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Year 4 > Rheumatology > Flashcards

Rheumatology Flashcards

1
Q

What is the first line management of an acute monoarthritic join

A

Joint Aspiration for WCC, gram stain and culture

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2
Q

Name two benefits of joint aspiration

A

Protects the joint from destruction
Can diagnose

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3
Q

What is the first line management for a patient with prosthetic joint infection

A

Refer to orthopaedics for full wash out and replacement

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4
Q

Onset of Ankylosing Spondylitis

A

20-30

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5
Q

What gene is involved in Ankylosing Spondylitis

A

HLA-B27

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6
Q

Features of AS

A

Inflammatory back pain: early morning stiffness and tenderness of sacroiliac joint

SPINEACHE:

Sausage digits (dactlitis)
Psoriasis
Inflammatory back pain
NSAID good response
Enthesitis
Arthritis
Chron’s or Colitis elevated CRP]HLA-B27
Eye (uveitis)

Reduced chest expansion and poor lumbar flexion (schober test)

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7
Q

Name some extra-articular features of AS

A

Upper lobe pulmonary fibrosis
aortitis -> aortic regurgitation

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8
Q

Name four diseases associated with HLA-B27

A

AS
Reactive Arthritis
Psoriatic Arthritis
Enteric Arthropathy

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9
Q

How can we diagnose Ankylosing Spondylitis

A

X-Ray showing development of syndesmophytes and BAMBOO SPINE

MRI (MOST SENSITIVE) - shows sacroillitis

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10
Q

What are syndesmophytes

A

Bony bridges between adjacent vertebrae

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11
Q

Pharmacological treatment of AS

A

NSAIDs

Second Line: DMARDs (especially if enthesitis is present over axial symptoms)

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12
Q

If someone with AS does not respond to NSAIDs, what is given

A

Infliximab

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13
Q

What serum should be checked for pernicious anaemia

A

Intrinsic factor antibodies

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14
Q

Name three antibodies found in coeliac’s

A

Anti tTg
IgA anti-endomysial
Anti-gliadin

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15
Q

In what condition are antimitochondrial antibodies found in

A

Primary biliary cirrhosis

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16
Q

In what condition are anti smooth muscle antibodies foundin

A

Autoimmune hepatitis

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17
Q

What antibodies are found in goodpasture’s syndrome

A

Antibdodies against collagen IV

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18
Q

What antibodies are found in granulomatosis with polyangitis

A

cANCA

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19
Q

What is the specific anti bodies found in SLE

A

Anti-Dsdna and Anti-Smith

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20
Q

What is the most sensitive antibodies for RA

A

Anti-CCP

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21
Q

What antibodies are found in Sjogren’s

A

Anti-Ro and Anti-La

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22
Q

What antibody is found in diffuse cutaenous systemic sclerosis

A

Anti-Scl-70

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23
Q

What autoantibody is found in limited cutaneous systemic sclerosis

A

Anti-centromere

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24
Q

What autoantibody is found in dermatomyositis

A

Anti-Jo1

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25
Q

Symptoms of APS

A

CLOT:

Clots
Livedo Reticularis (lace like mottled rash on lower skin)
Obstetric Loss
Thrombocytopenia

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26
Q

What cardiac symptoms can be found in APl

A

Aortic and mitral regurgitation

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27
Q

Name three autoantibodies seen in APL

A

ANti-cardiolipin antibodies
Anti-beta2-GPI antibdoies
Positive lupus anticoagulant

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28
Q

What condition can cause the APL blood tests to be false positive

A

Syphilis

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29
Q

What should APL be treated

A

Only when a thromboembolic event has taken place

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30
Q

Name four red flags for back pain

A

Onset <20 or >55
Thoracic or cervical spine pain
Pain is progressive or not relieved by rest
Spinal tenderness

