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Rheumatology > Conditions > Flashcards

Conditions Flashcards

1
Q

Symptoms of scleroderma

A

CREST
Calcinosis: calcium deposit in skin

Raynaud’s Phenomenon: spasms of blood vessels in response to cold/stress

Esophageal dysfunction: reflux, decreased motility

Sclerodactyly: thickening/tightening of skin of fingers/hands

Telangiectasia: dilation of capillaries causing red marks on skin

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2
Q

Examination findings of scleroderma

A

Abnormal nail fold capillaries/torn nails
Palmar erythema
Digital ulcers / pitted scars
Calcinosis
Telangiectasia
Perioral skin tightening
Joint crepitus (wrist/ankle)

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3
Q

Pulmonary complications of scleroderma

A

Pulmonary HTN
Interstitial lung disease
Pleural effusion
Lung cancer

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4
Q

Acute onset monoarthritis workup

A

FBC
LFT
Calcium
U+E
Urate
RF
Anti-CCP
ANA
CRP
XR

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5
Q

Poor prognostic features of RA

A

RF positive
anti-CCP positive
>20 joints swollen at presentation
Early functional impairment
Early age of onset
Smoking

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6
Q

Measures of disease activity in RA

A

ESR/CRP
Number of tender/swollen joints
Duration of early morning stiffness
Functional assessment
Visual analogue scale for patient reported global assessment

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7
Q

Ix for RA

A

RF
anti-CCP - most sens 94%
ESR/CRP
Normal Ix does not rule out RA!!

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8
Q

RA XR findings

A

Involve Thumb IPJ and all MCPJ
MC head erosions
MCPJ osteopaenia
Joint space narrowing
Carpal erosions

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9
Q

Diagnostic features of RA

A

Fhx
Early morning stiffness > 1hr
Swelling in >=5 joints
Symmetrical
RF/ anti-CCP positive
sx > 6/12
Raised ESR/CRP
Bony erosions on XR

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10
Q

RA mx

A

Simple analgesics
Omega-3 supplements
DMARDS
Steroids
Weight loss
Exercise
Psychosocial support
Sleep promotion
Vaccination

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11
Q

Maintaining remission of RA

A

Methotrexate 10mg weekly PLUS folic acid 5mg weekly (separate day)
PO pred 5-15mg and slow taper

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12
Q

MTX patient education

A

EtOH 2std max 2x per week
Contraception
Drug interactions w/ folate antagonists e.g. trimethoprim
Vaccination; pneumococcal, influenza
Avoid live vaccines
Regular LFT/renal monitoring
Weekly folic acid
Sun protection

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13
Q

MTX ADRs

A

Stomatitis
Alopecia
N/v
diarrhoea
myelosuppression
hepatotoxicity
Infections

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14
Q

MTX monitoring

A

4 weekly
- Efficacy, ADR
- Bloods; FBC/LFT/albumin/Cr for 3/12 or after increasing dose -> then 8 weeks for 6 months -> then 12 weekly

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15
Q

Long term health monitoring RA

A
  • Joint effects – number, tenderness, function
    • Extra-articular involvement; nodules, rash
    • CVD: BP, renal function
    • Risk of infection on immunomodulators
    • Toxicity; monitor for toxicity (skin, lungs, GIT, heart)
    • Lifestyle – smoking, BMI
    • ADLS; function, sleep, mood, fatigue
    • Annual foot review
    • Medication adherence
    • Steroids – osteoporosis risk, BP, lipids, cataracts
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16
Q

Osteoporosis risk factors

A

Female
Low body weight
Caucasian/Asian
Prev minimal trauma #
Hx of falls
Fhx
Premature menopause
RA
Hyperthyroidism
Malabsorption disease - coeliac
Smoking/ETOH
Physical inactivity
Lack of sunlight
Long term steroid use
PPI
SSRI

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17
Q

Major osteoporosis risk factors for MBS BMD

A

Parental hx #
Premature menopause
Low body weight
Immobility
Smoking
Alcohol > 2 std per day
RA
Hyperthyroid/hyperparathyroid
CKD
Coealic
DM
Depression
Steroids > 3/12 >=7.5mg / day
SSRI/PPIs

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18
Q

Minimal trauma # flow chart for postmenopausal women and men >50yo

A

Hip/vertebral -> straight to antiresorptives (can do baseline BMD but not essential)
Any other site -> BMD
-> if T score <=-1.5 -> antiresorptive
-> if T score > -1.5 -> specialist review

