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1. 4th year > Rheumatology > Flashcards

Rheumatology Flashcards

1
Q

pain pattern of osteoarthritis

A

worse on activity
worse at the end of the day
relieved by rest
morning stiffness <30 mins and inactivity gelling

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2
Q

ix osteoarthritis

A

Xray

  • loss of joint space
  • osteophytes
  • subchondral sclerosis
  • subchondral cysts
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3
Q

non pharm treatment osteoarthritis

A

weight loss
exercise
physio
walking aids

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4
Q

1st line treatment osteoarthritis

A

1st line paracetamol + topical NSAID

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5
Q

2nd line treatment osteoarthritis

A 
oral NSAID + PPI
opioids
capsaicin cream
intra-articular steroid
arthroplasty
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6
Q

is rheumatoid arthritis symmetrical or asymmetrical

A

symmetrical

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7
Q

pain pattern of rheumatoid arthritis

A

pain worse in the morning
pain better with activity and worse with rest
substantial morning stiffness, lasting hours, wears off with movement

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8
Q

main joints affected in rheumatoid arthritis

A

small joints of hands and feet - MCP and PIP

NOT DIP

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9
Q

what is felty’s syndrome

A

rheumatoid arthritis
splenomegaly
neutropenia

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10
Q

ix rheumatoid arthritis

A

xray
serology
usually clinical diagnosis

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11
Q

xray of rheumatoid arthritis

A

periarticular osteopenia
soft tissue swelling
reduced joint space
periarticular erosions

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12
Q

serology of rheumatoid arthritis

A

RF
more specific - Anti CCP (anti-cyclic cirtullinated peptide antibody)
thrombocytosis and moderate neurotrophilia

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13
Q

1st line ix for rheumatoid arthritis

A

RF

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14
Q

1st line treatment rheumatoid arthritis

A

DMARD monotherapy +/- short course of prednisolone

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15
Q

first line DMARD in rheumatoid arthritis

A

methotrexate

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16
Q

what needs to be monitored regularly with methotrexate

A

LFTs
FBC
U+E

before treatment and every 2-3 months

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17
Q

treatment of rheumatoid arthritis if inadequate response to 2 DMARDs, one of which was methotrexate. and a high DAS28 > 5.1

A

anti-TNF e.g. etanercept, infliximab, adalimumab

co-prescribed with methotrexate

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18
Q

tx flare of rheumatoid arthritis

A

steroids

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19
Q

monitoring rheumatoid arthritis

A

DAS28 and CRP

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20
Q

tx palindromic rheumatoid arthritis

A

hydroxychloroquine

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21
Q

important side effect of hydroxychloroquine

A

retinopathy - baseline ophthalmology examination and annual screening required

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22
Q

pain pattern of ank spond

A

progressive lower back pain
radiates to bum
marked morning stiffness and improves with exercise, better throughout the day
pain at night

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23
Q

1st line ix in ank spond

A

plain X ray of SI joints

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24
Q

ix if xray negative for ank spond but high suspicion

A

MRI

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25
Q

1st line tx ank spond

A

NSAIDs

encourage regular exercise e.g. swimming

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26
Q

tx peripheral joint disease in ank spond

A

sulfasalazine

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27
Q

tx non-responsive pain and stiffness in ank spond

A

anti-TNF

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28
Q

nail changes seen in psoriatic arthritis

A

pitting
onycholysis
subungal hyperkeratosis

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29
Q

ix psoriatic arthritis

A

Xray

- pencil in cup

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30
Q

tx mild peripheral psoriatic arthritis

A

NSAIDs

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31
Q

tx progressive psoriatic arthritis

A

methotrexate
anti-TNF if no response
ustekinumab, secukinumab

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32
Q

when is reactive arthritis seen

A

1-4 weeks after infection usually gastroenteritis or STI

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33
Q

most common site of reactive arthritis

A

knee

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34
Q

ix reactive arthritis

A

joint aspirate to rule out septic arthritis

STI test

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35
Q

tx reactive arthritis

A

self limiting
rest and NSAIDs
steroids if needed

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36
Q

lifestyle factors that increase change of gout

A

alcohol
red meat, kidney liver
oily fish

lose weight

stop thiazides

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37
Q

most common joint in gout

A

1st MTP

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38
Q

ix for gout

A

blood urate levels checked once episode has settled

joint aspiration with polarised light microscopy - needle shaped negatively birefringent crystals (also checked for septic arthritis)

