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Finals HH > Rheumatology > Flashcards

Rheumatology Flashcards

1
Q

Signs of OA in the hands?

A

Heberden’s nodes (DIP joints)
Bouchard’s nodes (PIP joints)
Squaring at base of the thumb

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2
Q

What is needed for Dx of OA without Ix? (4)

A

> 45
Activity related pain
No morning stiffness
No stiffness lasting less than 30mins

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3
Q

OA mx?

A
  1. Stepwise analgesia
    a) Oral paracetamol, Topical NSAIDs or topical capsaicin
    b) Oral NSAIDs + PPI
    c) Codeine & morphine
  2. Intra-articular steroid injections
  3. Joint replacement
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4
Q

Key x-ray changes in OA?

A

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

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5
Q

Genes associated with RA & RF positive patients?

A

HLA DR1 (RA)
HLA DR4 (RF)

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6
Q

Antibodies in RA?

A

Anti-CCP (more sensitive and specific)
RF (70%)

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7
Q

Common joints in RA?

A

PIP and MCP
Wrist and ankle
Can affect larger but less likely

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8
Q

Hand joint and indicative arhtiritis?

A

DIP = OA
PIP = OA or RA
MCP = RA

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9
Q

Signs of RA in the hands?

A
  • Z shaped deformity to the thumb
  • Swan neck deformity
  • Boutonnieres deformity
  • Ulnar deviation of the fingers at the knuckle
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10
Q

Extra-articular manifestations of RA?

A
  • Pulmonary fibrosis
  • Bronchiolitis obliterans
  • Felty’ syndrome
  • Secondary Sjogren’s
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11
Q

What is the triad of felty’s syndrome?

A

RA, neutropenia and splenomegaly

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12
Q

Ix for rheumatoid arthritis?

A
  • RF
  • If RF -ve -> check anti-CCP
  • CRP & ESR
  • X-ray hands and feet

Ultrasound joints if needed to evaluate synovitis

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13
Q

RA x-ray changes?

A

Joint destruction and deformity
Soft tissue swelling
Periarticular osteopenia
Boney erosions

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14
Q

What scoring system is used to monitor RA?

A

DAS28

Assessment of 28 joints for swelling, tender and ESR.CRP result

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15
Q

RA mx?

A

Flare ups and bridging - steroids

DMARDS:
1. Hydroxychloroquine, methotrexate, leflunomide or sulfsalazine
2. Combination of two
3. Methotrexate + TNF inhibitor (infliximab)
4. Methotrexate + rituximab

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16
Q

Signs of psioratic arthritis?

A
  • Nail pitting
  • Onycholysis (nail separation from nail bed)
  • Dactylitis (finger inflammation)
  • Enthesitis (entheses inflammation - where tendons insert onto bones)
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17
Q

Psoriatic arthritis x-ray changes?

A

Pencil-in-cup appearance
Periostitis (thickened and irregular outline of bone)
Ankylosis (bones joining together -> stiffness)
Osteolysis

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18
Q

What is arthritis mutilans?

A

Severe form of psoriatic arthritis where there is osteolysis of bones around joints in digits -> shortened fingers

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19
Q

Mx of psoriatic arthritis?

A

NSAIDs for pain
DMARDS
Anti-TNF medications (etancercept, inflixmiad or adalimumab)
Ustekinumab is last line

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20
Q

Common infections which trigger reactive arthritis?

A

Gastroenteritis
STIs

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21
Q

Triad of reactive arthritis

A

Bilateral conjunctivitis, anterior uveietis
Balanitis
Arthritis

Can’t see, pee or climb

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22
Q

Emergency rheumatology conditions for prompt hospital admission?

A

Septic arthritis
Systemic vasculitis
Giant cell arteritis

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23
Q

Rheumatology conditions for urgent referral?

A

Rheumatoid arthritis
Psoriatic arthritis
Ankylosing spondylitis
Suspected CTD with systemic involvement

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24
Q

Rheumatology conditions for routine refferral?

A

Suspected CTD without systemic involvement
Polymyalgia rheumatica (PMR)
Crystal arthritis

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25
Q

X-ray changes in AS?

A

Squaring of the vertebral bodies
Subchondral sclerosis and erosions
Ossification
Joint fusion

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26
Q

Mx of AS?

A
  1. NSAIDs
  2. Anti-TNF (etanercept, infliximab, adalimumab)
  3. Secukinumab

Steroids during flares

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27
Q

Antibody in SLE?

A

Anti-nuclear antibodies (ANA) [85%, non-specific]
Anti-dsDNA [70% but more specific]

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28
Q

Antibodies in systemic sclerosis?

A

Both - ANA
Limited - anti-centromere antibodies
Diffuse - anti-Scl-70

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29
Q

Antibodies associated with Sjogren’s?

A

Anti-Ro
Anti-La

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30
Q

Antibodies associated with polymyositis and dermatomyositis?

