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379 Cards in this Set
- Front
- Back
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what joints are frequently affected in osteoarthritis?
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DIPs, PIPs, hips, knees, lumbosacral, cervical
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how do Rheumatoid factor, ESR and CRP appear in osteoarthritis?
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normal
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radiological finding of joint space narrowing, subchondral scleroris, subchondral cysts and osteophytes are characteristics of what rheumatological disorders?
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osteoarthritis
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what non-medical interventions can be done for osteoarthritis?
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weight loss, low impact exercise, physiotherapy, support aids
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what pharmaceuticals can be used in osteoarthritis?
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NSAIDs/paracetamol; hyaluronic acid injections (?)
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what surgical management is available for osteoarthritis?
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joint debridement; joint replacement; joint fusion
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what systemic features are often seen in rheumatoid arthritis?
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fever, weight loss, fatigue, myalgia, dry eyes, pulmonary fibrosis, pleural effusions, pericarditis, valvular disease
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diagnosis of rheumatoid arthritis requires a patient meet four of what seven criteria?
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morning stiffness (1hr); 3+ joints involved; symmetrical arthritis; arthritis of the hands; rheumatoid nodules; RF positive; radiographic changes
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is rheumatoid factor positive in all rheumatoid arthritis?
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no, though it is one of the diagnostic features
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before commencing a patient with RA on DMARDs, what blood tests should be done?
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LFTs and HBV/HCV
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radiological findings of erosions and bony decalcifications are characteristic of what rhematological disorder?
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rheumatoid arthritis
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how can pain be managed in rheumatoid arthritis?
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NSAIDs, analgesics and steroids
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what DMARDs are commonly used in RA?
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methotrexate, leflunomide, TNF-alpha inhibitors
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when is methotrexate contraindicated in RA?
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immunodeficiency, bone marrow suppression, lung disease, alcohol abuse, pregnancy
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when is leflunomide contraindicated in RA?
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chronic liver disease
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is allopurinol used in gout or pseudogout?
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gout
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what are precipitants of gout? (list 3)
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frusemide, thiazide, aspirin, alcohol, cytotoxic drugs, shellfish, anchovies, liver/kidney, turkey, sardines
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what does joint aspirate look like with gout? with pseudogout?
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(gout:) needle-shaped crystals; (pseudo-gout:) rhomboid-shaped crysals
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what is common pain relief for gout? pseudogout?
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NSAIDs
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what is acute medication for gout eruptions?
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Colchicine
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what joints are typically involved in gout?
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first MTP and foot
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what joints are typically involved in pseudogout?
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knee, wrist, polyarticular
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where in a bone is osteomyelitis most likely to occur?
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(long bones:) at the juxta-epiphyseal region
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what are the likely organisms if one contracts osteomyelitis?
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Staph, pseudomonas, M tuberculosis
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what are the major risk factors for osteomyelitis?
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childhood, diabetes, immunosuppression, sickle cell anaemia
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a seperated shard of bone, in osteomyelitis, is called what?
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sequestrum
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what associated symptoms are seen with osteomyelitis?
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malaise, night sweats, fever
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how does osteomyelitis appear on radiograph?
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may be normal at first, then osteopenia seen near epiphysis, then marked bone lucency (osteonecrosis)
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Septic arthritis is a medical emergency. What immediate management needs to be done?
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Admit, aspirate joint and commence IV antibiotics
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75% of septic arthritis is in sexually active young adults. What organism is usually the cause?
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N. Gonorrhoea
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What organisms are usually the cause of septic arthritis?
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S. aureus, N. gonorrhea, streptococci, gram negatives
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What samples should be collected for culture, in septic arthritis?
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Blood, urine, endocervical, urethral, rectal, oropharygeal + arthrocentesis
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why is plain x-ray done in septic arthritis?
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to rule out osteomyelitis
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what antibiotics should be given in septic arthritis?
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1) flucloxacillin (for 2 weeks), OR 2) clindamycin ... and 3) cephalosporin if high risk for gram negatives
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what is the peak age of onset for ankylosing spondylitis?
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ages 20-30
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what percent of those with ankylosing spondylitis have back involvment?
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75%
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what is the site of inflammation in ankylosing spondylitis?
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enthesis (site of ligament and tendon insertion into bone)
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what type of joint is primarily affected by ankylosing spondylitis?
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fibrocartilaginous joints
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is ankylosing spondylitis improved or worsened with activity?
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improved; worsens with inactivity
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what are the major spinal limitations with ankylosing spondylitis?
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loss of lumbar lordosis; reduced lateral flexion, reduced chest expansion
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what percent of patients with ankylosing spondylitis have extra-spinal involvement?
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50%
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what eye pathology can occur in ankylosing spondylitis?
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acute anterior uveitis (putting at risk of secondary glaucoma)
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how do ESR and CRP appear in ankylosing spondylitis?
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elevated
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what HLA type is associated with ankylosing spondylitis?
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HLA-B27 (90-95% of patients)
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what pharmaceuticals are used in the management of ankylosing spondylitis?
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(pain:) NSAIDs; (disease-modifying drugs:) sulphasalazine, methotrexate, TNF-alpha inhibitors
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what percent of patients with psoriatic arthritis have psoriasis?
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2%
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what are common blood findings with psoriatic arthritis?
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elevated CRP/ESR; anaemia; RF negative
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what surgical management can be offered for psoriatic arthritis?
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synovectomy
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how many joints are usually involved in psoriatic arthritis?
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<4 (oligoarthritis)
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what HLA type is associated with reactive arthritis?
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HLA-B27 (65-95%)
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how long does reactive arthritis typically last?
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approximately 5 months
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what organisms are usually responsible for reactive arthritis?
