Rheumatology Flashcards
1
Q
What is the first line management of an acute monoarthritic join
A
Joint Aspiration for WCC, gram stain and culture
2
Q
Name two benefits of joint aspiration
A
Protects the joint from destruction
Can diagnose
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
4
Q
Onset of Ankylosing Spondylitis
A
20-30
5
Q
What gene is involved in Ankylosing Spondylitis
A
HLA-B27
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)
7
Q
Name some extra-articular features of AS
A
Upper lobe pulmonary fibrosis
aortitis -> aortic regurgitation
8
Q
Name four diseases associated with HLA-B27
A
AS
Reactive Arthritis
Psoriatic Arthritis
Enteric Arthropathy
9
Q
How can we diagnose Ankylosing Spondylitis
A
X-Ray showing development of syndesmophytes and BAMBOO SPINE
MRI (MOST SENSITIVE) - shows sacroillitis
10
Q
What are syndesmophytes
A
Bony bridges between adjacent vertebrae
11
Q
Pharmacological treatment of AS
A
NSAIDs
Second Line: DMARDs (especially if enthesitis is present over axial symptoms)
12
Q
If someone with AS does not respond to NSAIDs, what is given
A
Infliximab
13
Q
What serum should be checked for pernicious anaemia
A
Intrinsic factor antibodies
14
Q
Name three antibodies found in coeliac’s
A
Anti tTg
IgA anti-endomysial
Anti-gliadin
15
Q
In what condition are antimitochondrial antibodies found in
A
Primary biliary cirrhosis
16
Q
In what condition are anti smooth muscle antibodies foundin
A
Autoimmune hepatitis
17
Q
What antibodies are found in goodpasture’s syndrome
A
Antibdodies against collagen IV
18
Q
What antibodies are found in granulomatosis with polyangitis
A
cANCA
19
Q
What is the specific anti bodies found in SLE
A
Anti-Dsdna and Anti-Smith
20
Q
What is the most sensitive antibodies for RA
A
Anti-CCP
21
Q
What antibodies are found in Sjogren’s
A
Anti-Ro and Anti-La
22
Q
What antibody is found in diffuse cutaenous systemic sclerosis
A
Anti-Scl-70
23
Q
What autoantibody is found in limited cutaneous systemic sclerosis
A
Anti-centromere
24
Q
What autoantibody is found in dermatomyositis
A
Anti-Jo1
25
Symptoms of APS
CLOT:
Clots
Livedo Reticularis (lace like mottled rash on lower skin)
Obstetric Loss
Thrombocytopenia
26
What cardiac symptoms can be found in APl
Aortic and mitral regurgitation
27
Name three autoantibodies seen in APL
ANti-cardiolipin antibodies
Anti-beta2-GPI antibdoies
Positive lupus anticoagulant
28
What condition can cause the APL blood tests to be false positive
Syphilis
29
What should APL be treated
Only when a thromboembolic event has taken place
30
Name four red flags for back pain
Onset <20 or >55
Thoracic or cervical spine pain
Pain is progressive or not relieved by rest
Spinal tenderness
31
What improves pain in AS
MOvement
32
Symptoms of Behcet's disease
Oral ulcers
Genital ulcers
Erythema nodosum
33
Gout vs Pseudogout
Gout: negatively birefringent and needle-shaped
Pseudogout: Positively bifringent and rhomboid shaped crystals
34
What compound causes pseudogout
Pyrophosphate dihydrate crystals
35
Name two blood tests important to monitor in gout
Uric Acid
Renal Functions
36
What X-Ray finding is distinctive in pseudogout
Chondrocalcinosis (calcification of cartilage)
37
Symptoms of dermatomyositis
Purple rash on eyelids
Shawl sign positive
Gottron's papules (red scaly patches over MCP joint)
38
Invetsigations for dermatomyositis
CK
EMG
Muscle Biopsy
39
Risk Factors of Reactive Arthritis
Male
HLA B27
Previous GI or STD
40
Name a GI species that can cause reactive arthirtis
Shigella
41
Describe the onset of arthritis in reactive arthirtis
Peripheral arthritis after 1-4 weeks of infection : Asymmetrical oligoarthritis of the lower limb
Sacroiliac and lumbrosacal arthitis
Keratoderma blenhorragia
Conjunctivities, uveitis
