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roma Flashcards

1
Q

azathioprine adverse effects and interactions

A

-bone marrow suppression
-nausea-vomit
-pancreatitis
-increased risk for non-melanoma skin cancer
-interact with allopurinol

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2
Q

how does allopurinol cause interaction with azathioprine?

A

-cause severe bone marrow suppression-pancytopenia-low wbc-allow for cap/tonsillitis/pharyngitis
-allopurinol-xanthine oxidase inhibitor-metabolises 6-mp into active form=azathioprine

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3
Q

what is the next best step if temporal arteritis is suspected?

A

urgent high dose prednisolone before the temporal artery biopsy to prevent permanent vision loss

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4
Q

Treatment of Temporal Arteriti

A

Urgent High-Dose Glucocorticoids: Administered when suspected and before temporal artery biopsy
Visual Loss: IV methylprednisolone used if evolving visual loss; dramatic response expected
Urgent Ophthalmology Review: Visual damage is often irreversible
Other Treatments: Bisphosphonates for bone protection during steroid therapy, low-dose aspirin (evidence base weak)

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5
Q

Investigations for Temporal Arteritis

A

Raised Inflammatory Markers: ESR > 50 mm/hr (CRP may also be elevated)
Temporal Artery Biopsy: May show skip lesions
Creatine Kinase and EMG: Normal

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6
Q

Clinical Features of Temporal Arteritis

A

Age: Typically > 60 years old
Onset: Rapid (e.g., < 1 month)
Common Symptoms: Headache (85%), jaw claudication (65%)
Vision Testing: Key investigation; anterior ischemic optic neuropathy is a major complication
Ocular Complications: Swollen pale disc, blurred margins, amaurosis fugax, sudden permanent visual loss, diplopia
Physical Exam: Tender, palpable temporal artery

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7
Q

Temporal arteritis overlap with which other disease?

A

PMR=Overlap with Polymyalgia Rheumatica (PMR)
Definition: About 50% of temporal arteritis patients exhibit features of PMR.
PMR Features: Aching, morning stiffness in proximal limb muscles (not weakness), lethargy, depression, low-grade fever, anorexia, night sweats.

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8
Q

Lateral epicondylitis-tennis elbow-signs
Diagnostic
Management

A

worse on resisted wrist extension/suppination whilst elbow extended
X-ray usually normal/us-tendon thickening/mri-assess bone-cartilage-ligaments as well/cbc-rule out osteitis pubis
-rest.ice-nsaid-physio-steroid/lidocaine not directly into tendon-surgery if not better in 6 months
STEROID INJECTIONS AVOIDED IN INSERTIONAL tendinopathies-may cause TENDON RUPTURE

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9
Q

NORMAL IN PMR

A

CREATINE KINASE

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10
Q

SLE TX FIRST LINE

A

HYDROXYCHLOROQUINE

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11
Q

Methotrexate adverse effects

A

Pneumonitis
Pulm fibrosis
Liver fibrosis

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12
Q

Gout: management

A

Acute management
NSAIDs or colchicine are first-line
the maximum dose of NSAID should be prescribed until 1-2 days after the symptoms have settled
gastroprotection (e.g. a proton pump inhibitor) may also be indicated
colchicine
inhibits microtubule polymerization by binding to tubulin, interfering with mitosis. Also inhibits neutrophil motility and activity
has a slower onset of action
may be used with caution in renal impairment: the BNF advises to reduce the dose if eGFR is 10-50 ml/min and to avoid if eGFR < 10 ml/min BNF
the main side-effect is diarrhoea
oral steroids may be considered if NSAIDs and colchicine are contraindicated.
a dose of prednisolone 15mg/day is usually used
another option is intra-articular steroid injection
if the patient is already taking allopurinol it should be continued

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13
Q

Hydroxychloroquine side effects

A

Permanent bulls eye retinopathy

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14
Q

Cyclophosphamide side effect

A

Hemorrhagic cystatis

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15
Q

Pmr tx

A

Prednisolone

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16
Q

OA xr changes

A

Loss of joint space
Osteophytes forming at joint margins
Subchondral sclerosis
Subchondral cysts

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17
Q

APLS TX

A

primary thromboprophylaxis
low-dose aspirin
secondary thromboprophylaxis
initial venous thromboembolic events: lifelong warfarin with a target INR of 2-3
recurrent venous thromboembolic events: lifelong warfarin; if occurred whilst taking warfarin then consider adding low-dose aspirin, increase target INR to 3-4
arterial thrombosis should be treated with lifelong warfarin with target INR 2-3

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18
Q

DERMATOMYOSITIS SIGNS

A

Heliotrope rash-periorbital
Gottron’s papules-red papules over extensor surfaces of fingers
Gottron sign-violaceous macules, sometimes with associated oedema, over the knees and elbows. This is also associated with dermatomyositis

