Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Year 3 - Medicine > Rheumatology - Arthropathies > Flashcards

Rheumatology - Arthropathies Flashcards

1
Q

What is rheumatoid arthritis?

A

An autoimmune condition that causes chronic inflammation of the synovial lining of the joints, tendon sheaths and bursa.

It is a symmetrical polyarthritis.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What are the genetic associations with rheumatoid arthritis?

A
  • HLA DR4
  • HLA DR1
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Which antibodies are associated with rheumatoid arthritis?

A

Rheumatoid factor (RF) is an autoantibody that targets the Fc portion of the IgG antibody. This causes activation of the immune system against the patients own IgG, causing systemic inflammation.

Anti-CCP is an autoantibody that pre-dates the development of rheumatoid arthritis, and gives an indication that a patient will go on to develop rheumatoid arthritis in future.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Presentation of rheumatoid arthritis.

A

Symmetrical distal polyarthropathy:
- pain
- swelling
- stiffness
- fatigue
- weight loss
- myalgia

Most commonly affected joints are the wrist, ankle, and the MCP and PIP in the hands.

Pain from an inflammatory arthritis is worse after rest but improves with activity. Pain from a mechanical problem such as osteoarthritis is worse with activity and improves with rest.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

What is palindromic rheumatism?

A

Self-limiting and short episodes of inflammatory arthritis.

Having positive antibodies (ie. RF and anti-CCP) indicate that it will progress to full rheumatoid arthritis.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

What are the common joints affected in rheumatoid arthritis?

A
  • PIPJ, MCPJ, wrist
  • MTPJ, ankle
  • cervical spine

TOM TIP: The distal interphalangeal joints are almost never affected by rheumatoid arthritis. If you come across enlarged painful distal interphalangeal joints this is most likely to be Heberden’s nodes due to osteoarthritis.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Which signs may be seen in a patient with rheumatoid arthritis?

A
  • Z shaped deformity to the thumb
  • swan neck deformity (hyperextended PIPJ with flexed DIPJ)
  • Boutonnieres deformity (hyperextended DIPJ with flexed PIPJ)
  • ulnar deviation at MCPJ
  • rheumatoid nodules at the elbow
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

What are the extra-articular manifestations of rheumatoid arthritis?

A

3Cs, 3As, 3Ps and 3Ss:

  • carpal tunnel syndrome
  • CVD risk
  • cord compression (atlanto-axial subluxation)
  • anaemia of chronic disease
  • amyloidosis
  • arteritis
  • pericarditis
  • pleural disease
  • pulmonary disease (e.g. bronchiectasis)
  • Sjögren’s syndrome
  • scleritis
  • splenic enlargement
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

How is rheumatoid arthritis investigated?

A
  • RF and anti-CCP
  • CRP and ESR (inflammatory markers)
  • WCC to exclude septic arthritis
  • X-ray of hands and feet
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

What X-ray changes are present in rheumatoid arthritis?

A

LESS:

  • loss of joint space
  • erosions (periarticular)
  • soft tissue swelling
  • subluxation
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

What is the referral criteria for rheumatoid arthritis?

A

NICE recommend referral for any adult with persistent synovitis, even if they have negative rheumatoid factor, anti-CCP antibodies and inflammatory markers.

The referral should be urgent if it involves the small joints of the hands or feet, multiple joints or symptoms have been present for more than 3 months.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

What is the diagnostic criteria for rheumatoid arthritis?

A

ELAR criteria scores patients based upon:
- joints that are involved
- serology
- inflammatory markers
- duration of symptoms

A score of >5 indicates a diagnosis of rheumatoid arthritis.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

What is the DAS28 score?

A

Disease activity score bases the assessment of 28 joints, useful for monitoring disease activity and response to treatment.

Points are given for:
- swollen joints
- tender joints
- ESR / CRP results

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

How is rheumatoid arthritis managed?

A

First line: monotherapy with methotrexate

Second line: methotrexate + leflunomide or sulfasalazine

Third line: methotrexate + TNF inhibitor

Fourth line: methotrexate + rituximab

A short course of NSAIDs can be used at first presentation to settle the disease; they should be co-prescribed with proton pump inhibitors to lower risk of GI bleeding.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

What is osteoarthritis?

A

A mechanical arthritis occurring when joint overuse causes cartilage destruction.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Give some risk factors for osteoarthritis.

A
  • obesity
  • age
  • occupation
  • trauma
  • female sex
  • family history
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Presentation of osteoarthritis.

A
  • joint pain
  • stiffness
  • worsened by activity
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Which joints are commonly affected by osteoarthritis?

A
  • hips
  • knees
  • sacroiliac joints
  • DIPJ
  • wrist
  • cervical spine
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

What are the signs of osteoarthritis?