Mucosal ulcers
42
What is Felty Syndrome
RA
Splenomeglay
Neutropenia
43
How to manage felty syndrome
Same as RA
44
Name some medications that can cause gout
Thiazide diuretics
ACEi
Aspirin
45
What diet can cause gout
Sea food
46
Why can chemotherapy cause GOUT
Hyperuricaemia in tumour lysis syndrome
47
What is the first line test for gout
Synovial fluid analysis to EXCLUDE septic arthritis
48
When should uric acid levels be checked during investigation
2 weeks after the attack as they can be falsely normal
49
Management of an acute gout attack
NSAID: Indomethacin
Second Line: Colchicine
50
When shoudl colchicine be given over Indomethacin
When patient has GI side effects, past kidney or heart failure
51
What is a side effect of colchicine
Diarrhoea
52
If a patinet is experiencing diarrhoea on Colchicine, what should be done
Administer INtra-articular steroids
53
When should allopurinol be indicated
PROPHYLAXIS:
Start two weeks after attack
54
Name the criteria for prophylactic allopurinol
More than 2/3 attacks a year
Tophaceous gout
X-Ray shows joint destructino
Urate nephrolithasis
Polyarticular attacks are disabling
55
If allopurinol is contraindicated, what can be given
febuxostat
56
Symptmos of granulomatosis with polyangitis
URTI: Epixstasis, chonric sinusitis or saddle-nose
LRTI: Cough, Haemoptysis, pleuritis
pANCA and c-CANCA positive: Haematuria and proteinuria
57
X-Ray findings in granulomatosis with polyangitis
Bilateral lung infiltrates
58
What scoring system is used to determine hypermobility
Beighton score
59
What beighton score indicates hypermobility
4 or more
60
Management of hypermobility syndrome
Referral to physio
61
What histological appearance indicates IgG4 disease
tumefacien lesions with dense lymphocytic infiltrates and storiform fibrosis
62
Symptoms of IgG4 related disease
swelling of slaivary and lacrimal glands
and ent sinuses
63
What is a common extraarticular sign in IgG4 disease
Pancreatitis and sclerosing cholangitis
64
Management of IgG$ disease
Rituximab
65
How is Marfan's syndrome inherited
Autosomal dominant
66
Physical appearance of Marfan's syndrome
Disproportionately tall and thin with unusually long arms and legs
Arachnodactyly (long spider fingers)
High arch palate
67
Name some CV features of Marfan's
Aortic Regurgitation
Aortic root dilatation
Mitral valve prolapse
Abdominal aortic aneurysm
68
Eye symptoms in Marfan's Syndrome
Lens Discolouration
Closed angle glaucoma
69
Medical management of marfan's
BP control
70
How often is Methotrexate given
Once a week 2.5mg
71
How do we increase the dose of methotrexate
Titrate up by 2,5mg a week
72
Side effects of methotrexate
Cytopenia
Hepatotoxicity
Renal Impairmebt
Pulmonary Fibrosis
Teratogenicity
73
When should methotrexate be stopped
If LFTs are greater than 3 x from baseline mesaurement
74
What advice shohuld patients on methotrexate be given regarding contraception
Use while on it and for three months after
75
Name another antifolate medication other than methotrexate
Trimethoprim
76
What has to be prescribed alongside methotrexate
Folic Acid
77
How often is folate acid given alongside methotrexate
Once a week but one DIFFERENT days
78
What is the antidote for methotrexate
Folinic acid
79
Signs of microscopic polyangitis
Necrotising glomerulonephirtis
Fevers, weight loss, malaise
Palpable purpura of lower extremities
Mononeuritis multiplex
Alveolar haemorrhage (haemoptysis)
80
What causes OA pain to worsen
Movement
81
How long is morning stiffness with OA
Less than 20 mins
82
X-Ray features of OA
LOSS:
Loss of joint space
Osteophytes
Subchondral cysts
Subchondral sclerosis
83
Conservative management of OA
Weight loss and excercise
84
Pharmacological management of OA
NSAIDs
85
