rheumatol Flashcards
ankylosing spondylitis
chronic inflammatory disease of the axial spine
presents as hip and lumber spine pain in the young
involves spine, sacrum, entithesis, peripheral joints and digits
S+S: progressive spinal stiffness, uveitis, dactylitis.
can also get inflammatory bowel and psoriasis.
pain eased by mvt, worsened by rest + in the morning.
assoc with HLA B27.
RF: FH, male, under 40.
Ix: bloods- CRP, ESR- raised 50-70% of the time.
XRay/ MRI- sacroilitis, squared vertebra, romanus lesions (corner), bamboo sign.
Rx: daily NSAIDS with stomach protection.
if not effective after 2-4 weeks.
adalimumab, certolizumab, infliximib etc are all valid DMARDS to be put on.
bursitis
acute or chronic inflammation of the bursa
leads to thickening, fibrosis, villous formation, chalky deposits.
This may result from repetitive stress, infection, autoimmune disease, or trauma.
S+S: pain and tenderness over bursa, swelling if superficial.
aggravated by repetitive movements
RF: occupational, RA, limb length discrepancy, gout, penetrating injury.
Ix: clinical diagnosis
USS if unsure
Rx: conservative and rest
2’- corticosteroid injection
3’ excision.
if infection
1’ aspirate and antibiotics.
discuss gout
crystal arthropathy- associated with high uric acid levels.
S+S: a single acute hot, swollen and painful joint
- typically MTP, CMC, wrist, knee, ankle.
gouty tophi are typically seen on the hands, elbows and ears
RF: male, FH, fat, high purine diet, alcohol, diuretics, CVS, kidney disease.
Ix: bloods- raised serum urate level.
exclude septic arthritis.
joint aspirate - monosodium urate crystals- needle shaped and NEGATIVELY BIREFRINGENT OF POLARISED LIGHT.
x-ray- maintained joint space, lytic lesions, punched out erosions, sclerotic boarders
rx: flare- NSAIDS,
2’ colchicine
3’ steroids
prophylaxis- allopurinol.- not started until weeks after the attack.- continued through an attack.
lifestyle changes
Calcium Pyrophosphate Deposition Disease
aka pseudogout
calcium pyrophosphate form in blood, settle in joints.
inflammatory attack triggered in the joint.
Rf: age, hyper ca, iron, low mg, thyroid issues.
S+S: severe joint pain, warmth, swelling.
knees most commonly affected, wrists, shoulders, ankles, elbows all can be.
can be assoc with sig chondral damage and chronic arthritis.
Ix: aspiration of joint fluid (r/o septic arthritis) - POSITIVELY BIREFRINGENT RHOMBOID SHAPED CRYSTALS.
xr of joint- some radiopaque deposits in the cart.
Rx: NSAIDS
colchicine (gout med really)
mono + severe- sted injection
poly and severe- oral steds.
de quervains tenosynovitis
irritation and ‘myxoid’ degeneration of the tendon sheaths, leading to tendon pain at the wrist
thickening of the tendon sheath- compression of the tendon- pain.
APL and EPB affected.
Rf: post partum women, manual labour, 40s, 50s.
S+S: radial sided wrist pain, pain on radial deviation, tenderness on palp.
finkelsteins +ve.
Ix: clinical diagnossis
ultrasonogprahy can help.
Rx: self resolve
physio
splinting
antiinflams.
sted injection.
surgery if 2x sted injects dont work.
fibromyalgia
a ‘syndrome’ - widespread pain for at least 3/12. - due to altered pain processing and ‘centralisation’ of pain in the brain.
aetiology not known.
S+S: widespread chronic pain, brain fog, sleep and mood difficulties.
Rf: FH, other rheum stuff, 20-60y/o, female, prev psych trauma.
Ix: clinical diagnosis,
Rx: lifestyle
pain relief
specialist refferal.
osteomyelitis
infection of the bone or bone marrow
gradual onset of symptoms over several days.
S+S: dull pain- non mechanical. redness, warmth, systemic symptoms may also be present.
sometimes in spinal- pain is only symptom.
Ix: bone biopsy, sinus swab
blood culture if systemic symptoms
FBC
imaging.
