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Finals > Rheumatology > Flashcards

Rheumatology Flashcards

1
Q

What joints are commonly affected in osteoarthritis?

A

Hips, knees, DIP and PIP joints in hands, CMC joint at the base of the thumb, lumbar spine, cervical spine

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2
Q

What are some risk factors for developing osteoarthritis?

A

Obesity, age, occupation, trauma, female, family history

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3
Q

What x-ray findings are consistent with osteoarthritis?

A

Loss of joint space, osteophytes, subarticular sclerosis, subchondral cysts

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4
Q

Where are Heberden’s nodes and Bouchard’s nodes found?

A

Heberden’s = DIP
Bouchard’s = PIP

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5
Q

How long can morning stiffness last in those with osteoarthritis?

A

<30 minutes

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6
Q

How is osteoarthritis diagnosed?

A

Clinical diagnosis if patient is over 45, pain with activity and morning stiffness <30 minutes

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7
Q

How is osteoarthritis managed?

A

Therapeutic exercise, weight loss, physio

Topical NSAIDs = 1st line
Oral NSAIDs + PPI if more severe

Paracetamol and weak opiates are only recommended for short term infrequent use

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8
Q

What pattern of arthritis is seen in RA?

A

Symmetrical polyarthritis that tends to affect small joints

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9
Q

What are the risk factors for RA?

A

Female, middle age, smoking, obesity, family history (HLA DR4)

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10
Q

What antibodies are associated with RA?

A

Rheumatoid factor and anti-CCP

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11
Q

What is the classic presentation of someone with RA?

A

Pain and stiffness especially in morning >1 hour, symptoms are worse with rest and improve with activity, may have associated systemic symptoms

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12
Q

What is palindromic rheumatism?

A

Self-limiting episodes of arthritis affecting a few joints which last a few days and then completely resolve, joints appear normal between episodes

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13
Q

What hand signs are associated with severe RA?

A

Z shaped deformity of thumb, swan neck deformity, boutonniere deformity, ulnar deviation of the fingers at the MCP

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14
Q

What is atlantoaxial subluxation?

A

Occurs in the cervical spine due to RA, subluxation can cause spinal cord compression and is an emergency

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15
Q

What are some extra-articular manifestations of RA?

A

Pulmonary fibrosis, Felty’s syndrome, Sjogren’s syndrome, dry eye, episcleritis, scleritis, rheumatoid nodules, carpal tunnel, caplan syndrome

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16
Q

When should you do an urgent referral to rheumatology for query RA?

What symptoms

A

Persistent (few weeks) synovitis where there is no other clear cause - arrange baseline bloods and NSAIDs in meantime

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17
Q

What X-ray findings are associated with RA?

A

Periarticular osteopenia, bony erosions, soft tissue swelling, joint destruction and deformity

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18
Q

What is the initial management of RA?

A

Short term steroids are used in conjunction with DMARDs at beginning due to having a quicker effect

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19
Q

What DMARDs are most commonly used in RA?

A

Methotrexate = 1st line
Lefluonomide, sulfasalazine are alternatives

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20
Q

What medication is used to treat RA that is mild or during pregnancy?

A

Hydroxychloroquine

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21
Q

What gene is associated with spondyloarthropathies?

A

HLA B27

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22
Q

What extra-articular manifestations are common in psoriatic arthritis?

A

Uveitis and IBD

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23
Q

What pattern of arthritis is the most common in psoriatic arthritis?

A

Asymmetrical polyarthritis or very similar to RA (symmetrical polyarthritis)

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24
Q

What hand and nail signs can occur in psoriatic arthritis?

A

Nail pitting, onycholysis, subungual hyperkeratosis, nail ridging, dactylitis, enthesitis

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25
Q

What x-ray findings are associated with psoriatic arthritis?

A

Periostitis, ankylosis, osteolysis, dactylitis, pencil in cup appearance

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26
Q

What can be used to manage psoriatic arthritis?

A

DMARDs such as methotrexate, anti-TNF medications, usetkinumab

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27
Q

What pattern of arthritis is seen in reactive arthritis?

A

Acute monoarthritis - most commonly knee

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28
Q

What are the common triggers for reactive arthritis?

A

Chlamydia, gastroenteritis

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29
Q

What are the common features of reactive arthritis?

A

Bilateral conjunctivitis, hot swollen and painful joint, anterior uveitis, urethritis, fever, fatigue

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30
Q

What investigations need to be done in someone with reactive arthritis?

