Rheum Flashcards
Slow onset progressive ‘deep, boring’ bone pain.
Xray shoes lytic lesion with sclerotic edges
Brodies abscess
Acute osteomyelitis most common bug? What consider if neonates? if sickle cell? IVDU?
S aureus - most common for all
Group A b haemolytic strep / H inflenzae in neonates
Salmonella ssp in sickle cell
IVDU - consider Pseudomonas
Haematogenous osteomyelitis is most common in kids. What part of bone is affected?
Metaphysis
[bone cant swell and puss collects under periosteum -> sore]
Early morning stiffness of shoulders / neck. Mild anaemia, mild raised inflam? Key condition this is assoc with?
Polymyalgia
Giant cell arteritis (25% get)
Arthritis. Back predominant + uveitis in 15-40 year old =?
What else is common assoc? Gene? Most common heart issue?
Ankylosing spond
IBD
HLA B27 in 90%
Aortic incompetence
[also get arrhythmias etc…]
Ankylosing spond XR of spine shows? Pelvis?
Bamboo / tramtrack appearance
Fusion of sacroiliac joints
TNFa - key endocrine issue
Raised levels increase insulin resistance
Fever, malaise. The short duration of multiple asymmetric arthritis. conjunctivitis. Crusted skin lesion - where is this common? What positive
Reactive arthritis
[Usually follows infection - may not be such an easy giveaway in Q]
Skin lesion on palms / soles (brown in colour)
HLA-B27
Which arthritis have positive HLA B27
PEAR
Psoriatic
Enteric
Ankylosing spond
Reactive
Which arthritis has positive HLA B27
PEAR
Psoriatic
Enteric
Ankylosing spond
Reactive
Reactive arthritis. Often cause following enteric infection Eg salmonella, shigella …. What is the usual cause if urogenital? If Respiratory ?
Uro - chlamydia trachomatis
Respiratory - group a strep / chlamydia pneumonia
Sensitive and specific for Rheum A? Gene?
Anti ccp
HLA-DR4
DMARD of choice in RA? Other key Rx ?
Methotrexate (Usually with a course of steroids as DMRDS can take a couple months to work)
STOP SMOKING
Differentiate gonococcal arthritis from reactive arthritis
Gonococcal - Migratory polyarthritis
-Tendosynovitis
-Rash not really on hands / feet and may pustulate. Bit more extensive too
Reactive - Usually affects less joints (max 4)
-Tendosynovitis rare
-Rash usually on palms / soles
Which condition has bouchard / heberdens nodes ?
Osteoarthritis
OA most common finding on XR>?
Joint space narrowing
(may see ostoeophytes)
[subchrondral thickening]
Pseudogout other name? Seen on xray
Pyrophosphate arthropathy
chondrocalcinosis (calcified cartilage in articular space)
Oral / genital ulcers.
Erythema nodosum
Anteror uveitis ?
Common test done?
Gene?
Bechets syndrome
[Recurrent oral ulcers is key]
Skin prick with sterile needle -> pustule within 48hrs
HLA-B51
Rx if isolated mild oral ulcers in bechets?
Topical steroids
eg. triamcinolone
Drug-induced lupus? Antibodies?
procainamide, isonazid, hydralazine, sulphasalazine, penicillamine , antiepileptics ….
Basically if its a weird drug it might have caused it.
often ANA positive / anti-histone positive
but anti-dsDNA negative
Rx is to sop drug obvs
Most common antibody in lupus ? Specific? Which should all lupus also be tested for?
ANA - not specific tho
Anti ds-DNA more specific
Anti-phospholipid
Which inflam condition may develop bakers cyst
Rheum A
Also gout / OA
What is osteomalacia? Who classically gets it in questions? On Xr?
Inadequate mineralisation of bone
Vit D deficiency
- Sometimes Malabsorption - Coeliac / Crohns
Areas of low density with sclerotic zones
What is pagets ? Usual bloods finding? Rx? Monitoring blood test?
