Rheumatology Flashcards
Disc Prolapse
Age 40 male
Severe Lower Back Pain (LBP)
Spread into his buttock and Rt thigh
Relieved if lie down
Spinal stenosis due to osteophytes
Age 74 male
Backpain for last 2 yrs, lately worse
Refers to his buttock
Worse when he walks for a distance
Improve by sitting going down hill
Malignancy
Age 54 female
LBP for last 3/12, progressive worse
difficulty urinating and numbness in Rt leg
Absent knee reflex on the Rt
Semi-acute duration
Progressively worse
Some neurology
Do not miss/exclude
Inflammatory arthritis (Spondyloarthropathies)
Spinal Infection
Neoplasms
Fractures
Referred visceral pain
Red flags for lowerback pain
1)Neurological deficit
2)Trauma
3)Prev. surgery
4)Prolonged use of corticosteroids
5)Malignancy
6)Immunosuppression
7)Osteoporosis
8)Age onset < 20years
9)Inflammatory nature of pain
10)Unexplained fever/weight-loss
Mechanical lower back pain (causes)
-Nonspecific back pain (Muscle, tendon, ligament strain)
-Degenerative Disease (Spondylosis): Discs, Facet Joints
-Herniated Disc
-Spinal Stenosis
-Spondylolysis and Spondylolisthesis
-Fractures (Non- vs Osteoporotic)
-Severe kyphosis / scoliosis
MLBP Tx
- physical therapy to strengthen the back muscle
-some analgesia
-surgical intervention
Spondolysis
arthritis of the spine. Seen radiographically as disc space narrowing, osteophyte formation and arthritic changes of the facet joint.
- localized lumbar pain, but can refer downwards.
- Worse with standing or sitting, as well as with physical activity
- C-spine OA present with lateral neck pain, which do not refer below shoulders, worsen by lateral flexion or extension.
Herniated Disc
Acute onset
L4-L5/L5-S1 = 98%
Sharp, shooting, shock-like pain (often into legs)
Management often conservative initially
Typical Hx = pain in the center of the lower back with minimal radiation(if present locates to the buttocks or thighs), Deep dull ache pain, Improves = with standing, lying flat, reduce by extension. Worsen = with sitting, driving, lumbar flexion, bending, twisting, Valsalva maneuver, and coughing
Spinal Stenosis
Narrowing of the central spinal canal by bone or soft tissue elements, usually bony hypertrophic changes in the facet joints and by thickening of the ligamentum flavum
>60 yrs
Pain on extension (walking ,standing, going downhill, positional changes)
Relief (flexion) = Improved by rest, sitting, and lumbar flexion.
gluteal and lower extremity pain
fatigue that may or may not occur in conjunction with lower back pain
Spondylolysis & Spondylolisthesis
Fracture in pars interarticularis where the vertebral body and the posterior elements are joined. (L5)
Spondylolisthesis refers to the slipping forward of one vertebra on the next
When the defect in the pars interarticularis is not associated with a forward displacement, the term spondylolysis applies. LBP symptom, exacerbated by motion, lumber extension & twisting. Relieved extended rest. Progress to radicular pain into L5 distribution
Spondylolysis & Spondylolisthesis treatment
Bracing and rest are the cornerstones
Pain control and avoiding sports
Physical therapy should not be started until after an adequate rest period and once pain with daily activities has subsided: goals = Decrease extension stress of lumbar spine, strengthen elements that promote an anti-lordotic posture
slippage <50% + patient symptomatic = non-operative therapy (Stretching & strengthening exercises, anti-lodic brace, activity modification.)
Spina fusion (pain persists)
Cauda Equina Syndrome
Surgical emergency!
