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Phase 2a - Rheumatology > Rheumatology Conditions A > Flashcards

Rheumatology Conditions A Flashcards

1
Q

Osteoarthritis - Description

A

mechanical degeneration of synovial joint articular cartilage

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2
Q

Osteoarthritis - Risk Factors (9)

A

1) >50 years old
2) female
3) genetic (50%)
4) obesity
5) diabetes mellitus
6) inflammatory arthritis
7) trauma
8) occupation
9) joint hypermobilility

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3
Q

Osteoarthritis - Pathophysiology (6)

A

1) progressive articular cartilage degradation (many causes)
2) exposed underlying bones damage
3) increased osteoblast bone synthesis (repair mechanism)
4) subarticular sclerosis (bone overgrowth around articular surface)
5) osteophytes (calcified bone overgrowth at joint margins)

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4
Q

Osteoarthritis - Symptoms (5)

A

1) progressive joint pain (esp. after activity)
2) joint stiffness (esp. after rest, <30 mins in morning)
3) limited joint movement
4) crepitus (crunching sensation when moving joint)
5) tenderness around joint

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5
Q

Osteoarthritis - Signs (4)

A

1) Bouchard’s nodes (PIPJ bone swelling)
2) Herberden’s nodes (DIPJ bone swelling)
3) joint effusion (increased intra-articular fluid)
4) surrounding muscle wasting

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6
Q

Osteoarthritis - Investigations (2/3)

A

initial
1) joint x-ray (LOSS, loss of joint space, osteophytes, subchondral cysts, subchondral sclerosis)
2) normal CRP + ESR (exclude RA)
consider
1) joint MRI
2) rheumatoid factor (negative, exclude RA)
3) anti-CCP (negative, exclude RA)

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7
Q

Osteoarthritis - Management (6/1/3)

A 
conservative
1) regular exercise
2) weight loss
3) hot/cold packs
4) joint braces
5) joint supports
6) insoles
medical
1) analgesia
surgery
1) joint replacement (hip, knee)
2) osteotomy (change bone shape)
3) arthrodesis (joint immobilisation) (unmanageable pain)
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8
Q

Osteoarthritis - Management (Analgesia) (4)

A

1) paracetamol ± TOP NSAID
2) NSAID + PPI
3) codeine
4) IA corticosteroid (short term severe symptoms)

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9
Q

Rheumatoid Arthritis - Description

A

chronic systemic autoimmune inflammation that affects joints (synovium)

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10
Q

Rheumatoid Arthritis - Risk Factors (6)

A

1) 40-55 years old
2) female (2:1)
3) family history
4) genetic (HLA-DR1, HLA-DR4)
5) infection (e.g. gingivitis)
6) smoking

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11
Q

Rheumatoid Arthritis - Pathophysiology (9)

A

1) environmental trigger (e.g. smoking)
2) citrullination (arginine —> citrulline) of proteins (e.g. type 2 collagen)
3) genetic susceptibility (e.g. HLA-DR1)
4) citrullinated proteins no longer recognised as self-antigens
5) autoimmune reaction to citrullinated proteins (anti-CCP)
6) overproduction of inflammatory cytokines in joints
7) synovium proliferates forming pannus (thick swollen synovial membrane with granulation tissue)
8) articular cartilage degeneration due to pannus
9) underlying bones are exposed and damage (bony erosions)

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12
Q

Rheumatoid Arthritis - Symptoms (9)

A

1) joint pain (esp. MCP, PIP, MTP
2) joint stiffness (esp. in cold, >1 hour in morning)
3) joint tenderness (esp. MCP, PIP, MTP)
4) joint swelling (esp. MCP, PIP, MTP)
5) joint erythema (esp. MCP, PIP, MTP)
6) joint warmth (esp. MCP, PIP, MTP)
systemic
1) fatigue
2) fever
3) weight loss

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13
Q

Rheumatoid Arthritis - Signs (6)

A

1) ulnar deviation (swelling of MCPJ causes fingers to drift towards little finger)
2) Z thumb deformity (MCPJ hyperextension, PIPJ flexion)
3) swan neck deformity (PIPJ hyperextension, DIPJ flexion)
4) Boutonniere’s deformity (PIPJ flexion, DIPJ hyperextension)
5) rheumatoid nodules (esp. elbows)
6) surrounding muscle wasting

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14
Q

Rheumatoid Arthritis - Complications (9)

A

1) frozen shoulder
2) neuropathies (e.g. carpal tunnel syndrome)
3) tenosynovitis
4) pleural disease (inc. pleural effusion)
5) pericarditis
6) ischaemic heart disease
7) vasculitis
8) scleritis
9) osteopenia—>osteoporosis

