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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
What is the most common location for vertebral fractures? Why?
L1-L2 as thoracolumbar junction where spine becomes rigid thoracic spine
26
What are the 3 main patterns of vertebral fracture?
Flexion Extension Rotation
27
What are the 2 types of flexion vertebral fracture?
Compression- loses height on one side only | Axial burst- loses height on front and back
28
What is osteomyelitis?
Infection of the bone marrow which may spread to bone cortex and periosteum May causes inflammatory destruction of bone and necrosis
29
What is the most common site of osteomyelitis?
Distal femur/proximal tibia in children | Cancellous bone in adults- end of long bones and skull, ribs, vertebrae, pelvis
30
How can osteomyelitis spread?
Haematogenous spread | Direct (contiguous) spread
31
What is most common causative organism for osteomyelitis?
Staphylococcal aureus
32
Risk factors for osteomyelitis
Trauma/surgery, prosthetic joint, diabetes, peripheral arterial disease, alcoholism, IVDU, chronic steroid use, immunosuppression, TB. HIV
33
Presentation of osteomyelitis
Fever + painful swollen erythematous joints | Immobile joint/unable to weight bear
34
Investigations of osteomyelitis
Bone cultures gold standard | Blood cultures, MRI for acute
35
Management of osteomyelitis
Surgical debridement + stabilisation of bone | 6wks Flucloxacillin
36
Complications of osteomyelitis
Septic arthritis, sepsis, fracture, bone abscess
37
Causes of a hot swollen joint
Crystals, trauma, septic arthritis, inflammatory cause
38
Causes of the following findings on joint aspiration of a hot swollen joint: i) Frank pus ii) Turbid iii) Clear fluid
i) Frank pus- infection ii) Turbid- infection/crystals/RA iii) Clear- OA
39
Contraindications to joint aspiration
Absolute CI: prosthetic joint | Relative CI: purulent ulcer over joint, bleeding disorder
40
What characteristics suggest that a joint pain is inflammatory in nature?
- Young onset - Worse in morning - Improves with movement - Wakes them overnight - Anti-inflammatories help it
41
Risk factors for rheumatoid arthritis
Female, smoking, HLADR1+4
42
Describe the specific features which can be found in examination of the hand in rheumatoid arthritis
``` Z thumb Boutonniere deformity Ulnar deviation Swan-neck deformity Radio-ulnar subluxation Volar subluxation ```
43
Describe the pattern of arthritis found in rheumatoid arthritis
Insidious, bilateral symmetrical polyarthritis, in small joints of hands and feet Joints hot, red, swollen and stiff Joints boggy on examination DIP spared
44
Describe some systemic features of rheumatoid arthritis
Rheumatoid nodules Peripheral nerve entrapment Scleritis
45
What are the x-ray findings in rheumatoid arthritis?
``` Soft tissue swelling Periarticular osteopenia Loss of joint space Erosions Deformity ```
46
What score can be used to assess extent of disease in rheumatoid arthritis?
DAS28 score for disease acitivity
47
Management of rheumatoid arthritis
- Physio, OT, exercise - Simple analgesia, NSAIDs, COX inhibitors (eg Celecoxib) - Corticosteroids - DMARDs- Azathioprine, Ciclosporin, Methotrexate - Biologics- TNF inhibitors (Adalimumab), Anti-CD20 (Rituximab)
48
What 2 factors can be tested for in rheumatoid arthritis?
Anti-CCP | Rheumatoid factor
49
Causes of Raynaud's phenomenon
Primary or | Secondary to SSc, SLE, drugs, vascular damage eg atherosclerosis
50
Presentation of Raynaud's phenomenon
White phase (vasospasm) - -> Blue phase (hypoxia) - -> Red phase (vasodilatation)
51
Management of Raynaud's phenomenon
Avoid cold and trauma, warm up gently, massage/mvmts to restore circulation 1st line- Nifedipine Then SSRI/alpha blocker/PDE5 inhibitor
52
What antibodies can be present in SLE?