Typical Features:
Bladder / bowel dysfunction(urine retention + overflow)
Bilateral leg weakness/ numbness
Saddle sensory loss
Yellow flags - Chronicity
Beliefs that pain and activity is harmful
Emotional issues (depression / anxiety)
Work issues (dissatisfaction)
Compensation issues
History of LBP
Inflammatory Back Pain
pain/stiffness = >60min morning, improves during day
activity = improve symptoms
duration = chronic
age of onset = <40 years
Radio = sacroiliitis, spinal ankylosis, syndeamophytes
Inflammatory Back Pain (Features)
Plantar periostitis
Enthesitis
IBD
Uveitis
Psoriasis
ASAS/EULAR Recommendations for the Management of AS
Education, exercise, physical therapy, rehabilitation, patient associations, self help groups
NSAIDs
Axial /Peripheral disease, Analgesics
Surgery
Sulfasalazine
Local corticosteroids
TNF blockers
Golfer’s elbow
Medial Epichondilitis
inflamed, but the tendon insertions of the flexors of the forearm, which is why when he uses those muscles to flex his wrist, it aggravates the pain
part of Soft Tissue Rheumatisms
Soft Tissue Rheumatisms
pathology is in the ligaments, tendons and bursae surrounding a joint and not the joint itself
Clinical pattern recognition (Articular)
Deep diffuse pain
Active and passive painful
Joint swelling
Crepitation
Joint instability
Locking of the joint
Deformity
Clinical pattern recognition (Non- Articular)
Localized pain
Only Active painful
Point or local tenderness
Crepitation rare
physical findings are remote from joint capsule
Examples of soft tisue rheumatisms
Tennis elbow (lateral side)
De Quervain’s tendonitis
Rotator Cuff Syndrome
Tronchanteric bursitis
Anserine bursitis
Achilles tendinitis
Rheumatoid arthritis
Inflammatory in nature – worse in morning with morning stiffness (prominent, >1hour) eg. Lasting more 6 weeks
Poli-arthritis – multiple joints
Inflamed synovium
Symmetrical
Wrist / MCPs / PIPs is typical pattern of involvement
Swelling present
Sometimes = Redness, Warmth, fever, drenching night sweats, unintentional weight-loss
Osteo-arthritis
67yr old lady – typical age >60 years
Painful when knitting – mechanical type on pain
Bony deformities = Heberden’s nodes
Distal joints (DIPs) – typical pattern
Cartilage loss
(Morning) Stiffness not prolonged (10-15 minutes) <30min
Asymmetrical
No swelling, redness, fever, drenching night sweats, unintentional weight-loss
Warmth = very rarely
worse = evening
55yr man, severely painful Rt knee, 2 days, hypertensive, TB, loosing weight and experiencing some fever
Gout
Right age with Hpt - ? Possible metabolic syndrome which is associated
Acute onset
On TB treatment – PZA can trigger attack
Versus
Septic arthritis
Only 1 joint
Acute onset
Fever
Pain on Rt and Lt, 2 or more joints affected , Relieved by voltaren but pain persists
asymmetrical arthritis affecting a few (oligo-arthritis) affecting the weight-bearing joints of the lower limbs, is very typical of a Reactive arthritis (ReA)
Mono-arthritis (1 joint):
Septic
Gout
Pseudogout
Avascular necrosis (AVN)
Hemarthrosis
Trauma
Chronic infections (Mycobacterium/Fungal/Cryptococcus/Nocardia/Lyme’s disease
Prev chronic RA
Oligo-arthritis (2-4):
Reactive arthritis
Psoriatic
Sarcoidosis
IBD
Poli-arthritis (>4):
RA
OA
Gout
CPPD
SLE & Other CTD’s
Viral
Symmetrical:
RA
OA
CTD’s
Asymmetrical:
2-4 joints
Reactive arthritis (ReA)
Psoriatic (PsA)
Axial involvement:
Ankylosing Spondylitis
ReA
PsA
Arthritis assoc with IBD
Episodic course:
Gout
Pseudogout
Rheumatic fever
Autoinflammatory syndromes (Familial Mediterranean fever etc)
Reactive arthritis
Palindromic rheumatism
Extra-articular disease (Mucocutaneous manifestations)
Photosensitivity (SLE, Dermatomyositis)
Raynaud’s phenomenon (Scleroderma, Mixed Connective Tissue disease)
Mouth ulcers (SLE, Reactive arthritis(ReA))
Subcutaneous nodules (RA, Rheumatic fever, Gout)
Erythema nodosum (ReA, Arthritis assoc with IBD)
Nail dystrophy (Psoriatic arthritis(PsA))
Cutaneous vasculitis (Any CTD)
Extra-articular disease (Ocular disease)
Keratoconjunctivitis sicca (Sjogren’s)
Conjunctivitis (ReA)
Scleritis (RA)
Uveitis (Ankylosing spondylitis)
Retinal vasculitis (Bechet’s, any CTD)
EAD (Renal)
Acute renal failure (SLE, All vasculitides)