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15
Q

Rheumatoid Arthritis - Investigations (5/2)

A 
initial
1) joint x-ray (periarticular erosions: early—>soft tissue, late—>joint space loss, later—>bone)
2) high CRP + ESR*
3) rheumatoid factor* (70% positive)
4) anti-CCP* (70% positive)
5) FBC (anaemia, leucocytosis)
consider
1) joint MRI
2) joint ultrasound
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16
Q

Rheumatoid Arthritis - Diagnosis (5/3/2/2)

A 
≥6 = diagnosis
joints
1) 1 large joint = 0
2) 2-10 large joints = 1
3) 1-3 small joints = 2
4) 4-10 small joints = 3
5) >10 small joints = 4
serology
1) negative RF + anti-CCP = 0
2) low positive RF or anti-CCP = 2
3) high positive RF or anti-CCP = 3
inflammation
1) normal CRP + ESR = 0
2) high CRP or ESR = 1
duration
1) <6 weeks = 0
2) >6 weeks = 1
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17
Q

Rheumatoid Arthritis - Management (4/4/2)

A

conservative
1) regular exercise
2) weight loss
3) smoking cessation
4) physiotherapy
medical
1) DMARDs (e.g. methotrexate*, sulfasalazine)
2) IM, PO, IA corticosteroids (short term symptomatic flares)
3) NSAID
4) biological agent (e.g. TNF-αi infliximab)
surgery
1) synovectomy (reduce inflamed tissue bulk)
2) arthroplasty (severely affect joints)

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18
Q

Gout - Description

A

inflammatory arthritis due to intra-articular monosodium urate crystals

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19
Q

Gout - Causes (1)

A

1) hyperuricaemia

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20
Q

Gout - Risk Factors (Decreased Urate Excretion) (8)

A

90%

1) elderly
2) male (4:1)
3) post-menopausal
4) diabetes mellitus
5) hypertension
6) kidney disease
7) thiazide diuretic
8) aspirin

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21
Q

Gout - Risk Factors (Increased Urate Production) (5)

A

10%

1) alcohol (esp. beer)
2) purine rich foods (e.g. red meat)
3) sweeteners
4) lymphoproliferative disorders (e.g. ALL)
5) myeloproliferative disorders (e.g. CML)

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22
Q

Gout - Precipitants (5)

A

1) heavy meal
2) heavy drinking
3) cold
4) trauma
5) infection

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23
Q

Gout - Symptoms (5)

A

1) rapid onset severe joint pain (esp. 1st MTP, big toe >50%)
2) joint tenderness
3) joint swelling
4) joint erythema
5) joint warmth

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24
Q

Gout - Signs (2)

A

1) tophi (aggregates of monosodium urate crystals that form nodules in joints, esp. elbows, knees)
2) few joints affected (usually <4)

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25
Q

Gout - Complications (3)

A

1) osteoarthritis
2) nephrolithiasis
3) kidney disease

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26
Q

Gout - Investigations (1/3)

A

initial
1) joint fluid aspiration + microscopy (negatively bifringent crystals)
consider
1) serum uric acid (high, 2 weeks after attack)
2) joint x-ray (punched-out periarticular erosions)
3) joint ultrasound

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27
Q

Gout - Management (4/5/0)

A 
conservative
1) dietary advice (avoid purine rich foods, eat dairy)
2) weight loss
3) alcohol control
4) monitor RFT
medical 
1) NSAID (high dose) + PPI
2) colchicine (NSAID intolerant)
3) IM, PO, IA corticosteroids
4) allopurinol (3 weeks after attack)
5) replace thiazide diuretics with ARBs
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28
Q

Pseudogout - Description

A

inflammatory arthritis due to intra-articular calcium pyrophosphate crystals

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29
Q

Pseudogout - Risk Factors (7)

A

1) old age
2) female
3) hyperparathyroidism
4) haemochromatosis
5) diabetes mellitus
6) oestoarthritis
7) joint trauma

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30
Q

Pseudogout - Symptoms (6)

A

1) rapid onset severe joint pain (esp. wrist, knee)
2) joint tenderness
3) joint swelling
4) joint erythema
5) joint warmth
6) fever

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31
Q

Pseudogout - Investigations (2/4)

A

initial
1) joint fluid aspiration + microscopy* (positively birefringent crystals)
2) joint fluid aspiration + culture (exclude septic arthritis)
consider
1) joint x-ray (chondrocalcinosis - linear calcification parallel to articular surfaces)
2) FBC (leucocytosis)
3) UnE (exclude hyperparathyroidism)
4) iron studies (exclude haemochromatosis)

