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MRCP > Rheumatology > Flashcards

Rheumatology Flashcards

1
Q

Symptoms of gout

A

pain, swelling, erythema

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2
Q

Joints affected by gout

A

1st MTP
ankle, wrist, knee

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3
Q

Investigations of gout

A

fluid: needle shaped negatively birefingement monosodium urate crystals

XR: joint effusion, punched out erosions

Uric acid: check 2 weeks after acute episode

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4
Q

Gout Management

A

1) NSAIDS/cochicine +PPI
2) PO steroids
3) intra-articular steroids

URT

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5
Q

What is URT

A

Urate lowering therapy
allopurinol OD titrated until uric acid <360
+ colchicine

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6
Q

When is URT used?

A

if >=2 attacks in 1 year
tophi
renal disease
uric acid renal stones

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7
Q

What is gout

A

deposition of monosodium urate monohydrate in synovium caused by chronic hyperuricaemia

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8
Q

causes of gout

A

decrease uric acid secretion
-diuretics
-CKD
-lead toxicity
Increased production
- myelo/lymphoproliferative disorders
-cytotoxic drugs
-psoriasis

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9
Q

Pseudogout affected joints

A

knee, wrist, shoulder

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10
Q

pseudogout patho

A

deposition of calcium pyrophosphate dihydrate crystals in synovium

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11
Q

pseudogout investigations

A

fluid: +ve birefringement rhomboid shaped crystals
XR: chondrocalcinosis

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12
Q

Pseudogout management

A

Aspiration
NSAIDS or steroids

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13
Q

SLE epidemiology

A

women of childbearing age

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14
Q

SLE gene associations

A

HLA B8 DR2 DR3

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15
Q

Explained SLE pathophysiology

A

environmental trigger (sun, infection) causes apoptosis, cells aren’t cleared effectively (genetic) so there are XS nuclear antigens which are seen as foreign (genetic) causing immune response-> ANA, deposits in tissues causing inflam

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16
Q

What kind of reaction is SLE

A

type 3 hypersensitivity reaction

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17
Q

Features for diagnosis of SLE

A

1) malar rash
2) discoid rash
3) photosensitivity
4) mouth/nose ulcers
5) serositis (pericarditis, pleuritis)
6) arthritis 2+
7) renal disease - abnormal urine protein, glomerulonephritis
8) neuro - seizures, psychosis
9) blood - anaemia, thrombocytopenia
10) ANA
11) other antibody - anti smith, anti dsDNA anti phospholipid

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18
Q

Monitoring SLE

A

ESR
C3 C4

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19
Q

Management SLE

A

hydroxychloroquinine
NSAIDS
pred if internal organ involvement

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20
Q

Complications of SLE with pregnancy

A

neonatal lupus, congential heart block
associated with anti-RO (SSA) antibodies

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21
Q

RA presentation

A

swollen painful joints hands/feet
morning stiffness
gradual worsening

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22
Q

RA examination

A

+ve squeeze test
swan neck
boutonniere

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23
Q

Bloods RA

A

+ve RF (70-80%)
+ anti CCP antibody (70%)

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24
Q

XR RA

A

loss of joint space
soft tissue swelling
juxta-articular osteoporosis

later
periarticular erosions
subluxation

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25
Q

Management of RA

A

DMARD monotherapy +/- bridging pred

flares: PO/IM corticosteroids

TNF-inhibs: etanercept, infliximab

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26
Q

Examples of DMARDs

A

methotrexate: monitor FBC/LFT as risk of liver cirrhosis and myelosuppression
TNF-inhibs e.g infliximab, etanercept

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27
Q

Poor prognostic features of RA

A

RF +Ve anti CCP antibodies +ve
poor function status
early XR erosions (<2yrs)
extra articular features
HLA DR4

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28
Q

Complications of RA

A

resp: fibrosis, effusion, nodules
occular: keratoconjunctivitis sicca
OP
IHD

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29
Q

Example of safe and unsafe DMARD in pregnancy

A

MTX - stop 6/12 prior to conception
safe: sulfasaline, hydroxycholorquine

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30
Q

symptoms of PMR

A

over 60 and rapid onset
aching and morning stiffness in prox limb muscles
lethargy, low grade fever

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31
Q

Pathophysiology of Reactive Arthritis

A

following GI or STI infection
Symptoms develop 4 weeks later

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32
Q

What is Reactive Arthritis grouped with

A

HLA B27 gene, seronegative spondyloarthropathy

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33
Q

How does reactive arthritis present

A

Cant see cant pee cant climb a tree
1) arthritis - lower joints asymmetrical
2) conjuctivitis, anterior uveitis
3) circinate balanitis, urethritis
last around 4-6 months

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34
Q

Reactive arthritis management

A

NSAIDs, intra-articular steroids
MTX, sulfsalazine if persistent

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35
Q

Most common organism causing septic arthritis

A

Staph aureus

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36
Q

Most likely organism causing septic arthritis in sexually active adult

A

neisseria gonorrhoea

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37
Q

Most common cause of septic arthritis

A

haematogenous spread

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38
Q

Most common location of septic arthritis

A

knee

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39
Q

Presentation of septic arthritis

A

acute swollen joint
warm and fluctuant
fever

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40
Q

Investigations of septic arthritis

A

synovial fluid aspiration before Abx
blood cultures
imaging

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41
Q

Management of septic arthritis

A

IV fluxclox (clindamycin)
PO switch after 2 weeks (4-6 weeks Abx total)
needle aspiration to decompress
arthroscopic lavage

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42
Q

What is psoriatic arthritis

A

seronegative spondyloarthropathy

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43
Q

Psoriatic arthritis epidemiology

A

10-20% of psorasis patients within 10 years of skin lesions

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44
Q

Presentation of psoriatic arthritis

A

1) symmetrical: hands, wrists, ankles, DIJ
2) asym: digits
3) spondylitis: back stiffness, sacroilitis

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45
Q

Examination findings of psoriatic arthritis

A

Skin lesions
nail pitting, onycholysis, dactylitis
enthesis

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46
Q

Ix psoriatic arthritis

A

XR
- erosive changes + new bone formation
- periostitis
- pencil in a cup appearance

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47
Q

Management of psoriatic arthritis

A

mild: NSAIDS
mod: MTX

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48
Q

What is ankylosing spondylitis

A

HLA B27 gene - seronegative spondyloarthropathy

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49
Q

How does ank spon present

A

young male
gradual onset
back pain and stiffness, worse in the morning improves throughout the day

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50
Q

how do you examine ?ank spon

A

Schobers test
mark 10cm above and 5cm below L5
if <20cm when bending forward indicates restriction

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51
Q

Investigations ank spon

A

XR sacroiliac joints
-sacroiliitis
-squaring of lumbar vertebrae
- bamboo spine

MRI if XR -ve but high suspicion

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52
Q

Management ank spon

A

Regular exercise, PT
NSAIDS
DMARDs if peripheral joint involvement
anti-TNF (etanercept/adalimumam) if persistent

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53
Q

Risk factors for osteoporosis

A

glucocorticoids
RA
alcohol
Smoking
Low BMI
Hx parental hip #

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54
Q

Meds that increase risk of osteoporosis

A

*glucocorticoids
SSRI
Anti-epileptic
PPI

55
Q

Investigations for osteoporosis

A

DEXA scan T score
<=-2.5 : diagnostic
-2.5->-1: osteopaenia
>-1: normal

Bloods

56
Q

What is a T score on DEXA scan based on

A

bone mass of young population

57
Q

Osteoporosis management

A

Vit d and calcium supplementation
alendronate -> risedronate if not tolerated

58
Q

How do you manage risk of OP in patients taking glucocorticoids?

A
  1. > 65 + previous fragility #: offer bone protection
  2. <65: DEXA T score
    >0: reassure
    0-> -1.5: repeat scan 1-3 years
    -<1.5: bone protection
59
Q

Risk factors for osteoarthritis

A

Age, female
occupation
high BMI
trauma
FHx

60
Q

XR findings osteoarthritis

A

Loss of joint space
Osteophytes
Subarticular sclerosis
Subchondral cysts
Do not correlate to disease severity

61
Q

Presentation of osteoarthritis

A

joint pain and stiffness (lasting less than 30mins in the morning)
worse on exercise

62
Q

Joints commonly affected by osteoarthritis

A

Knee, hip, sacroiliac, c spine
DIP, CMC, wrist

63
Q

Examination findings of osteoarthritis

A

Haberdens nodes (DIP)
Bouchards nodes (PIP)
Squaring at thumb base (CMC)
Decreased grip and decreased ROM

64
Q

Diagnosis of osteoarthritis

A

clinical

65
Q

Management of osteoarthritis

A

lifestyle
PT/OT/Orthotics
Analgesia: PCM/topical NSAIDS -> PO NSAIDS -> opiods
IA steroid injections
joint replacement