Essentially rapid bone turnover ->Disorganised
-Bone increases in size but more brittle + prone to fracture
Raised ALP (normal Ca, PO4 and PTH)
Bisphosphonates
Monitor bone specific ALP
Pagets XR? Skull specific?
Cotton wool spots on skull
Mixed lytic/sclerotic. Bone expansion / trabecular thickening
Pagets rx if cant tolerate bisphophonates ?
Calcitonin
Complement levels in lupus
Low
WHO nephritis in SLE. Rx for Class I, II, III, IV, v
I and II - Hydroxychloriquine
III-V - Add cyclophosphamide and high-dose steroids
Rash in antipospholipid ? Antibodies?
Livedo reticularis
Anti-phospholipid, anti-cardiolipin, anti-B2-Glycoprotein2
TB drug -> gout
Pyrazinamide
[reduces uric acid clearance]
Cyclosporin also similar
Gout aspiration
negatively birefringent needle-shaped crystals
Knee swelling with
Positively birefringent brick shade crystals
CPDD
[Calcium pyrophosphate deposition disease]
WHICH IS PSEUDOGOUT
Chronic gout XR
punched out lesions
Hx of TB with plan to start biologic Rx. What needs to happen?
Prev adequate treated TB - Monitor 3 monthly
Not adequately treated - chemoprophylaxis prior to Rx
Teenager with marked thoracic kyphosis =
Scheuerman’s disease
->loss of disk space height (more in anterior region -> kyphosis)
Polymyositis
Lung fibrosis
Rhabdomyolysis =? Differnetiate from glomerulonephritis?
What is injury to kidneys?
Anti-jo syndrome
Glomerulonephritis would have protein and blood in urine
Also more likey pulm haemorrhage than dry cough
ATN secondary to myoglobin crystals in kidneys
Teen recent URTI. rash on legs and bum, joint pain, abdo pain, vomiting…=?
Seen on renal biopsy ?
HSP
IgA deposition
Positive ANA. What titre to imply connective tissue disease
> 1:160
Low Titre eg 1:40 very unspecific
Early most common sign of OA
Limited range of movement
crepitus is later sign
OP is usually treated with bisphosphonates. What if not tolerated, high-risk breast Ca? What if severe refractory disease?
Not tolerated / Breast Ca risk = Selective oestrogen receptor modulator (SERM) Eg. RALOXIFINE
Teriparatide (PTH analogue) / strontium for severe bad disease
[Strontium high risk CV complications]
Most important Management in Ankylosing spond
spinal extension exercises
Pagets disease of bone - common CN involved
CN VIII -> deafness from compression
Nephrotic syndrome + hip pain. What we worried about
Avascular necrosis
(secondary to prothrombotic state)
Fevers, malaise.
Upper limb claudication / upper limb hypotension =?Other Sx?
Takayasu disease ‘pulseless syndrome’
Narrowing of main branches off aorta
Sx based on where Stenosis may affect
renal artery -> hypertension
Coronaries -> angina
Jaw claudication
Key trigger in quesion on jaw claudication as to takayasu vs GCA
GCA older + temoral tenderness
Takayasu - young Asian women with vaguer complaints
CREST antibody vs systemic scelerosis
Anti centromere
Systemic = anti-scl70
[ANA will be positive in 90% too]
Rx of scleroderma renal crisi
ACE inhibitors
What is seen in joint aspiration of gout alongside needle crystals
lots of neutrophils
Abdo pain and arthralgia following RTI. Kidney impairment.
HSP again brother
IgA - get it in the brain
Differentiate post strep glomerulonephritis and HSP from q
Post strep - 1-2 weeks following
HSP - 1-2 days + abdo pain + arthralgia
2 causes of arthralgia and painless oral ulcers
Reactive arthritis
-Rash on soles / palms
Behcet’s
Muscle pain / weakness with reduced tendon reflexes? What blood test will be high? Key assoc? Diagnosis?
polymyositis
CK high
-3fold risk of malignancy associated
Diagnosis with Muscle biopsy
[emg can help]
Dermatomyositis is polymyositis with what?