Name the triad needed to diagnose OA
>45
Activity related joint pain
No stiffness lasting for 30 mins or more
86
What nodes are affected in OA
Heberden's AND BOucnhard's
87
When should topical NSAIDs be considered for OA
People with knee or hand OA
88
Other than topical NSAIDs what else is an adjunct treatment in hand or knee OA
TOpical capsaicin
89
If paracetomal or topical NSAIDs are insufficient in controlling hand and knee pain, what is given secondl ine
Oral COX-3 or switch NSAID
90
When should intraarticular injections be considered in OA
If pain is severe
91
When should Referral to orthopaedics be done for OA
If significantly affecting ADLs and severe pain, or functional limitation
92
What disease is associated with polyarteritis nodosa
Hep B
93
What part of the body is not affwected in Polyarteritis Nodosa
PULMONARY vessels (no lung symptoms)
94
First line investigation (blood test) for suspected polymyalgia rheumatic/ GCA
ESR (raised)
95
What is the definitive diagnosis for GCA
Temporal artery biopsy
96
Management of GCA
60mg OD Prednisolone (high dose)
97
When should prednisolone be stopped in GCA
over 1-2 years after the attack
98
What prophylaxis is given for GCA
Low dose aspirin
99
ONset of polymyalgia rheumatica
50+
100
Symptoms of polymyalgia rheumatica
Shoulder and hip girdle stiffness for over 1 hour
Low grae fever, reduced appetite and weight loss
101
Polymyalgia rheumatica vs polymyositis
Myositis: Proximal bilateral weakness with NO PAIN
PR: PAIN and STIFFNESS but no weakness
102
What ESR threshold indicates polymyalgia rheumatica
>60
103
Treatment of polymyalgia rheumatica
First DEXA scan and check history to reduce risk of ulcers.
THEN steroids
104
Are muscle bulk and reflexes affected in myositis?
No, not until very late in the disease
105
Extra MSK symptoms of myositis
Later on:
Respiratory failure
Dystonia and dysphagia
106
Onset of myositis
40-60
107
Pulmonary sign of myositis
Interstitial lung disease
108
Name tow CV symptoms of polymyositis
Raynaud's and myocarditis
109
Most common malignancy associated with myositis
Lung
110
First line investigation for polymyositis
CK levels
THEN EMG
THEN Muscle biopsy for definitive diagnosis
111
What enzyme levels are elevated in polymyostitis
CLAAA
Creatinine Kinase
Lactate Dehydrogenase
Aldolase
ALT
AST
112
What cancers are dermatomyositis associated with
Gastric, lung, GU and colon cancers
113
Treatment of Myositis
Steroids (high dose)
114
What must be monitored to track disease progression on treatment in myositis
CK levels
115
What is the purpose of hydroxychloroquine in dermatomyositis
Manages skin symptoms
116
Who should people with myositis be referred to
Physiotherapists
117
Risk Factors of pseudogout
Hyperparathyroidism
Hypophosphataemia
Hypomagnesemia (stimulates PTh production)
Previous joint surgery
Age
118
Management of raynaud's
Nifedipine
119
When should someone with raynaud's be referred to hospital
<12
Symptoms not responding to treatment
Severe ischaemia
120
What is systemic sclerosis
This is increased fibroblast activity resulting in abnormal connective tissue growth and ischaemia
121
What is limited cutaenous systemic sclerosis
Only affects the face, forearm and lower legs (up to knee)
122
What is the most common type of systemic sclerosis
Limited (CREST syndrome)
123
Presentation of Limited SSc
CREST:
Calcinosis
Raynauds
Oesophageal dysmotility
Sclerodactyly
Telangiectasia
124
WHat autoantibdoy in systemic sclerosis is more likely to cause progression to interstitial lung fibrosis and renal disease in SSc
Anti-scl-70
125
Name four deformities seen in RA
Swan neck
Z thumb
Ulnar deviation
Boutonierre hand deformity
Wrist subluxation
feet:
Hallux Valgus and hammer toes
126
Is the aixal spine involved in RA?
