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Phase 3b > Rheumatology > Flashcards

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
Q

Characteristics of diffuse systemic sclerosis

A

Scleroderma of trunk and proximal limbs
Death caused by interstitial lung disease
Renal disease and HTN
Anti-scl-70 antibodies

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26
Q

CREST syndrome?

A 
Calcinosis - WHITE DEPOSITS
Rayndaud's
Oesophageal dysmotility - DYSPHAGIA
Sclerodactyly - THICKENED HANDS
Telangiectasia - SPIDER NAEVI
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27
Q

Drug-induced SLE causes

A

Hydralazine
Procainamide

Isoniazid
Phenytoin

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28
Q

Antibody in Wegener’s granulomatosis

A

cANCA

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29
Q

Antibody in Churg-Strauss

A

pANCA (also seen in SLE, RA, IBD, autoimmune hepatitis)

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30
Q

Investigation and treatment of osteomyelitis?

A

MRI spine

Flucloxacilin 6 weeks
Clindamycin if allergic

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31
Q

What medication is given to osteoporosis patients who can’t tolerate bisphosphonates?

A

Strontium ranelate or raloxifene

32
Q

When should you offer a patient bisphosphonates?

A

> 65 years old with fragility fracture

<65 years and T score 3 months steroids

33
Q

What investigation is required before starting a patient on anti-TNF alpha drugs?

A

CXR - look for TB as can cause re-activation

34
Q

How do you monitor response to RA treatment?

A

CRP and DAS28

35
Q

Recurrent miscarriages, DVTs and PEs - what investigation? What other characteristics might you see?

A

Anti-cardiolipin - for anti-phospholipid syndrome

Other features: livedo reticularis, pre-eclampsia, prolonged APTT (paradoxical)

36
Q

Management of anti-phospholipid syndrome

A

Warfarin - aim for 2-3 INR in 6 months (lifelong and 3-4 INR if thromboembolism is recurrent)

37
Q

25 year old with salmon pink rash, arthralgia, fever that comes on in evenings and raised ferritin. RF and ANA negative - diagnosis and management?

A

Still’s disease

NSAIDs - trial 1 week before start steroids
Steroids
IL-1, methotrexate

38
Q

Adverse effects of bisphosphonates

A

Oesophageal problems - ulcers, oesophagitis

Osteonecrosis of jaw

Hypocalcaemia

Atypical fractures of proximal femoral shaft

39
Q

Management of gout

A

Acute: NSAIDs and colchicine (pred if contraindicated)

ULT: allopurinol offered after first attack (febuxostat 2nd line)

40
Q

What would you see on examination of a patient with ankylosing spondylitis?

A

Reduced lateral and forward flexion

41
Q

Kocher’s criteria for septic arthritis?

A

Non-weight bearing
Fever >38.5
WCC >12
ESR >40

42
Q

Treatment of septic arthritis

A

Synovial fluid

Fluclox or clindamycin for 6-12 weeks

Aspiration to decompress

Arthroscopic lavage

43
Q

Late lung change in ankylosing spondylitis?

A

Apical fibrosis

44
Q

Early and late x-ray findings in RA

A

Early: loss of joint space, juxta-articular osteoporosis, soft tissue swelling

Late: subchondral sclerosis, subluxation

45
Q

Old man, lower back and hip pain, raised ALP - diagnosis and treatment

A

Paget’s disease

Bisphosphonates

46
Q

What causes pseudogout and what is seen on joint aspirate?

A

Calcium pyrophosphate

Weakly birefringent rhomboid crystals

47
Q

Investigations and management of pseudogout?

A

Joint x-ray: chondrocalcinosis (linear calcifications of meniscus)

Joint aspirate (exclude septic arthritis)

NSAIDs, IA/IM/oral steroids

48
Q

Features of osteomalacia

A

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
Q

What immunoglobulin is found in breast milk?

50
Q

Initial management of newly-diagnosed RA

A

Methotrexate
Short-course steroids
Paracetamol for pain relief

51
Q

What needs to occur before a patient is started on hydroxychloroquine (along with LFT, U&E and FBC)?

A

Ophthalmic review as risk of retinopathy

52
Q

Sjorgen’s syndrome characteristics

A 
Dry eyes, mouth, vagina
Renal tubular acidosis 
Raynaud's 
Sensory polyneuropathy 
Arthralgia
53
Q

What antibodies are seen in Sjorgen’s

A

Anti-Ro and La
RA
ANA

54
Q

What is Schirner’s test?

A

Filter paper near conjunctival sac to assess tear formation - Sjorgen’s syndrome

55
Q

Management of Sjorgen’s

A

Artificial tears and saliva

Pilocarpine for saliva stimulation

56
Q

Dermatomyositis features

A 
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
Q

Antibodies in dermatomyositis

A

ANA

Anti-Jo-1

58
Q

What needs to be screened for following dermatomyositis diagnosis?

A

Malignancy

59
Q

Main side effect of colchicine?

60
Q

Rapid onset proximal shoulder and pelvic girdle muscle pains and stiffness, raised inflammatory markers but normal CK?

A

Polymyalgia rheumatica

61
Q

Treatment of polymyalgia rheumatica?

A

Prednisolone

62
Q

Risk factors for gout

A

Cytotoxic drugs (chemo)
Diuretics
CKD
Severe psoriasis

63
Q

Ankylosing spondylitis 6 As

A 
Anterior uveitis 
Achilles tendonitis 
Apical lung fibrosis 
Aortic regurgitation 
AV node block 
Amyloidosis
64
Q

Gout crystals in joint aspiration

A

Needle-shaped negatively birefringent under polarised light

65
Q

X-ray signs of gout

A

Joint effusion
Punched out erosions
Preservation of joint space until late stage
No osteopenia

66
Q

Osteogenesis imperfecta features

A 
Dental cares
Multiple fractures 
Blue sclera 
Autosomal dominant 
Deafness
Normal bloods
67
Q

Risk factors for osteomyelitis

A 
DM
Sickle cell anaemia 
IVDU 
Immunosuppression 
Alcohol excess
68
Q

Most common extrarticular RA complications

A

Resp: pulmonary fibrosis, pleural effusion

Eyes: keratoconjunctivitis sicca

Heart: IHD

Osteoporosis

Increased infection risk

Depression

69
Q

Still’s disease triad

A

Joint pain
Fevers in evening
Pink bumpy rash

NEGATIVE RF and ANA
Raised ferritin and WCC

70
Q

Middle-aged man with fever, itchiness, scleral icterus and red urine. Also has red purpura on legs. No respiratory symptoms. Likely diagnosis?

A

Polyarteritis nodosa

71
Q

What condition is temporal arteritis most associated with?

A

Polymyalgia rheumatica

72
Q

What must be tried before starting an ankylosing spondylitis patient on anti-tnf drugs?

A

2 NSAIDs on separate occasions 12 weeks apart

Physio throughout

73
Q

Allergic contact dermatitis - what kind of hypersensitivity reaction?

74
Q

Behcet syndrome triad and other features

A
  1. Oral ulcers
  2. Genital ulcers
  3. Anterior uveitis

+thrombophlebitis, neruo, GI, erythema nodosum
HLA-B51

75
Q

Raynaud’s phenomenon treatment

A

Nifedipine

Evening primrose oil and sildenafil

76
Q

How should methotrexate be prescribe?

A

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
Q

Causes of positive ANCA

A

IBD
SLE, RA, Sjorgen’s
Autoimmune hepatitis

Phase 3b (18 decks)

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