A
  • Heberden’s nodes (DIPJ)
  • Bouchard’s nodes (PIPJ)
  • squaring at base of the thumb
  • weak grip
  • reduced range of motion
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

What are the x-ray changes seen in osteoarthritis?

A

LOSS:

  • loss of joint space
  • osteopenia
  • subchondral cysts
  • subarticular sclerosis
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

How is osteoarthritis diagnosed?

A

NICE (2014) suggest that a diagnosis can be made without any investigations if the patient is over 45, has typical activity related pain and has no morning stiffness or stiffness lasting less than 30 minutes.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

How is osteoarthritis managed?

A

Conservative management including weight loss, physiotherapy and occupational therapy.

Pharmacological management:
- oral paracetamol and topical NSAIDs
- oral NSAIDs with PPI
- opiates such as codeine and morphine

Intra-articular steroid injections provide a temporary reduction in inflammation and improve symptoms.

Joint replacement can be used in severe cases. The hip and knee are the most commonly replaced joints.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

What are spondyloarthropathies?

A

A group of conditions that affect the spine and peripheral joints, associated with the presence of HLA-B27:
- ankylosing spondylitis
- enteropathic arthritis
- psoriatic arthritis
- reactive arthritis

24
Q

What is psoriatic arthritis?

A

An inflammatory arthritis associated with psoriasis.

25
Q

What are the signs of psoriatic arthritis?

A
  • plaques of psoriasis on skin
  • pitting of the nails
  • onycholysis (separation of nail from nail bed)
  • dactylitis (inflammation of full finger)
  • enthesitis (inflammation of the entheses)
26
Q

What is arthritis mutilans?

A

The most severe form of psoriatic arthritis, occurring in the phalanxes.

There is osteolysis (destruction) of the bones around the joints in the digits. This leads to progressive shortening of the digit. The skin then folds as the digit shortens giving an appearance that is often called a “telescopic finger”.

27
Q

How is psoriatic arthritis managed?

A

Management is similar to rheumatoid arthritis. There is a crossover between the systemic treatments of psoriasis and treatment of psoriatic arthritis. Treatment is often coordinated between dermatologists and rheumatologists.

Depending on the severity the patient might require:

NSAIDs for pain
DMARDS (methotrexate, leflunomide or sulfasalazine)
Anti-TNF medications (etanercept, infliximab or adalimumab)
Ustekinumab is last line (after anti-TNF medications) and is a monoclonal antibody that targets interleukin 12 and 23

28
Q

What is reactive arthritis?

A

A cause of acute monoarthritis, occurring in reaction to a recent infective trigger.

The most common infections that trigger reactive arthritis are gastroenteritis or Chlamydia trachomatis.

29
Q

Signs of reactive arthritis.

A
  • monoarticular joint pain, swelling and stiffness
  • bilateral conjunctivitis
  • anterior uveitis
  • dermatitis of the head of penis
30
Q

What is the management of reactive arthritis.

A

Patients presenting with an acute warm, swollen, painful joint need to be treated according to the local “hot joint” policy. This will involve giving antibiotics until the possibility of septic arthritis is excluded. Aspirate the joint and send a sample for gram staining, culture and sensitivity testing to exclude septic arthritis.

The aspirated fluid can also be sent for crystal examination to look for gout and pseudogout.

Management of reactive arthritis when septic arthritis is excluded:

NSAIDs
Steroid injections into the affected joints
Systemic steroids may be required, particularly where multiple joints are affected
Most resolve within 6 months and don’t recur. Recurrent cases may require DMARDs or anti-TNF medications.

31
Q

What is ankylosing spondylitis?

A

The most common spondyloarthropathy, being an inflammatory condition that mainly affects the spine and causes progressive stiffness and pain.

32
Q

Presentation of ankylosing spondylitis.

A

Most common in young adult males. Symptoms develop gradually over 3 months:

  • lower back pain and stiffness
  • sacroiliac pain
  • pain worse with rest, improves with movement

Note vertebral fractures are a key complication of ankylosing spondylitis.

33
Q

What are the associations of ankylosing spondylitis?

A
  • systemic symptoms (e.g. weight loss, fatigue)
  • chest pain
  • enthesitis
  • dactylitis
  • anaemia
  • aortitis
  • heart block
  • restrictive lung disease
  • pulmonary fibrosis (1%)
  • inflammatory bowel disease
34
Q

What is Schober’s test? What finding would be supportive of ankylosing spondylitis?

A

Have the patient stand straight. Find the L5 vertebrae. Mark a point 10cm above and 5cm below this point (15cm apart from each other). Then ask the patient to bend forward as far as they can and measure the distance between the points.

If the distance with them bending forwards is less than 20cm, this indicates a restriction in lumbar movement and will help support a diagnosis of ankylosing spondylitis.

