Rheumatology Flashcards
1
Q
Symptoms of gout
A
pain, swelling, erythema
2
Q
Joints affected by gout
A
1st MTP
ankle, wrist, knee
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
4
Q
Gout Management
A
1) NSAIDS/cochicine +PPI
2) PO steroids
3) intra-articular steroids
URT
5
Q
What is URT
A
Urate lowering therapy
allopurinol OD titrated until uric acid <360
+ colchicine
6
Q
When is URT used?
A
if >=2 attacks in 1 year
tophi
renal disease
uric acid renal stones
7
Q
What is gout
A
deposition of monosodium urate monohydrate in synovium caused by chronic hyperuricaemia
8
Q
causes of gout
A
decrease uric acid secretion
-diuretics
-CKD
-lead toxicity
Increased production
- myelo/lymphoproliferative disorders
-cytotoxic drugs
-psoriasis
9
Q
Pseudogout affected joints
A
knee, wrist, shoulder
10
Q
pseudogout patho
A
deposition of calcium pyrophosphate dihydrate crystals in synovium
11
Q
pseudogout investigations
A
fluid: +ve birefringement rhomboid shaped crystals
XR: chondrocalcinosis
12
Q
Pseudogout management
A
Aspiration
NSAIDS or steroids
13
Q
SLE epidemiology
A
women of childbearing age
14
Q
SLE gene associations
A
HLA B8 DR2 DR3
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
16
Q
What kind of reaction is SLE
A
type 3 hypersensitivity reaction
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
18
Q
Monitoring SLE
A
ESR
C3 C4
19
Q
Management SLE
A
hydroxychloroquinine
NSAIDS
pred if internal organ involvement
20
Q
Complications of SLE with pregnancy
A
neonatal lupus, congential heart block
associated with anti-RO (SSA) antibodies
21
Q
RA presentation
A
swollen painful joints hands/feet
morning stiffness
gradual worsening
22
Q
RA examination
A
+ve squeeze test
swan neck
boutonniere
23
Q
Bloods RA
A
+ve RF (70-80%)
+ anti CCP antibody (70%)
24
Q
XR RA
A
loss of joint space
soft tissue swelling
juxta-articular osteoporosis
later
periarticular erosions
subluxation
25
Management of RA
DMARD monotherapy +/- bridging pred
flares: PO/IM corticosteroids
TNF-inhibs: etanercept, infliximab
26
Examples of DMARDs
methotrexate: monitor FBC/LFT as risk of liver cirrhosis and myelosuppression
TNF-inhibs e.g infliximab, etanercept
27
Poor prognostic features of RA
RF +Ve anti CCP antibodies +ve
poor function status
early XR erosions (<2yrs)
extra articular features
HLA DR4
28
Complications of RA
resp: fibrosis, effusion, nodules
occular: keratoconjunctivitis sicca
OP
IHD
29
Example of safe and unsafe DMARD in pregnancy
MTX - stop 6/12 prior to conception
safe: sulfasaline, hydroxycholorquine
30
symptoms of PMR
over 60 and rapid onset
aching and morning stiffness in prox limb muscles
lethargy, low grade fever
31
Pathophysiology of Reactive Arthritis
following GI or STI infection
Symptoms develop 4 weeks later
32
What is Reactive Arthritis grouped with
HLA B27 gene, seronegative spondyloarthropathy
33
How does reactive arthritis present
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
34
Reactive arthritis management
NSAIDs, intra-articular steroids
MTX, sulfsalazine if persistent
35
Most common organism causing septic arthritis
Staph aureus
36
Most likely organism causing septic arthritis in sexually active adult
neisseria gonorrhoea
37
Most common cause of septic arthritis
haematogenous spread
38
Most common location of septic arthritis
knee
39
Presentation of septic arthritis
acute swollen joint
warm and fluctuant
fever
40
Investigations of septic arthritis
synovial fluid aspiration before Abx
blood cultures
imaging
41
Management of septic arthritis
IV fluxclox (clindamycin)
PO switch after 2 weeks (4-6 weeks Abx total)
needle aspiration to decompress
arthroscopic lavage
42
What is psoriatic arthritis
seronegative spondyloarthropathy
43
Psoriatic arthritis epidemiology
10-20% of psorasis patients within 10 years of skin lesions
44
Presentation of psoriatic arthritis
1) symmetrical: hands, wrists, ankles, DIJ
2) asym: digits
3) spondylitis: back stiffness, sacroilitis
45
Examination findings of psoriatic arthritis
Skin lesions
nail pitting, onycholysis, dactylitis
enthesis
46
Ix psoriatic arthritis
XR
- erosive changes + new bone formation
- periostitis
- pencil in a cup appearance
47
Management of psoriatic arthritis
mild: NSAIDS
mod: MTX
48
What is ankylosing spondylitis
HLA B27 gene - seronegative spondyloarthropathy
49
How does ank spon present
young male
gradual onset
back pain and stiffness, worse in the morning improves throughout the day
50
how do you examine ?ank spon
Schobers test
mark 10cm above and 5cm below L5
if <20cm when bending forward indicates restriction
51
Investigations ank spon
XR sacroiliac joints
-sacroiliitis
-squaring of lumbar vertebrae
- bamboo spine
MRI if XR -ve but high suspicion
52
Management ank spon
Regular exercise, PT
NSAIDS
DMARDs if peripheral joint involvement
anti-TNF (etanercept/adalimumam) if persistent
53
Risk factors for osteoporosis
glucocorticoids
RA
alcohol
Smoking
Low BMI
Hx parental hip #
54
Meds that increase risk of osteoporosis
*glucocorticoids
SSRI
Anti-epileptic
PPI
55
Investigations for osteoporosis
DEXA scan T score
<=-2.5 : diagnostic
-2.5->-1: osteopaenia
>-1: normal
Bloods
56
What is a T score on DEXA scan based on
bone mass of young population
57
Osteoporosis management
Vit d and calcium supplementation
alendronate -> risedronate if not tolerated
58
How do you manage risk of OP in patients taking glucocorticoids?