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19
Q

RA management for disease slowing

A

Methotrexate+short course prednisolone

choices for initial DMARD monotherapy:
methotrexate is the most widely used DMARD. Monitoring of FBC & LFTs is essential due to the risk of myelosuppression and liver cirrhosis. Other important side-effects include pneumonitis
sulfasalazine
leflunomide
hydroxychloroquine: should only be considered for initial therapy if mild or palindromic disease

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20
Q

Ra tx monitoring-scoring system

A

Crp monitoring
DAS28

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21
Q

ANKYLOSING SPONDYLITIS INITIAL MANAGEMENT

A

Exercise and nsaids

22
Q

What is the most sensitive antibody for sle

A

ANA

23
Q

No true weakness on examination of shoulder/pelvic girdle but there is pain. What is the condition?

A

Pmr-any weakness of muscle is due to pain/myalgia

24
Q

Rotator cuff injury presentation

A

Unilateral-pain on abduction of arm

25
Q

Frozen shoulder presentation

A

Unilateral pain and stiffness
First pain followed by stiffness

26
Q

Pseudogout-joint fluid shows

A

positively birefringent rhomboid shaped crystals. Pseudogout, also known as calcium pyrophosphate deposition (CPPD) disease, is characterized by the presence of positively birefringent rhomboid shaped crystals in the joint fluid. These crystals are composed of calcium pyrophosphate dihydrate (CPPD) and can cause acute inflammation and pain in affected joint

27
Q

Septic arthritis clinical features and diagnostic

A

Classic triad: fever/joint pain/restricted ROM
Monoarticular usually
Gonococcal arthritis is a variant
Absence of fever not rule out SA
Wbc count increased in synovial fluid analysis
Arthrocentesis with synovial fluid analysis
Xray of affected joint-might be normal

28
Q

Reactive arthritis clinical features, diagnosis, tx

A

Postinfectious with chlamydia, ureaplasma, shigella, salmonella, campylobacter, yersinia
1-4 wks latency
Oligoarthritis, asimetrik, acute onset
Sacroilitis, enthesitis, dactylitis
Conjunctivitis, urethritis, oral ulcers, aortic regurg, av block, pericarditis, diarrhea
Dx: clinical diagnosis—stool culture, urethral swab, labs-cbc: wbc and platelets high, esr and crp high, gram stain and cultures might be negative but PCR would show for chylamydia and gonorrhea
Tx: treat infection,nsaids first line-start high titrate down, steroids if nsaids contraindc, dmard if more than 6 months of ongoing symptoms-sulfasalazine/methotrexate

29
Q

RA early xray feature

A

Juxtaarticular osteoporosis/osteopenia
Swelling in small joints of hands

30
Q

Ra xray changes

A

Early x-ray findings
loss of joint space
juxta-articular osteoporosis
soft-tissue swelling
periarticular erosions
subluxation

31
Q

Dexa
-1 to -2.5=?
>-2.5=?

A

T-score of -1.0 to -2.5 indicates osteopenia, and a T-score of -2.5 or lower indicates osteoporosis

32
Q

AS schober test criteria

A

Schober’s test <5cm is suggestive of ankylosing spondylitis. This is an indication of reduced lumbar flexion.

33
Q

AS other features starts with A

A

Apical fibrosis
Anterior uveitis
Aortic regurgitation
Achilles tendonitis
AV node block
Amyloidosis
and cauda equina syndrome
peripheral arthritis (25%, more common if female)

34
Q

Osteoporosis in man-what hormone to check?

A

Testosterone

Hypogonadism is a common cause of osteoporosis in men. It is classified either as hypergonadotropic (primary gonadal failure) or hypogonadotropic (secondary to a defect in the hypothalamic-pituitary axis) hypogonadism. The role of androgens on male bone metabolism is twofold. First, androgens stimulate bone formation during puberty. Second, androgens prevent bone resorption during and after puberty.

35
Q

Gout tx including flares and long term

A

Acute management
NSAIDs or colchicine are first-line
the maximum dose of NSAID should be prescribed until 1-2 days after the symptoms have settled
gastroprotection (e.g. a proton pump inhibitor) may also be indicated
colchicine inhibits microtubule polymerization by binding to tubulin, interfering with mitosis. Also inhibits neutrophil motility and activity
has a slower onset of action
may be used with caution in renal impairment: the BNF advises to reduce the dose if eGFR is 10-50 ml/min and to avoid if eGFR < 10 ml/min BNF
the main side-effect is diarrhoea
oral steroids may be considered if NSAIDs and colchicine are contraindicated.
a dose of prednisolone 15mg/day is usually used
another option is intra-articular steroid injection
if the patient is already taking allopurinol it should be continued

