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MS3 - Mdemo > Rheumatology > Flashcards

Rheumatology Flashcards

1
Q

INFECTION at joints:

Two common microoganisms?

How is it diagnosed?

Symptoms?

A

staphylococi and strepticoci ( Gonococi in US)

dx: microscopy and culture of synovial fluid

Sx: night sweats and pyrexia, and a raised white blood cell count

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2
Q

3 visible features of OA in radiograph?

A
  1. Narrowing of joint (loss of patches of cartilage)
  2. Sclerosis of the bone (greater pressure leads to a higher density)
  3. Growth of bone edges (oosteophytes) to support the failing joint
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3
Q

4 different types of arthritis:

Age of prevalence?
Gender?

A

OA: +50, F>M (cartilage affected)
RA: 30-50, F>M (synovium affected)

AS: 15-30, M»F (enthesis affected)
Gout: 40 + M>(>)F (crystals affected)

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4
Q

3 visible features of RA on radiograph?

A
  1. Narrowing of joint (loss of patches of cartilage due to inflammation)
  2. juxta-articular osteoporosis (thining of the bone near the joint due to inflammation)
  3. erosions (Synovial cells become overgrown and invasive, and eat into the corners of the bones)
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5
Q

Ankolysing spondolytis pathology?

A

Inflammation healed followed by new bone formation (aka syndesmophytes)

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6
Q

Gout

  1. pathology?
  2. 4 features
  3. 4 RFs
  4. common position for tophi?
  5. Ix 2?
  6. acute and chronic Mx?
A
  1. sodium urate crystals form in synovial fluid In humans, serum urate levels are at or even above crystalisation concentrations and are probably kept soluble by serum (and synovial fluid) proteins. Either when these systems fail or urate levels rise too high, gout can occur
    crystals attract WBCs–> severe acute inflammation
    • arthritis (esp 1st MTP)
    • Crystal deposition in soft tissue (tophus)
    • renal disease
    • urolithiasis (bladder stones)
    • more common men
    • alcohol
    • aspirin
    • lowered renal function
    • diuretics
  4. digits, helix of ear, bursae and tendon sheath
5. 
Synovial fluid 
- needle-shape -ive birefringence
Blood
- raised ESR and CRP
6. 
Acute :
- NSAIDS
- Colchicine 
- Corticosteroids
Chronic:
- prophylatic eg allopurinol (reduces urate levels)
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7
Q

Arthritis vs rheumatism?

A

Arthritis is problems within joints, rheumatism is pain and stiffness from structures outside joints

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8
Q

Polymayalgia rheuamatica

Treatment?

A

A specific disease causing early morning proximal muscle stiffness but not arthritis.
It occurs in people over 60,
sometimes in associsation with temporal (or giant cell) arteritis (when younger people might be affected)

==> 15 mg of prednisolone

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9
Q

Pseudogout

  1. pathology
  2. presentation
  3. Ix 2
  4. Mx
A
  1. Calcium pyrophosphate crystals causing inflammation in joints
  2. acute onset joint pain, stiffness, swelling
    knee commonly affected
  3. synovial fluid:
    - rhomboid or rod shaped + birefringence
    Radiology:
    - chondrocalcinosis (knee menisci, triangular cartilage of wrist)
    - OA like changes
  4. Analgesics, aspiration, steroid injection, colchicine
    No chronic treatment: just reduce weight, physio, pain control and joint replacement
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10
Q

Osteomalacia and Rickets

  1. def
  2. difference
  3. cause
  4. Tx
A
  1. Failure of mineralization of the bones => softening of the bones,
  2. OM in adults, Rickets in children
  3. Typically through a deficiency of vitamin D or calcium
  4. Vit D supplements
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11
Q

4 types of rheumatic disease?

A
  1. soft tissue disease: tennis elbow, mech back pain, RSI
  2. Inflammatory: RA, seronegative SpA, crystal arthritis, connective tissue disease
  3. degenerative: OA, cervical spondolysis
  4. Others: fibromyalgia, metabolic
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12
Q

Seronegative spondyloarthritis
definition?
Examples?
Which one is NOT as highly (only 20%) associated with HLA-B27?

A
  • is an umbrella term for inflammatory diseases that involve both the joints and the entheses
  • seronegative: negative for rhuematoid factor
  • examples:
    1. Enteropathic
    2. Ankolysing spondolytis
    3. Psoriatic arthritis
    4. Reactive/reiter’s arthritis

Psoriatic arthritis

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13
Q

Connective tissue diseases?