Yes, the cervical spine stabilising ligaments can be detsroyed causing atlanto-axial subluxation
127
What is the first line managemnt of someone with Ra and nweck pain
CT cervical spine
128
Name three periarticular features of RA
Carpal tunnel syndrome
Tenosynovitis
Olecranon bursitis
129
Haematological symptoms of RA
Splenomegaly and amyloidosis
130
Derm symptoms of RA
Raynaud's and nodules on the knuckles
131
OPthalmic features of RA
Episcleritis and scleritis
132
Respiratory symptom of RA
Pleural effusions and fibrosis
133
Joint x ray findings in RA
Soft tissue swelling
Periarticular osteoporosis
Juxta-articular erosions
Narrowing of joint space
134
What scoring system can be used to grade the severity of RA
DAS28
135
Treatment of RA flares
Intraarticular steroids or oral steroids
136
When is surgery indicated for RA
If joint is destroyed
137
At what DAS28 level should DMARDs be givenb
>5.1
138
Second line treatment of RA
TWO demards
139
WIthin what time frame of symptom onset should DMARDs be started
within 3 months
140
third line management of RA
Infliximab
141
What vaccine should someone with RA be given
annual influenza and pneumococcal vaccine veery 5 years
142
WHat steroid sholud be given during pregnancy in those with RA
Prednisolone (oral steroids, not methotrexate) or hydroxychloroquine
143
Side effects of corticosteroids
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
Side efefct of hydroxychloroquine
Retinopathy
145
Side effect of NSAIDs
renal impiarment
GI upset
Asthma exacerbation
146
How should bisphosphonates be taken
mempty stomach, 30 mins before eating breakfast woth water and stand upright
147
Signs of adrenal suppresison from corticosteroids
Hyperkalaemic hypotension
148
How to manage an adrenal crisis from corticosteroids
IV hydrocortisone
149
How do we prevent an adrenal crisis from corticosteroids
Abruptly stop if course under 3 weeks
>3 weeks = tapering
double dose if unwell
if nil by mouth, move to IV hydrocortisone
150
What vaccinations are contraindicate din people on corticosteroids
Live vaccinations
151
What is sicca syndrome
Drying mucous membranes
152
Investigation for sjogren's syndrome
Schirmer's test: <5mm paper wet in 5 minutes
Lip biopsy to demonstrate lymphoid destruction
153
What other special tests can be used for sjogren's
rose bengal staining
Salivary flow rate monitoring
Slaivary gland biopsy
154
Triggers for SLE flares
COCP
UV light
Infections
Stress
155
Most common cardiac feature of SLE
Pericarditis
156
What should be moinitored in people with SLE
Renal Function
157
What two conditions are associated with SLE
Sjogren's and APL
158
What drugs can cause lupus
Sulfadiazine
Hydralazine
Procainamide
Isoniazide
Methyldopa
Quindiine
Minocycline
159
What autoantibody is specific for drug induced lupus
Anti-histones
160
What is the most specific test for lupus nephritis
Renal biopsy
161
What antibody dictates prognossis for SLE
Anti dsdna
162
SYmptoms of SLE
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
Management of severe SLE flares
Cyclophosphamide
164
Tretaing renal disease in SLE
ACEi
165
Treating thrombocytopenia in SLE
IV Ivg
166
Where is c-ANCA antibodies found
Granulomatosis with polyangitis
167
Where is p-ANCA found
Microscopic polyangitis
168
What type of osteogenesis imperfect is the most deadly
Type 2
169
Management of osteogenesis imperfecta
Oral rusendronnate daily i
