Rheumatology Flashcards
1
Q
What need to take alongside methotrexate
A
Folic acid- taken weekly at least 24 hours after methotrexate dose
2
Q
What drugs avoid if on methotrexate
A
Trimethoprin and co-trimoxazole as increases risk of BM aplasia
Aspirin as increases risk of toxicity
3
Q
Treatment of methotrxate toxicity
A
Folinic acid
4
Q
Side effects of methotrexate
A
Myelosuppression
Liver fibrosis
Pulmonary fibrosis
Pneumonitis
Mucositis
5
Q
Antibody for limited cutaneous systemic sclerosis
A
Anti-centromere
6
Q
Antibody for diffuse cutaneous systemic sclerosis
A
Anti-scl-70
7
Q
Rfx for pseudogout
A
Haemochromatosis
Hyperparathyroidism
Acromegaly
Wilsons
8
Q
What are pseudogout crystals made of
A
Calcium pyrophosphate
9
Q
Management of pseudogout
A
Do aspiration of fluid to exclude septic arthritis
NSAIDS
If severe can do intra-articular or oral steroids
10
Q
Joint aspiration of pseudogout
A
Positive birefringence rhomboid shaped crystals
11
Q
Reactive arthritis presentation
A
4 weeks post STI
Asymmetrical oligoarthritis of lower limbs
Urethritis
Conjunctivitis or anterior uveitis
Skin changes- circinate balanitis, keratoderma blenorrhagica
12
Q
Skin changes in reactive arthritis
A
circinate balanitis
keratoderma blenorrhagica
13
Q
Lateral epicondylitis presentation
A
Pain and tenderness over lateral epicondyle
Pain worse on extension of wrist against resistance with elbow extended or supination or wrist
14
Q
When may not need a DEXA scan to diagnose osteoporosis
A
Someone aged over 75 with a fragility fracture
15
Q
First line for osteoporosis
A
Alendronate and calcium/vitamin D supplements if intake not satisfactory
16
Q
Management options for osteoporosis
A
All patients will receive a bisphosphonate and calcium/vitaminD replacement if intake not satisfactory. Women can start HRT if want
Second line options include other bisphosphonates- risedronate or etidronate
Third line options- strontium or raloxifene
4th line denosumab
17
Q
If do not tolerate alendronate then what are second line bisphonates available
A
risedronate or etidronate
Have to have a lower T score to warrant (much stricter)
18
Q
Third line options for osteoporosis
A
Raloxifene
Strontium ranelate
19
Q
MOA of raloxifene
A
Selective oestrogen receptor modulator
20
Q
Risks of raloxifene
A
Increased VTE risk
21
Q
How is denosumab given
A
Subcut injection every 6 months
22
Q
Which bones does pagets affect
A
Skull
Spine
Pelvis
Long bones
23
Q
What causes a V shaped osteolytic lesion
A
Pagets
24
Q
Typical presentation of pagets
A
Bone pain
Pathological fracture
Bossing of skull
Deafness
25
Complications of pagets
Deafness
Sarcoma
Fractures
High output heart failure
26
Management of pagets
Bisphosphonate
27
MOA of bisphosphonates
Inhibit osteoclasts
28
Side effects of bisphosphonates
Osteonecrosis of jaw
Oesophagitis if do not drink enough water
Acute phase reaction
29
What must do before giving bisphosphonate
Correct vitamin D or calcium deficiency
30
When is only time give calcium in osteoporosis
If not enough dietary intake
31
What should all patients with osteoarthritis do
Local muscle strengthening and weight loss
32
2nd line for osteoarthritis
Oral NSAID and PPI
33
What can be used if analgesia unsuccessful for OA
Intrarticular steroids injections
34
What is it after starting bisphosphonate develop fever, myalgia and N&V
Acute phase reaction- normal
35
What is main precipitating factor for polyarteritis nodosa
Hep B
36
PAN presentation
Fever
Weight loss
Renal failure signs
Livedo reticularis
37
Rfx for osteoporosis
CKD
Endocrine disorders- most
Cancer
Malabsorption
38
Non antibody blood findings of SLE
ESR up
CRP can be normal
Low complement levels in active disease
39