Heliotrophic rash / gottron papules
=Reddish/purple rash round eyelids
Which disease is raynauds most associated with
Systemic sclerosis
=100% of systemic sclerosis have raynauds
Sjogren’s most specific antibody
Anti Ro
Polymyositis antibody
Anti Jo
Marfanoid habitus. What enzyme deficient ?
CBS
Cystathione beta synthase
Mutation in which gene for Marfan’s
Fibrillin 1
Egg allergy, which vaccine no no
influenza
classical finding on XR RA?
periarticular osteopenia
[OA and RA both get joint space narrowing so less specific]
Subchondral sclerosis in which arthritis?
OA
Punched out erosions in which arthritis
gout
Lipping at joint margins in which arthritis
OA
Ankylosing spond 1st line? Then?
Early PHYSIO [preventative of progression]
NSAID - must have a trial of 2x NSAID first
Then Anti TNF-a eg Adalimumab, enteracept, infliximab
How does eosinophilic granulomatosis with poly angitis usually present ? Super common blood tests? Ix of choice? Rx?
Wheeze / asthma 90% / nasal polyps
70% have mononeuritis multiplex
Eosinophillia and p ANCA
Skin biopsy - small vessel arteriopathy with granuloma formation
Usually just IV steroids. may need cytotoxic / plasma exchange 2nd line
Rheum A gene? strongest environmental?
HLA DR4
Smoking
Rheum A which type of joint affected? 1st line rx?
Only synovial joints affected
Methotrexate 1st line
-TNFa drugs 2nd
What does Rheumatoid factor target
Fc portion of IgG1
Heaviness/aching in both legs while walking. Worse symptoms on spinal extension (normal XR) =?
What if Sx worse on bending forward -> shooting pain?
What test often used to differentiate these?
Spinal stenosis
Lumbar disk Prolapse (sciatica type pain)
Straight leg raise - pain positive in prolapse
When is OP diagnosed
when bone mineral density 2.5 standard deviations below mean peak mass on DXA scan
Contra indications to bisphophonates
HypoCa
Uveitis
Delayed gastric emptying if oral
Couple drugs 2nd line for OP. Key side effects:
Raloxifine?
Denosumab?
Strontium?
Raloxifine - Hot flushes, cramps and clots
Denosumab - higher risk of osteonecrosis of jaw
Strontium - CV including PE and steven johnsons
Raloxifine especially good in OP for prevention of
Vertebral fractures
[doesn’t help with Hips]
Bilateral AVN of scaphoid called
Presiers disease
Poorly controlled diabetes and restricted shoulder movement? Rx? How long does condition last?
adhesive capsulitis
Physio -> if no good
intra articular steroid
18 - 24 months
Arthralgia, purpura, skin ulcers, glomerulonephritis and peripheral neuropathy =? Key associations?
Rx?
Cryoglobulinaemia
HepC
HIV, MGUS / Haemonc and connective tissue disease
Treat underlying condtion
What temp for cryoglobulins to give Sx
<37
Types of cryoglobulinaemia 1-3 key assoc with each ? Which has Rheum factor
Type 1 - Haem
-MGUS
-Myeloma
-CLL
-Waldenstrom macroglobulinaemia
Type 2 - Hep C / connective tissues
-Has Rhem factor
Type 3 - Hep C / connective tissue - no Rhem Factor
Which cryoglobulinaemia types have all 3 of
Purpura, arthralgia and weakness?[Meltzer’s triad]
Type 2 and 3
[think connective tissue = arthralgia]
Renal damage in cryiglobulinaemia
Membranoproliferative glomerulonephritis
Rheumatoid pleural effusion
ph?
Lactate?
glucose?
Trans/exudate?
Low PH and high lactate
Low glucose [This is key for Rhem effusion]
Exudate - inflammatory
Pleural effusion - protein for trans / exudate? what if in middle?
