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CCE > Rheumatology > Flashcards

Rheumatology Flashcards

1
Q

Name some recognised systemic manifestations of SLE

A 
Alopecia
Vasculitis
Epilepsy
Polyneuritis
Stroke
Chorea
Pleurisy 
Atelectasis
Pulmonary fibrosis
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2
Q

In a patient presenting with low back pain, what are 3 important factors to ask about in the history?

A

Neurological symptoms in legs: weakness, numbness, paraesthesia
Urinary/bowel symptoms: incontinence
FH of ankylosing spondylitis

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3
Q

What are the Calin criteria for inflammatory back pain?

A 
Age of patient at onset: under 40 (1)
Insidious onset (1)
Morning stiffness (1)
Persistence for months: over 3 (1)
Response to exercise: improves (1)
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4
Q

HLA B27 test has 90% sensitivity and 90% specificity in a population with chronic back pain for ank spond. In that population 5% will have ank spond. What are the chances of a patient with chronic back pain and a positive HLAB27 having ank spond?

A

about 30%
200 people with chronic back pain, 10 will have ank spond
Of those 10, 9 will test positive for HLAB27 (sensitivity)
Of the 190 that don’t have it, 10% false positive rate so 19. Out of 200 tests: 9 positives from people with AS, 19 positives from people without AS. So 9/28 chance = around 30%

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5
Q

What blood results would make you suspect that a patient has Paget’s disease of the bone?

A

Raised alkaline phosphatase

Plasma calcium, phosphate and aminotransferase all normal

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6
Q

What is osgood schlatter disease?

A

Tension at patella tendon leading to avulsion fracture

Symptoms of pain and swelling over tibial tubercle

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7
Q

What is osgood schlatter disease?

A

Tension at patella tendon leading to avulsion fracture

Symptoms of pain and swelling over tibial tubercle

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8
Q

What is an enthesis?

A

Where tendon inserts into bone, where the collagen fibres are mineralised and integrated into bone tissue

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9
Q

What is a bursa?

A

Fluid filled sac located between a bone and tendon which normally serves to reduce friction between two moving surfaces

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10
Q

How can you differentiate between articular and periarticular problems?

A

Articular: pain all planes, active = passive, capsular swelling/effusion, joint line tenderness, diffuse erythema/heat
Periarticular: pain in plane of tendon, active > passive, linear swelling, localised tenderness, localised erythema/heat

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11
Q

What is flexor tenosynovitis?

A

Inflammation of flexor tendon sheaths
Pain and stiffness in flexor finger/thumb, may extend to wrist
Reduced active flexion, crepitus, thickened tender tendon sheaths
May be associated with nodule – trigger finger
Can be associated with RA, Diabetes

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12
Q

What is treatment for flexor tenosynovitis?

A

Injection hydrocortisone

Surgery

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13
Q

What is de Quervains tenosynovitis? How can you test for it?

A

Inflammation of tendon sheath containing extensor pollicis brevis and abductor pollicis longus tendons
Pain, swelling radial wrist
Localised tenderness, crepitus, pain worse over radial styloid
Positive Finkelstein’s test

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14
Q

What is Finklesteins test?

A

With thumb flexed across the palm of the hand, ask patient to move the wrist into flexion and ulnar deviation
Positive if reproduces pain

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15
Q

What is the management for de Quervains tenosynovitis?

A

Rest from precipitating activity
Splintage
Steroid injection
Surgery

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16
Q

What conditions can precipitate carpal tunnel syndrome?

A 
Diabetes
Hypothyroidism
RA
Pregnancy
Acromegaly
Vasculitis
Trauma
Amyloid
Sarcoid
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17
Q

What does the median nerve supply in the hand?

A 
Lateral two lumbricals 
Opponens pollicis
Abductor pollicis brevis 
Flexor pollicis brevis
Sensory: Palmar surface thumb, lateral 2 1/2 digits
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18
Q

What are clinical features of carpal tunnel syndrome?

A 
Numbness/parasthesia in median nerve distribution
Pain, can radiate up arm
Worse at night
Hang hand over end of bed
Weakness of thumb (abduction)
Thenar wasting
Positive Tinel’s/Phalen’s
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19
Q

What investigation can be done for carpal tunnel syndrome?

A

Nerve conduction studies show reduced nerve conduction velocities across wrist

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20
Q

What is the management for carpal tunnel syndrome?

A

Avoidance of precipitating activity
Night time splints
Local steroid injection
Surgery – division of flexor retinaculum and decompression of carpal tunnel (80% success)

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21
Q

What are tennis and golfers elbows?

A

Tennis elbow: lateral epicondylitis, inflammation common extensor origin
Golfer’s elbow: medial epicondylitis, inflammation common flexor origin
Pain localised to specific area
Elbow flexion/extension does not cause pain
Pain upon: resisted wrist extension (Tennis)
resisted wrist flexion (Golfer’s)

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22
Q

What is management for tennis and golfers elbows?

A 
Rest from precipitating activity
Elbow clasps
Local corticosteroid injection
Physiotherapy – ultrasound and acupuncture
Surgery (often ineffective)
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23
Q

What problems can occur with the rotator cuff?

A 
Supraspinatous tendinitis/rupture
Rotator cuff tear
Adhesive capsultitis (frozen shoulder)
Acute calcific supraspinatous tendonitis
Subacromial bursitis
Acromioclavicular joint OA
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24
Q

What are the muscles of the rotator cuff and what are their functions?

A

Supraspinatous - abduction
Infraspinatous – external rotation
Teres minor – external rotation
Subscapularis – internal rotation

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25
Q

What is rotator cuff syndrome? And what test can be done for it?

A

Spectrum from mild supraspinatus tendinitis to complete tendon rupture
Chronic impingement of cuff under acromial arch
Pain often over acromial area extending into deltoid
Painful mid arc
Impingement test – abducted, flexed and internally rotated
Supraspinatus stress

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26
Q

How can a rotator cuff problem be investigated?

A

USS

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27
Q

What is the management for rotator cuff syndrome?

A

Rest, NSAIDs
Local steroid injection around tendon – subacromial space and PT
If chronic/rupture refer to Orthopaedics for surgical opinion

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28
Q

What is acute calcific supraspinatus tendonitis?

A

Calcium hydroxyapatite deposition near supraspinatus enthesis
Young adults, F>M, acute pain over several hours
Normally resolves over few days

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29
Q

What is the management for acute calcific supraspinatus tendonitis?

A

Minor – NSAID
Moderate – consider steroid injection
Severe – consider aspirating calcified material

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30
Q

What is adhesive capsulitis (frozen shoulder)?

A

Progressive pain and stiffness
Global reduction in movement, but particularly external rotation
Three phases: Pain (3-5 months), Adhesive phase (4-12 months), Recovery phase (12-42 months)
Associated with diabetes
Most patients recover by 30 months, but still have reduced movements

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31
Q

What is the management for frozen shoulder?

A

Analgesia, NSAIDs, Physiotherapy, steroid injection

Surgical opinion in difficult cases (manipulation under anaesthesia)

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32
Q

What are signs/symptoms of acromoclavicular joint OA?

A

High arc pain
Local tenderness
Adduction painful
Impingement

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33
Q

What is trochanteric bursitis?

A

Inflammation of superficial and deep bursa that separates gluteus muscles from posterior and lateral side of greater trochanter of the femur
Boring pain over lateral aspect of hip
May radiate down lateral thigh
Worse on walking or lying in bed at night
Localised tenderness upon pressure over greater trochanter

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34
Q

What is the management of trochanteric bursitis?

A

Rest
Analgesia
Steroid injection
Physio

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35
Q

What is Achilles’ tendonitis?

A

Inflammation of the achilles tendon
Sometimes at enthesis
Sometimes in middle avascular portion of tendon
Can be seen with seronegatives
Localised pain and swelling of Achilles tendon, with difficulty walking

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36
Q

What is a complication of Achilles’ tendonitis?

A

Achilles’ tendon rupture

37
Q

How do you investigate Achilles tendonitis?

A

USS

38
Q

What is the management for Achilles tendonitis?

A

Rest, NSAIDs, physiotherapy

Local steroid injection under U/S guidance into paratenon can help tenosynovitis – if no evidence of tear

39
Q

What is an Achilles’ tendon rupture? How can you test for it?

A

Acute rupture – sudden calf pain as if being hit on back of leg
Palpable gap in tendon
Some but little plantarflexion
Squeeze calf whilst prone - no plantarflexion in affected leg (Simmond’s)

40
Q

What is the management for Achilles’ tendon rupture?

A

Surgery to repair tendon

Conservative – below knee cast in ankle equinus 6 weeks

41
Q

What is fibromyalgia? What are symptoms?

A 
All over pain
Fatigue
Sleep disturbance
Depression
Anxiety
Irritable bowel
Tender spots
Diagnosis of exclusion
42
Q

Which conditions can mimic fibromyalgia?

A 
Systemic lupus erythematosus (SLE)
Hypothyroidism
Polymyalgia rheumatica
Malignancy 
Myopathy 
Metabolic bone disease
43
Q

What is the management for fibromyalgia?