A

Synovial fluid for MC+S (high WBC but will not culture anything), blood cultures, stool sample and STI testing to look for source

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31
Q

What is the management of reactive arthritis?

A

Treatment of the triggering infection, NSAIDs, steroid injection into affected joint

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32
Q

Which joints are affected in ankylosing spondylitis?

A

Spine and sacroiliac joints

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33
Q

What is the typical presentation associated with ankylosing spondylitis?

A

Young adult male in their 20s, gradual onset of symptoms, pain and stiffness in lower back worse with rest and improves with movement, SOB due to restricted chest wall movement

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34
Q

What diseases are associated with ankylosing spondylitis?

A

Anterior uveitis, aortic regurgitation, AV block, atypical lung fibrosis, anaemia of chronic disease, IBD, achilles tendinopathy

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35
Q

What test can be used to diagnose ankylosing spondylitis?

A

Schober’s test - two lines 15cm apart, bend forward should be at least 5cm improvement (20cm)

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36
Q

What do X-rays show in ankylosing spondylitis?

A

Bamboo spine, squaring of the vertebral bodies, subchondral sclerosis and erosions, syndesmophytes, ossification and fusion of facets

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37
Q

What is the most useful investigation for ankylosing spondylitis?

A

MRI spine as can show bone marrow oedema early in disease before there are XR changes

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38
Q

What is the management for ankylosing spondylitis?

A

Physio and mobilisation
1st line = NSAIDs
2nd line = anti-TNF e.g. adalimumab

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39
Q

What is the presentation for septic arthritis?

A

Rapid onset of hot/red/swollen/painful joint, fever, lethargy, limp, refusal to weight bear

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40
Q

What are the most common organisms for septic arthritis?

A

Staph aureus (most common), neisseria gonorrhoea, H.influenza, E.coli

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41
Q

What is the management for septic arthritis?

A

Joint aspiration for MC+S, empirical IV antibiotics for 4-6 weeks then oral (IV flucloxacillin = usual 1st line)

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42
Q

What antibodies are associated with SLE?

A

Anti-nuclear antibodies, anti-dsDNA are highly specific

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43
Q

What symptoms are associated with SLE?

A

Non-specific symptoms, joint pain, symmetrical small joint arthritis, photosensitive malar rash, lymphadenopathy, mouth ulcers, Raynaud’s phenomenon

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44
Q

What investigations are done in those with SLE? (not including autoantibodies)

A

FBC - anaemia of chronic disease
CRP and ESR
Urinalysis and urine PCR - lupus nephritis will –> proteinuria
Renal biopsy

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45
Q

What complications can occur due to SLE?

A

CVD, infections, anaemia, pericarditis, pleuritis, ILD, lupus nephritis, neuropsychiatric SLE, recurrent miscarriage, VTE

46
Q

What is the management of SLE?

A

1st line = hydroxychloroquine, NSAIDs, steroids

If resistant or more severe DMARDs and biologics can be used

47
Q

What are gouty tophi?

A

SC deposits of uric acid that typically affect the small joints of hands/elbows/ears, usually result of poorly controlled long term gout

48
Q

What are the risk factors for gout?

A

Male, obesity, high purine diet (meat and seafood), alcohol, diuretics, existing CKD, family history

49
Q

What joints are commonly affected in gout?

A

Base of big toe (MTP), wrist, base of thumb

50
Q

What crystals are found in aspiration of fluid from the joint in gout?

A

Negatively birefringent needle shaped crystals made from monosodium urate

51
Q

What X-ray findings are seen in gout?

A

Joint space maintained, lytic lesions in bone, punched out erosions with sclerotic borders and overhanging edges

52
Q

How is an acute flare of gout managed?

A

NSAIDs = 1st line
Colchicine = 2nd line
Steroids = 3rd line

53
Q

What prophylaxis can be given to patients to prevent further gout attacks?

A

Allopurinol 100mg (once acute attack has settled) + lifestyle changes

54
Q

Which joints are commonly affected in pseduogout?

A

Knee, shoulder, wrist and hips

55
Q

What will be seen on synovial fluid aspiration in psuedogout?

A

Positive birefringent rhomboid shaped calcium pyrophosphate crystals

56
Q

What are the X-ray changes associated with pseudogout?

A

Chondrocalcinosis (calcification of cartilage), loss of joint space, osteophytes, subarticular sclerosis, subchondral cysts

57
Q

What can be done to manage pseudogout?

