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Finals Revision > Rheumatology/Orthopaedics > Flashcards

Rheumatology/Orthopaedics Flashcards

1
Q

What is osteomalacia?

A

Defective bone mineralisation due to insufficient vitamin D

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2
Q

Risk factors for osteomalacia

A

Malabsorption, darker skin, CKD

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3
Q

Functions of vitamin D

A

Essential in calcium and phosphate absorption from intestines and kidneys
Regulates bone turnover and promotes bone reabsorption to increase serum calcium

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4
Q

What effect does low vitamin D have on calcium and phosphate?

A

Causes low calcium and phosphate

  • -> defective bone mineralisation
  • -> secondary hyperparathyroidism
  • -> PTH increases calcium reabsorption from bones
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5
Q

How is vitamin D produced/metabolised?

A

Produced from cholesterol by the skin in response to UV radiation
Kidneys metabolise it

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6
Q

Presentation of osteomalacia

A

Fatigue, bone pain, muscle weakness, muscle aches

Fractures

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7
Q

Which LFT is deranged in osteomalacia?

A

Raised ALP

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8
Q

Investigations in osteomalacia

A

Bloods- serum 25-hydroxy-vitamin D, serum calcium and phosphate low, raised ALP
X-ray
DEXA- low BMD

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9
Q

Management of osteomalacia

A

Supplement vitamin D- cholecalciferol

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10
Q

What is Paget’s disease?

A

Excessive bone turnover due to excessive activity of osteoblasts and osteoclasts
Especially axial skeleton
Patchy areas of high density (sclerosis) and low density (lysis)

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11
Q

Presentation of Paget’s disease

A

Bone pain, bone deformity, fractures, hearing loss

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12
Q

X-ray findings in Paget’s disease

A 
Bone enlargement and deformity
Osteoporosis circumscripta (low density lesions)
'Cotton wool' appearance of skull
'V-shaped' defect- osteolytic bone lesions on long bones
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13
Q

Investigations of Paget’s disease

A

X-ray

Raised ALP alone

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14
Q

Management of Paget’s disease

A

Bisphosphonates- restore normal bone turnover
NSAIDs for bone pain
Calcium + vitamin D supplements

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15
Q

Complications of Paget’s disease

A

Osteosarcoma, spinal stenosis

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16
Q

Which 4 muscles make up the Rotator Cuff?

A
  1. Supraspinatus
  2. Infraspinatus
  3. Subscapularis
  4. Teres minor
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17
Q

Supraspinatus:

i) origin
ii) insertion
iii) action

A

i) Origin: supraspinous fossa of scapula
ii) Insertion: great tubercle of humerus
iii) Action: Abducts 0-15 degrees

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18
Q

Infraspinatus:

i) origin
ii) insertion
iii) action

A

i) origin: infrasinatus fossa of scapula
ii) insertion: greater tubercle of humerus
iii) action: laterally rotates arm

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19
Q

Subscapularis:

i) origin
ii) insertion
iii) action

A

i) origin: subscapular fossa
ii) insertion: lesser tubercle of humerus
iii) action: medially rotates arm

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20
Q

Teres minor:

i) origin
ii) insertion
iii) action

A

i) origin: posterior surface of scapula
ii) insertion: greater tubercle of humerus
iii) action: laterally rotates arm

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21
Q

How is fractured neck of femur classified?

A

Intra or extracapsular
Displaced or Non-displaced
Complete or Incomplete

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22
Q

Findings on examination of a fractured NOF

A

Leg shortened + externally rotated
Pain on pin-rolling + axial loading
Unable to straight leg raise

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23
Q

Presentation of fractured NOF

A 
Hx of fall + pain + unable to weight bear
O/E:
- Leg shortened + externally rotated
- Pain on pin-rolling + axial loading
- Unable to straight leg raise
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24
Q

Complications of #NOF

A

Damage to medial femoral circumflex artery –> avascular necrosis of femoral head

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25
Q

What is the most common location for vertebral fractures? Why?

A

L1-L2 as thoracolumbar junction where spine becomes rigid thoracic spine

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26
Q

What are the 3 main patterns of vertebral fracture?

A

Flexion
Extension
Rotation

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27
Q

What are the 2 types of flexion vertebral fracture?

A

Compression- loses height on one side only

Axial burst- loses height on front and back

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28
Q

What is osteomyelitis?

