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Alice's finals cards > Rheumatology > Flashcards

Rheumatology Flashcards

1
Q

What are the 4 key changes on an X-ray of an osteoarthritic joint?

A

L- Loss of joint space
O- Osteophytes
S- Subchondral sclerosis
S- Subchondral cysts

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2
Q

What is the presentation of oestoarthritis?

A

Joint pain and stiffness which is worsened by activity

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3
Q

What signs of osteoarthritis are found in the hands?

A

Heberden’s nodes (DIP)
Bouchard’s nodes (PIP)

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4
Q

How is osteoarthritis diagnosed?

A

Can be made without any investigations if the pt is >45, has typical activity related pain, stiffness lasting < 30 mins and no morning stiffness

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5
Q

Management of osteoarthritis

A

Physiotherapy
oral paracetamol and topical NSAID
Add oral NSAID and PPI
?opiates
Intra-articular joint injections
joint replacement

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6
Q

What is the distribution pattern of rheumatoid arthritis?

A

Symmetrical and affecting multiple joints

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7
Q

Which 2 genes is RA often associated with?

A

HLA DR4
HLA DR1

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8
Q

What type of autoantibody is rheumatoid factor (RF)

A

It can be any type but is usually IgM

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9
Q

Which 2 antibodies are associated with RA?

A

Rheumatoid factor (RF)
Cyclic citrullinated peptide antibodies (anti CCP)

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10
Q

What is the usual presentation of RA?

A

Pain and stiffness of small joint of the hands and feet. . Worse in the morning
Better with activity
Associated with fatigue, wt loss

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11
Q

Which joints are almost never affected by rheumatoid arthritis?

A

DIP joints

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12
Q

What changes can be seen in the hands in RA?

A

Z shaped thumb
Swan neck deformity
Boutonnieres deformity
Ulnar deviation

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13
Q

What is Caplan’s syndrome?

A

Pulmonary fibrosis with pulmonary nodules, secondary to RA

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14
Q

Which investigations should be organised in RA?

A

RF, anti CCP antibodies
CRP, ESR
X-rays of hands and feet

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15
Q

What can be seen on X-ray of a joint in RA?

A

Joint destruction and deformity
Soft tissue swelling
Periarticular osteopenia
Boney erosions

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16
Q

What is the DAS28 score?

A

It is a score used in the monitoring of RA. It assesses 28 joints

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17
Q

What is the management of RA?

A

1st line= monotherapy with methotrexate, lefunomide or sulphasalazine
2nd line= 2 DMARDs in combination
3rd line= methotrexate + biological therapy (usually a TNF inhibitor)
4th line= rituximab

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18
Q

What should be prescribed alongside methotrexate?

A

Folic acid 5mg to be taken on a different day

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19
Q

What are the notable side effects of methotrexate?

A

Pulmonary fibrosis
Pneumonitis
Myelosuppresion
Liver fibrosis

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20
Q

What are the notable side effects of leflunomide?

A

Hypertension
Peripheral neuropathy

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21
Q

What are the notable side effects of sulfasalazine?

A

Temporary male infertility
Bone marrow supression

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22
Q

What are the notable side effects of hydroxychoroquine?

A

Retinopathy resulting in visual loss

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23
Q

What is the main side effect of anti-TNF medications?

A

Reactivation of TB and Hep B

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24
Q

What are the main side effects of rituximab?

A

Night sweats and thrombocytopenia

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25
Q

What are the signs of psoriatic arthritis?

A

Plaques of psorasis
Pitting of nails
Onycholysis
Dactylitis
Enthesitis

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26
Q

How is psoriatic arthritis screened for?

A

PEST tool

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27
Q

What are the changes seen on X-ray in psoriatic arthritis?

A

Periostitis
Ankylosis
Oestolysis
Dactylitis
Pencil in a cup appearance

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28
Q

What is the management for psoriatic arthritis?

A

NSAIDs
DMARDs
Anti-TNF
Ustekinumab (monoclonal antibody which targets interleukin 12 and 23)

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29
Q

What is reactive synovitis?

A

When synovitis occurs in the joints as a reaction to a recent infective trigger

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30
Q

Which infections commonly trigger reactive arthritis?

A

Gastroenteritis
STI (most often chlamydia)

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31
Q

What are the 3 common associated symptoms of reactive arthritis?

A

Bilateral conjunctivitis
Anterior uveitis
Circinate balanitis
(cant see, cant pee, cant climb a tree)

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32
Q

What is the management of reactive arthritis?

A

Aspirate the joint and send for gram staining, culture and sensitivity
NSAIDs
Steriod injections

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33
Q

Which gene is ankylosing spondylitis related to?