R: if small, antimicrobials.
if large collections- need draining,
chronic osteomyelitis is mainly surgical
remove any metalwork if around that area.
antibiotic therapy- dependant on sensitivities
but
floclox 2g QDS IV.
2’- VANC.
greater trochanetric bursitis
pain and inflammation around the greater trochanter
Rf: women, 40-60, trauma.
S+S: pain on palpation, antalgic gait, trendelenburg sign, single leg stance.
Ix: clinical diagnosis, USS may aid in diagnosis. xr may rule out stuff.
MRI gold standard
Rx: rest, activity modification, wt loss.
physiotherapy
steroid injection
Inflammatory bowel disease arthropathy
occurs in about half of people with inflam bowel disease.
strongly associated with HLA b-27
generally seronegative asymetric oligoarthritis- affecting large joints
treatment of IBD is usually the optimal course of disease treatment.
attatcks if olido- 10 weeks long or less, and resolve.
Ix: clinical diagnosis
bloods- non specific.
imaging- not essential- but can be used.
Rx:
nsaids
dmards
TNF-a inhibs.
seronegative arthritis
joint pain and evidence of inflammation without a positive rheumatoid factor.
ankylosing spondylitis, psoriatic arthritis, reactive arthritis, enteropathic arthritis, are all included in this umbrella.
hallmarks dactylitis, uveitis, skin changes, nail changes
Ix: good physical exam
bloods- inc inflam, metabolic profile.
CXR- to r/o out any nasties (sacroid, tb)
if CCA +ve but RF not– psoriatic with a worse prog.
Rx: as per individual disease identified.
impingement/ subacromial bursitis
most common source of shouler pain
caused by repetative overhead activities.
S+S: pain in ‘impingement’ arcs, pain lying on that side.
Ix: clinical diagnosis based on history
radiographs bilaterally to evaluate for structural change.
USS to look for bursa etc.
Rx: physiotherapy
nsaids,
can inject steroids if needed.
can do subacromial decompression.
inheritable connective tissue diseases- ehlers danlos syndrome
defective collagen synthesis- ineffective in its functions.
5 main types
skin elasticity
joint hypermobility
vascular type- prone to bruising easily
ocular-kyphoscoliosis type
arthrokalasis type- B/L congen hip dislocation.
S+S: flat feet, poor healing, Gi bleeds, hypotonia, high narrow palate, aneurisms, inc risk of pneumothorax
Ix: clinical diagnosis
Rx: normal life expectancy
minimise trauma risk
extra precautions during surgery- no skin tension on suturing.
inherited connective tissue disorders- marfans
autosomal dominant
mutation in fibrillin-1 gene (cr 15) – decreaces production of extracellular microfibril
this maintains and forms elastic fibres (skin lig bones) to stretch. - deficient in marfans.
S+S:
major signs- long limbs, tall, thin, spindly, thumb extends beyond clenched fist.
upward lens dislocation
pectus deformity (excavatum)
aortic dissection (root stretched)
minor signs: mitral prolapse, high arched palate, hypermobile, knee hyperextension, scoliosis, dec subcut fat.
Rx: incurable
prevent cardiac shenanigans
B blockers
annual echos- 5cm or more dilatation- surgical repair.
discuss both medial and lateral epidoncylitis
a chronic inflammatory condition of the common origins of the tendons
over use syndrome
peak onset 35-54 years old.
medial and lateral can be affected.
RF: repetitive mvt, work, hobbies etc.
S+S: pain rediating into the forearm. pain on palp. reduced grip strength.
cozens and mills test- help with the CLINICAL DIAGNOSIS.
Rx: activity modification, NSAIDS (topical or not)
steroids can help
physio/ orthosis.
debridement of tendon can be done if recalcitrant.
muscles affectes: medial- flexor carpi radialis, pronator teres
lateral: extensor carpi radialis brevis.
raynaulds phenomenon
a vascular condition- arterial vasoconstriction
caused by cold temps or stress.
S+S: numbness, tingling, discolouration- all in digits.
is a syndrome when assoc with connective tissue disease.
its a disease when no other causes.
THUMB is spared usually.
frostbite predisposes to this condition.
Ix: clinical diagnosis
Rx: lifestyle- stop smoking
keep warm
avoid B blockers.
can cive CCB, prostcyclin, nifedipine.
can lead to gangrene/ ulcers.