35
Q

How is ankylosing spondylitis investigated?

A
  • CRP and ESR raised
  • HLA B27 genetic test
  • X-ray of the spine and sacrum
  • MRI of the spine
36
Q

How is ankylosing spondylitis managed?

A

Conservative management included smoking cessation and physiotherapy.

Medications:
- NSAIDs to control pain
- steroids in flares of symptoms
- bisphosphonates to protect against osteoporosis in prolonged steroid use
- anti-TNF
- IL-17 inhibitors

37
Q

What is gout?

A

A crystal arthropathy associated with chronically high blood uric acid concentration, leading to deposition of monosodium urate crystals within the joint.

38
Q

Risk factors for gout.

A
  • male
  • obesity
  • high purine diet (e.g. meat, seafood)
  • alcohol
  • diuretics
  • family history
39
Q

Presentation of gout.

A

Acute monoarthropathy
- pain
- swelling
- hot
- gouty tophi

The obvious and extremely important differential diagnosis is septic arthritis.

40
Q

Which joints are typically affected by gout?

A
  • base of the big toe
  • wrists
  • base of the thumb
41
Q

How is gout investigated?

A
  • joint aspiration
  • joint x-ray
42
Q

Aspirated fluid suggestive of gout will show:

A
  • no bacterial growth (exclude septic arthritis)
  • needle shaped crystals
  • negatively birefringent of polarised light
  • monosodium urate crystals
43
Q

Joint xray suggestive of gout will show:

A
  • maintenance of joint space
  • lytic lesions in bone
  • punched out erosions
44
Q

How is acute gout managed?

A
  • NSAIDs first line
  • colchicine second-line
  • steroids third line
45
Q

How can acute gout attacks be prophylactically avoided?

A

Allopurinol is a xanthine oxidase inhibitor used for the prophylaxis of gout. It reduces the uric acid level.

Lifestyle changes can reduce the risk of developing gout. This involves losing weight, staying hydrated and minimising the consumption of alcohol and purine-based food (such as meat and seafood).

TOM TIP: Do not initiate allopurinol prophylaxis until after the acute attack is settled. Once treatment of allopurinol has been started then it can be continued during an acute attack.

46
Q

What is pseudogout?

A

A cyrstal arthropathy caused by calcium pyrophosphate crystals deposition within the joint.

47
Q

Presentation of pseudogout.

A

Typical presentation is an older adult with:

  • hot
  • swollen
  • stiff
  • painful

joint.

48
Q

Which joints are most commonly affected by pseudogout?

A
  • knee (most common)
  • shoulders
  • wrist
  • hip
49
Q

How is pseudogout investigated?

A
  • joint aspiration for synovial fluid
  • xray
50
Q

Aspirated fluid suggestive of pseudogout will show:

A
  • no bacterial growth (excludes septic arthritis)
  • calcium pyrophosphate crystals
  • rhomboid shapes crystals
  • positive birefringent of polarised light
51
Q

Xray findings suggestive of pseudogout will show:

A
  • chondrocalcinosis (calcium deposition within joint space)
  • loss of joint space
  • osteophytes
  • subarticular sclerosis
  • subchondral cysts
52
Q

How is pseudogout managed?

A

Chronic asymptomatic changes found on an xray do not require any action.

Symptoms usually resolve spontaneously over several weeks. Symptomatic management involves:

  • NSAIDs
  • Colchicine
  • Joint aspiration
  • Steroid injections
  • Oral steroids

Joint washout (arthrocentesis) is an option in severe cases.

53
Q

What is Sjögren’s syndrome?

A

An autoimmune condition that affects the exocrine glands, associated with rheumatoid arthritis and systemic lupus erythematous.

54
Q

Presentation of Sjögren’s syndrome.

A

MAD FRED!

Myalgia
Arthralgia
Dry mouth

Fatigue
Raynaud’s phenomenon
Enlarged parotids
Dry eyes

55
Q

Which antibodies are typically related to Sjögren’s syndrome?

A

Anti-Ro and anti-La antibodies

RF and anti-dsDNA may be seen

56
Q

What is Schirmer’s test?

A

The Schirmer test involves inserting a folded piece of filter paper under the lower eyelid with a strip hanging out over the eyelid.

This is left in for 5 minutes and the distance along the strip hanging out that becomes moist is measured. The tears should travel 15mm in a healthy young adult. A result of less than 10mm is supportive of Sjögren’s syndrome.

57
Q

What is the management of Sjögren’s syndrome?

A

Symptomatic management:
- artificial tears
- artificial saliva
- vaginal lubricants

Hydroxychloroquine is used to halt the progression of the disease.

Year 3 - Medicine (33 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions