Rheumatology Flashcards
1
Q
What 4 key x-ray changes can be seen in patients with osteoarthritis?
(HINT: LOSS)
A
L - loss of joint space
O - osteophytes
S - subchondral sclerosis (increased density of the bone along the joint line)
S - subchondral cysts (fluid-filled holes in the bone, aka geodes)
2
Q
In osteoarthritis:
- joint pain + stiffness may be worsened by activity, OR
- activity improves symptoms
A
- joint pain + stiffness may be worsened by activity
3
Q
In which joints do Heberden’s nodes form?
- DIP joints
- PIP joints
- MCP joints
A
- DIP joints
4
Q
In which joints do Bouchard’s nodes form?
- DIP joints
- PIP joints
- MCP joints
A
- PIP joints
5
Q
How is osteoarthritis diagnosed?
A
= can be made without investigations if,
- patient > 45
- has typical activity related pain
- has no morning stiffness OR, stiffness lasting < 30 mins
6
Q
Management options for osteoarthritis (5)
A
- patient education
- physiotherapy
- stepwise analgesia to control symptoms
- intra-articular steroid injections
- joint replacement
7
Q
In the stepwise analgesia approach to control symptoms in osteoarthritis, what is used first?
A
= oral paracetamol and topic NSAIDs OR, topical capsaicin (chilli pepper extract)
8
Q
What is capsaicin? and what is it used for?
A
= chilli pepper extract,
in osteoarthritis
9
Q
Which joints are most typically affected by rheumatoid arthritis?
- DIP joints
- PIP + MCP joints
A
- PIP + MCP joints
10
Q
What is Rugger Jersey Spine? and what is it associated with?
A
= osteosclerosis associated with secondary hyperparathyroidism of chronic renal failure
11
Q
Which of the following best describes bone changes associated with ‘osteoporosis’?
- deficient matrix, normal mineralisation
- normal matrix, deficient mineralisation
- normal matrix, normal mineralisation, increased reabsorption
A
- deficient matrix, normal mineralisation
12
Q
Which of the following best describes bone changes associated with ‘osteomalacia’?
- deficient matrix, normal mineralisation
- normal matrix, deficient mineralisation
- normal matrix, normal mineralisation, increased reabsorption
A
- normal matrix, deficient mineralisation
13
Q
Which of the following best describes bone changes associated with ‘hyperparathyroidism’?
- deficient matrix, normal mineralisation
- normal matrix, deficient mineralisation
- normal matrix, normal mineralisation, increased reabsorption
A
- normal matrix, normal mineralisation, increased reabsorption
14
Q
What is osteoporosis?
A
= condition where there is a reduction in the density of bones
15
Q
Effect of oestrogen on bones?
A
= essential to bone health because it promotes the activity of osteoblasts
(protective against osteoporosis)
16
Q
What is FRAX tool used for? and what does it calculate?
A
= used in assessing risk of osteoporosis
gives prediction of the risk of fragility fracture over the next 10 years
17
Q
When assessing bone density, which of the following scores is more clinically relevant?
- Z-score
- T-score
A
- T-score
18
Q
When doing a DEXA scan to assess bone density, where is a key location to scan for classification + management of osteoporosis?
A
= hip
19
Q
First-line pharmacological treatment for osteoporosis?
A
= Bisphosphonates
20
Q
Side effects of Bisphophonates (3)
A
- reflux + oesophageal erosions
- atypical fractures
- osteonecrosis: of jaw + external auditory canal
21
Q
Alendronate, Risedronate + Zoledronic acid are all examples of?
A
= Bisphosphonates
22
Q
What is osteoarthritis?
A
= referred to as ‘wear and tear’ in the joints, usually synovial joints and as a result of genetic factors, overuse and injury
23
Q
If oral paracetamol, topical NSAIDs or topical capsaicin does not work what is the next step, in the stepwise analgesia?
A
= add oral NSAIDs, consider PPI to protect stomach
23
Q
What is the 3rd step in analgesia to control symptoms in osteoarthritis? (after oral NSAIDs + PPIs)
A
= consider opiates (cautiously as Sessions include: dependence + withdrawal)
24
What is rheumatoid arthritis?
