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MRCP - Passmed > Rheumatology > Flashcards

Rheumatology Flashcards

1
Q

What is classically impaired in adhesive capsulitis (frozen shoulder)? Which patient population is more likely to get this?

A

Pain upon external rotation both on active and passive movement

Diabetes is major RF - 20% of diabetics develop this

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2
Q

Drug causes of gout?

A

diuretics: thiazides, furosemide
ciclosporin
alcohol
cytotoxic agents
pyrazinamide
aspirin

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3
Q

RFs for avascular necrosis of hip?

A

long-term steroid use
chemotherapy
alcohol excess
trauma

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4
Q

Differences between limited cutaneous systemic sclerosis and diffuse cutaneous systemic sclerosis?

A

Limited:
- Mainly affected proximal limbs + face
- Anti-centromere antibodies

Diffuse:
- Mainly affects trunk + proximal limbs
- Anti Scl-70 antibodies (higher risk of severe interstitial lung disease)

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5
Q

Features of systemic sclerosis? (scleroderma, limited cutaneous systemic sclerosis and diffuse cutaneous systemic sclerosis)

A

Condition of unknown aetiology characterised by hardened, sclerotic skin and other connective tissues.

It is four times more common in females

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6
Q

Main cause of death in diffuse cutaneous systemic sclerosis?

A

Respiratory involvement seen in 80% - ILD and PAH

other complications include renal disease (start on ACEi) and HTN

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7
Q

Examples of TNF-inhibitors?

A

Etanercept

Infliximab

Adalimumab

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8
Q

Inhertiance of Familial Mediterranean Fever?

A

Autosomal recessive

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9
Q

Features of familial mediterranean fever? mx?

A

Reoccurring episodes of abdo pain, fever, arthralgia and chest pain

Colchicine can help

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10
Q

DMARD safe in pregnancy and breastfeeding?

A

Sulfasalazine

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11
Q

Adverse effects of Sulfasalazine?

A

Oligospermia
SJS
Pneumonitis / lung fibrosis
Myelosuppression
May colour tears / contact lenses

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12
Q

Reactive arthritis features?

A

classic triad of urethritis, conjunctivitis and arthritis

(can’t see, pee or climb a tree)

Defined as arthritis develops following infection where organism can’t be recovered from joint

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13
Q

Features of osteomalacia?

A

Bone pain, tenderness and proximal myopathy (-> ?waddling gait)

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14
Q

Which individuals are susceptible to azathiopurine? Safe in pregnancy?

A

TPMT deficient people

Safe in pregnancy

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15
Q

Behcets triad?

A

oral ulcers, genital ulcers and anterior uveitis (HLA B51)

Also get thrombophelbitis and DVTs +
arthritis
neurological involvement (e.g. aseptic meningitis)
GI: abdo pain, diarrhoea, colitis
erythema nodosum

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15
Q

Behcets epidemiology?

A

Eastern mediterraneans
Men&raquo_space; with more severe disease
Young adults 20-40y
30% have FHx

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16
Q

What is deposited in pseudogout?

A
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17
Q

RFs for pseudogout?

A

Increasing age (main)

If younger:
Haemochromatosis
Wilsons
Hyperparathyroidism
low Mg, low PO4
acromegaly

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18
Q

Inflammatory arthritis involving DIP swelling + dactylitis (finger/toe swelling looks like sausages)-> ????

A

Psoriatic arthritis

Can also cause spinal stiffness and reduced cervical spine mobility

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19
Q

Type of collagen in osteogenesis imperfecta?

A

Type 1 collagen

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20
Q

What are Heberden’s nodes and Bouchard’s nodes? Which disease are they found in?

A

Heberdens node (painless bony swelling at DIP)

Bouchards node (painless bony swelling at PIP)

Found in OA due to osteophyte formation

Think about which letter is proximal / distal in alphabet

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21
Q

When to be careful giving sulfasalazine to patients?

A

If they have G6PD deficiency (Tito)

Allergy to aspirin / sulphonamides due to cross reactivity

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22
Q

What are the issues for SLE and pregnancy?

A

Risk of maternal autoantibodies crossing placenta -> neonatal lupus erythematosus

Complications inc. congenital heart block (associated strongly with anti-Ro ab) - Ro block!

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23
Q

Anti-ribonuclear protein (anti-RNP) is found in which disease? How do they present?

