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CP3 MDD > Multisystem > Flashcards

Multisystem Flashcards

1
Q

What are the features of fibromyalgia (5 common / 3 variable / 6 associated conditions)

A 
Common:
Widespread pain
Marked fatigue
Low affect/mood
Poor concentration
Non-restorative sleep

Variable locomotor sx:
Early morning stiffness
Finger swelling
Numbness/tingling fingers

Assoc conditions:
IBS
Allodynia (dyspareunia/hyperacusis / discomfort on touch)
Irritable bladder
Tension headache
Chemical sensitivity SEs to drugs
Depression
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2
Q

What hand signs would be seen O/E in RA?

A 
LOOK:
Wrist radial deviation
MCPJ ulnar deviation (at knuckles)
Swan neck (PIP ext / DIP flex) 
Boutonnieres (PIP flex / DIP ext)
Z thumb
Volar subluxation (late)

Palmar erythema
Small mm wasting

MOVE:
Reduced RoM
TEST:
Carpal tunnel signs

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3
Q

What are some complications of severe RA disease in hand?

A

Fusion (ankylosis)
Rupture of tendons (4th/5th from swelling/sublux)
Carpal tunnel

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4
Q

What may be seen o/XR in RA (4)

A

Loss joint space
Osteopenia (periarticular)
Swelling (soft tissues)
Erosions (marginal)

±Sublux/Dislocation

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5
Q

What signs may be seen in the feet O/E in RA?

A 
Hallux valgus
MTP lateral (fibular) deviation EXCEPT 5th
Hammer toe deformity

Callouses / ulcers

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6
Q

What blood tests for RA / results expected (5)

A

FBC: WCC↓/Platelets↓ (acute) // Anaemic (chronic)
CRP-ESR:↑

RF: 70%
ANA: 30%
Anti-CCP: Most specific

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7
Q

Outline the extra-articular manifestations in RA (8)

A

Eyes: kerato sicca / epi / scleritis
Atlanto-Axial Subluxation (50-80%)
Cardiac: IHD risk / Pericardial effusions
Pulm: Fibrosis / Exu effusions / Rh nodules
Abdo: Mesenteric ischaemia / Splenomeg (Felty’s)
Renal: amyloidosis
Skin: Rh nodules / Nail fold infarcts
Nervous: Entrapments / Sensory loss (nn vasculitis)
Haem: Felty’s / ACD

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8
Q

What is Felty’s syndrome?

A

Anaemia
Leucopenia
Splenomegaly

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9
Q

Outline the management of RA

A

MDT (ADL help / home adaptations)
Lifestyle: stop smoking (CV risk/↓DMARD effect)

DMARDs asap from Dx (MTX ± hydroxyC)
Short-term glucocorticoids (IM methylpred) for flares
NSAIDs (pain/stiffness)

Biologics (after 2+ DMARDs / DAS score)

Surgical:
Synovectomy / Arthroplasty (inc. excisional smalls)

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10
Q

What is the DAS score based on in RA? (4)

A

No. swollen stires
No. tender sites
CRP/ESR
Pt perception of severity

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11
Q

What are the extra-articular manifestations seen in Ank Spon (5)

A

Eyes: anterior uveitis
Pulm: Apical fibrosis
Cardiac: AVN block / Aortitis w. regurg
Renal: amyloidosis

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12
Q

What are the main joints involved in Ank Spon

A

Sacroiliac**
Hip
Shoulder
Costochondrals

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13
Q

What would be seen O/E in Ank Spon?

A

LOOK:
Question Mark posture (early)
Paraspinal mm wasting (late)

FEEL: SIJ tenderness
MOVE: ↓Lumbar RoM (lateral/forward)
TEST: Shober’s (↓length increase on flexion)

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14
Q

What will be seen o/XR in Ank Spon?

A 
Pelvic XR: 
Bilateral sacroilitis (narrowed joint space / fusion)

Spinal XR:
Squared vertebral bodies
Ossified discs
Ossified interspinous ligaments

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15
Q

What is the 1st/2nd line management for Ank Spon?

