Conditions Flashcards
Symptoms of scleroderma
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
Examination findings of scleroderma
Abnormal nail fold capillaries/torn nails
Palmar erythema
Digital ulcers / pitted scars
Calcinosis
Telangiectasia
Perioral skin tightening
Joint crepitus (wrist/ankle)
Pulmonary complications of scleroderma
Pulmonary HTN
Interstitial lung disease
Pleural effusion
Lung cancer
Acute onset monoarthritis workup
FBC
LFT
Calcium
U+E
Urate
RF
Anti-CCP
ANA
CRP
XR
Poor prognostic features of RA
RF positive
anti-CCP positive
>20 joints swollen at presentation
Early functional impairment
Early age of onset
Smoking
Measures of disease activity in RA
ESR/CRP
Number of tender/swollen joints
Duration of early morning stiffness
Functional assessment
Visual analogue scale for patient reported global assessment
Ix for RA
RF
anti-CCP - most sens 94%
ESR/CRP
Normal Ix does not rule out RA!!
RA XR findings
Involve Thumb IPJ and all MCPJ
MC head erosions
MCPJ osteopaenia
Joint space narrowing
Carpal erosions
Diagnostic features of RA
Fhx
Early morning stiffness > 1hr
Swelling in >=5 joints
Symmetrical
RF/ anti-CCP positive
sx > 6/12
Raised ESR/CRP
Bony erosions on XR
RA mx
Simple analgesics
Omega-3 supplements
DMARDS
Steroids
Weight loss
Exercise
Psychosocial support
Sleep promotion
Vaccination
Maintaining remission of RA
Methotrexate 10mg weekly PLUS folic acid 5mg weekly (separate day)
PO pred 5-15mg and slow taper
MTX patient education
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
MTX ADRs
Stomatitis
Alopecia
N/v
diarrhoea
myelosuppression
hepatotoxicity
Infections
MTX monitoring
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
Long term health monitoring RA
- 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
Osteoporosis risk factors
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
Major osteoporosis risk factors for MBS BMD
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
Minimal trauma # flow chart for postmenopausal women and men >50yo
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
BMD screening flow chart
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
Osteoporosis lifestyle mx
Falls prevention; home hazard removal, good footwear
Exercise; weight-bearing and balance training
Diet
- Calcium 1300mg / day
Sun exposure
Reduce alcohol/smoking
Weight loss
Bisphosphonate therapy for osteoporosis
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
RANKL inhibitor for osteoporosis
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
SERM for osteoporosis
Raloxifene 60mg daily
<60 yo and menopausal
Best if spinal osteoporosis
Reduces risk of breast Ca - but increase VTE/CVA
Tibolone for osteoporosis
Tibolone 2.5mg daily
<60yo, menopausal sx
Increase risk breast Ca/CVA
Gout risk factors
Purine-rich diet; meat, seafood
ETOH
Diuretics
CKD
T2DM
Obesity
Dehydration
Gout acute flare mx
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
Flare prophylaxis when starting urate-lowering drug
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)
Urate lowering therapy
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
Ankylosing spondylitis clinical features
HLA-B27
Enthesitis; achilles tendonitis, plantar fasciitis
Dactylitis
Uveitis
Schober test <5cm
Fusion of SIJ, bamboo spine, Dagger sign
Reactive arthritis features
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
Polymyalgia rheumatica
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
GCA clinical features
Headache
Jaw claudication
Polymyalgia rheumatica
Visual; diplopia, visual loss
Tender pulsatile enlarged temporal arteries
Raised ESR/CRP
Mx of GCA
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
Viral polyarthritis causes
Ross River, Barmah Fores
Dengue
Yellow fever
Parvovirus B19
Rubella
Hep B/C
HIV
EBV
Juvenile idiopathic arthritis
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
Diagnosis of SLE
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
Sjogren syndrome
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
Mx sicca sx
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
Clinical features of Marfan syndrome
Aortic regurg/dissection
MV prolapse
Arachnodactyly
Abnormal arm span
Marfan wrist sign
Marfan thumb sign
Eye; dislocated lens (ectopia lentis)
Raynaud syndrome
Digit vasospasms due to cold/stress
Cause; primary, secondary (scleroderma, etc)
tx
- DHP CCB (amlodipine 5-10mg daily)
Henoch-Schonlein purpura (HSP)
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
Kawasaki disease
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
Fibromyalgia mx
Regular graded exercise
CBT
Sleep hygiene
Reassurance and education; nil tissue damage, not progressive
1st line; amitriptyline 10mg
2nd line; Pregabalin 25-75mg
Paget’s disease of bone mx
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