19
Q

BMD screening flow chart

A

Age >=70yo or Major risk factors do BMD
if T score <= -2.5 -> antiresorptives
if T score >-2.5 -> Garvan fracture risk
Garvan # risk;
- Hip fracture >3%, any fracture >20% then tx antiresorptives
- if low risk - implement lifestyle changes

After tx - screen 2 yearly

20
Q

Osteoporosis lifestyle mx

A

Falls prevention; home hazard removal, good footwear
Exercise; weight-bearing and balance training
Diet
- Calcium 1300mg / day
Sun exposure
Reduce alcohol/smoking
Weight loss

21
Q

Bisphosphonate therapy for osteoporosis

A

Prior to prescribing
- Baseline renal, Ca, vitamin D (ensure replete >50)
Alendronate 70mg PO weekly
- Empty stomach, 2hrs from Ca/Iron/antacids
- Remain upright 60min
IV Zolendronic acid IV to avoid GIT ADR
ADR
- Myalgia, hypocalcaemia, AKI, osteonecrosis of jaw, oesophagitis
Duration
- 5 years oral, 3 years IV, if high risk (10 years oral, 6 years IV)
- After stop - BMD 2 years later

22
Q

RANKL inhibitor for osteoporosis

A

Denosumab 60mg subcut every 6/12
- Ensure vitamin D replete and sufficient Ca intake
- Can be used in CKD IV
- Crucial compliance - high risk fracture if late
- Duration; indefinite or replace with bisphosphonates
- Avoids GIT ADR

23
Q

SERM for osteoporosis

A

Raloxifene 60mg daily
<60 yo and menopausal
Best if spinal osteoporosis
Reduces risk of breast Ca - but increase VTE/CVA

24
Q

Tibolone for osteoporosis

A

Tibolone 2.5mg daily
<60yo, menopausal sx
Increase risk breast Ca/CVA

25
Q

Gout risk factors

A

Purine-rich diet; meat, seafood
ETOH
Diuretics
CKD
T2DM
Obesity
Dehydration

26
Q

Gout acute flare mx

A

1st line; NSAID 5/7 OR prednisolone 15-30mg 5/7
2nd; colchicine 1mg stat then 0.5mg 1hr later
Local steroid injection
Allopurinol 50mg and titrate every 2/52 based on serum urate level

27
Q

Flare prophylaxis when starting urate-lowering drug

A

Naproxen 250mg BD or 0.5-1mg colchicine daily
Duration; 6/12 or 3/12 after reaching target urate (w/o tophi) or 6/12 after reaching target urate (w/ tophi)

28
Q

Urate lowering therapy

A

Allopurinol 50mg and titrate 4/52 until target (max 900mg daily)
Add on Probenecid 250mg BD
Target urate
- w/o tophi; <0.36mmol/L
- with tophi; <0.30 mmol/L

29
Q

Ankylosing spondylitis clinical features

A

HLA-B27
Enthesitis; achilles tendonitis, plantar fasciitis
Dactylitis
Uveitis
Schober test <5cm
Fusion of SIJ, bamboo spine, Dagger sign

30
Q

Reactive arthritis features

A

Post genitourinary infection in male 20-40 - chlamydia is common cause
Post GIT infection; salmonella, shigella etc
Triad; conjunctivitis, arthritis, urethritis
Tx
- NSAID
- PO pred
- If suspect chlamydia - tx doxy 100mg BD 7/7

31
Q

Polymyalgia rheumatica

A

Ache/stiff shoulder/hip girdle area
Morning stiffness, improves with hot shower/activity
Usually >50yo and women
Ix; elevated ESR/CRP (some are normal tho)
Tx
- Pred 15mg 4/52 then taper by 2.5mg every 4/52
- don’t reduce dose if signs of active disease
- tx usually for 12/12
- Monitor inflamm markers as you taper

32
Q

GCA clinical features

A

Headache
Jaw claudication
Polymyalgia rheumatica
Visual; diplopia, visual loss
Tender pulsatile enlarged temporal arteries
Raised ESR/CRP

33
Q

Mx of GCA

A

Urgent referral rheumatologist
Urgent referral surgeon for temporal artery biopsy
Pred 40-60mg in two doses for 4/52 or until inflamm markers resolve -> reduce by 10mg every 2/52 until 20mg -> reduce by 2.5mg every 2/52 until 10mg -> reduce 1mg every 4/52
MTX 10mg PO + FA
Aspirin 100mg to reduce ischaemic events
Monitor visual sx/acuity -> if worsening then IV methylpred
Monitor ESR/CRP monthly

