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MBBS IV - CCT Preparation > Rheumatology > Flashcards

Rheumatology Flashcards

1
Q

Common causes of monoarthritis, oligo-arthritis and polyarthritis

A

Mono - Gouty or septic arthritis

Oligo (under 4) - Spondyloarthritis (e.g. Ankylosing spondylitis) and Enteropathic arthritides

Poly (>5 joints) - RA, SLE

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2
Q

Joints involved in spondyloarthritis

A

Axial joints and peripheral joints

Back pain and dactylitis

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3
Q

Sequence of hand examination

A

Ask questions about getting dressed, showering, working in kitchen

Ask patient to move hands/ joints in all directions - assess range of active movement

Palpate for joint tenderness, signs of inflammation

Palpate for any crepitation in joints casued by joint effusion

Test for grip strength by squeezing

Define all deformities: valgus/varus/ ulnar/ radial …etc

Look for extra-articular features:

  • Episcleritis, nodules, vasculitis for RA
  • Skin and nail lesions for psoriasis
  • Iritis, mucocutaneous lesions and cardiac complications in ankylosing spondylitis
  • Tophus deposition in gout
  • Septic vesicular lesions in gonococcal arthritis
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4
Q

Locations of small vessel vasculitis?

A

Ulnar aspect of elbows
Nail fold, bed and edge
Lower limbs
Fundi

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5
Q

Define Raynaud’s phenomenon

A

Raynaud’s phenomenon is a problem that causes

decreased blood flow to the fingers, ears, toes, nipples, knees, or nose due to spasms of blood vessels in those areas

Fingers that turn pale or white then blue when exposed to cold, or during stress or emotional upset

Hands that may become red, swollen and painful when warmed

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6
Q

Interpret:

Liliac/ purple rash around the eyes and face
Puffiness around eyes
Redness around neck at sun-exposed areas
Scaly, red, violaceous rash on the MCP and PIP joints
Raynaud’s phenomenon
+/- muscle tenderness
Finger tip black and scaly

What other peripheral signs?

A

Dermatomyositis

Liliac/ purple rash around the eyes and face - HELIOTROPIC RASH
Puffiness around eyes - PERIORBITAL EDEMA
Redness around neck at sun-exposed areas - PHOTOSENSITIVE RASH
Scaly, red, violaceous rash on the MCP and PIP joints - GOTTRON’S PATCHES
Raynaud’s phenomenon
+/- muscle tenderness
Finger tip black and scaly - DIGITAL VASCULITIS

Cardiac arrhythmia
Aspiration pneumonia and pulmonary fibrosis
Proximal muscle weakness***

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7
Q

Causes of dermatomyositis

A

Majority idiopathic
Juvenile or adult onset

Asso. with underlying connective tissue disorder
Asso. with malignancy, esp. NPC

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8
Q

D/dx of polymyositis without skin lesions

A

Drug and toxin induced myopathies (e.g. statins)

Rhabdomyolysis

Metabolic myopathies (hyper or hypothyroidism, acromegaly)

Infective myositis

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9
Q

Investigations for dermatomyositis

A

Creatinine kinase, Aspartate transaminase, LDH

Electromyography

MRscles

Anti-nuclear Ab, Anti-MDA Ab, Anti-Jo-1 Ab

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10
Q

Interpret:

Uremic features
Nodules on ear lobe, interphalangeal and metatarsophalangeal joints
Large first MTP joint nodule with signs of inflammation

Dx?
Causes?

A

Gouty arthritis

Under-secretion of uric acid: primary or secondary to drugs (diuretics, pyrazinamide)

Over production of uric acid: primary or secondary to excessive dietary intake, alcohol use or lymphoproliferative diseases, psoriasis, cytotoxic drugs

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11
Q

Ddx of gouty tophi

A

Rheumatoid nodule: also found at extensor surfaces, firmer, more discrete and smaller

Xanthomata: over large tendons e.g. Achilles’ tendon

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12
Q

Ddx for acute arthritis

A

Septic arthritis

Traumatic arthritis

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13
Q

Tests for gouty arthritis

A

Uric acid, renal function, CBC

Joint fluid: cell count, culture, microscopy: birefringent uric acid needle- shaped crystals**, increased WBC counts

X-ray: soft tissue swelling, erosive lesions if chronic

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14
Q

Precipitating factors of gout

A

Trauma
Dietary excess
Alcohol
Starvation

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15
Q

Interpret:

bony articular nodules at PIP and DIP, firm, no signs of inflammation
Tender on palpation
Limited ROM
Knee crepitation

Dx?
Causes?
Typical joints affected

A

Nodal OA

Idiopathic, associated with aging and chronic use of joints

CMC, MTP, Knee, cervical and lumbar spine, DIP, PIP

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16
Q

Ddx of nodal OA?

