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Internal Medicine > Rheumatology > Flashcards

Rheumatology Flashcards

1
Q

Differential monoarticular arthritis? (7)

A

Inflammatory (acule)

  • Crystalline 80%!
    → gout (Acute) (monosodium urate )
    → pseudogout (Acute) (ccpd: calcium pyrophosphate crystals )
    → calcium hydroxyapatite
    → calcium oxalate
  • septic !
    → bacterial
    → mycobacterium
    → Lyme disease
    → fungal
  • spondyloarthritis
  • psoriatic arthritis
  • reactive arthritis (previous diarrhoea/genital infection)
  • enteropathic arthritis

Non-inflammatory

  • osteoarthritis
  • trauma: fracture, haemarthrosis
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2
Q

Define oligoArthritis

A

5 or less joints

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3
Q

Define polyarthritis

A

> 5 joints

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4
Q

Differential Oligoarthritis? (8)

A

Inflammatory

  • Crystal
  • spondyloarthritides
    → ankylosing spondylitis
    → Psoriatic arthritis
    → enterohepatic spondyloarthropathies
    → reactive eg yersinia salmonella, campylobacter

Non-inflammatory

  • Osteoarthritis
  • hypothyroid
  • Amyloidosis
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5
Q

Differential polyarticular arthralgia? (5)

A

Inflammatory

  • rheumatoid arthritis
  • systemic rheumatic disease: SLE (small joints, synovitis), vasculitis, systemic sclerosis,polymyositis, dermatomyositis
  • infections: viral (hbv, HCV, parvo) (symmetrical, small joints), bac (endocarditis, Lyme disease), rheumatic fever
  • psoriatic arthritis (assymetrical, all joints and entheses, associated with nail pitting / onycholysis, dactylics ), reactive arthritis.
  • axial spondyloanthritis + enteropathic arthritis (lower > upper limbs)
  • juvenile idiopathic arthritis
  • chronic gout
  • chronic sarcoidosis ( often ankles)
  • calcium pyrophosphate arthritis

Non inflammatory

  • osteoarthritis
  • fibromyalgia
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6
Q

Investigation arthralgia?

A

Synovial fluid analysis, culture
Xray

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7
Q

Empirical treatment septic arthritis? (3)

A

Bone inFection Grub

  • Flucloxacillin 1 g/6h slowly iv (b lactamaSe resistant- narrow spec - streptococci, staph )
  • benzylpenicillin 1,2g / 4h iv (b lactase sensitive - broad spec- aerobic G + and G- , anaerobic )
  • with or without gentamicin (aminoglycoside- broad spec except strep and anaerobes-mostly G- )
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8
Q

Name 4 spondyloarthitides

A
  • Ankylosing spondylitis (schober test )
  • psoriatic arthritis
  • enterohepatic spondyloarthropathies
  • reactive arthritis eg yersinia salmonella, campylobacter
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9
Q

Diagnosis SLE?

A

Soap brain md (4 or more = diagnosis)

  • Serositis: pericarditis/pleuritis
  • oral/nasal ulcers
  • arthritis
  • photo sensitivity
  • blood disorders: haemolytic anaemia, leukopenia, lymphopenia, thrombocytopenia
  • renal involvement: persistent proteinuria/cellular casts
  • antinuclear antibodies
  • immunologic phenomena: anti-dsDNA, anti- Sm, antiphospholipid antibodies
  • neurological disorder: seizures, psychosis
  • malar rash
  • discoid rash
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10
Q

Treatment SLE? (6)

A
  • Lifestyle: sunblock
  • joints+skin: NSAIDs, hydroxychloroquine (malaria drug) if not controlled
  • low dose steroids
  • flares eg haemolytic anaemia, nephritis, severe pericarditis, CNS disease: high dose prednisolone with iv cyclophosphamide (immunosuppressant). Azathioprine (immunosuppressant) for maintenance.
  • rituximab = monoclonal antibody
  • Low dose aspirin for antiphospholipid syndrome
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11
Q

Tests for SLE? (4)

A
  • Ana
  • anti - dsdna
  • anti- Sm antibody
  • antiphospholipid antibody
  • low complement (c3, C4, CH50)
  • direct Coombs test in absence of haemolytic anaemia
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12
Q

