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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
What is rotator cuff syndrome? And what test can be done for it?
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
26
How can a rotator cuff problem be investigated?
USS
27
What is the management for rotator cuff syndrome?
Rest, NSAIDs Local steroid injection around tendon – subacromial space and PT If chronic/rupture refer to Orthopaedics for surgical opinion
28
What is acute calcific supraspinatus tendonitis?
Calcium hydroxyapatite deposition near supraspinatus enthesis Young adults, F>M, acute pain over several hours Normally resolves over few days
29
What is the management for acute calcific supraspinatus tendonitis?
Minor – NSAID Moderate – consider steroid injection Severe – consider aspirating calcified material
30
What is adhesive capsulitis (frozen shoulder)?
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
31
What is the management for frozen shoulder?
Analgesia, NSAIDs, Physiotherapy, steroid injection | Surgical opinion in difficult cases (manipulation under anaesthesia)
32
What are signs/symptoms of acromoclavicular joint OA?
High arc pain Local tenderness Adduction painful Impingement
33
What is trochanteric bursitis?
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
34
What is the management of trochanteric bursitis?
Rest Analgesia Steroid injection Physio
35
What is Achilles' tendonitis?
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
36
What is a complication of Achilles' tendonitis?
Achilles' tendon rupture
37
How do you investigate Achilles tendonitis?
USS
38
What is the management for Achilles tendonitis?
Rest, NSAIDs, physiotherapy | Local steroid injection under U/S guidance into paratenon can help tenosynovitis – if no evidence of tear
39
What is an Achilles' tendon rupture? How can you test for it?
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
What is the management for Achilles' tendon rupture?
Surgery to repair tendon | Conservative – below knee cast in ankle equinus 6 weeks
41
What is fibromyalgia? What are symptoms?
``` All over pain Fatigue Sleep disturbance Depression Anxiety Irritable bowel Tender spots Diagnosis of exclusion ```
42
Which conditions can mimic fibromyalgia?
``` Systemic lupus erythematosus (SLE) Hypothyroidism Polymyalgia rheumatica Malignancy Myopathy Metabolic bone disease ```
43
What is the management for fibromyalgia?
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
What are the criteria for the classification of RA?
``` 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
What baseline investigations are useful in RA?
``` ESR/PV/CRP FBC U&E/LFT RhF Anti CCP ANA Urine dip Radiology ```
46
What deformities occur in the hand in RA?
Swan neck and boutonnière Z shaped thumb Ulnar deviation (MCP) Volar subluxation (wrist)
47
What deformities happen in the foot in RA?
Hammer, overlapping and claw toes Splay foot, valgus deviation (MTP) MTP head subluxation Pes planus, valgus hind foot
48
What deformity can happen in the spine in RA?
Atlantoaxial subluxation
49
What are extra articular features of RA?
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
Who might be involved in the management of a patient with RA?
``` GP Rheumatologist Nurse specialist Physio Occupational therapist Podiatrist Orthotist Surgeons ```
51
What surgery can be done for a patient with RA?
Joint arthroplasty Tendon repair Synovectomy C spine stabilisation
52
What toxic effects can DMARDs have?
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
What risks do TNF alpha biologics have?
Infections esp TB Malignancy MS CCF
54
Which inflammatory cells are found in sacroiliac joints of patients with ankylosing spondylitis?
CD4 and CD8 T cells and macrophages
55
What is the diagnostic criteria for ankylosing spondylitis?
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
What is schobers test?
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
What are axial features of ankylosing spondylitis?
Early: Romanus lesion Advanced: bony ankylosis
58
What are peripheral features of ankylosing spondylitis?
Hip and shoulder disease | Peripheral enthesopathy
59
What are possible complications of ankylosing spondylitis?
Fracture: C5/6, C6/7, C7/T1 | Spondylodiscitis
60
What are extra articular features of ankylosing spondylitis?
``` 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
What investigations should be done for a patient with ankylosing spondylitis?
L spine and sacroiliac joint X-ray CRP and ESR HLA B27
62
What are treatment options for ankylosing spondylitis?
``` Physio NSAIDs DMARDs and steroids TNF alpha blockers Surgery ```
63
What is the peak age of onset for psoriatic arthritis?
35-50 years
64
What are the 5 clinical subgroups of psoriatic arthritis?
``` Symmetrical polyarthritis Asymmetrical oligoarthritis DIP disease Spondylitis Arthritis mutilans ```
65
What is treatment for psoriatic arthritis?
``` NSAIDs DMARDs Steroids TNF alpha OT/physio Surgery Dermatology ```
66
Who gets reactive arthritis?
Young adults, equal sex | Post urethritis/cervicitis or infectious diarrhoea
67
What are sero positive features of reactive arthritis?
Conjunctivitis Balanitis Oral ulcers Pustular psoriasis
68
What are treatments for reactive arthritis?
NSAIDs Steroids - intra articular Antibiotics - chlamydia DMARDs
69
What cultures might you take from a patient with reactive arthritis?
Throat Urine Stool Urethra/cervix
70
What can reiters syndrome be precipitated by?
``` Chlamydia Salmonella Campylobacter Shigella Yersinia ```
71
What criteria are required for diagnosis of Behçet's disease?
``` Oral ulceration plus two of: Genital ulcers Defined eye lesions Defined skin lesions Positive skin pathergy test ```
72
What conditions are associated with pseudogout?
``` Haemochromatosis Hyperparathryoidism Hypomagnesaemia Hypophosphatasia Hypothyroid Familial hypocalciuric hypercalcaemia ```
73
What pathogens usually precipitate a reactive arthritis?
``` Chlamydia trachomatis Yersinia Salmonella Shigella Campylobacter C diff Chlamydia pneumoniae ```
74
What factors predict a poor prognosis for progression in early RA?
``` Age Female Symmetrical small joint involvement Morning stiffness over 30 mins More than 4 swollen joints CRP >20 Positive RF and anti CCP ```
75
What are some complications of RA?
``` Ruptured tendons Ruptured joints (bakers cysts) Joint infection Spinal cord compression Amyloidosis ```
76
What deformities of the feet might be seen in RA?
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
Give some non articular manifestations of RA
``` 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
What are risk factors for developing carpal tunnel syndrome?
Obesity Repetitive wrist work Pregnancy RA
79
What is the mechanism of action of azathioprine?
Cytotoxic agent Metabolised to mercaptopurine Acts as purine analogue to inhibit DNA synthesis
80
What are serious complications of azathioprine therapy?
Renal failure | Bone marrow suppression
81
What enzyme activity needs to be checked before commencing a patient on azathioprine therapy?
TPMT - thiopurine methyltransferase
82
What are features of Behçet's disease?
``` Oral ulcers Genital ulcers Erythema nodosum Uveitis Inflammatory reaction when skin is pricked with a fine needle ```
83
What are treatment options for acute gout?
NSAIDs Colchicine Systemic glucocorticoids Intra articular glucocorticoids
84
Which antibody is present in polyarteritis nodosa?
pANCA
85
What are features of polyarteritis nodosa?
``` Malaise Weight loss Anaemia Fever Non specific pains Acute renal failure Livedo reticularis ```
86
What is polyarteritis nodosa?
Medium sized artery vasculitis with a predominance for renal vasculature
87
Which antibody is associated with primary biliary cirrhosis?
Anti mitochondrial antibody
88
In which conditions might ANA antibodies be present?
SLE Autoimmune hepatitis Post infection Inflammatory bowel disease
89
What is the treatment for acute gout?
NSAIDs: indomethacin | Colchicine

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