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
Risk factors for osteoarthritis
Age, female
occupation
high BMI
trauma
FHx
60
XR findings osteoarthritis
Loss of joint space
Osteophytes
Subarticular sclerosis
Subchondral cysts
Do not correlate to disease severity
61
Presentation of osteoarthritis
joint pain and stiffness (lasting less than 30mins in the morning)
worse on exercise
62
Joints commonly affected by osteoarthritis
Knee, hip, sacroiliac, c spine
DIP, CMC, wrist
63
Examination findings of osteoarthritis
Haberdens nodes (DIP)
Bouchards nodes (PIP)
Squaring at thumb base (CMC)
Decreased grip and decreased ROM
64
Diagnosis of osteoarthritis
clinical
65
Management of osteoarthritis
lifestyle
PT/OT/Orthotics
Analgesia: PCM/topical NSAIDS -> PO NSAIDS -> opiods
IA steroid injections
joint replacement
66
Osteomyelitis causes
staph aureus mainly
salmonella if sickle cell
67
Osteomyelitis investigations
MRI
68
Osteomyelitis management
6/52 Abx - fluclox (clinda)
69
RF for osteomyelitis
haematogenous: SS, IVDU, IE, immunosuppression
non-haematogenous: DM, diabetic foot ulcers, PAD
70
Pathophysiology of antiphospholipid syndrome
genetic factor: HLA DR7
environmental trigger: infection, drugs
anti-beta 2 glycoprotein1 and anti-cardiolipin encourage clot formation
71
Features of antiphospholipid syndrome
arterial/venous thrombosis
recurrent fetal loss
pre-eclampsia
72
investigations of antiphospholipid syndrome
antibodies: anti beta 2 glycoprotein 1, anti cardiolipin, lupus anticoagulant
thrombocytopenia
increased APTT
73
Antiphospholipid syndrome management
primary thromboprophylaxis: low dose aspirin
secondary - warfarin target 2-3
if further episode target 3-4 +aspirin
74
What is avascular necrosis of hip
death of bone tissue secondary to loss of the blood supply
75
Causes of avascular necrosis of hip
Steroids
Chemo
Alcohol
Trauma
76
features of avascular necrosis of hip
asymptomatic -> pain
77
Investigations of avascular necrosis of hip
XR - crescent sign, collapse of articular surface
MRI
78
Management of avascular necrosis of hip
joint replacement
79
Carpal Tunnel Cause
compression of median nerve
80
carpal tunnel symptoms
pain/pins and needles, thumb, middle finger, index finger
shaking hand improves symptoms
81
Examination findings of carpal tunnel
Tinnels: tapping
Phalens: flexion of wrist
weakness thumb abduction
wasting of thenar eminence
82
Diagnosis of carpal tunnel
electrophysiology - prolonged action potential
83
Management of carpal tunnel
6/52 conservative
- corticosteroid injection
- splint
If persists
- decompressive surgery
84
What is chronic fatigue syndrome
more than 3 months disabling fatigue affecting mental and physical function >50% of the time
85
How does chronic fatigue present
Fatigue
post exertional malaise
unrefreshing sleep
cognitive difficulties
86
Chronic fatigue investigations
full bloods inc coeliac
87
Chronic fatigue management
specialist referral
CBT
88
What is Cubital tunnel syndrome
compression of ulnar nerve in cubital tunnel
89
How does Cubital tunnel syndrome present
tingling/numbness 4th and 5th fingers
intermittent->constant->weakness and wasting
90
How is cubital tunnel syndrome diagnosed
clinical
can use NCS
91
How is cubital tunnel syndrome managed
PT, steroid injections, surgery
92
What is De Quervain's tenosynovitis
sheath containing the extensor pollicis brevis and abductor pollicis longus tendons is inflamed.