Name 2 antiphospholipid antibodies

A
  • Anticardiolipin antibodies
  • lupus anticoagulants
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13
Q

What is anti-phospholipid syndrome

A

Symptom complex that occurs secondary to SLE in 35%
Or as primary disease (majority)

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14
Q

Features antiphospholipid syndrome? (4)

A

CLOT

  • coagulation defect
  • livedo reticularis
  • obstetric: recurrent miscarriage
  • thrombocytopenia.
    Prothrombotic tendency affecting cerebral (stroke), renal and cv circulation
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15
Q

Name 3 drugs that cause SLE

A
  • Isoniazid
  • hydralazine (vasodilator to rx ht)
  • phenytoin

Will have antihistone antibodies. Predominantly skin and lung signs

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16
Q

Renal signs SLE? (2)

A
  • Persistent proteinuria > 0,5g/d or 3+ dipstix or
  • cellular casts
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17
Q

Causes erythema nodosum? (6)

A

NODOSUM

  • No cause in 60%
  • drugs: antibiotics eg sulfonamides, amoxicillin,
  • oral contraceptives
  • sarcoidosis or Lofgren’s syndrome
  • ulcerative colitis, ! Chrons, ! bechets
  • micro-organisms: tb + BCG. vaccine, viruses ( HSv, EBV, HIV, hep b+c), bacteria (streptococcus, campylobacter, syphilis, yersinia salmonella ), parasitic ( amebiasis, giardiasis)
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18
Q

Treatment gout attack? (2)

A
  • Strong NSAID eg indomethacin. If c/i, use colchicine 0,5mg bd /tds.
  • steroids
  • prophylaxis: allopurinol ( xanthine oxidase inhibitor)
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19
Q

Prevention gout? (2)

A
  • Lifestyle: avoid prolonged fasts, alcohol excess, purine rich food eg meat, seafood; weight loss, avoid low dose aspirin (increase serum urate)
  • allopurinol, wait 3 weeks after acute attack. Cover with NSAID / colchicine
  • other: febuxostat, uricosuric drugs
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20
Q

Extra-articular Presentation rheumatoid arthritis? (11)

A

SHOPPING CMV

  • systemic: fever, weight loss, fatigue
  • haematological: thrombocytosis,
  • ocular: scleritis, episcleritis, scleromalacia, keratoconjunctivitis sicca
  • pulmonary: pleural effusion, fibrosing alveolitis, obliterative bronchiolitis
  • neoplasm: lymphoma
    Nodules: elbows+lungs
    Neurological: peripheral neuropathy, cord compression
  • git: hepatosplenomegaly,
  • cardiac: carditis, effusion,
  • musculoskeletal: raynaud, carpal tunnel, osteoporosis, bursitis
  • vasculitis
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21
Q

articular signs rheumatoid arthritis? (7)

A

Rheumatoid wrists Zhow BUMPSSs

  • radial deviation wrist
  • z deformity thumb
  • boutonnière deformity
  • ulnar deviation of fingers
  • MCP
  • pip
  • swan neck
  • symmetrical
  • small and large joints, upper and lower limbs
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22
Q

Treatment rheumatoid arthritis

A
  • Steroids for flares
  • NSAIDs
  • dmard: methotrexate
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23
Q

What is boutonnière deformity

A

Occurs in ra
Finger flexed at pip, hyperextended at dip

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24
Q

What is swan neck deformity

A

Occurs in ra.

Pip hyper extension, dip flexion

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25
Q

What is Felty’s syndrome? (3)

A

Rare autoimmune disease with triad

  • Ra
  • splenomegaly
  • neutropenia

Also anaemia, thrombocytopenia, lymphadenopathy, weight loss, skin pigmentation, keratoconjunctivitis sicca, vasculitis / leg ulcers, nodules

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26
Q

Name 2 causes giant splenomegaly

A
  • Parasitic infection: malaria, leishmaniasis
  • myeloproliferative disorders: leukemia including CML, myelofibrosis
27
Q

Name 4 radiographic features rheumatoid arthritis

A
  • Periarticular osteoporosis
  • marginal joint erosions
  • joint subluxation
  • joint space narrowing
28
Q