A

HLA B27

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34
Q

Which are the key joints affected in ankylosing spondylitis

A

Sacroiliac joints and vertebral column

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35
Q

What is the classical X-ray finding in ankylosing spondylitis?

A

Bamboo spine

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36
Q

How does ankylosing spondylitis present?

A

Someone in their late teens or twenties
Onset > 3months
Lower back pain and stiffness
Sacroiliac pain
Vertebral fractures

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37
Q

Which test in examination can help to confirm a diagnosis of ankylosing spondylitis?

A

Schober’s test

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38
Q

Which investigations should be done for ankylosing spondylitis?

A

Inflammatory markers
HLA b27 test
X-ray of the spine and sacrum
MRI of the spine

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39
Q

What is the management of the ankylosing spondylitis?

A

NSAIDs
Steriods
Anti-TNF

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40
Q

What is the pathophysiology of SLE?

A

SLE is characterised by anti-nuclear antibodies. They are antibodies to proteins within a person’s own nucleus

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41
Q

How does SLE present?

A

Fatigue
Weight loss
Photosensitive malar rash
Myalgia and arthralgia
lymphadenopathy
Raynaud’s

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42
Q

Which investigations should be done for SLE?

A

ANA blood test
Urine protein: creatinine ratio (looking for lupus nephritis)
FBC, CRP, ESR

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43
Q

Which autoantibodies are associated with SLE?

A

ANA
Anti-dsDNA

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44
Q

How is SLE diagnosed?

A

SLICC or ACR criteria. Involves confirming the presence of antinuclear antibodies

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45
Q

How is SLE managed?

A

NSAIDs
Steroids
Hydroxychloroquine
Suncream for rash

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46
Q

How does discoid lupus erthyematosus present?

A

Photosensitive lesions which are inflamed, dry, crusty and scaling

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47
Q

How can a diagnosis of discoid erthyematosus be confirmed?

A

Skin biopsy

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48
Q

How is discoid lupus erythematosus managed?

A

Sun protection
Steriods
Hydroxychloroquine

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49
Q

What is limited cutaneous systemic sclerosis?

A

Used to be called CREST syndrome
C-Calcinosis
R-Raynaud’s phenomenon
E-oEsophageal dymotility
S-Sclerodactyly
T-Telangiesctasia

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50
Q

What is diffuse cutaneous systemic sclerosis?

A

Has many features of CREST syndrome but also CV, lung and kidney problems

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51
Q

What is scleroderma renal crisis?

A

Combination of severe hypertension and renal failure

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52
Q

How systemic sclerosis diagnosed?

A

using classification criteria from the american college of rheumatology

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53
Q

What are the main treatments for systemic sclerosis?

A

Steroids and immunosuppressants

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54
Q

Which other rheumatological disease has a strong association with polymyalgia rheumatica?

A

Giant cell arteritis

55
Q

Who does polymyalgia rheumatica usually affect?

A

Caucasian women 50 years old

56
Q

What are the core features of PMR?

A

Bilateral shoulder pain which may radiate to the elbow
Bilateral pelvic girdle pain
Worse with movement
Interferes with sleep
Stiffness for at least 45 mins in the morning

57
Q

How long do symptoms of PMR have to be present for diagnosis?

A

at least 2 weeks

58
Q

How is a diagnosis of PMR made?

A

Clinical presentation and response to steriods

59
Q

What is the management of PMR?

A

15mg prednisolone. If no response after one week then stop.

Continue for 4 weeks if there is a good response and slowly taper.

60
Q

What are the additional steps that should be taken when someone is started on steroid therapy?

A

DON’T STOP

DON’T- make them aware they will be dependent and mustn’t stop

S-Sick day rules (increase the dose)
T- Treatment card
O- Osteoporosis prevention
P- PPI

61
Q

What is giant cell arteritis?

A

It is also known as temporal arteritis. It is a systemic vasculitis of the medium and large arteries

62
Q

What is the key complication of GCA?

A

Vision loss

63
Q

What are the symptoms of GCA?

A

Severe unilateral headache
Scalp tenderness
Jaw claudication
Blurred or double vision
Irreversible painless complete sight loss

64
Q

What are the diagnostic criteria for GCA?

A

Clinical presentation
Raised ESR (>50mm/hour)
Temporal artery biopsy

65
Q

What is found on temporal artery biopsy in GCA?

A

Multinucleated giant cells

66
Q

What is seen on duplex ultrasound of temporal artery in GCA?

A

Hypoechoic halo

67
Q

What is the management of GCA?

