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Respiratory PACES > Rheum > Flashcards

Rheum Flashcards

1
Q

Gout

Investigations

treatment

causes of hyperuricaemia

A

chronic- tophi in skin around joints- ear, fingers, achilles

Bloods + ESR + urate
Joint aspiration in acute if concern re diagnosis- negatively birefringent and needle shaped
Clinical diagnosis reasonable
XR- punched out erosions in junta-articular bone

Treatment:

  • NSAID (colchicine second line)
  • if 2 or more episodes then allopurinol prophylaxis (inhibits xanthine oxidase)- start 2 weeks after acute
  • alternative is febuxostat

causes of hyperuricaemia
increased production: alcohol, tumour lysis/ lymphoproliferative
reduced excretions: CKD, thiazide diuretics, ciclosporin, hypothyroid, hyperparathyroid

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2
Q

CPPD

A

different types- monoarthropathy or symmetrical polyarthritis (pseudo rheumatoid)

on joint asp see weakly positive birefringement crystals which are rhomboid

RF: haemochromatosis

treatment: NSAIDs, inrtarticular steroids

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3
Q

seronegative spondyloarthropathies

A-E

A

•Asymmetrical large joint oligoarthritis (<5 joints) or monoarthritis
•HLA B27 (dont test for this though- 88% in AS, in all at least 50%)
•Certain joints- Axial (spinal and sacroiliac) inflammation
•Dactylitis- inflammation of entire digit (sausage digit due to soft tissue oedema and tenosynovial and joint inflammation
•Enthesitis- inflammation of site of insertion of tendon or ligament in to bone e.g. plantar fascitis, achilles tendonitis, costrochondritis
•Factor- no rheumatoid factor- i.e. seronegative
•Extra-articular-
o Anterior uveitis
o Psoriaform rashes
o Oral ulcers
o Aortic valve incompetence
o IBD

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4
Q

seronegative spondyloarthropathies-what are they?

A

1- ank spond
2- enteric arthropathy
3- psoriatic arthropathy
4- reactive (Reuters)

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5
Q

ank stond

Treatment

A

88% HLA B27

affects spine and sacroiliac
worst in morning, relieved by exercise

treat: exercises, NSAIDs, TNF alpha if persistent disease activity

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6
Q

ank spond associated

A 
6 As
apical fibrosis
anterior uveitis
aortic regurgitation
achilles tendonitis
AV node block
amyloidosis
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7
Q

enteropathic arthritis

A

large joint mono/asymmetrical oligoarthritis

10-15% of UC and crohns

improves with bowel symptoms

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8
Q

reactive arthritis

A

after GI or STI- due to crossreactivity

3 key symptoms:

  • arthritis (knees, ankles, toes)
  • urinary sx
  • conjunctivitis

cause: chlamydia
occurs a few weeks after acute infection

signs:

  • enthesitis
  • keratoderma blenorrhagica
  • dactylitis
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9
Q

psoriatic arthritis

A

20% of patients with psoriasis - esp if nail involvement

asymmetric involvement of small joints of hand INCLUDING DIP/ symmetrical seronegative/ arthritis mutilans/ sacroilitis

XR- pencil in cup deformity by bone erosion

NSAIDS, intraarticualr steroids, DMARDS as per RA

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10
Q

osteoarthritis XR findings

A 
Only abnormal in advanced disease – LOSS 
•	Loss of joint space
•	Osteophytes- see hand pic
•	Subarticular sclerosis
•	Subchrondral cysts
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11
Q

Heberdens

A

DIP
- think OA

differential of DIP affected:
chronic gout
psoriatic arthritis

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12
Q

bouchards

A

PIPJ

  • think OA
  • can be seen in RA
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13
Q

Differentials of hand joint swellings

A
  • RA
  • OA
  • CPPD (pseudo OA)
  • chronic gout
    psoriatic arthritis
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14
Q

septic arthritis

A

most common cause staph aureus
single joint + systemic features

urgent joint aspiration for MCS

treat with flucloxacillin

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15
Q

Acute monoarthritis

Differentials

A

Septic arthritis
Seronegative spondyloarthopathies- enteropathic and reactive
Crystal arthropathies- gout and CPPD
Trauma

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16
Q

Investigations acute mono arthritis

A

FBC, ESR, CRP, blood cultures
joint aspiration
consider XR if concern re fracture/ as baseline
If urinary symptoms MCS/ swab for chlamydia

17
Q

back pain red flags

A 
<20 or >55
constant/ nocturnal
worse lying down
fever/ sweats/ weight loss
hx of malignancy
immunosuppression
prolonged steroid use
thoracic back pain
morning stiffness
neurological signs 
bilateral
18
Q

vasculitis types

A

large: GCA, Takayasau
medium: PAN, kawasaki
Small
ANCA pos: microscopic polyangitis, GPA, churn strauss
ANCA neg: HSP, cryoglobulinaemia