A 
Sjogrens syndrome (dry mouth/eye, etc... autoimmune) 
Lupus
Scleroderma (thickened skin, autoimmune)
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14
Q

Methotrexate

  1. which conditions used for?
  2. Why folic acid given with methotrexate?
  3. Blood monitoring?
A
  1. psoriatic arthritis and RA
  2. improves gastric SEs.
    Normally given every other day to avoid interrupting DMARDs action
  3. For FBC: anaemia, bone marrow suppression
    Hepatotoxicity
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15
Q

heberden’s nodes?

A

bony prominence on the DIP joints

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16
Q

CRP vs ESR vs PV?

A

Markers of inflammation

I. C reactive protein

5-10 mg/L normal
10-40 mg/L mild inflammation
40-200 active inflammation
More sensitive than the others so slightly raised ESR with no change in CRP is not very alarming

II. ESR
Affected by anaemia

III. Plasma viscosity
Does not show

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17
Q

Palindromic arthritis?

A

stiffness and other symptoms come and go

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18
Q

What is swelling in MCP/PIP a sign of?

What about DIP?

A

RA

Either OA or psoriatic arthritis

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19
Q

RFs for gout?

A
  1. obesity
  2. alcohol
  3. dehydration
  4. diuretics/aspirin
  5. lowered renal function
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20
Q

Causes of OA?

A

Trauma/ageing
Hypermobility
occupation
gender (F>M)

21
Q

Modified mankin score?

A

shows degree of cartilage breakdown

22
Q

Vasculitis

  1. what is it?
  2. types?
  3. an example of large vessel types?
  4. 2 examples of medium vessel?
A
  1. a type of connective tissue disorder that causes inflammation of blood vessels, can lead to haemorrhage or infarct
  2. small, medium and large vessel
  3. giant cell arthritis
  4. Behcet’s syndrome, and granulomatosis with polyarteritis
23
Q 
Giant cell arthritis 
pathology?
sx? 
main complication?
diagnosis? problem with this method?
treatment?
A
  • vasculites that affects temporally artery
  • Sx: headache, tenderness and thickening of temporal artery
  • blindness (post. ciliary a. + opthalmic a. affected)
  • temporal a. biopsy + raised ESR
  • skip lesions, may get a sample without any thickening of the vessel, so should not rule out this if result is normal
  • high dose prednisolone, (>20 mg)
24
Q

Polymyalgia rheumatica?
Key sx?

Ix?

Management?

A

Sx:

  • SYMMETRICAL pain and stiffness in shoulder & pelvic gridles
  • proximal m. tenderness/weakness

Ix: raised ESR (not definitive)

at least 1 year on prednisolone

25
Q

OA

  1. pathology
  2. 2 types of causes?
  3. 4 joints commonly affected?
  4. 4 exam findings
  5. Management?
A
  1. loss of cartilage, exposing subchondral bone, sclerosis
2. 
I. primary: no obvious cause
II. secondary: 
a. Congenital: 
- developmental dysplasia of hip
- Perthes disease

b. Acquired:
- trauma,
- infection,
- avascular necrosis,
- RA
- metabolic : Pagets
- Iatrogenic : post op

    • hand (1st MCP, DIPs)
    • hip
    • knee
    • foot (1st MTP)

4.

  • varus knee
  • herberden’s nodes DIPs
  • Bouchard’s nodes PIPs
  • Baker’s cyst
5. 
Non-op:
- Oral: NSAIDS, codeine, paracetamol, glucosamine
- Injection: steroids, hyaluronic acid
Op:
- debride & wash (knee)
- replacement (hip/knee)
- fusion (foot/ankle)
- excision (1st MTP)
- realignment (varus knee, wedge osteotomy)
26
Q

RA

  1. Genetics?
  2. Immunological pathway?
  3. Palindromic rheumatism?
  4. Features in wrist and hand?
  5. Features in foot?
  6. Features in cervical spine?
  7. Blood tests?
  8. Treatment?
    9- Extra-articular symptoms
A
  1. presence of HLA-DR4 increases susceptibility
    • T-helperes accumulate in synovium
    • macrophages present HLA
    • T cells get activated releasing cytokines
    • Cytokines:
    • cause inflammation, increased synovial fluid, cartilage destruction, bone resorption,
      - B-cell differentiation and maturation
      - increased antibody production, (incl. rheumatoid factor)
  3. synovitis moves rapidly from one joint to another. flares up and settling quickly
    • Ulnar deviation of digits
    • radial deviation of wrist
    • Boutonniere deformity: flexed PIP, hyperextended DIP
    • Swan neck: flexed DIP, hyperextended PIP
    • z thumbs
  5. MARBLE walking:
    - proximal phalange subluxing dorsally, metatarsal head erodes, dislocating towards the floor
    • atlas slips forward on axis, compressing spine: pain radiating to occiput
    • damage between atlas and occiput: odontoid peg herniates through foramen magnum, could be life threatening

7.