What gel and coombs is contact dermatitis
IV
40
Management of PMR
Prednisolone
41
What is response of PMR to prednisolone
Very good- if no response then consider other diagnoses
42
Presentation of PMR
Older demographic
Rapid onset within 1 month
Aching and morning stiffness in proximal limb muscles
(weakness not a sx)
Can also get depression, fatigue, low grae fever
43
Investigation results for PMR
ESR and inflam markers up
CK normal
EMG normal
44
What needs to be monitored when on hydroxychloroquine
Visual acuity as it causes retinopathy (bulls eye)
45
RA X ray findings
Periarticular erosions
Lossof joint space
Subluxation
Juxta articular osteoporosis
46
What must do if likely to take steroid over 3 months
Take a bisphsophonate
47
Main side effect of colchicine
Diarrhoea
48
Stills disease presentation
Cyclical fever worse in evening
Salmon pink rash
Lymphadenopathy
49
What is classical blood finding in stills disease
Raised ferritin
50
Which DMARDS can take in pregnancy
Hydroxychloroquine
Azathioprine
Sulfasalazine
51
What is bamboo sign seen in
Ank spond
52
Best rule out test for SLE
ANA
53
Management of discoid SLE
Topical steroid cream
2nd line- hydroxychloroquine
54
Management of reactive arthritis
Start NSAID and rheum referral
55
What must do in all cases of dermatomyositis or polymyositis
Do a malignancy screen
56
What is rash that spares nasolabial folds
Malar rash
57
What is seen on early x ray of ank spond
Evidence of sacroiliitis- subchondral erosions and sclerosis
Squaring of vertebrae
58
First line for ank spond
NSAID and regular- exercise like swimming
Physio also recommended
59
Presentation of psoriatic arthritis
Most common- symmetric polyarthritis similar to RA
Asymmetrical oligoarthritis affecting hands and feet
Sacroiliitis
DIP joint disease
Arthritis mutilans
60
What should be given to patients with persistent very severe ank spond
Anti-TNF such as adalimumab and etanercept
61
What is pencil and cup deformity seen on x ray in
Psoriatic arthritis- describes periarticular erosions
62
How do schobers test
Identify L5
Mark 10 cm above and below this point
Ask to bend forward and touch toes with straight knees
Remeasure distance between points and if doesnt increase by 5 then indicative of reduced lumbar flexion
63
What demotes a positive schobers
Less than 5cm
64
Extra articular features of psoriatic arthritis
Skin lesions
Enthesitis
Dactylitis
Nail changes
65
What is management of psoriatic arthritis
Managed by rheumatologist
If mild -NSAID
More moderate/severe then methotrexate
Can consider ustekinumab (IL-12 and IL-23) or secukinumab (IL-17)
66
What is the underlying pathophysiology in GCA retinopathy
Anterior ischaemic optic neuropathy
67
How does aspirate appear in RA
Yellow and cloudy
68
What is main Ig in breast milk
IgA
69
Most common causes of drug induced lupus
Procainamide
Hydralazine
Isoniazid
Phenytoin
70
How manage drug induced lupus
Stopping the drug normally eradicates sx
71
What is cause if develop tingling, muscle aches and N&V after starting a bisphosphonate
Underling vitamin D or calcium defic which has been exacerbated by taking bisphosphonate
72
What is the Z score from DEXA scan adjusted for
Age
Gender
Ethnicity
73
How differentiate pseudogout from gout on X ray
Chondrocalcinosis in pseudo
Also can see same changes as in OA
74
Most common site of septic arthritis in adults
Knee
75
How monitor RA treatment
CRP
Disease activity score- DAS28
76
What is first line for RA
DMARD and short course of bridging prednisolone due to DMARD taking time to taking effect
77
First line DMARD options for RA
Methotrexate
Sulfasazine
Leflunonamide
78
How manage a RA flare
IM methylprednisolone
OR
Oral corticosteroids
79
