Rheumatology Flashcards

1
Q

what is ankylosis?

A

abnormal stiffening and immobility of a joint due to fusion of bones

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2
Q

What HLA is Ankylosing spondylitis associated with? main population affected?

A

HLA B27 (+ve in 90-95%)

affects young males 20-30 / 15-40

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3
Q

Modified Schober’s test - how?

A

The modified Schober’s test should be used for serial measurement

To perform this test, mark two points on the back (one 5 cm below and one 10 cm above a line drawn between the dimples of Venus)

On forward flexion, the distance between the two points should be >5 cm

If the distance is <5 cm, this indicates restricted forward flexion

-> tests lumbar spine in ankylosing spondylitis

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4
Q

what is ankylosing spondylitis?

A

A seronegative spondyloarthropathy and a chronic inflammatory disease of the axial skeleton that leads to partial or complete fusion and rigidity of the spine.

  • a seronegative spondyloarthropathy
  • features include pain, morning stiffness and reduced range of motion
  • mainly affects young men
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5
Q

Aetiology of ankylosing spondylitis

A

Genetic predisposition (90-95% patients are +ve for HLA B27)

Most commonly affects young males 20-30yo / 15-40yo

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6
Q

symptoms of ankylosing spondylitis

A
  • inflammatory back pain
  • morning stiffness (improves with movement)
  • peripheral enthesitis
  • peripheral arthritis may occur in up to 1/3 pts with hips and shoulders being most commonly affected.
  • tenderness of SI joints

Extra-articular
- anterior uveitis (20-30%)
- aortitis -> AR
- upper lobe pulmonary fibrosis
- IgA nephropathy (5%)
- may also have IBD

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7
Q

examination findings in ankylosing spondylitis

A
  • limited spinal motion
  • tenderness of the SI-joints (e.g. on FABER test)

Specific tests of the spine:
- lumbar: modified Schober’s test
- thoracic: reduced chest expansion in some (<5cm), dorsal kyphosis can develop as the disease progresses
- cervical: globally reduced movements, measure occiput to wall distance

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8
Q

ankylosing spondylitis management

A

Non-pharmacological:
- exercise and PT -> critical to maintain posture, flexibility and motility

Pharmacological:
-NSAIDs with PPI are first line
- DMARDs (sulfalazine, methotrexate -> for peripheral disease, don’t improve spinal inflammation)
- local steroid injections
- biologics (anti-TNF are first line biologics, anti-IL17 are second line, can also use anti-IL12/23)

Surgery may be indicated in some patients to improve QoL.

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9
Q

ix in ankylosing spondylitis

A
  • Lab: no diagnostic ix! FBC and inflammatory markers in primary care before referral; In secondary care HLA testing is carried out.
  • Imaging: plain X-rays useful in established disease but can be normal early on (pelvic, lumbar);
    MRI is the most sensitive, can also be useful in evaluating response to treatment.
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10
Q

oligoarthritis and polyarthritis definition

A

Oligo: 2-4

Poly: 5+

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11
Q

Nociplastic pain

A

a type of chronic pain that is not due to tissue damage or nerve damage

a third group of pain

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12
Q

Scoring system for hyper mobility

A

Beighton

(keep in mind that the score gets worse with age, so ask about childhood)

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13
Q

screening questions for fibromyalgia

A
  • sleep
  • fatigue
  • irritable bowel
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14
Q

Symptoms of fibromyalgia

A
  • Fatigue
  • exhaustion
  • chronic pain (back, chest, pelvic…)
  • headache
  • poor sleep (unrefreshing sleep)
  • palpitations
  • difficulty concentrating
  • brain fog
  • urine frequency
  • urge incontinence
  • IBS / change in bowel habit
  • reflux
  • depression anxiety
  • dry mouth
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15
Q

Definition and Aetiology of fibromyalgia

A

Definition: acquired disorder of pain/sensory processing (‘nociplastic pain’). It is a syndrome, not a disease.

Aetiology: Acquired, genetic predisposition; CNS is overreacting to sensations in the body.
More common in females (5:1), peak incidence at 30-40yo

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16
Q

Signs on clinical examination in fibromyalgia

A
  • tenderness
  • no joint swelling/redness/warmth, heat
  • GALS: many show generalised pain
  • hyperalgesia (things that should not be painful are painful)
  • alodynia (things that should be slightly painful are very painful)
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17
Q

Ix in fibromyalgia

A

Fibromyalgia is NOT a diagnosis of exclusion!!

