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Rheumatology Flashcards

1
Q

Red flags in rheumatological/bone pain?

A

Pain all the time - at rest

Infective

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2
Q

Red flags for back pain

A 
<16, >50 and new pain 
Hx of cancer 
Weight loss 
Recent infection 
Bladder/bowel symptoms 
Neurological dysfunction (gait, foot drop)
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3
Q

Why would RA cause cardiomegaly?

A

Pericardial effusion

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4
Q

How does RA usually affect the kidneys?

A

Nephrotic syndrome e.g. glomerulonephritis

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5
Q

What blood tests should be given to patients on methotrexate? How often should they be given?

A

FBC: cytopaenia, macrocytic anaemia
U&E: renal excretion so if there is AKI, methotrexate level will rise
LFT: potential hepatotoxicity

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6
Q

Methotrexate toxicity

A

Pancyotpaenia (bone marrow suppression due to high methotrexate levels)

GI haemorrhagic enteritis

Pancytopaenia

Macrocytic anaemia

Gum bleeding/ulcers

Hepatotoxicity

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7
Q

Methotrexate alternatives in pregnancy/breastfeeding

A

Sulfasalazine and hydroxychloroquine

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8
Q

Methotrexate drug interactions that cause bone marrow toxicity?

A

Trimethoprim (also affects folic acid cycle) or septrin: bone marrow toxicity

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9
Q

Examples of anti-TNFs

A

Rifliximab

Adalimumab

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10
Q

When should you pause a DMARD?

A

Before elective surgery

During infection and 2 weeks following the end of antibiotic regimen

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11
Q

When would you stop a DMARD before elective surgery? When would you restart?

A

Dose frequency +1 week prior to surgery

Start again 2-4 weeks after surgery

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12
Q

Steroid sick day rule?

A

Double dose and go IV if can’t take orally

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13
Q

Characteristics of ankylosing spondylitis

A

Young adult male, late teens/20s

> 3 months pain and stiffness in lower back and sacroiliac
Worse in mornings and can be woken at night
Eases on movement
Sacral fractures

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14
Q

What is Schober’s test?

A

L5 - mark
10cm above and 5 cm below
Bend over
If <20cm gap - restrictive disease

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15
Q

What X-ray changes would you see in ankylosing spondylitis?

A 
Bamboo spine 
Squaring of vertebral bodies 
Subchondral sclerosis and erosions 
Syndesmophytes (bony growths in ligaments)
Ossification 
Joint fusion
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16
Q

Stepwise management of ankylosing spondylitis?

A

NSAIDs (naproxen/ibuprofen) + physio
Steroids (oral or IM)
Anti-TNF (rifliximab, adalimumab, etanercept)
Secukinumab (anti-IL17)

Avoid smoking
Bisphosphonates
Surgery for deformities

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17
Q

Ankylosing spondylitis investigations

A

ESR and CRP raised
HLA-B27
MRI shows bone marrow oedema
Xray

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18
Q

Reactive arthritis characteristics

A

HLA-B27
Gonorrhoea, chlamydia or GI (organism can’t be found in joint)
Urethritis
Asymmetrical oligoarthritis of lower joints
Anterior uveitis/conjunctivitis
Dactylitis
Papules on palms/soles (keratoderma blenorrhagica)

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19
Q

SLE investigations

A 
ANA positive 
Anti-dsDNA 
RF (20% patients)
Anti-Smith 
ESR
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20
Q

Elbow pain worse on extension of wrist against resistance - likely diagnosis, characteristics and management?

A

Lateral epicondylitis (tennis elbow)
45-55 years
Dominant arm

Avoid muscle overload
Simple analgesia
Steroid injection
Physio

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21
Q

What should you take alongside methotrexate? What should be given in methotrexate toxicity?