19
Q

vasculitis signs

A
  • purpura
  • ulcers
  • livedo reticular
  • eye symptoms - episcleritis/scleritis
  • haemoptysis
  • nasal crusting + epistaxis

wegeners- saddle nose
charge strauss- asthma

20
Q

behcets

A

multisystem disorder recurrent ulceration

  • oral ulcers
  • genital ulcers
  • eye lesions- uveitis
  • skin lesions e.g. erythema nodosum
  • skin pathergy
21
Q

DMARD

A

METHOTREXATE

  • lung, liver
  • folic acid
  • trimethoprim and septrin CI

SULFASALAZINE
-rash, ulcers

LEFLUNOMIDE
- ulcers, liver, BP

HYDROXYCHLOROQUINE

  • retinopathy
  • NB continue in illness (only one)
22
Q

sarcoid sx and signs

A 
erythema nodosum
polyarthralgia
lupus pernio 
resp signs- SOB, cough
fever
23
Q

lofgrens

A

BHL + erythema nodosum + fever + polyarthralgia

excellent prognosis

24
Q

marfans features

A
  • tall stature with arm span to height ratio > 1.05
  • high-arched palate
  • arachnodactyly
  • pectus excavatum
  • pes planus
  • scoliosis of > 20 degrees
  • heart: dilation of the aortic sinuses (seen in 90%) which may lead to aortic aneurysm, aortic dissection, aortic regurgitation, mitral valve prolapse (75%),
  • lungs: repeated pneumothoraces
  • eyes: upwards lens dislocation (superotemporal ectopia lentis), blue sclera, myopia
  • dural ectasia (ballooning of the dural sac at the lumbosacral level)
25
Q

Rheumatoid arthritis - typical symptoms

A

symmetrical swollen, painful and stiff
morning stiffness
PIP, MCP NOT DIP

extraarticular:

  • rheumatoid nodules on extensor surfaces
  • tenosynovitis/ bursitis
  • raynauds
  • lung fibrosis
  • pericarditis
  • episcleritis/ scleritis

associated with sjogrens
NB felts is splenomegaly and neutropenia (1%)

26
Q

rheumatoid signs

A

symmetrical
tender joints
nodules

Boutonierre=injury to the tendons that straighten the finger. Is PIP flexion with DIP hyperextension

Swan neck= DIP flexion and PIP hyperextension
Ulnar devaition

atlano-axial subluxation

Lungs: fibrosis/ effusion
Feltys

27
Q

rheumatoid investigations

Treatment

A

FBC, UES, LFTs, CRP, ESR
RhF, CCP, ANA

Imaging: XR - juxta-articular osteopenia and decreased joint space–> erosions, subluxation or complete carpal destruction!

Calculate the DAS score
>5.1= active disease
<3.2= low disease activity
<2.6= remission

treatment:
NICE guidelines:
New active RA= methotrexate and one other DMARD + short term corticosteroids
Established stable RA= cautiously reduce doses (return to disease controlling if flares)
Move on to biologics if fit criteria only

28
Q

dactylitis vs sclerodactyly

A

dactylitis= inflammation of a digit/ toes
think seronegative spondyloarthropathies e.g. psoriasis, 5% gout, sickle cell

sclerodactyly=localised thickening and tightness
scleroderma

29
Q

alopecia

A

Alopecia areata: non scarring loss of scalp hair only (as opposed to alopecia universalis, which is complete loss of hair over the scalp and body).

Associations:
autoimmune- Hashimoto’s thyroiditis, pernicious anaemia, DM and vitiligo.

Other differentials:

  • trichtotillomania
  • Scarring hair loss is caused by discoid lupus erythematosus and lichen planus.
30
Q

arthritis multilans- differentials

A

psoriatic

RA

31
Q

rheumatoid examination

A
32
Q

hand exam features

A

Swellings of MCP, PIP, wrist, redness, boggy on palpation
guttering of interossei
deformities (subluxation and ulnar deviation at MCPJs, subluxation of wrist, swan neck, Boutonnieres, z thumb),
nails (psoriasis, infarcts, vasculitis)
thin and bruised skin (steroids)
scars (carpal tunnel release, wrist arthrodesis, tendon transfer etc)
rashes (psoriasis)
dactylitis (psoriatic arthritis)

33
Q

RA diagnosis criteria

A

ACR/EULAR 2010 criteria (need 6/10 score)

Joints (swollen/tender/USS/MRI evidence of synovitis, small joints)
Serology (RF or anti-CCP positive)
Acute phase reactants (CRP/ESR raised)
Duration ≥ 6 weeks

Respiratory PACES (5 decks)

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