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Medical School Finals > Speciality: Rheumatology > Flashcards

Speciality: Rheumatology Flashcards

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USMLE® Step 1 flashcards
1
Q

Systemic sclerosis

  1. Causes
  2. Presentation
  3. Ix
  4. Rx
A
  1. UK
    - Associated w/ anti-centromere antibodies.
    - ANA +’ve
    - RF positive
  2. CREST - Calcinosis, Raynaud’s, Oesophageal dysmotility, sclerodactyly, telangiectasia.
    - Limited SS = Raynaud’s, scleroderma (face and hands)
    - Diffuse SS = scleroderma all over, interstitial lung disease and pulmonary HTN.
  3. Autoantibody testing.
    - ANA = all
    - Anti-centromere = limited
    - Anti-SCL = diffuse
    - Nailfold capillaroscopy
  4. Steroid and immunosuppressants in diffuse disease.
    - Stop smoking
    - Gentle skin stretching
    - Avoid cold
    - Physio
    - MDT
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2
Q

Marfan’s syndrome

  1. Causes
  2. Presentation
  3. Ix
  4. Rx
A
  1. AD inherited
    - FBN1 gene on chromo 15
    - Protein fibrillin-1
  2. Tall, thin with increased arm ratio.
    - High arch palate
    - Pectus excavatum
    - Scoliosis
    - Dilatation of the aortic sinuses (dissection TAA)
    - Pneumothorax
  3. Clinical (Ghent criteria)
    - Echo, ECG
    - Genetic testing
  4. Nil
    - Manage risks
    - Regular Echo
    - BB and ACEI improves CV mortality etc.
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3
Q

Dermatomyositis

  1. Causes
  2. Presentation
  3. Ix
  4. Rx
A
  1. Autoimmune; RA, SLE
    - Related to infection; HIV
    - Drugs; Statins and colchicine
    - Malignancy; breast, ovarian, lung
  2. Skin = photosensitive.
    - Macular rash on the back and shoulders
    - Heliotrope rash in the peri-orbital region
    - Gottron’s papules on the extensor surfaces of the fingers.
    Others = Proximal muscles weakness and tenderness
    - Raynauds
    - Resp muscle weakness
    - ILD
    - Dysphagia.
  3. ANA Positive
    - Muscle/skin biopsy
    - MRI for inflamm
    - Look for malignancy
  4. Exercise and physio
    - Steroids, immunosuppress and DMARD.
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4
Q

Antiphospholipid syndrome

  1. Causes
  2. Presentation
  3. Ix
  4. Rx
A
  1. Antiphospholipid antibodies.
    - Associated w/ SLE, RA, SS, GCA.
    - UK pathology
  2. Recurrent venous and arterial thrombosis
    - Recurrent miscarriage
    - Livedo reticularis
    - Thrombocytopenia
    - Prolonged APTT (due to lupus anticoagulant autoantibodies)
    - Pre-eclampsia.
  3. FBC - thrombocytopenia and haemolytic anaemia
    - Clotting - long APTT and normal PT
    - CT/MRI/USS - clot hunting.
    - Autoantibodies - anticardiolipin and lupus anticoagulant.
  4. General - stop smoking, exercise, health diet and weight, avoid excessive alcohol.
    - Thrombosis management - warfarin or other
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5
Q

Osteogenesis imperfecta

  1. Causes
  2. Presentation
  3. Ix
  4. Rx
A
  1. AD inherited
    - Abnormal type 1 collagen due to dec synthesis of pro collagen polypeptides.
  2. Presents in kids
    - multiple ### in different states of healing
    - Atypical ###
    - Blue sclera
    - Deafness due to otosclerosis
    - Dental caries.
  3. In severe forms, prenatal USS for Dx.
    - XR
    - DEXA
    - Genetics
  4. MDT
    - Bisphosphonates bind to and stabilise bone by inhibiting osteoclasts.
    - Surgery; rods to stabilise etc.
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6
Q

Psoriatic Arthritis

  1. Causes
  2. Presentation
  3. Ix
  4. Rx
A
  1. Psoriasis
    - Autoimmune
  2. Arthropathy often precedes skin lesions.
    - Predilection for the DIP and fingers.
    - Nail changes; yellow, splitting etc.
    - Dactylitis
    - Arthritis mutilans - telescoping of the digit (pencil in cup deformity)
    - Tenosynovitis.
  3. Clinical
    - ESR/CRP high
    - RF negative
    - XR
  4. As for RA.
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7
Q

Ankylosing Spondylitis

  1. Causes
  2. Presentation
  3. Ix
  4. Rx
A
  1. HLA-B27 associated arthropathy.
  2. Males 20-30.
    - Back pain worse in the morning which improves with movement.
    - Anterior uveitis
    - Stiffness in hips
    - Loss of ROM of back
    - 5 A’s = Apical fibrosis, anterior uveitis, aortic regurgitation, achilles tendonitis, AV node block, Amyloidosis.
  3. ESR/CRP high
    - XR/MRI demonstrating sacroiliitis is required for Dx.
    - Modified New York criteria = low back pain for more than 3 months + limited chest expansion + limited ROM + sacroiliitis on XR.
  4. Regular exercise; swimming
    - NSAID for pain
    - Physio
    - - TNF; etanercept and adalimumab if severe
    - DMARDS can be used when peripheral joint disease, but not proven to work.
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8
Q

Complications of Rheumatoid arthritis

A
  • Resp = pulmonary fibrosis, pleural effusions, pulmonary nodules, pleurisy.
  • Ocular = Dry eyes, episcleritis, scleritis, osteoporosis
  • IHD
  • Infections
  • Depression.
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9
Q