Trans <25g/L
Exudate >35g/L
Lights criteria
Pleural effusion with
High triglycerides?
High amylase?
Very low glucose?
Triglycerides = chylothroax
Amylase - pancreas
Low glucose - rheumatoid
Pleural effusion needs drained if +ve culture, frank pus or what other biochem finding
ph <7.2
What has poorer prognosis in Rheum A
Positive IgM or IgG antibody?
Fast / slow onset?
Male/female?
Anaemia development by?
IgM bad
Slow onset
Females
Anaemia within 3 months
Hydroxychloroquine key side effects
Visual disturbance / alopecia in excess
How to test for conjuntival dryness in sjorgens syndrome? Antibody?
Schirmer’s test
(filter paper touched to eye and see how far tears go)
[Schirmer, Schjorgen]
Anti - Ro
normal ESR in old people
Men Age / 2
Women (Age + 10)/2
Rheum A >10years with splenomegaly and neutropenia
If presented earlier in Rhem history Eg in first year - what do you need to consider?
Felty syndrome
If early - consider Large Granular lymphocytic (LGL) leukaemia
[need marrow biopsy to differentiate]
Earliest sign on XR of ankylosing spond
Blurring of upper/lower vertebral rims at SI junction
Which inflammatory cytokine found in synovial joints of Rheum A
TNFa
[IL-1,6]
Long standing poorly controlled rheum A -> nephrotic syndrome? Whats happened
Secondary AA amlyloidosis
Which amyloid if primary? Secondary? Familial?
AL
AA
ATTR -Dominant inheritance
Primary Amlyoid is what? What is this closely related to?
Plasma cells producing light chains
Closely related to myeloma
Who gets AA amyloidosis
Chronic inflam conditions - Eg Rhem A / TB especially if poorly controlled
Presents very slowly
Most sensitive test for AL amyloid
Immunoglobulin free light chain assay
-raised kappa lambda ratio
Rx of AA amyloid? What about specifically AA amyloid in familial Mediterranean fever?
Rx of inflam condition
Colchicine
Symptoms of weakness / tingling / cold / parasthesia in 1 arm worse when abducted / above head? Normal bloods
Thoracic outlet syndrome
90% neurogenic
1% arterial
Surgery eg cholescystectomy -> swelling red painful ankle / knee / foot =?
Gout
Acute attack provoked by
-surgery
-fasting
-aspirin
-aki
XR of osteomyelitis in first week? After this?
Chronic osteomyelitis?
Nothing visible in first week
then periosteal reaction/elevation
Chronic - patchy sclerosis with honeycomb appearance
[+new bone formation]
Who gets epislceritis/ scleritis ?
Differentiate them
Pain
Level of hyperaemia (engorged vessles)
Photophobia
visual acuity
What if there was discharge?
Scleritis
More painful
Diffuse hyperaemia and vessles do not move when probed with cotton bud
photophobia and reduced acuity common
Episcleritis
Less painful
Focal vessles which move
Less photophobia and normal acuity
If discharge - think conjunctivitis
-Especially if diffuse hyperaemia
Who gets epislceritis/ scleritis ?
Differentiate them
Pain
Level of hyperaemia (engorged vessles)
Photophobia
visual acuity
What if there was discharge?
Scleritis
More painful
Diffuse hyperaemia and vessles do not move when probed with cotton bud
photophobia and reduced acuity common
Episcleritis
Less painful
Focal vessles which move
Less photophobia and normal acuity
If discharge - think conjunctivitis
-Especially if diffuse hyperaemia
Who gets epislceritis/ scleritis ?
Differentiate them
Pain
Level of hyperaemia (engorged vessles)
Photophobia
visual acuity
What if there was discharge?
50-70% have another systemic disease Eg Rheum A
Scleritis
More painful
Diffuse hyperaemia and vessles do not move when probed with cotton bud
photophobia and reduced acuity common
Episcleritis
Less painful
Focal vessles which move
Less photophobia and normal acuity
If discharge - think conjunctivitis
-Especially if diffuse hyperaemia
Scleritis vs epi with administration of phenyephrine drops
Epi - blanching of vessels
scler - no blanching
Primary vs secondary raynauds
Age?
