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Integrated Med > Rheumatology > Flashcards

Rheumatology Flashcards

1
Q

Causes of musculoskeletal injuries

A

Contusion: direct blow / compressive force to the muscle

Strain: excessive stretching of the muscles causes microtrauma at the musculotendinous junction

Sprain: excessive stretching / force causing rupture of collagen bundles within a ligament

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2
Q

Clinical features of epicondylitis

A

Gradual onset of
Localised epicondyle pain
Normal passive ROM

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3
Q

Management of epicondylitis

A

Stop exacerbating action

Conservative: NSAIDs, physio, splints, adjuncts
Medical: steroid injection
Surgical: release incision

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4
Q

What is the difference between lateral and medial epicondylitis

A

Lateral (tennis elbow) is inflammation of the common extensor tendon

Medial (golfers elbow) is inflammation of common flexor pronator tendon and ulnar collateral ligament

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5
Q

Peak age of tennis elbow (lateral epicondylitis)

A

40-55

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6
Q

Peak age of golfers elbow (medial epicondylitis)

A

50-60

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7
Q

Risk factors for lateral epicondylitis (tennis elbow)

A

Obesity
Smoking
Carpal tunnel

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8
Q

Risk factors for medial epicondylitis (golfers elbow)

A

Manual work
Sports

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9
Q

Signs / OE lateral epicondylitis (tennis elbow)

A

Tenderness over medial epicondyle
Pain with resisted wrist flexion and pronation +/- cubital tunnel signs

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10
Q

What is de quervains tensynovitis

A

Inflammation of synovial sheaths of thumb tendons

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11
Q

Symptoms of de quervains tensynovitis

A

Pain on radial border of wrist / forearm

Swelling around styloid process of radius

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12
Q

Management of de quervain’s tenosynovitis

A

Rest, splinting and NSAIDs
Local corticosteroid injections
Surgical release of tendon tunnel (if Sx persist)

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13
Q

3 main rotator cuff lesions

A
  1. Tendon tears
  2. Calcific tendinitis
  3. Adhesive capsulitis (frozen shoulder)
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14
Q

Signs and symptoms of tendon tears

A

Weakness and pain on shoulder movement (may disturb sleep)

Reduced ROM active > passive in direction of muscle action

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15
Q

Signs and symptoms of tendon tears

A

Weakness and pain on shoulder movement (may disturb sleep)

Reduced ROM active > passive in direction of muscle action

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16
Q

Management of tendon tears

A

Rest, ice, analgesia
Steroid injections
Physio
Arthroscopic / open surgery: if traumatic tear, if high functional demand, if no improvement in 12w

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17
Q

Pathogenesis of calcific tendinitis

A

Deposits of calcium hydroxyapatite crystals
(30-55y)
F>M

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18
Q

Signs and symptoms of calcific tendinitis

A

Very severe shoulder pain and stiffness +/- brachial plexus neuritis
Loss of ROM (active and passive)

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19
Q

Management of calcific tendinitis

A

Rest and analgesia
Steroid injections
Arthroscopic incision if Sx dont improve

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20
Q

Signs and symptoms of adhesive capsulitis (frozen shoulder)

A

Shoulder pain followed by increasing stiffness (no swelling or crepitus)
Loss of ROM esp external rotation
Normal strength

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21
Q

Management of adhesive capsulitis (frozen shoulder)

A

Analgesia (NSAID) +/- steroid injections
Physio
Arthroscopic release if no improvement in 12w

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22
Q

Risk factors for frozen shoulder

A

Age >40 and female
Following injury / surgery
Shoulder immobility
DM, thyroid disease, CVD, HTN

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23
Q

Symptoms of impingement syndrome

A

Pain on shoulder abduction between 45 and 120 degrees

Pain can be present at night and disrupt sleep
+/- arm weakness

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24
Q

Causes of impingement syndrome

A
  1. Subacromial bursitis - inflammed and swollen so narrows space (injury / overuse)
  2. Supraspinatus tendinitis - inflammed and thickened tendon (injury / overuse)
  3. Acromioclavicular arthritis - bony spurs narrow joint space (age)
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25
Q

Management of impingement syndrome

A

NSAIDs / physio

Steroid injection

Surgical: remove bony tissue

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26
Q

Symptoms of biceps tendon rupture

A

Sudden pop on heavy lifting (pop eye appearance)

