Rheumatology Flashcards
How does ankylosing spondylitis present?
it present in late teens, symptoms develop over 3 months. There is lower back and sacroiliac pain, stiffness, worse and night and in the morning and wakes the pt up from sleep. It improves with movement and there are flares and potential vertebral fractures
What are the signs of ankylosing spondylitis?
weight loss, fatigue, chest pain, plantar fasciitis, enthesitis, achilles tendonitis, dactylitis, anaemia, anterior uveitis, heart block, aortitis, restrictive lung disease, pulmonary fibrosis and IBD
how is ankylosing spondylitis investigated?
Schoeber’s test
inflammatory markers
HLA B27
XR spine
MRI
what are the findings on XR and MRI for AS?
XR - squaring of vertebral bodies, subchondral sclerosis and erosions, syndesmophytes, ossification, fusion of facet
MRI - bone marrow oedema
how is AS managed?
NSAIDs, steroids, anti TNF, monoclonal ABs, physio, exercise, avoid smoking, bisphosphonates, complication treatment, surgery for deformities
what are the risk factors for osteoarthritis?
female, FHx, trauma, age, obesity, occupation
what is the pathophysiology for OA?
imbalance between cartilage wear and repair from chondrocytes
how is OA diagnosed?
> 45 with pain related to activity, no or little morning stiffness and XR (loss of joint space, osteophytes, subchondral sclerosis, subchondral cysts)
how does OA present?
joint pain and stiffness that is worse with activity - deformity, instability, decreased function, Herberden’s and Bouchard’s nodes, weak grip, reduced ROM, squarring of base of thumb
how is OA managed?
patient education, weight loss, physio, occupational therapy, orthotics, analgesia, PPI, opiates, IA steroids, joint replacement
what is psoriatic arthritis?
it is an inflammatory arthritis that is associated with psoriasis, and is a seronegative spondyloarthropathy
how does psoriatic arthritis present?
psoriatic plaques, sacroiliitis, back stiffness, nail pitting and oncholysis, dactylitis, enthesitis, eye disease, aortitis, amyloidosis
how is psoriatic arthritis investigated?
PEST tool to screen, XR - periostitis, ankylosis, osteolysis, dactylitis, pencil in cup appearance
what is a complication of psoriatic arthritis?
arthritis mutilans - severe - progressive digit shortening and telescopic fingers
how is psoriatic arthritis managed?
NSAIDs, DMARDs, antiTNF, usekinumab
what is reactive arthritis?
synovitis due to infection - warm, swollen, painful joint
bilateral conjunctivits, anterior uveitis, circinate balanitis
how is reactive arthritis investigated?
r/o septic
genetic - HLAB27
how is reactive arthritis managed?
aspirate, gram stain, culture and sensitivities, crystal exam, NSAIDS, steroids, DMARDs, antiTNF
how does rheumatoid arthritis present?
symmetrical distal polyarthropathy, pain, swelling, stiffness, fatigue, weight loss, flu like, weakness, Z shaped thumb, swan neck and Boutonierres, ulnar deviation, PF, Felty’s, secondary sjorgen’s, bronchiolitis obliterans, anaemia, CV disease, Rheumatoid nodules, CTS, amyloidosis, lymphadenopathy
how is rheumatoid arthritis investigated?
clinical, RF, antiCCP, CRP, ESR, XR (joint destruction and deformity, soft tissue swelling, periarticular osteopenia, boney erosions)
how is rheumatoid arthritis managed?
steroids, NSAIDs, COX-2i, PPIs, methotrexate, biologics, surgery
what is SLE?
it is an inflammatory autoimmune connective tissue disease due to chronic inflammation - relapsing and remitting
how does SLE present?
fatigue, weight loss, arthralgia, myalgia, fever, photosensitive malar rash, lymphadenopathy, splenomegaly, SOB, pleuritic chest pain, mouth ulcers, hair loss, Raynaud’s
how is SLE investigated?
autoantibodies, FBC, C3 and 4, CRP, ESR, Igs, urinalysis and urine protein creatinine ratio, renal biopsy
what are some complications of SLE?
CV disease, infection, anaemia, decreased WCC and platelets, lupus nephritis, neuropsychatric, recurrent miscarriage, preterm birth etc
how is SLE managed?
NSAIDs and steroids, hydroxychloroquine, immunosuppressants, biologics
what is systemic sclerosis?
it is an autoimmune inflammatory and fibrotic connective tissue disease with limited or diffuse pattern
how does systemic sclerosis present?
hard, shiny, tight skin, decreased ROM, ulceration, telangiectasia, calcinosis, Raynauds, swallowing difficulty, acid reflux, oesophagitis, SOB, renal failure, dry cough, HTN
how is systemic sclerosis investigated?
nailfold capillaroscopy, autoantibodies (ANA, anticentromere, antiSCl70)
how is systemic sclerosis managed?
avoid smoking, cold, occupation and physiotherapy, gently skin stretching and emollients
immunosuppressants and steroids, PPIs, promotilities, analgesia, ABx, anti HTN, supportive
how does polymyalgia rheumatica present?
bilateral shoulder pain radiating to the elbows, pelvic girdle pain, worse with movement and interferes with sleep, stiffness in morning, low mood, loss of weight, fatigue, fever, pitting oedema, upper arm tenderness, CTS
how is PR investigated?
