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BPT Clinical Exam > Rheum Long > Flashcards

Rheum Long Flashcards

1
Q

Scleroderma Hx

A
  1. Derm
    - Raynauds, skin tightening
  2. Arthritis
    - Rheumatoid distribution, Carpel tunnel
  3. GI
    - Dysphagia, reflux, diarrhea
  4. Renal
    - HTN, CKD, SRC
  5. Resp
    - ILD, PHTN, pleurisy
  6. Cardiac
    - Pericarditis, arrhthymias, dilated cardiomyopathy -CCF
  7. Other
    - Erectile dysfunction, hypothyroid, non melanoma skin cancers
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2
Q

DDX of Scleroderma

-Non associated with Raynauds or ANA

A

Eosinophilic fascitis
Morphea
Nephrogenic systemic fibrosis
Diabetic cheiroarthopathy

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3
Q

CREST

A 
Calcinosis (deposits in subcut tissue at ends of fingers)
Raynaud's
Esophageal involvement 
Sclerodactyly
Telangiectasia
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4
Q

Ix for Systemic Sclerosis

A
  1. Basic Bloods:
    - FBE (Anaemia), ESR, Folate and B12 (malabsorption)
  2. Special Bloods:
    - Ig - (Hyper IgG in 50%), ANA, Anti-Scl 70 (diffuse), Anti centromere (limited)
  3. Imaging
    - CXR, HRCT
  4. Special tests:
    - Gscope and oesophageal manometry
    - PFTs
    - TTE
    - RHC
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5
Q

Tx for Systemic Sclerosis

A
  1. Reflux - PPI
  2. Raynauds - CCB, Prazocin, methyldopa, iloprost
  3. Dry eyes
  4. Malabsorption (ensure no SIBO), supplements
  5. ILD - Cyclophosphamide
  6. PHTN - Endothelin recepton antagonist, phosphodiesterase inhibitors, Prostanoids
  7. HTN - ACEi
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6
Q

Extra articular manifestations of RA

A
  1. Skin - Raynauds, leg ulcers
  2. Eyes - Dry eyes, scleritis, episcleritis, scleromalacia perforans, cataracts
  3. Sore throat, horeseness, neck pain 0 Suggests cricoaryteroid disease
    - Recurrent headaches at base of skull and arm tingling - thinck C1/2 sublaxation
  4. Lungs - ILD, pleural effusion, pleuritis
  5. Cardiac - Pericarditis, valvular disease atherosclerosis
  6. Renal - Drug use, amyloid
  7. CNS - PN, mononeuritis multiplex, cord compression, entrapment neuropathy
  8. Haeme - Anaemia, Felty’s (RA, leukopenia, splenomegaly)
  9. Systemic - fever, weight loss, fatigue
    • Vasculitic - digital arteritis, ulcers, PG
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7
Q

MTX Side effects

A

Hepatic and pulmonary toxicity
Leukopenia
Thrombocytopenia

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8
Q

SSZ Side effects

A 
Rash
Nausea
Haematological abnormalities
Abnormal LFTs
Reversible oligospermia
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9
Q

HCQ Side effects

A

Nausea
Pigmentation
Bull’s eye retinopathy

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10
Q

LEF Side effects

A

Diarrhea
Alopecia
Derranged LFTs

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11
Q

Causes of Arthritis and Nodules

A

RA (Seropositive)
SLE
Rheumatic fever (Jacoud’s arthritis)
Amyloid Arthropathy (usually associated with MM)

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12
Q

DDX for deforming symmetrical chronic polyarthropathy

A 
RA
PSoriatic arthritis or seronegative arthropathy
Chronic tophaceous gout
Primary generalised OA
SLE
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13
Q

Investigations to assess activity of RA

A

ESR or CRP
Hb - severity of normocytic anaemia correlates with activity
Anto CCP and RF titres
PResence of progressive erosions on serial XRs

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14
Q

DDx for raised ESR in RA

A

Active disease
Sjogrens
Amyloidosis
Infection

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15
Q

Tx of RA

A

General Principles

  • Education
  • PT - exercise and splinting of joints to prevent deformity
  • OT
  • Smoking cessation
  • Rest of inflamed joints
  • Anti inflammatories
  • CVS risk modification

Induce Remission
-DMARDS or biologics

Acute flare Mx
-Steroids, PO or intraarticular

Surgery

  • Joint replacements - Hip, shoulder, knee
  • Arthroplasty and relief of contractures
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16
Q

Risk factors for destructive disease in RA

A 
High titre RF or positive anti CCP
Constitutional Sx
Insidious onset
Erosions early on XR
Rheumatoid nodules early 
HLA DR4
17
Q

Rules for the use of biologics for RA

A
  1. Failure of at least 6 months of treatment with traditional DMARDs
  2. Tx must include MTX and combinations of HCQ, SSZ, or LEF
18
Q

Monitoring for disease activity during review of RA patient

A 
Fatigue
Morning stiffness
Weight loss
Functional limitations
Acute phase reactants (ESR and CRP)
19
Q

OA MX

A

Non pharm

  • Exercise: Stretching and mobility exercises to help maintain ROM; Aquatic exercise; exercise bike; Supervised or group exercise is better for reduction in pain
  • Gait aids: SPS, knee braces, foot orthoses
  • LoW: most important modifiable RF
  • Complimentary meds: Glucosamine, fish oil, chondroitin equal to placebo

Pharm

  • NSAIDS/Paracetamol
  • Topical NSAID/Capsaicin
  • Intraarticular steroids for acute flare
  • Opioids topical or oral (increased risk of CVS, fractures, and mortality compared to NSAIDs)
  • Duloxetine - superior than placebo