A

Infection of the bone marrow which may spread to bone cortex and periosteum
May causes inflammatory destruction of bone and necrosis

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29
Q

What is the most common site of osteomyelitis?

A

Distal femur/proximal tibia in children

Cancellous bone in adults- end of long bones and skull, ribs, vertebrae, pelvis

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30
Q

How can osteomyelitis spread?

A

Haematogenous spread

Direct (contiguous) spread

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31
Q

What is most common causative organism for osteomyelitis?

A

Staphylococcal aureus

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32
Q

Risk factors for osteomyelitis

A

Trauma/surgery, prosthetic joint, diabetes, peripheral arterial disease, alcoholism, IVDU, chronic steroid use, immunosuppression, TB. HIV

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33
Q

Presentation of osteomyelitis

A

Fever + painful swollen erythematous joints

Immobile joint/unable to weight bear

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34
Q

Investigations of osteomyelitis

A

Bone cultures gold standard

Blood cultures, MRI for acute

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35
Q

Management of osteomyelitis

A

Surgical debridement + stabilisation of bone

6wks Flucloxacillin

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36
Q

Complications of osteomyelitis

A

Septic arthritis, sepsis, fracture, bone abscess

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37
Q

Causes of a hot swollen joint

A

Crystals, trauma, septic arthritis, inflammatory cause

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38
Q

Causes of the following findings on joint aspiration of a hot swollen joint:

i) Frank pus
ii) Turbid
iii) Clear fluid

A

i) Frank pus- infection
ii) Turbid- infection/crystals/RA
iii) Clear- OA

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39
Q

Contraindications to joint aspiration

A

Absolute CI: prosthetic joint

Relative CI: purulent ulcer over joint, bleeding disorder

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40
Q

What characteristics suggest that a joint pain is inflammatory in nature?

A
  • Young onset
  • Worse in morning
  • Improves with movement
  • Wakes them overnight
  • Anti-inflammatories help it
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41
Q

Risk factors for rheumatoid arthritis

A

Female, smoking, HLADR1+4

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42
Q

Describe the specific features which can be found in examination of the hand in rheumatoid arthritis

A 
Z thumb
Boutonniere deformity
Ulnar deviation
Swan-neck deformity
Radio-ulnar subluxation
Volar subluxation
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43
Q

Describe the pattern of arthritis found in rheumatoid arthritis

A

Insidious, bilateral symmetrical polyarthritis, in small joints of hands and feet
Joints hot, red, swollen and stiff
Joints boggy on examination
DIP spared

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44
Q

Describe some systemic features of rheumatoid arthritis

A

Rheumatoid nodules
Peripheral nerve entrapment
Scleritis

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45
Q

What are the x-ray findings in rheumatoid arthritis?

A 
Soft tissue swelling
Periarticular osteopenia
Loss of joint space
Erosions
Deformity
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46
Q

What score can be used to assess extent of disease in rheumatoid arthritis?

A

DAS28 score for disease acitivity

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47
Q

Management of rheumatoid arthritis

A
  • Physio, OT, exercise
  • Simple analgesia, NSAIDs, COX inhibitors (eg Celecoxib)
  • Corticosteroids
  • DMARDs- Azathioprine, Ciclosporin, Methotrexate
  • Biologics- TNF inhibitors (Adalimumab), Anti-CD20 (Rituximab)
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48
Q

What 2 factors can be tested for in rheumatoid arthritis?

A

Anti-CCP

Rheumatoid factor

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49
Q

Causes of Raynaud’s phenomenon

A

Primary or

Secondary to SSc, SLE, drugs, vascular damage eg atherosclerosis

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50
Q

Presentation of Raynaud’s phenomenon

A

White phase (vasospasm)

  • -> Blue phase (hypoxia)
  • -> Red phase (vasodilatation)
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51
Q

Management of Raynaud’s phenomenon

A

Avoid cold and trauma, warm up gently, massage/mvmts to restore circulation
1st line- Nifedipine
Then SSRI/alpha blocker/PDE5 inhibitor

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52
Q

What antibodies can be present in SLE?