A

NSAIDs, colchicine, steroid injections, if severe washouts can be offered

58
Q

What are the risk factors for osteoporosis?

A

Older age, post menopausal females, reduced mobility and activity, RA, alcohol and smoking, long term steroids, SSRIs/PPIs/anti-oestrogens

59
Q

What does the FRAX tool or new fracture tool measure?

A

Predicts the risk of fragility fracture over the next 10 years - <10% is low risk, high risk if >10%

60
Q

What does a DEXA scan do?

A

Measures bone mineral density

61
Q

What is a Z score?

A

Represents the number of standard deviations the patient’s bone density falls below the mean for their age

62
Q

What is a T score?

A

T score represents the number of standard deviations below the mean for a healthy young adult

63
Q

What T score represents osteopenia and osteoporosis?

A

-1 to -2.5 = osteopenia
<-2.5 = osteoporosis

64
Q

When should the FRAX tool be used?

A

Women aged >65, men aged >75, younger patients with risk factors

65
Q

What should be done based on the risk calculated from the FRAX tool?

A

Low risk - reassure
Intermediate risk - offer DEXA and recalculate
High risk - offer treatment without DEXA

66
Q

What is the management of osteoporosis?

A

Vitamin D and calcium, bisphosphonates (denosumab is alternative), lifestyle advice

67
Q

What are the side effects of bisphosphonates?

A

Reflux and oesophageal erosions, atypical fractures, osteonecrosis of the jaw and external auditory canal

68
Q

How often should DEXA scans be repeated?

A

If low risk every 5 years
If on bisphosphonates every 3-5 years and treatment holiday can be considered

69
Q

What are the presenting features of GCA?

A

Unilateral headache, severe pain around temple/forehead, scalp tenderness, jaw claudication, visual changes

70
Q

What investigations can be performed to confirm diagnosis of GCA?

A

Raised inflammatory markers, temporal artery biopsy

Gold standard = temporal artery USS (shows halo sign)

71
Q

What is the management for GCA?

A

Prednisolone 40-60mg
IV methylprednisolone if visual changes

Steroids continued for 1-2 years

72
Q

What joints are affected in polymyalgia rheumatica?

A

Shoulder, pelvic girdle and neck

73
Q

What are the symptoms of polymyalgia rheumatica?

A

Pain and stiffness in shoulder, pelvic girdle and neck (muscle aches)

Symptoms worse in morning/after rest and interfere with sleep

Systemic symptoms

74
Q

What investigations are done in those with polymyalgia rheumatica?

A

Raised ESR and CRP

Done to rule out differentials only - clinical diagnosis and based on response to steroids

FBC, U+Es, LFTs, calcium, TFTs, serum electrophoresis, CK, antibodies for RA and SLE

75
Q

What is the management of polymyalgia rheumatica?

A

15mg prednisolone daily with follow up 1 week later - will have dramatic response

Steroids continued for 1-2 years

76
Q

What is the presentation of discoid lupus erythematosus?

A

Photosensitive lesions on face, scalp and ears - dry, red and scaly

Scarring alopecia

77
Q

What is the management of discoid lupus erythematosus?

A

Sun protection, topical steroids, hydroxychloroquine

78
Q

What antibodies are associated with Sjogren’s syndrome?

A

Anti-Ro and anti-La

79
Q

What are the symptoms of Sjogren’s syndrome?

A

Dry mouth, eyes and vagina

80
Q

What test can be used to help aid diagnosis of Sjogren’s?

A

Schirmer test - filter paper in eye <10mm = significant

81
Q

What is the management for Sjogren’s syndrome?

A

Artificial tears, artificial saliva, vaginal lubricants, pilocarpine can be used to stimulate tear and saliva production

82
Q

What is the difference between scleroderma and systemic sclerosis?

A

Scleroderma is a localised version of systemic sclerosis that only affects the skin whereas systemic sclerosis affected other organs as well

83
Q

What does CREST stand for in CREST syndrome/limited cutaneous systemic sclerosis?

A

Calcinosis
Raynaud’s phenomenon
Oesophageal dysmotility
Sclerodactyly
Telangiectasia

84
Q

What can be used to treat raynaud’s and what makes the symptoms worse?

A

Nifedipine can be used to treat

Beta blockers can worsen the symptoms

85
Q

What antibodies are associated with systemic sclerosis?

A

ANA, anti-centromere, anti-Scl-70

86
Q

What is the management of systemic sclerosis?