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Chlamydia trachomatis, Shigella, Salmonella, yersinia enterocollitica, Campylobacter jenui, Clostridium difficile
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what bacterial antigen is implicated in reactive arthritis?
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LPS
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what joints are typically involved in reactive arthritis?
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knee, ankle, MTP, wrist, sacroiliac
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when does reactive arthritis occur after initial infection?
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10-14 days
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what cultures should be sought with reactive arthritis?
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urine, faeces, urethral, synovial (if monoarthritis)
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what organism causes reactive arthritis and confers the highest likelihood of recurrence?
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Chlamydia (50% will recur)
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when should one consider administering suphasalazine or methotrexate for reactive arthritis?
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If the patient is not improving by 3 months
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what arthritis is associated with Crohn's/Ulcerative colitis?
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Enteropathic arthritis
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how long do attacks of enteropathic arthritis typically last?
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one month (coincides with flares of IBD)
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what is the classic precipitant of an SLE rash?
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UV exposure
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what are the characteritistics of SLE joint pain?
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migratory arthralgia; early morning stiffness; tenosynovitis, small joint synovitis (mimics RA)
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what type of renal disease is associated with SLE?
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proliferative GN (heavy haematuria, proteinuria and casts)
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what are the diagnostic markers used for SLE, in bloods?
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ANA, ENA (extractable nuclear antigens), low C3/C4 complements levels, Anti-dsDNA, anaemia, cytopenias. All of these do not always occur
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What percent of SLE patients have anti-dsDNA?
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30%
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for acute flares of SLE, what drugs are used to manage it?
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1) high dose steroids, 2) immunosupressants (ie. cyclophosphamide)
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What is the definition of osteoporosis?
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BMD T-score of < -2.5
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What is the definition of osteopenia?
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BMD T-score between -2.5 and -1.0
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What investigation is used to determine Bone Mineral Density?
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DXA (DEXA)
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What dietary and supplement requirements should be recommended to someone with osteopenia?
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Calcium, and vitamin D supplements
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What is first line therapy for osteoporosis?
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Bisphosphonates
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Which supplement does NOT have to be taken after meals: calcium citrate or calcium carbonate?
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Calcium citrate (as it doesn't require an acidic environment for absorption)
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What advice should be given to a patient that is starting bisphosphonates, about taking their medication?
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Take on an empty stomach, remain upright and avoid other other medications for 30min afterward
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If a patient has had a good response to bisphosphonate treatment, how long should they be taken before being reassessed?
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5-10 years
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What are major risk factors for osteoporosis, used to identify those who should be screened? (list three)
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>70 OR >60yo + any of the following factors: FHx; smoking; high alcohol intake; low calcium diet; low body weight; recurrent falls; sedentary lifestyle for many years
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Teriparatide is a synthetic version of what hormone (hint: used in treatment of osteoporosis)
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parathyroid hormone (PTH)
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What low impact exercise is proven to be excellent for prevention of osteoporosis and falls?
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Tai Chi
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what is the daily recommended intake for calcium?
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1200mg/day
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what are three red flags for back pain?
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1) age <20 or >60; 2) worsens when supine; 3) non-mechanical pain; 4) weight loss; 5) nighttime pain; 6) thoracic pain; 7) HIV positive; 8) IVDU; 9) immune suppression; 10) steroid use; 11) history of carcinoma; 12) structural deformity; 13) widespread neurological deficit
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how long does 'acute' back pain last for?
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6 weeks is not uncommon, but should start to improve in this time if one has been remaining mobile
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when should one order imaging for back pain?
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if any red flags are present
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what percent of acute back pain progresses to chronic?
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10-15%
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why does scleroderma frequently have HTN?
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due to renal involvement & fibrosis of vessel lumens
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what is the CREST constellation of scleroderma?
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Calcinosis; Reynaud's; Esophageal reflux; Sclerodactyly; Telangectasia
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what HLA type is associated with scleroderma?
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HLA-DR1
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what is the characteristic face of the scleroderma patient?
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Mask like: tight lips and nose
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what are the diagnostic criteria for scleroderma?
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1 Major - proximal scleroderma; OR 2 Minor - sclerodactyly; digital pitting scars; loss of substance from finger pads; bibasilar pulmonary fibrosis
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what medication cocktail is commonly prescribed for scleroderma?
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ARBs (Reynaud's); PPIs (GORD); ACE-I (HTN); analgesics (joint pain); Endothelin 1 antagonist (pulmonary HTN)
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what glands are typically affected in Sjogren's syndrome?
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salivary and lacrimal
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what sequelae are common in the eyes of Sjogren patients?
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conjunctivitis and blepharitis
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what oral sequelae are Sjogren patients at risk of?
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dental caries, due to their dry mouth
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Sjogren's is diagnosed with what progression of tear-line on the Schrimer tear test?
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<7mm (in 5 min)
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what blood results help diagnose Sjogren's sydrome?
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hypergammaglobulinemia; ANA; RF; Anti-Ro; Anti-La
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how should the eye symptoms of Sjogren's be managed?
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tear substitute during the day; viscous drops for night; soft contacts for corneal protection
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what is the RR of Lymphoma, in Sjogren's patients?
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40x
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How is the pain of fibromyalgia managed?
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Low dose TCAs (as it is unresponsive to NSAIDs and other analgesics); CBT; relaxation techniques
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weakness of extension of the thumb and forefinger is seen in what compression syndrome?
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radial tunnel syndrome
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anterior interosseus branch compression presents as?
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weakness of the pincer grasp, and pain along the forearm's radial border
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polyarticular refers to how many joints?
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5-6+
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what viruses commonly causes polyarticular arthritis?