Anti-nuclear antibodies- Anti-dsDNA, Anti-Sm
53
Risk factors for SLE
Ethnicity, HLADRB1/2/3, defective C4 complement gene, UV light, EBV, drugs (chlorpromazine, isoniazid), Female
54
Presentation of SLE
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
55
Describe the dermatological presentation of SLE
Malar butterfly rash, spares nasolabial folds, discoid lupus, photosensitive rash
56
Describe the arthritis seen in SLE
Symmetrical, non-erosive, inflammatory
57
How is SLE classified?
American College of Rheumatology classification
58
What is found on blood results in SLE?
Haemolytic anaemia, lymphopenia, leukopenia, thrombocytopenia
59
Management of SLE
``` Avoid sun exposure, simple analgesia Corticosteroids Hydroxychloroquine Cytotoxics- Cyclophosphamide, Azathioprine Anti-CD20- Rituximab ```
60
Aetiology of Sjogren's syndrome
Lymphocytic infiltration of exocrine glands
61
Risk factors for Sjogren's syndrome
Female, vitamin D deficiency, secondary to other autoimmune conditions
62
What are sicca symptoms?
Xeropthalmia and Xerostomia found in Sjogren's syndrome
63
What antibodies are found in Sjogren's syndrome?
Anti-Ro and Anti-La
64
Presentation of Sjogren's syndrome
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
65
Tests for Sjogren's syndrome
Anti-Ro + Anti-La antibodies | Schirmer's test- paper in eye <5mm
66
What criteria is used to assess Sjogren's syndrome?
Coppenhagen criteria + American-European consensus
67
Management of Sjogren's syndrome
Symptomatic- artificial tears + saliva, vaginal lubricant Blockage of puncta by electrocautery Immunosuppressants- Cyclophosphamide Hydroxychloroquine
68
Aetiology of Systemic Sclerosis
Increased fibroblast activity --> abnormal growth of connective tissue
69
Cardinal features of Systemic Sclerosis
1. Excessive collagen production and deposition 2. Vascular damage 3. Immune system activation
70
Types of Systemic Sclerosis
Limited or Diffuse
71
Risk factors for Systemic Sclerosis
Female, infections eg CMV/EBV, drugs eg vitamin K, cocaine, radiation, vitamin D deficiency
72
What antibodies can be found in Systemic Sclerosis?
Anti-centromere Ab (ACA) Anti-topoisomerase I Anti-RNA polymerase III
73
Presentation of Systemic Sclerosis
``` Limited- CREST Calcinosis Raynaud's (o)Esophageal dysmotility Sclerodactyly Telangiectasia ```
74
Management of Systemic Sclerosis
Emollients for skin PPI for reflux Immunotherapy- methotrexate, mycophenolate mofetil
75
Monitoring in Systemic Sclerosis
Annual echo for pulmonary hypertension | Annual lung function tests for pulmonary fibrosis
76
What is Polymyositis?
Connective tissue disease mainly affecting muscles
77
When does Polymyositis usually present?
Age 30-60
78
Aetiology of Polymyositis
Can be paraneoplastic syndrome of SCLC | Ass with HIV, HTLV-1, CoxsackieB
79
Presentation of Polymyositis
Inflammatory myopathy Onset weeks to months Proximal weakness, fatigue, muscle cramps, muscular atrophy
80
Blood tests in Polymyositis
Raised Creatinine Kinase | Anti-Jo-1 antibodies
81
Investigations in Polymyositis
Diagnosis by EMG + muscle biopsy PET/CXR for SCLC Anti-Jo-1 antibodies Raised CK
82
Management of Polymyositis
Mainly steroids | Immunosuppressants- Azathioprine
83
What is Dermatomyositis?
Connective tissue disease of skin and muscles
84
What is the peak age of onset of Dermatomyositis?