A

DMARDs and biologics can be used in widespread disease

Physio and OT

87
Q

Whats the difference between polymyositis and dermatomyositis?

A

Dermatomyositis involves characteristic skin changes - Gottron papules and heliotrope rash around eyelids - where polymyositis has no skin involvement

88
Q

What are the symptoms of polymyositis and dermatomyositis?

A

Gradual onset, symmetrical proximal muscle weakness causing difficulties standing from a chair, climbing stairs or lifting overhead

89
Q

What test is done in dermatomyositis/polymyositis?

A

Creatine kinase will be significantly raised

Electromyography, muscle biopsy and MRI may also be done

90
Q

What antibodies are present in polymyositis?

A

Anti-Jo-1

91
Q

What is the management for polymyositis/dermatomyositis?

A

Corticosteroids = 1st line
Alternatives = methotrexate, IV immunoglobulins and biologic therapy

92
Q

What are the symptoms of fibromyalgia?

A

Chronic pain at multiple sites not commonly affected with pain, lethargy, cognitive impairment, sleep disturbance, headaches, dizziness

93
Q

What is the management of fibromyalgia?

A

MDT approach - aerobic exercise, CBT, pregabalin, duloxetine, amitriptyline

94
Q

What is osteomalacia?

A

Defective bone mineralisation causes soft bones due to insufficient vitamin D (rickets in children)

95
Q

Why does low vitamin D lead to poor bone mineralisation?

A

Low vitamin D leads to low serum calcium and phosphate due to poor absorption from kidneys and poor bone turnover

96
Q

What is the bone profile of someone with osteomalacia?

A

Low calcium, low phosphate, high ALP, high PTH

97
Q

What is the management for osteomalacia?

A

Cholecalciferol - loading regime (4000IU daily) and then maintenance dose (800-2000IU)

98
Q

What is Paget’s disease?

A

Paget’s disease of the bone involves excessive bone turnover due to increased osteoclast and osteoblast activity which leads to patchy areas of high density and low density bones

99
Q

What is the presenting features of Paget’s disease?

A

May be asymptomatic, bone pain, bone deformity, fractures, hearing loss

100
Q

What can be seen on x-ray in someone with Paget’s disease?

A

Osteoporosis circumscripta, cotton wool appearance of skull, V-shaped osteolytic defects

101
Q

What is the management for Paget’s disease?

A

Bisphosphonates - check ALP levels for monitoring (should normalise)

102
Q

What is HSP, how does it present and how is it treated?

A

IgA small vessel vasculitis, presents with purpura, joint pain, abdominal pain and IgA nephritis, management is supportive

103
Q

What is microscopic polyangitis and how does it present?

A

Small vessel vasculitis, causes renal failure due to glomerulonephritis and diffuse alveolar haemorrhage causing haemoptysis

104
Q

What is granulomatosis with polyangitis and how does it present?

A

Small vessel vasculitis that affects the lungs and kidneys leads to cough, wheeze, haemoptysis and glomerulonephritis

105
Q

What is eosinophilic granulomatosis with polyangitis and how does it present?

A

Small vessel vasculitis that primarily affects the lungs and skin, presents with severe asthma in middle age

106
Q

What is polyarteritis nodosa and how does it present?

A

Medium vessel vasculitis that leads to renal impairment, hypertension, tender erythematous skin nodules, MI, stroke

107
Q

What is Kawasaki disease, how does it present and what is the management?

A

Medium vessel vasculitis that affects children under 5, presents with high fever (>5 days), widespread rash, skin peeling of the palms and soles, bilateral conjunctivitis and a strawberry tongue, treatment is with aspirin and IV immunoglobulins

108
Q

What is takayasu’s arteritis, how does it present?

A

Large vessel vasculitis that affects aorta and its branches, these vessels can swell and form aneurysms or becomes narrows and blocked, presents with fever, malaise and claudication

109
Q

What are the symptoms of Ehlers-Danlos?

A

Hypermobility, joint pain, easy bruising, poor wound healing, chronic pain, headaches, POTS, GI reflux, IBS, period issues, urinary incontinence, TMJ dysfunction

110
Q

Why are those with dermatomyositis/polymyositis screened for malignancy?

A

Dermatomyositis is commonly a paraneoplastic syndrome

111
Q

What are the blood test findings of someone with Paget’s disease?

A

An isolated rise in ALP

112
Q
A

Finals (21 decks)

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