Sex?
Tissue damage?
symmetry?
Capilliary scope ?
Antibodies?
Primary
30
Female
No damage
Symmetrical
Normal capilliaries
No antibodies
Secondary
50
Male
May get gangrene
asymmetrical
positive capillary scope
antibodies common
Allergic to allopurinol can get what in gout?
Probenicid (uricosuric agent)
White people often have which gene in SLE
HLA DR2 / HLA DR3
Who is most likely to get SLE
African-american
Women
20-40
High inflam markers with ++ lymphocytes and fracture of spine?
Potts disease
-spinal TB
What % of PA are HLA-B27 positive
20%
PA with skin lesions and nail involvement rx?
What if just joints?
If DMARDs no good
Methotrexate
[may use steroids for bridging]
joints only - sulphasalazine
TNFa - Adalidumab, enteracept, infliximab
Back pain, muscle weakness and bony tenderness.
Raised ALP and low Ca = ? What might PTH be? What may be found in urine? XR appearace?
Osteomalacia
-vit D deficiency
May have raised PTH (Secondary)
-> increased phosphate excretion in urine
[hypoPO4 in blood]
Translucent bands on XR
What class is allopurinol
Xanthine oxidase inhibitor
Which connective tissue disorder has highest maternal death -> recommended abortion until well controlled
Systemic sclerosis
Blood in pagets
ISOLATED raised ALP
Bechets Rx
Limited ulcers? 2nd line 3rd?
Evidence of Eye / GI / CNS / vascular
Topical steroid
->pred / azathioprine (for up to 2 years)
3rd line - TNFa inhibitors
Any systemic involvement
Pred + anti-TNFa
Which abx is contra indicated in methotrexate therapy? Why
Trimethoprim (or septrin of course)
Both folate antagonists -> methotrexate toxicity and bone marrow suppression
Why get you get gout in G6PD
Increased production of pentose sugars
[they basically mean more purines get produced]
Haemolytic anaemia and -> uric acid release may contribute a little bit
Persistent spiking fever, swollen DIPs, hepatosplenomegaly and transient salmon pink rash each time gets a fever?
Adult onset Still’s
Which drugs may precipitate stills flare
Penicillamine, rifampicin
Stepwise approach to stills Rx
NSAIDs
Steroids
Methotrexate
Anti-IL-1 / IL-6 or TNFa inhibitor
What theray is most effective for stills ? eg?
Anti IL-1 / 6
Toculizumab - IL-6
-Only licensed one
[Anakinra - IL-1]
Plaques on extensor surfaces + telescoping deformity on fingers with nail changes
Arthritis mutilans
Most common GI issue in SLE
Mouth ulcers
Old bogy with posterior displacement of cervical vertebrae with slowly progressing pain due to what?
Osteoarthritis
[get instability of the posterior facet joints]
Rheum A mab examples and explain which cytokine target by each?
TNFa - 3 of them
IL-6 - Eg toculizumab
Rx acut gout with slightly raised creatinine and on warfarin with INR 3
Still colchicine - can give renal dose (500mg BD in stead of QDS)
Big trauma/surgery to joint
->Severe pain which is often disproportionate to signs found. Also some skin changes eg dry / scaly
Reflex sympathetic dystrophy
What is the name of the test to measure lumbar flexion in ankylosing spond
Schobers
When would you use IV bisphophonates in Pagets?
History of GORD / oesophagitis….
