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Year 6 > Medical Shorts Rheum > Flashcards

Medical Shorts Rheum Flashcards

1
Q

Define RA

A

AI inflammatory symmetrical polyarthropathy

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2
Q

Risk factors for RA

A 
Genetics: HLA DR4/1
Female (young/middle-aged)
Smoking
Silica exposure
\+ve Rheum F / Anti-CCP Ab
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3
Q

Genetics RA

A

HLA DR1/4

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4
Q

Classical presentation of RA

4 main

A

Early morning stiffness (>1hr, improves w/use)
Pain
Swelling
Symmetrical joint involvement

+- systemic (fever, wt loss, fatigue)
+- extra-articular manifestations (e.g. pulmonary fibrosis)

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5
Q

Pathogenesis RA

A

AI inflammatory cytokines ->
induce proliferative granulation tissue (pannus) formation ->
erosion articular cartilage + bone

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6
Q

American College Rheumatology RA criteria

A

4/7 of

  • early morning stiffnes >1hr
  • arthritis >3 joint areas
  • arthritis of hands
  • symmetrical
  • rheumatoid nodules (elbows, lungs)
  • +ve Rheumatoid factor
  • radiographic changes
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7
Q

Extra-articular manifestations of RA

aNTI CCP OR RF

A

Nodules (elbow, lungs)
Tenosynovitis (de Quervain’s or AAS)
Immune (vasculitis, amyloidosis,Sjogren, AIHA)

Cardiac (pericarditis, effusion)
Carpal tunnel
Pulmonary fibrosis, effusion

Ophthalmic (episcleritis, scleritis, Sjogren’s)
Renal (nephrosis due to amyloidosis)

Raynaud’s
Felty’s RA

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8
Q

Atlanto-axial subluxation

A

Weakening of ligaments of C-spine due to rheumatoid tenosynovitis

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9
Q

Atlanto-axial subluxation (AAS)

Acute effects
Chronic effects

A

Weakening of ligaments of C-spine due to rheumatoid tenosynovitis
Posterior subluxation of odontoid peg -> spinal cord compression

Acute - dec. vagus nerve impulses -> cardiac arrest
Chronic - progressive spastic tetraparesis

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10
Q

Seronegative RA

A

= RA without Rheumatoid factor
30% RA seronegative, may still be anti-CCP +ve
Less severe disease, less likely to have extra-articular features

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11
Q

Joints affected in RA

A

MCP, PIP, wrist

Not DIP

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12
Q 
RA
Hand Exam (LOOK)
A 
Hands 
- ulnar deviation digits
- radial deviation wrist
- deformity: swan neck, Z, Boutoinierre's 
- swelling over MCP, PIP
- muscle wasting (interossei, thenal eminence)
- scars (carpal tunnel decompression)
- erythema (joint+ palmar)
Elbow
- nodules
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13
Q 
RA
Hand Exam (FEEL)
A

hot/swollen/painful joints?

= active synovitis

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14
Q 
RA
Hand Exam (MOVE)
A

fixed flexion in prayer position

decreased ROM

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15
Q 
RA
Hand Exam (FUNCTION) PPA
A

precision
power
aids

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16
Q

RA present hand examination

A

symmetrical deforming polyarthropathy
signs active synovitis (hot/swollen/painful joints)
signs of cause (rheumatoid nodules, psoriasis)

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17
Q

DDx RA

A

psoriatic arthritis

Jacoud’s arthropathy

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18
Q

Ix for RA

A

Clinical - Systemic exam for RA

Bloods - rheumatoid factor + anti-CCP Ab
(RF also in normal, SLE, Sjogren’s)

Imaging: X ray DONS
Deformity - of joints
Osteopenia - juxta-articular
Narrowing joint space
Swelling soft tissue
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19
Q

Systemic exam for RA

A 
Skin - steroid use
BP + pulse (increased risk AF and CVD)
Eyes: episcleritis, anaemia of CD
Neck: X-ray for AAS
Heart : pericardial rub
Lungs: pulmonary fibrosis, percuss for effusions
Abdo: splenomegaly 
Urine dip: nephrotic syndrome or DMARDS
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20
Q

RA Viva

Hx Questions

A

early morning stiffness, pain, swelling
affect on life
extra-articular features
treatments so far + any complications

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21
Q

RA Viva

Mx

A

MDT: GP, PT/OT, rheumatologist, orthopaedics

Conservative: PT/OT

Medical: analgesia (NSAIDs), steroids (IM, IO, intra-articular), DMARDs, Biologics, Others (CVD/prevention osteoporosis)

Surgical: carpal tunnel decompression, tendon repairs, arthroplasty

22
Q

DMARDs

5 names + SEs

A

methotrexate (+folic acid)