A

1st line – full dose NSAIDs 6wks (try 2+ diffs)

2nd line – biologics e.g. eternacept (NB not inflix)

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16
Q

List the 5 main subtypes of Psoriatic Arthritis

A 
Symm Poly (40%)
Asymm Oligo (30%)

DIPJ predom (10%)
Mutilans (5%)
Spondylitis

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17
Q

Outline the management of psoriatic arthritis

A

1 joint: Full-dose NSAID ± steroid

Multiple: treat same as RA (DMARDs) unless Spondylitis

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18
Q

What are the radiological differences b/wn:
Psoriatic + RA
Psoriatic (spond) + AS

A

Vs RA:
Early DIPJ involvement
Minimal osteopenia
Central erosions (pencil in cup)

Vs AS: Unilateral SIJ

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19
Q

What infections can reactive arthritis be caused by? (3)

A

Chlamydia
Campylobacter
Salmonella

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20
Q

What is the classic triad of Reiter’s syndrome?

What other features may be seen (4)

A

‘Can’t pee, see or climb a tree’:
• Dysuria
• Conjunctivitis
• Lower limb oligoarthritis

Others:
• Spondylitis
• Enthesitis (Achilles/Plantar)
• Skin (balanitis / keratoderma blenorrhagica – plaques)

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21
Q

How is Reactive Arthritis investigated and treated?

A

Joint Aspirate (exclude septic) – sterile

1st: full-dose NSAIDs ± steroid injections
2nd: Sulfasalazine (severe/extensive)

22
Q

What skin involvement is seen in SLE (4)

A

Chronic discoid (plaques)
Malar (nasolabial fold sparing)
Photosensitivity
Alopecia

23
Q

What other specific systems are involved in SLE + to what proportions (8)

A

MSK: arthritis (90%) / myalgia (50%)
Skin (75%)
CNS (60%): dep/anx** / seizures / vascular w. APL
Lung (50%): exu effusions / fibrosis
Renal (30%): interstitial nephritis
Cardiac (25%): pericarditis / higher artherosclerotic risk
Haem: ACD / Leucopenia / Thrombocytopenia / autoimmune haemolytic (rare)
Oral mucosal lesions (20%)

24
Q

What autoimmune disease are assoc w. 2º Sjorgen’s (4)

A

RA
SLE
Scleroderma
Polymyositis

25
Q

List features of Sjorgen’s (3 specifics + 4 systemics)

A

Dry eyes (keratoconjunctivitis sicca) / Dry mouth
Parotid enlargement
Vaginal dryness

Arthralgia
Oesophageal motility probs
Reynaud’s
NHL (1 in 6)

26
Q

What monitoring bloods should be ordered in SLE (4)

A

FBC
U+Es
Urine dip
C3/4 complement (reduced in active)

27
Q

Outline the management of SLE

A

Avoid CV risks
Avoid excess sunlight

Meds – mild (skin/arthritis/fatigue): NSAIDs + hydroxyC
Meds – severe (cardiac/renal): Pred + DMARDs

28
Q

What are the features of APL syndrome (3+3)

A

Venous**/Arterial thrombosis
Recurrent miscarriages
Livedo reticularis (lace-like mottled rash)

± Thrombocytopenia
± Migraines / Epilepsy

29
Q

How is APL Dx?

What is seen on coag studies ?

A 
Anticardiolipin Abs (2 results; 12wks apart)
APTT raised
30
Q

How is APL managed:
If no h/o thrombosis
If h/o thrombosis
If pregnant

A

No H/o thrombosis: low-dose aspirin + lifestyle
H/o thrombosis: Warfarin INR 3–4
Pregnant: Low-dose aspirin + LMWH + early delivery

31
Q

What are the main features of Systemic Sclerosis (scleroderma) (2)

A

Reynauds (long hx in limited cutaneous vs short in diffuse)

Skin tightening at extremities ± facial

32
Q

Another name for limited cutaneous scleroderma?

+ the features

A

CREST syndrome

Calcinosis
Reynaud's
Esophageal dysmotility
Sclerodactyly
Telangiectasia (skin/mucous membs e.g. →Pulm HTN
33
Q

What are the main complications of diffuse cutaneous scleroderma?

A

Myocardial fibrosis
Pulm fibrosis
Renal fibrosis

34
Q

What are some presentation features of Inclusion Body Myositis?

What specific tests + their results

A

White males >50
Insidious
Proximal/Distal mm weakness

Myositis-specific Ags: –ve
Mm biopsy: inflamm B-amyloid vacuole (inclusion body)

35
Q

List the Dx criteria for Polymyalgia Rheumatica (4; PMR)

A

Pelvic girdle +/ bilateral shoulder ache
Morning stiffness
Response – acute phase (evidence of)
>2wks

36
Q

What is the main complication of GCA

How is it monitored

A

Aortic / large vessel involvement (aneurysm / dissection)

Monitor with serials CXRs

37
Q

How is PMR + GCA treated?