A

Anti-nuclear antibodies- Anti-dsDNA, Anti-Sm

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53
Q

Risk factors for SLE

A

Ethnicity, HLADRB1/2/3, defective C4 complement gene, UV light, EBV, drugs (chlorpromazine, isoniazid), Female

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54
Q

Presentation of SLE

A

Fatigue, malaise, fever, lymphadenopathy
Malar butterfly rash, spares nasolabial folds, discoid lupus, photosensitive rash
Arthritis- symmetrical, non-erosive, inflammatory
Lupus nephritis (haematuria+proteinuria)
Raynaud’s, neuropsychiatric features, oral + nasopharyngeal ulcers, pleuritis, pericarditis, seizures

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55
Q

Describe the dermatological presentation of SLE

A

Malar butterfly rash, spares nasolabial folds, discoid lupus, photosensitive rash

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56
Q

Describe the arthritis seen in SLE

A

Symmetrical, non-erosive, inflammatory

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57
Q

How is SLE classified?

A

American College of Rheumatology classification

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58
Q

What is found on blood results in SLE?

A

Haemolytic anaemia, lymphopenia, leukopenia, thrombocytopenia

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59
Q

Management of SLE

A 
Avoid sun exposure, simple analgesia
Corticosteroids
Hydroxychloroquine
Cytotoxics- Cyclophosphamide, Azathioprine
Anti-CD20- Rituximab
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60
Q

Aetiology of Sjogren’s syndrome

A

Lymphocytic infiltration of exocrine glands

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61
Q

Risk factors for Sjogren’s syndrome

A

Female, vitamin D deficiency, secondary to other autoimmune conditions

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62
Q

What are sicca symptoms?

A

Xeropthalmia and Xerostomia found in Sjogren’s syndrome

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63
Q

What antibodies are found in Sjogren’s syndrome?

A

Anti-Ro and Anti-La

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64
Q

Presentation of Sjogren’s syndrome

A

Sicca symptoms- Xeropthalmia + Xerostomia
Keratoconjunctivitis, enlargement of parotid glands, dry mucosa, difficulty swallowing, dry cough, pancreatic disease, vaginal dryness, primary biliary cirrhosis, Raynaud’s phenomenon

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65
Q

Tests for Sjogren’s syndrome

A

Anti-Ro + Anti-La antibodies

Schirmer’s test- paper in eye <5mm

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66
Q

What criteria is used to assess Sjogren’s syndrome?

A

Coppenhagen criteria + American-European consensus

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67
Q

Management of Sjogren’s syndrome

A

Symptomatic- artificial tears + saliva, vaginal lubricant
Blockage of puncta by electrocautery
Immunosuppressants- Cyclophosphamide
Hydroxychloroquine

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68
Q

Aetiology of Systemic Sclerosis

A

Increased fibroblast activity –> abnormal growth of connective tissue

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69
Q

Cardinal features of Systemic Sclerosis

A
  1. Excessive collagen production and deposition
  2. Vascular damage
  3. Immune system activation
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70
Q

Types of Systemic Sclerosis

A

Limited or Diffuse

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71
Q

Risk factors for Systemic Sclerosis

A

Female, infections eg CMV/EBV, drugs eg vitamin K, cocaine, radiation, vitamin D deficiency

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72
Q

What antibodies can be found in Systemic Sclerosis?

A

Anti-centromere Ab (ACA)
Anti-topoisomerase I
Anti-RNA polymerase III

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73
Q

Presentation of Systemic Sclerosis

A 
Limited- CREST
Calcinosis
Raynaud's
(o)Esophageal dysmotility
Sclerodactyly
Telangiectasia
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74
Q

Management of Systemic Sclerosis

A

Emollients for skin
PPI for reflux
Immunotherapy- methotrexate, mycophenolate mofetil

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75
Q

Monitoring in Systemic Sclerosis

A

Annual echo for pulmonary hypertension

Annual lung function tests for pulmonary fibrosis

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76
Q

What is Polymyositis?

A

Connective tissue disease mainly affecting muscles

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77
Q

When does Polymyositis usually present?

A

Age 30-60

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78
Q

Aetiology of Polymyositis

A

Can be paraneoplastic syndrome of SCLC

Ass with HIV, HTLV-1, CoxsackieB

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79
Q

Presentation of Polymyositis

A

Inflammatory myopathy
Onset weeks to months
Proximal weakness, fatigue, muscle cramps, muscular atrophy

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80
Q

Blood tests in Polymyositis

A

Raised Creatinine Kinase

Anti-Jo-1 antibodies

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81
Q

Investigations in Polymyositis

A

Diagnosis by EMG + muscle biopsy
PET/CXR for SCLC
Anti-Jo-1 antibodies
Raised CK

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82
Q

Management of Polymyositis

A

Mainly steroids

Immunosuppressants- Azathioprine

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83
Q

What is Dermatomyositis?