= autoimmune condition that causes chronic inflammation of the syndical lining of joints, tendon sheaths + bursa
25
Does rheumatoid tend to be symmetrical or symmetrical?
= symmetrical
26
Is rheumatoid arthritis more common in men or women?
= women
27
Genetic associations with rheumatoid arthritis (2)
- HLA DR4
- HLA DR1
28
Antibodies which can be measured if rheumatoid arthritis is suspected?
- rheumatoid factor (RF)
- anti-CCP antibodies
29
Which of the following antibodies is more sensitive + specific to rheumatoid arthritis:
- rheumatoid factor
- anti-CCP antibodies
- anti-CCP antibodies
30
Systemic features associated with rheumatoid arthritis? (4)
- fatigue
- weight loss
- flu-like weakness
- muscle aches + weakness
31
What is Palindromic Rheumatism?
= rare type of inflammatory arthritis, where symptoms like those of rheumatoid arthritis – joint inflammation, pain and swelling – come on suddenly and then disappear just as quickly
32
What is atlantoaxial subluxation?
= radiologically identified increased mobility or laxity between the body of the first cervical vertebra (atlas) and the odontoid process of the second cervical vertebra (axis)
32
Rheumatoid arthritis - classical signs in the hands (4)
- Z-shaped deformity to thumb
- Swan neck deformity (hyperextended PIP and flexed DIP)
- Boutonnieres deformity (hyperextended DIP with flexed PIP)
- Ulnar deviation of the fingers at the knuckle (MCP joints)
33
What is psoriatic arthritis?
= inflammatory arthritis associated with psoriasis
34
Extra-articular manifestations associated with psoriatic arthritis? (2)
- uveitis
- IBD
35
What is arthritis mutilans? and what does it cause?
= most severe form of psoriatic arthritis, commonly affects phalanges
Osteolysis of the bones around the joint, leads to progressive shortening of the digits
36
What is PEST?
= Psoriasis Epidemiological Screening Tool - screening tool for psoriatic arthritis in patients with psoriasis
37
What does a 'pencil-in-cup' appearance on x-ray suggest?
= psoriatic arthritis, particular association with arthritis mutilans
38
Classic triad of reactive arthritis
- conjunctivitis
- urethritis
- arthritis
HINT: can't see, pee or climb in a tree
39
Important differential to exclude in patient with reactive arthritis
= septic arthritis
40
What is reactive arthritis?
= involves synovitis in 1 or more joints in response to an infective trigger
41
Common triggers of reactive arthritis (2)
- gastroenteritis
- sexually transmitted infection
42
Which of the following sexually transmitted infection is most likely to cause reactive arthritis?
- Chlamydia
- Gonorrhoea
- Chlamydia
(Gonorrhoea typically causes septic arthritis)
43
Investigation for reactive arthritis
= joint aspiration - synovial fluid sent for microscopy, culture and sensitivity testing
44
What is ankylosing spondylitis?
= inflammatory condition affecting the facial skeleton (mainly spine + sacroiliac joints) - causing stiffness and pain
45
Which gene is strongly associated with ankylosing spondylitis?
= HLA-B27 gene
46
Is ankylosing spondylitis more common in men or women?
= men
47
In ankylosing spondylitis does the pain
- improve with rest
- improve with activity
- improve with activity
48
What joints are mostly affected by ankylosing spondylitis? (2)
= vertebrae column joints + sacroiliac joints
49
5As - associations of ankylosing spondylitis
- anterior uveitis
- aortic regurgitation
- AV block (heart block)
- apical lung fibrosis (fibrosis of upper lobes)
- anaemia of chronic disease
50
What is Schober's Test used for?
= assess spinal mobility
51
What is 'bamboo spine' a typical x-ray finding for?
= ankylosing spondylitis
52
First-line pharmacological management for ankylosing spondylitis?