When can start biologics in RA
Failed response to 2 DMARDS
80
What biologics recommended currently for RA
TNF inhibitors
- etanercept
- infliximab
- adalimumab
81
How does methotrexate pneumonitis present
Fever
SOB
Cough
82
What HS type is SLE
III
83
Most common SE of bisphosphonates
Dyspepsia from oesophageal ulcers and oesophagitis
84
Skin features of dermatomyositis
Photosensitive rash
Heliotrope rash in periorbital area
Gottrons papules on extensor surface of hands
85
MOA of sulfasalazine
5-ASA
86
Side effects of sulfasalazine
Oligospermia
SJS
Pneumonitis
87
Management of raynauds
Refer to rheumatology
First line: CCB nifedipine
88
What can do if no response to nifedipine in raynauds
IV prostacyclin which can last weeks/months
89
What does T score of -2.5 mean
Bone density of 2.5 standard deviations below that of average healthy young adult
90
Management principles of SLE
NSAIDs
Sunblock
91
Management of SLE if internal organ involvement
Prednisolone
Cyclophosphamide
92
Gout X ray findings
Tophi
Joint effusion
Punched out erosions
93
X ray skull features in pagets
Thickening
Early on get lytic lesions these then develop into mixed lytic and sclerotic lesions
94
What is the mutation in in marfans
Fibrillin
95
Which wrist movements exacerbate lateral epicondylitis
Supination of wrist
Extension of wrist
96
What do if biopsy for GCA negative
Continue steroids regardless
97
How manage GCA
If eye involvement give IV methylprednisolone and then start high dose prednisolone
Oral prednisolone if no eye involvement
Do BEFORE biposy
Opthalmology review
98
Counselling for taking of bisphosphonate
Swallow with lots of water
Take 30 mins before breakfast
Sit upright for 30 mins after taking
To avoid oesophageal reactions
99
Complications of diffuse systemic sclerosis
Pulmonary fibrosis
Renal disease- severe glomerulonephritis with crises
Hypertension
100
How manage renal disease in diffuse systemic sclerosis
ACEi
101
How does osteomalacia present
Bone pain
Muscle tenderness
Proximal myopathy leading to waddling gait
Easy fractures
102
Which muscles are involved in abduction of arm
First 20 degrees= supraspinatus
Next part= deltoid
103
What is thromboprophylaxis used in anti-phospholipid syndrome
Primary prevention= low dose aspirin
Secondary prevention= lifelong warfarin
104
What is affected in ehlers danlos syndrome
Type III collagen
105
Features of ehlers danlos
Elastic, fragile skin
Joint hypermobility
Easy brusing
Aortic regurg, mitral valve prolapse
Sub arachnoid
106
What is celecoxib
NSAID
107
What type of WCC is seen in RA aspirate
Neutrophils
108
Side effects of azathioprine
Bone marrow depression
Pancreatitis
109
Features of SLE
General features
- fatigue
- fever
- mouth ulcers
- lymphadenopathy
MSK
- arthritis
Cardiovascular
- pericarditis
- myocarditis
Resp
- pleurisy
- fibrosis
Renal
- glomerulonephritis
- proteinuria
Neuropsych
- anxiety and depression
- psychosis
110
Management of fibromyalgia
CBT
Aerobic exercise
Medications- amitriptylline, pregabalin, duloxetine
111
Presentation of fibromyalgia
Chronic pain at multiple sites
Fatigue
Brain fog
112
How diagnose fibromyalgia
Clinical diagnosis using america college of rheum criteria
113
Eye complicatinos of RA
Keratoconjunctivitis sicca most common
Episcleritis and scleritis
114
Cardiac risk of RA
Increased risk of IHD- similar to that of DM
115
Start new drug and develop oral ulcers
Methotrexate due to mucositis
116
How to tell if hip pain is referred from the lumbar spine
Positive femoral nerve stretch
117
Most early x ray finding in RA
Juxta articular osteopenia/porosis
118
What are syndesmophytes seen in
Ank spond
119
If a young male presents with osteoporosis what is important to check