A

Connective tissue disease of skin and muscles

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84
Q

What is the peak age of onset of Dermatomyositis?

A

Age 50

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85
Q

Aetiology of Dermatomyositis

A

Can be paraneoplastic syndrome of SCLC

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86
Q

Presentation of Dermatomyositis

A

Diffuse proximal weakness from inflammatory myopathy
Skin: blue/purple upper eyelids- Heliotropic rash, periorbital oedema, subcutaneous calcification
Chest rash- Shawl sign
Knuckle rash- Gottron’s papules
Dilated capillary loops at fingernail base
Interstitial lung disease

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87
Q

Antibodies found in Dermatomyositis

A

ANA, Anti-Mi-2

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88
Q

Investigations for Dermatomyositis

A

ANA, Anti-Mi-2 antibodies

PET/CXR for paraneoplastic of SCLC

89
Q

Management of Dermatomyositis

A

Sunblock

Steroids, immunosuppressives- Azathioprine

90
Q

What heart problem is Dermatomyositis associated with?

A

Dilated cardiomyopathies

91
Q

Aetiology of Gout

A

Arthritis due to deposition of monosodium urate crystals within joints

92
Q

What is the most commonly affected joint in Gout?

A

1st MTPJ

93
Q

Risk factors for gout

A

Men, age, purine-rich foods, fructose, alcohol, CKD, obesity, diabetes, malignancy (tumour lysis syndrome)

94
Q

What blood test can be used in investigation of gout?

A

Uric acid > 360mmol/L

But can be normal in acute attack of gout as all uric acid is in joint rather than blood

95
Q

Exacerbating factors for gout

A

Cold and trauma reduce crystal solubility

96
Q

Presentation of gout

A

Time to maximal pain 6-24hrs, time to resolution- 14 days
Acutely pain red hot swollen joint
PODAGRA: the classic uric acid deposition in joint
TOPHI: chalky appearance beneath the skin- large crystal deposits

97
Q

What is found on joint aspiration in gout?

A

Strongly negatively birefringent needles

98
Q

X-ray findings in gout

A

Punched out lesions (juxta-articular erosions)
Areas of sclerosis + tophi
Loss of joint space, soft tissue swelling

99
Q

What is the most important differential of gout?

A

Septic arthritis

100
Q

Management of gout

A

Lifestyle: weight loss, diet, alcohol, avoid purine-rich foods, smoking cessation
NSAIDs/Cox-2 inhibitors- Naproxen
Acute: Colchicine 500mg BD
Prophylaxis: Allopurinol- xanthine oxidase inhibitor/Febuxostat

101
Q

Cautions/side effects of Colchicine

A

Caution in CKD

Side effect- diarrhoea

102
Q

Risk factors for Osteoarthritis

A

Age, female, obesity, stress on joints, RA

103
Q

Which joints are most commonly affected in Osteoarthritis?

A

Thumb most affected

2+3rd MCPJ

104
Q

Presentation of Osteoarthritis

A

Joint pain exacerbated by exercise and relieved by rest
Joint stiffness worse in morning/after rest
Reduced range of movement
Joint synovitis, crepitus
Advanced disease- rest and night pain

105
Q

Hand signs on examination of Osteoarthritis

A

Heberden’s (DIP) and Bouchard’s (PIP) nodes

106
Q

X-ray findings in Osteoarthritis

A

Osteophytes
Joint space narrowing
Bone cysts
Subarticular sclerosis

107
Q

Management of Osteoarthritis

A

Exercise, physio, paracetamol, NSAIDs
Intra-articular corticosteroid injections
Joint surgery

108
Q

What is Septic arthritis?

A

Infection causing inflammation in a joint

109
Q

Causative organisms of Septic arthritis

A

75% Staphylococcal aureus
Streptococci
Neisseria

110
Q

Most commonly affected joint in Septic arthritis

A

Knee most common

Then hip, shoulder, ankle, wrist

111
Q

Risk factors for Septic arthritis

A

Age, diabetes, RA/gout, joint surgery, prosthesis, skin infection, immunodeficiency

112
Q

Presentation of Septic arthritis

A

Single swollen joint with pain on active and passive movement, hot, tender, unable to weight bear
Fever, rigors

113
Q

Investigation of Septic arthritis

A

Joint aspiration- WCC, gram staining, culture

114
Q

Management of Septic arthritis

A

Surgical drainage + lavage

High dose antibiotics- 2-3wks IV Flucloxacillin

115
Q

What are seronegative spondyloarthropathies?