Monitoring + how this affects treatment

A

PMR: 15mg PREDNISOLONE o.d.

GCA:
No visual – 40mg od
Visual sx – 60mg od
SPLV – 80mg od

Plus PPI + Bone protection

Taper down steroids with CRP-ESR
PMR ~2yrs
GCA ~5yrs

38
Q 
What vasculitis disease involve in:
Large vessels 
Medium vessels
Medium/small vessels
Small vessels
A

Large: GCA / Takayasu’s

Mediums: Kawasaki / Polyarteritis Nodosa

Medium/smalls:
Wegener’s / Churg-Strauss / Microscopic Polyangiitis

Smalls: HSP / Cryoglobulinaemia

39
Q

What blood test can be done for medium/small vessel vasculitis diseases

A

ANCA (+ve)
p-ANCA: Churg-Strauss / Polyangiitis
c-ANCA: Wegener’s
(think more Complicated system involvement)

40
Q

Outline the management options for vasculitis diseases (4)

A

Corticosteroids (w. prolonged reduction)
Cyclophosphamide (ANCA+ve)
IVIG (Kawasaki)
Plasmaphoresis (life-threatening)

41
Q

What is seen on FBC in most rheumatic diseases?

+ list causes of these results

A 
Anaemia:
ACD 
Fe defc – assoc ulcers
Megaloblastic – Pernicious/MTX) 
Haemolysis – SLE/Drugs

Lymphopenia: SLE
Leucocytosis: acute SLE flare

Thrombocytopenia:
SLE/APL
Felty’s
MTX

42
Q

What REGULAR (non-rheum) blood tests are done for rheumatic diseases (3)

A

FBC
U+Es (GN – but urine dip better)
LFTs: raised ALP in most

43
Q

List some causes of +ve/raised Rheumatoid Factor (4)

A

RA* (+ve in 70%)
Sjorgen’s*
SLE (30%)
Scleroderma (30%)

44
Q

List some causes of +ve/raised ANA (5+3)

A 
SLE** (100%/ –ve excludes)
RA
Sjorgen's
Polymyositis
Scleroderma

Thyroid (graves/hashimotos)
GI (AIH/PBC/IBD)
Pulmonary (idiopathic fibrosis)

45
Q

When would anti-dsDNA be +ve?

A

SLE (almost 100% specific) – used for monitoring as s/o severe disease with e.g. renal involvement

RA +ve/–ve
Viruses (transiently): HIV/Parvovirus

46
Q

What malignancies are poly/dermatomyositis associated with? (5 Bs)

A 
Baby making (ovarian)
Boobs (breast)
Balls (prostate)
Bum (colon)
Bronchial
47
Q

How do Polymyositis / Dermatomyositis present?

A 
Poly:
• Insidious or acute
• Prox mm weakness / wasting (e.g. stairs)
• Systemic: malaise/wt loss/fever
• Untreated –> resp mm failure
Dermato: same but skin
• Heliotropic purple rash
• Periorbital oedema
• Gottron's papules 
• Shawl rash
48
Q

What are the main differentiating bloods in inflammatory myopathies?

A

Myositis-specific Ag:
• Poly/Dermato +ve
• Inclusion body –ve

Serum CK raised (both; v. high = unlikely malignancy)

49
Q

What Ix can be done into inflammatory myopathies

  1. in primary care setting? (3)
  2. secondary care (3)
A

GP: Tumour markers / CXR / Abdo USS

Hosp: EMG / MRI / mm biopsy

50
Q

Outline the management of poly/dermatomyositis

A 
Prednisolone (60-80mg) / DMARDs
(start whilst awaiting results)
• little response = cancer
• good response = not
• Titrate steroids down w. CK

If condition deteriorates:
• Temporarily increase steroids
• Whilst starting on azathio

51
Q

How may a typical case of Inclusion Body Myositis present?

A

White male <50
Insidious prox + distal mm wasting

Progressive / unresponsive to Pred + DMARDs

52
Q

What are the main cautions/CIs in Biologics Tx? (5)

A 
Malignancy (SCC risk)
Active infection
Latent TB
Pulmonary fibrosis
Severe HF

CP3 MDD (7 decks)

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