A

Mixed connective tissue disease

Present with:
- Raynauds before most sx (90%)
- Polyarthralgia / arthritis
- Myalgia + Dactylitis

M:F - 1:3
30-40y avg age

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24
Q

Which complements are low in active SLE disease?

A

C3, C4 due to formation of immune complexes and consumption

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25
Q

Mx of ank spond?

A

1st line - Exercise + NSAIDs

2nd - DMARDs only if peripheral joint involvement

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26
Q

Main target for pANCA and cANCA?

A

cANCA - serine proteinase 3 (PR3)

pANCA - myeloperoxidase (MPO)

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27
Q

Muscular inflammation + skin manifestations (red, scaly bumps over knuckles) - what disease? what is clinical sign? what is the main autoantibodies?

A

Dermatomyositis

Grotton’s papules - red scaly bumps over knuckles

Anti-Mi-2 - HIGH SPECIFIC (seen in 25%)
ANA (60%)

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28
Q

positive birefringent rhomboid-shaped crystals are seen in which disease?

A

Pseudogout

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29
Q

What is polyarteritis nodosa? Associated with which infection?

A

PAN - vasculitis affecting medium-sized arteries with necrotizing inflammation leading to aneurysm formation

Associated with Hep B infection

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30
Q

Fever, malaise, arthralgia

Mononeuritis multiplex, sensorimotor polyneuropathy

Livedo reticularis

Renal impairment +- haematuria

Which condition is this?

A

Polyarteritis Nodosa

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31
Q

Arterial/venous thrombosis, miscarriage, livedo reticularis → which disease and antibodies?

A

Antiphospholipid syndrome

Anticardiolipin + Anti-Beta2 glycoprotein I ab

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32
Q

gradual onset leg and back pain, weakness and numbness which is brought on by walking (with a normal clinical examination)

Diagnosis? Differentiate from claudication? Ix/ mx?

A

Spinal stenosis

Differentiation:
- Positional element - sitting > standing + easier to walk uphill v downhill

Ix: MRI
Mx: Laminectomy

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33
Q

CXR finding in ank spond?

A

Apical fibrosis

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34
Q

Organism for osteomyelitis? When is a different organism more likely?

A

Staph aureus

Salmonella more common in sickle cell

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35
Q

Fever/back pain with pain on extension of the hip

Diagnosis?

A

Iliopsoas abscess

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36
Q

What feature suggests psoriatic arthritis v RA?

A

Assymetrical oligoarthritis

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37
Q

XR features in ank spond? what if no changes but still suspecting

A

XR sacroiliac joint:
- Sacroilitis - subcondral sclerosis + sclerosis
- Squaring of lumbar vertebrae
- Syndesmophytes - ossification of outer fibres of annulus fibrosis
- Bamboo spine - LATE AND UNCOMMON

Early disease may not show XR changes so should get MRI - can show inflammation of sacroiliac joints (BM oedema)

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38
Q

Purple/red rash on upper eyelids - what is this called? seen in which disease? which ab?

A

Heliotrope rash - seen in dermatomyositis

Anti-Jo1 ab

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39
Q

Marfans gene? protein affected?

A

FBN1 gene chromosome 15

Protein fibrillin 1

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40
Q

Eye features in marfans?

A

Upward lens dislocation (superotemporal ectopia lentis)

Blue sclera

Myopia (near sightedness)

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41
Q

Low serum calcium,
low serum phosphate,
raised ALP and raised PTH

which disease?

A

Osteomalacia

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42
Q

Bisphosphonate MoA?

A

Inhibits osteoclasts

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43
Q

Which feature helps distinguish pseudogout from gout?

A

x-ray: chondrocalcinosis - knee this can be seen as linear calcifications of the meniscus and articular cartilage

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44
Q

worse on resisted wrist extension/suppination whilst elbow extended is suggestive of which disease?

A

Lateral epicondylitis (tennis elbow - also seen in house painting)

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45
Q

GPA - which antibody?

Eosinophilic granulomatosis w/ polyangitis + other - which antibody?

A

cANCA = granulomatosis with polyangiitis

pANCA = eosinophilic granulomatosis with polyangiitis + others

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46
Q

Advice on how to take bisphosphonate?

