Rheum Flashcards
Ix for rheumatoid arthritis
Nodules
Abdo exam- organomegaly
Lower extremities- ulcers
Anti CCP
X ray
Treatment of RhA
If evidence of RhA
Start on DMARD (hydroxy, methotrexate, sulfalazine)
+/- short prednisolone
Flares- CS - pred
If DAS >5.10- consider stepping up management
Refer early arthritis clinic
Side effects of tx of RhA
Meth- hair loss, PF
HC- bull eye lesions
Sulf- oospermia
Order of tx in RhA
2 DMARDs then biologics
What do you need to check for when giving infliximab, etanercept and adalilumab
Screen TB
Chest X ray
Ix needed when on methotrexate
FBC, U&Es, LFT every 4 months
Signs and symptoms of psoriatic arthritis
Asymmetrical polyarthritis
Can affect spine
Nail changes
DIP affected
Can have skin changes but not always
Tx of psoriatic arthritis
Methotrexate
Sx of reactive arthritis
Anterior Uveitis
Urethritis
Arthritis
Kertoderma blenorragia
After STI or GI infection
Tx of reactive arthritis
NSAIDs, refer to rheum
Signs and symptoms of AS
Morning stiffness
Gradual onset
Pain at night
Sacroiliitis
Squaring of lumbar vertebrae
Apical fibrosis
Anterior uveitis
Aortic regurgitation
Achilles tendonitis
AV node block
Amyloidosis
What hand sign do Seronegative arthritis have
Dactylitis
Sx of RhA
DIP spared- mainly MCP, PIP, wrist, knee
Nodules
Carpal tunnel
Ulcers, organomegaly
Sx of PR
Shoulder and hips- high ESR
Worse in mornings
Sore muscles
carpal tunnel
GCA
Tx of PR
Prednisilone 15mg OD
Continue until sx gone then tamper
What can temporal arteritis cause
Anterior Ischaemia optic neuropathy
White swollen optic disc
Tx of GCA
40-60mg pred, daily for 4 weeks, tapered over 6m- 1year
Methylprednisilone if eye affected
Sx of takayasu arteritis
Systemic features of a vasculitis e.g. malaise, headache
Unequal blood pressure in the upper limbs
carotid bruit and tenderness
absent or weak peripheral pulses
upper and lower limb claudication on exertion
aortic regurgitation (around 20%)
Ix and Tx of Takayasu Arteritis
MRA or CTA
Steroids
Sx of microscopic poly
pANCA
Fever
Muscle aches
Lung involvement
Renal
Skin lesions
ANCA positive vasculitides and sx
GPA- saddle shape nose, rhinos, epistaxis, LRT- haemoptysis, renal- nephritis
EGPA- asthma, RPGN
MP- pANCA, haemoptysis- Hep B
ANCA negative vasculitidies and sx
HSP- IgA vasculitis- rash, arthralgia, glomerulnephrtiis
Goodpastures- renal and lung involvement
Sx of dermatomyositis
From PNP syndrome
Gottrons papules over knuckles
Heliotrope on eyelids
Proximal Muscle weakness
ANA +- anti Jo
Sx of polymyositis
Proximal muscle weakness
Malignancy
May have raynauds and dysphagia
Ix of polymyositis
Raised CK 1000s
ALT and AST also raised
EMG
Anti-Jo
Muscle biopsy
Diffuse Scleroderma sx
Scleroderma affects limbs and trunk
Pulmonary fibrosis
Scl70 +
Hardening of the skin
Cold peripheries
Limited Scl sx
CREST
Pulmonary HTN- echo and ecg
Tx of diffuse sclerosis
Immunosuppression
PPI for regurg
ACEi for renal failure
Sx of behcets
Oral and genital Ulcers
Anterior uveitis
Mediterranean
Increased risk of VTE
Sx of Sjogrens
Inflammmed parotids
Dry
Painful sex
Arthralgia
Tx of sjogrens
Artificial tears
Hydroxy- arthralgia
Tx of SLE
Hydroxychloroquinine- maintenance
Falres- Prednisolone + Cyclophosphamide
ACE if proteinuria
Ix of SLE
ANA- sensitive
dsDNA- specific
C3 and 4 low- during active disease
Ix of gout
Negative needle on aspiration
Measure rate 2-4w after inflammation settles
Tx of gout
Acute- NSAIDs, colchicine- if low GFR- can cause diarrhoea
Long term- allopurinol
Sx of pseudo gout
Larger joints
Chondrocalcinosis
Positive rhomboid
Osteoporosis Tx
Vit D and calcium
Alendronate- weekly
risedronate or etidronate if cannot tolerate alendronate
When to give bisphosphonates
T > -2.5
T > -1.5 and on steroids
Tx of polymyalgia rheumatic
Tx with steroids for 3 weeks