Name 3 radiographic features osteoporosis

A
  • Osteopenia
  • vertebral # + non-ventebral #
  • cortical thinning
29
Q

Name 4 radiographic features Paget’s disease

A
  • Bone expansion
  • abnormal trabecular pattern
  • osteosclerosis (thickening of trabecular/ spongy bone) + lysis
  • pseudo-fractures
30
Q

Name 4 radiographic features psoriatic arthritis

A
  • Syndesmophytes + enthesophytes
  • juxta-articular new bone
  • sacroilitis
  • bone sclerosis
  • proliferative enthesis erosions
31
Q

Name 4 radiographic features osteoarthritis

A

LOSS

  • loss of joint space
  • osteophytes
  • Subchondral sclerosis
  • subchondral cysts

Joint deformity

32
Q

Paget’s disease biochemical abnormalities?

A
  • Alp very high!
  • phosphate normal
  • calcium normal
  • fgf 23 normal
  • PTH normal / high
  • 25 (oh)d normal / low
33
Q

Renal osteodystrophy biochemical abnormalities? (3)

A
  • fgf 23 very high! (Suppress P reabsorption + vit D synth, stim by high levels P + vit D)
  • PTH very high!
  • Alp high
  • phosphate normal / high
  • calcium normal / low
  • 25 (oh)d normal / low
34
Q

Primary hyperparathyroidism biochemical abnormalities? (2)

A
  • calcium high/very high!
  • PTH very high!
  • fgf 23 normal/ high
  • Alp normal / high
  • phosphate normal / low
  • 25 (oh)d normal / low
35
Q

Which serum tests are often positive in rheumatoid arthritis (2)

A
  • Rheumatoid factor (sensitivity 70%)
  • anti - citrullinated peptide antibodies (ACPAs) (sensitivity 70%, specificity > 95%)
36
Q

Which serum tests are often positive in SLE (6)

A
  • ANA (100%)
  • anti-dsDNA
  • anti-Sm
  • antiphospholipid antibodies
  • low complement C3 = active SLE
  • anti-histone antibody = drug induced lupus (80%)
37
Q

Which serum tests are often positive in systemic sclerosis (2)

A
  • Anti-topoisomerase - 1 (anti scl - 70 ) (15%)
  • anti-rna polymerase (15%)
  • Anti-centromere antibody= localised cutaneous systemic sclerosis (sensitivity 60%,specificity 98%)
38
Q

Which serum antibody tests are often positive in polymyositis, dermatomyositis

A
  • anti-JO-1 (anti - histidyl - trna synthetase) (20-30%)
  • Anti-mi-2
39
Q

Which serum antibody tests are often positive in Sjogren’s syndrome

A
  • Anti-la antibody (anti-ss-b) (60%)
  • anti-ro antibody (anti-ss - A) (40 - 80%)
40
Q

Most common site gout?

A

First metatarsophalangeal joint

41
Q

Most common site pseudogout?

A

CPPd crystal
Hand/ wrist,ankle, knee or hip

42
Q

Name 5 joint features of osteoarthritis

A
  • dip
  • pip
  • first CMC joints
  • knees, hips, back, neck
  • Heberden’s nodes (dip )
  • Bouchard’s nodes (pip)
43
Q

Name 4 causes back pain

A
  • Mechanical: soft tissue
  • destructive: malignancy, infection,
  • inflammatory: axial spondyloarthritis, psoriatic spondyloarthritis
  • other: #, prolapsed disc, spinal stenosis, Paget’s disease,
44
Q

Name 5 NSAIDs

A
  • Celecoxib (low risk gi bleed ) (selective cox 2 inhibitor)
  • etoricoxib (low risk gi bleed )
  • ibuprofen ( medium risk gi bleed ) (non-selective Cox inhibitor)
  • diclofenac ( medium risk gi bleed )
  • indomethacin ( high risk gi bleed )
45
Q

Name 5 dmards for ra

A
  • Methotrexate 10 - 25 mg weekly po (monitor FBC, lft)
  • sulfasalazine 2-4 g daily
  • hydroxychloroquine (monitor visual function)
  • gold / myocristin 50 mg 4 weekly IM (monitor FBC, urinalysis )
  • ciclosporin A (monitor bp, egfr )
46
Q

