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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
Management of reactive arthritis
Exclude septic arthritis - aspirate (culture and crystal) NSAIDs Intraarticular Steroids Systemic steroids
26
Define ankylosing spondylitis
An inflammatory condition mainly affecting the spine that causes progressive stiffness and pain. It mainly affects the sacroiliac joints and can progress to fusion,
27
What genetics are associated with ankylosing spiondylitis
HLA B27
28
History of ankylosing spndylitis
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
29
What conditions are associated with ankylosing spondylitis
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
30
Investigations in ankylosing spondylitis
Inflammatory markers - CRP and ESR HLAB27 Xray MRI - bone marrow oedema
31
What xray changes are seen in ankylosing spondylitis
Bamboo spine - later stagees Squaring of vertebral bodies Subchondral sclerosis and erosions Syndesmophytes Ossification of ligaments Fusion
32
Management of ankylosing spondylitis
NSAIDs Steroids - during flares Anti-TNF Secukinumab Physio Exercise Avoid smoking Bisphosphonates Manage complications Surgery for deformities
33
Define systemic lupus erythematosus
Inflammatory autoimmune connective tissue disease. Immune response to proteins within nuclei.
34
History of SLE
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
35
Investigations in SLE
Auto antibodies FBC C3 and C4 CRP + ESR Immunoglobulins Urinalysis - protein creatinine ratio Renal biopsy
36
What auto antibodies are tested in SLE
ANA anti-diDNA - very specific to SLE anti-ENA
37
Complications of SLE
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
38
Management of SLE
First line NSADs Steroids Hydroxychloroquine Suncream Immunosuppression Methotrexate, mycophenolate mofetil, azathioprine, tacrolimus, leflenomide, ciclosporin Biological Rituximab Belimumab
39
Define discoid lupus erythematosis
A non-cancerous chronic skin condition often found in women and associated with SLE. Rarely leisions can progress to squamous cell carcinoma
40
History of discoid lupus erythematosus
Lesions on face, ears and scalp Photosensitive Scaring alopecia Hyper or hypo-pigmented scars
41
What do discoid lupus erythematosus lesions look like
Inflamed Dry Erythematous Patchy Crusty and scaling
42
Management of discoid lupus erythematosus
Sun protection Topical steroids Intralesional steroid injection Hydroxychloroquine
43
Define systemic sclerosis
Often call scleroderma - autoimmune inflammatory and fibrotic connective tissue disease
44
What are the main patterns of systemic sclerosis
Limited cutaneous systemic sclerosis Diffuse cutaneous systemic sclerosis
45
Define limited cutaneous systemic sclerosis
Previously called CREST syndrome Calcinosis Raynaud's oEsophageal dysmotility Sclerodactyly Telangiectasia
46
Define diffuse cutaneous ststemic sclerosis
Includs features of CREST syndrome plus: Cardiovascular problems Lung problems Kidney problems
47
Define scleroderma
Hardening of the skin Shiny tight skin without normal folds. Most notable on the hands and face
48
Define sclerodactyly
Skin tightens around the joints restricting motion. Skin hardens and tightens further there is loss of fat pads Skin can also break and ulcerate
49
Define telangiectasia
Dilated small blood vessels in the skin - fine thready appearance
50
Define calcinosis
Calcium deposits built up under the skin - commonly in fingertips
51
Define Raynaud's phenomenon
Where fingertips go completely white and then blue in response to mild cold Caused by vasoconstriction
52
Define oesophageal dysmotility
Connective tissue dysfunction in the oesophagus commonly associated with swallowing difficulties, acid reflux and oesophagitis
53
Define scleroderma renal crisis
Acute condition where there is a combination of severe hypertension and renal failure
54
What auto antibodies are found in systemic sclerosis
ANA Anti-centromere antibodies - limited Anti-Scle-70 - diffuse
55
Management of systemic sclerosis
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
Define polymyalgia rheumatica
Inflammatory condition that causes pain and stiffness in the shoulders, pelvic girdle and neck. Strongly associated with giant cell arteritis
57
Features of polymyalgia rheumatica
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
Differentials for polymyalgia rheumatica
Osteoarthritis Rheumatoid arthritis SLE Myositis Cervical spondylitis Adhesive capsulitis Hyper or hypothyroidism Osteomalacia Fibromyalgia
59
Investigations in polymyalgia rheumatica
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
Management of polymyalgia rheumatica
Steroids! 15mg Pred OD Reducing regieme
61
What additional measures should be in place for patients of long term steroids
Don't STOP Don't immediately stop steoird Sick day rules - Treatment card Osteoporosis - bisphosphonates Proton pump inhibitor
62
Define giant cell arteritis
A systemic vasculitis of the medium to large arteries, typically presenting with temporal arteritis.