34
Q

Viral polyarthritis causes

A

Ross River, Barmah Fores
Dengue
Yellow fever
Parvovirus B19
Rubella
Hep B/C
HIV
EBV

35
Q

Juvenile idiopathic arthritis

A

Inflammatory arthritis <16yo and lasting 6/52 without any other cause
Features
- Joint pain/swelling
- Stiff after rest/sleep
- Fever, rash
- Fhx RA/autoimmune
Ix; always do FBC/ESR/CRP
Mx
- Refer rheum
- NSAID
- Panadol
- Weak opioids like codeine
- DMARDs
- Dietary calcium + vitamin D intake
- Land + aquatic exercise
- Orthotics for foot
- Psychosocial support

36
Q

Diagnosis of SLE

A

4/11 of;
- Malar rash
- Discoid rash
- Photosensitivity
- Oral ulcers
- Arthritis
- Serositis; pleurisy, pericarditis
- Renal features; proteinuria, casts
- Neurological/psych; seizures, psychosis
- Haematological; haemolysis, lymphopenia, thrombocytopenia
- Immune; positive anti-dsDNA, anti-Smith, antiphospholipid Abx
- ANA positive

36
Q

Sjogren syndrome

A

Chronic autoimmune lymphoid infiltration of exocrine glands (saliva, lacrimal) -> gland dysfunction and severe sicca sx
Cause; primary, secondary (RA, SLE, scleroderma)
Sx
- Fatigue
- Arthralgia
- Arthritis
- Raynaud
- Dry cough
- Rare - lymphoid malignancy
Dx
- Significant and severe sicca (severe dry eyes), polyclonal hypergammglobulinaemia, positive ANA, RO and La antibodies

37
Q

Mx sicca sx

A

Sunglasses outdoors
Avoid dry/heated air/cigarette smoke/TCA
Oral hydration
Good dental hygiene
Artificial salivary products (bicarb mouthwash)
Chewing gum to stimulate saliva
Ocular lubricants

38
Q

Clinical features of Marfan syndrome

A

Aortic regurg/dissection
MV prolapse
Arachnodactyly
Abnormal arm span
Marfan wrist sign
Marfan thumb sign
Eye; dislocated lens (ectopia lentis)

39
Q

Raynaud syndrome

A

Digit vasospasms due to cold/stress
Cause; primary, secondary (scleroderma, etc)
tx
- DHP CCB (amlodipine 5-10mg daily)

40
Q

Henoch-Schonlein purpura (HSP)

A

IgA vasculitis of childhood, 2-8yo, post strep A URTI
Sx
- Triad; purpura, large joint arthritis, abdominal pain
- Nephritis; haematuria, proteinuria, HTN
Ix
- BP
- Urinalysis - only Ix needed
- If HTN , macroscopic haematuria or proteinuria -> formal UMCS, UACR, UEC, ALBUMIN and consult paeds
Mx
- Assess for testes involvement, resp/neuro features -> paeds
- Panadol/ NSAID
- Severe pain; pred 1mg/kg
F/u
- Urinalysis/BP weekly for 4/52 -> 2 weekly for next 2/12 -> then 6 month review and 12 month review

41
Q

Kawasaki disease

A

Ddx; Scarlet fever, ARF, EBV, JIA, Stevens-Johnson syndrome, drug reaction, sepsis
Diagnostic criteria - Fever for >=5 days and 4/5 of following
- Bilat conjunctival injection
- Cervical LN
- Oral mucous membrane changes
- Erythema/oedema/desquamation of hands/feet
- Polymorphous rash
Ix; raised ESR/CRP, high neutrophils, abnormal LFT
Mx
- IV immunoglobulin 2g/kg single infusion over 12hrs
- IV methylpred 30mg/kg over 1hr up to 3/7; if fever persists after second dose IVIg
- Aspirin 3-5mg/kg until f/u TTE 6/12 post fever
- Defer any childhood immunisations for 11/12 post IgIG

42
Q

Fibromyalgia mx

A

Regular graded exercise
CBT
Sleep hygiene
Reassurance and education; nil tissue damage, not progressive
1st line; amitriptyline 10mg
2nd line; Pregabalin 25-75mg

43
Q

Paget’s disease of bone mx

A

Asymp - nil
Indications for tx; symp, risk of disease progression (<50yo, lesion at critical site like skull/vertebrae, active disease, neuro sx, hypercalcaemia)
Bisphosphonates
- Risendronate 30mg 2/12
- IV zolendronic acid 5mg stat dose
Monitor ALP 3/12 after dose
When in remission - ALP every 2 years

Rheumatology (1 decks)

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