170
What is Arthritis Mutilans
Found in psoriatic arthritis: Telescopic fingers from bone shortening
171
When does a DEXA scan become first line management in osteoporosis
When there is an intermediate risk (so if the person has immediate risk factors but hasn't yet fallen)
172
When does denosumab become first line management of osteoporosis
In young people to defer bisphsophonate use
173
What is Paget's disease of the bone
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
What is the distinctive investigation finding that indicates Paget's disease of the bone
Increased ALP with normal serum calcium levels
Just an isolated rise in ALP
175
Osteomalacia vs Paget's findings
Low ALP AND Low Serum Calcium vs Low ALP only
176
Management of a patient with a T-score <-1.5 and going to be on steroids
Prophylactic bisphosphonates
177
A lack of which substance causes marfan's
Fibrillin
178
Initial management of reactive arthritis
Ibuprofen
179
What pulmonary feature would be seen on a chest X Ray for ankylosing spondyltitis (late)
Apical Fibrosis
180
Appearance of RA on a joint aspiration
Raised WBC and yellow appearance (similar to septic)
181
Complication of parathyroidism
Pseudogout
182
What should all NSAIDs in osteoarhritis be prescribed with
PPIs
183
What T score is diagnostic of osteoporosis
<-2/5
184
What defines osteopenia
T score bweetn -1 and -2.5
185
First line management of osteoarthritis
Paracetomal + topical NSAIDs
186
When are calcium supplements indicated for osteoporosis
Only if dietary intake is inadequate
187
What type hypersensitivity is SLE
Type 3
188
Management of GCA when there are eye signs
IV methylperdnisolone
NOrmally Prednisolone oral otherwise
189
What substance (lack of) causes osteomalacia
Lack of vit D
190
Symptoms of osteomalacia
Proximal muscle weakness
Joint Pain
Increased risk of fractures
191
Symptoms of rickets
Craniotabes
Delayed closure of the fonatenelles
Rachitic rosary
Genu Varum (bow legs)
192
Lab results of osteomalacia
Low Vit D
Low blood calcium levels
Raised ALP
193
Role of Vit D
Bone mineralisation (so in osteomalacia and rickets, bones can't be mineralised and become soft)
194
What is osteomyelitis
Inflammation of the bone
195
How do organisms reach the bone to cause osteomyelitis
Haematogenously
196
Causative species for osteomyelitis
Staph Aureus
197
What is sequestrum
When dead bone in osteomyelitis detahces from the healthy bone
198
WHat is involucrum
Viable periosteum that seperated from the underlying bone
199
Presentation of osteomyelitis
Swelling are eryhtmea
Bone pain + immobile
Pain exacerbated by movement
200
Risk Factors for osteomyelitis
Blunt trauma history
201
What is pott's disease
Vertebral osteomyelitis from miliary TB (haematoginously spreadings)
202
Signs of vertebral osteomyelitis
Urinary retention, back pain and fever
203
What is chronic osteomyelitis
Asymptomatic but localised bone pain or decreased range of motion
204
Gold standard diagnosis of osteomyelitis
Bone Cultures
205
Is paracetamol routinely offered for osteoarthritis
No
206
When should someone be referred to orthopaedic surgery
If they are complaining about dialy activtities
207
What treatment can be given while waiting for DMARDs to kick in
Bridging steroids
Flares:
Intra-articular steroids
then IM Steroids
then oral
208
What diet should be recommended to people with RA
Meditteranean