Name 4 dmards for SLE

A
  • Hydroxychloroquine 200-400 mg daily po
  • azathioprine 1 - 2,5 mg /kg daily orally (monitor FBC, LFT)
  • cyclophosphamide (monitor FBC, LFT,eGFR)
  • mycophenolate mofetil (mmf) (monitor FBC, LFT)
47
Q

Which is the only dmard used for both ra and SLE

A

Hydroxychloroquine

48
Q

Name 3 biological drugs for ra

A
  • Rituximab
  • etanercept
  • abatacept
49
Q

Name biological drugs for SLE

A

Belimumab

50
Q

Name 3 systemic signs rheumatoid arthritis

A
  • fever!
  • weight loss
  • fatigue
  • susceptible to infection
51
Q

Name 3 haem signs rheumatoid arthritis

A
  • Thrombocytosis
  • anaemia
  • eosinophilia
52
Q

Name 4 ocular signs rheumatoid arthritis

A
  • scleritis
  • episcleritis
  • scleromalacia
  • keratoconjunctivitis sicca (sjogrens - dry eyes)
53
Q

Name 5 pulmonary manifestations of rheumatoid arthritis

A
  • effusion
  • fibrosing alveolitis
  • obliterative bronchiolitis
  • Nodules
  • Caplan’s syndrome
54
Q

Name 2 nodular manifestations of rheumatoid arthritis

A
  • Elbows
  • lungs

→ sinuses, fistulae

55
Q

Name 3 neurological manifestations of rheumatoid arthritis

A
  • Peripheral neuropathy
  • cord compression
  • mononeuritis multiplex
56
Q

Name neoplastic manifestations of rheumatoid arthritis

A

Lymphoma

57
Q

Name 2 lymphatic manifestations of rheumatoid arthritis

A

Hepatosplenomegaly
Felty’s syndrome

58
Q

Name 5 cardiac manifestations of rheumatoid arthritis

A
  • Effusion
  • carditis: myo, endo, peri
  • conduction defects
  • coronary vasculitis
  • granulomatous aortitis
59
Q

Name 6 musculoskeletal manifestations of rheumatoid arthritis

A
  • Raynaud
  • carpal tunnel
  • osteoporosis
  • bursitis
  • Muscle wasting
  • tenosynovitis
60
Q

Name vascular manifestations of rheumatoid arthritis

A

Vasculitis leading to:

  • digital arteritis
  • ulcers
  • pyoderma gangrenosum
  • mononeuritis multiplex
  • visceral arteritis
61
Q

Name 10 symptoms fibromyalgia

A

Common:

  • widespread pain, unresponsive to NSAIDs, analgesics, physio
  • fatigueability
  • disability
  • broken, non-restorative sleep (amitryptilline to treat)
  • low affect, irritability, poor concentration

Variable locomotor symptoms

  • early morning stiffness
  • feeling Of swelling in hands
  • distal finger tingling

Additional variable non-locomotor symptoms

  • non-throbbing bifrontal tension headache
  • colicky abdominal pain, bloating, IBS
  • irritable bladder
  • allodynia: hyperacusis, dyspareunia, discomfort when touched
  • frequent side effects with drugs
62
Q

Describe the European league against rheumatism ELAR / American college of rheumatology ACR 2010 criteria for diagnosis of rheumatoid arthritis

A

Joints affected (0-5)

  • 1 large (score o)
  • 2-10 large (1)
  • 1-3 small (2)
  • 4-10 small (3)
  • > 10 joints, with at least 1 small (5)

Serology (0-3)

  • negative rf and ACPA (o)
  • low positive rf or ACPA (2)
  • high positive rf or ACPA (3)

Duration of symptoms

  • <6 weeks (o)
  • > 6 weeks ( 1 )

Acute phase reactants

  • Normal crp+esr (o)
  • abnormal CRP / ESR (1)

Score 6 or more = definite RA.

63
Q

What is used to monitor rheumatoid disease activity

A

DAS28 (disease activity score 28):

  • count swollen joints
  • count tender joints
  • measure ESR
  • note patient global health assessment (1-100)

Internal Medicine (20 decks)

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