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27
Q

Risk factors for biceps tendon rupture

A

Smoking
Steroid use
Elderly

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28
Q

Management of biceps tendon rupture

A

If younger / fit and active: surgery
If older / not fit and active: leave for self resolution -> rest, ice, compression, elevation

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29
Q

Symptoms of greater trochanter pain syndrome

A

Pain over thigh / buttock (worse when lying on side and during exercise)
Localised tenderness to touch
No difficulty putting on shoes / socks

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30
Q

Causes of greater trochanter pain syndrome

A

Gluteal tendinitis / enthesitis
Trochanteric bursitis

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31
Q

Management of greater trochanter pain syndrome

A

2/3 resolve within 1y
Conservative: NSAID, physio, rest
Medical: steroid injection

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32
Q

Cause, symptoms and management of patellar bursitis

A

Cause: prolonged kneeling
Symptoms: localised anterior knee pain and tenderness + fluctuance swelling
Management: avoid kneeling (incision and drainage if infected)

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33
Q

Symptoms of Achilles tendinitis

A

Overuse injury most common in long distance runners

Ache / pain above heel after running / climbing stairs
Morning stiffness

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34
Q

Management of Achilles tendinitis

A

Rest, ice and analgesia
Stretching calf muscles and physio

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35
Q

Symptoms of plantar fasciitis

A

Stabbing pain under heel (worse with first steps after prolonged resting)
Worsened with prolonged standing / exercise

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36
Q

Examination findings with plantar fasciitis

A

Highly localised tenderness at medial tuberosity of calcaneus

Pain exacerbated with active or passive toe dorsiflexion

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37
Q

Management of plantar fasciitis

A

Rest, ice, analgesia (NSAID)
Physio / stretching
Lose weight, change footwear

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38
Q

What is subcalcaneal bursitis

A

Inflammation of bursa between calcaneus and plantar fascia

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39
Q

Symptoms of subcalcaneal bursitis

A

Dull ache under heel that worsens throughout the day

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40
Q

Management of subcalcaneal bursitis

A

Resolves in 6-8w
Rest, ice, analgesia
Comfortable footwear
Orthoptics

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41
Q

Management of subcalcaneal bursitis

A

Resolves in 6-8w
Rest, ice, analgesia
Comfortable footwear
Orthoptics

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42
Q

Management of ankle sprain

A

Rest, ice, compression and analgesia
Early mobilisation and strengthening exercises

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43
Q

Function of menisci

A

Spread load and disperse friction
Inner 75% is avascular so poor healing

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44
Q

Causes of meniscal damage

A

Degenerative tears
Acute tears -> twisting injury

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45
Q

Symptoms of meniscal injuries

A

Pain: intermittent and on knee movement
Locking and giving way
Swelling

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46
Q

What are the ottowa ankle rules to rule out fracture

A

Only X-ray ankle if pain near the malleolus and either
- unable to weight bear immediately after injury and when in ED
Or
Bony tenderness at posterior edge or tip of malleolus

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47
Q

Diagnosis of meniscal knee injuries

A

Hx and examination: Mcmurrays test
X-ray to ro fracture / OA
MRI scan = diagnostic

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48
Q

Management of meniscal knee injuries

A

Arthroscopic repair: if Sx are serious / younger patient
Conservative: activity modification, physio, nsaid (if degenerative tear / OA)

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49
Q

Causes of ligamental injuries of the knee

A

ACL/PCL injuries (rotational injuries when foot is planted eg footballers, skiers)
Isolated PCL injury: RTA (dashboard injury)
Collateral ligament injuries: lateral impact / opposing forces at knee and ankle

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50
Q

Symptoms of ACL / PCL injury

A

Acute swelling (30min) -> hvae to stop activity may be unable to weight bear

Collateral ligament: more insidious swelling

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51
Q

Management of ACL/PCL injury

A

Replacement with hamstring or patellar tendon graft -> dont tend to heal on their own

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52
Q

Management of collateral ligament injury

A

Immobilisation with knee brace and physio

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53
Q

Management of collateral ligament injury

A

Immobilisation with knee brace and physio

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54
Q

Neck and back pain red flags that indicate urgent MRI

A

New onset in <20 or >55
Constant night pain
Progressive motor weakness
Thoracic back pain
Saddle anaesthesia
Bladder / bowel incontinence
Hx of trauma / cancer
Unexplained weight loss
Fever
Steroid use
Recent infection

