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Conditions > Rheumatology > Flashcards

Rheumatology Flashcards

1
Q

What is osteoarthritis?

A

Wear-and-tear of the articular cartilage over time

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2
Q

What is the most common type of arthritis?

A

Osteoarthritis

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3
Q

Which joints are most commonly affected in osteoarthritis (4)?

A

Weight-bearing joints:

  • Hips
  • Knees
  • Spine
  • Hands
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4
Q

Describe the presentation of osteoarthritis (5).

A
  • Joint pain
  • Joint stiffness
  • Bouchard’s nodes
  • Heberden’s nodes
  • Squaring at the base of the thumb
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5
Q

Give one way in which osteoarthritis can be differentiated from inflammatory arthritis.

A

Osteoarthritis - symptoms are worse with activity

Inflammatory arthritis - symptoms improve with activity

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6
Q

How can osteoarthritis be diagnosed?

A

Without investigation if:

  • Patient is over 45
  • Typical activity related joint pain
  • No morning stiffness or stiffness that lasts less than 30 minutes
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7
Q

What can be used to confirm a diagnosis of osteoarthritis? Features?

A

X-ray - LOSS:

  • Loss of joint space
  • Osteophytes
  • Subchondral sclerosis
  • Subchondral cysts
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8
Q

What is the first line management for osteoarthritis (4)?

A

Patient education:

  • Lifestyle advice - diet, weight loss, exercise
  • Physiotherapy to improve joint strength
  • Orthotics
  • Heat and ice
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9
Q

What is the second line management for osteoarthritis (3)?

A

Analgesia - pain control:

  • Step 1 - oral paracetamol + topical NSAIDs
  • Step 2 - oral NSAIDs
  • Step 3 - opiates
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10
Q

How can the most severe cases of osteoarthritis be treated?

A

Joint replacement

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11
Q

What is the most common inflammatory arthritis?

A

Rheumatoid arthritis

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12
Q

Which joints are most commonly affected in rheumatoid arthritis?

A

Small joints of the hands and feet

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13
Q

Name 2 genes associated with rheumatoid arthritis.

A
  • HLA DR4 - often present in RA + patients

- HLA DR1 - occasionally present in RA + patients

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14
Q

Which antibody is most sensitive in diagnosing rheumatoid arthritis?

A

Rheumatoid factor

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15
Q

Which antibody is most specific in diagnosing rheumatoid arthritis?

A

Anti-CCP

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16
Q

Describe the presentation of rheumatoid arthritis (8).

A
  • Symmetrical polyarthritis
  • Joint pain - improves with activity
  • Joint stiffness
  • Joint swelling
  • Ulnar deviation
  • Swan neck deformity
  • Boutennieres deformity
  • Z-shaped deformity of the thumb
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17
Q

Which joints are almost never affected in rheumatoid arthritis?

A

Distal interphalangeal joints

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18
Q

What is the 1st line investigation for rheumatoid arthritis?

A

Bloods - measure RF and anti-CCP

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19
Q

What is the gold standard investigation for rheumatoid arthritis?

A

X-ray of hands and feet - shows erosions

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20
Q

What is the 1st line treatment for rheumatoid arthritis (3)?

A

DMARDs:

  • Methotrexate
  • Hydroxychloroquine
  • Sulfasalazine
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21
Q

Name 3 biologics that can be used to treat rheumatoid arthritis.

A
  • Infliximab
  • Adalimumab
  • Rituximab
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22
Q

Give 2 examples of anti-TNF drugs.

A
  • Infliximab

- Adalimumab

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23
Q

Give an example of an anti-CD20 drug.

A

Rituximab

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24
Q

What is used to monitor the progression of rheumatoid arthritis?

A

CRP - ESR takes longer to change so not as good

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25
Q

What is crystal arthritis?

A

Arthritis caused by the accumulation of crystals in the joint

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26
Q

What are the 2 types of crystal arthritis?

A
  • Gout

- Pseudogout

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27
Q

What type of crystal arthritis causes a more severe presentation?

A

Gout

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28
Q

What are the risk factors for gout (7)?

A
  • Male
  • Middle-aged
  • Family history
  • Existing cardiovascular/renal disease
  • Obesity
  • High purine diet - meat, seafood
  • Alcohol - high in fructose
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29
Q

Which joint is usually affected in gout?

A

Base of the big toe (metatarso-phalangeal joint)

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30
Q

What is it important to exclude in the case of a hot, painful and swollen joint?

A

Septic arthritis

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31
Q

Describe the presentation of gout (2).

A
  • 1 joint which is hot, painful and swollen

- Gouty tophi

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32
Q

How is gout diagnosed? Results?