  • FBC: (reduced RBC, in anaemia) or (reduced WBC in Felty’s syndrome/spleenomegaly)
  • Raised ESR, CRP and plasma viscosity
  • Rheumatoid factor found in blood
  • Anti-CCP (very specific)
    • NSAIDS
    • Corticosteroids
    • DMARDS
    • Biological agents:
      • Soluble TNF-α receptor: eg entanercept
      • Anti TNF-α: eg Infliximab, adalimumab
    • Rheumatoid nodules
    • Anaemia
    • Rheumatoid lung/heart
    • Eyes:
      • keratoconjuctivitis sicca: dry eyes
      • scleritis/episcleritis: red painful eyes
    • amyloidosis: chronic inflam.-> protein in urine
    • vasculitis
27
Q

2 nail signs of psoriatic arthritis?

A

pitting (white bits) and onycholysis

28
Q

Enthesis?

SPA

A

Insertion of tendon, ligament or capsule into bone

seronegative spondyloarhropathy where synovitis and enthesitis are seen

29
Q

Ankolysing spondylitis

  1. pathology
  2. Sx? (5)
  3. genetic factor?
  4. investigations
  5. Management
A
    • outer fibres of vertebral disc becomes inflamed, and attatch to the corner of the vertebral bodies
    • erosions cause squaring of vertebrae while ossification leads to formation syndesmophytes (bony bridges)
      2.
      I. Lower back pain, worse in the morning, goes away with using
      II. Abnormal schober test:
    • test mobility of lumbar spine during forward flexion.
    • Midpoint of a line between dimples of venus to a point 10 cm higher.
    • This should increase by at least 5cm during forward flexion, otherwise abnormal (fixed flexion of spine)
      III. Achilles tendonitis
      IV. Plantar fascitis
      V. extra-articular features (4 As)
    • acute anterior uvitis (dry painful eye, treated with steroid eye drop)
    • aortic incompetence/ ascending aortritis
    • apical lung fibrosis
    • amyloidosis
  2. HLA-B27
  3. Blood: raised CRP/ESR/PV, -ive RF, urea and electrolytes, liver function, bone profile, thyroid function
    X-ray: sacroiliac inflammation (sclerosis BOTH SIDES) and syndesmophytes
5. 
physio 
medication
- NSAIDS (indometacin) 
- DMARDS (sulphasalasine) 
- Biological agents 
surgery (hip replacement or spinal osteotomy)
30
Q

Reactive arthritis

  1. pathology
  2. clinical features (5)
  3. Ix? (4)
  4. Mx?
  5. Pathogens?
A
  1. aseptic arthritis, develops after an anatomically distant infection (normally GI or genitourinary tract), affecting young adults mainly
  2. I. asymmetrical oligoarticular pain in weight bearing joints, fingers and toes
    II. dactylitis (sausage digit)
    III. conjuctivitis
    IV. Urethritis
    V. Reiteres syndrome
  3. Blood: FBC, CRP, ESR
    Synovial fluid: examined, stained, cultured
    Cervical swab
    Midstream urine sample
  4. NSAIDs, steroid, DMARDS
5. 
Genitourinary Tract
- Chlamydia trachomatis
- Neisseria gonorrhoeae
- Mycoplasma fermentens

Gastrointestinal Tract:

  • Campylobacter jejuni
  • Cryptosporidium
  • Shigella flexneri
  • Enterotoxigenic E. coli
  • Giardia lamblia
  • Salmonella enteritidis
31
Q

Enteropathic arthritis def?

A

a type of SPA, ass with inflammatory bowel disease (eg crohns or ulcerative collitis)

32
Q

Psoriatic arthropathy

  1. def
  2. clinical features (5)
  3. Ix
  4. management
A
  1. a type of SPA ass. with psoriasis
    • pain, stiffness and swelling in PIPs and DIPs
    • dactylitis
    • pitting
    • onycholysis
    • telescoping of digits (resorption of bone- radiologically: pencil-in-cup
  3. X-ray: sacroilitis on ONE side
  4. DMARDS: sulphasalazine, methotrexate,
    Intramuscular gold injections,
    Immunosuppressant drugs: azathioprine and cyclosporin.
33
Q