If no improvement- consider alternate diagnosis
Tx of ankylosing spondylitis
Physio and NSAIDs whilst referred to rheum
Then DMARDs such as sulphasalazine
OA vs psoriatic arthritis feel
Bony vs boggy
Antibody in limited sclerosis
Anti-centromere
Antibody in diffuse sclerosis
Anti-scl70
First line Ix of AS
X ray spine and pelvis
Sjogren syndrome sx
Enlarged parotids
Dry mouth
Dry eyes
Sjogren syndrome dx
ANA +
Rh factor +
Schirmers +
Gout vs pseudo gout
Gout- toe- negative needles
Pseudo- positive rhomboids
Gout vs pseudo tx
Gout- NSAIDs, colchicine, pred if renal impair
Pseudo- NSAIDS
APS features
Clots,
livedo reticularis- lace like on skin of legs, miscarriage, low plt
APS dx
+ve blood test 2 occasions 12 weeks apart
Anti cardiolipin, lupus anticoagulant
APTT- wrongly prolonged in lab results
Plt low
Prosthetic with extreme pain ix
Synovial aspiration for septic arthritis
Polyartiritis nodosa sx
Ulcerating skin
Orchitis
Renal failure
Abdo pain
Arthritis
Hep B
No lung
No ANCA
Dx of polyartiritis nodosa
Biopsy of affected area
Dx of PR
ESR
PR vs myositis
Myositis causes weakness
PR- pain and stiff
Tx of GCA
60mg pred
Tapered over 1-2 years due to relapse
Disease RF for pseudogout
Haemachromatosis
Wilsons
Hyperparathyroid
Acromegaly
Low Mg, P
ECG changes in GPA
St elevation
Myositis
Tx of raynauds
CCB
DAS scoring of RA
2.6- 3.2 low
3.2-5.1 moderate
>5.1 high
Stool problems, painful lesions on shins and arthritis
Enteropathic arthritis
Seronegative arthropathies
PARE
Psoriatic
AS
Reactive
Enteropathic
RA features
MCP and wrist subluxation
Swan neck deformity
Boutonniere
Ulnar deviation
Z shaped thumb
Atlanto-axial joint subluxation
Carpal tunnel
Tenosynovitis
Anaemia
Amyloidosis
Nodules
Raynauds
Pneumonitis
Tx of non specific back pain
NSAIDs and PPI
Septic arthritis order of mx
Aspirate an culture
Then iv abx
Myositis Ix
CK
Then EMG
Then muscle biopsy definitive diagnosis
pANCA and cANCA positive
Subactute bacterial endocarditis
Dx of herniated disc
Straight leg raise
Other SE of steroids
glaucoma
Hyperglycaemia
Insomnia
Weight gain
Order of tests in GCA
ESR
Biopsy
Gene of AS
HLA B27
Most important test to monitor with scleroderma
Renal function tests
SLE presentation
Fever
Myalgia
Arthritis
Photosensitivty
Discoid rash
Raynauds
Renal
Neuro
Ulcers
Malar rash- spares nasolabial folds
Dx of SLE
ANA
dsDNA
Low complement
Headache, psychosis or fits in SLE and tx
Cerebral lupus
Steroids and cycle/aza
Lupus GLN tx
Protein uria- ACEi
Steroids and myco/cyclo
usually nephrotic
Nerve roots weaknesses
L2- hip flexion
L3- knee extension
L4- knee extension, inversion, dorsiflexion
L5- inversion, dorsiflexion
S1- eversion, knee flexion
Behcets HLA
HLA B51
Felty syndrome
RA
Splenomegaly
Neutropaenia
What are patent with sjogrens predipososed to
Lymphoma
What are patent with sjogrens predipososed to
Lymphoma
Allopurinol in acute gout
If already on continue to take
Marfans defect
Fibrillin
If starting on long term steroids what do you do
Bisphosphonate, Vit D, calcium suppliments
X ray features of psoriatic arthritis
Pencil and cup
Plantar spur
Periarticular erosions with bone resorption
If GCA with evolving visual loss mx
IV methylprednisolone
Hydroxychoroquien SE
Retinopathy- bulls eye ring
Enteropathic arthritis HLA
HLA B27
Patients allergic to aspirin/cotrimox are usually allergic to
Sulfalazine
Sx of AS
Reduced chest expansion, lateral and forward flexion
Uveitis- painful
Achilles tendonitis
Schober test
AS if <5cm
Meralgia parasthetica nerve and sx
Lateral cutaneous nerve compression
Parasthesia
Less sensation
Still disease
Pyrexia - arises in afternoon
Arthralgia
Salmon pink rash
Lymphadenopathy
Hypotensive- can mimic sepsis
Can have high ferritin and LFTs
When to give bone protection for steroids
If on >7.5 a day >3 months
If on methotrexate and in contact with varicella tx