A

Anti-Jo-1 - polymyositis, sometimes dermatomyositis
Anti-Mi-2 - dermatomyositis
ANA - dermatomyositis

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31
Q

Mx of SLE?

A

First line:
- NSAIDs
- Steroids
- Hydroxychloroquine

Resistant lupus:
- DMARDs

Severe disease -> biologics
- Rituximab
- Belimumab

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32
Q

Limited systemic sclerosis px?

A

C - Calcinosis
R - Raynaud’s
E - oEsophageal dysmotility
S - sclerodactyl
T - telangiectasia

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33
Q

Diffuse systemic sclerosis px?

A

CREST + systemic involvement:
- Hypertension, coronary artery disease (CVD)
- Pulmonary hypertension and pulmonary fibrosis (LUNG)
- Glomerulonephritis, scleroderma renal crisis (kidneys)

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34
Q

Mx of Raynauds?

A

Nifedipine (CCB)

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35
Q

Polymyalgia rheumatica px?

A

Pain and stiffness in shoulders, pelvic girdle and neck

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36
Q

PMR Mx?

A

Prednisolone 15mg then gradually reduced
+ osteoporosis prevention (bisphosphonates, calcium and VitD)
+ gastric protection (PPI)

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37
Q

PMR Ix?

A

Dx is clinical, excluding other causes and +ve response to oral corticosteroids

Request ESR, PV and CRP
Exclude giant cell arteritis

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38
Q

Px of giant cell arteritis?

A

Severe unilateral headache
Scalp tenderness when brushing hair
Jaw claudication
Blurred or double vision

Associated symptoms - fever, myalgia, fatigue, weight loss, loss of appetitie, peripheral oedema

39
Q

Dx of giant cell arteritis?

A

Clinical presentation
Raised ESR
Temporal artery biopsy -> multinucleated giant cells

40
Q

Mx of giant cell arteritis?

A

Immediate steroids (prednisolone 40-60mg) - quick response
Aspirin - decreases visual loss & strokes
PPI

41
Q

What are myositis, polymyositis and dermatomyositis?

A

Myositis is inflammation of the muscles
Polymyositis is chronic inflammation of the muscles
Dermatomyositis is inflammation of the skin and muscles

42
Q

Ix in myositis?

A

Creatine kinase - is released in muscle inflammation, normally <300 in myositis

> 1000 indicates polymyositis / dermatomyositis

43
Q

Causes of raised creatine kinase?

A

Rhabdomyolysis
AKI
M.I
Statins
Exercise

44
Q

Common cancers which cause polymyositis / dermatomyositis?

A

Lung
Breast
Ovarian
Gastric

45
Q

Px of polymyositis?

A

Muscle pain, fatigue and weakness
Bilaterally, proximal muscles
Shoulder and pelvic girdle
Develops over weeks

46
Q

Dermatomyositis skin features?

A

Gottron lesions - scaly red knuckles, elbows and knees
Photosensitive red rash on back, shoulders and neck
Purple rash on face and eyelids
Periorbital oedema
Subcutaneous calcinosis

47
Q

Definitive dx of polymyositis

A

Muscle biopsy

48
Q

Mx of polymyositis / dermatomyositis?

A

Corticosteroids first line

If steroids inadequate:
- Immunosuppressants (azathioprine)
- IV immunoglobulins
- Biologics (infliximab, etanercept)

49
Q

What are the anti-phospholipid antibodies?

A

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

50
Q

Antiphospholipid associations?

A

Venous thromboembolism
Arterial thrombosis
Recurrent miscarriage, pre-eclampsia
Livedo reticularis (purple mottled rash)
Endocarditis
Thrombocytopenia

51
Q

What is needed for dx of antiphospholipid syndrome?

A

Hx of thrombosis or pregnancy complications + persistent antibodies

52
Q

Mx of antiphospholipid syndrome?

A

Long term warfarin
If pregnant -> LMWH + aspirin

53
Q

What is Sjogren’s syndrome?

A

Autoimmune condition affecting exocrine glands -> dryness

54
Q

Test for Sjogrens?

A

Schirmer test - filter paper under lower eyelid

55
Q

Mx of Sjogrens?

A

Artificial tears
Artificial saliva
Vaginal lubricants
Hydroxychloroquine

56
Q

What is Henoch-Schonlein purpura?

A

IgA small vessel vasculitis commonly presenting with purpuric rash affecting lower limbs or buttocks in children.

Triggered by an URTI or gastroenteritis

57
Q

Features of HSP? (4)

A

Purpura (100%)
Joint pain (75%)
Abdo pain (50%)
Renal involvement (50%)

58
Q

Mx of HSP?

A

Supportive

59
Q

What is the blood test for vasculitis?

A

Anti neutrophil cytoplasmic antibodies (ANCA)

60
Q

What are p-ANCA (MPO antibodies) found in?

A

Microscopic polyangiitis
Churg-Strauss syndrome / Eosinophilic Granulomatosis with Polyangiitis

61
Q

What are c-ANCA (PR3 antibodies) found in?

