Rheum / MSK Flashcards
Osteoporosis risk factors
SHATTERED Family
Steroid use >5mg/day prednisolone
Hyperthyroidism; hyperparathyroidism, hypercalciuria
Alcohol and tobacco use
Thin (BMI <22)
Testosterone low (e.g. anti androgen in cancer of prostate)
Early menopause
Renal or liver failure
Erosive/inflammatory bone disease (e.g. RA or myeloma)
Dietary Ca low/malabsorption or Diabetes mellitus type 1
Family history
Back pain history
SOCRATES
Early morning
Red flags
- Feel when wiping
- Urinary retention / incontinence
- Bowel incontinence
- Pain + weakness in legs
Weight loss
Bowel habit
Trauma - even minor falls
OP risk factors
Band like pain round chest or abdo
Infective - Fevers / Night sweats
Social
Alcohol
Smoking
IVDU
PMH
HIV
Immunosupression
Diabetes
Previous back surgery
DH
- Steroids
- Immunosupressives
- Any NSAIDs - important for Ank spond
FH
IBD
Psoriatis
Social
How affecting function and work
Smoking - especially for inflam back pains
Ank spond additional features to ask about
All the other seroneg arthritis (cross over HLA B27)
Skin rash - psoriasis
IBD / bowel symptoms
Recent infection / STI
Anterior uveitis
Enthesitis - Achillies / golfers / tennis elbow / plantar fasciitis
SOBOE
Pain ful red eyes
Frothy urine
pain achilies
AAAAAAs of ank spond
- Anterior uveitis
- Aortitis -> Aortic regurg
- AV block (fibrosis of conduction system)
- Apical pulm fibrosis and reduced chest expansion
- AA Amyloidosis - Nephrotic syndrome
- IgA nephopathy
- Achilles tendonitis + enthesitis eg plantar fasciitis, tennis elbow
Which are the segregative arthritis
HLA B27
Psoriatic arthritis
Enteropathic - IBD
Ank spond
Reactive arthritis
Score for symotoms in Ank Spond
BASDI score
Bath Ank Spond disability index score
Main breathing issue in Ank Spond
Restrictive breathing defect
Exam of inflam back pain eg ank spond? What other bits might you examine?
Hands nail pitting
Squeeze of joints
Spinal movements
Forward / back / side / twist
Schobers test
Spinal palpation
Precuss spine
Listen to heart and lungs
Chest expansion
Hip flexion / extension
How do you do schobers test
Draw a line between dimples
Draw line 10cm above and 5cm below
then bend foward and measure lumbar spine movement
Should increase >10cm
If <5 likely pathological;
5-10cm intermediate
Ank spond Ix
Bedside
* ECG - AV block
* Renal dip - protein -> ACR
Bloods
* FBC / CRP
* Consider HLAB27
* If peripheral arthopathy - CCP / ANA / RF
Imaging
- XR sacroiliac joints
- MRI more sensitive but less specific
- CXR - fibrosis / failure
Management of Ank spond
Physio stretching
Education
NSAIDS x2 -> Anti-TNFa
If peripheral disease - DMARDS eg methotrexate / sulphasalazine
Discitis key risks
IVDU
Immunosuppressed
TB - ever treatment or from endemic area
Brucella - Mild / unpasterised cheese
- Farmers / vets (vets as aerosol from placenta high risk)
Myotonic dystrophy inheritence? what is it? Gene?
Autosomal dominant
-> Muscle weakness and myotonia (Inability of a contracted muscle to relax )
Type 1 - CTG repeat with anticipation
Type 2 - different gene, less anticipation more proximal weakness
What is myotonia
Inability of a contracted muscle to relax
Myotonic dystrophy exam CNs? Limbs? Extra bits?
Frontal balding
Bilateral and symmetrical ptosis
Facial muscle weakness
Cataracts
CN exam
-Eye movements usually normal
-Muscles of face tend to be wasted and weak
-Test for myotonia - ask patient to hold eyes tight shut for 10 seconds and they will struggle to re open
- Speech tends to be dysarthria
- Ask about swallowing
Fundoscopy to assess for cataracts
Test visual acuity
Limbs
Tone tends to be reduced
Distal weakness eg footdrop
Ask to grip hand for 5 seconds tight then relax- if myotonia they will struggle
Precussion myotonia - tap thenar eminence -> involuntary thumb flexion
Additionals
Cataracts
Heart -
- Pulse for rate and rhythm - I would like an ECG
- Check for PPM / ICD
Endocrine
- Check for diabetic fingerprick marks
- Check for gynaecomastia
- State would perform scrotal exam for hypoplasia
Myotonic dystrophy differentials of ptosis? Myotonia?
