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Station 5 > Rheumatology > Flashcards

Rheumatology Flashcards

1
Q

Causes of dupuytrens?

A

Familial, idiopathic, liver disease, diabetes

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2
Q

How would you assess function in a patient with suspected RA?

A

Squeeze my fingers
Write a word
Pick up a coin

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3
Q

Investigations in RA?

A

RF, Anti-CCP, ANA, inflammatory markers, immunoglobulins

XRs of Chest, hands and feet

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4
Q

Radiological changes in RA? (4)

A

Soft tissue swelling
Loss of joint space
Articular erosions (associated with worse prognosis)
Periarticular osteoporosis

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5
Q

How would you treat a patient with rheumatoid arthritis?

A

Steroids for acute flare.

DMARDS- methotrexate (with folic acid) , hydroxycloroquine, sulfasalazine, luflonamide.

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6
Q

Main side effects of methotrexate (3)

A

Fibrosis, hepatitis and neutropenia

WH during infection

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7
Q

Name 2 ophthalmological complication of RA?

A

Dry eyes

Scleritis

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8
Q

Cardiac complications of RA?

A

Pericarditis

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9
Q

Serious side effect of hydroxychloroquine?

A

Retinopathy- should see optician every year.

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10
Q

Clinical examination findings in pseudoxanthoma elastic? (4)

A

Plucked chicken skin appearance in neck axillae
Blue sclerae
HTN (premature coronary artery disease)
Mitral valve prolapse

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11
Q

Presenting problems in Pseudoxanthoma elasticum?

A 
Hyperextensible joints 
Reduced acuity 
HTN 
MI or CVA 
Gastric bleed
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12
Q

Where are the degenerative elastic fibres generally found in pseudoxanthoma elasticum?

A

Skin
Vessels
Eyes

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13
Q

Cause of Ehlos Danlos?

A

Defect in collagen causing increased skin elasticity?

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14
Q

Cardiac complications of Ehlos Danlos?

A

Mitral valve prolapse

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15
Q

Examination finds in Ehlos Danlos on inspection?

A 
Fragile skin (bruising) 
Hyperextendible skin (tents when pulled- don't do) 
Joint hyper mobility and dislocation (scars from joint repair/replacement)
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16
Q

Inheritance of Ehlos Danlos?

A

AD

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17
Q

Most common conditions associated with Raynauds?

A

Scleroderma

SLE

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18
Q

In a patient with suspected CTD, what should you examine for? (systematic)

A

Hands- Raynauds and small joint inflammation (with stiffness), Jaccouds arthropathy.
Arms- discoid rash +/- scarring
Face- photosensitive rashes, hair loss, scleritis/dry eyes, ulcers in mouth.
Neck- difficulty swallowing
Chest

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19
Q

In a patient with suspected CTD, what should you examine for/ ask about in hands and arms? (systematic)

A

Hands- Raynauds and small joint inflammation (with stiffness+/- destruction), Jaccouds arthropathy (SLE)
Arms- discoid rash +/- scarring/scaling

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20
Q

Face symptoms in suspected CLD?

A

Face- photosensitive rashes, hair loss, scleritis/dry eyes, ulcers in mouth.
Neck- difficulty swallowing

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21
Q

Respiratory associations with SLE?

A 
Pleural effusion 
Fibrosing alveolitis (ILD)
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22
Q

Neurological associations with SLE?

A

Ataxia

Chorea

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23
Q

Screening for lupus nephritis?

A

Urine ACR

BP

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24
Q

Diagnostic investigations in SLE?

A

ANA and anti-dsDNA

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25
Q

Investigations to look for disease activity in SLE?

A

Inflammatory markers and elevated immunoglobulins.

Reduced complements.

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26
Q

Full list of investigations in suspected CTD?

A

ANA, dsDNA, inflammatory markers, anti-phospholipid, complements, urine dip

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27
Q

Management in cutaneous/joint SLE?