Testosterone
120
What are the 2 types of raynauds
Raynauds disease (primary)
Raynauds phenomena (secondary)
121
Typical presentation of primary raynauds disease
Women under 30
Bilateral disease
122
Causes of secondary raynauds
Connective tissue diseases
Leukaemia
123
What suggests secondary raynauds
Auto-antibodies
Rash
Unilateral
Ulcers
Arthritis
124
Management of sjogrens
Symptomatically
- Artifical tears
- Can use pilocarpine to stimulate saliva production
Hydroxychloroquine if arthritis
125
What connectie tissue diseases are associated with raynauds
Systemic sclerosis
RA
SLE
Sjogrens
126
What is risk of sjogrens
Lymphoma
127
Person on chemo develops acutely painful joint, most likely cause
Gout as chemo increases urate production
128
What medication consider for housebound patients
Vitamin D
129
X ray findings of osteoarthritis
Loss of joint space
Osteophytes
Subchondral cysts
Subchondral erosions
130
Skin finding of behcets
Erythema nodosum
131
Other than shoulders, where else does PMR affect
Hip girdle muscles
132
Presentation of meralgia parasthetica
Burning sensation over antero-lateral aspect of thigh caused by compression of the lateral cutaneous nerve
133
What nerve is affected in meralgia parasthetica
Lateral cutaneous nerve of thigh, comes straight off spinal chord
134
How many different NSAIDs have to be on before trying a TNF alpha inhibitor for ank pond
2 12 weeks apart
135
Arthritis with one very swollen finger
Psoriatic arthritis due to dactylitis
136
When measure urate in a gout attack
2 weeks after inflammation settles as urate levels can be low, normal and high during an attack
137
Poor prognostic factors in RA
Anti- CCP antibodies
Early erosions on X ray
RF positive
HLA DR4
Insidious onset
Extra articulate features like rheum nodules
Poor baseline at presentation
138
What is most important investigation to monitor marfans
Echocardiogram to look for aortic root dilation as predisposes to aortic dissection
139
Features of osteogenesis imperfecta
Pathological fractures
Blue sclera
Hearing loss from otosclerosis
Dental problems
140
How can a RA flare present
Acute worsening of stiffness and pain
Fever
Malaise
141
What does raised CRP in SLE suggest
Underlying infection
142
Which DMARD causes a low sperm count
Sulfasalazine
143
What is chronic fatigue syndrome
Where have excessive tiredness for over 3 months which is debilitating physically and mentally with no obvious cause
144
Features of chronic fatigue syndrome
sleep problems, such as insomnia, hypersomnia, unrefreshing sleep
muscle and/or joint pains
headaches
painful lymph nodes without enlargement
sore throat
cognitive dysfunction- brain fog
physical or mental exertion makes symptoms worse
general malaise
dizziness
nausea
palpitations
145
Management of chronic fatigue syndrome
Refer to CFS specialist for
- CBT
- exercise with expert
- energy management
146
TB drug causing drug induced lupus
Isoniazid
147
What investigation need to do prior to doing surgery on a RA patient
Cervical X rays to rule out atlanto-axial instability
If this was present could lead to cervical compression during ventilation
148
Uses of denusomab
Osteoporosis
Prevention of fractures in bone mets
149
Contraindications for bisphosphonates
Reflux
eGFR<30
150
What can be used to prevent pathological fractures in bony mets
Bisphosphonates
Denusomab
151
What is presentation of trochanteric bursitis
Pain and tenderness over lateral hip/upper thigh
Pain on resisted movement
Can’t lie on it while sleep
In people who overuse legs- runners
Also main demographic is 50-70 year old women
152
X ray finding in psoriatic arthritis
Pencil in cup appearance
Periarticular erosions
153
What is antisynthetase syndrome