Surgery

20
Q

Extraarticular manifestations of Ank Spond

A

Uveitis
AR
Symptoms of cauda equina (late)
Upper lobe interstitial lung disease (Late)

21
Q

Diagnosis of Axial Spondyloarthritis

A
  1. Age < 45
  2. > 3 months of back pain
  3. HLA B27 positive + 2 or more of:
    -Inflammatory back pain
    -Enthesitis
    -Uveitis
    -Dactylitis
    -IBD
    -Family Hx of SPA or HLA B27
    Elevated CRP
    -REsponse to NSAIDs
  4. Sacroilitis on XR or MRI
22
Q

Mx of axial spondyloarthritis

A
  1. Exercise program for flexibility
  2. NSAIDs - reliev Sx and slow radiographic progression
  3. Anti TNF alpha if not responsive to NSAIDs
  4. ?Surgical options
23
Q

ARA criteria for SLE

A

Need 4 out of 11

  • Malar rash - sparing the nasolabial folds
  • Discoid rash
  • Photosensitivity rash
  • Oral Ulcers
  • Arthritis affecting 2 or more peripheral joints
  • Serositis - pleurisy, pericarditis
  • Renal disorder - Proteinuria > 0.5 g/day or cellular casts
  • Neuro disorder - Seizures, psychosis
  • Haeme - haemolytic anaemia, leukopenia, lymphopenia, thrombocytopenia
  • Immunological disorder - dsDNA, anti-Sm, positive APLS ab
  • ANA >1:160
24
Q

SLE Hx

A
  • General Sx: Nausea, weight loss, malaise, thrombosis
    -MSK: arthralgia, arthritis, myalgia, myositis
    -Derm: rash, alopecia, oral and nasal ulcers
    -Fever
    -Neuro psych Sx - delirium, dementia, seizures, chorea, neurpathy, stroke, headache, MS like symptoms, anxiety, depression
    -Renal - haematuria, oedema, renal failure
    -Resp - pleurisy
    -CVS - pericarditis, myocarditis, valvular lesions, CAD
    HAeme - anaemia, lymphadenopathy
    -GI - diarrhea, pseudo bowel obstruction, perforation
    -APLS Symptoms
    -Sicca symptoms
25
Q

KEy Symptoms for SLE

A 
Apthous ulcers
Serositis
Raynauds
Alopecia
Photsensitivity rash
Dry eyes and mouth
Thrombosis
miscarriage
Nephritis
26
Q

Features of MCTD

A
  • OVerlapping features of SLE, SS, and polmyositis
  • High anti U1RNP
  • PErcardial effusion
  • Raynaud’s, swollen hands, fatigue and arthritis
  • PAH is main cause of death
27
Q

Major causes of death in SLE

A

Infection
Renal failure
Lymphoma
AMI

28
Q

Mx of SLE

A

General

  • Sun protection and avoidance
  • Rest and NSAIDs for arthralgia and myalgia
  • Cease smoking

Suppressing disease activity

  • HCQ (Skin and joint)
  • Steroids if serious disease manifestation
  • AZA/MMF/Cyclophosphamide -Renal Lupus
  • MTX - Joints
  • Raynaud’s: CCB
  • Ritux/Belimumab - on special access scheme for some patients

Managing Disease complications

  • CVS modification
  • Thrombosis and hypercoagulability
  • Bone health
  • Routine Pap smears - risk of cervical dysplasia
29
Q

General Vasculitis Sx to ask on Hx

A 
Fatigue
fever
myalgia
arthralgia
Vasculitic skin rashes - palpable purpura
Renal disease
HTN
GI symptoms
30
Q

GPA Hx specifics

A

Ganulomatosis with polyangiitis

  • Nasal congestion/Rhinorrhea
  • Bloody nasal discharge
  • Cough (initially dry, but may progress to hemoptysis)
  • Breathlessness
  • Renal involvement
31
Q

GCA Hx specifics

A
  • PMR Sx
  • Bitemporal headache
  • Visual disturbance - diplopia, visual loss
  • Jaw claudication
  • Scalp tenderness
32
Q

PAN Hx specifics

A

Hep B risk factors
USually multi system involvement
-e.g. foot drop, abdo pain, chest pain

33
Q

EGPA Hx specifics

A
  • Asthma
  • PEripheral eosinophilia
  • Allergic rhinitis/nasal polyps
  • Eczema
  • Cough and breathlessness
  • PNS - symmetrical PN or mononeuritis multiplex
34
Q

Mixed essential cryoglobulinemia Hx specifics

A

Small vessels due to RF bound to IgG

  • Palpable purpura
  • Raynauds
  • Arthritis
  • Neuropathy
  • Hep C is common
35
Q

Levido reticularis DDx

A 
Cholesterol atheroembolism
APLS
Vasculitis
Atrial myxoma
Bacterial endocarditis
TTP
36
Q

IX for vasculitis

A 
ESR
Renal function - GPA, MPA, PAN
LFTs- usually derranged in GPA and PAN
Urine MCS, casts, RBC morphology
CXR - bilateral diffuse interstial abnormality in GPA, peripheral fluffy patchy infiltrative pattern in EGPA
c-ANCA and anti PR3 antibodies- GPA
p-ANCA - EGPA and consider sural nerve Bx
MPA - p-ANCA and REnal Bx
PAN - Angiography/Bx
37
Q

Tx of GPA

A

High dose steroids
Cyclophosphamide
Bactrim adjunct
Ritux if above fails

38
Q

PAN Mx

A

High dose pred
Cyclophosphamide - 90% go into remission
If associated with Hep B - Interferon alpha or antivrial vidarabine is helpful to lead to remission

39
Q

EGPA MX

A

Steroids alone effective

MAy need other immunosuppression if not

BPT Clinical Exam (11 decks)

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