A

Topical steroids

Hydroxychloroquine

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28
Q

Treatment of moderate SLE?

A

Pred and Aza

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29
Q

Treatment of severe SLE?

A

Methylpred, mycophenylate (lupus nephritis), cyclophosphamide.

30
Q

Serious side effects of cyclophosphamide? HHIT

A

Haemorrhagic cystitis
Haematological
Infertiluty
Teratogenicity

31
Q

Common causes of proximal myopathy?

A

Dermatomyositis
Thyroid dysfunction
Cushings

32
Q

Complications associated with ankylosing spondylitis? (5)

A 
Anterior uveitis
Aortic regurgitation
AV heart block- look for PPM
Apical fibrosis 
Arthritis (may be psoriatic arthropathy)
33
Q

What the bedside tests could you do in Ank Spond except Schobers?

A

Increased occiput-wall distance. >2cm is abnormal

34
Q

Treatments for ankylosing spondylitis.

A

Physiotherapy
Analgesia
Anti-TNF - ertanacept/infliximab/adulimumab

35
Q

Associations in gout/

A 
Obesity 
HTN 
CKD
Urate stones/nephropathy 
Lymphoproliferative disorders
36
Q

Investigations in gout?

A

Bloods including urate (unreliable)

Joint aspiration to rule out infection and look for needle shaped negatively birefringent crystals

37
Q

Treatment of acute attack of gout?

A

Treat cause
Increase hydration
High dose NSAIDs
Colchicine

38
Q

Classical XR appearance of gout

A

Punched out periarticular changes

39
Q

Where do you usually see OA changes in the hand?

A

Interphalangeal joints with Heberdens nodes (and sometimes Bouchards at the PIP)

40
Q

XR features in OA?

A

Loss of joint space, osteophytes, peri-articular sclerosis and cysts

41
Q

Treatment of OA? (4)

A

Physio
Analgesia
Joint replacements
Weight reduction (if affecting weight bearing joint)

42
Q

Difference between Raynauds disease and Raynauds phenomenon

A

Raynauds disease is idiopathic

Raynauds phenomenon is associated with underlying CTD

43
Q

What would you see in the hands in systemic sclerosis?

A

Sclerodactyl- prayer sign
Calcinosis
Raynauds

Should assess function- holding a cup or pen

44
Q

What would you see in the face of someone with scleroderma?

A 
Tight skin 
Beaked nose 
Microstomia 
Perioral furrowing 
Alopecia 
Telangiectasia
45
Q

Name the respiratory and cardiac complications of scleroderma?

A

Hypertension
Pericarditis
Pulmonary HTN

Interstitial fibrosis (basal)

46
Q

What does CREST stand for?

A 
Calcinosis 
Raynauds 
(o)Esophageal dysmotility 
Sclerodactyl 
Teleangiectasia
47
Q

What investigations would you do in scleroderma?

A

ANA (+ve in 90%), anti-centromere (limited), scl-70 (diffuse)
Hand XRs calcinosis
To look for respiratory complications: CXR, HRCT, spirometry
Too look for GI disease- contrast scans, FBC and folate
Renal disease, U&Es, urinalysis, microscopy and renal biopsy
Cardiac disease: ECG and echo

48
Q

What would you see in the face of someone with Marfans?

A

High arched palate with crowded teeth

Iridonesis with upward lens dislocation

49
Q

What signs of Marfans might there be in the thorax?

A

Pectus carinatum or excavatum
Scoliosis
Scars from previous cardiac surgery of chest drains (PTX)

50
Q

What are the common cardiac complications of Marfans?

A

Aortic regurgitation (may have metallic valve)
Mitral valve prolapse
Co-arctation
Aortic dissection

51
Q

What is the inheritance of Marfans syndrome?

A

Autosomal dominant on chromosome 15. Defect in the fibrilin protein

52
Q

Describe the management of a patient with Marfans?

