arthritis?

A

10-20%

105
Q

Psoriatic arthritis - arthritis features

A

May be symmetrical similar to RA or asymmetrical

Sacroilitis

DIP joint

Arthritis mutilans - severe hand defmority

106
Q

Psoriatic arthritis - skin features

A

Psoriatic skin lesions
Nail pitting
Oncholysis

107
Q

Psoriatic arthritis - periarticular disease

A

Enthesitis
Tenosynovitis
Dactylitis

108
Q

Psoriatic arthritis - xray changes

A

Erosive changes and new bone formation

Periostitis

“pencil in cup” appearance

109
Q

Uses of methotrexate within rheumatology

A

inflammatory arthritis - RA

psoriasis

110
Q

Methotrexate and pregnancy

A

Avoid for 6 months after treatment in men and women

111
Q

Methotrexate side effects

A

Mucositis
Pneumonitis

Myelosuppression

Pulmonary fibrosis
Liver fibrosis

112
Q

Methotrexate - monitoring

A

FBC, U+E, LFT

Before starting then weekly until stable, 2-3 months when stable

113
Q

Methotrexate - prescribing

A

weekly

with folic acid 5mg weekly on a different day

114
Q

Methotrexate - treatment for toxicity

A

Folinic acid

115
Q

What is dermatomyositis?

A

inflammatory disorder

causing symmetrical, proximal muscle weakness and characteristic skin lesions

116
Q

Dermatomyositis - skin features

A

Photosensitive

Macular rash over back and shoulder

Heliotrope rash around eyes

Gottron’s papules = red papules over back of fingers

Mechanics hands

Nail fold capillary dilation

117
Q

Dermatomyositis - non-skin features

A

Proximal muscle weakness, may be tender

Raynaud’s

Respiratory muscle weakness
Interstitial lung disease

Dysphagia
Dysphonia

118
Q

Dermatomyositis - causes

A

Idiopathic

Connective tissue disease

Malignancy

119
Q

Dermatomyositis - investigations

A

ANA in 80%

Anti-Jo-1 antibodies
Anti SRP antibodies
Anti-Mi-2 antibodies

Screen for underlying malignancy

120
Q

Marfan’s syndrome - inheritance

A

Autosomal dominant

121
Q

Marfan’s syndrome - features

A 
tall
high arched palate
long, slim fingers
pectus excavatum
pes plantus (flat foot)
scoliosis
122
Q

Marfan’s syndrome - complications

A

Dilation of aortic sinuses = aortic aneurysms, aortic dissection, aortic regurg, mitral valve prolapse

Repeat pneumothorax

Eyes = upwards lens dislocation, blue sclera, myopia

123
Q

Marfan’s syndrome - management

A

beta blockers
avoid vigorous exercise and contact sports
surgery - aortic root graft replacement

124
Q

Osteoarthritis - main joints affected in the hand

A

carpometacarpal

DIP

PIP

125
Q

Osteoarthritis - xray changes

A

Loss of joint space

Subchondral sclerosis

Subchondral cysts

Osteophytes at joint margins

126
Q

Osteoarthritis - management

A

weight loss, support braces, muscle strengthening exercises

1st = paracetamol + topical NSAIDS

2nd = oral NSAIDS (+PPI), opioids, capsaicin cream, intraarticular steroids

If not working refer for joint replacement

127
Q

Rheumatoid arthritis - features

A

Swollen, painful joints in hand and feet

Gradually gets worse and involves larger joints

Stiffness worse in morning

Positive squeeze test

128
Q

Rheumatoid arthritis - late signs O/E of the hands

A

swan neck deformity

boutonniere’s deformity

129
Q

Rheumatoid arthritis - investigations

A

Rheumtaoid factor in 70-80%
Anti-cyclic citrulinated antibody - in 70%, specific
Raised ESR
Raised CRP

130
Q

Most specific antibody test for rheumatoid arthritis?

A

anti-cyclic citrulinated antibody

131
Q

Rheumatoid arthritis - xray findings

A

Loss of joint space

Juxta-articular osteoporosis

Soft tissue swelling

Periarticular erosins

Subluxation

132
Q

Rheumatoid arthritis - poor prognostic factors

A 
Rf positive
Anti-CCP antibodies positive
Poor functional status at diagnosis
Xray shows early erosions (<2 years)
HLA DR4
Insidious onset 
Female
133
Q