= NSAIDs
53
Patient presents with malar rash which is 'butterfly' shaped across the nose + cheeks. What is the diagnosis?
= systemic lupus erythematosus (SLE)
54
What is Systemic Lupus Erythematosus (SLE)?
= inflammatory autoimmune connective tissue disorder
55
Is SLE more common in men or women?
= women
56
Anti-nuclear antibodies (ANA) are associated with what condition?
= Systemic Lupus Erythematosus (SLE)
57
Which of the following antibodies are associated with Sjögren's syndrome:
- anti-Ro and anti-La
- anti-Scl-70
- anti-Jo-1
- anti-Ro and anti-La
58
What is the leading cause of disease in those with SLE?
= cardiovascular disease
59
First-line pharmacological options for treating SLE? (3)
- Hydroxychloroquine
- NSAIDs
- Steroids (e.g., Prednisolone)
60
Which of the following antibodies are associated with systemic sclerosis:
- anti-Ro and anti-La
- anti-Scl-70
- anti-Jo-1
- anti-Scl-70
61
What is Discoid Lupus Erythematosus (DLE)?
= autoimmune chronic skin condition
62
What can be used to confirm a diagnosis of discoid lupus erythematosus (DLE)?
= skin biopsy
63
Clinical features of Limited Cutaneous Systemic Sclerosis (CREST syndrome) (5)
C - calcinosis
R - Raynaud's phenomenon
E - oEsophageal dysmobility
S - Sclerodactyly
T - Telangiectasia
64
Medical emergency associated with systemic sclerosis
= Scleroderma renal crisis
65
What is Raynaud's disease?
= where Raynaud’s phenomenon occurs without an associated systemic disease. Idiopathic and makes up 80-90% of patients with this phenomenon
66
Most important secondary cause of Raynaud's disease?
= systemic sclerosis
67
What is Nailfold Capillaroscopy? and what is it used for?
= technique to magnify + examine the peripheral capillaries where the skin meets the base of the fingernail (nail fold)
Used to distinguish cause of Raynaud's phenomenon - Raynaud disease vs. systemic sclerosis
68
First-line pharmacological management for Raynaud's phenomenon?
= Nifedipine (ca channel blocker)
69
What type of drug can worsen symptoms of Raynaud's?
= beta-blockers
70
Which of the following autoantibodies are associated with 'limited cutaneous systemic sclerosis'?
- anti-centromere antibodies
- anti-Scl-70 antibodies
- anti-centromere antibodies
71
Which of the following autoantibodies are associated with 'diffuse cutaneous systemic sclerosis' and more severe disease?
- anti-centromere antibodies
- anti-Scl-70 antibodies
- anti-Scl-70 antibodies
72
Medical management options in 'diffuse cutaneous systemic sclerosis' (2)
- DMARDs (e.g., Methotrexate)
- biological therapies (e.g., Rituximab)
73
Important lifestyle factor modification which should be encouraged in patients with Rheumatoid arthritis?
= smoking cessation
(increased risk of developing rheumatoid arthritis with cigarette smoking)
74
What is a DAS28 score?
= Rheumatoid arthritis severity score
75
What kind of arthritis is associated with onycholysis on clinical examination?
(= when your nail separates from its nail bed)
= psoriatic arthritis
76
What is polymyalgia rheumatica? Which part of the body is usually affected?
= inflammatory condition that causes pain + stiffness in the shoulders, pelvic girdle and neck
77
What other condition is polymyalgia rheumatica strongly associated with?
= giant cell arthritis
78
Characteristic features of pain and stiffness in polymyalgia rheumatica:
- worse in the morning and somewhat improves with activity
- worse in the evenings, better on rest
- worse in the morning and somewhat improves with activity
78
Risk in abruptly stopping steroids?
= adrenal crisis
78
Pharmacological treatment for polymyalgia rheumatica?
= steroids (15mg Prednisolone daily)
79
What is giant cell arteritis also known as?
= temporal arteritis
80
Key complication in giant cell arteritis (temporal arteritis)?