A

Granlomatosis with polyangitiis

62
Q

Young Asian woman with weak pulse in one arm?

A

Takayasu’s arteritis

63
Q

Hepatitis B positive vasculitis?

A

Polyarteritis nodosa

64
Q

Bizarre asthma in adults vasculitis?

A

Chrug-Strauss syndrome / Eosinophilic granulomatosis with polyangiitis

65
Q

Epistaxis, crusty nasal secretions, sinusitis, URTI, rapidly progressing glomerulonephritis vasculitis?

A

Wagner’s granulomatosis / granulomatosis with polyangiitis

66
Q

Behcet’s disease px?

A

Recurrent oral and genital ulcers
- Oral ulcers >3 year, they have a red halo
- Genital ulcers often develop on two opposing surfaces facing each other (kissing ulcers)

67
Q

What is the pathergy test?

A

Used in Ix of Behcet’s disease

Abrasion created to look for a wheal forming

68
Q

Typical joints for gout?

A

Base of big toe (metatarsophalangeal joint)
Wrists
Base of thumb (carpometacarpal joints)
Large joints - Knee and ankle

69
Q

What causes gout?

A

Chronically high uric acid levels -> urate crystals deposited in joint

70
Q

Dx of gout?

A

Aspiration of joint fluid showing:
- Needle shaped crystals
- Negatively birefringent of polarised light
- Monosodium urate crystals

71
Q

What would a joint x-ray of gout show?

A

Lytic lesions of bone
Punched out erosions
Joint space maintained

72
Q

Gout Mx during a flare?

A
  1. NSAIDs
  2. Colchine
  3. Steroids
73
Q

Gout prophylaxis?

A

Allopurinol + lifestyle changes

(lose weight, stay hydrated, less alcohol, less meat/seafood)

74
Q

What causes pseudogout?

A

Calcium pyrophosphate crystals deposited in joint (chondrocalcinosis)

75
Q

Common joints for pseudogout?

A

Knees
Shoulders
Wrists
Hips

Chronic condition and can affect multiple joints

76
Q

Dx of pseudogout?

A

Aspiration of synovial fluid will show?
- Calcium pyrophosphate crystals
- Rhomboid shaped crystals
- Positive birefringent of polarised light

77
Q

What is seen on x-ray of pseudogout?

A

Chondrocalcinosis - thin white line in joint space showing calcium deposition
+ LOSS

78
Q

Mx of pseudogout?

A

Self-limiting over several weeks

Symptomatic mx:
- NSAIDs
- Colchine
- Steroid injection
- Oral steroids

Severe -> joint washout

79
Q

Medications which increase Rx of osteoporosis?

A

Steroids, SSRIs, PPIs, ant-epileptics and anti-oestrogens

80
Q

Bone mineral density and T-score?

A

More than -1 = normal
-1 to -2.5 = osteopenia
Less than -2.5 = osteoporosis

81
Q

Mx of osteoporosis?

A

Calcium + VitD + bisphosphonates

If bisphosphonates contraindicated:
- Denosumab
- Strontium ranelate
- HRT

82
Q

Examples of bisphosphonates?

A

Alendronate (once weekly, oral)
Risedronate (once weekly, oral)
Zoledronic acid (one yearly, IV)

83
Q

Bisphosphonate side effects?

A

Reflux and oesophageal erosions
Atypical fractures
Osteonecrosis of the jaw
Osteonecrosis of the external auditory canal

84
Q

What is osteoporosis and osteopenia?

A

Osteoporosis is when there is a reduction in the density of bones

Osteopenia is a less severe reduction in bone density

85
Q

What is osteomalacia?

A

This is when there is defective bone mineralisation causing “soft” bones. Due to inadequte VitD.

86
Q

Mx for osteomalacia?

A

VitD supplements (colecalciferol)

87
Q

What is Paget’s disease?

A

Excessive bone turnover due to excessive activity of osteoblasts and osteoclasts -> patches of sclerosis and lysis

Causes enlarged, misshaped bones

88
Q

X-ray findings of Paget’s disease?

A

Bone enlargement and deformity
Well defined osteolytic lesions
Cotton wool appearance of the skull
V-shaped defects in long bones

89
Q

Mx of Paget’s disease?

A

Bisphosphonates
+ calcium & VitD
+ NSAIDs for bone pain

Monitor ALP

90
Q

Two key complications of Paget’s disease?

A

Osteosarcoma

Spinal stenosis and spinal cord compression (Dx - MRI)

91
Q

Side effects of methotrexate? (5)

A

Bone marrow suppression & leukopenia
Liver toxicity
Pneumonitis
Mouth ulcers and mucositis
Highly teratogenic

92
Q

Side effects of sulfasalazine? (2)

A

Male infertility
Bone marrow suppression

93
Q

Side effects of hydroxychloroquine? (4)

A

Reduced visual acuity
Nightmares
Liver toxicity
Skin pigmentation

Finals HH (21 decks)

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