Age 50
85
Aetiology of Dermatomyositis
Can be paraneoplastic syndrome of SCLC
86
Presentation of Dermatomyositis
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
87
Antibodies found in Dermatomyositis
ANA, Anti-Mi-2
88
Investigations for Dermatomyositis
ANA, Anti-Mi-2 antibodies | PET/CXR for paraneoplastic of SCLC
89
Management of Dermatomyositis
Sunblock | Steroids, immunosuppressives- Azathioprine
90
What heart problem is Dermatomyositis associated with?
Dilated cardiomyopathies
91
Aetiology of Gout
Arthritis due to deposition of monosodium urate crystals within joints
92
What is the most commonly affected joint in Gout?
1st MTPJ
93
Risk factors for gout
Men, age, purine-rich foods, fructose, alcohol, CKD, obesity, diabetes, malignancy (tumour lysis syndrome)
94
What blood test can be used in investigation of gout?
Uric acid > 360mmol/L | But can be normal in acute attack of gout as all uric acid is in joint rather than blood
95
Exacerbating factors for gout
Cold and trauma reduce crystal solubility
96
Presentation of gout
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
What is found on joint aspiration in gout?
Strongly negatively birefringent needles
98
X-ray findings in gout
Punched out lesions (juxta-articular erosions) Areas of sclerosis + tophi Loss of joint space, soft tissue swelling
99
What is the most important differential of gout?
Septic arthritis
100
Management of gout
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
Cautions/side effects of Colchicine
Caution in CKD | Side effect- diarrhoea
102
Risk factors for Osteoarthritis
Age, female, obesity, stress on joints, RA
103
Which joints are most commonly affected in Osteoarthritis?
Thumb most affected | 2+3rd MCPJ
104
Presentation of Osteoarthritis
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
Hand signs on examination of Osteoarthritis
Heberden's (DIP) and Bouchard's (PIP) nodes
106
X-ray findings in Osteoarthritis
Osteophytes Joint space narrowing Bone cysts Subarticular sclerosis
107
Management of Osteoarthritis
Exercise, physio, paracetamol, NSAIDs Intra-articular corticosteroid injections Joint surgery
108
What is Septic arthritis?
Infection causing inflammation in a joint
109
Causative organisms of Septic arthritis
75% Staphylococcal aureus Streptococci Neisseria
110
Most commonly affected joint in Septic arthritis
Knee most common | Then hip, shoulder, ankle, wrist
111
Risk factors for Septic arthritis
Age, diabetes, RA/gout, joint surgery, prosthesis, skin infection, immunodeficiency
112
Presentation of Septic arthritis
Single swollen joint with pain on active and passive movement, hot, tender, unable to weight bear Fever, rigors
113
Investigation of Septic arthritis
Joint aspiration- WCC, gram staining, culture
114
Management of Septic arthritis
Surgical drainage + lavage | High dose antibiotics- 2-3wks IV Flucloxacillin
115
What are seronegative spondyloarthropathies?
-ve for anti-CCP and rheumatoid factor | Include AS, Enteropathic arthritis, psoriatic arthritis, Reiter's syndrome
116
What is Pseudogout?
Calcium Pyrophosphate Deposition | A bone constituent released from bone into joint during bony erosion in OA
117
Risk factors for Pseudogout
Elderly, dehydration, OA, long term steroids
118
Presentation of Pseudogout
Acute: mono/oligoarthritis, mostly knees, acute joint pain, swelling, warmth, fever, tenderness Chronic: destructive changes like OA
119
Investigations of Pseudogout
Raised WCC X-ray Aspiration
120
X-ray findings in Pseudogout
Linear opacification of articular cartilage
121
Findings on joint aspiration in Pseudogout
Intra + extracellular weakly positive birefringent rhomboid crystals
122
Management of Pseudogout
Treat the cause, ice, rest | NSAIDs, intra-articular steroids, systemic steroids
123
What is Osteoporosis?
Reduced bone mass and microarchitectural destruction of bone
124
What are Osteoporotic fractures?
Fractures from mechanical force that would not usually result in a fracture
125
What are the most common locations of osteoporotic fractures?
