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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
Risk factors for osteoarthritis
Elderly Female Obese Joint trauma
26
Presentation of osteoarthritis
pain/stiffness on movement worse at end of day/after use crepitus
27
4 questions to ask in osteoarthritis history
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
Examination of osteoarthritis
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
DDx osteoarthritis
Psoriatic arthritis
30
Joints affected in OA
``` DIP joints CMC of thumb knees hip shoulder ```
31
Ix of osteoarthritis
X ray (LOSS) ESR/CRP - rule out inflammatory arthropathies RF/Anti CCP-Abs
32
Radiograph findings in OA
Loss joint space Osteophytes Subchondral cysts Subchondral sclerosis
33
Mx of OA
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
Define Gout
acute inflammatory monoarthritis | caused by monosodium urate crystals deposition in joints
35
Risk factors for gout
Male Middle aged Increased meat + alcohol Higher socioeconomic status
36
Causes of hyperuricaemia in gout
``` decreased excretion (Idiopathic, thiazides, methotrexate) Increased production uric acid (Lesch-Nyhan, PRPP excess, tumour lysis syndrome, von Gierke's disease) ```
37
Crystals in Gout
Needle-shaped Negatively birefringent MSU crystals
38
Symptoms in gout
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
Causes of high urate in Gout | 5 D's
Drugs - thiazides, cytotoxics Drinking EtOH Diet (beef, pork, lamb, seafood) cvD risk )smoke, lipids, BP, DM, FHx)
40
Ix in gout
Bloods (lipids, glucose, urate levels, CRP/ESR) X-ray (punched out, periarticular erosions) Joint aspiration (-ve birefringent, needle)
41
Mx of acute Gout
``` remove cause increase hydration 1. indomethacin or diclofenac 2. colchicine 3. steroids ```
42
Mx of chronic gout
modify precipitants allopurinol (XO inhibitor) manage CVD risk
43
Examination of tophaceous gout Look Extras
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
DDx gout
Pseudogout Septic arthritis CREST calcinosis
45
What is pseudogout?
Calcium pyrophosphate crystal deposition in joint space
46
Risk factors for pseudogout
>50 years Female majority idiopathic but can be associated with haemochromatosis, hyperparathyroidism, joint trauma
47
Crystals in pseudogout
Calcium pyrophosphate Rhomboid shape +ve birefringence
48
Hx in Pseudogout
acute monoarthropathy pain + swelling PMH trigger (surgery, infection, trauma) Knee
49
Joints affected in pseudogout
Knee
50
Ix in pseudogout
``` arthrocentesis with synovial fluid analysis X ray (show chondrocalcinosis) ```
51
Mx acute and chronic pseudogout
acute: NSAIDs, colchicine, steroids chronic: colchicine
52
Colchicine MOA
? MOA | Thought to inhibit cell mitosis, WBC migration and phagocytosis

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