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EBV, HBV, parvovirus B19
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what clues would point to SLE as the cause of polyarticular arthritis?
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other system involvement (renal, skin, lung, CNS, blood)
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acute monoarthritis can be caused by?
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gout, pseudogout, septic arthritis
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chronic monoarthritis is caused by?
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osteoarthritis
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migratory arthritis is caused by?
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lyme disease, gonococcal infection, rheumatic fever
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gonococcal arthritis presents as?
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monoarthritis or migratory arthritis
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oligoarticular arthritis involves how many joints?
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multiple joints <5-6
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oligoarticular asymmetric arthropathies include?
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osteoarthritis and spondyloarthropathies
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synovial aspirate with a WBC count between 5K and 50K is classified as?
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inflammatory arthritis
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true or false: osteoarthritis commonly presents with warm, swollen joints?
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False: osteoarthritis is a non-inflammatory arthritis
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if a patient presents with a painful, swollen right knee and has been bitten by an insect, what is the most common cause?
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Lyme disease
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a mono-arthropathy which has been progressively worsened for years is most likely?
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Osteoarthritis
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if a young woman presents with polyarticular, symmetrical swelling and pain and investigations show she is positive IgM for parvovirus, how should this be managed?
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NSAIDs until resolved (usually months)
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what are the two contraindications to joint aspiration, for arthritis?
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1) cellulitis, and 2) bleeding diathesis
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what are the 'three Cs' of tests to be ordered for joint aspirates?
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Cells, Culture, Crystals
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when should a joint aspirate be taken for arthritis?
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always (necessary for diagnosis)
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a joint aspirate with a WBC count >50,000 is classified as?
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Septic arthritis
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what percent of normal patients will be positive for anti-nuclear antibodies (ANAs)?
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5-10%
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anti-dsDNA antibodies are found in what rheumatological condition(s)?
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(specific for) SLE. 80% of patients will have Ab
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what two ANAs are specific for SLE?
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anti-dsDNA and anti-SM (Smith)
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anti-histone ANAs are found in what condition?
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Drug-induced Lupus (95%)
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what percent of Lupus patients are positive for anti-Smith antibodies?
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25-30%
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anticentromere antibodies are found in what condition?
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CREST syndrome
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CREST syndrome usually has what antibodies?
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anti-centromere antibodies
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what ANAs may be positive in Sjogren's Syndrome?
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anti-Ro (SSA), or anti-La (SSB)
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anti-Ro (SSA) antibodies are found in which condition(s)?
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Sjogren's, Neonatal Lupus, and ANA-negative Lupus
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the ANA 'anti-RNP' is characteristic of what condition?
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100% mixed connective tissue disease (MCTD)
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Rheumatoid factor is an antibody against?
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the Fc portion of another antibody
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Rheumatoid arthritis is positive for RF in what percent of cases?
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80%
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what level of RF is a poor prognostic indicator for RA and is an indication for early aggressive treatment?
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high RF, >1:1000
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Is RF specific to RA?
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No, it can be positive in: osteomyelitis, TB, and chronic diseases such as endocarditis
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positive C-ANCA is indicative of what disorder(s)?
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Wegener's Granulomatosis
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P-ANCA is found in which disorder(s)?
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Polyarteritis nodosum (PAN), and Inflammatory Bowel Disease (IBD)
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What antiphospholipid antibody is found in Lupus?
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Lupus Anticoagulant (LA) - which elevates the PTT
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Lupus anticoagulant causes what sequelae?
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The hypercoaguable state induced can result in: a) venous/arterial thrombosis, b) spontaneous abortions, c) paradoxically elevated PTT
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If a woman with Lupus Antibody is symptomatic, how should her pregnancies be managed?
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With anticoagulant (heparin) the duration of the pregnancy
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what part of the joint is mostly involved in rhematoid arthritis?
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the synovium
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is RA symmetric or asymmetric?
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symmetric
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what is the predominant cell type responsible for the autoimmune response in RA?
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T-cells
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what are the three major cytokines responsible for inflammatino?
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TNF(alpha), IL-1, IL-6
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True or false: RA often involves the back, DIP or both
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False: back pain and DIP involvement is rare in RA
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Diagnosis of Rhematoid Arthritis requires 4 of the 7 diagnostic criteria be met. Name 4.
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1) morning stiffness >1 hr, 2) swelling of wrists, MCPs, PIPs >6wks, 3) swelling of 3 joints for >6wks, 4) symmetric joint swelling for >6wks, 5) joint erosion on X-ray, 6) RF-positive, 7) Rheumatoid nodules
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What two diagnostic criteria for RA are also indicators of aggressive, early-erosive disease?
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1) RF-positive, and 2) Rheumatoid nodules
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what causes rheumatoid nodules?
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A focal vasculitis in areas of mechanical stress
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what percent of RA patients have rheumatoid nodules?
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20-30%
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what are the common locations of rheumatoid nodules?
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olecranon, occiput, achilles tenden
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Felty's Syndrome is RA with what extra features?
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a) splenomegaly, and b) neutropenia [neutropenia may leave susceptible to Gram negative infections]
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what X-ray findings are consistent with RA?
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joint erosion, periosteal depletion
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what will the WBC count by in synovial aspirate in RA?
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5,000-50,000 (inflammatory)
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before intubation or anaesthesia, in an RA patient, what investigation should be done?
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Cervical X-ray, to assess atlantoaxial subluxation
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how common is atlantoaxial subluxation in RA patients?
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25-80% of patients
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what percent of RA patients have a raised ESR?
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All of them
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what is the risk of intubating an RA patient with severe atlantoaxial subluxation?