Rheumatoid arthritis - complications

A

pulmonary fibrosis, pleural effusion

keratoconjunctiva sicca
episcleritis, scleritis
corneal ulcer, keratits

osteoporosis

IHD

depression

134
Q

What is Felty’s syndrome

A

RA + splenomegaly + low WCC

135
Q

Rheumatoid factor - initial therapy

A

DMART + bridging prednisolone

136
Q

Rheumatoid factor - treating flares

A

Oral or IM corticosteroids

137
Q

Rheumatoid arthritis - management

A

1st line = DMARTS

TFT inhibitors if inadequate response to 2x DMARTs

138
Q

Types of DMARDS

A

Methotrexate

Sulfasalazine

Lefluzonmide

Hydroxychloroquine

139
Q

Types of TNF inhibitors

A

Etanercept

Infliximab

Adalimumab

140
Q

Side effects of etanercept

A

Demyelination

Reactivation of TB

141
Q

Side effects of infliximab

A

Reactivation of TB

142
Q

Side effects of adalimumab

A

Reactivation of TB

143
Q

Osteomalacia - causes

A

Vit D deficiency - malabsorption, lack of sunlight, diet
CKD
Drugs - anticonvulsants
Inherited - hypophosphaemic rickets

144
Q

Osteomalacia - xray changes

A

Translucent bands called looser’s zones or pseudofracture

145
Q

Osteomalacia - management

A

Vit D supplementation

Calcium supplement if dietary calcium insufficient

146
Q

What is leflunomide?

A

DMARD used in rheumatoid arthritis

147
Q

Leflunomide - what to monitor

A

FBC
LFT
Blood pressure

148
Q

Leflunomide - side effects

A

Diarrhoea

HTN

Weight loss

Peripheral neuropathy

Myelosuppression

Pneumonitis

149
Q

Leflunomide - pregnancy

A

Avoid pregnancy for 2 years after stopping in women and 3 months after stopping in men

150
Q

Leflunomide - contraindications

A

Pregnancy
Pre existing lung disease
Pre existing liver disease

151
Q

Hydroxychloroquine - pregnancy

A

Can be used in pregnancy and breastfeeding

152
Q

Hydroxychloroquine - uses

A

Rheumatoid arthritis
SLE
Discoid lupus

153
Q

Hydroxychloroquine - side effects

A

Retinopathy (bull’s eye retinopathy)

Corneal deposits

154
Q

Hydroxychloroquine - monitoring

A

Annual ophthalmology screening for retinopathy

155
Q

Systemic sclerosis - antibodies

A

ANA
Rheumatoid factor

Anti-scl-70 antibodies in diffuse cutaneous

Anti-centromere antibodies in limited cutaneous

156
Q

Limited cutaneous systemic sclerosis

A

CREST is a subtype

Scleroderma affects face and distal limbs

Anti-centromere antibodies

157
Q

Features of CREST syndrome

A 
Calcinosis
Raynaud's
oEsophageal dismotility
Sclerodactyly
Telangiectasia
158
Q

Diffuse cutaneous systemic sclerosis

A

Scleroderma affects trunk and proximal lumbs

Scl-70 antibodies

Interstitial lung disease
Pulmonary artery hypertension
Renal disease
HTN

159
Q

Scleroderma

A

No internal organ involvement
Tightening and fibrosis of skin
Plaques on liver

160
Q

Sulfasalazine - uses

A

Inflammatory arthritis e.g. RA

IBD

161
Q

Sulfasalazine - cautions

A

G6PD deficiency

Allergy to aspirin or sulphonamides

162
Q

Sulfasalazine - side effects

A

Oligospermia

Steven Johnsons Syndrome

Pneumonitis/ lung fibrosis

Coloured tears, stained contact lens

Myelosuppression

Heinz body anaemia

Megaloblastic anaemia

163
Q

Azathioprine - side effects

A

Bone marrow suppression

N+V

Pancreatitis

Increased risk of non-melanoma skin cancer

164
Q

Azathioprine - interactions

A

Allopurinol therefore need lower dose

165
Q

Azathioprine - in pregnancy

A

Safe

166
Q

What is polymyositis?

A

Inflammatory disorder causing symmetrical proximal muscle weakness

167
Q

Polymyositis - pathophysiology

A

T cell mediated cytotoxic process against muscle fibres

168
Q

Polymyositis - associations

A

Idiopathic
Connective tissue disorders
Malignancy

169
Q

Polymyositis - features

A

Proximal muscle weakness, may be tender

Raynaud’s

Respiratory muscle weakness
Interstitial lung disease

Dysphagia
Dysphonia

170
Q

Polymyositis - investigations

A

Raised CK

Muscle biopsy

Anti-Jo-1 antibodies

171
Q

Polymyositis - management

A

Sunblock
Exercise to maintain strength
Steroids
Azathioprine if steroids fail

172
Q

What is polyarteritis nodosa?

A

Vasculitis affecting medium sized arteries

with necrotising inflammation leading to aneurysm formation

173
Q

Polyarteritis nodosa - associations

A

Hep B

174
Q

Polyarteritis nodosa - who is typically affected?