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55
Q

Structural differentials of neck / back pain

A

Mechanical
Disc prolapse
Spinal stenosis
Spondylolisthesis

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56
Q

Inflammatory differentials of neck / back pain

A

Spondyloarthropathies
Sacroilitis
Polymyalgia rheumatica

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57
Q

Destructive differentials of neck and back pain

A

Malignancy
Infection

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58
Q

Metabolic differentials of neck and back pain

A

Osteoporosis
Osteomalacia
Pagets

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59
Q

Neck and back pain as a result of referred pain locations

A

Major viscera
Uro-genitary
Aorta
Hip

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60
Q

What is a radiculopathy

A

Conditions where pinched nerve roots cause pain, paraesthesia, weakness in a dermatomal distribution (unilateral)

Causes LMN signs (hyporeflexia, hypotonia)

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61
Q

What are myelopathies

A

Conditions where compressed spinal cord causes pain, paraesthesia, weakness bilaterally + other neurological symptoms

  • causes UMN signs (hyperreflexia, hypertonia, spasticity)
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62
Q

What is cervical spondylosis

A

Cervical radiculopathy caused by age related degenerative changes to the spine
- ageing causes disc degeneration which reduces shock absorption
- results in osteophyte development
- osteophytes pinch nerve roots as they leave the spinal canal
May develop into myelopathy

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63
Q

Symptoms of cervical spondylosis

A

Pain in neck (radiating down arm)-> brachial neuralgia
Tingling / numbness in one dermatome
+/- weakness in 1 arm

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64
Q

OE of cervical spondylosis

A

Pain reproduced with lateral neck flexion towards affected side

Motor: modest upper muscle weakness
Sensory: reduced pin prick sensation discrimination
LMN: hyporeflexia, hypotonia

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65
Q

OE of cervical spondylosis

A

Pain reproduced with lateral neck flexion towards affected side

Motor: modest upper muscle weakness
Sensory: reduced pin prick sensation discrimination
LMN: hyporeflexia, hypotonia

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66
Q

Diagnosis of cervical spondylosis

A

Neurological examination: myotomes, dermatomes, reflexes
MRI if no improvement / considering surgery

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67
Q

Management of cervical spondylosis

A

Mostly self limiting in 6-12w
1. Conservative: rest, physio, analgesia
Hard collar for neck immobilisation

  1. Surgical: ACDF (anterior cervical discectomy and fusion)
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68
Q

Who does cervical disc prolapse affect

A

30-40y
Hx of mild neck trauma

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69
Q

Symptoms of cervical disc prolapse

A

Pain in neck
Tingling / numbness / paraesthesia in one dermatome of arm
+/- weakness in one arm

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70
Q

Management of cervical disc prolapse

A
  1. Conservative : rest, physio, analgesia
  2. Surgical: microdiscectomy
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71
Q

What is cervical canal stenosis

A

Cord compression
Is more serious than cervical radiculopathy

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72
Q

What is cervical canal stenosis

A

Cord compression
Is more serious than cervical radiculopathy

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73
Q

Causes of cervical canal stenosis

A

Age related degeneration : osteophyte formation and ligament hypertrophy
Disc bulging / herniation: common in younger patients

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74
Q

Symptoms of cervical canal stenosis

A

Gait abnormalities : spastic and ataxic
Loss of fine motor skills
Tingling in fingers

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75
Q

OE of cervical canal stenosis

A

Gait abnormalities : spastic and ataxic
Wasting on shoulder girdle muscles
UMN signs: spasticity, clonus, hyperreflexia, hypertonia

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76
Q

Management of cervical canal stenosis

A

Surgical intervention: laminectomy -> progressive deterioration

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77
Q

What is hoffman’s sign

A

Flick middle finger and watch for reflexive movement of index / thumb
-> positive in UMN pathology eg spinal cord compression

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78
Q

Pathology of lumbar disc prolapse

A

Common in 25-55y
With age increased risk of prolapse through defect in surrounding annulus fibrosus
Results in compression of nerve roots

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79
Q

Symptoms of lumbar disc prolapse

A

Often onset during lifting / bending / twisting
Stabbing lower back pain radiating down leg / buttock
Numbness / tingling in one leg

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80
Q

OE of lumbar disc prolapse

A

Pain reproduced with straight leg raise
Motor signs: modest lower muscle weakness
Sensory signs : reduced pin prick sensation discrimination
LMN signs : hyporeflexia, hypotonia