clinical and response to steroids, inflammatory markers, bloods, serum protein electrophoresis, urine
how is PR managed?
prednisolone, and wean off slowly
bisphosponates, vit D, Ca, PPI
how does giant cell arteritis present?
severe unilateral headache, scalp tenderness, jaw claudication, visual changes, painless sight loss, fever, muscle aches, weight loss, fatigue, peripheral oedema, loss of appetite
how is GCA diagnosed?
clinical, ESR >50, TA biopsy, FBC, LFTs, increased CRP, USS
how is GCA managed?
steroids, aspirin, PPI, vascular surgery
what is poly and dermatomyositis?
inflammation in the muscles (and skin)
how do poly/dermatomyositis present?
muscle pain, fatigue, weakness, shoulder and pelvic girdle, gottron lesions, photosensitive erythematous rash, purple rash, periorbital oedema, subcutaneous calcinosis
how is poly/dermaomyositis investigated?
clinical, increased CK, autoantibodies, EMG, muscle biopsy
how are poly/dermatomyositis managed?
r/o cancer, corticosteroids, immunosuppressants, azathioprine, IVIg, biologics
how does vasculitis present?
purpura, joint and muscle pain, peripheral neuropathy, renal impairment, HTN, anterior uveitis and scleritis, fatigue, fever, weight loss, anorexia, anaemia
how is vasculitis investigated?
CRP, ESR, ANCA (p and c)
how is vasculitis managed?
steroids, immunosuppressants
give some examples of vasculitis?
small - HSP, eosinophilic granulomatosis with polyangitis
medium - polyarteritis nodosa, Kawasaki
large - GCA
how does antiphospholipid present?
livedo reticularis, Libmann Sacks endocarditis, thrombocytopenia
how is antiphospholipid investigated?
lupus anticoagulants and antibodies, Hx of thrombus and pregnancy complication
how is antiphospholipid managed?
warfarin, LMWH and aspirin in pregnancy
what are complications of antiphospholipid?
thrombosis, recurrent miscarriage, MI, CVA, still birth, preeclampsia
what is bechets and how does it present?
it is an inflammatory condition associated with HLA B51 and presents with mouth ulcers, genital ulcers, skin lesions, eye changes such as uveitis, MSK issues such as stiffness, GI, CNA and venous issues
how is bechets investigated?
pathergy test - look for weal > 5mm
how is bechets managed?
steroids, colchicine, anaesthetic topically, immunosuppressants, biologics
what is gout?
it is a crystal arthropathy - high uric acid - negative birefringent crystals in needle shape and monosodium urate
how does gout present?
gouty tophi, hot, swollen, tender joint
what are the risk factors for gout?
male, obesity, high purine intake, alcohol, diuretics, CVD, CKD, FHx
how is gout diagnosed?
aspiration, XR (maintained joint space, lytic lesions, punches out erosions, sclerotic border with overhanging edges)
how is gout managed?
flare - NSAIDs, colchicine, steroids
prophylaxis - allopurinol and lifestyle
what is pseudogout?
it is a crystal arthropathy - calcium pyrophosphate - positive birefringent and rhombus shaped crystals
how is pseudogout managed?
NSAIDs, colchicine, joint aspiration, steroids, washout/arthrocentesis if severe
what is osteoporosis?
it is a reduction in BMD with decreased strength and increased risk of fractures
what are the risk factors for osteoporosis?
female, post menopause, steroids, obesity, increasing age, decreased mobility, SSRIs, PPIs, antiepileptics, antioestrogens, alcohol, smoking
how is osteoporosis investigated?
FRAX tool, BMD from DEXA
how is osteoporosis managed?
activity, weight loss, Ca and vit D intake, avoid falls, stop smoking and reduce alcohol, calcichew D3, bisphosphonates, HRT, denosumab, strontium ranelate, raloxifene
what is sjorgen’s syndrome?
autoimmune affecting the exocrine glands resulting in dry mucous membranes, eyes, and vagina
what is sjorgen’s associated with?
anti Ro and anti La ABs
what are some complications of sjorgen’s?
eye disease, oral problems, vaginal problems, pneumonia, bronchiectasis, peripheral neuropathy, renal impairment, NHL, vasculitis
how is sjorgen’s investigated and managed?
ix - Schilmer test
mx - artificial tears, saliva, vagina lubricants, hydroxychloroquine
what is osteomalacia?
it is soft bones due to defective mineralisation due to insufficient vitamin D
how does osteomalacia present?
fatigue, bone pain, muscle weakness, muscle aches, fractures
how is osteomalacia investigated?
serum 25-hydroxy-vitamin D, ca, P, ALP, PTH, XR, DEXA
how is osteomalacia managed?
vitamin D (cholecalciferol) - treatment and maintenance
what is pagets disease of the bone?
it is a disorder of bone turnover - not coordinated - lysis and sclerosis - mishapen and prone to fracture
how does pagets present?
bone pain and deformity, fractures, hearing loss
how is pagets investigaed?
XR (bone enlargement and deformity, osteoporosis circumscripta, cotton wool skull, V shaped defects), biochemistry (increased ALP, normal Ca and P)
how is pagets managed?
bisphosphonate, NSAIDs, Ca, Vit D when on bisphosphonates, surgery, ALP monitoring
what are some complications of pagets?
osteosarcoma, spinal stenosis, SCC