A

-ve for anti-CCP and rheumatoid factor

Include AS, Enteropathic arthritis, psoriatic arthritis, Reiter’s syndrome

116
Q

What is Pseudogout?

A

Calcium Pyrophosphate Deposition

A bone constituent released from bone into joint during bony erosion in OA

117
Q

Risk factors for Pseudogout

A

Elderly, dehydration, OA, long term steroids

118
Q

Presentation of Pseudogout

A

Acute: mono/oligoarthritis, mostly knees, acute joint pain, swelling, warmth, fever, tenderness
Chronic: destructive changes like OA

119
Q

Investigations of Pseudogout

A

Raised WCC
X-ray
Aspiration

120
Q

X-ray findings in Pseudogout

A

Linear opacification of articular cartilage

121
Q

Findings on joint aspiration in Pseudogout

A

Intra + extracellular weakly positive birefringent rhomboid crystals

122
Q

Management of Pseudogout

A

Treat the cause, ice, rest

NSAIDs, intra-articular steroids, systemic steroids

123
Q

What is Osteoporosis?

A

Reduced bone mass and microarchitectural destruction of bone

124
Q

What are Osteoporotic fractures?

A

Fractures from mechanical force that would not usually result in a fracture

125
Q

What are the most common locations of osteoporotic fractures?

A

Spine, forearm, hip, shoulder, distal radius

126
Q

What is T and Z score for osteoporosis?

A

T score- BMD in relation to young health population

Z score- BMD in relation to a SD of their age

127
Q

What scan is most important in osteoporosis?

A

DEXA scan

128
Q

Risk factors for osteoporosis

A

Female, age, low BMI, parental hip fracture, previous fracture, steroids, alcohol, smoking

129
Q

What is FRAX score?

A

10 year probability of a major osteoporotic fracture in people aged 40-60
- Age, sex, BMI, previous fracture, parental hip #, current smoking, glucocorticoid use, RA, secondary osteoporosis, alcohol, femoral head BMD

130
Q

Management of Osteoporosis

A

Lifestyle: reduce falls, nutrition, smoking cessation
Calcium + vitamin D supplements
Bisphosphonates- Alendronic acid- whole glass of water sit up for 30 mins on empty stomach
Denosumab if cannot comply

131
Q

Most common demographic for Reactive Arthritis

A

HLAB27 white young adults

132
Q

Aetiology of Reactive Arthritis

A

Follows GI/GU infection by 1-6 weeks

  • Campylobacter, Shigella, Salmonella
  • Chlamydia trachomatis, HIV
133
Q

What is Reiter’s syndrome?

A

The group of symptoms seen in Reactive Arthritis

  1. Can’t pee- Urethritis
  2. Can’t see- Conjunctivitis
  3. Can’t climb a tree- Oligoarthritis
134
Q

Presentation of Reactive Arthritis

A

Asymmetrical lower limb oligoarthritis, lower back pain, heel pain, erythema nodosum, mouth ulcers, aortic regurgitation

135
Q

What cardiac abnormality can present in Reactive Arthritis?

A

Aortic regurgitation

136
Q

Investigations for Reactive Arthritis

A

Culture/serology for causative infection

137
Q

Management of Reactive Arthritis

A

Rest, physio, NSAIDs

Corticosteroids, Abx for organism, Sulfasalazine

138
Q

What is Enteropathic Arthritis?

A

Seronegative spondyloarthropathy due to IBD (also Coeliac, Whipple’s disease, Bypass)

139
Q

What are the 2 types of Enteropathic Arthritis?

A

Axial form

Peripheral form

140
Q

How does the axial form of Enteropathic Arthritis present?

A

Spondylitis + Sacroiliitis

Lower back pain down legs, worse in morning, prolonged sitting/standing worsens symptoms

141
Q

How does the peripheral form of Enteropathic Arthritis present?

A

Asymmetric oligoarticular arthritis of lower limbs

142
Q

Which IBD is the peripheral form of Enteropathic Arthritis more common in?

