Rheumatology Flashcards
Causes of dupuytrens?
Familial, idiopathic, liver disease, diabetes
How would you assess function in a patient with suspected RA?
Squeeze my fingers
Write a word
Pick up a coin
Investigations in RA?
RF, Anti-CCP, ANA, inflammatory markers, immunoglobulins
XRs of Chest, hands and feet
Radiological changes in RA? (4)
Soft tissue swelling
Loss of joint space
Articular erosions (associated with worse prognosis)
Periarticular osteoporosis
How would you treat a patient with rheumatoid arthritis?
Steroids for acute flare.
DMARDS- methotrexate (with folic acid) , hydroxycloroquine, sulfasalazine, luflonamide.
Main side effects of methotrexate (3)
Fibrosis, hepatitis and neutropenia
WH during infection
Name 2 ophthalmological complication of RA?
Dry eyes
Scleritis
Cardiac complications of RA?
Pericarditis
Serious side effect of hydroxychloroquine?
Retinopathy- should see optician every year.
Clinical examination findings in pseudoxanthoma elastic? (4)
Plucked chicken skin appearance in neck axillae
Blue sclerae
HTN (premature coronary artery disease)
Mitral valve prolapse
Presenting problems in Pseudoxanthoma elasticum?
Hyperextensible joints Reduced acuity HTN MI or CVA Gastric bleed
Where are the degenerative elastic fibres generally found in pseudoxanthoma elasticum?
Skin
Vessels
Eyes
Cause of Ehlos Danlos?
Defect in collagen causing increased skin elasticity?
Cardiac complications of Ehlos Danlos?
Mitral valve prolapse
Examination finds in Ehlos Danlos on inspection?
Fragile skin (bruising) Hyperextendible skin (tents when pulled- don't do) Joint hyper mobility and dislocation (scars from joint repair/replacement)
Inheritance of Ehlos Danlos?
AD
Most common conditions associated with Raynauds?
Scleroderma
SLE
In a patient with suspected CTD, what should you examine for? (systematic)
Hands- Raynauds and small joint inflammation (with stiffness), Jaccouds arthropathy.
Arms- discoid rash +/- scarring
Face- photosensitive rashes, hair loss, scleritis/dry eyes, ulcers in mouth.
Neck- difficulty swallowing
Chest
In a patient with suspected CTD, what should you examine for/ ask about in hands and arms? (systematic)
Hands- Raynauds and small joint inflammation (with stiffness+/- destruction), Jaccouds arthropathy (SLE)
Arms- discoid rash +/- scarring/scaling
Face symptoms in suspected CLD?
Face- photosensitive rashes, hair loss, scleritis/dry eyes, ulcers in mouth.
Neck- difficulty swallowing
Respiratory associations with SLE?
Pleural effusion Fibrosing alveolitis (ILD)
Neurological associations with SLE?
Ataxia
Chorea
Screening for lupus nephritis?
Urine ACR
BP
Diagnostic investigations in SLE?
ANA and anti-dsDNA
Investigations to look for disease activity in SLE?
Inflammatory markers and elevated immunoglobulins.
Reduced complements.
Full list of investigations in suspected CTD?
ANA, dsDNA, inflammatory markers, anti-phospholipid, complements, urine dip
Management in cutaneous/joint SLE?
Topical steroids
Hydroxychloroquine
Treatment of moderate SLE?
Pred and Aza
Treatment of severe SLE?
Methylpred, mycophenylate (lupus nephritis), cyclophosphamide.
Serious side effects of cyclophosphamide? HHIT
Haemorrhagic cystitis
Haematological
Infertiluty
Teratogenicity
Common causes of proximal myopathy?
Dermatomyositis
Thyroid dysfunction
Cushings
Complications associated with ankylosing spondylitis? (5)
Anterior uveitis Aortic regurgitation AV heart block- look for PPM Apical fibrosis Arthritis (may be psoriatic arthropathy)
What the bedside tests could you do in Ank Spond except Schobers?
Increased occiput-wall distance. >2cm is abnormal
Treatments for ankylosing spondylitis.
Physiotherapy
Analgesia
Anti-TNF - ertanacept/infliximab/adulimumab
Associations in gout/
Obesity HTN CKD Urate stones/nephropathy Lymphoproliferative disorders
Investigations in gout?
Bloods including urate (unreliable)
Joint aspiration to rule out infection and look for needle shaped negatively birefringent crystals
Treatment of acute attack of gout?
Treat cause
Increase hydration
High dose NSAIDs
Colchicine
Classical XR appearance of gout
Punched out periarticular changes
Where do you usually see OA changes in the hand?
Interphalangeal joints with Heberdens nodes (and sometimes Bouchards at the PIP)
XR features in OA?
Loss of joint space, osteophytes, peri-articular sclerosis and cysts
Treatment of OA? (4)
Physio
Analgesia
Joint replacements
Weight reduction (if affecting weight bearing joint)
Difference between Raynauds disease and Raynauds phenomenon
Raynauds disease is idiopathic
Raynauds phenomenon is associated with underlying CTD
What would you see in the hands in systemic sclerosis?