A

Aspiration of the synovial fluid from the joint:

  • No bacterial growth
  • Monosodium urate crystals
  • Needle-shaped crystals
  • Negatively bifringent of polarised light
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33
Q

How is a gout flare up managed (3)?

A

1st line - NSAIDs (not aspirin)
2nd line - colchicine (those who cannot tolerate NSAIDs e.g renal impairment)
3rd line - steroids

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34
Q

What drugs can be given for gout prophylaxis (2)?

A

1st line - allopurinol (given a month after gout attack)

2nd line - febuxostat

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35
Q

What can someone do to reduce the risk of gout (5)?

A
  • Weight loss
  • Stay hydrated
  • Reduce alcohol intake
  • Reduce consumption of purine-rich foods e.g red meat, seafood
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36
Q

Who is more likely to be affected by pseudogout?

A

Elderly

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37
Q

Which joint is most commonly affected by pseudogout?

A

Knee

38
Q

How is pseudogout diagnosed? Results?

A

Aspiration of the synovial fluid from the joint:

  • No bacterial growth
  • Calcium pyrophosphate crystals
  • Rhomboid-shaped crystals
  • Positively bifringent under polarised light
39
Q

What is osteoporosis?

A

A condition where there is a reduction in bone density

40
Q

What is osteopenia?

A

A less severe reduction in bone density as seen in osteoporosis

41
Q

What are the risk factors for osteoporosis?

A

SHATTEREDD:

  • Steroid use
  • Hyperthyroidism/hyperparathyroidism
  • Alcohol and smoking
  • Thin - low BMI
  • Testosterone low
  • Early menopause
  • Renal or liver failure
  • Erosive/inflammatory bone disease
  • Dietary calcium decreased
  • Diabetes mellitus type 1
42
Q

Name a key group where osteoporosis should be considered. Why?

A

Post-menopausal women:

  • Lower levels of oestrogen
  • Oestrogen is protective against osteoporosis as it inhibits osteoclasts
43
Q

What can be given to post-menopausal women to prevent osteoporosis?

A

Hormone replacement therapy (HRT)

44
Q

What is the 1st line investigation for osteoporosis?

A

FRAX tool - measures the risk of a fragility fracture over the next 10 years

45
Q

What information is inputted into the FRAX tool (9)?

A
  • Age
  • Sex
  • BMI
  • Co-morbidities
  • Smoking
  • Alcohol
  • Previous fractures
  • Glucocorticoid use
  • Bone mineral density from DEXA scan
46
Q

What is the gold standard investigation for osteoporosis?

A

DEXA scan - measures bone mineral density

- Gives a T score at the person’s hip

47
Q

What is a T score?

A

The number of standard deviations below the mean for a healthy young adult their bone mineral density is

48
Q

What is a normal T score?

A

T score > -1

49
Q

What T score suggests osteopenia?

A

T score -1 - -2.5

50
Q

What T score suggests osteoporosis?

A

T score < -2.5

51
Q

What T score suggests severe osteoporosis?

A

T score < -2.5 and pathological fracture present

52
Q

What is the 1st line treatment for osteoporosis?

A

Bisphosphanates e.g alendronate and AdCal

53
Q

What is a common side effect of bisphosphonates? What can be done to prevent this?

A

Reflux:

  • Taken on an empty stomach first thing in the morning
  • Remain upright for at least an hour after taking
54
Q

What is 2nd line treatment for osteoporosis? How does it work?

A

Denosumab - inhibits osteoclast activity

55
Q

What lifestyle changes can be made to manage osteoporosis?

A
  • Exercise
  • Maintain a healthy weight
  • Smoking cessation
  • Reduce alcohol consumption
  • Adequate vitamin D and calcium
56
Q

What are the 4 features of spondyloarthropathies?

A
  • Axial inflammation - spine and sacro-iliac joints
  • Asymmetrical peripheral arthritis
  • Seronegative - absence of rheumatoid factor
  • Strong association with HLA-B27
57
Q

Name 4 spondyloarthropathies.

A
  • Ankylosing spondylitis
  • Psoriatic arthritis
  • Reactive arthritis (Reiters syndrome)
  • Enteropathic arthritis
58
Q

What is a useful mnemonic for spondyloarthropathies?

A

SPINE ACHE:

  • Sausage digits - dactylitis
  • Psoriasis
  • Inflammatory back pain
  • NSAIDs good response
  • Enthesitis - heel
  • Arthritis
  • Crohn’s, UC
  • HLA-B27
  • Eyes - uveitis, iritis
59
Q

What is ankylosing spondylitis?