A

Middle aged men

175
Q

Polyarteritis nodosa - features

A

Fever, malaise, arthralgia

Hypertension

Mononeuritis multiplex
Sensorimotor polyneuropathy

Testicular pain
Haematuria
Renal failure

Livedo reticularis

176
Q

Polyarteritis nodosa - investigations

A

Hep B surface antigen

pANCA in 20%

Biopsy of small artery = necrotising inflammation

Arteriography = microaneurysms

177
Q

How many people with Paget’s disease of the bone are symptomatic?

A

1 in 20

178
Q

Paget’s disease of the bone - typical presentation

A

older man with bone pain and isolated rise in ALP

179
Q

Paget’s disease of the bone - features

A

Bone pain - pelvis, lumbar spine, pelvis
Bowing of tibia
Bossing of skull

180
Q

Paget’s disease of the bone - skull xray findings

A

Thickened vault

Osteoporosis circumscripta

181
Q

Paget’s disease of the bone - complications

A 
Deafness
Bone sarcoma
Fracture
Skull thickening
High output cardiac failure
182
Q

Paget’s disease of the bone - predisposing factors

A

Increased age
Male
Northern latitude
Family history

183
Q

Paget’s disease of the bone - treatment

A

Bisphosphonates - oral risedronate or IV zoledronate

184
Q

Indications to treat Paget’s disease of the bone

A

Bone pain
Skull or long bone deformity
Fracture
Peri-articular Paget’s

185
Q

What is Paget’s disease of the bone?

A

Increased and uncontrolled bone turnover

186
Q

What is gout?

A

Microcrystal synovitis

caused by deposition of monosodium urate monohydrate in synovium

187
Q

Causes of reduced excretion of uric acid

A

Diuretics
CKD
Lead toxicity

188
Q

Causes of increased production of uric acid

A

Myeloproliferative or lymphoproliferative disorders
Cytotoxic drugs
Severe psoriasis

189
Q

Gout - features

A

Pain, swelling, erythema

70% first presentations affect the 1st metatarsophalangeal joint

190
Q

Gout - xray features

A

Joint effusion

Punched out lesions with sclerotic margins

Joint space is preserved until late disease

Eccentric erosions

Soft tissue tophi

191
Q

Gout - acute management

A

Colchicine or NSAIDS (+PPI)
Steroids if both contraindicated
Continue allopurinol if already on it

192
Q

Gout - when to start chronic management

A

After first attack

193
Q

Gout - 1st line chronic management

A

Allopurinol

With colchicine cover

194
Q

Gout - 2nd line chronic management

A

febuxostat

195
Q

Gout - precipitating drugs

A

Thiazide diuretics

196
Q

What is behcet’s syndrome?

A

Autoimmune mediated inflammation of arteries and veins

197
Q

Behcet’s syndrome - features

A

Oral ulcers
Genital ulcers
Anterior uveitis

198
Q

Antiphospholipid syndrome - secondary causes

A

SLE

Lymphoproliferative disorders

199
Q

Antiphospholipid syndrome - features

A

Venous and arterial thrombosis
Recurrent fetal loss
Livedo reticularis

200
Q

Antiphospholipid syndrome - investigations

A

prolonged APTT

Thrombocytopenia

201
Q

Antiphospholipid syndrome - primary thromboprophylaxis

A

Low dose aspirin

202
Q

Antiphospholipid syndrome - secondary thromboprophylaxis

A

1st VTE: warfarin with target INR 2-3

Further VTE: warfarin with target INR 3-4

Arterial thrombus then warfarin INR 2-3

203
Q

Ankylosing spondylitis - features

A

Young men with lower back pain and stiffness
Insidious onset
Stiffness worse in the morning and better with exercise
Pain at night

204
Q

Ankylosing spondylitis - examination

A

Reduced lateral flexion
Reduced forward flexion, assessed using Schober’s test
Reduced chest expansion

205
Q

Ankylosing spondylitis - non joint features

A

Atypical fibrosis

Anterior uveitis

Aortic regurg

AV node block

Achilles tendonitis

Amyloidosis

Cauda equina

Peripheral arteritis

206
Q

Ankylosing spondylitis - investigations

A

Raised ESR, raised CRP

MRI spine

Xray sacroiliac joint = sacroilitis, squaring of lumbar vertebrae, bamboo spine, syndesmophytes

207
Q

Ankylosing spondylitis - xray of sacroiliac joint findings

A

sacroilitis
squaring of lumbar vertebrae
bamboo spine
syndesmophytes

208
Q

Ankylosing spondylitis - management

A

Regular exercise
NSAIDS
physiotherapy
DMARDS only if peripheral joint involvement

