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Med Finals - Medicine > Rheumatology > Flashcards

Rheumatology Flashcards

1
Q

Define osteoarthritis

A

Wear and tear of the joints - non inflammatory degeneration of joints.

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2
Q

Risk factors for osteoarthritis

A

Obesity
Age
Occupation
Trauma
Female
FH

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3
Q

Signs of osteoarthritis on xray

A

LOSS
Loss of joint space
Osteophytes
Subchondral sclerosis
Subchondral cysts

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4
Q

History of osteoarthritis

A

Joint pain and stiffness
Worsened by activity
Better in the morning
Deformity
Instability
Reduced function

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5
Q

Commonly affected joints in osteoarthritis

A

Hips
Knees
Sacro-iliac joints
DIP
CMC joint at base of thumb
Wrist
Cervical spune

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6
Q

Signs of osteoarthritis in the hands

A

Heberden’s nodes
Bouchard’s nodes
Squaring at the base of thumb
Reduced motion

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7
Q

Management of osteoarthritis

A

Weight loss
Physio
OT
NSAIDs
(Opiates)
Intra-articular steroids
Joint replacement

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8
Q

Define rheumatoid arthritis

A

An autoimmune condition that causes chronic inflammation of the synovial lining of the joints, tendon sheaths and bursa. A symmetrical polyarthritis.

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9
Q

What genetics are associated with rheumatoid arthritis

A

HLA DR4
HLA DR1

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10
Q

What auto antibodies should be tested in rheumatoid

A

Rheumatoid factor - not sensitive or specific
Anti-CCP - much better

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11
Q

History of rheumatoid arthritis

A

Symmetrical distal polyarthropathy
Pain
Swelling
Stiffness - morning
Fatigue
Weight loss
Flu like illness
Muscle aches and weakness
Pain worse after rest and improves with activity

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12
Q

Common joints affected in rheumatoid arthritis

A

PIP
MCP
Wrist and ankle
Metatarsophalangeal joints
Cervical spine
Large joints
Not distal inter phalangeal joints!

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13
Q

Signs of rheumatoid arthritis in the hands

A

Palpation of the synovium feels boggy
Z shaped deformity of the thumb
Swan neck deformity
Boutonniers deformity
Ulnar deviation

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14
Q

Extra-articular manifestations of rheumatoid arthritis

A

Pulmonary fibrosis - caplan’s syndrome
Bronchiolitis
Felty’s syndrome - RA, neutropenia and splenomegaly
Sjorgren’s syndrome
Anamia
Cardiovascular disease
Episcleritis and scleritis
Rheumatoid nodules
Lymphadenopathy
Carpel tunnel syndrome
Amyloidosis

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15
Q

Investigations in rheumatoid arthritis

A

Clinical diagnosis
RF
Anti-CCP
CRP and ESR
Xray
Ultrasound - synovitis

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16
Q

Xray changes seen in rheumatoid arthitis

A

Joint destruction and deformity
Soft tissue swelling
Periarticular osteopenia
Boney erosions

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17
Q

Management of rheumatoid arthritis

A

Physio
OT
NSAIDs
DMARDs - methotrexate (+folic acd), leflunomide, sulfasalazine (hydroxychloroquine)
2 in combination
Biologicals - TNF inhibitors (infliximab, asalimumab)

Surgery - deformities

Rituximab

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18
Q

Define psoriatic arthritis

A

Inflammatory arthritis associated with psoriasis. Part of the seronegative spondyloarthropathy group

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19
Q

What are the possible patterns of psoriati arthritis

A

Symmetrical polyarthritis - simmilar to RA but DIP affected
Asymmetrical pauciarthritis - affect only a few joints in fingers and toes
Spondylitic pattern - back stiffness, sacroiliitis, atlanto-axial joint involvement

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20
Q

Clinical signs of psoriatic arthritis

A

Plaques of psoriasis
Pitting of the nails
Onycholysis - separation of nail from ben
Dactylitis - inflammation of full finger
Enthesitis - inflammation of entheses, points of tendon insertion on bone.

Eye disease
Aortitis
Amyloidosis

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21
Q

Xray changes seen in psoriatic arthritis

A

Periostitis
Ankylosi - bones joining together
Osteolysis
Dactylitis - soft tissue swelling
Pencil-in-cup appearance!