66
Q

Osteomyelitis causes

A

staph aureus mainly
salmonella if sickle cell

67
Q

Osteomyelitis investigations

A

MRI

68
Q

Osteomyelitis management

A

6/52 Abx - fluclox (clinda)

69
Q

RF for osteomyelitis

A

haematogenous: SS, IVDU, IE, immunosuppression
non-haematogenous: DM, diabetic foot ulcers, PAD

70
Q

Pathophysiology of antiphospholipid syndrome

A

genetic factor: HLA DR7
environmental trigger: infection, drugs
anti-beta 2 glycoprotein1 and anti-cardiolipin encourage clot formation

71
Q

Features of antiphospholipid syndrome

A

arterial/venous thrombosis
recurrent fetal loss
pre-eclampsia

72
Q

investigations of antiphospholipid syndrome

A

antibodies: anti beta 2 glycoprotein 1, anti cardiolipin, lupus anticoagulant
thrombocytopenia
increased APTT

73
Q

Antiphospholipid syndrome management

A

primary thromboprophylaxis: low dose aspirin
secondary - warfarin target 2-3
if further episode target 3-4 +aspirin

74
Q

What is avascular necrosis of hip

A

death of bone tissue secondary to loss of the blood supply

75
Q

Causes of avascular necrosis of hip

A

Steroids
Chemo
Alcohol
Trauma

76
Q

features of avascular necrosis of hip

A

asymptomatic -> pain

77
Q

Investigations of avascular necrosis of hip

A

XR - crescent sign, collapse of articular surface
MRI

78
Q

Management of avascular necrosis of hip

A

joint replacement

79
Q

Carpal Tunnel Cause

A

compression of median nerve

80
Q

carpal tunnel symptoms

A

pain/pins and needles, thumb, middle finger, index finger
shaking hand improves symptoms

81
Q

Examination findings of carpal tunnel

A

Tinnels: tapping
Phalens: flexion of wrist
weakness thumb abduction
wasting of thenar eminence

82
Q

Diagnosis of carpal tunnel

A

electrophysiology - prolonged action potential

83
Q

Management of carpal tunnel

A

6/52 conservative
- corticosteroid injection
- splint
If persists
- decompressive surgery

84
Q

What is chronic fatigue syndrome

A

more than 3 months disabling fatigue affecting mental and physical function >50% of the time

85
Q

How does chronic fatigue present

A

Fatigue
post exertional malaise
unrefreshing sleep
cognitive difficulties

86
Q

Chronic fatigue investigations

A

full bloods inc coeliac

87
Q

Chronic fatigue management

A

specialist referral
CBT

88
Q

What is Cubital tunnel syndrome

A

compression of ulnar nerve in cubital tunnel

89
Q

How does Cubital tunnel syndrome present

A

tingling/numbness 4th and 5th fingers
intermittent->constant->weakness and wasting

90
Q

How is cubital tunnel syndrome diagnosed

A

clinical
can use NCS

91
Q

How is cubital tunnel syndrome managed

A

PT, steroid injections, surgery

92
Q

What is De Quervain’s tenosynovitis

A

sheath containing the extensor pollicis brevis and abductor pollicis longus tendons is inflamed.

93
Q

Features of De Quervains tenosynovitis

A

pain on the radial side of the wrist
tenderness over the radial styloid process
abduction of the thumb against resistance is painful

94
Q

Examination of De Quervains tenosynovitis

A

Finkelstein’s test
thumb in fist, deviate hand towards ulnar side, if pain at radial side +ve test

95
Q

Management of De Quervains tenosynovitis

A

Analgesia
steroid injection
split
surgery

96
Q

How would dermatomyositis present

A

symmetrical prox muscle weakness (shoulder/hip)-> wasting
fever, weight loss, fatigue
Gottrons papules - purple lesions tops small joints of fingers
Heliotrope rash - bilat discolouration around eyes

97
Q

Investigation findings of dermatomyositis

A

ANA +ve
Anti Jo 1, Anti Mi 2
Increased CK

98
Q

How do you manage dermatomyositis

A

pred

99
Q

How do you manage discoid lupus erythema?