A

An inflammatory condition which mainly affects the spine causing progressive pain and stiffness

60
Q

Which joints are typically affected in ankylosing spondylitis (2)?

A
  • Joints of the vertebral column

- Sacroiliac joints

61
Q

Describe the presentation of ankylosing spondylitis.

A
  • Gradual onset of symptoms
  • Lower back pain - worse on rest, better with movement
  • Pain is worse in the morning and at night
  • Pain wakes them from their sleep
  • Lower back stiffness
62
Q

What is a complication of ankylosing spondylitis?

A

Vertebral fracture

63
Q

Name a test which can be used in the examination of ankylosing spondylitis.

A

Schober’s test

64
Q

How is Schober’s test done?

A
  • Patient stands straight
  • Find L5 vertebrae
  • Mark a point 10 cm above and 5 cm above
  • Patient bends forward
  • If the distance between the 2 points is less than 20 cm, suspect ankylosing spondylitis
65
Q

How is ankylosing spondylitis diagnosed?

A

No single test:

  • CRP/ESR - elevated
  • HLA-B27 genetic testing
  • X-ray
66
Q

Describe the X-ray changes seen in ankylosing spondylitis (3).

A
  • Bamboo spine
  • Squaring of the vertebral bodies
  • Subchondral sclerosis and erosions
67
Q

What can be used to treat flare-ups in ankylosing spondylitis?

A

Steroids

68
Q

Name other conditions which ankylosing spondylitis can result in (5).

A

5 As:

  • Anterior uveitis
  • Autoimmune bowel disease
  • Apical lung fibrosis
  • Aortic regurgitation
  • Amyloidosis
69
Q

What is psoriatic arthritis?

A

Inflammatory arthritis associated with psoriasis

70
Q

Describe the presentation of psoriatic arthritis.

A
  • Psoriasis - seen in patient or 1st degree relative
  • Joint pain
  • Joint stiffness
  • Dactylitis
  • Onycholysis
  • Pitting of the nails
71
Q

How can psoriatic arthritis be differentiated from rheumatoid arthritis?

A
  • Psoriatic arthritis - asymmetrical pattern of joints affected
  • Rheumatoid arthritis - symmetrical pattern of joints affected
72
Q

Name the screening test used for psoriatic arthritis.

A

PEST tool

73
Q

What is used to diagnose psoriatic arthritis?

A

CASPAR criteria

74
Q

Name a classic X-ray finding of psoriatic arthritis.

A

Pencil-in-cup appearance

75
Q

Name the most severe form of psoriatic arthritis. How does it present?

A

Arthritis mutilans - short, telescopic finger

76
Q

What is enteropathic arthritis?

A

Inflammatory arthritis associated with GI pathologies e.g IBD

77
Q

What is reactive arthritis?

A

Inflammation of a joint that occurs as a reaction to a recent infective trigger

78
Q

What is the most common cause of reactive arthritis?

A

STIs e.g chlamydia

79
Q

What is it important to exclude when reactive arthritis is suspected?

A

Septic arthritis

80
Q

Describe the presentation of reactive arthritis (3).

A
  • Recent infection
  • Single joint affected
  • Joint is hot, swollen and painful
81
Q

What is associated with reactive arthritis?

A

‘Can’t see, pee or climb a tree’

  • Conjunctivitis
  • Urethritis
  • Arthritis
82
Q

How is reactive arthritis diagnosed?

A

Joint aspiration - exclude septic arthritis and crystal arthritis

83
Q

What is septic arthritis?

A

An infection that occurs within a joint

84
Q

What type of joints can septic arthritis affect?

A
  • Native joints

- Joint replacements

85
Q

What is the most common causative organism of septic arthritis in native jpints?

A

Staphylococcus aureus

86
Q

What is the most common causative organism of septic arthritis in joint replacements?

A

Staphylococcus epidermidis

87
Q

What is the most common causative organism of septic arthritis in IVDUs, immunocompromised and extremes of age?

A

E. coli or pseudomonas

88
Q

Which joint is most commonly affected in septic arthritis?

A

Knee

89
Q

Describe the presentation of septic arthritis (2).

A
  • 1 joint which is hot, red, swollen and painful

- Systemic symptoms - fever, lethargy

90
Q

How is septic arthritis diagnosed?

A

Joint aspiration

91
Q

How is septic arthritis treated?

A
  • Antibiotics for 3 - 6 weeks

- Sepsis 6

92
Q

What are the risk factors for septic arthritis?

A
  • Older age
  • Open fracture
  • Pre-existing joint disease
  • Prosthetic joint
  • Recent joint surgery
  • Recent steroid injection into the joint
  • Immunosuppression
  • Diabetes

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