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31
Q

What improves pain in AS

A

MOvement

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32
Q

Symptoms of Behcet’s disease

A

Oral ulcers
Genital ulcers
Erythema nodosum

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33
Q

Gout vs Pseudogout

A

Gout: negatively birefringent and needle-shaped

Pseudogout: Positively bifringent and rhomboid shaped crystals

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34
Q

What compound causes pseudogout

A

Pyrophosphate dihydrate crystals

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35
Q

Name two blood tests important to monitor in gout

A

Uric Acid
Renal Functions

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36
Q

What X-Ray finding is distinctive in pseudogout

A

Chondrocalcinosis (calcification of cartilage)

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37
Q

Symptoms of dermatomyositis

A

Purple rash on eyelids
Shawl sign positive
Gottron’s papules (red scaly patches over MCP joint)

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38
Q

Invetsigations for dermatomyositis

A

CK
EMG
Muscle Biopsy

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39
Q

Risk Factors of Reactive Arthritis

A

Male
HLA B27
Previous GI or STD

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40
Q

Name a GI species that can cause reactive arthirtis

A

Shigella

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41
Q

Describe the onset of arthritis in reactive arthirtis

A

Peripheral arthritis after 1-4 weeks of infection : Asymmetrical oligoarthritis of the lower limb

Sacroiliac and lumbrosacal arthitis

Keratoderma blenhorragia
Conjunctivities, uveitis
Mucosal ulcers

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42
Q

What is Felty Syndrome

A

RA
Splenomeglay
Neutropenia

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43
Q

How to manage felty syndrome

A

Same as RA

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44
Q

Name some medications that can cause gout

A

Thiazide diuretics
ACEi
Aspirin

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45
Q

What diet can cause gout

A

Sea food

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46
Q

Why can chemotherapy cause GOUT

A

Hyperuricaemia in tumour lysis syndrome

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47
Q

What is the first line test for gout

A

Synovial fluid analysis to EXCLUDE septic arthritis

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48
Q

When should uric acid levels be checked during investigation

A

2 weeks after the attack as they can be falsely normal

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49
Q

Management of an acute gout attack

A

NSAID: Indomethacin

Second Line: Colchicine

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50
Q

When shoudl colchicine be given over Indomethacin

A

When patient has GI side effects, past kidney or heart failure

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51
Q

What is a side effect of colchicine

A

Diarrhoea

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52
Q

If a patinet is experiencing diarrhoea on Colchicine, what should be done

A

Administer INtra-articular steroids

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53
Q

When should allopurinol be indicated

A

PROPHYLAXIS:
Start two weeks after attack

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54
Q

Name the criteria for prophylactic allopurinol

A

More than 2/3 attacks a year
Tophaceous gout
X-Ray shows joint destructino
Urate nephrolithasis
Polyarticular attacks are disabling

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55
Q

If allopurinol is contraindicated, what can be given

A

febuxostat

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56
Q

Symptmos of granulomatosis with polyangitis

A

URTI: Epixstasis, chonric sinusitis or saddle-nose

LRTI: Cough, Haemoptysis, pleuritis

pANCA and c-CANCA positive: Haematuria and proteinuria

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57
Q

X-Ray findings in granulomatosis with polyangitis

A

Bilateral lung infiltrates

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58
Q

What scoring system is used to determine hypermobility

A

Beighton score

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59
Q

What beighton score indicates hypermobility

A

4 or more

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60
Q

Management of hypermobility syndrome

A

Referral to physio

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61
Q

What histological appearance indicates IgG4 disease

A

tumefacien lesions with dense lymphocytic infiltrates and storiform fibrosis

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62
Q

Symptoms of IgG4 related disease

A

swelling of slaivary and lacrimal glands

and ent sinuses

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63
Q

What is a common extraarticular sign in IgG4 disease

A

Pancreatitis and sclerosing cholangitis

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64
Q

Management of IgG$ disease

A

Rituximab

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65
Q

How is Marfan’s syndrome inherited

A

Autosomal dominant

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66
Q

Physical appearance of Marfan’s syndrome

A

Disproportionately tall and thin with unusually long arms and legs

Arachnodactyly (long spider fingers)