A

Rheumatoid arthritis: spares DIP, mainly MCP, symmetrical and inflammatory

Spondyloarthritis e.g. psoriatic arthritis: Inflammatory signs, nail changes, skin changes

17
Q

Interpret:

Cutaneous, silvery areas at extensor surfaces of limbs, scalp, umbilicus and lower back
Pitting nails
Signs of inflammation and pain at isolated joints, not symmetrical

Additional signs?

Dx?
Typical joints affected?

A

Psoriatic arthritis

Tendonitis
Uveitis
Dactylitis

Psoriatic arthritis

  • 5% spinal disease
  • 10% DIP disease
  • 35% symmetrical/ asymmetrical polyarthritis
  • 50% Asymmetrical oligoarthritic
18
Q

Causes of psoriatic arthritis

A

Familial predisposition

Up to 75% with HLA-B27 positive

19
Q

Ddx of psoriatic arthritis?

A

Rheumatoid arthritis: symmetrical polyarthritis

Ankylosing spondylitis with sacroilliitis

Inflammatory bowel disease associated arthritis

20
Q

Interpret:

Smooth, shiny and tight skin on face and hands
Raynaud’s phenomenon +ve
Finger ulcers
Flexion contracture

Additional classical signs?

Dx?
Ddx?

A

Scleroderma

Reduced oral aperture 
Associated pulmonary fibrosis 
Arthritis 
Beaked nose 
Sclerodactyly

Systemic sclerosis with overlapping symptoms

21
Q

Describe Raynaud’s phenomenon

Causes?

A

Triphasic color changes:
ischemia in white
Cyanosisi in blue
reactive hyperthermia for red

Scleroderma 
Dermatomyositis 
Polymyositis 
Atherosclerosis 
Buerger's disease
22
Q

Tests for scleroderma

A

Anti-nuclear Ab
Anti- Scl 70 Ab
Chest X-ray with pulmonary fibrosis
Lung function test with restrictive pattern
Barium swallow with esophageal immobility

23
Q

What causes finger ulceration in Scleroderma

Which joints are typically infected in systemic sclerosis

A

Severe Raynaud’s phenomenon causes digital ulceration
Infection possible

Systemic sclerosis: affecting joints distal to MCP only

24
Q

Interpret:

Dry eyes with gritty/ sand sensation 
Dry mouth with complications 
MCP and PIP joints inflammation 
Lymphadenopathy 
Raynaud's phenomenon 
Gland swelling

Which oral complications and what is the name of the classical dry mouth sign?
Which glands swell?
Dx?

A

Sjogren syndrome

Cracker sign + dental carries, peri-odontitis and oral candidiasis

Parotid and submandibular gland swelling

25
Q

Ddx of Sjogren syndrome

A

Lymphoma
Amyloidosis
Parotid tumor: Adenoid cystic or pleomorphic adenoma

26
Q

Tests for dry eyes in Sjgoren syndrome + 3 lab tests

A

Schirmer’s test for dry eyes

Serum electrolyte: Secondary renal tubular acidosis causing hypoK
Immune markers: Anti-nuclear Ab, Anti-Ro and Anti-La
Salivary gland biopsy

27
Q

Interpret:

Polyarthritis in hands and hip 
Malar rash 
Tired-looking 
Cutaneous vasculitic lesions on both palms 
Pleural rub

Most likely Dx?
What other systemic involvements?

A

SLE

Lupus nephritis
Lupus serositis causing chest pain
Anemia and thrombocytopenia

28
Q

Hand deformities in RA

A

Bilateral ulnar deviation of Metacarpophalangeal joints
Swan neck deviation/ Z-shape deformity of index and little finger
Thenar and intrinsic hand muscle wasting

29
Q

Systemic complications of long-standing RA

A

MSS: tendon rupture, joint deformities, septic arthritis

Lung: pleural effusion, nodules and fibrosing alveolitis

Pericarditis

Keratoconjunctivitis

Splenomegaly, anemia, amyloidosis

Neurological: mononeuritis, entrapment neuropathies e.g. CTS

30
Q

Features seen in RA patients with long term immunosuppression

A

Steroids:

Cushingoid features: Acne, Hirsutism, Buffalo hump, central obesity

Diabetes, Hypertension, cataracts, glaucoma

Increase susceptibility to infections

Gastric ulcers

Osteoporosis, avascular necrosis of hip joint

MBBS IV - CCT Preparation (10 decks)

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