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MRCP > Rheumatology > Flashcards

Rheumatology Flashcards

1
Q

Langerhan histiocytosis

A

Abnormal prolif of histiocytes

Px - in early childhood —> LYTIC bone lesions

Ft:

  • bone pain
  • cutaneous nodules
  • recurrent otitis media/mastoiditis
  • tennis racquet shaped birbeck granules on electron microscopy
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2
Q

Osteoporosis risk factors:

SHATTERED Family

A

Steroids >5mg/day

Hypercalciuria, hyperthyroidism hyperparathyroidism

Alcohol and tobacco

Thin bmi < 22

Testosterone low

Early menopause

Renal or liver fx

Erosive Ibd Or RA

dietary ca low/malabsorption

Fhx

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3
Q

Osteoporosis - meds that worsen

A

Steroids

SSRI

PPI

Glitzines

LT heparin

Aroma tase inhibitor

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4
Q

Osteoporosis management

A

Treatment indicated if:

Post menopausal woman with DEXA (T =< -2.5 S.D) (Don’t have to do if >75) &Sx)

vit D and calc supplementation

ALendronic Acid = 1st line

If GI sx—> risedronate or etidronate

If can’t tolerate bisphosphonates
(T < -3.5)
-strontium Ranelate = increase osteoblasts and reduce osteoclast
- raloxifene = selective oestrogen receptor modulator
- denosumab - mab inhibits RANK ligand which inhibits maturation of osteoclasts

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5
Q

RA in preg

A

Disease can improve in preg then most flare after delivery

NSAIDs up to 32 weeks - after which causes early PDA CLOSURE

MTX not safe - stop 6/12 prior

Leflunomide not safe

Hydroxychllroquine and sulfasalazine are safe

Refer to
Obstetric anaesthetics —> risk of Atlanto-axial dislocation

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6
Q

Osteoporosis if at risk of

Steroid induced

A

T-score 0 - nothing

T- score 0 —> -1.5: rpt DEXA 1-3yr

T score

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7
Q

Mcardle disease

A

AR glycogen storage disease.

Distal muscle cramping on use wirh a second wind.

distinguish between myositis and Mcardles as McArdles has second wind and myositis will have 100x ULN of CK

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8
Q

SLE antibody assoc with congenital heart block

A

Anti-Ro

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9
Q

Paget’s disease

A

Old man with bone pain and Normal Ca and nomral PO4- with raised ALP

Classical ft if untx:

  • Bowing of tibia
  • Bossing of skull.

it is due to high osteoclast activity.

RF:

  • Inc ages
  • male sex
  • nothern latitude
  • fhx

Urine Hydroxyproline

Indications for tx - bone pain, skull or long bone deformit, periarticular Paget’s:
- Bisphosphonat - PO risedronate or IV zoledronate

Complications:
-Deafness
bone sarcoma 
fractures 
skull thickening 
high output cardic failure.
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10
Q

Adult onset stills disease

A

Triad:

  • fever
  • joint pain
  • salmon rash
Arthralgia 
Salmon pink rash 
Pyrexia 
High ferritin 
LN

RF negative

Mx:

NSAID - try for one week
Fx —> steroids —> fx—-> MTX/IL1/ anti TNF

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11
Q

Osteogenesis imperfects

A

Brittle bone disease

A.D
Collagen type 1

Px in childhood m
# following minor trauma 
Blue sclera 
Deafness 
Dental imperfections
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12
Q

Osteoporosis dexa scan

A

> -1 = normal

-1 —> -2.5 = osteopaenia

< -2.5 = osteoporosis

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13
Q

Anyiphospholipid sundrome

A

Paradoxical prolonged APTT and low platelets

Thrombocytopenia
Recurrent thrombosis
Recurrent foetal loss

Liverdo reticularis
Pre eclampsia
Pulm htn

Assoc SLE

Mx
- warfarin for 6/12 aim 2-3

Recurrent - lifelong warfarin

If event whilst on warfarin - lifelong and aim 3-4

Arterial thrombus = warfarin lifelong 2-3

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14
Q

Ankylosing spondylitis features:

The A’s

A 
Ant uveitis 
Aortic  regurge 
Apical fibrosis 
AV block 
Achillis tendonitis 
Amyloidosis
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15
Q

Ankylosing spndylitis

  • most useful radiological inx
A

X~Ray lumbar spine most useful for diagnosis and monitorin

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16
Q

Reactive arthritis - joint aspirate

A

CULTURE NEGATIVE

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17
Q

Occular manifestations of RA

A

KEratoconjunctiva sicca - most common - sore gritty eyes

scleriti

episcleritis

Keratitis

corneal ulcer

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18
Q

Stronges RF of thrombus in anti-phospholipid

A

Lupus anticoagulant

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19
Q

CREST with dysphagia

A

most common complication is malabsorption due to a sclerosed small bowel leading to bacterial overgrowth

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20
Q

Pagets disease

A

Bone pain + uni lat Hearliung loss + isolated high ALP

Tx: Bisphosphonates

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21
Q

Dermatomyositis

A

Photosensitive, muscle pain + Weakness, heliotrope rash. Gottrenns papuoles.