Test AB, if neg VZIG
Diffuse vs limited sclerosis
Diffuse- proximal limb, trunk
ILD- fibrosis, Pul HTN
Limited- distal limb
APLS tx
Before VTE- aspirin
After first VTE- Lifelong warfarin
Affects of tamoxifen on bones
Protective since agonist in the bones
RF of osteoporosis
Steroids, PPI, levothyroxine
RhA
Low BMI
Smoking
CKD
Osteoporosis of the hand sx
DIP affected
Bouchards- proximal
Herberdens- distal
Squaring of thumbs
OA of hands tx
para and Topical NSAIDs first
Oral NSAIDs, opioids, capsaicin cream and IA steroids next
Methotrexate SE
Mucositis
Myelosuppression
Pneumonitis- reticular shadowing on CXR
Pul fibrosis
Liver fibrosis
Methotrexate pneumonitis presentation
New dry cough, dyspnoea, fever
reticular shadowing on CXr
Tx of RhA in pregnancy
Hydroxychloroquine
Causes of Raynauds
Vibrating tools
Scleroderma
RhA
SLE
Primary cause - bilateral
What predisposes you to azathioprine deficiency
TMPT deficiency
X ray of different arthritis
Septic- effusion
Psoritatic- periarticular erosions and bone resorption
OA- LOSS
RhA- LESS- proximal joints
Erosions, subluxation, soft tissue swelling
Medication for all housebound patients
Vit D
Pseudogout knee x ray
Chondrocalcinosis
Visible cartilage on edges
Antibodies for demote/polymyositis
Anti Jo
Antibodies for sjorgrens
Anti Ro/La
If someone with SLE has high WCC, raised CRP and normal kidney function
Underlying infection
As CRP usually normal in SLE, kidney function oddly derange too
Chronic fatigue syndrome Dx
Normal tests- FBC, ESR, U+E
Sx persistent for 3 months
Presentation of osteomalacia
Bone pain
proximal myopathy
Waddling gait
Low Vit D
X ray of AS
Subchondral erosions
Sclerosis
Squaring of vertebrae
Syndesmophytes
Ossification of supraspinous ligament
Signs of Pagets on X ray
Osteolysis in early disease → mixed lytic/sclerotic lesions later
skull x-ray: thickened vault, osteoporosis circumscripta
Tx of Pagets
Bisphosphonates
Oral risedronate
Signs of psoas abcess
Hip extension
Fever
Meds you can take for SLE in pregnancy
Azathioprine
Poor prognosis of RhA
RhF or anti CCP positive
Early erosions
Nodules
Insidious onset
When to give Anti TNFa for AS
After failed 2 NSAIDs and has active disease on 2 occasions 12 weeks apart
What should you correct before giving BP
Vit D and calcium
What suggests primary raynauds rather than secondary
<40
Bilateral
Infective flexor tenosynovitis sx
Fixed flexion, tenderness, pain on passsive extension
If IVDU presents with discitis what other ix should you do
Echo- since IE can cause discitis
Rheumatoid arthritis joint aspiration
Yellow
High PMN
No crystals
Extra articular sx of RhA
Multisystemic effect- unwell, fevers, fatigue
Haem- anaemia, splenomegaly- felty , amyloid- kidneys
Derm- nodules
Opthalmic- dry eyes (keratoconjunctivitis sicc)
Pleural- nodules, fibrosis
Pericardial- IHD
Increased risk of neck breaks- due to Atlanto-axial subluxation
Drug induced lupus causes
Hydralazine PIMP
Procainimide
Isoniazid
Minocycline
Phenytoin
Tx of Stills disease
NSAIDs
After 1 week no improvement- steroids
What should you monitor with HSP
BP and urine dipstick
OP and osteopenia on DEXA
-1 to -2.5 is osteopenia
OP >-2.5
Type of deposits in pseudo gout
calcium pyrophosphate dihydrate crystals
Osteoarthritis tx
Oral paracetamol or topical NSAID (only for hands or knee)
Then oral NSAIDs with PPI
Azathioprine SE
BM suppression
N+V
Pancreatitis
What should you co prescribe with methotrexate
Folate for myelosuppression
Organism of septic arthritis in young sexually active people
Gonorrheoa
X ray of AS
Subchondral erosions
Sclerosis
Squaring of lumbar vertebrae
Immune hypersensitivity reactions
1- immediate
2- AB against antigen- graves
3- deposition- SLE
4- delayed
What do you need to do before surgery for RHA patietn
AP and lateral neck X rays
