Rheumatology Flashcards
ank spond treatment?
- encourage regular exercise such as swimming
- NSAIDs are the first-line treatment
- physiotherapy
DMARDS (e.g. sulfasalazine) in severe disease.
Diagnosis of old man, bone pain, raised ALP?
pagets
Hypersensitivity reactions - types?
Type 1 - Anaphylaxis
Type 4 - delayed hypersensitivity
2 and 3 and 5 all kinds of other shit
Most common cause of death in marfans?
Aortic dissection
femoral nerve stretch test?
Patient lies on their side and the hip is extended with a straight leg. Flexing the knee then recreates the pain
RA specific antibodies?
AntiCCP
SLE antibodies
Anti-dsDNA
ANA is positive always
When to give bisphosphonates in osteoporosis?
Treatment is indicated following osteoporotic fragility fractures in postmenopausal women who are confirmed to have osteoporosis (a T-score of - 2.5 SD or below).
In women aged 75 years or older, a DEXA scan may not be required ‘if the responsible clinician considers it to be clinically inappropriate or unfeasible’.
What bloods do you need to check before starting azathioprine?
check thiopurine methyltransferase deficiency (TPMT) before treatment
Features of PMR?
typically patient > 60 years old
usually rapid onset (e.g. < 1 month)
aching, morning stiffness in proximal limb muscles
weakness is not considered a symptom of polymyalgia rheumatica
also mild polyarthralgia, lethargy, depression, low-grade fever, anorexia, night sweats
Common causes of drug induced lupus?
procainamide
hydralazine
Management of PMR?
Steroids (e..g pred 15mg OD)
Review in 1 week
If not responding reconsider diagnosis.
What is Livedo reticularis?
Livedo reticularis is the skin rash most commonly associated with antiphospholipid syndrome
Common drug cause of cataracts?
Pred
Common drug cause of Corneal opacities?
Hydroxychloroquine
Common drug cause of Interstitial lung disease?
Sulfasalazine and leflunomide
Ank spond examination features?
- reduced lateral flexion
- reduced forward flexion - Schober’s test - a line is drawn 10 cm above and 5 cm below the back dimples (dimples of Venus). The distance between the two lines should increase by more than 5 cm when the patient bends as far forward as possible
- reduced chest expansion
Features of osteomalacia?
- bone pain
- bone/muscle tenderness
- fractures: especially femoral neck
- proximal myopathy: may lead to a waddling gai
Osteoporosis management?
Alendronate first line, if not tolerated then risendronate. If neither are tolerated then rheum referral for ?strontium ranelate or raloxifene
Treatment of pagets disease?
Bisphosphonates
What food do you need to avoid with gout?
Liver, kidneys, seafood, oily fish (mackerel, sardines) and yeast products
Methotrexate side effects?
Myelosuppression
Liver cirrhosis
Pneumonitis
Pneumonitis
Sulfasalazine side effects?
Rashes
Oligospermia
Heinz body anaemia
?Interstitial lung disease
Leflunomide side effects?
Liver impairment
Interstitial lung disease
Hypertension
Hydroxychloroquine side effects?
Retinopathy
Corneal deposits
prednisolone side effects?
Cushingoid features Osteoporosis Impaired glucose tolerance Hypertension Cataracts
Gold side effects?
Proteinuria
penicillamine side effects ?
Proteinuria
Exacerbation of myasthenia gravis
Etanercept, infliximab, adalimumab side effect?
Reactivation of TB?
What factors predict poor prognosis in RA?
rheumatoid factor positive anti-CCP antibodies poor functional status at presentation X-ray: early erosions (e.g. after < 2 years) extra articular features e.g. nodules HLA DR4 insidious onset
What joints can you give topical nsaids for osteoarthritis?
Hands or knee
What do you do if a patient has been on bisphosphonates for 5 years?
Reassess fracture risk with DEXA/Bisphosphonates and risk factors:
Age >75 Glucocorticoid therapy Previous hip/vertebral fractures Further fractures on treatment High risk on FRAX scoring T score
Diagnosis for long term steroid therapy and insidious onset joint pain on movement?
Osteonecrosis of femoral head
Untreated physical signs of pagets disease?
bowing of tibia, bossing of skull
Skin changes in reactive arthritis?
circinate balanitis (painless vesicles on the coronal margin of the prepuce) keratoderma blenorrhagica (waxy yellow/brown papules on palms and soles)
Management of phospholipid syndrome?
Management - based on EULAR guidelines
Primary thromboprophylaxis (no VTE) low-dose aspirin
Secondary thromboprophylaxis (had VTE) - 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
When you start allopurinol for the first time what other drug may you also need to prescribe?
Colchicine cover should be considered when starting allopurinol.
NSAIDs can be used if colchicine cannot be tolerated.