Advanced myositis where get fibrosis of the lungs
Additionally can get scleroderma and raynauds
154
Polyarthritis causes
SLE
RA
Seronegative spondyloarthropathies
Sarcoid
TB
HSP
Pseudogout
155
Patient from subcontinent has 3 month history of fever, weight loss and polyarthritis
TB
156
What are codmans triangle and sunburst appearance seen in
Osteosarcoma
157
What is onion skin appearance on x ray
Ewings sarcoma
158
Inheritance of marfans
AD
159
Causes of dactylitis
SCD
Seronegative spondyloarthropathies
- reactive arthritis
- psoriatic arthritis
160
Antibodies seen in myositis'
Anti-jo
ANA
161
What is anti-scl 70 same as
Anti topoisomerase
162
What is the management of reactive arthritis
Analgesia
If refractory use steroids
If persistent can use methotrexate and sulfasalazine
163
What use for NSAID refractory reactive arthritis
Oral pred
164
Which joints most commonly affected in OA of hands
Carpometacarpal
DIP
165
Painful purple lesion on finger of someone with SLE
Oslers nodes
166
Causes of osler nodes
SLE
Endocarditis
Gonorrhoea
Typhoid
Haemolytic anaemia
167
Presentation of osler nodes
Painful purple nodes on fingers
168
First line for RA
Methotrexate with bridging prednisolone
169
Where do majority of shoulders dislocate
Anteriorly
170
Management of shoulder dislocation
Reduction in all cases
If recent then can do without sedation/analgesia
If longer duration then may require analgesia/sedation
171
Presentation of medial epicondylitis
Pain and tenderness in medial epicondyle
Symptoms worsened by wrist pronation and flexion
Numbness and tingling in 4th and 5th fingers as ulnar nerve compression
172
Medial vs lateral epicondylitis
Medial- golfers elbow
Lateral- tennis elbow
173
What is cubital tunnel syndrome
Compression of the ulnar nerve
174
Presentation of cubital tunnel syndrome
Tingling in the 4th and 5th fingers
Worse when resting elbow on a surface
175
What causes tingling/numbness in 4th and 5th fingers after resting elbow on a flat surface
Cubital tunnel syndrome
176
Which movements exacerbate golfers elbow
Wrist flexion and pronation
177
Differential for PMR where have shoulder pain and restricted movement
Supraspinatus tear
178
Characteristics of spondyloarthropathies
Sacroiliitis
Large joint arthritis
Enthesisi
Iritis
Dactylitis
179
Which organisms are associated with reactive arthritis
Shigella
Neisseria
Yersinia
Campylobacter
Chlamydia
180
Which T-score reading is used for FRAX tool
Neck of femur reading
181
Most specific antibody for SLE
Anti-dsDNA
182
What use for osteoporosis if very low eGFR
Denosumab
183
When can consider biologic for RA
Trialled at least 2 DMARDs and still have moderate disease activity
184
Monitoring for methotrexate
FBC, U&Es and LFT every 3 months
185
If no response to NSAIDs for ank spond what use
Adalimumab or secukinumab
186
Dose of pred for PMR
15mg
187
What imaging most indicated to confirm ank spond
MRI whole spine
188
What needs to be given alongside allopurinol when start giving for gout prophylaxis
Low dose allopurinol alongside colchicine to prevent acute flares as allopurinol can precipitate attacks
189
What measure when give allopurinol for gout prophylaxis
Urate levels
190
Most important side effect to warn people about when starting allopurinol
Rash as very common cause of SJS
191
What is alternative to allopurinol in prophylaxis
Febuxostat- also a xanthine oxidase inhibitor
192
What medications may be used for fibromyalgia
Antidepressants
- fluoxetine
- amitryptylline
- duloxetine
193
What biologics use for RA, alternatives to anti-TNF alpha
Anti-IL6
Jak inhibitor
Anti-CD20 (rituximab)
194
What test for pre TNF a inhibitors
HIV
Hep B,C
TB
195