Spine, forearm, hip, shoulder, distal radius
126
What is T and Z score for osteoporosis?
T score- BMD in relation to young health population | Z score- BMD in relation to a SD of their age
127
What scan is most important in osteoporosis?
DEXA scan
128
Risk factors for osteoporosis
Female, age, low BMI, parental hip fracture, previous fracture, steroids, alcohol, smoking
129
What is FRAX score?
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
Management of Osteoporosis
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
Most common demographic for Reactive Arthritis
HLAB27 white young adults
132
Aetiology of Reactive Arthritis
Follows GI/GU infection by 1-6 weeks - Campylobacter, Shigella, Salmonella - Chlamydia trachomatis, HIV
133
What is Reiter's syndrome?
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
Presentation of Reactive Arthritis
Asymmetrical lower limb oligoarthritis, lower back pain, heel pain, erythema nodosum, mouth ulcers, aortic regurgitation
135
What cardiac abnormality can present in Reactive Arthritis?
Aortic regurgitation
136
Investigations for Reactive Arthritis
Culture/serology for causative infection
137
Management of Reactive Arthritis
Rest, physio, NSAIDs | Corticosteroids, Abx for organism, Sulfasalazine
138
What is Enteropathic Arthritis?
Seronegative spondyloarthropathy due to IBD (also Coeliac, Whipple's disease, Bypass)
139
What are the 2 types of Enteropathic Arthritis?
Axial form | Peripheral form
140
How does the axial form of Enteropathic Arthritis present?
Spondylitis + Sacroiliitis | Lower back pain down legs, worse in morning, prolonged sitting/standing worsens symptoms
141
How does the peripheral form of Enteropathic Arthritis present?
Asymmetric oligoarticular arthritis of lower limbs
142
Which IBD is the peripheral form of Enteropathic Arthritis more common in?
Peripheral- Crohn's
143
Management of Enteropathic Arthritis
Improve IBD --> improve arthritis IA/Systemic steroids, Sulfasalazine DMARDs: methotrexate, azathioprine
144
What is vasculitis?
Inflammation of blood vessels
145
What classification is used to group vasculitis?
``` 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
What part of the body does Ankylosing Spondylitis affect?
Axial skeleton
147
Define ankylosing
Fusing of 2 joints
148
What is the peak age of onset of Ankylosing Spondylitis?
20s-30s
149
Risk factors for Ankylosing Spondylitis
HLAB27 | Male
150
Presenation of Ankylosing Spondylitis
Morning stiffness, inflammatory back pain, sacroiliitis, enthesitis, fever, weight loss, fatigue, asymmetric peripheral arthropathies, reduced chest expansion, reduced lumbar motion
151
Extra-articular manifestations of Ankylosing Spondylitis
``` 6 As Apical fibrosis Anterior uveitis Aortic regurgitation Achilles tendonitis AV node block Amyloidosis ```
152
What special test can be done on examination to assess for Ankylosing Spondylitis?
Schober's test- ability to flex the lower back
153
Diagnosis of Ankylosing Spondylitis
Radiological (sacroiliitis on x-ray) + 1 clinical criteria
154
What can be found on x-ray in Ankylosing Spondylitis?
``` Sacroiliitis Squared vertebral bodies Syndesmophytes Fusion of vertebral column- Bamboo spine Fusion of spinous processes- Dagger spine Kyphoscoliosis ```
155
Management of Ankylosing Spondylitis
``` Posture, physio, exercise 1st line- NSAIDs, Cox-2 inhibitors Local/oral corticosteroids TNF-alpha inhibitor- Etanercept Surgery ```
156
Types of Psoriatic Arthritis
- Rheumatoid pattern - Lone DIP disease - Arthritis mutilans - Asymmetrical oligoarticular pattern - Juvenile onset
157
What is Arthritis Mutilans?