  • BM suppression, hepatotoxic, pulm fibrosis
  • monitor FBC, LFTs, CXR

sulfasalazine

  • BM suppression, hepatitis, rashes, dec sperm
  • FBC, LFTs

hydroxychloroquine

  • retinopathy
  • monitor visual acuity

penicillamine

  • drug induced lupus, nephrotic syndrome
  • monitor urine

gold
- nephrotic syndrome, monitor urine

23
Q

Biologicals for RA

2 names

A

Used if severe RA, unresponsive to DMARDs

anti TNF-a

  • Infliximab/Remicade
  • Etanercept/Enbrel
  • Adalimumab/Humira

B cell depletion
- Rituximab (anti-CD20 mAb)

risks of opportunistic infections (TB) +rashes

24
Q

Define osteoarthritis

A

Asymmetrical degenerative disease

due to wear + wear of heavily-used joints

25
Q

Risk factors for osteoarthritis

A

Elderly
Female
Obese
Joint trauma

26
Q

Presentation of osteoarthritis

A

pain/stiffness on movement
worse at end of day/after use
crepitus

27
Q

4 questions to ask in osteoarthritis history

A
  1. pain and stiffness (more at end day/after use? night pain? pain dec. after rest?)
  2. loss of function (ADLs)
  3. Asymmetric joint involvement
  4. NO systemic symptoms in OA
28
Q

Examination of osteoarthritis

A

General: elderly, walking aid?

Hands:
asymmetrical DIP joint deformity (fixed flexion)
squaring CMC joint of thumb
Heberden’s (distal) and Bouchard’s (proximal) nodules
disuse atrophy
decreased function

Extra:
other joint involvement/scars

29
Q

DDx osteoarthritis

A

Psoriatic arthritis

30
Q

Joints affected in OA

A 
DIP joints
CMC of thumb 
knees
hip
shoulder
31
Q

Ix of osteoarthritis

A

X ray (LOSS)

ESR/CRP - rule out inflammatory arthropathies
RF/Anti CCP-Abs

32
Q

Radiograph findings in OA

A

Loss joint space
Osteophytes
Subchondral cysts
Subchondral sclerosis

33
Q

Mx of OA

A

Conservative - wt bearing exercise, lose wt, PT/OT, social services if cannot do ADLs

Medical
paracetamol, NSAIDs, weak opioids, intra-articular steroids)

Surgical
joint arthroplasty

34
Q

Define Gout

A

acute inflammatory monoarthritis

caused by monosodium urate crystals deposition in joints

35
Q

Risk factors for gout

A

Male
Middle aged
Increased meat + alcohol
Higher socioeconomic status

36
Q

Causes of hyperuricaemia in gout

A 
decreased excretion (Idiopathic, thiazides, methotrexate)
Increased production uric acid (Lesch-Nyhan, PRPP excess, tumour lysis syndrome, von Gierke's disease)
37
Q

Crystals in Gout

A

Needle-shaped
Negatively birefringent
MSU crystals

38
Q

Symptoms in gout

A

asymmetrical joint distribution
swollen, red painful
PODAGRA (painful MTP of big toe)
TOPHI (external ear, olecranon bursa, Achilles tendon)

acute attacks - after meal or xs alcohol

39
Q

Causes of high urate in Gout

5 D’s

A

Drugs - thiazides, cytotoxics
Drinking EtOH
Diet (beef, pork, lamb, seafood)
cvD risk )smoke, lipids, BP, DM, FHx)

40
Q

Ix in gout

A

Bloods (lipids, glucose, urate levels, CRP/ESR)

X-ray (punched out, periarticular erosions)

Joint aspiration (-ve birefringent, needle)

41
Q

Mx of acute Gout

A 
remove cause
increase hydration
1. indomethacin or diclofenac
2. colchicine
3. steroids
42
Q

Mx of chronic gout

A

modify precipitants
allopurinol (XO inhibitor)
manage CVD risk

43
Q

Examination of tophaceous gout

Look

Extras

A

Look

  • asymmetrical arthritis small joints hands + feet (esp 1st MTP)
  • gouty tophi )joints, ears, tendons)
  • decreased ROm and function

Extras
BMI, HTN, drug chart, LNs, Chronic renal failure

44
Q

DDx gout

A

Pseudogout
Septic arthritis
CREST calcinosis

45
Q

What is pseudogout?

A

Calcium pyrophosphate crystal deposition in joint space

46
Q

Risk factors for pseudogout

A

> 50 years
Female
majority idiopathic
but can be associated with haemochromatosis, hyperparathyroidism, joint trauma

47
Q

Crystals in pseudogout

A

Calcium pyrophosphate
Rhomboid shape
+ve birefringence

48
Q

Hx in Pseudogout

A

acute monoarthropathy
pain + swelling
PMH trigger (surgery, infection, trauma)
Knee

49
Q

Joints affected in pseudogout

A

Knee

50
Q

Ix in pseudogout

A 
arthrocentesis with synovial fluid analysis 
X ray (show chondrocalcinosis)
51
Q

Mx acute and chronic pseudogout

A

acute: NSAIDs, colchicine, steroids
chronic: colchicine

52
Q

Colchicine MOA

A

? MOA

Thought to inhibit cell mitosis, WBC migration and phagocytosis

Year 6 (9 decks)

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