ANA
Anti-Jo1
Ant-mi-2 - most specific

SCREEN ALL FOR MALIGNNACY

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22
Q

Behcets sydrrome

A 
Ant uveitis 
Gental ulcers 
ORal ulcers 
Aseptic meningitis 
DVT
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23
Q

Drug induced lupus

A

Arthralagia
myalgia
plurisy
malar rash

ANA +
ant-dsDNA - neg
Anti-histone +

Causes:
Procanamide
hydralazine

isoniazid
phenytoin
Penicillamine

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24
Q

Z score

A

Useful in diagnosing secondary osteoperosis #

  • always use in children, young adults, pre-menopausal women and men <50
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25
Q

MTX

A

Dihydrofolate reductase inhibitor

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26
Q

limtied cutaneous systemic sclerosis

A
  • anti-centromere
  • Face + Distal limbs
  • CREST
  • LT complication - Pulm HTN
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27
Q

diffuse cutaneous systemic sclerosis

A
  • ant-Scl-70
  • Trunk+ prox limb
  • LUNG INVOLVEMENT - 80% ILD nd PAH
  • Renal dx + HTN
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28
Q

Scleroderma

A
  • Tight skin

- Plaques

29
Q

Antibodies in systemic sclerosis

A

ANA - 90%

RF - 30%

anti-centromere - Limited cutaneous

anti-Scl-70 - Diffuse cutaneous

30
Q

ank spond tx

A

1st line: Ex regime + NSAIDS

2nf - anti-TNF - Etanacerpt

31
Q

septic Arthritis

A 
Kocher Criteria:
Fever >38.5
Non WB
Raised ESR
Raised WCC

common causes - Staph A + N.gonnorhea (young adults)

Mx:

  • Aspirrate
  • IV Fluclox or Clinda (pen allergy) - 2-6/52
32
Q

What medication should be avoided with MTX

A

Trimethoprim

Combo –> BM failure

33
Q

minimum steroid use for Osteoperosis mx

A

equivalant of pred >/= 7.5mg for 3/12

34
Q

Mx of steroid induced osteoperosis:

A

1st line allendronate

> 65 or prev fragilty fracture –> Protection

<65 - Then they need T score:
- >0 - nothign
- 0 to -1.5 - rpt scan 1-3yrs
-

35
Q

Osteoperosis - inx for secondary causes

A

Hx + physical

FBC/LFT/ Alb / Cr/ Ca/ ESR/ PO4-/TFT

DEXA

36
Q

Osteoperosis DEXA scan

A

T score:

  • Based on bone mass of young reference oplation
  • > -1.0 = Normal
  • 1.0 to - 2.5 = osteopaenia
37
Q

Osteoperosis Mx - post menopausal women w/ osteoperotic #

A

Tx if postmenopausal + osteoperotic # + T score 75 yrs –> dnt need dexa

Offer Vit D + Ca to all - unless levels normal

1) Alendronate
2) if GI problems tjem Risedronate or etidronate
3) Can’t tolerate any bisphosphonate –> Strontium ranelate and raloxifene. (base on strict T score)

38
Q

Osteoperosis medication - notes

A

Bisphosphonates:

  • reduce risk of #
  • alendronate + Risedronate > etidronate ant reducing # risk

Raloxifene:

  • Selective oestrogen receptor modulator
  • prevents bone loss + reduce vertebral # risk.
  • worsen menopausal sx
  • VTE risk !!!!!!
  • decrease risk of breast Ca !!!!!