High arch palate

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67
Q

Name some CV features of Marfan’s

A

Aortic Regurgitation
Aortic root dilatation
Mitral valve prolapse
Abdominal aortic aneurysm

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68
Q

Eye symptoms in Marfan’s Syndrome

A

Lens Discolouration
Closed angle glaucoma

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69
Q

Medical management of marfan’s

A

BP control

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70
Q

How often is Methotrexate given

A

Once a week 2.5mg

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71
Q

How do we increase the dose of methotrexate

A

Titrate up by 2,5mg a week

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72
Q

Side effects of methotrexate

A

Cytopenia
Hepatotoxicity
Renal Impairmebt
Pulmonary Fibrosis
Teratogenicity

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73
Q

When should methotrexate be stopped

A

If LFTs are greater than 3 x from baseline mesaurement

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74
Q

What advice shohuld patients on methotrexate be given regarding contraception

A

Use while on it and for three months after

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75
Q

Name another antifolate medication other than methotrexate

A

Trimethoprim

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76
Q

What has to be prescribed alongside methotrexate

A

Folic Acid

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77
Q

How often is folate acid given alongside methotrexate

A

Once a week but one DIFFERENT days

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78
Q

What is the antidote for methotrexate

A

Folinic acid

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79
Q

Signs of microscopic polyangitis

A

Necrotising glomerulonephirtis
Fevers, weight loss, malaise
Palpable purpura of lower extremities
Mononeuritis multiplex
Alveolar haemorrhage (haemoptysis)

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80
Q

What causes OA pain to worsen

A

Movement

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81
Q

How long is morning stiffness with OA

A

Less than 20 mins

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82
Q

X-Ray features of OA

A

LOSS:

Loss of joint space
Osteophytes
Subchondral cysts
Subchondral sclerosis

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83
Q

Conservative management of OA

A

Weight loss and excercise

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84
Q

Pharmacological management of OA

A

NSAIDs

85
Q

Name the triad needed to diagnose OA

A

> 45
Activity related joint pain
No stiffness lasting for 30 mins or more

86
Q

What nodes are affected in OA

A

Heberden’s AND BOucnhard’s

87
Q

When should topical NSAIDs be considered for OA

A

People with knee or hand OA

88
Q

Other than topical NSAIDs what else is an adjunct treatment in hand or knee OA

A

TOpical capsaicin

89
Q

If paracetomal or topical NSAIDs are insufficient in controlling hand and knee pain, what is given secondl ine

A

Oral COX-3 or switch NSAID

90
Q

When should intraarticular injections be considered in OA

A

If pain is severe

91
Q

When should Referral to orthopaedics be done for OA

A

If significantly affecting ADLs and severe pain, or functional limitation

92
Q

What disease is associated with polyarteritis nodosa

A

Hep B

93
Q

What part of the body is not affwected in Polyarteritis Nodosa

A

PULMONARY vessels (no lung symptoms)

94
Q

First line investigation (blood test) for suspected polymyalgia rheumatic/ GCA

A

ESR (raised)

95
Q

What is the definitive diagnosis for GCA

A

Temporal artery biopsy

96
Q

Management of GCA

A

60mg OD Prednisolone (high dose)

97
Q

When should prednisolone be stopped in GCA

A

over 1-2 years after the attack

98
Q

What prophylaxis is given for GCA

A

Low dose aspirin

99
Q

ONset of polymyalgia rheumatica

A

50+

100
Q

Symptoms of polymyalgia rheumatica

A

Shoulder and hip girdle stiffness for over 1 hour

Low grae fever, reduced appetite and weight loss

101
Q

Polymyalgia rheumatica vs polymyositis

A

Myositis: Proximal bilateral weakness with NO PAIN

PR: PAIN and STIFFNESS but no weakness

102
Q

What ESR threshold indicates polymyalgia rheumatica

A

> 60

103
Q

Treatment of polymyalgia rheumatica

A

First DEXA scan and check history to reduce risk of ulcers.