209
Q

Osteoporosis - major risk factors

A

Steroids

RA

Family history of hip fracture

Smoking

Alcohol

Low BMI

210
Q

Osteoporosis - drug causes

A

Steroids

SSRIs

Antiepileptics

PPIs

Glitazones

Heparin

211
Q

Osteoporosis - first line investigations for secondary cause

A 
FBC
U+E 
LFT
CRP 
TFT
Bone profile
212
Q

Bone protection against osteoporosis - management if high risk and <65 years

A

DEXA scan

T score >0 = reassure
T score 0 to -1.5 = repeat in 3 years
T score < -1.5 = bone protection

213
Q

Bone protection against osteoporosis - management if high risk and >65 years

A

If high risk or previous fragility fracture then treat

214
Q

Bone protection against steroid induced osteoporosis

A

Give if taking steroids >3 months

Treat with alendronate
Should be vitamin D and calcium replete

215
Q

Osteoporosis - 1st line management

A

Alendronate

216
Q

Osteoporosis - 2nd line management

A

Risedronate or etidronate

217
Q

Osteoporosis - 3rd line management

A

If can’t tolerate bisphosphonates

Strontium ranelate or raloxifene

218
Q

Osteoporosis - who should we treat?

A

Post-menopausal women and men over 50 with DEXA T score < -2.5

Women >75 with fragility fracture

Long term steroids

219
Q

Raloxifene - mechanism of action

A

Selective oestrogen receptor modulator

Prevents bone loss and reduces vertebral fracture
No impact on non-vertebral fractures

220
Q

Raloxifene - side effects

A

Menopausal symptoms

Increased risk of VTE

Decreased risk of breast cancer

221
Q

Strontium ranelate - mechanism of action

A

Reduces resorption by osteoclasts and increases deposition by osteoblasts

222
Q

Osteoclasts

A

Resorb bone

223
Q

Osteoblasts

A

Deposit bone

224
Q

Strontium ranelate - side effects

A

Increased cardiovascular events

Increased VTE

Steven Johnson syndrome

225
Q

Strontium ranelate - contraindications

A

previous cardiovascular events

previous VTE

226
Q

Bisphosphonates - mechanism of action

A

inhibit bone absorption by osteoclasts by promoting apoptosis

227
Q

Bisphosphonates - indications

A

prevention and treatment of osteoporosis
hypercalcaemia
Paget’s disease
pain from bony metastases

228
Q

Bisphosphonates - side effects

A

Oesophagitis, oesophageal ulcers
Osteonecrosis of the jaw

Atypical stress fractures of femur

Hypocalaemica

Acute phase response after administration - fever, myalgia, arthralgia

229
Q

Bisphosphonates - instructions when taking

A

Whilst sitting or standing upright
at least 30 minutes before food
with water
stay upright for 30 minutes afterwards

230
Q

Bisphosphonates - duration when treating osteoporosis

A

Reassess need after 5 years

Stop if patient <75, T score > -2.5, low risk according to FRAX

231
Q

Bisphosphonates - calcium and vitamin D

A

Give vitamin D

Give calcium only if dietary intake is inadequate

232
Q

What is chronic fatigue syndrome?

A

> 4 months of fatigue affecting function more than 50% of the time

No other disease which may explain symptomes

233
Q

Chronic fatigue syndrome - features

A 
Fatigue
Sleep disturbance
Muscle or joint paint
Headaches
Painful lymph nodes without enlargement
Sore throat
Lack of concentration
234
Q

Chronic fatigue syndrome - investigations

A

All normal

FBC U+E LFT CRP ERP Calcium Ferritin CK Ceoliac screen Glandular fever Urinalysis

235
Q

Chronic fatigue syndrome - management

A

CBT
Graded exercise therapy
Pacing
Low dose amitryptilline for poor sleep

236
Q

Discoid lupus erythematous - features

A 
Erythematous, raised rash
May be scaly
Photosensitive
On face, neck, ears, scalp
Lesions heal with atrophy, scarring and pigmentation
237
Q

Discoid lupus erythematous - management

A

Topical steroids
Hydroxychloroquine
Avoid sun exposure

238
Q

Who should take vitamin D supplements?

A

Pregnant and breastfeeding
Children aged 6 months to 5 years
Adults >65
People not exposed to much sun

239
Q

Follow up when taking vitamin D supplements

A

Calcium level at one month

240
Q

Polymyalgia rheumatica - features, patient age and symptom onset

A

Patient >60 years
Onset in <1 month
Aching and morning stiffness in proximal limb muscles

241
Q

Polymyalgia rheumatica - investigations

A

Raised ESR >40
Raised CRP
Normal CK

242
Q

Polymyalgia rheumatica - management

A

Oral prednisolone

Bone protection

243
Q

Polymyalgia rheumatica - management if does not respond well to prednisolone

A

Refer to secondary care to consider other diagnoses

AKT (20 decks)

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