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Fracturing the joint and causing para/quadraplegia
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what are the symptoms an RA patient may experience with atlantoaxial subluxation?
|
neck pain, and C2 radicular pain (parasthesia of the hands/feet)
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which RA patients should receive methotrexate? How is it monitored?
|
All but the most mild cases. LFTs and FBC should be monitored every 2-3 months (first year)
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what are the first line drugs which are commenced upon diagnosis of RA?
|
1) NSAIDs, 2) corticosteroids, 3) methotrexate (MTX). Cease #1 & 2 after a few weeks, when MTX begins working
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how are TNF inhibitors (infliximab, etc) used in management of RA?
|
As second line treatment for severe disease
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Enterecept, Adalimumab and Infliximab are examples of what type of drug?
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Tumor Necrosis Factor (TNF) inhibitors
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what percent of SLE patients are women?
|
90%
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what environmental factor should SLE patients be advised against exposure to?
|
UV(-B) light
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4 of the 11 diagnostic criteria are required for diagnosis of SLE. Name 4.
|
1) Malar rash, 2) Discoid rash, 3) Photosensitivity rash, 4) oral ulcers [painless], 5) arthritis [non-erosive], 6) serositis [pleuritis/pericarditis], 7) renal involvement, 8) neurologic involvement, 9) haematologic involvement, 10) immunologica involvement [anti-dsDNA, anti-SM], 11) antinuclear antibodies
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In SLE what is a discoid rash?
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one with raised edges, and may leave scars behind
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how does photosensitivity present in SLE?
|
a sunburn that persists for an excessive time
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what investigation should be done for SLE patients with a raised creatinine level?
|
a renal biopsy - differentiate GN
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what CNS involvement can occur in SLE?
|
psychosis, seizures
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what markers should one look for in an SLE flare-up?
|
decreased C3/C4/CH50 and elevated anti-dsDNA
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how is SLE managed between flare-ups?
|
UV protection [sunscreen, clothing, sunglasses]
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how are SLE skin rashes managed?
|
corticosteroid cream
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what is the treatment of choice for SLE discoid rashes?
|
hydroxychloroquinine
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what is the mainstay of treatment for SLE flare ups?
|
oral corticosteroids, and symptomatic treatment
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when are cytotoxic drugs (azathioprine, cyclophosphamide) indicated for SLE?
|
in Lupus nephritis (after biopsy)
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how are fertility rates affected in SLE?
|
they are normal
|
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how is pregnancy affected in SLE?
|
spontaenous abortions and stillbirths (LA causes placental infarcts)
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what markers should be screened for in pregnancy, in SLE patients?
|
SSA (anti-Ro) antibodies, which can cause neo-natal lupus and heart block
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|
what four drugs are commonly associated with drug-induced Lupus?
|
1) hydralazine, 2) isoniazid, 3) procainamide, 4) quinidine
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is drug-induced Lupus usually ANA-positive?
|
not necessarily; if from hydralazine or quinidine, often negative
|
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how does Drug-Induced Lupus present?
|
Arthritis and Fever are the key features; no visceral involvement, usually
|
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how is drug-induced Lupus managed?
|
Cease medication [should stop in 1-2 weeks]. If persists, investigate other possibilities
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what major organs are involved in Scleroderma?
|
*Skin, GIT, lungs, kidneys
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what percent of patients with Scleroderma experience Raynaud's phenomenon?
|
100%
|
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what percent of Scleroderma patients experience skin thickening?
|
100%
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what GIT involvement is characteristic of Scleroderma?
|
Pseudo-echalasia: esophogeal dysmotility, hypomotility, bowel dilatation
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what lung involvement is characteristic of Scleroderma?
|
Pulmonary fibrosis (most common cause of death)
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What is the most common cause of death in Scleroderma?
|
Pulmonary fibrosis
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|
Describe a Scleroderma Renal Crisis
|
Malignant hypertension with Acute Renal Failure
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How is a Sclerodermal Renal Crisis treated?
|
ACE-Is
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What ANA are found in Scleroderma?
|
scl-70 & scl-90
|
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How is Scleroderma cured?
|
There is no cure, only management of symptoms
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What treatment is given to patients with scleroderma?
|
D-penicllamine (for skin); CCBs (for Raynaud's); ACE-Is (HTN/renal)
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Limited Scleroderma is characterized by the CREST constellation. What does it stand for?
|
Calcinosis; Raynaud's; Esophageal Dysmotility; Sclerodactyly; Telangectasia
|
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What is the typical distribution of skin involvement in CREST syndrome?
|
Glove and Stocking distribution
|
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Which has a better prognosis: Scleroderma or CREST?
|
CREST, which has a slower progression
|
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|
what pulmonary involvement is characteristic of CREST syndrome?
|
1) Pulmonary Hypertension [present in 25-50%], 2) Interstitial Lung Disease [10%]
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What ANA is found in CREST syndrome?
|
Anti-centromere
|
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|
Raynaud's phenomenon sees pallor and cyanosis in extremities in response to what stimuli?
|
Cold or emotional stress
|
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|
What percent of the population experiences Raynaud's phenomenon?
|
5%
|
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What is secondary Raynaud's phenomenon?
|
When it occurs with other disease (such as Scleroderma or CREST)
|
|
|
Sjogren's is an autoimmune disease against what organs?
|
Endocrine organs (lacrimal and parotid glands)
|
|
|
What types of immune cells are found in glands in Sjogren's syndrome?
|
Lymphocytes
|
|
|
How is Sjogren's Syndrome managed?
|
Symptomatically: artificial tears
|
|
|
What complication results from lack of saliva production in Sjogren's?
|
Dental caries
|
|
|
Sjogren's can be primary, but may also be secondary to which autoimmune diseases?
|
1) RA, 2) SLE, 3) primary biliary sclerosis
|
|
|
What cancer are Sjogren's patients at increased risk of?