Xray

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39
Q

tx acute gout 1st line

A

NSAID

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40
Q

2nd line acute gout treatment if NSAID not tolerated

A

colchicine

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41
Q

3rd line acute gout treatment

A

steroids

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42
Q

1st line urate lowering therapy after 1st attack of gout

A

allopurinol - don’t start during acute flare but if already taking then continue through flare

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43
Q

2nd line urate lowering therapy gout

A

febuxostat

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44
Q

precribing urate lowering therapy key points

A

start 2-4 weeks after acute attack

when starting, give cover with colchicine as risk of acute attack

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45
Q

what drug can allopurinol not be given with

A

azathioprine

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46
Q

joint aspirate of pseudogout

A

positively birefringent rhomboid shaped crystals

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47
Q

joints often affected in pseudogout

A

knee wrist shoulder

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48
Q

xray of pseudogout

A

chondrocalcinosis

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49
Q

tx pseudogout

A

1st line - NSAIDs +/- steroids
2nd line - colchicine
3rd - steroids

no prophylactic treatment

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50
Q

type of hypersensitivity in SLE

A

3

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51
Q

rash of SLE

A

malar rash that spares the nasolabial folds

photosensitivity

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52
Q

ix SLE

A

urinalysis - look for glomerulonephritis
bloods - FBC, U+E, ESR
immunology
BP and cholesterol (CVD risk)

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53
Q

immunology of SLE

A

Anti-ANA (sensitive not specific)
RF
Anti-dsDNA (specific)
Anti-smith (Sm) (specific)

(can also see anti-Ro, Anti-La and anti-RNP)

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54
Q

markers of disease activity of SLE

A

anti-DsDNA

complement - inversely

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55
Q

tx SLE mild skin disease and arthralgia

A

hydroxychloroquine

Nsaids, topical steroids

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56
Q

tx moderate SLE

A

immunosuppression - methotrexate, azathoiprine, mycophenolate

oral steroids

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57
Q

tx SLE severe organ disease

A

IV prednisolone and cyclophosphamide

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58
Q

tx SLE unresponsive cases

A

IV immunoglobulin and rituximab

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59
Q

flare of SLE

A

steroids

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60
Q

most common cause of drug induced lupus

A

hydralazine

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61
Q

thrombocytopenia is seen in most connective tissue diseases except _____ which shows thrombocytosis

A

thrombocytopenia seen in most e.g. SLE, APLS

thrombocytosis seen in rheumatoid arthritis

62
Q

platelet count and APTT in anti-phospholipid syndrome

A

thrombocytopenia

rise in APTT

63
Q

diagnosis of anti-phospholipid syndrome

A

positive immunology on 2 occasions 12 weeks apart

64
Q

immunology of anti-phospholipid syndrome

A

anti-cardiolipin
lupus anticoagulation test
anti-beta-2 glycoprotein

65
Q

primary prophylaxis in anti-phospholipid syndrome

A

low dose aspirin

- if aspirin CI then clopidogrel

66
Q

tx anti-phospholipid syndrome after a VTE or arterial thrombosis

A

life long warfarin

67
Q

tx of anti-phospholipid syndrome if VTE happens while already on warfarin

A

warfarin + low dose aspirin

68
Q

tx anti-phospholipid syndrome between pregnancy/planning pregnancy

69
Q

tx anti-phospholipid syndrome during pregnancy

A

aspirin when confirmed on urine test

LMWH when FHB detected

70
Q

cancer associated with sjogrens

71
Q

dx sjogrens

A

schirmer’s
immunology
gland biopssy - focal lymphocytic infiltration

72
Q

immunology of sjogrens

A 
Anti Ro
Anti La 
hypergammaglobulinaemia
low C4 
RF
ANA
73
Q

tx sjogrens

A

eye drops
artificial saliva
pilocarpine
arthralgia and fatigue - hydroxychloroquine, NSAID