A

Surveillance of aortic root size with annual TTE
Beta blockers and ARBs to slow aortic root dilatation and pre-emptive aortic root surgery to present dissection and aortic rupture.
Screening of family members.

53
Q

Investigations and treatment of GCA?

A

Bloods including ESR and CRP. ESR >80 highly specific as are platelets >400. (ideally take bloods prior to starting steroids)
Temporal artery USS +/- biopsy if cranial features.
PET-CT if non cranial features.

Start 40-60mg Pred (+PPI)
If visual symptoms refer to ophthalmology on same day. If no visual symptoms refer to Rheum to be seen in 1-3 days.

54
Q

Investigations in suspected PMR?

A

FBC, CRP, ESR, LFTS, RF, Anti CCP, CK, TFT, Vitamin D

55
Q

Which DMARDs are considered safe in pregnancy?

A

Sulfasalazine and hydroxychloroquine although you should avoid sulfasalazine in men TTC as it affects sperm.

56
Q

How would you offer to measure RA disease activity?

A

DAS 28

57
Q

How can you distinguish between psoriatic arthritis and rheumatoid arthritis?

A

DIPs spared in RA and involved in PA.
Dactylitis in PA.
Typically causes enthesitis (ligaments) in PA but tenosynovitis in RA)

58
Q

What are typical hand XR findings in Psoriatic arthritis?

A

Pencil in cup deformity.

59
Q

How would you manage psoriatic arthritis?

A

NSAIDs or COX-2 inh if mono or oligoarthritis or spondyloarthropathy.
In multiple joints affective then DMARDs.

60
Q

How is Ank Spond managed?

A

NSAIDs or Cox-2 and physio. Biologics if no response.

Steroids and DMARDs not usually effective in spondyloarthropathy.

61
Q

Common causes of reactive arthritis?

A

GI- salmonella, shigella, campylobacter

GU- chlamydia

62
Q

Treatment of reactive arthritis?

A

NSAIDs and steroids if refractory. If recurrent synovitis then start on DMARDs.

63
Q

In what level of renal impairment would you avoid NSAIDs? When would you avoid colchicine?

A

eGFR <50 avoid NSAIDs and reduce colchicine to 500mg OD

eGFR <10 avoid colchicine and give prednisolone.

64
Q

What is found on joint aspiration in pseudo gout?

A

Positively birefringent rhomboid crystals.

65
Q

How might Pagets disease present?

A

Asymptomatic
Bone pain
Deafness

66
Q

Treatment of Pagets disease?

A

Analgesia
Hearing aids in deafness
Bisphosphanates

67
Q

When are biologics (anti-TNF) indicated in Ank Spond

A

When failed two NSAIDs taken for at least 4 weeks and as indicated by the BAS-DAI score

68
Q

What investigations would you do in suspected ank spond?

A

Baseline bloods including CRP/ESR
Consider HLA B27 (positive in 90%)
XR lumbar spine and pelvis. If normal consider MRI
Urine dip (IgA nephropathy and amyloidosis) and ECG (AV conduction block)

69
Q

What are the clinical features and signs of osteogenesis imperfecta?

A

Features: deafness, joint problems, dental problems, bruising and fragile skin, aortic dissection
Signs: blue sclera, hyper mobile joints, scoliosis

70
Q

Diagnosis of osteogenesis imperfecta?

A

Clinical and FH (AD). Gene testing may support the diagnosis but not all genes have been identified.

71
Q

Management of osteogenesis imperfecta?

A

Good diet and stopping smoking to maintain bone health.
Bisphosphanates.
MDT approach: OT/Physio/podiatry/geneticist
Cardiology follow up re aortic root dilatation

72
Q

How would you examine a patient with suspected ankylosis getting spondylitis?

A

Examine back- look for scoliosis, examine all back movements, examine for spinal tenderness. Occipital- wall and schobers.

Look at eyes 
Listen to heart and do collapsing pulse 
Listen for apical fibrosis 
Look for psoriasis 
Other arthropathy

Station 5 (12 decks)

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