A

Peripheral- Crohn’s

143
Q

Management of Enteropathic Arthritis

A

Improve IBD –> improve arthritis
IA/Systemic steroids, Sulfasalazine
DMARDs: methotrexate, azathioprine

144
Q

What is vasculitis?

A

Inflammation of blood vessels

145
Q

What classification is used to group vasculitis?

A 
Chapel Hill Criteria- used when ANCA is present
Infective- eg Syphilitic aortitis
Non-infective- 
- Large eg GCA
- Medium eg Kawasaki
- Small eg immune complex
- Variable eg Behcet's
146
Q

What part of the body does Ankylosing Spondylitis affect?

A

Axial skeleton

147
Q

Define ankylosing

A

Fusing of 2 joints

148
Q

What is the peak age of onset of Ankylosing Spondylitis?

A

20s-30s

149
Q

Risk factors for Ankylosing Spondylitis

A

HLAB27

Male

150
Q

Presenation of Ankylosing Spondylitis

A

Morning stiffness, inflammatory back pain, sacroiliitis, enthesitis, fever, weight loss, fatigue, asymmetric peripheral arthropathies, reduced chest expansion, reduced lumbar motion

151
Q

Extra-articular manifestations of Ankylosing Spondylitis

A 
6 As
Apical fibrosis
Anterior uveitis
Aortic regurgitation
Achilles tendonitis
AV node block
Amyloidosis
152
Q

What special test can be done on examination to assess for Ankylosing Spondylitis?

A

Schober’s test- ability to flex the lower back

153
Q

Diagnosis of Ankylosing Spondylitis

A

Radiological (sacroiliitis on x-ray) + 1 clinical criteria

154
Q

What can be found on x-ray in Ankylosing Spondylitis?

A 
Sacroiliitis
Squared vertebral bodies
Syndesmophytes
Fusion of vertebral column- Bamboo spine
Fusion of spinous processes- Dagger spine
Kyphoscoliosis
155
Q

Management of Ankylosing Spondylitis

A 
Posture, physio, exercise
1st line- NSAIDs, Cox-2 inhibitors
Local/oral corticosteroids
TNF-alpha inhibitor- Etanercept
Surgery
156
Q

Types of Psoriatic Arthritis

A
  • Rheumatoid pattern
  • Lone DIP disease
  • Arthritis mutilans
  • Asymmetrical oligoarticular pattern
  • Juvenile onset
157
Q

What is Arthritis Mutilans?

A

A late-stage presentation of Psoriatic Arthritis
Pencil-in-cup appearance on x-ray
Telescoping seen O/E

158
Q

Presentation of Psoriatic Arthritis

A

Joint stiffness, pain + swelling
Psoriatic rash- psoriasis mostly precedes arthritis
Nail changes- pitting, yellowing, onycholysis
Enthesopathy- achilles, plantar fascia
Anterior uveitis

159
Q

X-ray findings in Psoriatic Arthritis

A

Mild bony erosion at edge of cartilage
DIP/PIP involvement
‘Pencil-in-cup’ appearance in arthritis mutilans

160
Q

Management of Psoriatic Arthritis

A

Monotherapy for rash + arthritis- Methotrexate, Retinoids, Psoralen A, UVA
Ustekinumab- cytokine modulator
Surgical

161
Q

Main concerning complication of Psoriatic Arthritis

A

Atlanto-axial subluxation

162
Q

What is Onycholysis?

A

Loosening or separation of the nail from the nail bed

163
Q

What is Juvenile Idiopathic Arthritis?

A

Joint inflammation in <16s persisting > 6 weeks

164
Q

Types of Juvenile Idiopathic Arthritis

A 
Oligoarticular- 1-4 joints
Polyarticular- 5 or more joints
Systemic- with fever > 39 for >2wks + rash/lymph nodes/hepatosplenomegaly/serositis
Juvenile psoriatic
Enthesitis-related
165
Q

Describe the rash seen in Juvenile Idiopathic Arthritis

A

Salmon-pink rash

166
Q

Diagnosis of Juvenile Idiopathic Arthritis

A

Clinical diagnosis

167
Q

Findings on USS of Juvenile Idiopathic Arthritis

A

Joint fluid, synovial hypertrophy, erosions

168
Q

Management of Juvenile Idiopathic Arthritis

A

Physio, NSAIDs, IA/Systemic steroids

1st line- subcut Methotrexate (then Etanercept)