A

Take at least 30 minutes before breakfast with plenty of water + sit-upright for 30 minutes following

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47
Q

Pain on the radial side of the wrist/tenderness over the radial styloid process + worse upon ulnar deviation?

A

De Quervain’s tenosynovitis

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48
Q

Cause of bulls eye retinopathy? what does this lead to?

A

Can lead to severe and permenant visual loss

Seen in Hydroxychloroquine use (see how many OOOOOO there is like a bullseye)

49
Q

Denosumab MoA?

A

RANKL inhibitor (nuclear factor kappa-I)

50
Q

Apremilast MoA? When is it used?

A

phosphodiesterase type-4 (PDE4) inhibitor - used in active psoriatic arthritis - if patients have inadequate response / intolerant to prev DMARD therapy

51
Q

HLA in reactive arthritis?

A

HLA B27

52
Q

patients older than 65 years who have taken, or who are likely to remain on oral corticosteroids for more than 3 months

Need what tx and why?

A

Oral bisphosphonates - osteoporosis protection

53
Q

Drug that can cause exposed bone in oral cavity? Sign name?

A

Osteonecrosis of jaw secondary to bisphosphonate use

54
Q

Pain is usually elicited by resisted wrist flexion with pronation while keeping the elbow flexed 90 degrees or resisted forearm pronation with the elbow extended

Suggestive of which condition?

A

Medial epicondylitis (Golfer’s elbow)

55
Q

No trauma

Painful swelling on posterior elbow

Middle aged man

Diagnosis?

A

Olecranon bursitis

56
Q

Poor prognostic features of RA?

A

rheumatoid factor positive
anti-CCP antibodies
poor functional status at presentation
X-ray: early erosions (e.g. after < 2 years)
extra articular features e.g. nodules
HLA DR4
insidious onset

57
Q

What is an early XR finding in RA?

A

Juxta-articular osteoporosis/osteopenia

58
Q

Which patients should be offered prophylaxis against gout?

A

All patients after their 1st attack (2-4 weeks post acute)

59
Q

How is risk of osteonecrosis of jaw increased in those with bisphosphonates?

A

IV therapy v oral

60
Q

What happens to prophylactic allopurinol dose during acute gout attack?

A

Continue allopurinol in current dose

61
Q

What are syndesmophytes and when are they seen?

A

This is the ossification of the outer fibres of annulus fibrosus seen in Ank Spond

62
Q

Gram staining in septic arthritis is …..

A

Gram staining is negative in around 30-50% of cases

63
Q

Anti-Jo1 ab seen in?

A

Anti-Jo-1 (Polymyositis/Dermatomyositis):

‘Jo can’t flex her muscles’ (muscle weakness in polymyositis/dermatomyositis).

(anti-mi2 is more secific for dermatomyositis)

64
Q

Anti-dsDNA seen in?

A

Anti-dsDNA (Systemic Lupus Erythematosus - SLE):

‘Double Stranded DNA gets SLE-iously messed up’ (dsDNA links to lupus).

65
Q

Anti-Smith ab seen in?

A

Anti-Smith (Anti-Sm) (SLE):

‘Smith is sleek for SLE’ (Smith exclusively ‘slinks’ to lupus).

66
Q

Anti-Ro / La seen in?

A

Anti-Ro/Anti-La (Sjögren’s Syndrome and SLE):

‘Ro and La make you dry like the Sahara’ (dryness in Sjögren’s).

67
Q

Anti-centromere is seen in?

A

(Limited Systemic Sclerosis - CREST):

‘Centering on limited CREST’ (centromere links to limited CREST).

68
Q

Anti-Scl-70 is seen in?

A

Anti-Scl-70 (Diffuse Systemic Sclerosis):

‘Scl-erosis spreads like 70 mph across the body’ (diffuse systemic sclerosis).

69
Q

Anti-Mitochondrial (AMA) is seen in?

A

Anti-Mitochondrial (AMA) (Primary Biliary Cholangitis):

‘Your bile ducts scream ‘AMA-zing, we’re out of order!’’ (Primary Biliary Cholangitis).

70
Q

apremilast MoA?

A

phosphodiesterase type-4 (PDE4) inhibitor → suppression of pro-inflammatory mediator synthesis and promotion of anti-inflammatory mediators

71
Q

Sjogrens patients are at increased risk of which ca?

A

Lymphoid ca

72
Q

Mx of discoid lupus in order?