Sclerodactyl- prayer sign
Calcinosis
Raynauds
Should assess function- holding a cup or pen
What would you see in the face of someone with scleroderma?
Tight skin Beaked nose Microstomia Perioral furrowing Alopecia Telangiectasia
Name the respiratory and cardiac complications of scleroderma?
Hypertension
Pericarditis
Pulmonary HTN
Interstitial fibrosis (basal)
What does CREST stand for?
Calcinosis Raynauds (o)Esophageal dysmotility Sclerodactyl Teleangiectasia
What investigations would you do in scleroderma?
ANA (+ve in 90%), anti-centromere (limited), scl-70 (diffuse)
Hand XRs calcinosis
To look for respiratory complications: CXR, HRCT, spirometry
Too look for GI disease- contrast scans, FBC and folate
Renal disease, U&Es, urinalysis, microscopy and renal biopsy
Cardiac disease: ECG and echo
What would you see in the face of someone with Marfans?
High arched palate with crowded teeth
Iridonesis with upward lens dislocation
What signs of Marfans might there be in the thorax?
Pectus carinatum or excavatum
Scoliosis
Scars from previous cardiac surgery of chest drains (PTX)
What are the common cardiac complications of Marfans?
Aortic regurgitation (may have metallic valve)
Mitral valve prolapse
Co-arctation
Aortic dissection
What is the inheritance of Marfans syndrome?
Autosomal dominant on chromosome 15. Defect in the fibrilin protein
Describe the management of a patient with Marfans?
Surveillance of aortic root size with annual TTE
Beta blockers and ARBs to slow aortic root dilatation and pre-emptive aortic root surgery to present dissection and aortic rupture.
Screening of family members.
Investigations and treatment of GCA?
Bloods including ESR and CRP. ESR >80 highly specific as are platelets >400. (ideally take bloods prior to starting steroids)
Temporal artery USS +/- biopsy if cranial features.
PET-CT if non cranial features.
Start 40-60mg Pred (+PPI)
If visual symptoms refer to ophthalmology on same day. If no visual symptoms refer to Rheum to be seen in 1-3 days.
Investigations in suspected PMR?
FBC, CRP, ESR, LFTS, RF, Anti CCP, CK, TFT, Vitamin D
Which DMARDs are considered safe in pregnancy?
Sulfasalazine and hydroxychloroquine although you should avoid sulfasalazine in men TTC as it affects sperm.
How would you offer to measure RA disease activity?
DAS 28
How can you distinguish between psoriatic arthritis and rheumatoid arthritis?
DIPs spared in RA and involved in PA.
Dactylitis in PA.
Typically causes enthesitis (ligaments) in PA but tenosynovitis in RA)
What are typical hand XR findings in Psoriatic arthritis?
Pencil in cup deformity.
How would you manage psoriatic arthritis?
NSAIDs or COX-2 inh if mono or oligoarthritis or spondyloarthropathy.
In multiple joints affective then DMARDs.
How is Ank Spond managed?
NSAIDs or Cox-2 and physio. Biologics if no response.
Steroids and DMARDs not usually effective in spondyloarthropathy.
Common causes of reactive arthritis?
GI- salmonella, shigella, campylobacter
GU- chlamydia
Treatment of reactive arthritis?
NSAIDs and steroids if refractory. If recurrent synovitis then start on DMARDs.
In what level of renal impairment would you avoid NSAIDs? When would you avoid colchicine?
eGFR <50 avoid NSAIDs and reduce colchicine to 500mg OD
eGFR <10 avoid colchicine and give prednisolone.
What is found on joint aspiration in pseudo gout?
Positively birefringent rhomboid crystals.
How might Pagets disease present?
Asymptomatic
Bone pain
Deafness
Treatment of Pagets disease?
Analgesia
Hearing aids in deafness
Bisphosphanates
When are biologics (anti-TNF) indicated in Ank Spond
When failed two NSAIDs taken for at least 4 weeks and as indicated by the BAS-DAI score
What investigations would you do in suspected ank spond?
Baseline bloods including CRP/ESR
Consider HLA B27 (positive in 90%)
XR lumbar spine and pelvis. If normal consider MRI
Urine dip (IgA nephropathy and amyloidosis) and ECG (AV conduction block)
What are the clinical features and signs of osteogenesis imperfecta?
Features: deafness, joint problems, dental problems, bruising and fragile skin, aortic dissection
Signs: blue sclera, hyper mobile joints, scoliosis
Diagnosis of osteogenesis imperfecta?
Clinical and FH (AD). Gene testing may support the diagnosis but not all genes have been identified.
Management of osteogenesis imperfecta?
Good diet and stopping smoking to maintain bone health.
Bisphosphanates.
MDT approach: OT/Physio/podiatry/geneticist
Cardiology follow up re aortic root dilatation
How would you examine a patient with suspected ankylosis getting spondylitis?
Examine back- look for scoliosis, examine all back movements, examine for spinal tenderness. Occipital- wall and schobers.
Look at eyes Listen to heart and do collapsing pulse Listen for apical fibrosis Look for psoriasis Other arthropathy