A

Folic acid

Toxicity: folinic acid

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22
Q

SLE diagnostic criteria (at least 4)

A
  1. Malar rash
  2. Discoid rash (can scar)
  3. Photosensitivity
  4. Ulcers (mouth and nose)
  5. Serositis (pleuritis, pericarditis) +myocarditis/endocarditis
  6. Arthritis
  7. Renal disorder (diffuse proliferative glomerulonephritis)
  8. Neurological disorders (seizures)
  9. Blood disorders (anaemia, thrombocytopaenia, leukopaenia)
  10. Antibodies
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23
Q

Antibodies associated with systemic sclerosis?

A

ANA (90%)
RF (30%)

Diffuse: Anti-scl-70

Limited: Anti-centomere antibodies

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24
Q

Limited systemic sclerosis characteristics

A

Raynaud’s phenomenon
Scleroderma of face and hands
Anti-centomere antibodies

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25
Characteristics of diffuse systemic sclerosis
Scleroderma of trunk and proximal limbs Death caused by interstitial lung disease Renal disease and HTN Anti-scl-70 antibodies
26
CREST syndrome?
``` Calcinosis - WHITE DEPOSITS Rayndaud's Oesophageal dysmotility - DYSPHAGIA Sclerodactyly - THICKENED HANDS Telangiectasia - SPIDER NAEVI ```
27
Drug-induced SLE causes
Hydralazine Procainamide Isoniazid Phenytoin
28
Antibody in Wegener's granulomatosis
cANCA
29
Antibody in Churg-Strauss
pANCA (also seen in SLE, RA, IBD, autoimmune hepatitis)
30
Investigation and treatment of osteomyelitis?
MRI spine Flucloxacilin 6 weeks Clindamycin if allergic
31
What medication is given to osteoporosis patients who can't tolerate bisphosphonates?
Strontium ranelate or raloxifene
32
When should you offer a patient bisphosphonates?
>65 years old with fragility fracture <65 years and T score 3 months steroids
33
What investigation is required before starting a patient on anti-TNF alpha drugs?
CXR - look for TB as can cause re-activation
34
How do you monitor response to RA treatment?
CRP and DAS28
35
Recurrent miscarriages, DVTs and PEs - what investigation? What other characteristics might you see?
Anti-cardiolipin - for anti-phospholipid syndrome Other features: livedo reticularis, pre-eclampsia, prolonged APTT (paradoxical)
36
Management of anti-phospholipid syndrome
Warfarin - aim for 2-3 INR in 6 months (lifelong and 3-4 INR if thromboembolism is recurrent)
37
25 year old with salmon pink rash, arthralgia, fever that comes on in evenings and raised ferritin. RF and ANA negative - diagnosis and management?
Still's disease NSAIDs - trial 1 week before start steroids Steroids IL-1, methotrexate
38
Adverse effects of bisphosphonates
Oesophageal problems - ulcers, oesophagitis Osteonecrosis of jaw Hypocalcaemia Atypical fractures of proximal femoral shaft
39
Management of gout
Acute: NSAIDs and colchicine (pred if contraindicated) ULT: allopurinol offered after first attack (febuxostat 2nd line)
40
What would you see on examination of a patient with ankylosing spondylitis?
Reduced lateral and forward flexion
41
Kocher's criteria for septic arthritis?
Non-weight bearing Fever >38.5 WCC >12 ESR >40
42
Treatment of septic arthritis
Synovial fluid Fluclox or clindamycin for 6-12 weeks Aspiration to decompress Arthroscopic lavage
43
Late lung change in ankylosing spondylitis?
Apical fibrosis
44
Early and late x-ray findings in RA
Early: loss of joint space, juxta-articular osteoporosis, soft tissue swelling Late: subchondral sclerosis, subluxation
45
Old man, lower back and hip pain, raised ALP - diagnosis and treatment
Paget's disease | Bisphosphonates
46
What causes pseudogout and what is seen on joint aspirate?
Calcium pyrophosphate Weakly birefringent rhomboid crystals
