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General Medicine > Rheumatology > Flashcards

Rheumatology Flashcards

1
Q

What are the important questions to ask a rheum history?

A
  • morning stiffness
  • (F)Hx of psoriasis
  • specific joints involved
  • Hx of recent viral illness
  • Hx of GI/GU infection
  • “gritty eyes”
  • headaches
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2
Q

What are the important examinations in a rheum patient?

A
  • check areas pt claims are swollen but also other areas, esp. feet (make a fist, stand up, look from end of bed)
  • nail changes e.g. pitting, teleangiectasia, abnormal nail fold capillaries
  • eyes: ciliary flush
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3
Q

What is Wells’ score?

A

Subacute DVT

+1pt for:

  • active cancer
  • paralysis, recent plaster immobilisation of lower extremities
  • recently bedridden for 3days or major surgery within last 12wks
  • localised tenderness along deep venous system
  • entire leg swollen
  • calf swelling >3cm larger than asymptomatic side
  • pitting oedema confined to symptomatic leg
  • collateral superficial veins
  • previously documented DVT

-2 pts for alternative diagnosis at least as likely as DVT

Clinical probability of DVT unlikely if <2

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4
Q

Give some differentials for DVT.

A

Baker’s cyst rupture

OA in knee joint

meniscal tear in knee joint

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5
Q

What are the questions to ask in the history of polyarticular rheum pts?

A
  • time frame
  • onset
  • ?preceding infection/family with preceding infection
  • pain
  • regional or generalised, symmetrical or asymmetrical, peripheral or axial
  • inflammation present
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6
Q

What are the differentials for a symmetrical chronic polyarticular inflammatory arthropathy?

A
  • RA: targets hands and feet
  • psoriatic arthritis: Hx of psoriasis, targets hands and feet
  • SLE: mimics RA by targeting hands and feet, blood tests to exclude
  • vasculitis: constitutional features, unusual features
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7
Q

What are the relevant examination findings in a polyarticular rheum patient?

A

Signs of inflammation:
- joint held in “loose-pack” position

Swollen PIP & MCP

Suprapatellear effusions

Warm joints

Make a fist - check flexion of MCP, PIP, and DIP, sulci between MC heads

Bimanual palpation for tenderness and swelling

Late: Boutonnière’s and swan-neck deformity

Wrist: puffy ulnar styloid, De Quervain’s tenosynovitis

Knees:

  • genu valgum in RA
  • genu varum in OA

Feet:

  • toes not fully touching ground
  • MTP subluxation downwards
  • pes planus
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8
Q

What are the features of psoriatic arthritis?

A

Nail pitting

“Summer pink” coloured scaly patches on extensor surfaces

Often asymmetrical inflammation

DIPJ involvement

Dactylitis

FHx

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9
Q

What are the features of Marfan’s syndrome?

A

Autosomal dominant

Lens dislocation

Dilated aortic root

Spontaneous pneumothorax

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10
Q

What are the features of Ehlers-Danlos?

A

Hypermobility type: marked joint hypermobility

Classical: hyper-elastic skin, severe bruising, abnormal scars, widespread hypermobility

Vascular: thin translucent skin which bruises easily, characteristic facies, fragile blood vessels

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11
Q

What are the differentials for widespread pain in a rheum pt?

A
  • fibromyalgia
  • polymyalgia rheumatica: over 50yrs, inflammatory pattern, proximal muscles affected, neck pain
  • OA
  • SLE
  • metabolic disease
  • malignancy
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12
Q

What are the features of fibromyalgia?

A

Diagnosis of exclusion; chronic widespread pain and allodynia

  • 2%-10% incidence, more common in women, peak onset 40-50yrs
  • myoarthralgic pattern
  • axial and peripheral
  • no swelling or objective features of inflammation, normal CRP and ESR
  • no associated systemic features
  • exercise makes symptoms worse
  • overwhelming fatigue

Management: physiotherapy, psychologist, drugs (strong opioids and corticosteroids contraindicated)

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13
Q

What are the differentials for a monoarticular joint in a rheum pt?

A

ACUTE

  • Septic arthritis: exclude using blood cultures, joint aspirate, polarised light microscopy, FBCs
  • Crystal arthritis

CHRONIC

  • mechanical
  • inflammatory arthritis
  • chronic infection
  • foreign body
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14
Q

What are the features of gout?