A

Top steroids
PO Anti malarials
avoid sun

100
Q

How does discoid lupus erythema present

A

erythematous raised rash on neck/face/scalp/ears
when healing scars cause alopecia

101
Q

Commmon causes of drug induced lupus

A

procainamide
hydralazine

102
Q

What Is Ehlers-Danlos

A

Autosomal dom connective tissue disorder affecting type III collagen

103
Q

Presentation of Ehlers Danlos

A

Hypermobility (joint dislocation), elastic fragile skin (Easy brusing)

104
Q

Cardiac association with Ehlers Danlos

A

aortic regurgitation, mitral valve prolapse and aortic dissection

105
Q

Diagnosis: lateral epicondyle pain,
worse on resisted wrist extension or forearm supination when elbow extended acute episode 6-12 weeks

A

Lateral epicondylitis (tennis elbow)
episodes late 6months - 2 years

106
Q

Diagnosis: medial epicondyle pain, worse on wrist flexion and pronation, accompanied by numbness/tingling 4th and 5th finger

A

Medial epicondylitis (golfers elbow) tingling due to ulnar nerve involvement

107
Q

Diagnosis: pain 4-5cm from lateral epicondyle, worse by extending elbow and pronating forearm

A

Radial tunnel syndrome
due to overuse

108
Q

Diagnosis: swelling over posterior aspect of elbow in middle aged man

A

olecranon bursitis

109
Q

Diagnosis: tingling 4th 5th finger progressing to numbness, worse when elbow resting on firm surface or flexed for periods of time

A

Cubital tunnel syndrome
compression of ulnar nerve

110
Q

Familial Mediterranean Fever epidemiology, presentation and management

A

Ex: turkish, armenian, arabic
Px: fever, abdo pain, pleurisy, pericarditis, lower limb rash
Mx: colchicine

111
Q

Fibromyalgia symptoms and epidemiology

A

women 30-50
pain at multiple sites
fatigue, sleep disturbance, cog impairment

112
Q

Fibromyalgia management

A

education, exercise, CBT
pregabalin, duloxetine, amitriptyline

113
Q

Pathophysiology Marfans

A

autosomal dominant CTD
defect in FBN1 gene on chromosome 15

114
Q

Symptoms Marfans

A

tall
long fingers
high arched palate
heart: aortic sinus dilation -> aneurysm, mitral valve prolapse
pneumothorax
eyes: blue sclera, myopia

115
Q

Marfans management

A

ECHO monitoring
B blockers/ACE inhibs

116
Q

What is Pagets disease of the bone

A

Increased osteoclastic resorption

117
Q

How does Pagets disease of bone present

A

older male with bone pain and increased ALP

118
Q

Common areas for Pagets disease of bone to affect

A

pelvis, lumbar spine, femur
bowing of tibia, bossing of skull

119
Q

Investigtaions Pagets

A

Increased ALP
XR: osteolysis -> mixed lytic/sclerotic lesions
skull XR: thickened vault, osteoporosis circumsciptia

120
Q

Management of Pagets

A

PO risedronate IV zoledronate if
bone pain
skull or long bone deformity
fracture
periarticular Paget’s

121
Q

what is Raynauds?

A

exaggerated vasoconstriction to cold or emotional stress

122
Q

causes of Raynauds

A

primary
secondary: connective tissue disorder (scleroderma), leukaemia, OCP

123
Q

Management of Raynauds

A

nifedipine
IV prostacyclin

124
Q

What is Sjogrens syndrome?

A

Autoimmune affecting exocrine glands ->dry mucosal surfaces

125
Q

Causes of Sjogrens syndrome

A

primary; Sicca syndrome
secondary: RA, CTD

126
Q

Presentation of Sjogrens syndrome

A

middle aged women
dry eyes blurred vision
dry mouth
dry skin and vagina

127
Q

Investigations of Sjogrens syndrome

A

ANA +ve 70%
RF +ve 50%
Anti Ro, Anti La
Histology: focal lymphocytic infiltration

128
Q

Management of Sjogrens syndrome

A

Artificial tears and saliva
Pilocarpine

129
Q

What is temporal arteritis

A

medium and large vessel vasculitis ?cause

130
Q

How does temporal arteritis present?

A

> 60 year old, rapid <1month
headache
jaw claudication
tender palpable temporal artery
visual loss
50% PMR

131
Q

Why can you get visual loss in temporal arteritis

A

occlusion of posterior ciliary artery -> ischaemia of optic nerve head

132
Q

Investigations of temporal arteritis

A

increased ESR
temporal biopsy: skip lesions
fundoscopy: swollen pale disc, blurred margins

133
Q

Management of temporal arteritis

A

no visual loss: high dose pred
visual loss: IV Methylpred
urgent opthal review
bisphosphonates

MRCP (19 decks)

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