169
Q

Aetiology of Sarcoidosis

A

Inflammatory- formation of non-caseating epithelioid granulomata

170
Q

Presentation of Sarcoidosis

A

Fever, fatigue, weight loss
Lungs- restrictive defect
Skin- erythema nodosum, papules on face, lymphadenopathy
Eyes- granulomatous uveitis
Joints- Inflammatory arthritis with periarticular soft tissue swelling, tenosynovitis, dactylitis, osteopenia
Neurosarcoidosis- nerve lesions, Bell’s palsy, diabetes insipidus

171
Q

Describe the arthritis seen in Sarcoidosis

A

Inflammatory arthritis with periarticular soft tissue swelling, tenosynovitis, dactylitis, osteopenia

172
Q

Investigations of Sarcoidosis

A

CXR for staging

BAL- raised lymphocytes

173
Q

Findings on CXR in Sarcoidosis

A

Bilateral hilar and paratracheal lymphadenopathy

174
Q

How is Sarcoidosis officially diagnosed?

A

Histology- granulomatous inflammation

175
Q

Management of Sarcoidosis

A

1st line- oral glucocorticoids- Prednisolone
2nd line- anti-metabolites- MTX, azathioprine
Joints- NSAIDs
Eye disease- topical corticosteroids/intraocular injection

176
Q

Complications of Sarcoidosis

A

PE, lung fibrosis, arrhythmia, sudden cardiac death, uveitis, conjunctivitis, nerve damage, stroke/TIA, lymphoma

177
Q

What is the inheritance pattern of Marfan’s syndrome?

A

Autosomal dominant

178
Q

What is the aetiology of Marfan’s syndrome?

A

Autosomal dominant connective tissue disorder

Defect in FBN1 gene on chromosome 15 which codes for Fibrillin-1 protein

179
Q

Presentation of Marfan’s syndrome

A

Tall stature, long arms, high-arched palate, arachnodactyly, pectus excavatum, pes planus, scoliosis
Heart- dilatation of aortic sinuses –> aortic aneurysm, dissection, regurgitation and mitral prolapse
Lungs- pneumothorax
Eyes- upwards lens dislocation, blue sclera, myopia
Dural ectasia

180
Q

Management of Marfan’s syndrome

A

Echo monitoring for heart

Beta blockers/ACE inhibitors

181
Q

Most common age of onset of Fibromyalgia

A

Age 20-50

182
Q

Is Fibromyalgia more common in men or women?

A

Women

183
Q

Presentation of Fibromyalgia

A

Chronic widespread pain, lower back/neck/shoulder pain
Unrefreshing sleep, persistent fatigue, paraesthesia
Feeling of swollen joints, headaches
Anxiety/Depression

184
Q

What classification is used for Fibromyalgia?

A

American College of Rheumatology

185
Q

Management of Fibromyalgia

A

Graded exercise programme
CBT
Antidepressants- tricyclics, SSRI

186
Q

What should be given with Methotrexate to reduce the risk of GI side effects?

A

Folic acid

187
Q

Which drugs should be avoided whilst taking methotrexate?

A

Trimethoprim, Co-trimoxazole, aspirin

188
Q

What is Giant Cell Arteritis/Temporal Arteritis?

A

Immune-mediated vasculitis of medium and large vessels, especially carotid and extra-cranial branches

189
Q

Risk factors for Giant Cell Arteritis/Temporal Arteritis

A

Polymyalgia Rheumatica, women aged 60-80

190
Q

Presentation of Giant Cell Arteritis/Temporal Arteritis

A

NEW onset temporal headache, scalp tenderness, jaw/tongue claudication
Visual- blurred vision, amaurosis fugax, irreversible vision loss

191
Q

Which artery is diseased to cause visual loss in Giant Cell Arteritis/Temporal Arteritis?

A

Opthalmic artery

192
Q

Findings on examination of Giant Cell Arteritis/Temporal Arteritis

A

Temporal artery tender to palpation and reduced pulsation

193
Q

Investigations in Giant Cell Arteritis/Temporal Arteritis

A

ESR > 50

Temporal artery biopsy within 2 weeks of starting steroids

194
Q

What does temporal artery biopsy show in Giant Cell Arteritis/Temporal Arteritis?

