MSK (Rheum and T&O) Flashcards
pattern of joints affected in RA
symmetrical polyarthritis
which joints are usually spared in RA?
DIP
characteristics of inflammatory joint pain
worse in the morning, improves with exercise
which joints are usually affected in primary nodal osteoarthritis
distal interphalangeal joints (DIP)
most specific antibody for RA
anti-citrullinated peptide Ab
investigations for suspected RA
Acute phase markers
CRP and ESR will usually be high if there is ‘active’ disease
Serological tests
Rheumatoid factor (antibody specific for IgG Fc)
~60-70 % sensitivity and specificity for RA
Anti-cyclic citrullinated peptide antibodies (‘anti-CCP’ antibodies or ‘ACPA’)
~60-70% sensitivity and ~95% specificity for RA
Radiology
US or MRI can demonstrate synovitis and early erosive damage
X rays are most useful for monitoring erosive changes
Other blood tests
FBC, U&E, LFTs will be required prior to initiating drug treatment
who is involved in the MDT of a pt with RA?
Rheumatology consultant
General practitioner
Rheumatology nurse specialist
Hand therapist
Occupational therapist
Physiotherapist
Podiatrist
Psychology/counselling services
Surgeon
management of RA
- analgaesics
- NSAIDs, hydroxychloroqine
- DMARDs- eg. methotrexate/ sulfazalazine (started early in the course of the disease)
- plus steroid (flares can do IM, interarticular or oral)
- anti-TNF therapy (for pts who have active disease despite DMARDs)
- physiotherapy
what deformities can occur as RA progresses?
ulnar deviation
palmar subluxation of metacarpophalangeal joints
Boutonniere deformity (flexion of PIP, hyperextension of DIP)
Swan neck deformity (hyperextension of PIP, flexion of DIP)
inflammation of flexor tendon sheath-> carpal tunnel syndrome
features of psoriatic arthritis?
symmetrical or asymmetrical polyarthritis
onycholysis with brown discoloration of the nails
arthritis mutilans in severe disease
common joints affected in RA
small joints of the hands and feet except DIP
proximal interphalangeal joints
metacarpophalangeal joints
metatarsophalangeal joints
wrists
clinical of osteoarthritis
worse on movement
over 60
heberdens nodes on DIP
Bouchard node on PIP
boney swelling
hips and knees common
radiological features of osteoarthritis
Loss of joint space
Osteophytes
Subchondral sclerosis
Subchondral cysts
most common causative organism of septic arthritis
staph aureus
management of septic arthritis
joint aspiration for MC&S
emperical antibiotics ASAP
- eg. flucloxacillin, gentamycin and benpen
immobilise the joint
causes of reactive arthritis
sterile arthritis following an attack of dysentry (campylobacter, salmonella, shigella, yersinia) or urethritis (chlamydia, ureaplasma)
They are gram-negative organisms, with a lipopolysaccharide component within their cell wall
clinical features of reactive arthritis
acute, asymmetric lower limb arthritis 1-4 weeks following infection
conjunctivitis
enthesitis (plantar facitiis or achilles tendonitis)
ciricinate balanitis (painless, superficial penile ulcer)
keratoderma blenorrhagica (painless red plaques on soles or palms)
nail dystrophy
mouth ulcers
what is Reiters disease
triad of urethritis, arthritis and conjunctivitis
features of reactive arthritis
management of reactive arthritis
- NSAIDs
- local steroid injection for symptomatic control
- treat underlying cause
pathophysiology of reactive arthritis
CD4 T cell sensitisation of bacterial antigens
antigens disseminate systemically to joint (sterile) causing T cell activation and inflammation of the joint
what are the crystals of pseudogout
calcium pyrophosphate
underlying conditions that may result in pseudogout
hypothyroidism
hyperparathyroidism
wilsons
haemachromatosis
Xray findings of pseudo gout
chondrocalcinosis (calcification of hyline cartilage)
what is seen under polarised light in gout vs pseudogout?
