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Medicine Year 2 2 > Rheumatology/ MSK > Flashcards

Rheumatology/ MSK Flashcards

1
Q

RHEUMATOID ARTHRITIS

What is it?

A
  • chronic systemic inflammatory disease with a symmetrical, deforming and peripheral polyarthritis
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2
Q

RHEUMATOID ARTHRITIS

Epidemiology between males and females pre and post menopausal?

A

PRE- F:M 3:1

POST- 1:1

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3
Q

RHEUMATOID ARTHRITIS

Aetiology?

A

Genetics- HLA-DR4 and HLA-DR1

Presence of rheumatoid factor- autoantibodies against Fc portion of IgG

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4
Q

RHEUMATOID ARTHRITIS

Pathology?

A

1) Lymphocytes and macrophages produce IL-1 and TNFalpha, releasing metalloproteinases that destroy cartilage
2) Proliferation and growing of synovium over the articular cartilage (known as pannus), destroys articular cartilage and subchondral bone producing bony erosions

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5
Q

RHEUMATOID ARTHRITIS

Features of Inflammatory?

A

1) Pain eases with use
2) Significant stiffness >60 min
3) Synovial +- bony soft swelling
4) Hot and red
5) Younger patients with possible family history
6) Hands and feet
7) Responds to NSAID’s

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6
Q

OSTEOARTHRITIS

Features of Degenerative?

A

1) Pain increases with use
2) <30 mins of stiffness; not prolonged
3) no swelling (maybe hard swelling)
4) Not inflamed
5) Older people, prior occupation/sport
6) Common in CMCJ, DIPJ and knees
7) Less response to NSAID’s

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7
Q

RHEUMATOID ARTHRITIS

Signs?

What are the late deformities?

A
  • symmetrical painful and stiff small joints (MCP, PIP, MTP, wrist)

Nodules and neuropathy

Early= inflammation but no joint damage

Later= Deformities:

1) Ulnar deviation of fingers
2) Boutonnieres
3) z thumb (swan neck)
4) Swan neck

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8
Q

RHEUMATOID ARTHRITIS

Diagnosis?

A

bloods- Anaemia, rheumatoid factor +ve (70%), anti- CCP positive (90%), increased CRP, ESR, platelets

X-Rays 1) loss of joint space 2) Soft tissue swelling
3) Osteopenia next to cartilage 4) Joint deformity

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9
Q

RHEUMATOID ARTHRITIS

Treatment? (1st line, 2nd line and symptom and flare up relief)

A

1st - DMARDs (methotrexate, hydroxychloroquine)

2nd- biological agents alongside 1st line (infliximab, rituximab)

NSAIDs = symptom relief

Steroids (IM,IV) treat bad flare ups

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10
Q

OSTEOARTHRITIS

Risk factors and M:F RATIO?

A

1) Obesity
2) Age
3) Joint trauma
4) Active occupation

F:M 3:1

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11
Q

OSTEOARTHRITIS

What is the difference between primary and secondary

A

primary OA is generalised. Secondary is in joints that have already been damaged

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12
Q

OSTEOARTHRITIS

Signs?

A

1) Pain on movement and relieved by rest
2) Stiffness <30 mins
3) Crepitus present
4) bony swelling
5) 1st MCPJ and knees
6) Decreased RoM

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13
Q

OSTEOARTHRITIS

Diagnosis?

A

1) negative rheumatoid factor
2) X-Ray = LOSS

Loss of joint space
Osteophytes
Subchondral cysts
Subarticular sclerosis

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14
Q

OSTEOARTHRITIS

Treatment?

A

1) Physical management (padded shoes, stick, weight loss, brace)

1st- Paracetamol + topical NSAID
2nd- weak opioid and PO NSAID/PPI

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15
Q

OSTEOARTHRITIS

Treatment to relieve severe pain?

A

intra-articular steroids

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16
Q

OSTEOARTHRITIS

What if a patient works at night and has significant limitations of function?

A

consider surgery

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17
Q

OSTEOPOROSIS

What is the definition?

A

A bone density of >2.5 standard deviations below young adult mean

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18
Q

What is Osteopenia?

A

A bone density of between -1 and -2.5 standard deviations below young adult mean

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19
Q

OSTEOPOROSIS

Causes?

A

1) Increased bone loss
2) Inadequate peak adult bone mass
3) Women lose trabeculae with age

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20
Q

OSTEOPOROSIS

rISK FACTORS?