If ptosis unilateral
-> CN III palsy / Horner’s syndrome
Bilateral ptosis
- Myaesthenia / congenital ptosis / senile
Myotonic
Mytonic congenita
Hypokalaemic periodic paralysis
Investigations myotonic dystrophy
Bloods
CK
Special
- EMG - ‘dive bomber’ poentials
Genetic testing - gold standard
- DMPK gene for type 1 (CTG repeat) and the CNBP gene for type 2
Complications
* Pulm function for neuromuscular insufficiency
* Cardio complications (conduction block / cardiomyopathy) - ECG + ECHO
* Overnight pulse oximetry / sleep studies
* Screen Thyroid function / diabetes / testosterone
* Visual testing - ref to opthal if cataract
Management of myotonic dystrophy
No cure - MDT conservative
SLT / dietetics
Physiotherapy
Genetic counselling - 50% risk of kids
Palliative care if deteriorating - life expectancy around mid 50s
Annual review
- Test visual function for cataracts
- ECG if abnormal for cardio / PPM if heart block
- OSA
- Evidence of respiratory faiure
- Evidence of diabetes
Drugs
Phenyton / Mexiletine (Na channel blocker) for management of myotonia
Rheum Arthritis painful hands history
Tell me a bit more about it
Early morning stiffness > 1 hour each morning
Duration of symptoms (≥ 6 months)
Pattern of joint involvement (symmetrical / asymmetric, small joint / large joint, oligo/polyarthritis)
expect small joint symmetrical
Constitutional symptoms
-Fever
-Malaise
-Lymphadenopathy
Extra-articular manifestations
Episcleritis (painless) and scleritis
- Have you ever noticed that your eyes are red?
- Have you ever had pain in your eyes?
Interstitial lung disease
-Do you feel breathless when you walk?
- Have you had a cough which has not gone away?
** Rheumatoid nodules
- Have you noticed any unusual bumps on your skin?
** Raynaud’s phenomenon
- Have you noticed your hands changing colour in the cold?
Glomerulonephritis
- Have you ever noticed blood in your urine?
Systemic vasculitis
- Have you noticed any rashes anywhere on your body?
- Have you noticed any unusual bruises on your body?
- Any skin ulcers?
Mononeuritis / polyneuropathy
- Have you noticed any tingling in your hands or feet?
- Have you noticed any weakness in your hands or feet?
Rule out other disorders
Connective tissue disease
- Systemic lupus erythematosus – mouth ulcers, alopecia
- Mixed connective tissue disease – tightening of skin over digits
Arthritides
- Psoriatic arthritis – itchy plaques on extensors
- Polyarticular gout – asymmetric involvement, precipitants (meat, alcohol, diuretics)
- Osteoarthritis – gets better with activity
- Enteropathic arthritis Change in bowel habit
Screen for complications
[Rhem SOFAA]
Secondary amyloidosis
– nephrotic syndrome
Osteoporosis
- Have you ever fractured a bone?
- How did this happen?
Felty’s syndrome (neutropaenia, splenomegaly + RA, usually > 20 years)
- Have you noticed any fullness in your tummy?
- Do you feel you are getting the flu more often than usual?
Atlanto-axial subluxation
- Is there any pain at the back of the head or neck?
- Have you ever experienced the room spinning around you?
Anaemia
- Do you feel tired?
- Do you get any chest pain or short of breath when you walk?
Carpal tunnel syndrome
- Do you notice any tingling in your thumb or index finger?
- Do you have any problems using your thumb?
Functional status
- How is this affecting your life?
- Make sure you ADDRESS CONCERNS
- Are you able to do things like unlock a door with a key or uncap a bottled drink?
- Do you have any difficulty with buttons?
Social history
- Smoking - makes much worse
- Alcohol - consider gout
DH
- Tried any thing to help?
- Gp prescribed anything?
Familty historu
- Any inflammatory conditions / arthritis
Common drugs used for Rheum A and thier main complications? Best for pregnancy?
Steroids – exogenous Cushing’s, osteoporosis, cataracts, weight gain
Methotrexate – pulmonary fibrosis, marrow suppression
Sulphasalazine – rash, funny coloured secretions eg eye / urine…
- Best for pregnancy
Hydroxychloroquine – retinitis, need screening within 6 months
Leflunomide - Hangs in body for 2 years -> may need to have cholestryramine washout if pregnant
Biologics – opportunistic infections
AntiTNFa - inflix, adalib, etaercept
AntiCD20- Rituxumab
Anti-IL6 - Toculizumab
Some METH SUccers Hyde LEFtover Biftas
hEYEdroxycloroquine
Difference in joints affected in hand of psoriatic vs rheum arthritis
Rhem more MCP and PIP
Psoriatic more DIP
Rheum patient presents with breathlessness. Key things to screen in history?