47
Investigations and management of pseudogout?
Joint x-ray: chondrocalcinosis (linear calcifications of meniscus) Joint aspirate (exclude septic arthritis) NSAIDs, IA/IM/oral steroids
48
Features of osteomalacia
Ricket's: bow legged, knock knees, hypocalcaemia Proximal myopathy, bone pain, muscle tenderness, fractures Low vit D, calcium, phosphate Raised ALP Looser's zones (stress fractures) on x-ray
49
What immunoglobulin is found in breast milk?
IgA
50
Initial management of newly-diagnosed RA
Methotrexate Short-course steroids Paracetamol for pain relief
51
What needs to occur before a patient is started on hydroxychloroquine (along with LFT, U&E and FBC)?
Ophthalmic review as risk of retinopathy
52
Sjorgen's syndrome characteristics
``` Dry eyes, mouth, vagina Renal tubular acidosis Raynaud's Sensory polyneuropathy Arthralgia ```
53
What antibodies are seen in Sjorgen's
Anti-Ro and La RA ANA
54
What is Schirner's test?
Filter paper near conjunctival sac to assess tear formation - Sjorgen's syndrome
55
Management of Sjorgen's
Artificial tears and saliva Pilocarpine for saliva stimulation
56
Dermatomyositis features
``` Macular rash over back Periorbital rash Gottlon's papules over backs of fingers Dry, scaly hands Symmetrical proximal muscle weakness Raynaud's Respiratory muscle weakness ```
57
Antibodies in dermatomyositis
ANA | Anti-Jo-1
58
What needs to be screened for following dermatomyositis diagnosis?
Malignancy
59
Main side effect of colchicine?
Diarrhoea
60
Rapid onset proximal shoulder and pelvic girdle muscle pains and stiffness, raised inflammatory markers but normal CK?
Polymyalgia rheumatica
61
Treatment of polymyalgia rheumatica?
Prednisolone
62
Risk factors for gout
Cytotoxic drugs (chemo) Diuretics CKD Severe psoriasis
63
Ankylosing spondylitis 6 As
``` Anterior uveitis Achilles tendonitis Apical lung fibrosis Aortic regurgitation AV node block Amyloidosis ```
64
Gout crystals in joint aspiration
Needle-shaped negatively birefringent under polarised light
65
X-ray signs of gout
Joint effusion Punched out erosions Preservation of joint space until late stage No osteopenia
66
Osteogenesis imperfecta features
``` Dental cares Multiple fractures Blue sclera Autosomal dominant Deafness Normal bloods ```
67
Risk factors for osteomyelitis
``` DM Sickle cell anaemia IVDU Immunosuppression Alcohol excess ```
68
Most common extrarticular RA complications
Resp: pulmonary fibrosis, pleural effusion Eyes: keratoconjunctivitis sicca Heart: IHD Osteoporosis Increased infection risk Depression
69
Still's disease triad
Joint pain Fevers in evening Pink bumpy rash NEGATIVE RF and ANA Raised ferritin and WCC
70
Middle-aged man with fever, itchiness, scleral icterus and red urine. Also has red purpura on legs. No respiratory symptoms. Likely diagnosis?
Polyarteritis nodosa
71
What condition is temporal arteritis most associated with?
Polymyalgia rheumatica
72
What must be tried before starting an ankylosing spondylitis patient on anti-tnf drugs?
2 NSAIDs on separate occasions 12 weeks apart | Physio throughout
73
Allergic contact dermatitis - what kind of hypersensitivity reaction?
IV
74
Behcet syndrome triad and other features
1. Oral ulcers 2. Genital ulcers 3. Anterior uveitis +thrombophlebitis, neruo, GI, erythema nodosum HLA-B51
75
Raynaud's phenomenon treatment
Nifedipine Evening primrose oil and sildenafil
76
How should methotrexate be prescribe?
Once weekly, starting 7.5mg (only one strength dose) Folic acid once weekly at least 24 hours after metho Avoid pregnancy at least 6 months after stopping
77
Causes of positive ANCA
IBD SLE, RA, Sjorgen's Autoimmune hepatitis

Phase 3b (18 decks)

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