A 
Steroids
Hyperthyroidism
Alcohol and smoking
Thin BMI <22
Testosterone low
Early menopause
Renal/liver failure
Erosive bone disease (RA)
Dietary calcium low
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21
Q

OSTEOPOROSIS

Gold standard diagnosis?

A

DEXA scan- only needed for <75 years

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22
Q

OSTEOPOROSIS

Treatment? (lifestyle)

A
  • cessation of smoking
  • alcohol
  • calcium/ vit D increase
  • weight bearing exercise
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23
Q

OSTEOPOROSIS

Medical treatment?

A

1st- Bisphosphonates
2nd - strontium ranelate
3) Teriparatide
4th- denosumab

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24
Q

SYSTEMIC LUPUS ERYTHEMATOSUS

Epidemiology?

A
  • Women aged 20-40
  • F:M 9:1
  • Afro-american
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25
Q

SYSTEMIC LUPUS ERYTHEMATOSUS

Pathogenesis?

A

1) Apoptotic cell fragments aren’t closed fully by phagocytes
2) Taken up by APC’s in lymphoid tissue
3) Self antigens presented to T cells, stimulates B cells
4) Increase in complement activation, immune complex deposition and neutrophils = CLINICAL MANIFESTATIONS

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26
Q

SYSTEMIC LUPUS ERYTHEMATOSUS

Symptoms and Signs? (by organ)

A

Skin - butterfly/ Malar rash, photosensitivity
MSK- myalgia, arthralgia
general- tired, malaise, fever
CVS- Raynaud’s & pericarditis
Blood- anaemia, thrombocytopenia, leukopenia
Renal- proteinuria
Neuro- Epilepsy, migraines, neuropathies

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27
Q

SYSTEMIC LUPUS ERYTHEMATOSUS

Diagnosis?

A

4 of the Signs

FBC= anaemia, thrombocytopenia, leukopenia
increased ESR and normal CRP = Lupus
low complement factors (C3&4)
presence of anti-nuclear antibody (ANA)

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28
Q

What does ESR stand for?

A

erythrocyte sedimentation rate

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29
Q

SYSTEMIC LUPUS ERYTHEMATOSUS

Treatment?

A

Major organ involvement= IV Cyclophosphamide
Just MSK manifestation= PO prednisolone

For rashes= topical steroids and avoid sun

Maintenance- NSAIDs, hydroxychloroquine, steroids, azathioprine/ methotrexate

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30
Q

ANTIPHOSPHOLIPID SYNDROME

What is it?

A
  • Recurrent thromboses/ miscarriages

- Persistently negative blood tests for antiphospholipid antibodies

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31
Q

ANTIPHOSPHOLIPID SYNDROME

Cause?

A

C- Coagulation defect
L- Livedo reticulosis (lace-like purplish discoloration of the skin)
O- Obstetrics (miscarriage)
T- Thrombocytopenia

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32
Q

ANTIPHOSPHOLIPID SYNDROME

Features?

A

Arteries- stroke, TIA, MI
Veins- DVT
Miscarriages

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33
Q

ANTIPHOSPHOLIPID SYNDROME

Treatment?

A

No previous thromboses = Aspirin/Clopidogrel
Previous thromboses = Warfarin/ NOAC
Pregnant = Aspirin and Heparin

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34
Q

POLYMYOSITIS/ DERMATOMYOSITIS

What are they and what is the difference?

A

DERMATOMYOSITIS involves the skin

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35
Q

POLYMYOSITIS/ DERMATOMYOSITIS

What are they?

A
  • Inflammation of muscle
  • progressive symmetrical proximal muscle weakness
  • autoimmune mediated striated muscle inflammation (myositis)
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36
Q

POLYMYOSITIS/ DERMATOMYOSITIS

Signs?

A

1) Proximal muscle wasting
2) Proximal muscle weakness
3) Macular rash
4) General (fever, malaise)
5) Arthralgia
6) Hard to move (e.g. off of a chair/ up the stairs)

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37
Q

POLYMYOSITIS/ DERMATOMYOSITIS

Specific dermatomyositis features?

A

purple eyelids and scaly red plaques on knuckles

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38
Q

POLYMYOSITIS/ DERMATOMYOSITIS

Tests?

A
  • Muscle biopsy
  • Electromyography
  • Creatine Kinase increased

-Anti-JO antibodies (SPECIFIC)

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39
Q

POLYMYOSITIS/ DERMATOMYOSITIS

Treatment?