A

Patient education: About condition, Reassure that no serious pathology, No harm in exercising
Cognitive behavioural therapy (CBT)
Low dose amitriptyline
Graded aerobic exercise regime

44
Q

What are the criteria for the classification of RA?

A 
Morning stiffness >1 hour >6 weeks
Arthritis of 3 or more joints >6 weeks 
Arthritis of hand joints: wrist, PIP, MCP >6 weeks 
Symmetric arthritis 
Rheumatoid nodules
Positive rheumatoid factor 
Radiographic changes 
4 present - refer
45
Q

What baseline investigations are useful in RA?

A 
ESR/PV/CRP
FBC
U&E/LFT
RhF
Anti CCP
ANA
Urine dip
Radiology
46
Q

What deformities occur in the hand in RA?

A

Swan neck and boutonnière
Z shaped thumb
Ulnar deviation (MCP)
Volar subluxation (wrist)

47
Q

What deformities happen in the foot in RA?

A

Hammer, overlapping and claw toes
Splay foot, valgus deviation (MTP)
MTP head subluxation
Pes planus, valgus hind foot

48
Q

What deformity can happen in the spine in RA?

A

Atlantoaxial subluxation

49
Q

What are extra articular features of RA?

A

Systemic: weight loss, fever, lymphadenopathy, fatigue
Ocular: keratoconjunctivitis sicca, scleritis, episcleritis
Pulmonary: alveolitis, fibrosis, nodules, pleural effusions,
Cardiac: carditis, conduction disturbance, coronary arteritis
Vasculitis: ischaemia and infarction
Feltys syndrome
Amyloidosis: nephrotic syndrome, cardiac, malabsorption
Anaemia
Osteoporosis

50
Q

Who might be involved in the management of a patient with RA?

A 
GP
Rheumatologist
Nurse specialist
Physio
Occupational therapist 
Podiatrist 
Orthotist 
Surgeons
51
Q

What surgery can be done for a patient with RA?

A

Joint arthroplasty
Tendon repair
Synovectomy
C spine stabilisation

52
Q

What toxic effects can DMARDs have?

A

Bone marrow toxicity: thrombocytopenia, leucopenia, pancytopenia
Liver toxicity: >2x increase AST or ALT or lowered albumin
Renal toxicity and hypertension: >1+ blood and or protein, >30% rise creatinine
Pulmonary: dry cough and dyspnoea

53
Q

What risks do TNF alpha biologics have?

A

Infections esp TB
Malignancy
MS
CCF

54
Q

Which inflammatory cells are found in sacroiliac joints of patients with ankylosing spondylitis?

A

CD4 and CD8 T cells and macrophages

55
Q

What is the diagnostic criteria for ankylosing spondylitis?

A

Radiologic criteria: sacroiliitis grade 2 bilaterally or 3-4 unilaterally
Clinical criteria: LBP and stiffness >3 months improved with exercise and not relieved by rest, limitation of L spine motion in frontal and saggital planes, limitation of chest expansion
Diagnosis requires radiologic criteria and at least one clinical

56
Q

What is schobers test?

A

Mark level L5
Mark 5cm below and 10cm above this point
Patient touch toes while keeping knees straight
If distance between two points doesn’t increase by 5cm, sign of restriction in lumbar flexion - ankylosing spondylitis

57
Q

What are axial features of ankylosing spondylitis?

A

Early: Romanus lesion
Advanced: bony ankylosis

58
Q

What are peripheral features of ankylosing spondylitis?

A

Hip and shoulder disease

Peripheral enthesopathy

59
Q

What are possible complications of ankylosing spondylitis?

A

Fracture: C5/6, C6/7, C7/T1

Spondylodiscitis

60
Q

What are extra articular features of ankylosing spondylitis?

A 
Uveitis 
Psoriasis 
Inflammatory bowel 
Aortic regurgitation 
Conduction defects 
Upper lobe fibrosis 
Neurological: fracture dislocation - cauda equina syndrome, Atlanto-axial disease 
Renal: amyloidosis, IgA nephropathy
61
Q

What investigations should be done for a patient with ankylosing spondylitis?

A

L spine and sacroiliac joint X-ray
CRP and ESR
HLA B27

62
Q

What are treatment options for ankylosing spondylitis?

A 
Physio
NSAIDs 
DMARDs and steroids 
TNF alpha blockers
Surgery
63
Q

What is the peak age of onset for psoriatic arthritis?

A

35-50 years

64
Q

What are the 5 clinical subgroups of psoriatic arthritis?