A

Acute or chronic

Risk factors:

  • male
  • diabetes
  • high alcohol intake
  • high purine intake
  • 40-50yrs

Starts in MTPJs –> midfoot –> ankle –> knees –> olecranon bodies

Diagnosis req. 2 of:

  • typical Hx
  • tophi
  • increased serum urate
  • crystals in joint during attack

Rapid onset, exquisite pain

Late X-ray features = punched out erosions, overhanging sclerotic margins, normal joint space

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15
Q

What is the management of gout?

A

ACUTE

  • NSAIDs
  • colchicine
  • corticosteroids

PROPHYLAXIS

  • allopurinol (or febuxostat if allergic)
  • indicated if 2-3
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16
Q

What are the features of pseudogout?

A

Presents in elderly pts in association with OA

Targets knee, wrists, shoulders, hips,

X-ray: deposition of crystals in cartilage, osteophytes, OA, chondrocalcinosis

Rx - same as for gout (except no prophylaxis)

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17
Q

What are red flag symptoms in spinal pain?

A

Presentation <20yrs or onset 55yrs<

Non-mechanical pain

Thoracic pain

Hx = carcinoma, steroids, HIV, immunosuppression

Fever, weight loss

Widespread neurological symptoms and signs

Structural deformity

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18
Q

What are the investigations in osteoporosis?

A

X-ray if Hx of fracture

DEXA scan

Vitamin D and calcium levels

FBC - ?anaemia

U&Es and LFTs - before giving bisphosphonates

ALP - metabolic disease

Thyroid function

Testosterone, PSA

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19
Q

What is the definition of a fragility fracture?

A

Fracture which occurs as a result of a fall from standing height or less, at walking speed or less

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20
Q

What are the risks of bisphosphonates?

A

Risk of atypical fractures with >5yrs use e.g.femoral shaft

Very small risk of osteonecrosis of the jaw

Avoid in pregnancy

Caution in renal impairment

Swallow whole at least 30min before food with glass of water without any other tablets

Can give IV e.g. zoledronate infusions

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21
Q

What are the causes of osteomalacia?

A

Calcium/vitamin D deficiency

Cirrhosis (defective hydroxylation)

Anticonvulsants (increased degradation)

Renal failure (defective hydroxylation)

22
Q

What are the features of SLE?

A

More females than males

15-55yrs

Afro-Caribbeans esp.

Malar rash is painless, non-transient, nasolabial sparing

23
Q

What are the diagnostic criteria of SLE?

A

A RASH POINTS Medical Diagnosis

Antinuclear antibodies 
Renal 
Arthralgia/arthritis 
Serositis 
Haematological abnormalities 
Photosensitivity 
Oral ulcers 
Immunological abnormalities 
Neurological abnormalities 
Malar rash 
Discoid rash

SLICC criteria - at least 1 clinical and 1 immunological finding

24
Q

What are the investigations in SLE?

A

Bloods:

  • FBC
  • CRP, ESR

Immunological:

  • ANA
  • ENAs
25
Q

What is the management of SLE?

A

DMARDs = rituximab, mycophenolate, cyclophosphamide, hydroxychloroquine, azathioprine, methotrexate

Wear sunscreen

Vaccines

26
Q

What are the features of giant cell arteritis?

A

More female than male

50yrs<

New headache: usually temporal

Caucasians

Jaw claudication

PMR symptoms

New prominent temporal arteries

Ophthalmic artery involvement - blindness

27
Q

What are the diagnostic criteria for giant cell arteritis?

A

GIANT - 3/5

Granulomatous inflammation 
Increased CRP/ESR/PV
Age>50yrs 
New Headache 
Temporal artery abnormalities
28
Q

What are the features of polymyalgia rheumatica?

A

Pain and stiffness in pelvis, shoulder girdle, and neck

Sudden onset
Muscle strength normal
Prompt. dramatic response to steroids
Elevated CRP

Fever 
Fatigue 
Weight loss 
Anorexia 
Age>50yrs
29
Q

What is erythema nodosum? What causes it?

A

Red, tender nodules in legs and ankles

NODOSUM 
NO cause
Drugs esp. Abx 
OCP
Sarcoidosis
Ulcerative colitis/Crohn's 
Malignancy/microbial causes
30
Q

What is Kawasaki disease? How does it present?

A

Idiopathic self-limiting systemic vasculitis which predominantly affects children

Kranked up temperature 
Konjunctivitis
Kandy tongue 
Knobbly neck 
Knuckles are red 
Krackly skin
31
Q

Describe the features of the ESR test.