A

Steroids (prednisiolone 40-60mg)
Aspirin
PPI

68
Q

What is a LATE complication of GCA?

A

Aortitis leading to aortic aneurysm and aortic dissection

69
Q

What is polymyositis?

A

Inflammation in the muscles

70
Q

What is dermatomyositis?

A

Connective tissue disorder where there is chronic inflammation in the skin and muscles

71
Q

What is the key investigation for myositis?

A

Creatinine kinase blood test. CK should be less than 300U/L, in myositis the result is usually in the thousands

72
Q

What can cause polymyositis or dermatomyositis?

A

It can be a paraneoplastic syndrome caused by lung, breast, ovarian or gastric cancers

73
Q

How does polymyositis and dermatomyositis present?

A

Muscle pain, fatigue, weakness
Bilaterally
Mostly affects shoulder and pelvic girdle
develops over weeks

74
Q

What are the skin features of dermatomyositis?

A

Gottron lesions (knuckles, elbows and knees)
Photosensitive erythematous rash

75
Q

Which autoantibodies are present in dermomyositis and myositis?

A

Anti-Jo-1 antibodies: polymyositis (but often present in dermatomyositis)
Anti-Mi-2 antibodies: dermatomyositis.
Anti-nuclear antibodies: dermatomyositis.

76
Q

What is the definitive diagnostic test for dermomyositis?

A

Muscle biopsy

77
Q

What is the first line treatment for dermomyositis and myositis?

A

Corticosteriods

78
Q

What is antiphospholipid syndrome?

A

A disorder associated with antiphospholipid antibodies where the patient is in a hypercoagulable state

79
Q

What are the main associations of antiphospholipid syndrome?

A

Thrombosis, pregnancy complications and recurrent miscarriage

80
Q

What are the antiphospholipid antibodies associated with antiphospholipid syndrome?

A

Lupus anticoagulant
Anticardiolipin antibodies
Anti-beta-2 glycoprotein I antibodies

81
Q

What is livedo reticularis?

A

A purple lace like rash which is seen in antiphospholipid syndrome

82
Q

How is a diagnosis of antiphospholipid syndrome made?

A

When there is a history of thrombosis or pregnancy plus persistent antibodies

83
Q

What is the management of antiphospholipid syndrome?

A

long term warfarin unless pregnant when women are started on LMWH (enoxaparin) plus aspirin

84
Q

What is Sjogren’s syndrome?

A

An autoimmune condition which affects the exocrine glands. It leads to the symptoms of dry mucus membranes (mouth, eyes, vagina)

85
Q

What is the difference between primary and secondary sjogren’s?

A

Primary is when the condition occurs in isolation, secondary is when it occurs related to SLE or RA

86
Q

Which autoantibodies are associated with Sjogren’s?

A

anti-Ro and anti-La

87
Q

Which test is used to diagnose sjogrens and how is it conducted?

A

Schirmer’s test. Involves inserting a folded piece of filter paper under the lower eyelid with a strip hanging out. Leave for 5 mins and see how far the tears travel along the strip. Should be 15mm

88
Q

What is the management of Sjogren’s?

A

Artificial tears
Artificial saliva
Vaginal lubricants
Hydroxychloriquine is used to halt the progression of the disease

89
Q

What are the general symptoms of vasculitis?

A

Purpura
joint and muscle pain
Peripheral neuropathy
Renal impairment
HTN

90
Q

Which tests should be done to test for vasculitis?

A

Inflammatory markers (CRP and ESR)

ANCA is the antibody present in vasculitis!!

p-ANCA (MPO antibodies): Microscopic polyangiitis and Churg-Strauss syndrome

c-ANCA (PR3 antibodies): Wegener’s granulomatosis

91
Q

How should vasculitis be managed?

A

Steroids and immunosuppressants

92
Q

What type of vasculitis is henoch-schonlein purpura?

A

IgA vasculitis. Inflammation occurs due to immunoglobulin A deposits in the blood vessels

93
Q

What are the 4 classic features of henoch-scholein purpura?

A

Pupura
Joint pain
Abdo pain
Renal involvement

94
Q

What is the management of HSP?

A

Analgesia, fluids, rest. Should resolve in 4-6 weeks

95
Q

What is eosinophillic granulomatosis with polyangiitis?

A

Used to be known as Churg-Strauss syndrome. It is a small and medium vessel vasculitis which is most associated with lung and skin problems.. Can present with severe asthma and elevated eosinophil levels

96
Q

What is wegener’s granulomatosis?

A

Small vessel granulomatous vasculitis which affects the respiratory tract and kidneys

97
Q

What are the features of wegners granulomatosis?

A

Nose bleeds
Crusty nose secretions (ew)
hearing loss
Saddle shaped nose
Cough, wheeze haemoptysis
Glomerulonephritis

98
Q

What does Behçet’s disease present with?

A

Recurrent oral and genital ulcers

99
Q

Which gene is Behçet’s disease linked with?

A

HLA B51

100
Q

What do the ulcers in Behçet’s disease look like?

A

Painful and sharply circumscribed with a red halo

101
Q

What are skin findings in Behçet’s disease?

A

Erethema nodosum
Papules and pustules
Vasculitic types rashes

102
Q

What are they investigations for Behçet’s disease?

A

The pathergy test.

103
Q

What is the management of Behçet’s disease?

A

Topical and systemic steroids
Colchicone
immunosupressiants

104
Q

What causes gout?

A

High blood urate. This leads to urate crystals being deposited in the joint

105
Q

What are gouty tophi?

A

Subcutaneous deposits of uric acid

106
Q

Which are the classic joints affected by gout?

A

Base of the big toe
Wrists
Base of thumb

107
Q

How is gout diagnosed?

A

Apirate the joint. the fluid will show needle shaped crystals which are negatively bifringent of polarised light

108
Q

what is seen on X-ray of a gouty joint?

A

Lytic lesions, punched out erosions, sclerotic borders and overhanging edges

109
Q

How should a flare of gout be managed?

A

NSAIDs
Colchicine

110
Q

What is a notable side effect of colchicine?

A

diarrhoea

111
Q

How should gout be prevented?

A

Allopurinol (xanthine oxidase inhibitor) and lifestyle changes

112
Q

When should gout prophylaxis be initiated?

A

After the acute attack

113
Q

What is pseudogout?

A

a crystal arthropathy caused by calcium pyrophosphate crystals

114
Q

What does pseudogout aspirate show?

A

Rhomboid crystals which are positively birefringent of light

115
Q

What is the classic xray change seen in pseudogout?

A

Chondrocalcinosis. A thin white line in the joint space which is caused by calcium deposition

116
Q

What are the management options for pseudogout?

A

NSAIDs
Colchicine
Joint aspiration
Steroid injections

117
Q

What does the FRAX score predict?

A

A person’s risk of a fragility fracture in the next 10 years

118
Q

What factors are considered in a FRAX score?

A

age, BMI, co-morbidities, smoking, alcohol, bone mineral density and FHx

119
Q

Which joint is the T score measured at in osteoporosis?

A

The hip

120
Q

What is the range of T scores suggestive of osteopenia?

A

-1 to -2.5

121
Q

What is the T score indicative of osteoporosis?

A

Less than -2.5

122
Q

What is the management of osteoporosis?

A

Bisphosphonates (alendronate 70mg once weekly)
Calcium and vitamin D

123
Q

What is the potential side effect of bisphosphonates and how is this managed?

A

Reflux and oesophageal erosions

124
Q

What is osteomalacia?

A

there is defective bone mineralisation which results in soft bones Due to insufficient vitamin D

125
Q

What are the symptoms of vitamin D deficiency?

A

Fatigue
Bone pain
Muscle weakness
Muscle aches
Pathological fractures
looser zones

126
Q

What is the investigation for osteomalacia?

A

Serum 25-hydroxyvitamin D

127
Q

What is the treatment and dosing for osteomalacia?

A

Supplementary vitamin D (colecalciferol)
50,000 IU one weekly for 6 weeks
20,000 IU twice weekly for 7 weeks
4000 IU daily for 10 weeks

128
Q

What is Paget’s disease of bone?

A

Excessive bone turnover. This is due to excessive activity of osteoblasts and osteoclasts

129
Q

Why is there increased risk of pathological fractures in paget’s disease?

A

There is areas of high and low density bone which results in large and mishapen bones

130
Q

What does paget’s disease present with?

A

Bone pain
Bone deformity
Fractures
Hearing loss

131
Q

What are the key x-ray findings in paget’s disease?

A

bone enlargment
Osteoporosis circumscripta (lytic lesions of the skull)
Cotton wool appearance of the skull
V shaped defects in the long bones

(Basically just lytic lesions)

132
Q

What is seen on blood tests in paget’s disease?

A

Raised ALP
Normal calcium and phosphate

133
Q

What is the management of paget’s disease?

A

Bisphosphonates
NSAIDs
Calcium and vit D

134
Q

What are the 2 key complications of paget’s disease?

A

Osteosarcoma
Spinal stenosis and cord compression

Alice's finals cards (23 decks)

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