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22
Q

Management of psoriatic arthritis

A

Similar the rheumatoid
NSAIDs
DMARDs
Anti-TNF
Ustekinumab

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23
Q

Define reactive arthritis

A

Where synovitis occurs in the joints as a reaction to a recent infective trigger. typically acute monoarthritis in the lower limb.
Most common infections - gastroenteritis, STI (chlamydia, gonococcal septic arthritis)

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24
Q

What conditions are associated with reactive arthritis

A

Bilateral conjunctivitis
Anterior uveitis
Circinate balanitis
Can’t see, pee or climb a tree

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25
Q

Management of reactive arthritis

A

Exclude septic arthritis - aspirate (culture and crystal)
NSAIDs
Intraarticular Steroids
Systemic steroids

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26
Q

Define ankylosing spondylitis

A

An inflammatory condition mainly affecting the spine that causes progressive stiffness and pain. It mainly affects the sacroiliac joints and can progress to fusion,

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27
Q

What genetics are associated with ankylosing spiondylitis

A

HLA B27

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28
Q

History of ankylosing spndylitis

A

Young adult male in late teens or 20s
Gradual onset of lower back pain and stiffness
Worse at night and in the morning
Symptoms fluctuate with flares

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29
Q

What conditions are associated with ankylosing spondylitis

A

Systemic symptoms - fatigue, weight loss
Chest pain - costovertebral cost sternal joints
Enthesitis
Dactylitis
Anaemia
Anterior uveitis
Aortitis
Heart block
Restrictive lung disease
Pulmonary fibrosis
Inflammatory bowel disease

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30
Q

Investigations in ankylosing spondylitis

A

Inflammatory markers - CRP and ESR
HLAB27
Xray
MRI - bone marrow oedema

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31
Q

What xray changes are seen in ankylosing spondylitis

A

Bamboo spine - later stagees
Squaring of vertebral bodies
Subchondral sclerosis and erosions
Syndesmophytes
Ossification of ligaments
Fusion

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32
Q

Management of ankylosing spondylitis

A

NSAIDs
Steroids - during flares
Anti-TNF
Secukinumab

Physio
Exercise
Avoid smoking
Bisphosphonates
Manage complications
Surgery for deformities

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33
Q

Define systemic lupus erythematosus

A

Inflammatory autoimmune connective tissue disease. Immune response to proteins within nuclei.

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34
Q

History of SLE

A

Fatigue
Weight loss
Arthralgia
Myalgia
Fever
Photosensitive malar rash - butterfly shaped
Lymphadenopathy and splenomegaly
Shortness of breath
Pleuritic chest pain
Mouth ulcers
Hair loss
Raynaud’s

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35
Q

Investigations in SLE

A

Auto antibodies
FBC
C3 and C4
CRP + ESR
Immunoglobulins
Urinalysis - protein creatinine ratio
Renal biopsy

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36
Q

What auto antibodies are tested in SLE

A

ANA
anti-diDNA - very specific to SLE
anti-ENA

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37
Q

Complications of SLE

A

Cardiovascular - chronic inflammation in blood vessels, HTN and coronary artery disease
Infection - 2dry to immunosuppression
Anaemia
Pancytopenia
Pericarditis
Interstitial lung disease - pulmonary fibrosis
Lupus nephritis
Neuropsychiatric SLE - inflammation of the central nervous system
Recurrent miscarriage
VTE

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38
Q

Management of SLE

A

First line
NSADs
Steroids
Hydroxychloroquine
Suncream

Immunosuppression
Methotrexate, mycophenolate mofetil, azathioprine, tacrolimus, leflenomide, ciclosporin

Biological
Rituximab
Belimumab

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39
Q

Define discoid lupus erythematosis

A

A non-cancerous chronic skin condition often found in women and associated with SLE. Rarely leisions can progress to squamous cell carcinoma

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40
Q

History of discoid lupus erythematosus

A

Lesions on face, ears and scalp
Photosensitive
Scaring alopecia
Hyper or hypo-pigmented scars

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41
Q

What do discoid lupus erythematosus lesions look like

A

Inflamed
Dry
Erythematous
Patchy
Crusty and scaling

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42
Q

Management of discoid lupus erythematosus

A

Sun protection
Topical steroids
Intralesional steroid injection
Hydroxychloroquine

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43
Q

Define systemic sclerosis

A

Often call scleroderma - autoimmune inflammatory and fibrotic connective tissue disease

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44
Q

What are the main patterns of systemic sclerosis

A

Limited cutaneous systemic sclerosis
Diffuse cutaneous systemic sclerosis

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45
Q

Define limited cutaneous systemic sclerosis

A

Previously called CREST syndrome
Calcinosis
Raynaud’s
oEsophageal dysmotility
Sclerodactyly
Telangiectasia

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46
Q

Define diffuse cutaneous ststemic sclerosis

A

Includs features of CREST syndrome plus:
Cardiovascular problems
Lung problems
Kidney problems

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47
Q

Define scleroderma

A

Hardening of the skin
Shiny tight skin without normal folds.
Most notable on the hands and face

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48
Q

Define sclerodactyly

A

Skin tightens around the joints restricting motion. Skin hardens and tightens further there is loss of fat pads
Skin can also break and ulcerate

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49
Q

Define telangiectasia

A

Dilated small blood vessels in the skin - fine thready appearance

50
Q

Define calcinosis

A

Calcium deposits built up under the skin - commonly in fingertips

51
Q

Define Raynaud’s phenomenon

A

Where fingertips go completely white and then blue in response to mild cold
Caused by vasoconstriction

52
Q

Define oesophageal dysmotility

A

Connective tissue dysfunction in the oesophagus commonly associated with swallowing difficulties, acid reflux and oesophagitis

53
Q

Define scleroderma renal crisis

A

Acute condition where there is a combination of severe hypertension and renal failure

54
Q

What auto antibodies are found in systemic sclerosis

A

ANA
Anti-centromere antibodies - limited
Anti-Scle-70 - diffuse

55
Q

Management of systemic sclerosis

A

Steroids and immunosuppressants

Avoid smoking
Gentle skin stretching
Regular emollients
Avoid cold triggers
Physio
OT

Nifedipine - raynauds
PPI - gi symptoms
Analgesia
Abx for skin infection
Antihypertensive
Treat pulmonary hypertension
Supportive management

56
Q

Define polymyalgia rheumatica

A

Inflammatory condition that causes pain and stiffness in the shoulders, pelvic girdle and neck. Strongly associated with giant cell arteritis

57
Q

Features of polymyalgia rheumatica

A

Present for at least 2 weaks
Bilateral should pain that may radiate to the elbow
Bilateral pelvic girdle pain
Worse on movement
Interferes with sleep
Stiffness for atleast 45 minutes

Others - systemic symptoms, upper arm tenderness, carpel tunnel, pitting oedema

58
Q

Differentials for polymyalgia rheumatica

A

Osteoarthritis
Rheumatoid arthritis
SLE
Myositis
Cervical spondylitis
Adhesive capsulitis
Hyper or hypothyroidism
Osteomalacia
Fibromyalgia

59
Q

Investigations in polymyalgia rheumatica

A

Clinical diagnosis and response to steroids
Inflammatory makers - ESR CRP

FBC
UE
LFT
Calcium
Serum protein electrophoresis - myeloma
Thyroid
Creatinine kinase - myositis
Rheumatoid factor
Urine dip

Autoantibodies

60
Q

Management of polymyalgia rheumatica

A

Steroids!
15mg Pred OD
Reducing regieme

61
Q

What additional measures should be in place for patients of long term steroids

A

Don’t STOP
Don’t immediately stop steoird
Sick day rules -
Treatment card
Osteoporosis - bisphosphonates
Proton pump inhibitor

62
Q

Define giant cell arteritis

A

A systemic vasculitis of the medium to large arteries, typically presenting with temporal arteritis.

63
Q

History of giant cell arteritis

A

Severe unilateral headache around the temple or forehead
Scalp tenderness may be noticed on brushing hair
Jaw claudication
Blurred or double vision
Irreversible painless complete sight loss can occur rapidly

Fever
Muscle aches
Fatigue
Weight loss
Loss of appetite
Peripheral oedema

64
Q

Investigations in giant cell arteritis

A

Clinical diagnosis
Raised ESR
Temporal artery biopsy
FBC
LFT - alp
CRP
Duplex US - hypoechoic halo sign

65
Q

What is seen on temporal artery biopsy in giant cell arteritis

A

Multinucleated giant cells

66
Q

Management of giant cell arteritis

A

Steroids!
40-60mg prednisolone

Aspirin - decreases visual loss and stroke
PPI for Gi protection on steroids

67
Q

Define myositis

A

Infalmmation within the muscles

68
Q

Define polymyositis

A

Condition of chronic inflammation in the muscles

69
Q

Define dermatomyositis

A

A connective tissue disorder where there is chronic inflmmation of the skin and muscles

70
Q

Features of dermatomyositis

A

Gottron lesions - scaly erythematous patches on knuckles, elbows and knees
Photosensitive erythmatous
Purple rash on the face and eyelids
Periorbital oedema
Subcutaneous calcinosis

71
Q

Define antiphospholipid syndrome

A

A disorder associated with antiphospholipid antibodies where the blood becomes prone to clotting. Can occur on its own or with other autoimmue conditions, maily SLE

72
Q

What conditions are associated with antiphospholipid syndrome

A

DVT
PE
Stroke
MI
Renal thrombosis
Recurrent miscarriage
Stillbirth
Preeclampsia
Livedo reticularis - purle lace like rash
Libmann0Sacks endocarditis - non bacterial growths on valves
Thrombocytopenia

73
Q

Management of antiphospholipid syndrome

A

Warfarin
Pregnancy - LMWH

74
Q

Define Sjogren’s sndrome

A

Autoimmune condition that affects the exocrine glands - leads to symptoms of dry mucous membranes like mouth and eyes. Can be secondary to SLE

75
Q

What test can be done for Sjogren’s syndrome

A

Schirmer test
Folded piece of filter paper under eyelid - tears don’t travel as far in Sjogren’s

76
Q

Management of Sjogren’s syndrome

A

Replacement of fluids
Artificial tears, saliva, lubricants
Hydroxychloroquine

77
Q

Complications of Sjogren’s syndrome

A

Infections
Rarely can affect other organs

78
Q

Define vasculitis

A

Inflammation of the blood vessels

79
Q

Examples of small vessel vasculitis

A

Henoch-Schonlein purpura
Eosinophilic granulomatosis with polyangitis - Churg-strauss syndrome
Microscopic polyangitis
Granulomatosis with polyangitis

80
Q

Examples of medium vessel vasculitis

A

Polyarteritis nodosa
Churg-Strauss syndrome
Kawasaki disease

81
Q

Examples of large vessel vasculitis

A

Giant cell arteritis
Takaysu’s arteritis

82
Q

Presentation of vasculitis

A

Purpura
Joint and muscle pain
Peripheral neuropathy
Renal impairment
Gastrointestinal disturbance
Anterior uveitis
Hypertension

Systemic manifestations

83
Q

Investigations in vasculitis

A

Inflammatory markers
ANCA!
p-ANCA - microscopic polyangitis and Churg-Straus syndrome
c-ANCA - granulomatosis with polyangitis

84
Q

Management of vasculitis

A

Steroids
Immunosuppressants

85
Q

Define Henoch-Schonlein purpura

A

IgA vasculitis commonly presenting with purpuric rash in lower limbs and buttocks.
Often triggered by upper airway infection or gastroeenteritis. Children under 10.

86
Q

Classic features of Henoch-Scholein purpura

A

Purpura
Joint pain
Abdominal pain
Renal involvement

87
Q

Define granulomatosis with polyangitis

A

Previously Wegener’s granulomatosis
Small vessel vasculitis affecting respiratory tract and kidneys

88
Q

Clinical features of Kawasaki disease

A

Persistant high fever >5 days
Erythematous rash
Bilateral conjuntivitis
Erythema and desquamation
Strawberry tongue

89
Q

Complication of Kawasaki disease

A

Coronary artery aneurysm

90
Q

Management of Kawasaki disease

A

Aspirin
IV Ig

91
Q

Define Takayasu’s arteritis

A

Large vessel vasculitis mainly affecting the aorta and its branches. These swell and form aneurysms or become narrowed and blocked

92
Q

Define Behcet’s disease

A

Complex inflammatory condition that characteristically presents with recurrent oral and genital ulcers.

93
Q

Define gout

A

A type of crystal arthropathy associated with chronically high blood uric acid levels. Urate crystals are deposited in the joint causing it to become hot, swollen and painful

94
Q

Risk factors for gout

A

Male
Obesity
High purine diet - meat, seafood
Alcohol
Diuretics
Existing cardiovascular or kidney disease
FH

95
Q

Joints most commonly affected by gout

A

Base of the big toe - metatarsophalangeal joint
Wrists
Base of thumb - carpometacarpal joints
Large joints - knee and ankle

96
Q

Investigations in gout

A

Exclude septic arthritis - aspiration
Xray

97
Q

What crystals are seen in gout

A

Needle shaped negatively birefringent monosodium urate crystals

98
Q

Xray changes seen in gout

A

Maintained joint space
Lytic lesions
Punched out lesions
Erosions can have sclerotic borders with overlying edges

99
Q

Managenent of gout

A

Acute flare
NSAIDs
Colchicine
Steroids

Cholchicine

Prophylaxis
Allopurinol - once acute attack over
Weight loss, hydration, diet improvement

100
Q

Define pseudo gout

A

Crystal arthropathy caused by calcium pyrophosphate, also known as chondrocalcinosis

101
Q

Crystals seen in pseudo gout

A

Rhomboid shaped positively birefringent calcium pyrophosphate crystal

102
Q

Management of pseudo gout

A

NSAIDS
Cholchicine
Joint aspiration
Steroid injections
Oral steroids

103
Q

Define osteoporosis

A

Condition where there is a reduction in the density of bones

104
Q

Define osteopenia

A

Refers to a less severe reduction in bone density than osteoporosis

105
Q

Risk fractures for osteoporosis

A

Age
Female
Reduced mobility
Low BMI
Rheumatoid arthritis
Alcohol and smoking
Long term corticosteroids
SSRIs, PPIs, anti-epileptics and anti-oestrogens
Post menopausal women! no oestrogen

106
Q

What tool is used to assess risk of fragility fracture

A

FRAX tool
10 year proability or major osteoporotic fracture and hip fracture

107
Q

What is measured with a DEXA scan

A

Bone mineral density

108
Q

What is measured with a DEXA scan

A

Bone mineral density - give this as a T score

109
Q

What T score is considered normal

A

> -1

110
Q

What T score suggests osteopenia

A

-1 to -2.5

111
Q

What T score suggests osteoporosis

A

<-2.5

112
Q

Management of osteoporosis

A

Lifestyle
Activity and exercise
Maintain weight
Calcium intake
Adequate vit D
Avoid falls
Stop smoking and alcohol

Vit D and calcium supplementation
Bisphosphonates
Denosumab
Strontium ranelate
Raloxifene
Hormone replacement

113
Q

Define osteomalacia

A

A condition where there is defective bone mineralisation causing soft bones. Results from vitamin D insufficiency. If present can lead to rickets.

114
Q

Presentation of osteomalacia

A

Fatigue
Bone pain
Muscle weakness
Muscle aches
PAthological fractures

115
Q

Risk factors for vit D deficiency

A

Darker skin
Low exposure to sunlight
Live in colder climates
Spend more time indoors

116
Q

Investigations in osteomalacia

A

Vit d levels
Serum calsium + phosphat low
Raised ALP
PArathyroid hormone raised
Xray
DEXA

117
Q

Management of osteomalacia

A

Vit D supplement

118
Q

Define pagets disease

A

Refers to disorder of bopne turnover - excessive bone turnover due to excessive activity if blasts and clasts leads to patchy areas of high and low density resulting in misshapen bones with structural problems increasing the risk of fracture.

119
Q

Xray changes seen in pagets disease of bone

A

Bone enlargement and deformity
Osteoporosis circumscripta - well defined osteolytic lesions that appear less dense compared with normal bone
Cotton wool appearance - skull
Vshaped defects - in long bones

120
Q

Management of pagets diseas of bone

A

Bisphosphonates
NSAIDs
Calcium and vit D supplementation
Surgery - fracture, severe deformity or arthritis

121
Q

Complications of Paget’s disease of bone

A

Osteogenic sarcoma - osteosarcoma
Spinal stenosis

122
Q

Define osteosarcoma

A

A type of bone cancer with very poor prognosis
Presents with increased focal bone pain swelling and fracture.

Med Finals - Medicine (10 decks)

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