|
Lymphoma or other lymphoproliferative disorders
|
|
|
What is the Schirmer's test used for in Sjogren's? Is it diagnostic?
|
It measures tear production. It is NOT diagnostic, but rather a screening test
|
|
|
Rose Bengal staining of the eyes in Sjogren's will reveal?
|
Small corneal ulcerations
|
|
|
What ANAs are found in Sjogren's?
|
anti-Ro (SSA) or anti-La (SSB)
|
|
|
What allele is common to Spondylarthropathies?
|
HLA-B27 (90%)
|
|
|
What antibodies and complement changes are seen in Spondylarthropathies?
|
None; Spondylarthropathies are seronegative
|
|
|
What joints are involved in Spondylarthropathies?
|
Lower back and SI joints
|
|
|
What X-ray findings are characteristic of Spondylarthropathies?
|
haziness and fibrosis of SI and lower back; 'bamboo' spine
|
|
|
Are Spondylarthropathies oligoarticular or polyarticular? Symmetric or asymmetric?
|
Oligoarticular and asymmetric
|
|
|
what extra-articular manifestations are found in Spondylarthropathies?
|
1) erythema nodosum [inflammation of fat cells, creating red nodules], 2) ulcers of the oral mucosa and genitals, 3) eyes: uveitis and conjunctivitis, 4) cardiac valves
|
|
|
Reither's syndrome is another name for?
|
Reactive arthritis
|
|
|
what age group typically presents with Ankylosing spondylitis?
|
20-30s
|
|
|
what is the gender difference for ankylosing spondylosis?
|
M:F = 4:1
|
|
|
what physical examinations should be performed to test for ankylosing spondylitis?
|
a) back against the wall, b) Schober's test [lower lumbar flexion]
|
|
|
what back complication is a patient with ankylosing spondylitis at risk of?
|
vertebral fracture with minimal impact
|
|
|
Reactive Arthritis after infectious diarrhoea is commonly caused by what organisms?
|
Campylobacter*, Shigella, Salmonella
|
|
|
Reactive Arthritis after non-gonococcal urethritis is commonly caused by what organisms?
|
Chlamydia*, Ureaplasma
|
|
|
What mucocutaneous manifestations are seen with Reactive Arthritis, post non-gonococcal urethritis?
|
1) keratoderma blennorrhagica [thickened skin on palms/soles], 2) Circunate balanitis [erythema around glans penis], 3) oral/genital ulcers
|
|
|
what percent of the population is positive for HLA-B27?
|
10-15%
|
|
|
How is Reiter's syndrome (Reactive Arthritis) treated?
|
Antibiotics (2-3 courses of tetracyclines)
|
|
|
Enteropathic arthritis is associated with what autoimmune disease(s)?
|
Inflammatory Bowel Disease (IBD) - Crohn's and UC
|
|
|
Psoriasis which later presents with chronic back pain is characteristic of what Spondylarthropathy?
|
Psoriatic Arthritis
|
|
|
How is Ankylosing Spondylitis managed medically?
|
NSAIDs, and DMARDs [sulphasalazine, MTX, TNF-alpha inhibitors]
|
|
|
How is Psoriatic Arthritis managed medically?
|
NSAIDs, and DMARDs [sulphasalazine, MTX, TNF-alpha inhibitors], intra-articular corticosteroids
|
|
|
what surgical management is available for psoriatic arthritis?
|
synovectomy
|
|
|
Should patients with Spondylarthropathies be advised against exercise?
|
No, exercise improves symptoms, but patients should be well-educated about the risks of trauma to their back
|
|
|
What is the most common joint disease?
|
Osteoarthritis
|
|
|
What joint is mostly commonly affected by osteoarthritis?
|
The knee
|
|
|
What are the three most commonly affected joints in osteoarthritis?
|
1) knee, 2) base of thumb, 3) DIPs
|
|
|
What is the most disabling joint to have OA involvement in?
|
The hip
|
|
|
What tissue is affected in OA?
|
articular cartilage
|
|
|
Secondary remodeling of the joint, in OA, leads to hypertrophic growths called?
|
osteophytes
|
|
|
What is the leading cause of chronic disability?
|
OA of the knee
|
|
|
how long does morning stiffness last in OA?
|
< 20-30 min
|
|
|
What joints of the fingers are commonly involved in OA?
|
DIPs, PIPs, base of thumb
|
|
|
What changes are seen in ESR and FBC in OA?
|
None; ESR and blood studies are normal
|
|
|
What are major risk factors for OA?
|
age, female, major joint trauma, repetitive stress, obesity
|
|
|
What is the only modifiable risk factor for OA?
|
obesity
|
|
|
X-ray findings of a OA joint may include?
|
Joint space narrowing; osteophytes, subchondral cyts
|
|
|
What non-pharmacological treatment is suggested for OA?
|
1) weight loss and 2) muscle strengthening
|
|
|
What is first line medication for OA?
|
paracetamol (2-3g taken throughout day)
|
|
|
what is second line medication for OA, after paracetamol?
|
low dose NSAIDs
|
|
|
what cream can be used topically for OA?
|
capsaicin cream
|
|
|
how is severe OA managed in large joints?
|
joint replacement (arthroplasty)
|
|
|
After building a clinical picture from history and exam, what investigation can be used to verify diagnosis of OA?
|
Joint x-ray
|
|
|
What molecule precipitates an attack of gout?
|
monosodium urate (MSU)
|
|
|
What molecule precipiates an attack of pseudogout?
|
CPPD (calcium pyrophosphate deposition)
|
|
|
How are gout and pseudogout distinguished?
|
synovial fluid analysis
|
|
|
Podagra refers to gout affecting which joint?