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32
Q

Pseudogout - Management (0/4/2)

A 
medical
1) NSAID (high dose) + PPI
2) colchicine (NSAID intolerant)
3) IM, PO, IA corticosteroid
4) paracetamol
surgery
1) joint fluid aspiration
2) joint replacement
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33
Q

Osteoporosis - Description

A

decreased bone density

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34
Q

Osteoporosis - Risk Factors (10)

A

1) >50 years old (female)
2) >65 years old (male)
3) female
4) family history
5) Caucasian
6) Asian
7) smoking
8) alcohol
9) steroids
10) low BMI (<19)

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35
Q

Osteoporosis - Symptoms (2)

A

1) vertebral pain

2) vertebral tenderness

36
Q

Osteoporosis - Signs (1)

A

1) increased kyphosis (abnormally outwardly curved thoracic spine)

37
Q

Osteoporosis - Complications (1)

A

1) fracture (wrist, spine, hip)

38
Q

Osteoporosis - Investigations (5/0)

A

initial

1) x-ray (fracture, not osteopenia)
2) dual absorption x-ray absorptiometry (DEXA) scan* (T score<2.5)
3) serum Ca2+ (normal)
4) serum PO43- (normal)
5) serum ALP (normal)

39
Q

Osteoporosis - Management (6/3/0)

A

conservative
1) dietary advice (high dietary calcium, vitamin D intake)
2) weight bearing exercise
3) balance exercise
4) home fall prevention (inc. home visits)
5) smoking cessation
6) alcohol control
medical
1) bisphosphonates (1st line)
2) calcium supplement (e.g. calcium carbonate)
3) vitamin D supplement (e.g. ergocalciferol)

40
Q

Ankylosing Spondylitis - Description

A

spine and sacroiliac joint sclerosis and immobility due to new bone formation caused by chronic inflammation

41
Q

Ankylosing Spondylitis - Risk Factors (5)

A

1) 15-30 years old
2) male (more severe)
3) HLA-B27
4) Native American
5) Klebsiella pneumoniae

42
Q

Ankylosing Spondylitis - Pathophysiology (3)

A

1) inflammation of enthesis (site of ligament attachment to bone)
2) enthesitis heals with sclerosis and new bone formation (syndesmophytes)
3) fusion of vertebral bodies

43
Q

Ankylosing Spondylitis - Symptoms (7)

A

1) sacroiliac joint pain (radiates to hips/buttocks, better at night)
2) progressive lower spinal pain (worse at night, relieved by exercise)
3) progressive spinal stiffness (relieved by exercise)
4) progressive limited spinal movement (frontal, sagittal)
5) sleep disturbances
6) fatigue
7) dyspnoea (kyphotic or costochondral joint)

44
Q

Ankylosing Spondylitis - Signs (4)

A

1) decreased thoracic expansion
2) decreased lordosis (abnormally straight cervical and lumbar spine)
3) increased kyphosis (abnormally outwardly curved thoracic spine)
4) Schober’s test

45
Q

Ankylosing Spondylitis - Complications (5)

A

1) enthesitis (e.g. Achilles tendonitis, plantar fasciitis)
2) iritis/uveitis
3) aortitis —> aortic regurgitation
4) osteoporosis
5) anaemia

46
Q

Ankylosing Spondylitis - Investigations (3/3)

A

initial
1) MRI (sacroiliitis, bone marrow oedema)
2) pelvic x-ray (sacroiliitis, sacroiliac joint margin erosion/sclerosis)
3) cervical, thoracic, lumbar x-ray (bamboo spine, sacroiliac joint margin erosion/sclerosis, syndesmophytes)
consider
1) FBC (normocytic anaemia)
2) high CRP + ESR
3) rheumatoid factor (negative)

47
Q

Ankylosing Spondylitis - Management (3/4/2)

A 
conservative
1) regular exercise
2) good posture
3) physiotherapy
medical
1) NSAID
2) analgesia (e.g. paracetamol, codeine)
3) IA corticosteroid (short term severe symptoms)
4) TNF-αi (refractory, severe)
surgery
1) hip replacement
2) spinal osteotomy
48
Q

Psoriatic Arthritis - Description

A

chronic autoimmune inflammatory joint disease associated with psoriasis

49
Q

Psoriatic Arthritis - Risk Factors (3)

A

1) psoriasis
2) HLA-B27
3) family history

50
Q

Psoriatic Arthritis - Patterns (5)