93
Features of De Quervains tenosynovitis
pain on the radial side of the wrist
tenderness over the radial styloid process
abduction of the thumb against resistance is painful
94
Examination of De Quervains tenosynovitis
Finkelstein's test
thumb in fist, deviate hand towards ulnar side, if pain at radial side +ve test
95
Management of De Quervains tenosynovitis
Analgesia
steroid injection
split
surgery
96
How would dermatomyositis present
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
Investigation findings of dermatomyositis
ANA +ve
Anti Jo 1, Anti Mi 2
Increased CK
98
How do you manage dermatomyositis
pred
99
How do you manage discoid lupus erythema?
Top steroids
PO Anti malarials
avoid sun
100
How does discoid lupus erythema present
erythematous raised rash on neck/face/scalp/ears
when healing scars cause alopecia
101
Commmon causes of drug induced lupus
procainamide
hydralazine
102
What Is Ehlers-Danlos
Autosomal dom connective tissue disorder affecting type III collagen
103
Presentation of Ehlers Danlos
Hypermobility (joint dislocation), elastic fragile skin (Easy brusing)
104
Cardiac association with Ehlers Danlos
aortic regurgitation, mitral valve prolapse and aortic dissection
105
Diagnosis: lateral epicondyle pain,
worse on resisted wrist extension or forearm supination when elbow extended acute episode 6-12 weeks
Lateral epicondylitis (tennis elbow)
episodes late 6months - 2 years
106
Diagnosis: medial epicondyle pain, worse on wrist flexion and pronation, accompanied by numbness/tingling 4th and 5th finger
Medial epicondylitis (golfers elbow) tingling due to ulnar nerve involvement
107
Diagnosis: pain 4-5cm from lateral epicondyle, worse by extending elbow and pronating forearm
Radial tunnel syndrome
due to overuse
108
Diagnosis: swelling over posterior aspect of elbow in middle aged man
olecranon bursitis
109
Diagnosis: tingling 4th 5th finger progressing to numbness, worse when elbow resting on firm surface or flexed for periods of time
Cubital tunnel syndrome
compression of ulnar nerve
110
Familial Mediterranean Fever epidemiology, presentation and management
Ex: turkish, armenian, arabic
Px: fever, abdo pain, pleurisy, pericarditis, lower limb rash
Mx: colchicine
111
Fibromyalgia symptoms and epidemiology
women 30-50
pain at multiple sites
fatigue, sleep disturbance, cog impairment
112
Fibromyalgia management
education, exercise, CBT
pregabalin, duloxetine, amitriptyline
113
Pathophysiology Marfans
autosomal dominant CTD
defect in FBN1 gene on chromosome 15
114
Symptoms Marfans
tall
long fingers
high arched palate
heart: aortic sinus dilation -> aneurysm, mitral valve prolapse
pneumothorax
eyes: blue sclera, myopia
115
Marfans management
ECHO monitoring
B blockers/ACE inhibs
116
What is Pagets disease of the bone
Increased osteoclastic resorption
117
How does Pagets disease of bone present
older male with bone pain and increased ALP
118
Common areas for Pagets disease of bone to affect
pelvis, lumbar spine, femur
bowing of tibia, bossing of skull
119
Investigtaions Pagets
Increased ALP
XR: osteolysis -> mixed lytic/sclerotic lesions
skull XR: thickened vault, osteoporosis circumsciptia
120
Management of Pagets
PO risedronate IV zoledronate if
bone pain
skull or long bone deformity
fracture
periarticular Paget's
121
what is Raynauds?
exaggerated vasoconstriction to cold or emotional stress
122
causes of Raynauds
primary
secondary: connective tissue disorder (scleroderma), leukaemia, OCP
123
Management of Raynauds
nifedipine
IV prostacyclin
124
What is Sjogrens syndrome?
Autoimmune affecting exocrine glands ->dry mucosal surfaces
125
Causes of Sjogrens syndrome
primary; Sicca syndrome
secondary: RA, CTD
126
Presentation of Sjogrens syndrome
middle aged women
dry eyes blurred vision
dry mouth
dry skin and vagina
127
Investigations of Sjogrens syndrome
ANA +ve 70%
RF +ve 50%
Anti Ro, Anti La
Histology: focal lymphocytic infiltration
128
Management of Sjogrens syndrome
Artificial tears and saliva
Pilocarpine
129
What is temporal arteritis
medium and large vessel vasculitis ?cause
130
How does temporal arteritis present?
>60 year old, rapid <1month
headache
jaw claudication
tender palpable temporal artery
visual loss
50% PMR
131
Why can you get visual loss in temporal arteritis
occlusion of posterior ciliary artery -> ischaemia of optic nerve head
132
Investigations of temporal arteritis
increased ESR
temporal biopsy: skip lesions
fundoscopy: swollen pale disc, blurred margins
133
Management of temporal arteritis
no visual loss: high dose pred
visual loss: IV Methylpred
urgent opthal review
bisphosphonates