What type of infection precedes reactive arthritis
GI/GU
[not flu like illness]
What is keratoderma blenorrhagica
Aseptic abscess which occurs on palms / soles in reactive arthritis
ONLY in 10%
Why do people have raised uric acid in gout
Impaired renal excretion 90%
Long history of rheum A. Now chest pain hypotensive and low voltage qrs
Tamponade (rheum effusion)
What bloods might you expect in PMR
High ESR (not just a bit raised)
normochromic/normocytic anaemia
[Often deranged LFTs]
Non-productive chronic cough with global wheeze - often in a chronic inflammatory disease eg RA/SLE/Polymyositis
Bronchiolitis obliterans
Rx with steroids - though poor prognosis
What is more common in reactive arthritis: Neg RheumFactor or presence of a rash
Neg rheum factor - seronegative arthritis
Rash in 10%
Polyarteritis Nodosa
Vessels affected - which are spared?
ANCA?
30% associated with?
Males-females
Rx?
Medium - Usually just renal + Abdo - SPARES lungs
[mononeeuritis multiplex too]
ANCA Negative
30% HepB
Males more affected
Pred/cyclophosphamide
How to make diagnosis of PAN if no accessible vessels?
Angiogram - eg of kidneys - will demonstrate string of aneurysms ‘rosary sign’
How to make a diagnosis of PAN if no accessible vessels?
Angiogram - eg of kidneys - will demonstrate Aneurysms
Most common cause of death in systemic sclerosis
Pulm fibrosis
[used to be renal issues but Rx has improved]
Most common cardiac involvement SLE
Pericarditis with small pericardial effusion
GPA most commonly affects
Lungs 90%
kidneys 80%
Rx of PAN who HepB positive
Antivirals + plasma exchange
Usual exam of joint pain in SLE
Often normal - but may have some swelling
1st line/ Best Ix for diagnosis of ank spond
XR first line
MRI sacroiliac spine
Inflam arthritis - best drugs for men/women wanting to have babies \DMARD?
Stronger?
Hydroxychloriquine
Anti-TNFa
A young man wanting to start a family but realises is infertile. What dmard was he given
Cyclophosphamide
-May irreversibly affect male fertility
why no sulfasalasine in men wanting to have a baby
May drop sperm count while taking
most definitive diagnostic test for sjorgrens
Biopsy of labial gland
[behind lower lip]
Why lose pulses in takayasu?
Inflammation -> transmural fibrosis -> obstruction
Loose bodies in knee joint + locking of joint? Cause?
Osteochondritis dissecans
Local necrosis of cartilage - most commonly medial femoral condyle
Antibodies in stills disease
Usually all negative
[occationally ANA - which linked to uveitis]
Plateltes in antiphopholipid
Usually low
Management of antiphopholipid?
What if all 3 antibodies are positive ? What are the 3?
Anti coag eg doac / warfarin
If all 3 positive - warfarin
phospholipid, cardiolipin and anti-beta-2-glycoprotein?
Antiphospholipid rx in preg?
Low dose aspirin
[low dose LMWH if not tolerated]
Gull wing / T pattern on Xray of PIPs in
Erosive osteoarthritis
When do you use febuxostat
Chronic hyperUric acid when allopurinol not tollerated
polymyositis and interstitial lung disease =
Anti-Jo syndrome
Erythematous rash and polyarthralgia, Dry eyes/mouth, Raised IgG, ANA, Anti-Ro, RF =
Primary Sjogren’s
Anti ro remains pretty specifi. In secondary sjorgrens anti Ro is likely to be negative
Felty syndrome HLA
HLA DRW4
Pain in hips / knees. Bloody diarrhoea, abdo pain and fever. Barium enema shows ‘rose thorn’ ulcers. What is it?
Crohns - enteropathic arthritis
Barium enema may show rose thorn ulcers, cobblestone and strictures
Dermatomyositis. Key Ix for Dx
Muscle biopsy
Arthroscopy in Rhem A
Marked vascular proliferation in synovial membrane
[Fluid is usually turbid with reduced viscosity ]
HLA DR2
Rheumatic fever - but proftective agaisnt Rheum A
[Also in good pastures]
HLA DR 3
Anti-CCP negative Rhem A
T1DM
Key feature on biopsy of EGPA
Necrotising granuloma with an eosinophilic core
[in small and medium-sized vessles]
Single most common blood finding osteomalacia
ALP raised
AVN of hip suspected what is the Ix
MRI
Bilat erosions of SI joints on XR
Ankylosing spond
Marfinoid, osteoporosis, learning disability? Key eye symptoms?