A

1) asymmetrical oligoarticular - <5 joints (esp. weight bearing)
2) symmetrical polyarticular - >5 joints (esp. small joints) (RA like)
3) spondylarthritis - sacroiliac joints and cervical spine (AS like)
4) distal interphalangeal predominate - DIP joints
5) arthritis mutilans - DIP joints (severe)

51
Q

Psoriatic Arthritis - Symptoms (5)

A

1) joint pain
2) joint swelling
3) joint stiffness
4) joint erythema
5) joint warmth

52
Q

Psoriatic Arthritis - Signs (3)

A

1) dactylitis (DIP, AM)
2) nail abnormalities (e.g. ringing, pitting) (DIP, AM)
3) telescoping fingers (bone resorption collapses finger soft tissue) (AM)

53
Q

Psoriatic Arthritis - Complications (1)

A

1) cardiovascular conditions

54
Q

Psoriatic Arthritis - Investigations (6/0)

A

initial

1) joint x-ray* (erosion) (AO, SP)
2) pelvic, spinal x-ray (sacroiliitis, syndesmophytes) (SA)
3) hand, feet x-ray (DIP ‘pencil in cup’ erosion) (DIP, AM)
4) normal CRP + ESR
5) rheumatoid factor (negative)
6) anti-CCP (negative)

55
Q

Psoriatic Arthritis - Management (1/4/2)

A

conservative
1) physiotherapy
medical
1) DMARD (e.g. methotrexate, sulfasalazine)
2) NSAID
3) IA corticosteroid (short term severe symptoms)
4) TNF-αi (e.g. infliximab) (refractory, severe)
surgery
1) hip replacement
2) joint replacement

56
Q

Reactive Arthritis - Description

A

acute inflammatory arthritis post GI or GU infection

57
Q

Reactive Arthritis - Causes (5)

A 
GI
1) Salmonella
2) Shigella
3) Campylobacter
GU
4) Gonorrhoea
5) Chlamydia
58
Q

Reactive Arthritis - Risk Factors (3)

A

1) 20-40 years old
2) male
3) HLA-B27

59
Q

Reactive Arthritis - Symptoms (8)

A 
large joints asymmetrical (esp. sacroiliac, knees, ankles)
1) joint pain
2) joint swelling
3) joint stiffness
4) joint erythema
5) joint warmth
systemic
1) fever
2) fatigue
3) weight loss
60
Q

Reactive Arthritis - Signs (1)

A

1) dactylitis

61
Q

Reactive Arthritis - Complications (6)

A

1) conjunctivitis
2) uveitis
3) urethritis
4) cervicitis
5) enthesitis
6) secondary osteoarthritis

62
Q

Reactive Arthritis - Investigations (6/0)

A

initial

1) stool culture (gen. negative unless tested very early)
2) urine culture (gen. negative unless tested very early)
3) high CRP + ESR
4) rheumatoid factor (negative)
5) anti-CCP (negative)
6) x-ray (chronic - sacroiliitis, enthesitis)

63
Q

Reactive Arthritis - Management (3/4/0)

A 
conservative
1) screen sexual partners
2) rest
3) splint
medical
1) antibiotics
2) NSAID
3) IA corticosteroid (short term severe symptoms)
4) DMARD (chronic, >6 months)
64
Q

Septic Arthritis - Description

A

acute inflammatory arthritis due to joint infection (medical emergency)

65
Q

Septic Arthritis - Causes (5)

A

1) Staphylococcus aureus
2) Streptococci
3) Neisseria gonorrhoea
4) Haemophilus influenzae
5) Escherichia coli

66
Q

Septic Arthritis - Risk Factors (7)

A

1) osteoarthritis
2) rheumatoid arthritis
3) prosthetic joint
4) IA corticosteroid
5) IV drug abuse
6) diabetes mellitus
7) alcohol

67
Q

Septic Arthritis - Symptoms (7)

A

1) joint pain (agonising in young, muted in old)
2) joint swelling
3) joint tenderness
4) joint erythema
5) joint warmth
6) loss of joint function
7) fever

68
Q

Septic Arthritis - Complications (2)

A

1) joint destruction

2) osteomyelitis

69
Q

Septic Arthritis - Investigations (4)

A

initial

1) blood culture (identify bacteria)
2) joint fluid aspiration + stain, culture (identify bacteria)
3) joint fluid aspiration + microscopy (exclude gout/pseudogout)
4) high CRP + ESR (CRP may be normal)

70
Q

Septic Arthritis - Management (3/4/1)