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81
Q

Management of lumbar disc prolapse

A

Conservative : rest, physio, analgesia
Surgical: nerve root block, microdiscectomy (remove piece of prolapsed disc)

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82
Q

What is cauda equine syndrome

A

Compression of cauda equine nerve roots causing pain, paraesthesia and weakness

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83
Q

Symptoms of cauda equina syndrome

A

Bilateral and acute onset
Stabbing lower back and leg pain
Lower limb weakness
Bladder / bowel disturbance
Saddle anaesthesia
Sexual dysfunction

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84
Q

Causes of cauda equina syndrome

A

Herniated lumbar disc = most common
Spinal stenosis
Spinal tumour
Spinal infection
Severe injury to lower back
Congenital malformation

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85
Q

Investigations for cauda equina syndrome

A

Lower limb motor function
Lower limb sensory function
Reflexes
DRE -> sphincter tone
Pre and post micturition bladder scan (>200ml)
MRI

86
Q

Management of cauda equina syndrome

A

Immediate referral to neurosurgery
-> urgent decompression eg via discectomy

87
Q

What is lumbar canal stenosis

A

Cauda equina compression causing neurogenic claudication
Usually L4/5 or L5/S1 level

88
Q

Causes of lumbar canal stenosis

A

Age related degeneration: osteophyte formation and ligament hypertrophy
Disc bulging / herniation : consider in younger patients

89
Q

Symptoms of lumbar canal stenosis

A

Hx of back pain -> dermatomal distribution
Leg pain / weakness / heaviness that limits walking distance -> distance progressively decreases

Slowly relieved by rest
Feels better by bending forwards / going uphill

90
Q

What is lumbar spondylosis

A

Stress fractures in pars interarticularis of vertebra (commonly L5)

91
Q

What is spondylolisthesis

A

Slippage of one vertebra on the one below

92
Q

Causes of spondylolisthesis

A

Spondylolysis
Age related degeneration

93
Q

Symptoms of spondylolisthesis

A

Neck / back pain
Radiculopathy

94
Q

Red flag for back pain that could indicate tumour

A

Bony pain over a single spinal segment

95
Q

What is a syringomyelia

A

A fluid filled cyst within the spinal cord

96
Q

Causes of syringomyelia

A

Chiari malformation
Spinal cord tumour
Spinal cord injury
Spinal cord infection eg meningitis

97
Q

Symptoms of syringomyelia

A

Pain and stiffness in neck, shoulder, arms and back
Muscle wasting and weakness
Loss of sensation and reflexes
Painless burning sensation in fingers
Headaches

98
Q

Management of syringomyelia

A

Drain syrinx
Correct underlying cause

99
Q

Initial investigations for rheumatoid arthritis

A

Rheumatoid factor (RF)
Anti cyclic citrullinated peptide antibody - can be detected up to 10yrs before development of RA
X-rays

100
Q

What is high RF levels associated with

A

Severe progressive disease but not a marker of disease activity

101
Q

What other conditions are associated with positive RF

A

Felty’s syndrome
Sjögren’s syndrome
Infective endocarditis
SLE
Systemic sclerosis

102
Q

Presentation of rheumatoid arthritis

A

Swollen painful joints in hands and feet
Stiffness worse in morning
Gradual onset - larger joints become involved
Positive squeeze test - discomfort on squeezing across the metacarpal or metatarsal joints

103
Q

Side effects of methotrexate

A

Myelosuppression
Liver cirrhosis
Pneumonitis

104
Q

Rheumatoid arthritis X-ray changes

A

Loss of joint space
Juxta-articular osteoporosis
Soft tissue swelling
Periarticular erosions
Subluxation

105
Q

Initial therapy for RA

A

Methotrexate (most widely used DMARD) / sulfasalazine / leflunomide

+/- a short course of bridging prednisolone

106
Q

How to manage RA flares

A

Oral or IM corticosteroids

107
Q

Indication for a TNF inhibitor with RA

A

Inadequate response to at least 2 DMARDs including methotrexate

Etanercept / infliximab / adalimumab

108
Q

Ocular manifestations of RA

A

Keratoconjunctivitis sicca
Episcleritis
Scleritis
Corneal ulceration
Keratitis

109
Q

Poor prognostic factors in RA

A

RF positive
Anti CCP antibodies
Poor functional status at presentation
X-ray : early erosions
Extra articular features
HLA DR4
Female