A 
Symmetrical polyarthritis 
Asymmetrical oligoarthritis 
DIP disease 
Spondylitis 
Arthritis mutilans
65
Q

What is treatment for psoriatic arthritis?

A 
NSAIDs 
DMARDs 
Steroids
TNF alpha 
OT/physio 
Surgery 
Dermatology
66
Q

Who gets reactive arthritis?

A

Young adults, equal sex

Post urethritis/cervicitis or infectious diarrhoea

67
Q

What are sero positive features of reactive arthritis?

A

Conjunctivitis
Balanitis
Oral ulcers
Pustular psoriasis

68
Q

What are treatments for reactive arthritis?

A

NSAIDs
Steroids - intra articular
Antibiotics - chlamydia
DMARDs

69
Q

What cultures might you take from a patient with reactive arthritis?

A

Throat
Urine
Stool
Urethra/cervix

70
Q

What can reiters syndrome be precipitated by?

A 
Chlamydia
Salmonella 
Campylobacter
Shigella
Yersinia
71
Q

What criteria are required for diagnosis of Behçet’s disease?

A 
Oral ulceration plus two of:
Genital ulcers
Defined eye lesions 
Defined skin lesions
Positive skin pathergy test
72
Q

What conditions are associated with pseudogout?

A 
Haemochromatosis 
Hyperparathryoidism 
Hypomagnesaemia 
Hypophosphatasia 
Hypothyroid 
Familial hypocalciuric hypercalcaemia
73
Q

What pathogens usually precipitate a reactive arthritis?

A 
Chlamydia trachomatis 
Yersinia
Salmonella
Shigella 
Campylobacter 
C diff
Chlamydia pneumoniae
74
Q

What factors predict a poor prognosis for progression in early RA?

A 
Age
Female 
Symmetrical small joint involvement 
Morning stiffness over 30 mins
More than 4 swollen joints
CRP >20
Positive RF and anti CCP
75
Q

What are some complications of RA?

A 
Ruptured tendons
Ruptured joints (bakers cysts)
Joint infection 
Spinal cord compression 
Amyloidosis
76
Q

What deformities of the feet might be seen in RA?

A

Foot broadens and a hammer toe develops
Exposure of metatarsal heads to pressure by forward migration of protective fibrofatty pad causes pain
Ulcers or calluses may develop under metatarsal head and dorsum of toes
Flat medial arch and loss of flexibility of foot
Valgus deformity of ankle

77
Q

Give some non articular manifestations of RA

A 
Scleritis 
Sjögren's syndrome
Lymphadenopathy
Pericarditis
Bursitis 
Nodules
Tendon sheath swelling 
Tenosynovitis
Amyloidosis 
Sensorimotor polyneuropathy 
Pleural effusion
Fibrosing alveolitis 
Anaemia 
Carpal tunnel syndrome
Nail fold lesions of vasculitis
Splenomegaly (feltys syndrome)
Leg ulcers
Ankle oedema
78
Q

What are risk factors for developing carpal tunnel syndrome?

A

Obesity
Repetitive wrist work
Pregnancy
RA

79
Q

What is the mechanism of action of azathioprine?

A

Cytotoxic agent
Metabolised to mercaptopurine
Acts as purine analogue to inhibit DNA synthesis

80
Q

What are serious complications of azathioprine therapy?

A

Renal failure

Bone marrow suppression

81
Q

What enzyme activity needs to be checked before commencing a patient on azathioprine therapy?

A

TPMT - thiopurine methyltransferase

82
Q

What are features of Behçet’s disease?

A 
Oral ulcers
Genital ulcers
Erythema nodosum 
Uveitis 
Inflammatory reaction when skin is pricked with a fine needle
83
Q

What are treatment options for acute gout?

A

NSAIDs
Colchicine
Systemic glucocorticoids
Intra articular glucocorticoids

84
Q

Which antibody is present in polyarteritis nodosa?

A

pANCA

85
Q

What are features of polyarteritis nodosa?

A 
Malaise
Weight loss
Anaemia
Fever
Non specific pains
Acute renal failure
Livedo reticularis
86
Q

What is polyarteritis nodosa?

A

Medium sized artery vasculitis with a predominance for renal vasculature

87
Q

Which antibody is associated with primary biliary cirrhosis?

A

Anti mitochondrial antibody

88
Q

In which conditions might ANA antibodies be present?

A

SLE
Autoimmune hepatitis
Post infection
Inflammatory bowel disease

89
Q

What is the treatment for acute gout?

A

NSAIDs: indomethacin

Colchicine

CCE (20 decks)

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