= vision loss - which is often irreversible
81
Elderly white patient presents with unilateral headache, scalp tenderness, jaw claudication, blurry vision and a PMHx of polymyalgia rheumatica - what do you think is the diagnosis?
= giant cell arthritis
82
Which test can help diagnosis a patient with suspected giant cell arteritis (temporal arteritis)?
= temporal artery biopsy
83
Pharmacological treatment for giant cell arteritis (temporal arteritis)?
= steroids
84
Giant cell arteritis (temporal arteritis: which of the following would you give to a patient with visual symptoms OR, jaw claudication?
- 40-60mg Prednisolone daily
- 500mg-1000mg Methylprednisolone daily
- 500mg-1000mg Methylprednisolone daily
85
Giant cell arteritis (temporal arteritis: which of the following would you give to a patient with NO visual symptoms OR, jaw claudication?
- 40-60mg Prednisolone daily
- 500mg-1000mg Methylprednisolone daily
- 40-60mg Prednisolone daily
86
Which specialists are involved in managing patients with giant cell arteritis (temporal arteritis)? (3)
- rheumatology (diagnosis + management)
- vascular surgeons (temporal artery biopsy)
- ophthalmology (review for visual symptoms)
87
What is polymyositis + dermatomyositis?
= autoimmune disorders causing muscle inflammation (myositis)
88
Gottron papules + heliotrope rash are characteristic skin changes seen in which autoimmune condition?
= dermatomyositis
89
What is important to investigate and rule-out in patients with polymyositis or dermatomyositis?
= underlying cancer - they are paraneoplastic syndromes
90
What blood test is critical in investigation a patient with polymyositis or dermatomyositis?
= creatine kinase (CK)
91
Which of the following conditions is associated with anti-Jo-1 antibodies?
- SLE
- giant cell arteritis
- polymyositis
- diffuse cutaneous systemic sclerosis
- limited cutaneous systemic sclerosis
- polymyositis
92
First-line treatment in both polymyositis + dermatomyositis?
= corticosteroids
93
The following antibodies: Lupus anticoagulant, Anticardiolipin antibodies, Anti-beta-2 glycoprotein I antibodies - are associated with which condition?
= antiphospholipid syndrome
94
Patient presents with thrombosis (blood clot), and has a history of recurrent miscarriages - what is likely the diagnosis?
= antiphospholipid syndrome
95
What is catastrophic antiphospholipid syndrome?
= rare complication associated with antiphospholipid syndrome - with rapid thrombosis in multiple organs within a few days. Has a high mortality rate
96
Pharmacological treatment for antiphospholipid syndrome
= long-term Warfarin - used to prevent thrombosis
97
What may be used in patients with antiphospholipid syndrome who are pregnant? (2)
= low-molecular weight Heparin + aspirin - used to reduce the risks
(Warfarin is contraindicated in pregnancy)
98
What is Sjögren's syndrome? and what symptoms as associated with this condition?
= = autoimmune condition affecting the exocrine glands, notably the lacrimal + salivary glands
Causes symptoms of dry mouth, eyes, and vagina
99
What are 'sicca symptoms'?
= dry eyes + mouth
100
Primary vs secondary Sjögren's syndrome?
Primary Sjogren’s – where the condition occurs in isolation
Secondary Sjogren’s – where it occurs due to other disease such as SLE and rheumatoid arthritis
101
Anti-Ro and Anti-La are associated with which condition?
= Sjögren's syndrome
102
Sjögren's syndrome: Describe the Schirmer Test
= involves inserting folded filter paper under the lower eyelid with the end hanging out. Moisture from the eye will travel by diffusion along the filter paper
After 5 minutes, the distance that the moisture travels along the filter paper is measured
In a healthy young adult, 15mm is expected. Less than 10mm is significant
103
What is Pilocarpine used for?