110
Q

Cause of carpal tunnel syndrome

A

Increased pressure on the median nerve as it passes through carpal tunnel at the wrist

111
Q

Risk factors for carpal tunnel syndrome

A

Pregnancy
DM
Thyroid disease
Wrist fracture
Wrist arthritis
Idiopathic

112
Q

Symptoms of carpal tunnel syndrome

A

Tingling / pain / numbness in radial 4 digits (not pinky) - may radiate into forearm
Worse at night
Provoked by gripping
Relieved by shaking hand / dangling over side of bed
May have reduced coordination

113
Q

Management of carpal tunnel syndrome

A

Activity modification
Splint wrist at night
NSAIDs + steroid injection
Optimise underlying conditions eg thyroid
Surgery: if persistent symptoms >6w

114
Q

Benefits of surgery for carpal tunnel syndrome

A

Without it is likely that wasting and numbness will worsen
Surgery should improve tingling / pain but may take 1y
Muscle weakness unlikely to improve but wont worsen

115
Q

Cause of cubital tunnel syndrome

A

Increased pressure on the ulnar nerve at the elbow

116
Q

Symptoms of cubital tunnel syndrome

A

Tingling / pain / numbness in 5th finger -> may radiate into forearm
Exacerbated with prolonged elbow flexion
+/- claw hand

117
Q

Management of cubital tunnel syndrome

A

Similar to carpal tunnel
- activity modification
- splint
- NSAID + steroid injection
- surgery

118
Q

Cause of Morton’s neuroma

A

Inflammatory lesion of digital nerve due to irritation / compression eg wearing tight shoes

119
Q

Symptoms of Morton’s neuroma

A

Pain / burning between toes / ball of foot
Tingling / sensory loss between toes

120
Q

Management of Morton’s neuroma

A

Offloading insoles
Steroid injection
Surgical incision of digital nerve

121
Q

Clinical presentation of fibromyalgia

A

Widespread pain
Fatigue
Unrefreshing sleep

122
Q

Functional illnesses associated with fibromyalgia

A

IBS
Chronic migraine
Chronic pelvic pain
Chronic fatigue syndrome

123
Q

Investigations for fibromyalgia

A

Screen for comorbidities eg depression
Find / rule out underlying causes eg RA

124
Q

Diagnostic criteria for fibromyalgia

A
  1. Widespread pain involving all 4 quadrants of the body
  2. Scoring >7 on the WPI and >5 on SSS or 3-6 on the WPI and >9 on SSS
  3. Present for >3m
125
Q

Management of fibromyalgia

A

Education: reassure, relapsing and remitting, good and bad days, sleep hygiene
Exercise: long term graded exercise programmes
CBT: for pain related depression / anxiety
Pharmacological: sleep low dose TCAs, analgesia

126
Q

Aetiology of gout

A

Pathological reaction of joint / periarticular tissues to monosodium urate monohydrate crystals

127
Q

What is primary gout

A

> 90% due to inherited defect of uric acid secretion
Usually males >40y

128
Q

What is secondary gout

A

Chronic hyperuricaemia due to renal impairment or drug therapy
Mainly >65y and post menopausal women

129
Q

Initial presentation of gout

A

Acute mono arthritis in distal joint
- sudden pain with red, hot, swollen joint
- often wakes patient early in the morning
+/- fever / malaise

130
Q

Presentation of untreated gout

A

Recurrent attacks with reducing time between
- progressive cartilage and bone erosion
- inflammatory polyarthritis in feet / hands / wrists
- deposition of palpable masses of urate crystals

131
Q

Risk factors for primary gout

A

Male
Age
FH
Metabolic syndrome: TGs, obesity, HTN, DM
High alcohol intake
High protein diet

132
Q

Risk factors for secondary gout

A

Reduced excretion: CKD, thiazide diuretics, NSAIDs, cytotoxic drugs

Increased production: myeloproliferative disorders

133
Q

Aetiology of pseudo gout

A

Calcium pyrophosphate crystal deposition
Mainly idiopathic
Can be caused by: OA, trauma, dehydration, inherited metabolic disorder

134
Q

Presentation of pseudogout

A

Usually asymptomatic: incidental finding of chondrocalcinosis on X-ray
Acute attack: similar symptoms to gout mainly in knee