Strontium:

  • increase osteoblast abd recrease osteoclast
  • Specialisst onlu
  • Risk of CVD!!!
  • DO NOT USE IF VTE Hx
  • Steven Johnson syndrome risk

Denosumab

  • MAb –> inhibits RANK ligand –> inhibit maturation ofosteoclast
  • S/C 6/12

Hip protectors
- good in NH

Falls risk assessment

  • consider in high risk
  • no strict evidence of reduced # rate.
39
Q

Hypomagnesaemuoa

A

Causes:

  • Drugs: diuretics + PPIs
  • TPN
  • diarrhoea
  • EtOH
  • Hypokalaemoa/hypocalcaemia
  • Ciarrhoea causing conditions - Crohns/UC
  • Gitellmans/Barterrs

Ft:

  • Similair to hypocalcarima
  • Causes decreased PTH –> hypoCa
  • ECG similar to hypokalaemia
  • Prolonged QT
  • Exacerbate dig toxicity

Mx - <0.4:
- IV MgSo40 - 40mmol / 24hr

Mx - >0.4:

  • PO mg = 10-20 mmol/day
  • Can cause diarrhoea
40
Q

hypermagnesaemia

A

Sc:

  • lethargy
  • drowsy
  • paralysis
  • low BP
  • Heart bock –> cardiac arrest
Causes:
- CKD
- Adrenal insufficiency 
- Mg infusion
- milk alkali 
- I 
 Enemas 
- Tumour lysis syndrome 
- Theophyllin intoxication 
- Rhabdomyolysis
41
Q

Hypophosphataemia

A

CauseS:

  • EtOH
  • liver fx
  • hyperPTH
  • DKA
  • Refeeding
  • Osteomalcoa
ConsequenceS:
- Haemaolysis  
- WCC / platelet dysfn 
-Muscle wakness / Rhabdomyolysis (<0.3)
CNS dysfn
-
42
Q

Hyperphosphataemia

A

Causes:

  • CKD
  • Rhabdomyolysis
  • Tumour lysis
  • lactic and ketoacidosis
  • Exogenous
  • Vit D intoxication
  • low PTH
  • pseudohypoparathyroidism
  • Acromegaly
  • Thyrotoxicosis
  • Bisphosphonates

Mx - Acute :
- Saline infusion + Loop diuretic

Mx - CKD

  • low PO4- diet
  • PO4- nbinders
  • Dialysis.
43
Q

Obesity - BMI

A 
Healthy 18.5 - 24.9 
Overweight - 25 - 29.9 
 Obesity 1: 30 - 34.9 
Obesity II: 35 - 39.9 
Obesity 3; >40
44
Q

Criteria for bariatric surgery

A
  • BMI > 40
    BMI 35 - 40 + other sig dx that could be improved with WL.
  • all appprop non-surgical therapies have been tried and failed for 6/12
  • intensive speciailist mx available/accepted
  • Fit for anaesthetic

can give as first line under special=st conditions if BMI >50

45
Q

Severe malnutrition

A

Marasmus

  • deficiency of both protein + calaories
  • growth fx more sever e in marasmus

Kewashikor:
- Protein deficiency - I.e. diet of solely carb

Oedema:

  • Kwashikor +ve
  • Masrasmus -ve
46
Q

Anion gap

A

= (Na + K) - (HCO3- + Cl-)

Normal anion gap = 8-14

Metabolic acidosis + Normal Anion agap:

  • GI HCO3- loss
  • RTA
  • Acetozolamide
  • AlCl injection - (Cl - replaces HCO3-)
  • Addisons

High anion gap acidosis:

  • Lactic acidosis (lost HCO3-)
  • ketoacidosis (as above)
  • AKI and advanced CKD
  • LFx
  • Toluene ingestion
  • Intoxication - methanol, ASA, ethylene glycol
47
Q

Hypoalbuminaemia and the anion gap

A

Low albumin does contribute to Anion gap (but is not measured)

Every 1g of albumin decrease –> fall of 2.5 –> 3 mmoles in AG

therefore in a high anion gap acidosis with hypoalabuminaemia –> normal AG

Particular issure in ICU

A lactic acidosis in Ia low olb ICU pt –> normal anion gap.

48
Q

Metabolic acidosis spec causes

A

MA with diarrhoea

  • GI contents mostly alkaline + high K_
  • Hypokalaemia
  • low urinary K_
  • Low pH

RTA - covered prev

MA wiith ureteric diversion or ileal loop diversion:

  • Hyperchloraemix
  • Urinary CL- exchange for HCO3-
49
Q

Metabollic alkalosis

A

GI hydrogen loss:

  • Vomittin/pyloric stenosis
  • NG suction
  • Antacids.

Intracellular shift of H+
- hypokalaemia

Alkali administratuin

Renal hydrogen loss:

  • Cushings
  • loop/thiazide diuretic
  • Post -hypercapnic alkalosis.
  • hyperCa + milk-alkali syndrome

Volume depletion

50
Q

Spec metabolic alkalosis

A

Gastic H+ loss:

  • Meatb alkalosis
  • but aslo get acidic urine - NaHCO3- is reabsrorbed to maintain plasma Vol.