= stimulates muscarinic, stimulating the parasympathetic nerves and promoting salivary and lacrimal gland secretion - used in Sjögren's syndrome
104
Treatment options in Sjögren's syndrome (5)
Artificial tears (e.g., polyvinyl alcohol eye drops during the day and carbomer gel at night)
Artificial saliva
Vaginal lubricants
Pilocarpine (oral) – can be used to stimulate tear and saliva production
Hydroxychloroquine may be considered, mainly in patients with associated joint pain
105
What is Behçet's disease? and what are the main features?
= complex inflammatory condition affecting blood vessels + tissues
Main features: recurrent oral + genital ulcers
106
What is vasculitis?
= inflammation of the blood vessels
107
Which of the following are ANCA positive? (3)
- Henoch-Schoenlein Purpura
- Microscopic polyangiitis
- Granulomatosis with polyangiitis
- Eosinophilic granulomatosis with polyangiitis
- Polyarteritis nodosa
- Kawasaki disease
- Giant cell arteritis
- takayasu's arteritis
- Microscopic polyangiitis
- Granulomatosis with polyangiitis
- Eosinophilic granulomatosis with polyangiitis
108
Which of the following types of vasculitis was previously known as Wegener's granulomatosis?
- Microscopic polyangiitis
- Granulomatosis with polyangiitis
- Eosinophilic granulomatosis with polyangiitis
- Polyarteritis nodosa
- Granulomatosis with polyangiitis
109
Which of the following types of vasculitis was previously known as Churg-Strauss Syndrome?
- Microscopic polyangiitis
- Granulomatosis with polyangiitis
- Eosinophilic granulomatosis with polyangiitis
- Polyarteritis nodosa
- Eosinophilic granulomatosis with polyangiitis
110
Which of the following types of vasculitis is an IgA vasculitis?
- Henoch-Schoenlein Purpura
- Microscopic polyangiitis
- Granulomatosis with polyangiitis
- Eosinophilic granulomatosis with polyangiitis
- Polyarteritis nodosa
- Kawasaki disease
- Giant cell arteritis
- Takayasu's arteritis
- Henoch-Schoenlein Purpura
111
Which of the following types of vasculitis' main feature is renal failure caused by glomerulonephritis?
- Henoch-Schoenlein Purpura
- Microscopic polyangiitis
- Granulomatosis with polyangiitis
- Eosinophilic granulomatosis with polyangiitis
- Polyarteritis nodosa
- Kawasaki disease
- Giant cell arteritis
- Takayasu's arteritis
- Microscopic polyangiitis
112
Which of the following types of vasculitis is associated with a 'saddle-shaped nose' due to nasal bridge collapse?
- Henoch-Schoenlein Purpura
- Microscopic polyangiitis
- Granulomatosis with polyangiitis
- Eosinophilic granulomatosis with polyangiitis
- Polyarteritis nodosa
- Kawasaki disease
- Giant cell arteritis
- Takayasu's arteritis
- Granulomatosis with polyangiitis
113
Which of the following types of vasculitis typically presents with severe asthma in middle aged patients?
- Henoch-Schoenlein Purpura
- Microscopic polyangiitis
- Granulomatosis with polyangiitis
- Eosinophilic granulomatosis with polyangiitis
- Polyarteritis nodosa
- Kawasaki disease
- Giant cell arteritis
- Takayasu's arteritis
- Eosinophilic granulomatosis with polyangiitis
114
Which of the following types of vasculitis typically presents in children under 5, with widespread erythematous maculopapular rash, skin peeling on palms + soles, conjunctivitis + strawberry tongue?
- Henoch-Schoenlein Purpura
- Microscopic polyangiitis
- Granulomatosis with polyangiitis
- Eosinophilic granulomatosis with polyangiitis
- Polyarteritis nodosa
- Kawasaki disease
- Giant cell arteritis
- Takayasu's arteritis
- Kawasaki disease
115
Which of the following types of vasculitis is a large vessel vasculitis, which mainly affects the aorta and it's branches. Can also lead to 'pulseless disease' due to reduction in pulse due to stenosis or occlusion of vessels?