Osteoprosis

  1. def
  2. common sites of fracture
  3. RFs
  4. Ix?
  5. Mx?
A
    • characterized by low bone mass and micro-architectural deterioration of bone tissue, leading to enhanced bone fragility and an increase in fracture risk.
  2. distal radius, NOF, vertebrae
3. 
I. Endogenous:
- Females
- Caucasians and Asians
- age
- FHx
II. Exogenous:
- hypogonadism
- glucocorticoids
- alcohol
- Immobilisation
- low BMI
- low Ca/vit D
- smoking
III. Secondary to:
- coeliac or crohns
- cushin's
- thyroid problem
  1. I. DEXA scan:
    - -1< normal <0
    - -2.5< osteopenia< -1
    - -2.5>osteoprosis
    II. Blood
    - Simple blood tests (Serum calcium, phosphate and alkaline phosphatase and urinary calcium) are normal in primary osteoporosis.
    - a raised alkaline phosphatase, a raised level of PTH may indicate secondary cause
    - a low phosphate/ Vit D may indicate secondary cause
  2. I. Physio/Lifestyle (diet, smoking, exercise)
    II. Medication:

a. Bisphosphonates:
- adhere to hydroxyapatite and inhibit osteoclasts, suppressing bone resorption
- Alendronate and risedronate (once a week)
- Zoledronate (once a year)
b. Ca and vit D
c. Denosumab (every 6 mo)
d. synthetic PTH (Triparetide, once a day)
e. raloxifene (oestrogen like effect)
f. strontium (stimulates OB, inhibits OC)
g. others: calciterol (active vit D), calcitonin (analgesic hormone)

III. surgery
vertebroblasty (injection of cement into the vertebral body)

34
Q

Bisphosphonates

  • 2 complications?
  • method of taking them?
  • how long is a course?
A
  • TMJ necrosis and atypical femoral fracture
  • taken away from meals with water only, sitting up for 30 minutes
  • 3-5 years followed by a break
35
Q

PTH

  1. released from? in response to?
  2. effect?
A
  1. thyroid gland, fall in calcium

2. increase Ca and decrease phosphates + increase Ca reabsorption in kidney

36
Q

Vit D

  1. active form? where is it converted to its active form?
  2. function?
A
  1. calcitriol, in kidney and liver
  2. Increased Ca and phosphates absorption in gut
    Increased OC resorption of bone
    Overall: increase serum Ca
37
Q

Reiter’s syndrome

A

An episode of peripheral arthritis of more than one month’s duration occurring in association with urethritis / cervicitis or diarrhoea
Reactive arthritis

38
Q

Paget’s disease

Def?
Tx?

A
  • Disease of bone remodelling
  • Increased OB and OC activity=>unrganised bone laid
  • Areas of bone become abnormally large, deformed with high vascularity
  • Bisphosphonates
39
Q

Systemic lupus erythematous

  1. MSK features 2
  2. Dermatological features 4
  3. CVS features 3
  4. RESP features 1
  5. REnal
  6. Investigations? 3
  7. Management for mild, moderate and severe?
  8. Age of onset of sx?

9 4 triggers of sx?

A
    • polyarticular non-erosive arthalgia
    • Jaccoud deformity (extended MCP/PIP, flexed DIP, claw hand due to thickening of skin)
    • photosensitivity
    • butterfly or discoid rash
    • alopecia
    • ulcers
    • Raynaurds
    • Libman-sacks endocarditis
    • vasculites (eg livedo reticularis)
  4. fibrosis
  5. glomerular nephritis
  6. ANA and anti-ds DNA antibody
    High ESR
    Low complement (C3, C4) levels
    • Mild: NSAIDS + antimalarial drugs: hydroxychlorquine
    • Moderate: Steroids + DMARDS
    • Severe: Steroids + cytotoxic drugs (eg cyclophosphamide)
  8. 15 to 40

9.

  • overexposure to sun
  • E2 contraceptives
  • infection
  • stress
40
Q

Sjogren’s syndrome

  1. def
  2. genetic association?
  3. Ocular feature?
  4. Oral feature?
  5. Other exocrine features
  6. Investigations 5
  7. Management? 2
A
  1. chronic autoimmune disease, inflamed exocrine glands eg lacrimal and salivary
  2. HLA-DR3
    • reduced tear secretion => destruction of cornea/conjunctiva => dry, sore, red eye
    • xerostomia (dryness)
    • difficulty swallowing
    • vaginal dryness
    • Reduced GI secretion: oesophagitis, gastritis
  6. I. Schirmer’s test
    - reduced tear production shown by a filter paper (>5mm wetness after 5 min)
    II. Rose Bengal staining
    - stains damaged cornea/conjunctiva epithelium visible with slit lamp
    III. Salivary flow rate
    - isotope scan, measuring excretion rate and uptake rate of radiolabelled dye
    IV. Labial gland biosy
    - shows lymphotic infiltration
    V. blood
    - raised ESR
    - Anti-Ro (causes conduction defects in foetus) and anti-La
    - RF +
    - ANA +
  7. Dry eye:
    - tear substitue: eg hypomellose
    - occlusion of cannalicali=> blocks tear drainage
    Dry moth:
    - salivas substitute
    - cholinergic drugs: pilocarpine (SE: sweating/ GI cramps)
41
Q