|
MTP of the 1st toe
|
|
|
What complication may arise from chronic gout?
|
1) Connective tissue damage, 2) Joint erosion, 3) renal failure
|
|
|
What pain killer is contraindicated in gout?
|
aspirin, as it may precipitate an attack
|
|
|
What anti-TB medications may precipitate gout?
|
pyrazinamide and ethambutol
|
|
|
What are common non-pharmacological precipitants of gout?
|
Alcohol, Infection, Trauma
|
|
|
How long does a flare-up of gout typically last?
|
It will generally resolve on it's own after ~15 days
|
|
|
Are serum uric acid levels useful for diagnosing gout?
|
No, they are quite variable, but are useful for monitoring effectiveness of treatment
|
|
|
Is X-ray useful for management of gout?
|
Yes, it can monitor joint erosions
|
|
|
How do uric acid crystals appear on cytology?
|
negatively birefringent crystals, which are needle shaped
|
|
|
What is first choice NSAID for gout flare-ups?
|
indomethacin (high doses)
|
|
|
What are contraindications for indomethacin in gout?
|
Renal failure or Peptic Ulcer Disease
|
|
|
What is second line treatment for acute gout, if a patient has PUD? renal failure?
|
Peptic Ulcer Disease: colchicine. Renal failure: Steroids
|
|
|
How is gout managed in the chronic phase of the disease?
|
allopurinol (or probenecid for 'undersecretors')
|
|
|
Which gout patients should receive allopurinol?
|
Those with 3+ episodes (commence between flares)
|
|
|
What are some common side effects of allopurinol to be aware of?
|
1) rash, 2) renal failure
|
|
|
If a patient presents with a second attack of suspected gout, what is the first step in the management in this patient?
|
arthrocentesis (always needs to be done to exclude arthritis)
|
|
|
what is basic management of uncomplicated gout, if a patient is presenting for their third flare-up?
|
1) arthrocentesis - confirm Dx, 2) indomethacin, 3) allopurinol - once flare has subsided
|
|
|
Who is high risk of pseudogout?
|
Elderly patients, with pre-existing joint damage (RA or OA)
|
|
|
What joint is commonly affected in pseudogout?
|
The knee
|
|
|
What four comorbidities (beginning with H) may occur with pseudogout?
|
Haemochromatosis, Hyperparathyroidism, Hypophosphatasia, Hypomagnesia
|
|
|
How does joint aspirate appear in pseudogout?
|
positive-birefringent, rhomboid crystals
|
|
|
How does pseudogout appear on X-ray?
|
a) linear deposits [chondrocalcinosis], b) erosions, c) punched-out lesions
|
|
|
How is pseudogout managed?
|
(same as gout:) indomethacin/NSAIDs
|
|
|
Why is septic arthritis a medical emergency?
|
Joint destruction can be rapid and irreversible
|
|
|
In a monoarthritis, what medical emergency must always be considered?
|
Septic arthritis
|
|
|
What is the most common causative organism of septic arthritis?
|
Gonorrhoea (70% of the cases under 40)
|
|
|
Who is more susceptible to non-gonococcal septic arthritis?
|
The elderly, with pre-existing joint destruction
|
|
|
What organism most commonly cause non-gonococcal septic arthritis?
|
E coli and Staph aureus
|
|
|
How is a diagnosis of septic arthritis made?
|
arthrocentesis with WBC > 50,000
|
|
|
How is gonococcal septic arthritis treated?
|
Ceftriaxone
|
|
|
How is non-gonococcal septic arthritis treated?
|
Vancomycin, or nafcillin
|
|
|
What size vessels are involved in Wegener's Vasculitis?
|
Small vessels
|
|
|
What organs are commonly affected in Wegener's vasculitis?
|
Upper and Lower respiratory tract, and Kidneys (nephritis)
|
|
|
What signs should one look for in the respiratory tract of a patient with Wegener's vasculitis?
|
(URT) sinusitis and rhinitis, (LRT) haemoptysis
|
|
|
What auto-antibody should one look for in Wegener's vasculitis, to help confirm diagnosis?
|
C-ANCA, though not diagnostic (alone) since not all are positive
|
|
|
How is Wegener's vasculitis diagnosed?
|
Nasal septum biopsy
|
|
|
How is Wegener's vasculitis treated?
|
steroids & cyclophosphamide
|
|
|
With treatment, what is the prognosis for patients with Wegener's vasculitis?
|
5-10 years
|
|
|
What types of vessels are involved in Polyarteritis Nodosum (PAN)
|
medium sized vessels
|
|
|
What organ should be investigated to differentiate between Polyarteritis Nodosum and Churg-Strauss?
|
Lungs, which are involved in Churg-Strauss, but not in PAN
|
|
|
What organs are typically involved in Polyarteritis Nodosum?
|
a) small nerves [foot drop], b) kidneys [raised creat], c) GIT [vague pain, and aneurysms]
|
|
|
what virus is positive in 25% of Polyarteritis Nodosum cases, and must be investigated before commencing treatment?
|
Hepatitis B virus
|
|
|
what is a common finding from small nerve involvement of Polyarteritis Nodosum?
|
foot drop
|
|
|
What investigation should be done on the abdomen of a patient with Polyarteritis Nodosum?
|
Angiogram, to look for aneursyms
|
|
|
What auto-antibody is commonly found (but not always) in Polyarteritis Nodosum?
|
P-ANCA
|
|
|
How is Polyarteritis Nodosum (PAN) diagnosed?
|
Nerve biopsy
|
|
|
How Polyarteritis Nodosum treated?
|
With steroids and cyclophosphamide
|
|
|
What are the four common Vasculitic Syndromes?