- Henoch-Schoenlein Purpura
- Microscopic polyangiitis
- Granulomatosis with polyangiitis
- Eosinophilic granulomatosis with polyangiitis
- Polyarteritis nodosa
- Kawasaki disease
- Giant cell arteritis
- Takayasu's arteritis
- Takayasu's arteritis
116
What is Ehlers-Danlos Syndrome?
= group of genetic conditions involves defects in collagen, causing hypermobility in the joints and abnormalities in the connective tissue of the skin, bones, blood vessels and organs
117
Which of the following types of EDS, is most common and the least severe type?
- hypermobile EDS
- classical EDS
- vascular EDS
- kyphoscoliotic EDS
- hypermobile EDS
118
Which of the following types of EDS, presents with stretchy skin and serve joint hyper-mobility?
- hypermobile EDS
- classical EDS
- vascular EDS
- kyphoscoliotic EDS
- classical EDS
119
Which of the following types of EDS, presents with translucent skin and blood vessel rupture?
- hypermobile EDS
- classical EDS
- vascular EDS
- kyphoscoliotic EDS
- vascular EDS
120
What is the Beighton Score used for?
= used to assess for hypermobility and support the diagnosis of Ehlers-Danlos Syndrome
121
What scores you points on the Beighton Score used to assist diagnosis of Ehlers-Danlos Syndrome? (5)
- place palms flat on floor with straight legs
- hyperextend elbows
- hyperextend knees
- bend thumb to touch forearm
- hyperextend little finger past 90 degrees
122
True or false: postural orthostatic tachycardia (POTS) can occur with hyper mobile Ehlers-Danlos Syndrome?
= true
123
What is gout?
= a type of crystal arthropathy associated with chronically high blood uric acid levels, rate crystals deposited in joint, causing it to become inflamed
124
What are gouty tophi?
= subcutaneous uric acid deposits (typically seen on the hands, elbows and ears)
125
Critical differential diagnosis essential to exclude in patient with suspected gout or pseudogout?
= septic arthritis
126
Most affected joints by gout? (2)
- metatarsophalangeal joint (base of big toe)
- carpometacarpal joint (base of thumb)
127
Which of the following on crystals on joint fluid aspiration indicates gout?
- rhomboid-shaped and positively birefringent
- needle-shaped and negatively birefringent
- needle-shaped and negatively birefringent
128
First-line pharmacological treatment option for acute flare of gout?
= NSAIDs (e.g., Naproxen) with PPI for gastro-protection
129
Second-line pharmacological treatment option for acute flare of gout?
= Colchicine
130
What is used for prophylaxis of gout?
= Allopurinol
(xanthine oxidase inhibitors)
131
Lifestyle changes to reduce your risk of gout? (4)
- lose weight
- stay hydrated
- minimise consumption of alcohol
- avoid purine-based foods (e.g., meat + seafood)
132
Is prophylaxis for gout continued during an acute attack?
= yes
133
What is pseudogout?
= crystal arthropathy caused by calcium pyrophosphate crystals collecting in the joints
134
What is calcium pyrophosphate deposition disease (CPPD) also known as?
= pseudogout
135
Which joints are typically affected by pseudogout? (4)
- knees
- shoulders
- hips
- wrists
136
What investigation is used to confirm diagnosis of pseudogout?
= joint aspiration
137
Which of the following on crystals on joint fluid aspiration indicates pseudogout?
- rhomboid-shaped and positively birefringent
- needle-shaped and negatively birefringent
- rhomboid-shaped and positively birefringent
(calcium pyrophosphate crystals)
138
Chondrocalcinosis is a classic x-ray change in which condition?
= pseudogout
139
Typical acute presentation of pseudogout? (age)
= over 65 years old
140
First-line treatment option for pseudogout?
=NSAID (e.g., Naproxen), with PPI for gastroprotection
141
Second-line treatment option for pseudogout?
= Colchicine
142
How long do symptoms need to be present to diagnose Chronic Fatigue Syndrome?
= 3 months
143
Which type of murmur is associated with Ehlers-Danlos?
= aortic regurgitation
144
What can be prescribed alongside Methotrexate to avoid bone marrow suppression?
= folate
145