Milk-alkali syndrome:
- Triad of hyperCa + metab alkalosis + inhestion of large amounts of Ca w/ absorbable alkali.
- Hyper Ca –> increased HCO3- reavs –
> worsones alkalosis.

Post - hypercapnic alkalosis:

  • Chronic resp acidosis –> compensation via increase urinary H+ excretion –> Raisd HCO30-.
  • Rapid lowering of PCO2 (mechanic ventilation) –> fall in HCO3- + CL-.
51
Q

Hypothermia

A

Acute (immersive)

Subacute (Exhaustion) hypothermia - unable to generate heat.

Chronic - gradual loss - elderly with inadequate heating

ECG:

  • J waves
  • PR prolonged
  • QT prolonged.
  • Arrythmias

Mx:
= >30 –> Surface rewarming

<30 00<> internal warming:

  • warmed IVI
  • Warm bladdrer washout
  • Warm humidified O2:
  • Peritoneal lavage
  • pleural lavage.
  • VF or profound deterioration –> ECMO

Cardiac arrest:

  • not dead till warm and dead
  • decreased metabolism of drugs - trherefore avoid IV drugs until >30.
  • hypothermia protects brain during arrest –> therefore can have full neuyro recovery despite prolonged arrest.
52
Q

Gout

A

US of joint:

  • Effusion
  • DOuble contorur sign = deposition of urate crystal on cartilage surface

Xray:

  • Well defined punched out erosions with sclerotic margins juxta-artixular
  • joint space preserved
  • Soft tissue tophi
53
Q

RF for Carpal tunnel syndrome

MEDIAN TRAP

A 
myxoedema
edema
db
idiopathic 
acromegaly
Neoplasm

Trauma
RA
Amyloiid
Preg / Obesity

54
Q

Adult onset stills dx

A

Ft:

  • Arthralgia
  • Elevated ferritin
  • SALMON PINK RASH
  • Pyrexia - late afternoon/early evening.
  • RF & AN-

Yamaguchi criteria.

Mx:

1) NSAIDs
2) Steroids
3) If sx persist –> MTX/ IL-1 or anti-TNF

55
Q

Drug induced lupus

A

arthralagia
myalgia
plurisy
malar rash

DO NOT GET GLOMERULONEPHRITIS

56
Q

Which markers used in dx monitoring in SLE

A

anti-dsDNA
C3/C4
ESR

57
Q

Bisphosphnate side effects

A

osteonecrosis of jaw
Oesopphagitis/ulcers

allendronate: - atypical # of femoral shaft

58
Q

Osteomalacia

A

Normal bony tissue but less dense
IF growing then it’s called Rickets.

Low Vit D
High ALP
Low Ca/PO4-

Xray - Cupped metaohysis.
- Adults = loosers zones = translucent bands

MX:
- Vit D + Ca

59
Q

Osteopetrosis

A

Marble bone disease.

Fx in Osteoclast fn –> reduced resorption of bone – VVV.thick/brittle bone –> prone to fracture

Ca/PO4-/ALP all normal

60
Q

Poor prognostic factors for RA

A 
RF positive 
Anti-CCP present 
Insidious onsen 
Poor functional capacity at presentation
Xray features - Early erosions
exra-articular features - nodules
61
Q

Relapsing Polychondritis

A

repeated inflammation of cartillage. Therefore affects anywhere with cartilage:

Nose –> Saddle nose
Ears –> Cauliflower ears
Airways –> Resp symptoms

Mx:
Remission –> Steroids

Maintenance –> MTX/AZA (Steroid sparing)

62
Q

MAnagemen of adult onset stills

A

NSAIDs 1st line

if fx –> TNF inhib or Il-1 inhib (Anakinra)

63
Q

Leflunomide

A

Used in RA

NOT SAFE in preg –> stop 2 years before

Ons topping –> Long washout period –> may require co-admi n of cholecystyramine

Monitor:
- FBC/LFT/BP

S/E:

  • Diarrhoea
  • HTN
  • WL
  • Pneumonitis
  • myelosupression
  • PEriph neuropathy
64
Q

Newly diagnosed RA - what Mx to slow dx progression

A

MTX + one other DMARD + steroid

65
Q

SLE what complement is low

A

C3 + C4

66
Q

Initial Mx of BEchets

A

Prednisolone

67
Q

Lupus 1st line MX of choice

A

Hydroxyxhloroquine

then after –> steroids –> Fx —> Belimumab

68
Q

antiGBM vs vasculitits

A

anti-GB - normal ESR

OTher vasculitis - raise dESR

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