THEN steroids

104
Q

Are muscle bulk and reflexes affected in myositis?

A

No, not until very late in the disease

105
Q

Extra MSK symptoms of myositis

A

Later on:

Respiratory failure
Dystonia and dysphagia

106
Q

Onset of myositis

A

40-60

107
Q

Pulmonary sign of myositis

A

Interstitial lung disease

108
Q

Name tow CV symptoms of polymyositis

A

Raynaud’s and myocarditis

109
Q

Most common malignancy associated with myositis

A

Lung

110
Q

First line investigation for polymyositis

A

CK levels

THEN EMG

THEN Muscle biopsy for definitive diagnosis

111
Q

What enzyme levels are elevated in polymyostitis

A

CLAAA

Creatinine Kinase
Lactate Dehydrogenase
Aldolase
ALT
AST

112
Q

What cancers are dermatomyositis associated with

A

Gastric, lung, GU and colon cancers

113
Q

Treatment of Myositis

A

Steroids (high dose)

114
Q

What must be monitored to track disease progression on treatment in myositis

A

CK levels

115
Q

What is the purpose of hydroxychloroquine in dermatomyositis

A

Manages skin symptoms

116
Q

Who should people with myositis be referred to

A

Physiotherapists

117
Q

Risk Factors of pseudogout

A

Hyperparathyroidism
Hypophosphataemia
Hypomagnesemia (stimulates PTh production)
Previous joint surgery
Age

118
Q

Management of raynaud’s

A

Nifedipine

119
Q

When should someone with raynaud’s be referred to hospital

A

<12
Symptoms not responding to treatment
Severe ischaemia

120
Q

What is systemic sclerosis

A

This is increased fibroblast activity resulting in abnormal connective tissue growth and ischaemia

121
Q

What is limited cutaenous systemic sclerosis

A

Only affects the face, forearm and lower legs (up to knee)

122
Q

What is the most common type of systemic sclerosis

A

Limited (CREST syndrome)

123
Q

Presentation of Limited SSc

A

CREST:

Calcinosis
Raynauds
Oesophageal dysmotility
Sclerodactyly
Telangiectasia

124
Q

WHat autoantibdoy in systemic sclerosis is more likely to cause progression to interstitial lung fibrosis and renal disease in SSc

A

Anti-scl-70

125
Q

Name four deformities seen in RA

A

Swan neck
Z thumb
Ulnar deviation
Boutonierre hand deformity
Wrist subluxation

feet:
Hallux Valgus and hammer toes

126
Q

Is the aixal spine involved in RA?

A

Yes, the cervical spine stabilising ligaments can be detsroyed causing atlanto-axial subluxation

127
Q

What is the first line managemnt of someone with Ra and nweck pain

A

CT cervical spine

128
Q

Name three periarticular features of RA

A

Carpal tunnel syndrome
Tenosynovitis
Olecranon bursitis

129
Q

Haematological symptoms of RA

A

Splenomegaly and amyloidosis

130
Q

Derm symptoms of RA

A

Raynaud’s and nodules on the knuckles

131
Q

OPthalmic features of RA

A

Episcleritis and scleritis

132
Q

Respiratory symptom of RA

A

Pleural effusions and fibrosis

133
Q

Joint x ray findings in RA

A

Soft tissue swelling
Periarticular osteoporosis
Juxta-articular erosions
Narrowing of joint space