135
Q

Aetiology of calcific periarthritis

A

Hydroxyapatite deposition in periarticular tissues (muscles, cartilage etc)

136
Q

Presentation of calcific periarthritis

A
  1. Acute attack: spontaneously or following trauma: pain and tenderness, swelling and erythema
137
Q

Diagnosis of crystal arthropathies (gout)

A
  1. Joint aspiration for polarised light microscopy
  2. Serum urate levels
  3. Determine cause
  4. Consider X-ray
138
Q

Management of crystal arthropathies (acute attack)

A

Do not start allopurinol until acute attack has resolved
Pain relief: fast acting oral NSAIDs
Stop attack: joint aspiration and intra articular steroid injection

139
Q

Long term management of gout

A

Aim to lower serum urate <360Umol /L
1st: Allopurinol OD
2nd: febuxostat (avoid in CVD)
Monitor serum urate monthly

140
Q

MOA of allopurinol

A

Xanthine oxidase inhibitor -> reduced urate production

141
Q

Lifestyle factors to manage in gout

A
  1. Reduce alcohol and eat healthily and ensure plenty of fluids
  2. Weight management
  3. Optimise control of comorbidities
  4. Medication review : stop NSIAD, consider alternative diuretic
142
Q

Side effects of allopurinol

A

Skin rash
N&V
Headaches
Drowsiness
Altered taste
Avoid with azathioprine

143
Q

Indications for long term Tx in gout

A

Recurrent attacks
Evidence of bone / joint damage
Tophi
Associated renal disease
Severely elevated serum urate

144
Q

Pathophysiology of RA

A

Common systemic inflammatory disease affecting synovial joint lining to cause symmetrical polyarthritis
Autoimmune destruction of cartilage and bone

145
Q

Risk factors for rheumatoid arthritis

A

Age (40s)
Female
FH
Smoking
Obesity

146
Q

Extra articular features of RA

A
  1. Lungs: fibrosis, pleural effusions
  2. CVS: pericarditis, atherosclerosis
  3. Eyes: episcleritis, scleritis, keratoconjunctivitis
  4. Vasculitis: splinter haemorrhages, vasculitis ulcers
  5. Peripheral neuropathy
147
Q

Investigations for RA

A

Thorough hx and examination
FBC
RF
ANA antibody
Anti CCP antibodies
X-ray joints: soft tissue swelling, periarticular erosions

148
Q

What is seronegative spondyloarthritis

A

A group of inflammatory arthropathies
No serum markers but an association with HLA-B27

149
Q

Types of seronegative spondyloarthritis (PEAR)

A

Psoriatic
Enteropathic (IBD)
Ankylosing spondylitis
Reactive

150
Q

Shared clinical features of seronegative spondyloarthritis

A

Asymmetrical mono / oligoarthritis of large joints including spine and SIJ
Affects tendons : plantar fasciitis, tendinitis
Extra-articular Sx: iritis, palmar / plantar rashes, dactylitis, mouth ulcers, IBD

151
Q

Clinical presentation of psoriatic arthritis

A

Stiffness, swelling
Asymmetrical oligoarthritis of weight bearing joints (mimics OA)
Or symmetrical polyarthritis (mimics RA)
Or spondylitis
Or arthritis mutilans

152
Q

Diagnosis of psoriatic arthritis

A

Clinical features
Lack of RF, ANA, CPP
Bony spurs on xray

153
Q

Management of psoriatic arthritis

A

Similar to RA: NSAIDs / DMARDs (if peripheral joints)
Biologics

154
Q

Clinical presentation of ankylosis spondylitis

A

20-30y
Insidious lower back and buttock pain
Morning stiffness and restricted spinal motion
+/- extra articular features

155
Q

Diagnosis of ankylosis spondylitis

A

MRI : bony bridges between vertebrae
Bloods: mildly raised ESR

156
Q

Management of ankylosis spondylitis

A
  1. Physio and OT
  2. Analgesia: strong NSAIDs
  3. Anti-TNF-a
  4. Surgery : if progressive and affecting QoL
157
Q

What triggers reactive arthritis

A

Enteric or genitourinary infection (sti)

158
Q

Causative organisms of reactive arthritis

A

Salmonella, E. coli, campylobacter, shigella
Chlamydia, gonorrhoea
Streptococcus

159
Q

Clinical presentation of reactive arthritis

A

Acute, symmetrical oligoarthritis of lower limbs / back
Hot swollen joints
Fever and malaise
+/- extra articular features

160
Q

Management of reactive arthritis

A

Full dose NSAIDs
Intra articular steroid injections
Abx if identified organism

161
Q

Extra articular features in reactive arthritis

A

Reiter’s triad : conjunctivitis, urethritis, arthritis (can’t see, can’t wee, can’t bend the knee)
Skin rashes / erythema nodosum

162
Q

What are the 2 different types of enteropathic arthritis

A

Type I: oligoarticular and asymmetrical (+ active IBD)
Type II: polyarticular and symmetrical

163
Q

Management of enteropathic arthritis

A
  1. Treat IBD
  2. Treat arthritis
    - use NSAIDs with caution as can worsen IBD
    - DMARD: sulfasalazine as helps IBD
    - anti-TNF - a
164
Q

Examples of multisystem connective tissue disease

A

SLE
Dm/Pm
Sjogrens
Scleroderma
APS

165
Q

What are multisystem connective tissue disease

A

Autoimmune conditions (associated with ANA antibody)
Can present with: myalgia, fatigue, rashes, photosensitivity, mouth ulcers, indigestion

166
Q

Characteristic pathological features of multisystem connective tissue disease

A
  1. Inflammation (widespread aches / pains)
  2. Fibrosis (skin lesions)
  3. Vasospasm (secondary raynauds)
  4. Thrombosis (nail infarcts, VTE)
167
Q

Red flags of connective tissue diseases

A

BP >230/120
Casts in urine
SOB
CNS signs
Severe abdo pain
Ischaemic vasculitis

168
Q

Risk factors for SLE

A

Female
Afro Caribbean / Asian
FH
UV light
Oestrogens
Stress

169
Q

Clinical presentation of SLE

A

Relapsing and remitting
Skin: malar rash, discoid rash, mucosal ulcers
Vascular: nail edge infarcts, splinter haemorrhages, raynauds
MSK: symmetrical polyarthritis
Lungs: pleuritis
Heart: pericarditis
CNS: seizures, psychosis, anxiety and depression
Renal: nephritis
Haem: pancytopenia, lymphadenopathy, organomegaly

170
Q

Management of SLE

A

Skin: topical steroids +/- hydroxychlorquine + vit D
Joints: NSAIDs, hydroxychloroquine, steroids if severe
Severe flares: strong immunosuppression (eg cyclophosphamide)

171
Q

Complications of SLE

A

Thromboembolic disease
Atherosclerosis
Infection

172
Q

What is antiphospholipid syndrome

A

Tendency to recurrent thrombosis and / or persistently increased antiphospholipid Abs

173
Q

Clinical presentation of antiphospholipid syndrome (CLOT)

A

Coagulation defect (arterial or venous thromboembolism)
Livedo reticularis (+/- chronic leg ulcers)
Obstetric issues (recurrent miscarriage)
Thrombocytopenia

174
Q

Management of antiphospholipid syndrome

A

If antiphospholipid Ab +ve but no clinical thrombosis : low dose aspirin and lifestyle advice (avoid COCP, avoid smoking)
Recurrent miscarriage: low dose aspirin + LMWH
Thrombotic event: lifelong warfarin

175
Q

What is scleroderma

A

Vascular damage and fibrosis within the skin and organs due to excess collagen

176
Q

Clinical presentation of scleroderma

A

Skin fibrosis
Fibrosis of GI tract, heart, lungs, kidneys

177
Q

What is limited scleroderma

A

Peripheral skin involvement (distal to elbows and knees)
Anti centromere antibodies

178
Q

Clinical presentation of limited scleroderma (CREST)

A

Calcinosis (calcium deposits under skin)
Raynauds
Esophageal dysmotility : heartburn
Sclerodactyly : thick swollen fingers
Telangiectasia

179
Q

Management of scleroderma

A

Skin: topical steroids
HTN, pulmonary HTN and raynauds: CCBs
Reflux: PPIs
Pain: ibuprofen / paracetamol

180
Q

What is diffuse scleroderma

A

Widespread skin changes
Anti Scl-70 antibodies

181
Q

Clinical presentation of diffuse scleroderma

A

Heart (arrhythmia)
Lungs (SOB, pulmonary HTN)
Kidneys (AKI and HTN)

182
Q

What is Sjögren’s syndrome

A

Autoimmune destruction and fibrosis of exocrine glands

183
Q

Clinical presentation of Sjögren’s syndrome

A

Dry eyes, mouth, vagina, skin
Dry throat / sinuses - cough
Parotid swelling

184
Q

Extra glandular features of Sjögren’s syndrome

A

Polyarthritis / arthralgia
Raynauds / rashes
Vasculitis
Nephritis
Peripheral neuropathy
Increased risk of lymphoma

185
Q

Investigations for Sjögren’s syndrome

A

Schirmer’s test: blotting paper inside lower eyelid to measure amount of moisture produced in 5 mins
Antibodies : anti Ro, anti La, ANA

186
Q

Management of Sjögren’s syndrome

A

Artificial tears and saliva (+/- muscarinic agonists)
Frequent drinks, sugar free pastilles

187
Q

What conditions are classed as idiopathic inflammatory myopathies

A

Polymyositis
Dermatomyositis
Inclusion body myositis

188
Q

Clinical presentation of idiopathic inflammatory myopathies

A

Proximal muscle weakness
Characteristic rash in dermatomyositis

189
Q

Investigations for idiopathic inflammatory myopathies

A

FBC (anaemia and increased ESR)
CK = elevated
ANA, RF and MSAs = often positive
Electromyograph = spontaneous muscle fibrillation
Muscle biopsy
MRI

190
Q

Management of idiopathic inflammatory myopathies

A

High dose corticosteroids (1m prednisolone)
Immunosuppressants

191
Q

What is systemic vasculitis

A

Inflammation of vessel walls
May cause aneurysm / rupture or occlusion and organ damage

Can be primary or secondary to underlying disease / drug induced
Classified based on size of smallest vessel involved

192
Q

Systemic symptoms of systemic vasculitis

A

Malaise
Myalgia
Arthralgia / arthritis
Headache
Fever
Weight loss

193
Q

Cutaneous symptoms of systemic vasculitis

A

Purpura
Infarct
Ulcer
gangrene

194
Q

Mucosal symptoms of systemic vasculitis

A

Ulcers
Conjunctivitis / scleritis / episcleritis / uveitis
Retinal haemorrhage

195
Q

ENT symptoms of systemic vasculitis

A

Epistaxis
Nasal crusting
Stridor
Hearing loss

196
Q

Resp symptoms of systemic vasculitis

A

Dyspnoea
Haemoptysis

197
Q

CV symptoms of systemic vasculitis

A

Pericarditis
Angina
MI
Thrombosis
Bruits

198
Q

GI symptoms of systemic vasculitis

A

Abdo pain
Bloody diarrhoea
Perforation

199
Q

Renal symptoms of systemic vasculitis

A

HTN
Proteinuria
Haematuria
Casts
Renal failure

200
Q

Neuro symptoms of systemic vasculitis

A

Stroke
Seizures
Confusion

201
Q

Management of systemic vasculitis

A

Large vessel - steroids usually enough
Medium / small vessel - IV cyclophosphamide + steroids

202
Q

Vessels involved in large vessel vasculitis

A

GCA
Takayasu’s arteritis

203
Q

Medium vessels involved in vasculitis

A

Kawasakis disease
Polyarthritis Nodosa

204
Q

Small vessels involved in vasculitis

A

Granulomatosis with polyangitis
Churg Strauss syndrome
HSP

205
Q

Clinical features of polymyalgia rheumatica

A

Acute onset of:
- bilateral stiffness and aching of proximal joints (shoulders, hips)
- morning stiffness >45 mins
- acute phase response: ESR, fatigue, fever, night sweats, weight loss

206
Q

What is a common emergency in polymyalgia rheumatica

A

Giant cell arteritis
- headache
- jaw pain

  • needs urgent high dose corticosteroids
207
Q

Management of polymyalgia rheumatica

A
  1. Low dose prednisolone (10-20mg for 2w then wean down to maintenance dose for 1-2y)
  2. Co-prescribe bone protection (PPI) with long term steroids
  3. Follow up
208
Q

Risk factors for pseudogout

A

Hyperparathyroidism
Haemochromatosis
Low Mg, low P
Acromegaly

209
Q

What are the side effects of hydroxychloroquine

A

Retinopathy

Can be used in pregnant women

210
Q

How to differentiate between gout and pseudogout

A

Pseudogout will show chondrocalcinosis on xray

Integrated Med (6 decks)

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