If have anorexia, what is most likely to improve bone density
Putting on weight
Periods returning
196
What happens when stop denosumab
Rebound increase in bone turnover
197
What need to do for patients stopping denosumab
Give bisphosphonates as stopping associated with rebound increased bone turnover
198
Markers of SLE disease activity
Dropping C3 and C4
Raising ESR
Raising dsDNA titre
199
What is p-ANCA actually
Anti myeloperoxidase
200
What is c-ANCA actually
Anti proteinase 3
201
Significance of CRP in SLE vs RA
SLE- not indicator of disease activity, if raised likely to be infectious cause
RA- indicator of disease activity
202
Stepped approach for OA
Topical NSAID
Oral NSAID with PPI
Avoid strong opiates but can use co-codamol if exacerbation
Intrarticular steroids
Joint replacement
203
Ank spond associations
5 A's
AV block
Apical fibrosis
Anterior uveitis
Aortic regurg
Anaemia of chronic disease
204
Spirometry findings of ank spond
Restrictive- most typically due to kyphosis and not fibrosis as a late complication
205
Extra presentations of ank spond
Plantar fasciitis
Vertebral fractures
Chest pain from inflammation from inflammed sternocostal joints
Dactylitis
206
What is discoid lupus erythematosus
Chronic autoimmune skin condition which presents with inflammed, dry and scaly patches plus are highly photosensitive on the face and scalp
207
Chronic effects of discoid lupus erythematosus
Scarring
Hyperpigmentation and hypopigmentation
208
Complications of lupus
Infection risk
CVD risk
Anaemia- from haemolytic anaemia, ACD, kidney disease
Lupus nephritis
Pleuritis and pericarditis
Interstitial lung disease
Neuropsychiatric complications
VTE from recurrent miscarriage
209
What is main course of SLE
Relapsing remitting
210
Most common cause of death in SLE
CVD
211
Management principles of SLE at all times
Hydroxychloroquine
Good sun protection
212
Management of SLE relapses
Steroids
If more severe then DMARDS- methotrexate, mycophenolate motefil, cyclophosphamide
Biologics- rituximab, belimumab
213
Sclerodactyly meaning
Skin tightening around hands which reduces movement and function
214
How does calcinosis appear
White deposits under skin
215
Consequence of oesophageal dysmobility in systemic sclerosis
Dysphagia
Acid reflux
216
How manage GI problems in systemic sclerosis
PPIs for GORD
Metoclopramide helpful for dysphagia
217
Management of systemic sclerosis
Principles around symptom control like CCB for raynauds, metoclopramide for dysmobility
If diffuse disease then consider DMARDs like methotrexate
218
Principle drug management of pulmonary HTN
Bosentan- endothelin receptor antagonists
219
Diagnosing GCA
ESR up
USS will show halo sign where occluded temporal artery
Biopsy diagnostic performed by vascular surgeons
220
Management of myositis
Refer to rheumatology
- do malignancy screen in new cases
- corticosteroids first line
221
Antibodies in APL
Lupus anticoagulant
Anti beta 2 glycoprotein I
Anti cardiolipin
222
Investigations for sjogrens
Schirmers- hold paper under eyelid and assess moisture travel
Antibodies- anti Ro and La
Salivary gland biopsy may be used to confirm diagnosis but not necessary
223
First, 2nd and third line for gout
1st Naproxen
2nd Colchicine
3rd Prednisolone
224
When start allopurinol for gout prophylaxis
Do after even 1 attack
Start a few weeks after attack
225
When taking a bisphosphonate when reassess need
3-5 years
226
When encourage HRT for osteoporosis
If early menopause
227
What are looser zones seen on x ray in
Osteomalacia
228
Osteomalacia management
Just vit D- cholecalciferol
229
First line imaging for ank spond
MRI whole spine
230
What imaging use for RA
USS and MRI will demonstrate inflammation
X rays will show bony changes