A 
conservative
1) monitor CRP + ESR
2) joint immobilisation
3) physiotherapy
medical
1) stop DMARDs + TNFαi
2) double corticosteroid dose
3) IV antibiotics (2 weeks) (after fluid aspiration)
4) NSAID
surgery
1) joint drainage
71
Q

Osteomyelitis - Description

A

infection of bone and/or bone marrow

72
Q

Osteomyelitis - Causes (5)

A

1) Staphylococcus aureus (90%)
2) Streptococci
3) Pseudomonas
4) Escherichia coli

73
Q

Osteomyelitis - Risk Factors (5)

A

1) trauma (penetrating)
2) surgery (contamination)
3) IV drug abuser
4) diabetes mellitus
5) peripheral vascular disease

74
Q

Osteomyelitis - Routes (3)

A

1) direct (e.g. trauma, surgery) - common
2) contiguous (e.g. DM, PVD)
3) haematogenous (skin—>blood—>bone) - rare

75
Q

Osteomyelitis - Symptoms (9)

A

1) dull pain at infection site
2) infection site swelling
3) infection site tenderness
4) infection site erythema
5) infection site warmth
6) fever
7) fatigue
8) malaise
9) draining sinus tracts (chronic)

76
Q

Osteomyelitis - Complications (3)

A

1) septic arthritis
2) fracture
3) growth retardation

77
Q

Osteomyelitis - Investigations (3/3)

A 
initial
1) FBC (leucocytosis - acute)
2) high CRP + ESR
3) x-ray (osteopenia)
consider
1) bone MRI (marrow oedema)
2) bone marrow biopsy*
3) bone marrow culture*
78
Q

Osteomyelitis - Management (2/1/1)

A 
conservative
1) monitor CRP + ESR
2) limb immobilisation
medical
1) antibiotics (high dose)
surgery
1) surgical debridement
79
Q

Systemic Lupus Erythematosus - Description

A

multisystemic inflammatory autoimmune disorder

80
Q

Systemic Lupus Erythematosus - Risk Factors (7)

A

1) 20-40 years old
2) female
3) family history
4) African/Asian descent in West
5) genetics
6) drugs (e.g. hydralazine, penicillamine)
7) smoking

81
Q

Systemic Lupus Erythematosus - Pathophysiology (7)

A

1) inefficient phagocytise removal of apoptotic cellular remnant bless
2) blebs transferred to lymphoid tissue
3) normally hidden nuclear antigens are recognised as foreign
4) antigens stimulate production of autoantibodies
5) autoantibodies either circulate or deposit in tissues
6) autoantibodies actuate complement system and neutrophil influx
7) multisystem inflammatory autoimmune disorder

82
Q

Systemic Lupus Erythematosus - Symptoms (8)

A

1) arthralgia (RA like)
2) seizures
3) psychosis
systemic
4) fever
5) fatigue
6) weight loss
7) malaise
8) myalgia

83
Q

Systemic Lupus Erythematosus - Signs (7)

A

1) butterfly erythema
2) photosensitive rash
3) discoid rash
4) oral ulcers
5) alopecia
6) vasculitic lesions
7) Raynaud’s pheno (digit colour change to red—>white—>blue due to artery spasm)

84
Q

Systemic Lupus Erythematosus - Complications (7)

A

1) anaemia (chronic haemolytic)
2) pericarditis/myocarditis/endocarditis
3) cardiovascular disease
4) pleuritis/pleural effusion
5) nephritis
6) vasculitis
7) depression

85
Q

Systemic Lupus Erythematosus - Investigations (7/1)

A

initial
1) anti-nuclear antibodies (95% positive)
2) anti-dsDNA antibodies (60% positive, highly specific) (confirmation)
3) anti-Smith antibodies (confirmation)
4) FBC (anaemia, leucopenia, thrombocytopenia)
5) normal CRP
6) high ESR
7) UnE (high urea, creatine)
consider
1) any test that confirms complications

86
Q

Systemic Lupus Erythematosus - Monitoring (3)

A

1) anti-dsDNA antibodies
2) C3 + C4 levels
3) ESR

87
Q

Systemic Lupus Erythematosus - Management (4/6/0)

A

conservative
1) monitor
2) high factor sunscreen
3) weight loss (CVD risk)
4) smoking cessation (CVD risk)
medical
1) hydroxychloroquine (arthralgia, fatigue, skin disease)
2) NSAID (arthralgia, fever)
3) PO/IM corticosteroid (arthralgia, serositis)
4) TOP corticosteroid (rash)
5) immunosuppressant (e.g. methotrexate, azarthioprine)
6) cyclophosphamide (neuropsychotic symptoms, nephritis)

Phase 2a - Rheumatology (2 decks)

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