63
History of giant cell arteritis
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
Investigations in giant cell arteritis
Clinical diagnosis Raised ESR Temporal artery biopsy FBC LFT - alp CRP Duplex US - hypoechoic halo sign
65
What is seen on temporal artery biopsy in giant cell arteritis
Multinucleated giant cells
66
Management of giant cell arteritis
Steroids! 40-60mg prednisolone Aspirin - decreases visual loss and stroke PPI for Gi protection on steroids
67
Define myositis
Infalmmation within the muscles
68
Define polymyositis
Condition of chronic inflammation in the muscles
69
Define dermatomyositis
A connective tissue disorder where there is chronic inflmmation of the skin and muscles
70
Features of dermatomyositis
Gottron lesions - scaly erythematous patches on knuckles, elbows and knees Photosensitive erythmatous Purple rash on the face and eyelids Periorbital oedema Subcutaneous calcinosis
71
Define antiphospholipid syndrome
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
What conditions are associated with antiphospholipid syndrome
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
Management of antiphospholipid syndrome
Warfarin Pregnancy - LMWH
74
Define Sjogren's sndrome
Autoimmune condition that affects the exocrine glands - leads to symptoms of dry mucous membranes like mouth and eyes. Can be secondary to SLE
75
What test can be done for Sjogren's syndrome
Schirmer test Folded piece of filter paper under eyelid - tears don't travel as far in Sjogren's
76
Management of Sjogren's syndrome
Replacement of fluids Artificial tears, saliva, lubricants Hydroxychloroquine
77
Complications of Sjogren's syndrome
Infections Rarely can affect other organs
78
Define vasculitis
Inflammation of the blood vessels
79
Examples of small vessel vasculitis
Henoch-Schonlein purpura Eosinophilic granulomatosis with polyangitis - Churg-strauss syndrome Microscopic polyangitis Granulomatosis with polyangitis
80
Examples of medium vessel vasculitis
Polyarteritis nodosa Churg-Strauss syndrome Kawasaki disease
81
Examples of large vessel vasculitis
Giant cell arteritis Takaysu's arteritis
82
Presentation of vasculitis
Purpura Joint and muscle pain Peripheral neuropathy Renal impairment Gastrointestinal disturbance Anterior uveitis Hypertension Systemic manifestations
83
Investigations in vasculitis
Inflammatory markers ANCA! p-ANCA - microscopic polyangitis and Churg-Straus syndrome c-ANCA - granulomatosis with polyangitis
84
Management of vasculitis
Steroids Immunosuppressants
85
Define Henoch-Schonlein purpura
IgA vasculitis commonly presenting with purpuric rash in lower limbs and buttocks. Often triggered by upper airway infection or gastroeenteritis. Children under 10.
86
Classic features of Henoch-Scholein purpura
Purpura Joint pain Abdominal pain Renal involvement
87
Define granulomatosis with polyangitis
Previously Wegener's granulomatosis Small vessel vasculitis affecting respiratory tract and kidneys
88
Clinical features of Kawasaki disease
Persistant high fever >5 days Erythematous rash Bilateral conjuntivitis Erythema and desquamation Strawberry tongue
89
Complication of Kawasaki disease
Coronary artery aneurysm
90
Management of Kawasaki disease
Aspirin IV Ig
91
Define Takayasu's arteritis
Large vessel vasculitis mainly affecting the aorta and its branches. These swell and form aneurysms or become narrowed and blocked
92
Define Behcet's disease
Complex inflammatory condition that characteristically presents with recurrent oral and genital ulcers.
93
Define gout
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
Risk factors for gout
Male Obesity High purine diet - meat, seafood Alcohol Diuretics Existing cardiovascular or kidney disease FH
95
Joints most commonly affected by gout
Base of the big toe - metatarsophalangeal joint Wrists Base of thumb - carpometacarpal joints Large joints - knee and ankle
96
Investigations in gout
Exclude septic arthritis - aspiration Xray
97
What crystals are seen in gout
Needle shaped negatively birefringent monosodium urate crystals
98
Xray changes seen in gout
Maintained joint space Lytic lesions Punched out lesions Erosions can have sclerotic borders with overlying edges
99
Managenent of gout
Acute flare NSAIDs Colchicine Steroids Cholchicine Prophylaxis Allopurinol - once acute attack over Weight loss, hydration, diet improvement
100
Define pseudo gout
Crystal arthropathy caused by calcium pyrophosphate, also known as chondrocalcinosis
101
Crystals seen in pseudo gout
Rhomboid shaped positively birefringent calcium pyrophosphate crystal
102
Management of pseudo gout
NSAIDS Cholchicine Joint aspiration Steroid injections Oral steroids
103
Define osteoporosis
Condition where there is a reduction in the density of bones
104
Define osteopenia
Refers to a less severe reduction in bone density than osteoporosis
105
Risk fractures for osteoporosis
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
What tool is used to assess risk of fragility fracture
FRAX tool 10 year proability or major osteoporotic fracture and hip fracture
107
What is measured with a DEXA scan
Bone mineral density
108
What is measured with a DEXA scan
Bone mineral density - give this as a T score
109
What T score is considered normal
>-1
110
What T score suggests osteopenia
-1 to -2.5
111
What T score suggests osteoporosis
<-2.5
112
Management of osteoporosis
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
Define osteomalacia
A condition where there is defective bone mineralisation causing soft bones. Results from vitamin D insufficiency. If present can lead to rickets.
114
Presentation of osteomalacia
Fatigue Bone pain Muscle weakness Muscle aches PAthological fractures
115
Risk factors for vit D deficiency
Darker skin Low exposure to sunlight Live in colder climates Spend more time indoors
116
Investigations in osteomalacia
Vit d levels Serum calsium + phosphat low Raised ALP PArathyroid hormone raised Xray DEXA
117
Management of osteomalacia
Vit D supplement
118
Define pagets disease
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
Xray changes seen in pagets disease of bone
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
Management of pagets diseas of bone
Bisphosphonates NSAIDs Calcium and vit D supplementation Surgery - fracture, severe deformity or arthritis
121
Complications of Paget's disease of bone
Osteogenic sarcoma - osteosarcoma Spinal stenosis
122
Define osteosarcoma
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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