A late-stage presentation of Psoriatic Arthritis Pencil-in-cup appearance on x-ray Telescoping seen O/E
158
Presentation of Psoriatic Arthritis
Joint stiffness, pain + swelling Psoriatic rash- psoriasis mostly precedes arthritis Nail changes- pitting, yellowing, onycholysis Enthesopathy- achilles, plantar fascia Anterior uveitis
159
X-ray findings in Psoriatic Arthritis
Mild bony erosion at edge of cartilage DIP/PIP involvement 'Pencil-in-cup' appearance in arthritis mutilans
160
Management of Psoriatic Arthritis
Monotherapy for rash + arthritis- Methotrexate, Retinoids, Psoralen A, UVA Ustekinumab- cytokine modulator Surgical
161
Main concerning complication of Psoriatic Arthritis
Atlanto-axial subluxation
162
What is Onycholysis?
Loosening or separation of the nail from the nail bed
163
What is Juvenile Idiopathic Arthritis?
Joint inflammation in <16s persisting > 6 weeks
164
Types of Juvenile Idiopathic Arthritis
``` 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
Describe the rash seen in Juvenile Idiopathic Arthritis
Salmon-pink rash
166
Diagnosis of Juvenile Idiopathic Arthritis
Clinical diagnosis
167
Findings on USS of Juvenile Idiopathic Arthritis
Joint fluid, synovial hypertrophy, erosions
168
Management of Juvenile Idiopathic Arthritis
Physio, NSAIDs, IA/Systemic steroids | 1st line- subcut Methotrexate (then Etanercept)
169
Aetiology of Sarcoidosis
Inflammatory- formation of non-caseating epithelioid granulomata
170
Presentation of Sarcoidosis
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
Describe the arthritis seen in Sarcoidosis
Inflammatory arthritis with periarticular soft tissue swelling, tenosynovitis, dactylitis, osteopenia
172
Investigations of Sarcoidosis
CXR for staging | BAL- raised lymphocytes
173
Findings on CXR in Sarcoidosis
Bilateral hilar and paratracheal lymphadenopathy
174
How is Sarcoidosis officially diagnosed?
Histology- granulomatous inflammation
175
Management of Sarcoidosis
1st line- oral glucocorticoids- Prednisolone 2nd line- anti-metabolites- MTX, azathioprine Joints- NSAIDs Eye disease- topical corticosteroids/intraocular injection
176
Complications of Sarcoidosis
PE, lung fibrosis, arrhythmia, sudden cardiac death, uveitis, conjunctivitis, nerve damage, stroke/TIA, lymphoma
177
What is the inheritance pattern of Marfan's syndrome?
Autosomal dominant
178
What is the aetiology of Marfan's syndrome?
Autosomal dominant connective tissue disorder | Defect in FBN1 gene on chromosome 15 which codes for Fibrillin-1 protein
179
Presentation of Marfan's syndrome
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
Management of Marfan's syndrome
Echo monitoring for heart | Beta blockers/ACE inhibitors
181
Most common age of onset of Fibromyalgia
Age 20-50
182
Is Fibromyalgia more common in men or women?
Women
183
Presentation of Fibromyalgia
Chronic widespread pain, lower back/neck/shoulder pain Unrefreshing sleep, persistent fatigue, paraesthesia Feeling of swollen joints, headaches Anxiety/Depression
184
What classification is used for Fibromyalgia?
American College of Rheumatology
185
Management of Fibromyalgia
Graded exercise programme CBT Antidepressants- tricyclics, SSRI
186
What should be given with Methotrexate to reduce the risk of GI side effects?
Folic acid
187
Which drugs should be avoided whilst taking methotrexate?
Trimethoprim, Co-trimoxazole, aspirin
188
What is Giant Cell Arteritis/Temporal Arteritis?
Immune-mediated vasculitis of medium and large vessels, especially carotid and extra-cranial branches
189
Risk factors for Giant Cell Arteritis/Temporal Arteritis
Polymyalgia Rheumatica, women aged 60-80
190
Presentation of Giant Cell Arteritis/Temporal Arteritis
NEW onset temporal headache, scalp tenderness, jaw/tongue claudication Visual- blurred vision, amaurosis fugax, irreversible vision loss
191
Which artery is diseased to cause visual loss in Giant Cell Arteritis/Temporal Arteritis?