A

Mononuclear cell infiltration or granulomatous inflammation with multinucleated giant cells

195
Q

Management of Giant Cell Arteritis/Temporal Arteritis

A

40mg Prednisolone
60mg if visual symptoms or claudication
Low-dose aspirin 75mg + PPI

196
Q

What is Anti-phospholipid syndrome?

A

Autoimmune disorder with raised anti-phospholipid antibodies

197
Q

What antibodies are found in Anti-phospholipid syndrome?

A

Lupus anticoagulant, Anti-cardiolipin antibody, anti-B2-glycoprotein I antibody

198
Q

Risk factors for Anti-phospholipid syndrome

A 
Female
Secondary to other autoimmune disease eg SLE, GCA, psoriatic arthritis
Infections eg HIV, varicella
Drugs eg phenothiazides, phenytoin
Sickle cell, GBS
199
Q

Presentation of Anti-phospholipid syndrome

A

Vascular thrombosis: DVT, PE, MI, CVA
Adverse pregnancy outcomes: miscarriage, pre-eclampsia, IUGR
Livedo reticularis (purple mottled rash), Nephropathy, Retinal thrombosis

200
Q

Investigations in Anti-phospholipid syndrome

A

CT brain- CVA
CTPA- PE
CT abdomen- Budd-Chiari syndrome
Doppler- DVT

201
Q

Management of Anti-phospholipid syndrome

A

Manage cardiovascular risk factors
Acute- Heparin 1000U/hr
Long-term- Warfarin/antiplatelet

202
Q

Presentation of small vessel vasculitis

A

Palpable purpura 1-3mm, splinter haemorrhages, urticaria + vesicles, Livedo reticularis

203
Q

Examples of small vessel vasculitis

A

Henoch-Schonlein purpura, SLE, Sjogren’s, IBD, Hairy cell leukaemia

204
Q

Examples of medium vessel vasculitis

A

Granulomatosis with polyangiitis, Churg-Strauss syndrome, Kawasaki, GCA, Behcet disease, Erythema induratum

205
Q

Presentation of medium vessel vasculitis

A

Ulcers, digital infarcts, nodules, Livedo reticularis, papulo-necrotic lesions, hypertension

206
Q

Examples of large vessel vasculitis

A

Kawasak, Behcet, Syphilis, GCA, Takayasu’s arteritis

207
Q

Presentation of large vessel vasculitis

A

End-organ ischaemia- TIA/CVA

Hypertension, aneurysms, dissection/haemorrhage/rupture

208
Q

Risk factors for Polymyalgia Rheumatica

A

Age > 50
Female
GCA

209
Q

Presentation of Polymyalgia Rheumatica

A

Severe bilateral pain + stiffness (>45min in morning) in shoulder, neck and pelvic girdle

210
Q

Investigations in Polymyalgia Rheumatica

A

Raised ESR/CRP

211
Q

Management of Polymyalgia Rheumatica

A

Prednisolone 15mg up to 2 years

Methotrexate if cannot tolerate steroids

212
Q

What is Behcet’s syndrome?

A

An autoimmune inflammation of blood vessels

213
Q

Risk factors for Behcet’s syndrome

A

Male, young adults, FH, HLAB51

214
Q

Presentation of Behcet’s syndrome

A 
Triad of...
1. Oral ulcers
2. Genital ulcers
3. Anterior uveitis
Thrombophlebitis + DVT, arthritis, erythema nodosum
215
Q

How is Behcet’s syndrome diagnosed?

A

Clinical diagnosis

216
Q

What additional test can be done to assess for Behcet’s syndrome?

A

Pathergy test- puncture site following needle prick becomes inflamed with small pustule forming

217
Q

What side effect can Hydroxychloroquine cause?

A

Bull’s eye retinopathy

218
Q

Adverse effects of steroids

A

CVS- hypertension, CCF
CNS- mood disturbance, psychosis, sleep disturbance
Endocrine- adrenal suppression, growth failure in children, insulin resistance, diabetes, disturbance of thyroid function, hypokalaemia
GI- ulcers, fatty liver
Haem- leukocytosis
Immunosuppression
Bones- osteoporosis, avascular necrosis of bone
Eyes- cataracts, raised IOP, glaucoma
Skin- moon face, truncal obesity, dorsolumbar hump, thin skin, striae

Finals Revision (13 decks)

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