A

Indicates presence of fibrinogen and Igs

Anaemia increases the ESR

Collected in an EDTA tube

Male<50yrs should be <5mm/h
Female<50yrs should be <7mm/h
Over 50yrs should be <30mm

Advantages:

  • widely used
  • well established in diagnosis and monitoring

Disadvantages:

  • no technique for calibration
  • no test for accuracy, poor reproducibility
  • test takes 1hr
  • must be carried out within 4hrs of sampling
  • raised ESR in pregnancy
32
Q

Describe the features of a PV test.

A

Indicates presence of fibrinogen and Igs

Anaemia has no effect

Collected in an EDTA tube

Should be between 1.5-1.72

Advantages:

  • automatable
  • sensitive
  • not affected by haematocrit
  • measurement can be made on stored blood samples

Disadvantages:

  • not widely used
  • lack of familiarity with interpreting
33
Q

Describe the features of a CRP test.

A

Indicates C-reactive protein.

Anaemia has no effect

Collected in a serum tube

Should be <10mg/l

Advantages:

  • automatable
  • sensitive
  • not affected by haematocrit
  • measurement can be made on stored blood samples
  • good at monitoring sepsis

Disadvantages:

  • short-lived indicator
  • not raised in SLE
34
Q

What are the features of episcleritis?

A

Superficial - between sclera and conjunctiva

Mild discomfort

Redness well localised

Vision not impaired

35
Q

What are the features of scleritis?

A

Anterior or Posterior

Idiopathic, RA, ANCA+ve vasculitis

Severe pain

Diffuse redness

Vision impaired

Use systemic steroids +/- immunosuppression

36
Q

What are the features of corneal ulcers?

A

Usually due to bacterial/viral infection

Ulceration through stroma (“melt”) often heralds RA/vascultitis

Identify by fluoroscein staining

Very painful

Loss of vision

Systemic steroids + cyclophosphamide

37
Q

What are the features of iritis?

A

Ocular pain

Photophobia

Cloudy vision

Red eye or normal looking eye

Causes: IBD, HLA-B27 arthritis

38
Q

What is keratoconjunctivitis sicca?

A

Dry eye - conjunctival and corneal punctate erosions

Causes: RA, Sjögren’s

S&S:

  • sensation of foreign body in eye
  • dryness
  • pain
  • no vision impairment

Ix: Schirmer’s tear test

Mx: tear replacement

39
Q

What are Gottron’s papules?

A

Rash over MCP and PIP

Occurs in poly/dermatomyositis

40
Q

What is the Chapel-Hill classification?

A

?

Upper airway = stridor, nasal crushing, saddle nose
Lungs = multinucleated giant cells
Renal = systemic sclerosis
C-ANCA = most strongly associated
Biopsy = granulomata +/- necrosis
High dose steroids until remission, then low dose steroids

41
Q

What are the first line DMARDs?

A

Methotrexate +/- hydroxychloroquine +/- sulfasalazine

42
Q

Describe the administration of methotrexate.

A

Give 1/wk

Affects folic acid and adenosine pathways - must give folic acid concomitantly

ADRs:

  • hepatofibrosis
  • interstitial lung disease
  • teratogenic
  • abortifacent
43
Q

Describe the administration of hydroxychloroquine.

A

Interferes with antigen presentation to B-cells by affecting MHCII molecules

Causes ocular toxicity –> retinopathy

ADRs are dose-related

Requires blood monitoring

44
Q

Describe the administration of sulfasalazine.

A

Aspirin cross-sensitivity

Excreted in bodily fluids

Causes agranulocytosis, azoospermia

45
Q

What are the second line DMARDs?

A

Azathioprine, leflunomide, ciclosporin, mycophenolate

46
Q

Describe the administration of azathioprine.

A

Check TPMT levels at baseline (deficient individuals require lower dose and more frequent monitoring)

47
Q

Describe the administration of leflunomide.

A

Causes hypertension, headache, bone marrow and liver toxicity

Long half-life

48
Q

Describe the administration of ciclosporin.

A

Causes hypertension, nephrotoxicity, hyperlipidaemia, hyperuricaemia, gum hypertrophy, and hypertrichosis

49
Q

Describe the administration of mycophenolate.

A

Causes proteinuria, N&V, mouth ulcers, taste loss

50
Q

What are the third line DMARDs?

A

Biologics

Anti-TNF, B-cell depleters, anti-IL-6

  • all parenteral
  • weekly or fortnightly
  • regular monitoring
  • criteria for starting: definitive diagnosis, minimum duration of symptoms, tried conventional therapy, active disease measured by validated tool
51
Q

When are steroids indicated in rheumatic disease?

A

Bridge when starting DMARDs (takes 12wks to work)

Flare

Systemic involvement

General Medicine (12 decks)

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