|
Wegener's Vasculitis, Polyarteritis Nodosum, Churg-Strauss, and Temporal Arteritis
|
|
|
What type of vessels are involved in Churg-Strauss vasculitis?
|
medium sized vessels
|
|
|
What organ is involved in Churg-Strauss that is not affected in Polyarteritis Nodosum?
|
Lungs
|
|
|
On FBC, what abnormalities will one see in the WBCs of a patient with Churg-Strauss?
|
Raised eosinophils (10%+ of WBCs)
|
|
|
In older patients with a new diagnosis of asthma, what vasculitis should be considered?
|
Churg-Strauss syndrome
|
|
|
How is Churg-Strauss syndrome diagnosed?
|
With a biopsy of the lung
|
|
|
What is the typical clinical picture of Temporal (Giant Cell) Arteritis?
|
>50 yrs, headache/scalp tenderness (unilateral), jaw claudication, visual disturbances
|
|
|
If a 60 yr old woman presents with visual changes, headache behind her R eye, scalp tenderness and jaw claudication, what is the next best step?
|
Measure her ESR level (>60)
|
|
|
For Giant Cell Arteritis (GCA) what does the memory trick '60:60:60' represent?
|
Age: >60, ESR > 60, prednisone: 60mg
|
|
|
If Temporal Arteritis is suspected in a patient, when should steroids be commenced?
|
After ESR results (>60), before temporal artery biopsy is performed
|
|
|
If one commences a patient on prednisone for a clinical picture of GCA and a raised ESR, but the biopsy returns negative, what is the next step in management?
|
Cease steroids
|
|
|
How is Temporal Arteritis (GCA) diagnosed?
|
temporal artery biopsy (3cm)
|
|
|
How is Churg-Strauss treated?
|
steroids & cyclophosphamide
|
|
|
How is Temporal Arteritis (GCA) treated?
|
Prednisone (60mg)
|
|
|
In which joints might a patient with Temporal Arteritis experience muscle stiffness?
|
Shoulder and hips (polymyalgia rheumatica)
|
|
|
A diffuse lilac rash over sunexposed areas, with proximal muscle stiffness should make one suspect which myopathy?
|
Dermatomyopathy
|
|
|
What is the clinical presentation of inflammatory myopathies (ie. polymyositis, dermatomyositis, inclusion-body myositis)?
|
Proximal muscle weakness, no ocular or endocrine involvement
|
|
|
What lab work should be done on a patient with proximal muscle weakness, if myopathy is suspected?
|
CPK and aldolase [both increased], Anti-Jo antibodies
|
|
|
How are inflammatory myopathies, with proximal muscle weakness, treated?
|
Steroids! (ironically)
|
|
|
How are inflammatory myopathies diagnosed?
|
a) labs [CPK, aldolase, anti-Jo], b) muscle biopsy, c) EMG studies [biopsy first, as less painful]
|
|
|
How is response to treatment monitored in inflammatory myopathies?
|
Muscular improvement
|
|
|
what portion of the spine is most commonly involved in OA?
|
L4/5 or L5/S1
|
|
|
why might patients with RA become out of breath easily?
|
Due to restrictive lung disease: pulmonary fibrosis
|
|
|
RF is a non-specific biomarker for RA. In light of this, what biomarkers have been used in recent years? What percent of cases are positive?
|
Anti-citrullinated protein antibodies (ACPA), such as CCP (cyclic-citrullinated antibody) and MCV (mutated citrullinated vementin) have a near 95% specificity for RA. Only 65% of patients are positive for it, however.
|
|
|
what are the contraindications to the DMARD methotrexate?
|
a) bone marrow suppression, b) significant lung disease, c) immunodeficiency, d) pregnancy, e) alcohol abuse
|
|
|
the most common source of bacteria in osteomyelitis is?
|
haematological spread
|
|
|
what are the most common three organisms to cause osteomyelitis?
|
Staph, Pseudomonas, Mycobacterium tuberculosis
|
|
|
what is the typical presentation of osteomyelitis?
|
bone pain and tenderness, accompanied by malaise, fever and night sweats
|
|
|
on x-ray of osteomyelitis, where is one most likely to find bone changes?
|
near the epiphysis: osteopenia
|
|
|
after an initial x-ray, what investigation can confirm the diagnosis of osteomyelitis?
|
bone aspirate/biopsy and culture
|
|
|
what imaging modalities can be used for osteomyelitis, after x-ray, to assess extent of infection?
|
Bone technetium scans, Labelled White Cell Scans, MRI
|
|
|
how is osteomyelitis treated?
|
in patient: IV antibiotics [fluclox, clinda, ceph], pain relief. surgical resection of infected bone may be required.
|
|
|
what organisms usually cause septic arthritis?
|
Staph aureus, N gonorrhoea, Streptococci, Gram negatives
|
|
|
what is the typical presentation of septic arthritis?
|
preceding illness or pre-existing joint damage, short onset, fever/malaise, frozen joint and severe pain
|
|
|
which is the medical emergency: reactive or septic arthritis?
|
Septic arthritis, which can rapidly and irreversibly damage the joint
|
|
|
in septic arthritis, culture and sensitivity should be run on what samples?
|
arthrocentesis, blood, urine, endocervical, rectal, oropharyngeal
|
|
|
what is the WBC in joint aspirate of septic arthritis?
|
>50,000
|
|
|
what is the differential diagnosis for septic arthritis and what investigation is used to rule it out?
|
X-ray is used to rule out osteomyelitis
|
|
|
how is septic arthritis managed?
|
(in-patient:) 1) joint aspirate investigations urgently, 2) clindamycin/flucloxacillin +/- cephalosporin, 3) pain relief +/- ice packs, 4) serial aspirates of joint until dry
|
|
|
what percent of people with enteric/genital infection will develop reactive arthritis?