A

1st - PO prednisolone

2nd- Azathioprine/ methotrexate

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40
Q

SYSTEMIC LUPUS ERYTHEMATOSUS

Symptoms and Signs by the Pneumonic-

A 
Serositis 
Oral ulcers
Arthritis
Photosensitivity 
Blood disorders (low RBC,WBC,Platelets)
Renal disorders (lupus nephritis)
Antinuclear Ab
Immunological disorder (anti-dsDNA/ antiphospholipid Ab)
Neurological disorder (cerebral lupus)

Malar rash- fixed erythema over malar eminence
Discoid rash - erythromatous raised patches with adherent keratotic scaling and scarring

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41
Q

GOUT

What is it and what is the male to female ratio?

A

Hyperuricaemia and intra articular sodium urate crystals

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42
Q

GOUT

How may hyperuricaemia occur?

(aetiology)

A

Increased production- psoriasis, genetics, diet (shellfish, red meat, alcohol)

or

Decreased excretion from the kidneys - (CKD, NTN, thiazides, alcohol)

90% IS IDIOPATHIC

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43
Q

GOUT

Signs?

A
  • Acute severe pain
  • swelling and redness (inflammation)

50% occurs at 1st MTPJ

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44
Q

GOUT

What is it precipitated by?

A
  • cold
  • alcohol
  • diuretics
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45
Q

GOUT

Investigations?

A
  • Joint aspiration- shows urate crystals in synovial fluid
  • X-ray shows:
    1) Soft tissue swelling
    2) Peri-articular erosions
    3) Norma joint space
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46
Q

GOUT

Treatment?

A
  • NSAIDs, Colchicine, Steroids (prednisolone injection)

- Allopurinol

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47
Q

GOUT

Lifestyle advice?

A

Lose weight
stop drinking
avoid meats with high purines (red meat, shellfish)

48
Q

PSEUDO-GOUT

What is it?

A

deposition of calcium pyrophosphate crystals in articular cartilage - normally in the larger joints

49
Q

PSEUDO-GOUT

What would an X-ray show?

A

1) Chondrocalcinosis and soft tissue calcium deposits
2) Positive birefringent (optical property of a material having a refractive index)
3) Calcium pyrophosphate crystals

50
Q

PSEUDO-GOUT

who is it most commonly found in

A

elderly women

51
Q

PSEUDO-GOUT

Investigations and Treatment?

A
  • Joint aspiration

NSAIDs, colchicine, intra-articular steroid injections

52
Q

Features of SERONEGATIVE SPONDYLARTHROPATHIES

blood

MSK

Extra

A

1) negative rheumatoid factor
2) HLA-B27 positive

3) Dactylitis- inflammation of an entire digit (a finger or toe)
4) Enthesitis- irritability of soft tissues (muscles, tendons or ligaments) where it enter into the bones
5) Asymmetrical large joint oligoarthritis

6) extra- articular problems
such as aortic valve incompetence or IBD

53
Q

ANKYLOSING SPONDYLITIS

What is it and what is the epidemiology?

A

inflammatory disorder of the spine

F:M 1:6 (most common in young men)

54
Q

ANKYLOSING SPONDYLITIS

What is it relieved by?

A

Exercise

55
Q

ANKYLOSING SPONDYLITIS

Features in terms of spine shape?

A

1) Increased T spine kyphosis= top of back is excessively curved

2) Loss of lumbar lordosis, hip and knee flexion
= bottom of the back is curved

they will have a very straight back at the bottom then curve over like a C shape

56
Q

ANKYLOSING SPONDYLITIS

Other features? (not spine)

A
  • Achilles tendonitis (swelling and pain of Achilles)

- Plantar fasciitis (heel pain)

57
Q

ANKYLOSING SPONDYLITIS

Investigations?

A
  • X-ray
  • MRI

these will show:

1) bony spurs
2) calcified interspinous ligaments - bamboo spine
3) Erosion and sclerosis of SI joints

58
Q

ANKYLOSING SPONDYLITIS

Treatment?

A
  • NSAIDs and exercise
  • TNF alpha blockers if NSAIDs aren’t working
  • Local steroid injections
59
Q

SEPTIC ARTHRITIS

Septic arthritis can destroy a whole joint in only 24 hours. What organisms are common causes?

A

Staph aureus
Streptococci
N.gonnorhoeae
gram negatives

60
Q

SEPTIC ARTHRITIS

Risk factors?

A
  • DM
  • Immunosuppression
  • Prosthetic joint
61
Q

SEPTIC ARTHRITIS

Features?