  • you can do a ‘fibromyalgia syndrome diagnostic’ worksheet - ‘symptoms severity index’
  • explain to the patient that there is no test you can do to confirm the diagnosis
  • normal bloods

Tests to do just in case / ‘to make sure I am not missing anything’
- ESR
- FBC
- U&E (?renal failure)
- Ca, phosphate
- TFT
- HbA1c
- urine dip

DO NOT DO: RF, ANA, ANCA, CK, Igs, Vit D (unless you have a goof reason; e.g. a % of people have RF+ but no RA, everyone is Vit D deficienct so that won’t help you

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18
Q

Management of fibromyalgia

A

Conservative
- MDT: relationship, careful communication
- Education/Information
- Exercises - slow and steady
- CBT/ACT

Medical
- antidepressant (amitriptyline) - NO gabapentin/opioids/benzos/NSAIDs

Other
- acupuncture

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19
Q

Prognosis of fibromyalgia

A
  • can expect to have the condition for a longer time, perhaps even life long.
  • some treatments and measures can help with symptoms
  • may experience flares
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20
Q

RFs for fibromyalgia

A
  • female
  • traumatic childhood
  • stressful or traumatic events/PTSD
  • family history
  • repetitive injuries
  • illness (such as viral infections)
  • obesity
21
Q

prevalence of RA in the UK

A

1%

22
Q

what is secondary prevention?

A

stop at 1 -> after an incident prevent further ones

23
Q

Counsel someone on a bisphosphonate

A

oesophagitis is a common side effect and a big reason why people stop

24
Q

Fracture risk assessment tool name

A

FRAX

https://frax.shef.ac.uk/FRAX/tool.aspx?country=9

25
Q

Where are Bouchard’s and Heberden’s nodes? What conditions do you see them in?

A

HD BP

Heberdens - distal

bouchards - proximal

seen in OA

26
Q

X-ray features of OA

A

LOSS

loss of joint space
osteophytes
subchondral cysts
subchondral sclerosis

27
Q

X-ray features of RA

A

uniform joint space loss
periarticular osteopenia
marginal erosions
soft tissue swelling

28
Q

pathognomonic findings of ank spond on x-ray

A

syndesmophyte formation
bamboo spine
dagger sign

-> seen in advanced forms of ank spond in the spine

29
Q

imaging for ank spond

A

MRI is better in early diseases

X-ray can have some typical findings as well

30
Q

extradural bleed

A

MMA bleeding

31
Q

subdural bleed shape

A

banana/crescenteric

32
Q

subdural

What type of blood? Which vessles? Which patients?

A

venous bleeding
shearing of the bridging vessels
commoner in elderly patients
alcoholic patients, pts on blood thinners, pts with liver disease

NAI in children

33
Q

SAH

causes

A
  • most commonly due to ruptured Berry aneurysm
  • ## can be due to trauma
34
Q

intraparenchymal haemorrhage - causes and location

A

HTN is the most commonest cause

commonly located in brainstem/other deep grey matter structures

can be due to tumours or haemorrhagic transformation of an infarct

35
Q

Impacted vs distracted #

A

impacted: 2 ends of a bone are pressed into one another.

distracted: bones pulled apart and there is a gap in the middle

36
Q

1st line gold standard medication in RA

A

methotrexate

37
Q

what medication can be used in women of childbearing age to manage RA?

A

sulfalazine

38
Q

What is Birt Hogg Dube syndrome?

A

it is an AD condition featuring:
- skin lesions (fibrofolliculomas)
- lung cysts
- increased risk of renal cancer

-> regular monitoring (every 2 years lung and kidneys MRI/CT) and derm review

(first described and named after 3 Canadian physicians )

39
Q

enthesitis

A

inflammation of where the tendon inserts

e.g. Achilles tendonitis
plantar fasciitis

40
Q

What does non-radiographic change mean in the context of SpA?

A

No x-ray changes

may have MRI changes and changes in inflammatory markers

41
Q

which biologic DMARDs are licensed in SpA?

A

TNF alpha blockers
IL-17a
IL-23i
JAKi (not in PMH of VTE)

42
Q

what ocular adverse effect is hydroxychloroquine associated with?

A

retinopathy

43
Q

Diagnostic criteria for PMR

A

age over 50
sx > 2/52
bilateral shoulder and/or pelvic girdle aching
morning stiffness lasting 45 minutes
evidence of an acute phase response
normal muscle strength

44
Q

Radiograph features of Ank Spond

A

Radiographs may be normal early in disease, later changes include:
- sacroiliitis: subchondral erosions, sclerosis
squaring of lumbar vertebrae
- ‘bamboo spine’ (late & uncommon)
- syndesmophytes: due to ossification of outer fibers of annulus fibrosus
- CXR: apical fibrosis

45
Q

What are the extra-articular features of and spond?

A
  • Anterior Uveitis
  • Atlanto-Axial subluxation
  • Apical Fibrosis
  • Aortic Regurgitation
  • AV conduction defect
  • IgA Nephropathy
  • Amyloidosis
46
Q

Posture in Ank spons

A

stooped

-> loss of lumbar lordosis
-> hyperextended neck
-> flexed hips and knees

47
Q

Radiographic features of ank spond

A
  • Squaring Vertebral bodies, Romanus lesion
  • Erosion, sclerosis, narrowing SIJ
  • Bamboo Spine
  • Bone Marrow Oedema
48
Q

Which condition is pencil in a cup deformity associated with?

A

Psoriatic arthritis