74
Q

what should be considered in any middle-aged patient presenting with new onset raynauds

A

systemic sclerosis

75
Q

immunology of systemic sclerosis

A

ANA
RF

limited - anti-centromere
diffuse - anti-SCL 70

76
Q

s/s limited systemic sclerosis

A

CREST + P

calcinosis 
raynauds 
esophageal dysmotility
sclerodactyly - face and distal limbs
telangiectasia
77
Q

s/s diffuse systemic sclerosis

A

same as limited but with involvement of organs and skin involves trunk and proximal limbs

78
Q

tx systemic sclerosis

A 
PHTN - bosentan
raynauds - CCB, iloprost, bosentan
renal - ACEI
GI - PPI
ILD - cyclophosphamide
79
Q

monitoring in systemic sclerosis

A

annual ECHO
chest CT
BP control

80
Q

what is mixed connective tissue disease

A

features of SLE, systemic sclerosis and polymyositis

81
Q

immunology of mixed connective tissue disease

82
Q

tx mixed connective tissue disease

A

significant disease - immunosuppression
raynauds - CCB

annual echo and PFTs

83
Q

presentation of polymyosistis/dermatomyosis

A

symmetrical proximal muscle weakness usually of girdles that presents with difficulties of ADL

dermatomyositis has skin involvement

84
Q

3 skin manifestations of dermatomyositis

A

gottrons - scaly rough pink papules over knuckles
heliotropic rash - lilac rash around eyes
shawl sign - macular rash over back and shoulders

85
Q

most common systemic manifestation of polymyosistis

A

interstitial lung disease - SOB

86
Q

what cancers are at an increased risk in polymyosistis/dermato

A 
breast
ovarian
lung
bladder
bowel
87
Q

bloods of polymyosistis/dermatomyositis

A 
very elevated CK
anti jo1
anti SRP 
ANA
anti-RNP
88
Q

ix of polymyosistis/dermatomyositis

A

CK
immunology
EMG - abnormal
biopsy - diagnostic

89
Q

muscle biopsy of polymyosistis/dermatomyositis

A

perivascular inflammation and muscle necrosis

90
Q

tx polymyosistis/dermatomyositis

A

malignancy screening

prednisolone (initially 40mg) + immunosuppresion e.g. azathioprine/methotrexate

91
Q

disease similar to polymyosistis/dermatomyositis but more common in men and weakness tends to be asymmetrical and affect distal or proximal muscle groups

A

inclusion body myositis

92
Q

presentation of PMR

A

proximal myalgia of hip and shoulder girdles

morning stiffness > 1 hour, symptoms improve as day goes on

93
Q

key difference in PMR and polymyositis

A

PMR - pain predominant

polymyositis - weakness predominant

94
Q

CK and EMG of PMR

A

both normal

95
Q

bloods of PMR

A

raised CRP and ESR

ESR

96
Q

tx PMR

A

15mg oral prednisolone and gradually reduce over 18 months

97
Q

tx PMR if associated with GCA

A

40-60mg prednisolone

98
Q

what investigation is key in PMR

A

vision testing

99
Q

key features of GCA

A 
rapid onset 
visual disturbance 
headache 
jaw claudication
scalp tenderness
100
Q

diagnostic test of GCA

A

temporal artery biopsy ASAP - 100% specificity if positive but not very sensitive due to patchy involvement