A

hot, red, swollen and painful joint

62
Q

SEPTIC ARTHRITIS

Which joint is it found most commonly in? (>50%)

A

knee joint

63
Q

SEPTIC ARTHRITIS

Investigation?

A
  • joint aspiration for synovial fluid

- bloods (WCC) and cultures

64
Q

SEPTIC ARTHRITIS

Treatment?

A

S.aureus/ strep= Flucloxacillin

Gram negatives/ gonorrhoeae = Cefuroxime

65
Q

BACK PAIN

types?

A

Mechanical
Inflammatory
Serious

66
Q

BACK PAIN

Name some examples of inflammatory and mechanical back pain

A

Mechanical=disc prolapse, fracture, osteoarthritis

Inflammatory= ankylosing spondylitis, infection

67
Q

BACK PAIN

Give some examples of reasons for serious back pain

A
  • Myeloma
  • TB
  • Metastases
  • Osteomyelitis
68
Q

BACK PAIN

Red flags?

A

1) Age between 20&50
2) Constant pain- no relieved by rest
3) History of cancer, TB, HIV or immunosuppression
4) Systemically unwell
5) Neuro deficit

69
Q

BACK PAIN

Investigation and treatment?

A

MRI and treat with analgesia, rest and physio

70
Q

MALIGNANT LUMPS

Features?

A

over 5cm, increasing growth, deep in fascia, painful

71
Q

MALIGNANT LUMPS

Investigations?

A

Ultrasound-based sarcoma score

For malignancy, this will show irregular/nodular edges and vascularity on the doppler

  • CT and MRI plus biopsy for diagnosis
72
Q

MALIGNANT LUMPS

Treatment?

A

surgery + Radiotherapy adjunct

73
Q

OSTEOMYELITIS

Who normally gets it?

A

children

74
Q

OSTEOMYELITIS

What is it?

A

infection through the blood or compound fracture

Develops in the metaphysis due to blood network

75
Q

OSTEOMYELITIS

Organisms involved?

A

s.aureus
influenzae
salmonella

76
Q

OSTEOMYELITIS

Pathology?

A

1) Transient bacterium
2) Acute inflammation of bone
3) Necrosis
4) Formation of new bone
5) If untreated, sinuses to skin form

77
Q

OSTEOMYELITIS

Symptoms?

A
  • fever
  • erythema
  • Pain
  • swelling
78
Q

OSTEOMYELITIS

Tests?

A
  • MRI and CT
  • blood cultures
  • aspirate
79
Q

OSTEOMYELITIS

Treatment?

A

Flucloxacillin + fusidic acid for 4-6 weeks

80
Q

General Sequence of Raynauds?

A 
white (vasoconstriction) 
to blue (cyanosis)
then red (hyperaemia)
81
Q

FIBROMYALGIA

What is it?

A
  • chronic fatigue/ pain & Absence of pathology

- much more common in women

82
Q

FIBROMYALGIA

Yellow flags?

A

1) Social withdrawal
2) Emotional problems
3) Work problems
4) Lack of support

83
Q

FIBROMYALGIA

What is it associated with?

A
  • chronic fatigue syndrome
  • IBS
  • pain at 11-18 pressure points
84
Q

FIBROMYALGIA

Treatment?

A
  • educate and reassure
  • painkillers
  • Amitriptyline (TCAs)
85
Q

What is Raynaud’s and how is it treated?

A
  • spasms of the arteries supplying hands & feet

treated with heat! and stop beta blockers if able to

86
Q

SJOGRENS SYNDROME

What is it

A

immunological mediated destruction of epithelial exocrine cells

87
Q

SJOGRENS SYNDROME

Epidemiology?

A

F:M 9:1, middle aged women

88
Q

SJOGRENS SYNDROME

Signs?

A
  • dry eyes
  • dry mouth (xerostomia)
  • dry vagina
  • Raynaud’s
  • RA
  • SLE
89
Q

SJOGRENS SYNDROME

Difference between primary and secondary?

A

P- occurring by itself

S- secondary to SLE or RA

90
Q

SJOGRENS SYNDROME

Diagnosis?

A

ANA +ve in 74%
Anti- RO SPECIFIC
Rheumatoid factor positive

Labial gland biopsy- shows destruction of gland plus lymphocyte infiltration

91
Q

SJOGRENS SYNDROME

Treatment?

A

1) Tear and saliva replacement

2) NSAID’s and hydroxychloroquine for arthralgia

92
Q

SCLERODERMA

What is it?

A

multisystem disease involving skin and Raynaud’s occurring early

93
Q

SCLERODERMA

Pathology?