gout:
negatively birefringent needle shaped crystals
psuedogout:
positively birefringent rhomboidal crystals
what are the crystals in gout
monosodium urate (MSU) crystals
management of anklyosing spondylitis
NSAIDs and spinal exercises
associated features of ankylosing spondylitis
anterior uevitis- sudden onset pain, blurred vison and photophobia
conjunctivitis- red, itchy eyes
plantar faciitis, achillies tendonitis
what is GCA associated with
polymyalgia rheumatica
back pain red flags
<20y >50yrs
sphincter disturbance
history of malignancy
neurological disturbance
leg pain
features of feltys syndrome
Extraarticular features of seropositive RA
[SANTA]
splenomegaly
Arthritis
neutropenia
thrombocytopenia
anaemia
Investigations for RA
Bedside:
squeeze test/ hand examination
bloods:
FBC (anaemia), CRP, ESR (inflammation)
Abs- ANA, anti CCP and RF
Imaging
Xray for basline
USS for synovitis
MRI
features of seronegative spondyloarthropathies
PEARL HEADS
Psoriatic arthrtis
Eneropathic arthritis
Ank spond
Reactive arthritis
HLA B27
Enthesitis
Axial, asymmetrical, oligoarthritis
Dactylitis
Seronegative (no RF)
associated complications of ankylosing spondylitis
AAAAAA
Anterior uveitis
Apical lung fibrosis
Aortic regurgitiation
AV node block
Achilles tendonitis
Amyloidosis
Name of a grading system for ankylosing spondylitis
New york criteria
management of Ank spond
Conservative:
Physiotherapy/ exercise
Medical:
NSAIDS –> aTNF (etanercept) –> aIL17 (secukinumab)
surgical: hip replacement
systemic features of connective tissue disease
rash
hair loss
fatigue
fever
chest pain
cough
Raynauds
features of limited systemic sclerosis (CREST syndrome)
Calcinosis
Raynauds
Esophogeal dysmotility
Sclerodactyle
Telangectasia
features of polymyositis
Inflammation of striated muscle
o Progressive symmetrical proximal muscle weakness (associated myalgia & arthralgia)
o Wasting of shoulder and pelvic girdle
o Dysphagia, dysphonia, respiratory weakness
features of dermatomyositis
§ Periorbital heliotrope rash on eyelids ± oedema
§ Gottron’s papules: knuckles, elbows, knees
§ Mechanics hands: painful, rough skin cracking of fingertips
§ Macular rash (shawl sign +ve: over back and shoulders)
§ Nailfold erythema
§ Retinopathy: haemorrhages and cotton wool spots
§ Subcutaneous calcifications
Investigations for suspected myositis
bloods:
CK raised
LFTs- raised ALP, AST and LDH
myositis pannel- anti Jo1, anti mi2, anti-srp
CLAAA
CK
LDH
ALP
AST
Antibodies- anti jo anti mi anti srp
EMG
biopsy (diagnostic)
Malignancy screen- as can be a feature of a paraneoplastic syndrome
Management of GCA
immediate steroids 40-60mg
ESR and temporal artery biopsy
visual symptoms –> IV methylprednisolone
common areas of muscle wasting in polymyositis
shoulder
pelvic girdle muscles
causes of peripheral muscle wasting
Neuro LMN disease:
ALS
cervical myelopathy
side effects of methotrexate
anaemia
leukopenia and infections
thromboctyopenia
pulmonary fibrosis
GI upset
skin changes
pathophysiology of sjogrens
autoimmune destruction and fibrosis of exocrine glands resulting in dry mouth, dry eyes (and also dry vagina)
anti-Ro and anti-La commonly associated
management of acute gout
STOP allopurinol
- strong NSAID eg. indomethacin
- colchicine if NSAIDs CI
- intra articular sterid injections
prevention of future attacks
lifestyle changes- reduce ETOH, wt loos, avoid purine rich food
allopurinol
low dose aspirin
features of bechets
oral and genital ulcers
occular involvement- anterior/ posterior uveitis, retinal vascular lesions
Conditions associated with carpal tunnel syndrome/ positive tinels test
RA
demyelination
Pregnancy
cardiac failure
hypothyroidism
what is the function of the ACC
prevents anterior translocation of the tibia at the knee
which nerve is responsible for claw hand deformity?
ulnar
which nerve is responsible for wrist drop?
radial
(Rist-Radial)