134
Q

What scoring system can be used to grade the severity of RA

A

DAS28

135
Q

Treatment of RA flares

A

Intraarticular steroids or oral steroids

136
Q

When is surgery indicated for RA

A

If joint is destroyed

137
Q

At what DAS28 level should DMARDs be givenb

A

> 5.1

138
Q

Second line treatment of RA

A

TWO demards

139
Q

WIthin what time frame of symptom onset should DMARDs be started

A

within 3 months

140
Q

third line management of RA

A

Infliximab

141
Q

What vaccine should someone with RA be given

A

annual influenza and pneumococcal vaccine veery 5 years

142
Q

WHat steroid sholud be given during pregnancy in those with RA

A

Prednisolone (oral steroids, not methotrexate) or hydroxychloroquine

143
Q

Side effects of corticosteroids

A

CORTICOSTEROIDS:

Cushing’s
Osteoporosis
Retardation of growth
Thin skin
Immunosupression
Cataracts
Oedema
Suppression of HPA axis
Teratogenic
Emotional disturbances (psychosis)
Rise in BP
Obesity
Hirtustism
DM
Striae

144
Q

Side efefct of hydroxychloroquine

A

Retinopathy

145
Q

Side effect of NSAIDs

A

renal impiarment
GI upset
Asthma exacerbation

146
Q

How should bisphosphonates be taken

A

mempty stomach, 30 mins before eating breakfast woth water and stand upright

147
Q

Signs of adrenal suppresison from corticosteroids

A

Hyperkalaemic hypotension

148
Q

How to manage an adrenal crisis from corticosteroids

A

IV hydrocortisone

149
Q

How do we prevent an adrenal crisis from corticosteroids

A

Abruptly stop if course under 3 weeks
>3 weeks = tapering
double dose if unwell
if nil by mouth, move to IV hydrocortisone

150
Q

What vaccinations are contraindicate din people on corticosteroids

A

Live vaccinations

151
Q

What is sicca syndrome

A

Drying mucous membranes

152
Q

Investigation for sjogren’s syndrome

A

Schirmer’s test: <5mm paper wet in 5 minutes
Lip biopsy to demonstrate lymphoid destruction

153
Q

What other special tests can be used for sjogren’s

A

rose bengal staining
Salivary flow rate monitoring
Slaivary gland biopsy

154
Q

Triggers for SLE flares

A

COCP
UV light
Infections
Stress

155
Q

Most common cardiac feature of SLE

A

Pericarditis

156
Q

What should be moinitored in people with SLE

A

Renal Function

157
Q

What two conditions are associated with SLE

A

Sjogren’s and APL

158
Q

What drugs can cause lupus

A

Sulfadiazine
Hydralazine
Procainamide
Isoniazide
Methyldopa
Quindiine
Minocycline

159
Q

What autoantibody is specific for drug induced lupus

A

Anti-histones

160
Q

What is the most specific test for lupus nephritis

A

Renal biopsy

161
Q

What antibody dictates prognossis for SLE

A

Anti dsdna

162
Q

SYmptoms of SLE

A

A RASH POINts MD:

Arthalgia
Renal disease
ANA positive
Serositis
Haematological (haemolysis/low platelet count)
Photosensitive rash
Oral ulcers
Immuno tests (antidsdna, anti-smith)
Neuropsychiatric (seizures)
Malar Rash
Discoid Rash

163
Q

Management of severe SLE flares

A

Cyclophosphamide

164
Q

Tretaing renal disease in SLE

A

ACEi

165
Q

Treating thrombocytopenia in SLE

A

IV Ivg

166
Q

Where is c-ANCA antibodies found

A

Granulomatosis with polyangitis

167
Q

Where is p-ANCA found

A

Microscopic polyangitis

168
Q

What type of osteogenesis imperfect is the most deadly

A

Type 2

169
Q

Management of osteogenesis imperfecta

A

Oral rusendronnate daily i

170
Q

What is Arthritis Mutilans

A

Found in psoriatic arthritis: Telescopic fingers from bone shortening

171
Q

When does a DEXA scan become first line management in osteoporosis

A

When there is an intermediate risk (so if the person has immediate risk factors but hasn’t yet fallen)

