Rheumatology Flashcards
Quick Rheumatological function screen
- Have you been affect by pain or stiffness in your joints
- How does this affect you
- Can you walk up stairs
- Stand up from a chair
- Dress and wash yourself
Rheum patient Exam
1) Gait
Stride length, smoothness, turning around, stance, heel strike. Hemiplegic, Parkinsonian, high steppage, ataxic.
2) Arm
3) Legs
4) Spine
Patterns of Joint involvement
Extrarticular features of Rheumatoid Arhthritis
- Splenomegaly, neutropenia
- Interstitial lung disease (UIP)
- Rheumatoid nodules
- Glomerulonephritis
- Premature Coronary artery disease
- Aortic or mitral regurgitation murmurs
- Raynauds
- Skin ulcers
- Sicca symptoms / Secondary Sjogrens (parotid enlargement, scleritis, dry mouth)
- Scleritis
- Amyloidosis
- Peripheral Neuropathy or Entrapment neuropathy
Assessing current activity of Rheumatoid Arthritis
- Number of active joints
- Severity and duration of early morning stiffness
- Functional ability
- ESR / CRP
- Rated fatigue
Differential for Deforming Symmetrical polyarthropathy
- Rheumatoid arthritis
- Seronegative:
> Psoriatic
> Reactive - Gouty arthropathy (typically asymmetric)
-SLE (correctible)
Xray changes Rheumatoid arthritis
- Symmetric joint space narrowing
- Periarticular osteopenia
- Rheumatoid nodules
- Swan necking / boutaneires
- Marginal joint erosions
Management Rheumatoid Arthritis
Non- Pharmacological
- Smoking Cessation
- Physiotherapy: Exercise and splinting of joints
- Occupational therapy
- Rest of inflamed joints
Pharmacological
- NSAIDS
- MTX, Lefulonomide, Hydroxychloroquine, Sulfasalazine
- Need to fail 6 months of traditional DMARD to qualify
- TNF
- Rituximab
- Tocilizumab
- Tofacitinib
- Abatacept
Risk factors for severe rheumatoid arthritis
- High RF titre
- Anti-CCP positivity
- Insidious onset
- Early erosions on Xray
- HLA DR 4
- Rheumatoid nodules early
Folic acid with methotrexate
reduces GI, mouth ulcers
Rheumatoid arthritis in pregnancy
Generally improves during pregnancy
- MTX stop 3 months prior
- Lefulonamide - cease
- Sulfasalazine -> cease in men 3 months prior due to reversible oligospermia
- DMARDS generally ok
Management of Osteoarthritis
Non-Pharmacological
- Physiotherapy range of motion and strengthening
- Aquatic exercise
- Exercise bicycle
- Mobility aids
- Weight loss
Pharmacological
- NSAIDS
- Not much evidence for paracetamol
- Intrarticular corticosteroids
- Surgery
Extra-articular Manifestations of Seronegative Spa
- Aortic Regurgitation
- Apical lung fibrosis
- Inflammatory bowel disease
- Uveitis (40%)
Diagnostic criteria for axial spondyloarthritis
- Age <45yo
- 3 Months of inflammatory back pain
- HLA - B27 plus: back pain ,enthesitis, uveitis, dactylics, inflammatory bowel disease, elevated CRP
- Sacroilitis on Xray or MRI
Systems review SLE
Diagnostic criteria SLE
Lupus in Pregnancy
Increased severity of illness generally
- generally continue hydroxychloroquine
- Give aspirin and clean if concurrent APLS
Measurement of disease activity in lupus
- ESR > CRP
- Anti-DSDNA titre
- Low C3/C4
Mixed connective tissue disease
Overlapping features of SLE, Scleroderma and polymyositis.
Anti-RNP antibodies
Hydroxychloroquine in SLE
-Reduces skin manifestations
- Improves joint disease
- Reduces incidence of renal involvement
- Improves survival
Hydroxychloroquine side effects
Mainly retinal toxicity
- ensure annual ophthalmology review
SLE management
- Hydroxychloroquine for everyone (ensure ophtal review)
- Mycophenolate or Cyclophosphamide if Renal disease
- Steroids for complications including AIHA, ITP, Pleuritic
- Aggressive cardiovascular disease risk reduction
- Anticoagulation if concurrent APLS
Features of polyarteritis Nodosa
Scleroderma clinical features
- Sclerodactyly
- Telangiectasia
- Calcinosis
- Oesophageal dysmotility
- Raynauds
- Reduced mouth opening
- Renal crisis
- Pulmonary fibrosis
- Pulmonary hypertension
- Dilated cardiomyopathy
- Arthropathy in a rheumatoid distribution
Reduced mouth opening
<20mm
Management of scleroderma
- Oesophageal -> PPI treat SIBO
- Raynauds: CCB, PDE5, Iloprost if severe
- Renal crisis: ACE-I
- Pulmonary hypertension: Bosnian, sildenafil
- Interstitial lung disease: mycophenolate or cyclophosphamide
Signs of steroid use
Skin atrophy
Bruising
Cushingoid appearance
Psoriatic nail changes
-Onycholysis
- Pitting
- ridging
- Discolouration
Ankylosing spondylitis exam findings
-Loss of lumbar lordosis
-Exaggerated thoracic kyphosis
-Increased occiput to wall distance (suggests cervical involvement)
-Enthesitis
- Reduced lateral flexion and rotation of back
- Schobers test <5cm abnormal
Xray changes in Ankylosing Spondylitis
-Juxtaarticular osteosclerosis
-Joint ankylosis
-Erosions
-Lateral bridging syndesmophytes