Opthalmic artery
192
Findings on examination of Giant Cell Arteritis/Temporal Arteritis
Temporal artery tender to palpation and reduced pulsation
193
Investigations in Giant Cell Arteritis/Temporal Arteritis
ESR > 50 | Temporal artery biopsy within 2 weeks of starting steroids
194
What does temporal artery biopsy show in Giant Cell Arteritis/Temporal Arteritis?
Mononuclear cell infiltration or granulomatous inflammation with multinucleated giant cells
195
Management of Giant Cell Arteritis/Temporal Arteritis
40mg Prednisolone 60mg if visual symptoms or claudication Low-dose aspirin 75mg + PPI
196
What is Anti-phospholipid syndrome?
Autoimmune disorder with raised anti-phospholipid antibodies
197
What antibodies are found in Anti-phospholipid syndrome?
Lupus anticoagulant, Anti-cardiolipin antibody, anti-B2-glycoprotein I antibody
198
Risk factors for Anti-phospholipid syndrome
``` Female Secondary to other autoimmune disease eg SLE, GCA, psoriatic arthritis Infections eg HIV, varicella Drugs eg phenothiazides, phenytoin Sickle cell, GBS ```
199
Presentation of Anti-phospholipid syndrome
Vascular thrombosis: DVT, PE, MI, CVA Adverse pregnancy outcomes: miscarriage, pre-eclampsia, IUGR Livedo reticularis (purple mottled rash), Nephropathy, Retinal thrombosis
200
Investigations in Anti-phospholipid syndrome
CT brain- CVA CTPA- PE CT abdomen- Budd-Chiari syndrome Doppler- DVT
201
Management of Anti-phospholipid syndrome
Manage cardiovascular risk factors Acute- Heparin 1000U/hr Long-term- Warfarin/antiplatelet
202
Presentation of small vessel vasculitis
Palpable purpura 1-3mm, splinter haemorrhages, urticaria + vesicles, Livedo reticularis
203
Examples of small vessel vasculitis
Henoch-Schonlein purpura, SLE, Sjogren's, IBD, Hairy cell leukaemia
204
Examples of medium vessel vasculitis
Granulomatosis with polyangiitis, Churg-Strauss syndrome, Kawasaki, GCA, Behcet disease, Erythema induratum
205
Presentation of medium vessel vasculitis
Ulcers, digital infarcts, nodules, Livedo reticularis, papulo-necrotic lesions, hypertension
206
Examples of large vessel vasculitis
Kawasak, Behcet, Syphilis, GCA, Takayasu's arteritis
207
Presentation of large vessel vasculitis
End-organ ischaemia- TIA/CVA | Hypertension, aneurysms, dissection/haemorrhage/rupture
208
Risk factors for Polymyalgia Rheumatica
Age > 50 Female GCA
209
Presentation of Polymyalgia Rheumatica
Severe bilateral pain + stiffness (>45min in morning) in shoulder, neck and pelvic girdle
210
Investigations in Polymyalgia Rheumatica
Raised ESR/CRP
211
Management of Polymyalgia Rheumatica
Prednisolone 15mg up to 2 years | Methotrexate if cannot tolerate steroids
212
What is Behcet's syndrome?
An autoimmune inflammation of blood vessels
213
Risk factors for Behcet's syndrome
Male, young adults, FH, HLAB51
214
Presentation of Behcet's syndrome
``` Triad of... 1. Oral ulcers 2. Genital ulcers 3. Anterior uveitis Thrombophlebitis + DVT, arthritis, erythema nodosum ```
215
How is Behcet's syndrome diagnosed?
Clinical diagnosis
216
What additional test can be done to assess for Behcet's syndrome?
Pathergy test- puncture site following needle prick becomes inflamed with small pustule forming
217
What side effect can Hydroxychloroquine cause?
Bull's eye retinopathy
218
Adverse effects of steroids
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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