Gout management

A

1) NSAID if not contraindicated
2) Colchicine (SE = diarrhoea)
3) Joint steroid injection
4) Urate-lowering therapy = allopurinol

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10
Q

Bouchards nodes

A
  • PIPJ
  • Hard/bony growths.
  • OA
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11
Q

Heberdens nodes

A
  • DIPJ
  • Chronic swelling
  • Permanent bony growth
  • Skews fingertip laterally.
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12
Q

Pseudogout

  1. Causes
  2. Presentation
  3. Ix
  4. Rx
A
  1. Microcrystal synovitis caused by calcium pyrophosphate crystals.
    - RF’s = HH, hyperparathyroidism, acromegaly, low phosphate, Wilson’s disease.
  2. Gout Sx
  3. Knee, wrist and shoulders most commonly affected.
    - Joint aspiration; weakly positive birefringent crystals.
    - XR - chondrocalcinosis.
  4. NSAID’s or joint injection of steroids.
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13
Q

Tennis elbow (lateral epicondylitis)

  1. Causes
  2. Presentation
  3. Ix
  4. Rx
A
  1. Following activity such as house painting or tennis.
    - Worse pain on resisted wrist extension with the elbow extended.
  2. Pain and tenderness over the lateral epicondyle.
    - Pain lasts 6mo-2y
  3. Clinical
    - CRP, MRI if required.
  4. Avoiding excessive use
    - Simple pain relief
    - Steroid injection
    - Physio.
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14
Q

Sjogren’s syndrome

  1. Causes
  2. Presentation
  3. Ix
  4. Rx
A
  1. Autoimmune affecting exocrine glands.
    - Results in dry mucus membranes.
    - Associated w/ CTD and RA.
    - More common in women.
    - Link with developing lymphoma.
  2. Dry eyes
    - Dry mouth
    - Dry fanny
    - Arthralgia
    - Raynauds
    - Sensory polyneuropathy.
    - Parotitis.
  3. RF positive
    - ANA positive
    - Anti-RO/LA
    - Schirmers test for tears.
  4. Artifical tears/saliva/vaginal lubricants.
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15
Q

DEXA scan

A
  • Bone density calculation
  • XR of hip/spine
  • > -1 = normal
  • -1 to -2.5 = mildly reduced
  • below -2.5 = osteoporosis.
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16
Q

Osteoporosis management

A

1) Calcium + D AND alendronate
2) If can’t tolerate –> ridendronate
3) If can’t tolerate –> strontium ranelate and raloxifene.
4) Denosumab

  • Most people fail to tolerate due to upper GI Sx such as reflux.
  • After Rx for 5 years; treatment should be reassessed w/ an updated FRAX and DEX
  • Often has all normal blood tests.
17
Q

Paget’s disease of the bone

  1. Causes
  2. Presentation
  3. Ix
  4. Rx
A
  1. Increased and uncontrolled bone turnover.
    - Osteoclasts disorder increase resorption and increased bone remodelling.
    - RF’s - age, male, northern countries, FHx
  2. Older male with bone pain and raised ALP.
    - Bone pain in the skull, spine, pelvis, femur.
    - Bowing or tibia and bossing of skull.
    - Raised ALP in isolation.
    - Cranial nerve 8 entrapment - deafness.
    - Pathological ###

3) raised ALP
- Calcium, phos and PTH normal.
- XR - osteolysis and excessive bone formation.

  1. NSAIDS
    - Bisphosphonates
    - Surgery for deformity
    - Monitor for osteosarcoma.
18
Q

Gout

  1. Causes
  2. Presentation
  3. Ix
  4. Rx
A
  1. Deposition of uric acid crystals in the joint space.
    - RF’s = Male, meat, alcohol, diuretics, obesity ,HTN, CKD
  2. Acute pain in a joint which becomes swollen, tender and red.
    - Knee
    - 1st MTP
    - small hand joints
    - Ankles.
    - Gouty tophi.
  3. Acute 1st MTP inflammation is clinically suggestive.
    - Crystals in synovial fluid is diagnostic.
    - Serum uric acid (high, but normally normal or low in attack)
    - XR for changes; punched-out lesions, sclerosis.
  4. General - elevated and rested
    - NSAID, colchicine (main SE is diarrhoea) in acute flare.
    - Steroids injections.
    - Allopurinol to prevent attack (urate lowering therapy).
19
Q

Polymyalgia Rheumatica

  1. Causes
  2. Presentation
  3. Ix
  4. Rx
A
  1. Vasculitis w/ giant cells.
    - Overlaps w/ GCA
    - Muscle arteries affected.
  2. Typical patient >60yo
    - Usually rapid onset <1mo
    - Aching and morning stiffness in non-wasted proximal muscles.
    - Lethargy, arthralgia, depression, fever, anorexia and night sweats.
  3. ESR raised
    - Others include, bloods, bone profile, TFT, CK etc.
    - Always consider and rule out GCA
    - Response to steroids
  4. Prednisolone daily 15mg/od
20
Q

MTX interactions

A
  • Trimethroprim
  • Co-trimoxazole
  • High dose aspirin
21
Q

RA management

A

1) First line = DMARD + short course of steroids
- Monitor CRP and DAS28 for disease activity.
- Beware of using sulfasalazine in those who are allegic to aspirin.

2) TNF when inadequate response to atleast 2 DMARD’s including MTX.
- Etanercept
- Infliximab
- Adalimumab
- Rituximab

22
Q

Large vessel vasculitis

A
  • Temporal arteritis

- Takayasu’s

23
Q

Medium vessel vasculitis

A
  • Polyarteritis nodose

- Kawaski disease

24
Q

Small vessel Vasculitis

A
  • ANCA associated (wegeners, churg-strauss)

- HSP

Medical School Finals (24 decks)

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