101
Q

tx GCA with visual involvement

102
Q

tx GCA if no visual involvement

103
Q

when should treatment of GCA be started

A

as soon as suspected, do not wait for biopsy

taper off over 2 years

104
Q

key ix in vasculitis

A

urinalysis

105
Q

2 examples of large vessel vasculitis

A

GCA

Takayasu

106
Q

2 examples of medium vessel vasculitis

A

polyarteritis nodosa

kawasaki

107
Q

3 examples of small vessel vasculitis

A

GPA
eGPA
microscopic polyangitis

108
Q

Anti PR3

109
Q

anti MPO

110
Q

ESR and CRP in vasculitis

111
Q

tx large vessel vasculitis

A

40-60mg prednisolone and gradually reduce

may + methotrexate, azathoprine

112
Q

necrotising inflammation leading to aneurysm formation that occurs in middle aged med and is associated with Hep B

A

polyarteritis nodosa

113
Q

s/s kawasaki

A

children
high grade fever resistant to antipyretics
conjunctival injection
bright red cracked lips
strawberry tongue
red palms of hands and soles which later peel

114
Q

tx kawasaki

A

high dose aspirin + IV immunoglobulin

115
Q

screening in kawasaki

A

Echo - coronary artery aneurysms

116
Q

where does GPA affect

A

upper and lower resp tract

kidneys

117
Q

s/s GPA

A

chronic sinusitis, nasal crusting, saddle nose

nose bleeds

cough and haemoptysis, SOB, cavitating opacities on XR

deaf, rash, joint pain

haematuria and proteinuria

118
Q

what kind of kidney disease does GPA cause

A

Rapidly progressive glomerulonephritis - nephritic syndrome

119
Q

immunology of GPA

120
Q

urinalysis and renal biopsy of GPA

A

nephritic syndrome

epithelial crescents in Bowman’s capsule

121
Q

tx GPA initially

A

high dose steroids which are tapered off while other drugs start to work

122
Q

tx GPA major organ involvment

A

cyclophosphamide - once remission induced by this treatment can be maintained with methotrexate or azathioprine

123
Q

tx GPA mild disease

A

methotrexate / azathioprine - less toxic than cyclophosphamide

rituximab

124
Q

s/s EGPA

A

late onset asthma

sinusitis

125
Q

bloods of EGPA

A

eosinophilia
pANCA
MPO

126
Q

immunology of MPA

127
Q

what kind of kidney disease does MPA cause

A

rapidly progressive glomerulonephritis

128
Q

vasculitis general mangement - localised disease. early systemic

A

steroids + methotrexate/azathioprine

129
Q

vasculitis general mangement generalised

A

cyclophosphamide + steroids

plasma exchange

then azathioprine

130
Q

vasculitis general mangement refractory

A

rituximab

IV immunoglobulin

131
Q

vasculitis general mangement aggressive disease course

A

IV steroids and cyclophosphamide

132
Q

is azathioprine safe in pregnancy

133
Q

what needs checked before starting azathioprine

A

TMPT levels

134
Q

describe HSP

A

child with joint pain and purpuric rash over buttocks and lower limbs a few weeks after an URTI

135
Q

immunology of HSP

A

IgA mediated

136
Q

what needs monitored following HSP

A

BP and urinalysis

137
Q

triad of behcets

A

oral ulcers
genital ulcers
anterior uveitis

138
Q

dx of behcets

A

clinical

Pathergy test

139
Q

tx behcets

A

steroids or DMARD or rituximab

140
Q

tx raynauds

A

CCB - nifedipine 1st line

IV prostacyclin

141
Q

tx chronic fatigue / fibromyalgia

A

CBT

graded exercise programme

142
Q

inheritance ehlers danlos

143
Q

inheritance marfans

144
Q

how often is methotrexate taken

145
Q

what should be coprescirbed with methotrexate

A

folic acid 5mg once weekly take > 24 hours after methotrexate dose

146
Q

what drugs should never be prescribed with methotrexate

A

trimethoprim

co-trimoxazole

147
Q

can hydroxychloroquine be used in pregnancy

148
Q

ix if bleeding / infection occurs in someone taking azathioprine

149
Q

is sulfasalazine safe in pregnancy

A

yes and in breast feeding

150
Q

when are NSAIDs CI in pregnancy

A

3rd trimester –> cardiac malformation

1. 4th year (23 decks)

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