Rheumatology Flashcards
Describe typical presentation of rheumatoid arthritis
Female, 30 – 50 years old
Symmetrical, affecting MCPs, PIPs, MTPs and typically spares DIPs (can affect any other joint)
History > 6 weeks
Morning stiffness > 30 minutes duration
List investigations to do for suspected RA
RF and anti-CCP
FBC
Inflammatory markers
X-ray (changes more apparent in established disease, USS/MRI in early disease)
Describe treatment for RA
Initially DMARD monotherapy – methotrexate
Steroids (acutely) – PO/IM or intra-articular
Symptom control with NSAIDs (PPI cover) if no contraindication
If disease still severe after combination DMARDs – biologics (anti-TNFs)
OT/PT, podiatry, psychological
List the extra-articular manifestations of RA
3Cs – carpal tunnel syndrome, increased cardiac risk, cord compression
3As – anaemia, amyloidosis, arteritis
3Ps – pericarditis, pleural disease, pulmonary disease
3Ss – Sjogrens, scleritis, splenic enlargement
List x-ray features of RA
Loss of joint space
Erosions (periarticular)
Soft tissue swelling
Subluxation
Describe polymyalgia rheumatica
Clinical syndrome characterised by pain and stiffness of the shoulder, hip girdles and neck
Average age of onset is 70 years & is associated with GCA
Describe the typical presentation of polymyalgia rheumatica
Elderly patients with new sudden onset of proximal limb pain and stiffness (neck, shoulders, hips)
Difficulty rising from chair/combing hair (proximal muscle involvement)
Night time pain
Systemic symptoms – fatigue, weight loss, low grade fever
List investigations done for suspected polymyalgia rheumatica
Typical history & examinations
Inflammatory markers – ESR/PV, CRP
Consider temporal artery biopsy if symptoms of GCA
Describe the treatment for polymyalgia rheumatica
Dramatic response within 5 days of starting prednisolone (15mg daily)
Has to be tapered very slowly; rapid taper is associated with symptom relapse
Methotrexate can be steroid-sparing in relapsing patients
Describe ankylosing spondylitis
Inflammatory disorder of the spine
Radiographic changes at the sacroiliac joints are present
Describe the typical presentation of ankylosing spondylitis
Young men (teens – mid-thirties)
Bilateral buttock pain, chest wall & thoracic pain
Prolonged morning stiffness in the lower back and buttocks
Pain and stiffness improve with exercise but not with rest
Progressive loss of spinal movement
Describe examination findings for ankylosing spondylitis
Often normal
Later:
1) Loss of lumbar lordosis & exaggerated thoracic kyphosis
2) Schober’s test (mark skin 10cm above and 5cm below PSIS, bend forward with straight legs, distance increase to >20cm is normal)
3) Reduced chest expansion
List investigations for suspected ankylosing spondylitis
CRP may be raised but often normal
MRI spine & SI joints
List treatment options for ankylosing spondylitis
NSAIDs
Physio
TNF inhibitors
IL-17 inhibitors
List extra-articular manifestations of ankylosing spondylitis
Anterior uveitis
Aortic incompetence
AV block
Apical lung fibrosis
Amyloidosis
Describe SLE
Multisystemic autoimmune disease
Autoantibodies are made against a variety of autoantigens which form immune complexes
Inadequate clearance of immune complexes results in a host of immune responses which cause tissue inflammation & damage
List common signs and symptoms of SLE
Serositis
Oral ulcers
Arthritis
Photosensitivity – malar/discoid rash
Blood disorders
Renal involvement
Autoantibodies – ANA positive in > 90% cases
Immunologic tests
Neurologic disorder – seizures or psychosis
List investigations for suspected SLE
Raised ESR or plasma viscosity
Anaemia & leukopenia are common
Anti-Ro, anti-La, anti-dsDNA, antiphospholipid antibodies
C3 and C4 fall with disease activity
Urinalysis – detecting renal disease
Skin biopsy
Renal biopsy
Describe the treatment for SLE
Sun protection
Healthy lifestyle – increased CVS risk
Hydroxychloroquine – helpful for rash and arthralgia
Mycophenolate mofetil, azathioprine and rituximab
Prednisolone – for flares
Describe the management for osteoarthritis
Non-drug therapy: strengthening & range of movement exercises, weight loss, walking stick
Pharmacological therapy: regular paracetamol, NSAIDs short term, intra-articular corticosteroids can be offered
Surgery: if nothing else has worked, surgery can be considered
Describe fibromyalgia
Common disorder if central pain processing characterised by chronic widespread pain in all 4 quadrants of the body
Allodynia, a heightened and painful response to innocuous stimuli is often present
List symptoms and signs of fibromyalgia
Pain
Joint/muscle stiffness
Profound fatigue
Unrefreshed sleep
Numbness
Headaches
IBS
Depression & anxiety
List treatment options for fibromyalgia
Should be specifically tailored based on pain intensity, function and associated features
Low dose amitriptyline
Pregabalin may be effective
Opiates NOT recommended
CBT
Describe osteoporosis
Characterised by low bone mass, deterioration of bone tissue & disruption of bone architecture -> compromised bone strength & increased risk of fracture