A

topical steroid cream

oral antimalarials may be used second-line e.g. hydroxychloroquine

avoid sun exposure

73
Q

What are the features of Felty syndrome?

A

(RA + splenomegaly + low white cell count)

74
Q

Extra articular manifestations of RA?

A

respiratory: pulmonary fibrosis, pleural effusion, pulmonary nodules, bronchiolitis obliterans, methotrexate pneumonitis, pleurisy

ocular: keratoconjunctivitis sicca (most common), episcleritis, scleritis, corneal ulceration, keratitis, steroid-induced cataracts, chloroquine retinopathy
osteoporosis

ischaemic heart disease: RA carries a similar risk to type 2 diabetes mellitus

increased risk of infections

depression

75
Q

An X-ray of the skull is performed, which shows large, well-defined lytic lesions and a thickened vault.

Can be seen in which disorder - raised ALP? What other markers of bone turn over are also raised?

A

Pagets disease of bone:

procollagen type I N-terminal propeptide (PINP)
serum C-telopeptide (CTx)
urinary N-telopeptide (NTx)
urinary hydroxyproline

76
Q

Who does Raynauds disease (primary) typically present in and how?

A

Young women with bilateral sx

77
Q

What is the majority (90%) of cases of gout due to?

A

decreased renal excretion of uric acid

78
Q

What are the main features of SLE mx?

A

Basics: Use NSAIDs + sun-block

Hydroxycholoroquine - tx of choice

If internal organ involvement eg renal, neuro, eye - consider pred and cyclophosphamide

79
Q

What are the antibodies associated with anti-phospholipid syndrome?

A

Anti-cardiolipin antibodies and anti-beta2 glycoprotein I antibodies

80
Q

Which antibodies for CREST syndrome

A

CREST = Limited (central) systemic sclerosis = anti-centromere antibodies

81
Q

Which ab are most specific and sensitive for SLE?

A

ANA is 99% sensitive

anti-Sm & anti-dsDNA are 99% specific

82
Q

Mx of Familial Mediterranean Fever?

A

colchicine may help

83
Q

Clotting in antiphospholipid syndrome?

A

Prolonged APTT + Thrombocytopaenia

84
Q

Mx of Raynauds if CCB doesnt work / CI?

A

IV prostacyclin (eg epoprostenol) infusion - effects can last weeks - months

85
Q

What examination findings can be seen with carpal tunnel?

A

weakness of thumb abduction (abductor pollicis brevis)

wasting of thenar eminence (NOT hypothenar)

Tinel’s sign: tapping causes paraesthesia

Phalen’s sign: flexion of wrist causes symptoms

86
Q

patients aged 75 and over with a history of fragility fractures

Mx of osteoporosis?

A

Start bisphosphonates w/out DEXA

87
Q

What DEXA score quantifies osteoporosis?

A

the BMD threshold for defining osteoporosis is a T-score of - 2.5 SD or below

88
Q

tingling in the little and ring finger and worsening of symptoms when the elbow is bent for prolonged periods

Suggestive of which dx?

A

Cubital tunnel syndrome

89
Q

features of polyarteritis nodosa?

A

fever, malaise, arthralgia

weight loss

hypertension

mononeuritis multiplex, sensorimotor polyneuropathy

testicular pain

livedo reticularis

haematuria, renal failure

perinuclear-antineutrophil cytoplasmic antibodies (ANCA) are found in around 20% of patients with ‘classic’ PAN

hepatitis B serology positive in 30% of patients

90
Q

PAN - what antibody is likely to be positive?

A

No antibodies - rarely pANCA (20%)

91
Q

Reflexes and nerve roots pneumonic?

A

S1, S2: Ankle jerk, or “buckle my shoe”

L3, L4: Knee jerk, or “kick the door”

C5, C6: Biceps and brachioradialis reflexes, or “pick up sticks”

C7, C8: Triceps reflex, or “lay them straight”

92
Q

Sensory loss dorsum of foot
Weakness in foot and big toe dorsiflexion

What nerve root is affected?

A

L5 compression

93
Q

Which nerve roots when compressed show +ve femoral stretch and sciatic nerve stretch?