The BSR guidelines suggest this may need to be continued for 6 months
RA xray changes?
Early x-ray findings
- loss of joint space
- juxta-articular osteoporosis
- soft-tissue swelling
Late x-ray findings
- periarticular erosions
- subluxation
Management of raynauds phenomena?
all patients with suspected secondary Raynaud's phenomenon should be referred to secondary care first-line: calcium channel blockers e.g. nifedipine IV prostacyclin (epoprostenol) infusions: effects may last several weeks/months
Causes of raynauds phenomena?
Raynaud’s disease (primary) typically presents in young women (e.g. 30 years old) with bilateral symptoms.
Secondary causes of Raynaud’s phenomenon
- connective tissue disorders; scleroderma (most common); rheumatoid arthritis; systemic lupus erythematosus
- leukaemia
- type I cryoglobulinaemia, cold agglutinins
- use of vibrating tools
- drugs: oral contraceptive pill, ergot
- cervical rib
What investigations should you perform before starting biologics?
Tuberculin skin test and CXR to look for active or latent TB
What pt groups are advised to take vitamin d supplementation?
all pregnant and breastfeeding women should take a daily supplement containing 10µg of vitamin D
all children aged 6 months - 5 years. Babies fed with formula milk do not need to take a supplement if they are taking more than 500ml of milk a day, as formula milk is fortified with vitamin D
adults > 65 years
‘people who are not exposed to much sun should also take a daily supplement’ e.g. housebound patients
Calcium, PTH, ALP and phosphate in CKD? (secondary hyperparathyroidism)
Low serum calcium, raised serum phosphate, raised ALP and raised PTH
Kidneys not able to activate vit d or excrete phosphate (calcium then is used up boud to phosphate - calcium phospahte) - the low blood calcium raises PTH (to raise calcium levels, osteoclasts activated which raises ALP.
Bleeding times (APTT and PT) and Plts in antiphospholipid syndrome?
Antiphospholipid syndrome leads to a raised APTT and normal PT and can result in thrombocytopenia.
Calcification of cartilage on XR common in gout or pseudogout?
Pseudogout
Location of heberdens and bouchards nodes?
Heberden’s nodes - swelling of the distal interphalangeal joints.
Bouchard’s nodes - swelling of proximal interphalangeal joints
How long does chronic fatigue syndrome have to be present for diagnosis?
4 months
If someone is going to start long term steroid therapy what is the guidelines around bone protection?
If above 65 or previous fragility fracture - start
If not then do DEXA.
Greater than 0 - Reassure
Between 0 and -1.5- Repeat bone density scan in 1-3 years
Less than -1.5 - Offer bone protection
Associated conditions/features of Ank spond?
Apical fibrosis Anterior uveitis Aortic regurgitation Achilles tendonitis AV node block Amyloidosis
What RA drug should be avoided if allergic to aspirin?
Sulfasalazine
How does femoroacetabular impingement present?
active young adult
hip/groin pain worse on prolonged sitting and associated with snapping, clicking or locking of the hip
How many episodes of gout before offering allopurinol?
Just offer after first
Where is pain often felt in radial tunnel syndrome?
Tender distal to the common extensor origin with no pain overlying the lateral epicondyle itself
Common SE of colchicine to warn patients of?
Diarrhoea
Drug causes of gout?
diuretics: thiazides, furosemide ciclosporin alcohol cytotoxic agents pyrazinamide aspirin
What test should you use to diagnose RSV?
Nasopharyngeal aspirate
Colles fracture in ventrally of dorsally displaced?
dorsally
What is the urinary sodium in pre-renal failure?
Low (<20)
What is the most common cause of renal AKI?
acute tubular necrosis
What is the urinary sodium and the urea in acute tubular necrosis?
Urea <150
Sodium typically >30
Difference in UTI relapse and recurrent UTI?
Recurrent if new organism
Relapse if the same
Epilepsy choice of drug summarised
All have sodium valproate as first line option apart from focal which has carbamazapine or lamotrigine.
Absence has ethosuximide as well
Tonic clonic has lamotrigine as well
Most common type of renal stone?
Calcium oxalate
COmmon ABG finding with PE?
Type 1 resp failure (May blow off CO2 and be alkalotic)
What drugs to avoid if taking azathioprine?
Allopurinol, ACEI and Warfarin
What antihypertensives may cause impotence?
Thiazides and b-blockers
extra -renal complications of PCKD?
Mitral valve prolapse
Berry aneurysms
increased colonic dilatations
RCC
What vitamin deficiency is most associated with angular chelitis?
B2
What organism commonly causes erysipelas?
Strep pyogenes
Reed sternberg cells indicate what?
hodgkins lymphoma
What antidepressants have the least drug interactions?
Citalopram and sertraline