Glomerulonephritis (SLE, Wegener’s)
Renal calculi (Gout)
EAD (cardiopulmonary dx)
Pleuritis (SLE)
Pericarditis (SLE, Rheumatic fever)
Interstitial lung disease (RA, Scleroderma, SLE, Ank Spond)
Nodules – other than sub-cutaneous (RA, Gout)
Pulmonary hypertension (Scleroderma)
Valvular heart disease (Rheumatic fever, SLE, Ank Spond)
Myocarditis (SLE, Vasculitides
EAD (Neuro dx)
Mononeuritis multiplex (Vasculitides, SLE)
Stroke (Vasculitides, SLE)
Joint exam
Look: Swelling, Posture, Deformity, Redness
Feel: Warmth, Bogginess, Tenderness
Move: Limited range of movement (ROM), Crepitus, Stability
Active to Passive movement
Manoeuvres like Pain with Resisted movement
Septic arthritis
Rapid onset, Typically Mono-articular, Inflammatory arthritis, Joints most commonly affected: Knee (50%), Hip (common in children), Ankle, Shoulder
Aetiology: Young sexually active adults (Neisseria gono.) , Elderly (Staph A, Strept. pneum., grame - bacilli)
Risk fx: Prosthetic joints, Skin infection, Joint surgery, Previous damaged joints (RA), Elderly (>80 years old), Diabetes mellitus, Intravenous drug use, Atypical joints affected
Polyarticular Infective causes
-Gonnococcal arthritis (Neisseria gonorrhoeae)
-Bacterial endocarditis – septic emboli
-Viral disease = Hepatitis B virus, Parvovirus B19, HIV, Rubella virus
-Arthropod-borne viruses (Tick bite fever)
-Rheumatic fever
-Poncet’s disease (Reactive immunological process against TB, not actually AFB’s in joints)
Gout (Initially)
Acute onset
First metatarsophalangeal joint most commonly (>50% of cases)
Intermittent
Asymmetrical joint involvement
Fever
Gout (Later)
Tophous gout
Poli-arthritis
Chronic, losses it’s episodic nature, but can still have attacks
Commonly affect the elbows and hands
Can mimic RA
Gout
Risk fx: Obesity, Diabetes mellitus, Hyperlipidaemia, Hypertension, Alcohol use, Thiazide diuretics, Renal insufficiency, Myeloproliferative diseases
Investigations: FBC: ↑ WCC, ESR/CRP (during acute attack) ↑ serum urate, Urate crystals in synovial fluid and/or tophi
X-ray= Asymmetric soft tissue swelling
‘Punched out’ bay-like erosions – not necessarily assoc with joint
polyarthritis
Aetiology: acute (<6w) =viral (lyme dx)
Chronic(>6w) = <60 years: RA, SLE, PA
>60 years: (Gout/CPPD), OA
Osteoarthritis (Sx)
Most common form of arthritis
Prevalence increase directly with age (Uncommon < 40 years)
Pain worsens with use
Morning stiffness < 30min
Slow progressive deformity – bony
(Heberden / Bouchar’s)
No systemic manifestation
Joint distribution (OA)
Joints commonly involved:
-Larger weight-baring joints: Knee, Hip
-Hands: DIP (Heberden’s nodes), PIP (Bouchard’s nodes), First carpometacarpal joint
-Cervical and lumbar spine
Joints spared: Wrist, MCP joints, Elbow, Shoulders, Ankle
OA (more info)
X-ray: Joint space narrowing, Subchondral sclerosis, Osteophytes, Subchondral cysts
Lab: Normal FBC, Normal ESR or slight increase in ESR (mild ↑ in erosive OA), -ve RF, -ve ANA
RA (signs and sx)
Inflammatory Polyarthritis, symmetrical, affects small and large joints, Affects all ethnic groups
40-60 years
+ Rheumatoid factor = supports dx but clinical dx (Don’t need RF sero -)
Morning stiffness
Spares: DIP joints
MCP subluxation with ulnar deviation!!!!
Z- deformity
RA (lab, x- ray, classification)
Lab: FBC: Anaemia, thrombocytosis , ↑ ESR/CRP +ve RF (60-70%) , aCCP (60-70%)
X-ray: Soft tissue swelling, Juxta-articular osteopenia, Uniform joint space narrowing, Marginal erosions
Classification: ≥6/10 = RA
SLE (signs & sx)
Involve many organs
20-40 yrs
F>M
Early morning stiffness
Symmetrical polyarthritis
Joints: PIP, MP, wrist, elbows, shoulders, knees, ankles and MTPJ
Malar/discoid rash
SLE (Lab,X-ray, Classification)
Lab: FBC: Anaemia, ↓ WCC/lymphopaenia, ↑ ESR, normal CRP, +ve ANA (99%)
X-ray: Soft tissue swelling, Joint space narrowing, No erosions.
Classification: Clinical vs Immunologic
SLE clinical
Acute cutaneous lupus
Chronic cutaneous lupus
Oral ulcers
Non-scarring alopecia
Synovitis > 2 joints
Serositis
Renal
Neurologic
Hemolytic anemia
Leucopenia/Lymphopenia
Thrombocytopenia
SLE Immunological
ANA
Anti-dsDNA
Anti-Sm
aPL antibodies
Low complement
Direct Coomb’s test