Homocystinuria
posterior lens dislocation
Joint hyperlaxity / dislocations, skin laxity and easy bruising in normal height? Inheritance? Genes?
Ehlers-danlos
Variable
-Dominant in classical form
-Kyphoscoliotic / vardio-valvular - ressessive
COL5, COL3, TNXB, PLOD1
Rhem with raised MCV anaemia
Methotrexate fucking with folate
HLA B8 and DR3 in
Graves
Dermatomyositis Rx
Pred +
MTX or Azathioprine
[May give you a TPMT level in Q]
Pagets most common location
Lumbar spine
[pelvis second]
Lupus on pred / hydroxychloroquine
Fever + cough
ESR 80, CRP 50, Lymphopenia, thrombocytopenia
Rx?
Increase steroids as active lupus
[thrombo/lymphopenia, raised ESR]
Abx as cough
[raised CRP]
Swollen PIPs with ulnar deviation bilat
Pitting of nails and onycholysis
Psoriatic arthritis
Nail changes = psoriatic
Tests for lateral epicondylitis
wrist extension / supination
Chair raise test
Acute gout given allopurinol what happens
GOUT GETS WORSE
How reduced are platelets in active SLE
Minorly reduced
Diffuse cutaneous scleroderma Antibodies
Anti- RNA polymerase
Anti-topoisomerase-1 also called
Anti-Scl70
the single most important thing for peak bone mass
Genetic
[More than physical activity / weight]
HIV gout prophylaxis if prev attacks
Colchicine
Allopurinol messes with concentrations of antiretrovirals
Neck pain radiating to the arm
Weakness of biceps and triceps
XR narrowing c5/c6 =
Disk prolapse
Man with connective tissue disease wants to start a family
Which DMARD ?
Azathioprine
Bar MTX what other DMARDs first line for rheum A
Sulphasalzine, leflunomide
first sign of Rheum a in a knee
Effusion
Best way to differentiate gout
Trial of colchicine
[Better and raised uric acid, erosion son Xray, and elbow nodules]
Deaf, bowing of legs raised ALP, normal Ca
Pagets
Most common cause for pain at base of thumb in older person
OA
De Quervains would have Hx of repetitive action
AVN - Hx of trauma
Ank Spond which nephropathies do they get
Enlarged kidneys and when older?
Effect of drugs?
If Haematuria?
AA amyloid - apple green birefringence
NSAID induced
IgA nephropathy - linked to ankylosing spond
Why Adalidumab / enteracept over infliximab
Cheaper
Rx of chronic fatigue
CBT
[Graded exercise therapy no longer recommended]
Long-term steroids planned - prevention of osteoporosis
Bisphosphonates, Ca and Vit D
Gets gout which cardiac meds need stopped
Thiazides / thiazide like eg indapamide
Which vasculitis do the Japanese get
Takayasu
Swelling of forearms with peaud’orange. Raised eosinophils and carpal tunnel =? What else is seen
Eosinophilic fasiculitis
Hypergammaglobulinaemia
Which complement factors reduced in early onset SLE
C4 deficiency most assoc
Osteoperosis but GFR < 35. What Rx
Denosumab
Orogenital ulceration
Arthritis
DVT
uveitis
Anti-phospholipid antibodies
Bechets
20% positive for antiphpholipid
polymyositis 1st line rx
Pred
2 months polyarthralgia, dry eye, fevers, ANA, RF, Anti-Ro, AntiDsDNA
SLE (DsDNA) with secondary Sjogren’s
Calcificic tendonitis usual crystals
Calcium hydroxyapatite
no eye involvement GCA how much pred
60mg
Most common pulm involvement in SLE
Effusions
Rheum A with pancytopenia and lung fibrosis 2 possible drugs
MTX
Gold