Extra articular pulm fibrosis
Methotrexate therapy
Anaemia
- Chronic disease
- NSAIDs / GI symotoms
Infection
Immunosupressed
- Felty syndrome
- Medication related
Lymphoma
- Fever weight loss night sweats
Rheumatoid hand exam? What else would you examine if time permits?
Ask if any particular pain first
Inspection:
- Vasculitic lesions
- Nail fold infarcts
- Wasting of the small muscles of the hand
- Swollen joints and their distribution
- Symmetry
- Deformities of rheumatoid hand:
- Rheumatoid nodules (usually over extensor surfaces of elbow and finger joints)
- Scars suggesting previous decompression of carpal tunnel / tendon release
- Look for active synovitis
- Ulnar deviation at MCP / swan neck / Boutonnier
Palpate
- Ask if any joints are painful again
- Examine each small joint of the hand, then the other joints in turn
Function
Power
- Make a fist
- Squeeze my fingers as tight as possible
- Make a ring with index and thumb and then I do same and pull
Function
- Do up a button
- Write with a pen
- Prayer sign / reverse prayer sign
- Put your hands behind your head
Extra-articular manifestations
- Look at eyes for scleritis / episcleritis
- Listen for fine basal crepitations of interstitial lung disease
- Listen for aortic regurgitation
Complications
- Conjunctival pallor
- Test forward flexion and extension of the cervical spine
- Look for evidence of exogenous Cushing’s
- Check for cataracts secondary to steroid use
- Tinnel’s test for carpal tunnel syndrome
What are the deformities seen in rheumatoid hand
Swan neck deformity: hyperextension of PIPJ with flexion at DIPJ and MCPJ
Boutonnier’s deformity: flexion at PIPJ with hyperextension of DIPJ and MCPJ
Z deformity of thumb: hyperextension of IPJ, fixed flexion and subluxation of MCPJ
Ulnar deviation of fingers
Subluxation of MCPJ
Rhem differentials
Small joint symmetrical polyarthritis
- Rheum most likely
Seronegative
- Psoriatic, more likely DIP + nail changes
- Enteropathic - GI symptoms / mount ulcers usually affects a larger joints
- Reactive - Eye signs, urethitis (though 50% dont get symptoms
- Ank spond - Alternating buttock pain
- Gout - especially big toe and tophi
- Calciumpyrophospate deposition
Osteoarthitiis
- Especially if lack of inflammatory symptoms
Rheum Athritis investigations
FBC
- Anaemia
- Raised platelets (inflammation)
- Neutropenia eg felty
ESR / CRP
- U&E / LFTs - drugs
- Rheumatoid factor + Anti-CCP (disease progression)
- Consider ANA / ANCA especially if rash on face / connective disease symptoms
- Consider HLA B27 if history unclear
Protein Dip / Albumin creatinine ratio
Plain XRs of hands and feet as baseline
- May affect how aggressive treatment if erosions
Rheumatoid factor is what
IgM antibody to FC portion of IgG
-Not specific, and actually more prevelant in sjorgrens syndrome
though it does correlate with progression
Management of Rheumatoid? How to monitor symptoms?
Disease Activity Score for symptoms to help direct management / response to treatment
MDT from begining
- Physio for joint function
- OT (50% not in same job at 2 years)
- Scoring systems
- Patient groups / support groups
Medications
- Usually trial of NSAIDs + PPI / paracetamol
- Steroids especially if symptoms for 3 months already
DMARDS
- Methotrexate (or sulphasalazine) first line usually + folic acid
- Anti-TNFa
Patient treated for rheum A comes in after treatment for UTI completely run down ….
Given trimethropim and on methotrexate -> myelosupression
DMARD best for preg and breast feeding in rheum A
Sulphasalazine
Biologics in Rheum? screening?
Anti- TNF
- Etanercept, Adalidumab, Infliximab
- Screening for TB / BBV / varicella
- High risk for infection
- Keep vaccines eg flu / pneumococcus updated
Anti CD20
- Rituxumab
Anti - IL6
- Toculizamab
Duchenne vs becker vs myotonic dystrophy
Gene?
Symptoms?
Diagnosis?
Complications
Duchenne vs becker vs myotonic dystrophy
Gene?
Symptoms?
Diagnosis?
Complications