|
1-5%
|
|
|
how long does it take for reactive arthritis to occur after initial infection?
|
10-14 days
|
|
|
in reactive arthritis, what is the epitope to which antibodies are made?
|
LPS from the bacteria
|
|
|
genital infection with chlamydia puts one at risk of what arthritis?
|
Reactive arthritis
|
|
|
genital infection with gonorrhoea puts one at risk of what arthritis?
|
Septic arthritis
|
|
|
what joints are typically involved in enteropathic arthritis?
|
distribution tends to be either: a) peripheral, or b) spondylarthropathic
|
|
|
What disease are extractable nuclear antigens (ENAs) associated with?
|
Lupus
|
|
|
What common antigens are included in the category of ENA?
|
Ro, La, Sm, RNP, Scl-70, Jo1
|
|
|
Anti-Jo1 antibodies are directed against?
|
synthetase
|
|
|
What systemic features are common in polymyositis?
|
(gradual onset of) fever, weight loss, fatigue
|
|
|
On muscle biopsy of polymyositis, what findings would one expect?
|
fibre necrosis, and inflammatory cell infiltrate
|
|
|
What are EMG studies used for in diagnosis of polymyositis?
|
To exclude neuropathy
|
|
|
What biomarker is useful to measure in polymyositis, to monitor disease activity?
|
Creatinine kinase (CK)
|
|
|
How are polymyositis patients with respiratory/pharyngeal involvement managed?
|
As in-patients: IV methyl-prednisone (1g/day for 3 days). Consider immunosuppresants: azathioprine and methotrexate
|
|
|
In an elderly woman, presenting with a recent onset of muscle pain and stiffness around the shoulder and pelvic girdle, vasculitis should be considered?
|
Polymyalgia Rheumatica
|
|
|
What investigations should be done for Polymyalgia rheumatica?
|
serum ESR/CRP, FBC (often normocytic-anaemia)
|
|
|
What does the urgent treatment of Polymyalgia rheumatica involve?
|
High dose steroids, gradually tapered down (may require up to 2 years), with osteoporosis prophylaxis. Consider augmentation with methotrexate or azathioprine
|
|
|
How is Raynaud's syndrome treated?
|
a) avoid cold exposure, b) CCBs or ARBs
|
|
|
What treatment should be given to patients with scleroderma?
|
Corticosteroids, methotrexate, ARBs (Raynaud's/HTN), PPIs (GORD), analgesics, endothelin 1 antagonists (bosetan, for pul-HTN)
|
|
|
What is the diagnosis of exclusion if a patient experiences diffuse muscle pain (neck/back) which is unresponsive to NSAIDs and worsens with physiotherapy?
|
Fibromyalgia (which has normal lab work)
|
|
|
How is fibromyalgia managed?
|
low dose TCAs (amytriptyline) +/- fluoxetine
|
|
|
How does plantar fasciitis present?
|
pain under heel, worse when standing/walking
|
|
|
what are some risk factors for plantar fasciitis?
|
obesity, high-arched foot, excessive pronation, limited dorsiflexion of the ankle, prolonged standing, faulty shoes
|
|
|
How is plantar fasciitis diagnosed?
|
On history and examination (X-ray may help find heel spurs)
|
|
|
How is plantar fasciitis managed?
|
avoidance of exacerbating activities, heat/ice, taping, massage/stretching, orthotics, NSAIDs/corticosteroids
|
|
|
How is plantar fasciitis managed if conservative treatment fails after 12 months?
|
plantar fasciotomy - US guided needle to disrupt fascia
|
|
|
How is achilles tendonopathy treated?
|
RICE, physiotherapy, NSAIDs
|
|
|
What are risk factors for Dupytren's contracture?
|
alcohol, family history, Scandinavian ancestry, liver cirrhosis, manual labor, rock climbing, trauma, diabetes, phenytoin (for epilepsy)
|
|
|
What is medical management of Dupytren's contracture?
|
collagenase injection, which allows stretching/snapping of aponeurosis
|
|
|
What is medical mangement of carpal tunnel syndrome?
|
a) corticosteroid injection proximal to wrist (ulnar side of palmaris longus), b) wrist splints
|
|
|
what is the treatment of radial tunnel syndrome (weakness of thumb/finger extension)?
|
Surgical decompression
|
|
|
How is rotator cuff tendonopathy managed?
|
a) NSAIDs, b) corticosteroid injection, c) physiotherapy, d) surgical decompression
|
|
|
How are symptomatic ganglia of the wrist managed, aside from 'bible bashing'?
|
Corticosteroid injection or surgical dissection (half resolve; half recur)
|
|
|
At what angle of scoliosis should one consider surgery?
|
40-45 degrees
|
|
|
At what angle of scoliosis should once brace the back immediately?
|
>30 degrees
|
|
|
At what angle scoliois should one simply monitor progress/changes every 6 months?
|
<20 degrees
|
|
|
what percent of acute lower back pains become a chronic condition?
|
10-15%
|
|
|
how is lower limb 'compartment syndrome' managed?
|
surgery
|
|
|
How are osteomas managed, if they become symptomatic?
|
radioablation
|
|
|
where do osteomas typically occur?
|
subperiosteal surface of the cortex, in skull and facial bones
|
|
|
how is osteosarcoma treated?
|
chemotherapy
|
|
|
what is the prognosis of osteosarcoma if no mets are present?
|
5 year survival = 66%
|
|
|
what is the prognosis of osteosarcoma if mets ARE present?
|
5 yr survival = 20%
|
|
|
what is the most common benign bone tumour?
|
osteochondroma
|