172
Q

When does denosumab become first line management of osteoporosis

A

In young people to defer bisphsophonate use

173
Q

What is Paget’s disease of the bone

A

Increased osteoclastic bone resorption followed by compensatory increase in new bone formation

This causes an excess in woven bone over lamellar bone growth which is weaker

174
Q

What is the distinctive investigation finding that indicates Paget’s disease of the bone

A

Increased ALP with normal serum calcium levels

Just an isolated rise in ALP

175
Q

Osteomalacia vs Paget’s findings

A

Low ALP AND Low Serum Calcium vs Low ALP only

176
Q

Management of a patient with a T-score <-1.5 and going to be on steroids

A

Prophylactic bisphosphonates

177
Q

A lack of which substance causes marfan’s

A

Fibrillin

178
Q

Initial management of reactive arthritis

A

Ibuprofen

179
Q

What pulmonary feature would be seen on a chest X Ray for ankylosing spondyltitis (late)

A

Apical Fibrosis

180
Q

Appearance of RA on a joint aspiration

A

Raised WBC and yellow appearance (similar to septic)

181
Q

Complication of parathyroidism

A

Pseudogout

182
Q

What should all NSAIDs in osteoarhritis be prescribed with

A

PPIs

183
Q

What T score is diagnostic of osteoporosis

A

<-2/5

184
Q

What defines osteopenia

A

T score bweetn -1 and -2.5

185
Q

First line management of osteoarthritis

A

Paracetomal + topical NSAIDs

186
Q

When are calcium supplements indicated for osteoporosis

A

Only if dietary intake is inadequate

187
Q

What type hypersensitivity is SLE

A

Type 3

188
Q

Management of GCA when there are eye signs

A

IV methylperdnisolone

NOrmally Prednisolone oral otherwise

189
Q

What substance (lack of) causes osteomalacia

A

Lack of vit D

190
Q

Symptoms of osteomalacia

A

Proximal muscle weakness
Joint Pain
Increased risk of fractures

191
Q

Symptoms of rickets

A

Craniotabes

Delayed closure of the fonatenelles

Rachitic rosary

Genu Varum (bow legs)

192
Q

Lab results of osteomalacia

A

Low Vit D

Low blood calcium levels

Raised ALP

193
Q

Role of Vit D

A

Bone mineralisation (so in osteomalacia and rickets, bones can’t be mineralised and become soft)

194
Q

What is osteomyelitis

A

Inflammation of the bone

195
Q

How do organisms reach the bone to cause osteomyelitis

A

Haematogenously

196
Q

Causative species for osteomyelitis

A

Staph Aureus

197
Q

What is sequestrum

A

When dead bone in osteomyelitis detahces from the healthy bone

198
Q

WHat is involucrum

A

Viable periosteum that seperated from the underlying bone

199
Q

Presentation of osteomyelitis

A

Swelling are eryhtmea

Bone pain + immobile

Pain exacerbated by movement

200
Q

Risk Factors for osteomyelitis

A

Blunt trauma history

201
Q

What is pott’s disease

A

Vertebral osteomyelitis from miliary TB (haematoginously spreadings)

202
Q

Signs of vertebral osteomyelitis

A

Urinary retention, back pain and fever

203
Q

What is chronic osteomyelitis

A

Asymptomatic but localised bone pain or decreased range of motion

204
Q

Gold standard diagnosis of osteomyelitis

A

Bone Cultures

205
Q

Is paracetamol routinely offered for osteoarthritis

A

No

206
Q

When should someone be referred to orthopaedic surgery

A

If they are complaining about dialy activtities

207
Q

What treatment can be given while waiting for DMARDs to kick in

A

Bridging steroids

Flares:
Intra-articular steroids

then IM Steroids

then oral

208
Q

What diet should be recommended to people with RA

A

Meditteranean

Year 4 (16 decks)

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