A

1) Endothelial cell lesion
2) Increased vascular permeability = increased cytokine + growth factors
3) This activates fibroblasts in ECM
4) Uncontrolled and irreversible thickening of connective tissue and blood vessel walls

94
Q

SCLERODERMA

Limited Cutaneous Scleroderma signs? CREST

A 
Calcinosis
Raynauds
oesophageal dysnfunction
Sclerodactyly (tight and thick hands)
Telangiectasia (spider veins, e.g. appearance of elderly overweight persons cheeks)
95
Q

SCLERODERMA

Diffuse cutaneous Scleroderma signs?

A
  • skin involvement
  • heart involvement
  • kidney = CKD
  • Lung = pulmonary HTN and fibrosis
96
Q

SCLERODERMA

Investigation?

A

X-rays - calcinosis a fibrosis

Barium swallow - oesophagus dysfunction

97
Q

SCLERODERMA

Treatment?

A

Immunosuppression = IV cyclophosphamide

  • PPI’s, ACE-I, ARB’s
98
Q

PSORIATIC ARTHRITIS

Features?

A
  • Asymmetrical oligoarthritis
  • symmetrical polyarthritis resembling RA
  • Arthritis Mutilans- severe form that destroys bones in hands and feet
99
Q

PSORIATIC ARTHRITIS

Investigations?

A

on X-ray you will see pencil in cup deformity and narrowed joint space

100
Q

PSORIATIC ARTHRITIS

Treatment?

A

NSAIDs
Local steroid injections

Severe= methotrexate and infliximab

101
Q

REACTIVE ARTHRITIS

What is it?

A

sterile arthritis following an infection e.g. salmpnella, shigella, campylobacter, chlamydia

102
Q

PSORIATIC ARTHRITIS

Features?

A
  • young an <4 week after infection
  • joints of lower limb affected asymmetrically
  • superficial ulcers on penis and mouth
  • red plaques on palms and soles
103
Q

PSORIATIC ARTHRITIS

What will X-ray show and how is it treated?

A

X-ray will show enthesitis- joint irritability where it enters bones

Treat- NSAIDs and local steroids
Methotrexate if relapse

104
Q

What is enteropathic arthritis?

A

large joint oligoarthritis due to IBD

105
Q

VASCULITIS

What is it?

A

inflammation of blood vessel walls

106
Q

VASCULITIS

Signs?

A
  • Anaemia
    +
    increased ESR/CRP
107
Q

VASCULITIS

Give examples of Problems related to large, medium and small Blood Vessels

A 
Large = Giant cell arteritis, Takayasu's arteritis
Medium = Polyarteritis Nodosa, Kawasaki's
Small = ANCA +ve and -ve vasculitis
108
Q

Features of Giant Cell arteritis?

A

1) headache
2) tenderness over temple
3) Jaw claudication on chewing
4) Dilated temporal artery (tender)
5) Sudden transient loss of vision due to retinal artery involvement= EMERGENCY
6) >50 year old women
7) increased ESR

109
Q

Features of Polymyalgia rheumatica

A

increased ALP, ESR, CRP

Neck and shoulder stiffness/ pain- cant lift arms

Creatine Kinase is NORMAL so shows its not a myositis/ myopathy

110
Q

treatment of Polymyalgia Rheumatica?

A

Oral prednisolone then Azathioprine if it doesn’t work

111
Q

Epidemiology of Polyarteritis Nodosa?

A

MIDDLE AGED MEN + Hep B associates

112
Q

Features of Polyarteritis Nodosa?

A

1) Fever, malaise, weight loss
2) HTN
3) Renal impairment
4) Rash
5) Malabsorption

113
Q

how is it diagnosed and treated?

A

Angiogram/ Biopsy and steroids (small vessel arteritis is ANCA +VE and treated with steroids)

114
Q

What is Dactylitis?

A

Dactylitis- inflammation of an entire digit (a finger or toe)

115
Q

What is Enthesitis?

A

Enthesitis- irritability of soft tissues (muscles, tendons or ligaments) where it enter into the bones

116
Q

Example of a Bisphosphonate and its pathophysiology

A

Alendronic acid - inhibit osteoclast activity

same as calcitonin

denosumab inhibits osteoclast formation

teriparatide stimulates osteoblast formation

117
Q

Common fracture sites for osteoporosis?

A

Pathological- distal radius, proximal femur

other - ribs, hip, upper arm, wrist, spine, forearm

Medicine Year 2 2 (15 decks)

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