A

+ve sciatic nerve stretch test: L5, S1

+ve femoral stretch test: L3, L4

94
Q

Similarities and differences between L3 /4 compression

A

Both:
+ve femoral stretch test
reduced knee reflex
weak hip adduction

L3:
Sensory loss over anterior thigh
Weak hip flexion, knee extension and hip adduction

L4:
Sensory loss anterior aspect of knee and medial malleolus
Weak knee extension and hip adduction

95
Q

Features of lateral epicondylitis?

A

worse on resisted wrist extension/supination whilst elbow extended

96
Q

Which connective tissue disorder is most associated with raynauds?

A

Scleroderma (systemic sclerosis)

Also - RA + SLE

97
Q

What are the skin features of reactive arthritis?

A

circinate balanitis (painless vesicles on the coronal margin of the prepuce)

keratoderma blenorrhagica (waxy yellow/brown papules on palms and soles)

98
Q

Mycophenolate mofetil MoA?

A

Inhibits of inosine-5’-monophosphate dehydrogenase which is needed for purine synthesis

99
Q

What indicates poor prognosis in Polymyositis?

A

ILD - eg fibrosing alveolitis or organising pneumonia

Seen in 20%

100
Q

What is the defect in osteogenesis imperfecta?

A

Type IV collagen (mutations in the COL1A1 or COL1A2 genes)

101
Q

What can relieve carpal tunnel pain in some patients?

A

Shaking their hands

102
Q

What antibody is associated with systemic sclerosis?

A

anti-centromere (CREST - limited cutaenous)

anti-scl-70 (diffuse cutaneous)

103
Q

Which systemic sclerosis is more likely to involve ILD and PAH?

A

Diffuse cutaneous systemic sclerosis

104
Q

Main difference between limited cutaneous and diffuse cutaneous systemic sclerosis?

A

Diffuse cutaneous systemic sclerosis = trunk + proximal limbs mainly

Limited cutaneous systemic sclerosis = face and distal limbs predominately

105
Q

What are the causes of drug induced lupus?

A

Most common causes
> procainamide
> hydralazine

Less common causes
> isoniazid
> minocycline
> phenytoin

106
Q

What are the features of Ank spond?

A

6As:

Apical fibrosis
Anterior uveitis
Aortic regurgitation
Achilles tendonitis
AV node block
Amyloidosis

107
Q

L5 lesion features?

A

loss of foot dorsiflexion + sensory loss dorsum of the foot

108
Q

Which condition is likely to display DIP swelling and dactylitis?

A

psoriatic arthritis

109
Q

Mx of GCA?

A

Uncomplicated GCA (no visual involvement and/or jaw/tongue claudication) - oral pred

Complicated GCA (with visual involvement and/or jaw/tongue claudication) - IV methylpred 3 days before oral pred

Same day ophthal rv
Bone protection w bisphosphonates if long course of steroids

110
Q

What is a possible complication of Temporal arteritis / GCA which presents with swollen pale disc and blurred margins on fundoscopy?

A

anterior ischemic optic neuropathy

111
Q

What can happen to the eyes in Marfans syndrome?

A

upwards lens dislocation (superotemporal ectopia lentis)

blue sclera

myopia

112
Q

Mx of Sjogrens?

A

Artificial salvia + tears

Pilocarpine can help stimulate saliva production

113
Q

Approximately what percentage of patients with psoriasis develop an associated arthropathy?

A

10-20%

114
Q

Marfans inheritance?

A

AD

115
Q

Mx of secondary thromboprophylaxis in antiphospholipid syndrome?

A

Initial VTE - lifelong warfarin 2-3 INR

Recurrent whilst on Warfarin - life long increase INR to 3-4 and consider low dose aspirin

Arterial thrombosis - life long aspirin 2-3

116
Q

Ab associated with congenital heart block in SLE?

A

Anti-RO = ROad Block = Congenital heart block in SLE.

117
Q

How can you distinguish pseudogout from gout on XR?

A

Chondrocalcinosis helps to distinguish pseudogout from gout

118
Q

Anti-U1 RNP is +ve in which disorder?
What other ab may be positive?

A

Mixed connective tissue disease

ANA is usually +ve

119
Q

Dermatomyositis antibodies

Most common v most specific?

A

Most common = ANA (60%)

Most specific = Anti Mi 2

120
Q

patients usually experience exacerbated pain upon wrist extension against resistance when their elbow is extended

seen in which disorder?

A

Lateral epicondylitis

MRCP - Passmed (17 decks)

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