Antiphospholipid syndrome (APS)

  1. 4 features?
  2. investigations? 2
  3. management
A

1.
- recurrent thrombosis (venous (DVT/PE) and arterial (cerebral ischaemia))
- fetal loss (miscarriage)
- thrombocytopenia (deficiency of platelets in the blood. This causes bleeding into the tissues, bruising, and slow blood clotting after injury.)
- persistant high level of antiphospholipid antibody
2.
Antiphospholipid antibody in blood:
- lupus anticoagulants
- anticardiolipin
NOTE: they normally induce a prolonged duration of procoagulation
3.
warfarin if thrombosis Sx are present (INR 2.5-3.0)
heparin during pregnancy

42
Q

Polymyositis & dematomyosits (PM & DM)

  1. Pathology? 2
  2. Myositis feature
  3. Cutaneous features 5
  4. Ix 4
  5. Mx
A
    • Autoimmune inflammatory diseases of muscles (and skin DM)
    • Tissue infiltrated with inflammatory cells and subsequent degeneration and necrosis
  2. symmetrical proximal muscle weakness developing over weeks/months
    • Gottron’s papules (red, scalpy, papules/plaques over MCP,PIP)
    • Helitrope rash (over eyelid, periorbital oedema)
    • Macular rash (red rash over face, neck, shoulders)
    • calcinosis ( ca deposits, more in juvenile)
    • periungal telangiectasia (cuticles thickened and irregular)
4. 
Blood: 
- serum level of muscle enzymes (raised creatine kinase) 
- ESR
- ANA, anti-Jo-1 
Muscle biopsy:
- histological inflammatory cells
- most definite diagnosis
  1. steroids
43
Q

Systemic sclerosis and related conditions

  1. def
  2. types 2
  3. SSC symptoms? 5
  4. Ix
  5. Mx
A
  1. hardening of skin
  2. I. localised cutaneous scleroderma (LCS): confined to skin
    II. Systemic scleroderma (SSC): involves internal organs as well
  3. CREST
    - calcinosis
    - raynaurds
    - oEsophagus (microstomia)
    - sclerodactyly
    - telangiectasia
  4. ANA and other antibodies
  5. Not many disease modifying atm
    Antifibrotics may be effective if given early
44
Q

Mnemonic for SLE symptoms

A 
IM DAMN SHARP
Immunological: ANA, anti-dsDNA, ENA (anti- Lo and sm)
Malar rash
Discoid rash
Arthritis 
Mucositis: dry eye/mouth
Neurological: headache, seizure, psychosis, stroke
Serositis: pleurisy, 
Haemological: Reduced WBC, RBC, platelets, complements (C3,4)
ANA
Raynaurds
Photosensitive
45
Q

Polyarteritis nadosa

  1. Def
  2. Ass with which pathogen?
  3. Sx 4
  4. Ix
  5. Mx
A
  1. Necrotising inflammation of medium size vessels leading to aneurysm formation
  2. Associated with hep b infection

3.

  • fever, weight loss, and malaise
  • Gastrointestinal upset
  • vasculitic rash.
  • Renal, pulmonary, and cardiovascular involvement may also occur,
    • Biopsy of the affected organ
    • angiography of vessels: shows multiple micro aneurysms
  2. High dose steroids
    Cyclophosphamide
46
Q

Behcet’s syndrome

A

Medium vessel vasculitis with

  • recurrent oral aphthous ulcers,
  • genital ulcers, and
  • uveitis
47
Q

Granulomatosis with polyarteritis or GPA (aka Wegner’s granulomatosis)

A

Medium vessel vasculitis with characteristic saddle-nose deformity due to perforated septum.
It is systemic and can affect kidneys and lungs among others

48
Q

Inflammatory vs mechanical pain? 5

A 
Inflam:
- Morning stiffness
- Lasts 30 or more mins in morning 
- Eases off with exercise and worse at rest
- Night pain waking up in the middle of the night
- better with corticosteroids
Mech
- Morning stiffness
- Lasts 30 or less mins in morning 
- Eases off with rest and worse post exe
- No night pain 
- no change with corticosteroids
49
Q

steroid SE?

A

Bruises on the hand

MS3 - Mdemo (5 decks)

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