Indications for urate-lowering therapy (ULT)
the British Society of Rheumatology Guidelines now advocate offering urate-lowering therapy to all patients after their first attack of gout
ULT is particularly recommended if:
>= 2 attacks in 12 months
tophi
renal disease
uric acid renal stones
prophylaxis if on cytotoxics or diuretics

ULT-

allopurinol is first-line
initial dose of 100 mg od, with the dose titrated every few weeks to aim for a serum uric acid of < 360 µmol/l CKS
a lower target uric acid level below 300 µmol/L may be considered for patients who have tophi, chronic gouty arthritis or continue to have ongoing frequent flares despite having a uric acid below 360 µmol/L
a lower initial dose of allopurinol should be given if the patient has a reduced eGFR
colchicine cover should be considered when starting allopurinol. NSAIDs can be used if colchicine cannot be tolerated. The BSR guidelines suggest this may need to be continued for 6 months
the second-line agent when allopurinol is not tolerated or ineffective is febuxostat (also a xanthine oxidase inhibitor)
in refractory cases other agents may be tried:
uricase (urate oxidase) is an enzyme that catalyzes the conversion of urate to the degradation product allantoin. It is present in certain mammals but not humans
in patients who have persistent symptomatic and severe gout despite the adequate use of urate-lowering therapy, pegloticase (polyethylene glycol modified mammalian uricase) can achieve rapid control of hyperuricemia. It is given as an infusion once every two weeks

36
Q

Fibromyalgia-how long should the symptoms be present before dx can be made

A

3 months

37
Q

Raynaud-which medication help

A

Nifedipine

38
Q

Ewing sarcoma=location, appearance

A

Ewing’s sarcoma - malignant tumour that occurs most frequently in the diaphysis of the pelvis and long bones
Onion skin appearance on xray
Ews fli1 protein

39
Q

Osteochondroma

A

most common benign bone tumour
more in males, usually diagnosed in patients aged < 20 years
cartilage-capped bony projection on the external surface of a bone

40
Q

Osteosarcoma

A

most common primary malignant bone tumour
seen mainly in children and adolescents
occurs most frequently in the metaphyseal region of long bones prior to epiphyseal closure, with 40% occuring in the femur, 20% in the tibia, and 10% in the humerus
x-ray shows Codman triangle (from periosteal elevation) and ‘sunburst’ pattern
mutation of the Rb gene significantly increases risk of osteosarcoma (hence association with retinoblastoma)
other predisposing factors include Paget’s disease of the bone and radiotherapy

41
Q

Chondrosarcoma

A

malignant tumour of cartilage
most commonly affects the axial skeleton
more common in middle-age

42
Q

Osteoma

A

benign ‘overgrowth’ of bone, most typically occuring on the skull
associated with Gardner’s syndrome (a variant of familial adenomatous polyposis, FAP)

43
Q

Giant cell tumor

A

tumour of multinucleated giant cells within a fibrous stroma
peak incidence: 20-40 years
occurs most frequently in the epiphyses of long bones
X-ray shows a ‘double bubble’ or ‘soap bubble’ appearance

44
Q

Which medications increase the risk of gout

A

pyrazinamide and ethambutol can increase uric acid levels.

45
Q

Temporal arteritis visual pathology

A

Anterior ischemic optic neuropathy accounts for the majority of ocular complications in temporal arteritis

46
Q

———— is a risk factor for pseudogout

A

Haemochromatosis is a risk factor for pseudogout

Risk factors include haemochromatosis, hyperparathyroidism, hypophosphataemia, hypothyroidism and hypomagnesemia. Also old age is a big risk factor.

47
Q

patients with Sjogren’s syndrome have an increased risk of ———

A

patients with Sjogren’s syndrome have an increased risk of lymphoid malignancies.

48
Q

Pencil in cup

A

Psoriatic arthritis due to periarticular erosions and bone resorption

49
Q

Which antibiotics have risk of severe bone marrow suppression if used with methotrexate

A

Trimethoprim and co-trimoxazole, anti-folate antibiotics, should be avoided concurrently with methotrexate due to the risk of bone marrow aplasia

50
Q

Sle clinical features

A

General features
fatigue
fever
mouth ulcers
lymphadenopathy

Skin
malar (butterfly) rash: spares nasolabial folds
discoid rash: scaly, erythematous, well demarcated rash in sun-exposed areas. Lesions may progress to become pigmented and hyperkeratotic before becoming atrophic
photosensitivity
Raynaud’s phenomenon
livedo reticularis
non-scarring alopecia

Musculoskeletal
arthralgia
non-erosive arthritis

Cardiovascular
pericarditis: the most common cardiac manifestation
myocarditis

Respiratory
pleurisy
fibrosing alveolitis

Renal
proteinuria
glomerulonephritis (diffuse proliferative glomerulonephritis is the most common type)

Neuropsychiatric
anxiety and depression
psychosis
seizures

51
Q

Pain improves with exercise

A

Ankylosing spondylitis

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