Rheumatology Flashcards
X ray findings of osteoarthritis
Loss of joint space
Osteophytes formation
Subchondral cysts
Subchondral sclerosis
Heberdens and Bouchard nodes, what and where
Osteoarthritic signs
Bouchard is PIP inflamation
Heberdens is DIP inflamation
What is the difference in the joints affected by rheumatoid vs osteoarthritis
Osteoarthritis affects large weight bearing joints, and in the hand often CMC and DIP. Often asymmetrical
Rheumatoid is symmetrical and can affect smaller joints. SPARES DIP CLASSICALLY
How does pain and stiffness differ after resting (e.g in the morning) in RA vs OA
In RA, it can last over 30 mins, and is worse after rest
In OA, it usually lasts less after rest and is worse after use (e.g a long day)
Joints affected more commonly in RA
Smaller: wrist, ankle MCP and PIP
DIPs are SPARED in RA!
Associated symptoms of RA
Fatigue, weight loss, flu like illness and muscle aches
Serology for RA and what is better
Rheumatoid factor: 70% of RA patients have
Anti CCP- more sensitive and more specifc
Check for CRP and ESR also
What scores can be used to monitor RA
DAS28 and HAQ
What features are poor prognostic indicators in RA
Younger onset,
Male
More joints affected
Seropositive for RF and anti CCP
What is 1,2 and 3rd line mx of RA
1- DMARD alone e.g methotrexate,sulfasalazine or hydroxychloroquine (hydroxy is mildest)
2- 2 DMARD combined
3- Methotrexate + biological- TNF inhibitor
Give two examples of anti-TNF drugs
Infliximab and adalimumab
Side effect profile of methotrexate
Mouth ulcers and mucocitis
Liver toxicity
Myelosuppressipn leading to leukopenia
Teratogenic
Side effect of sulfasalazine
Male infertility
Side effects of anti TNF drugs
Vulnerable to infection
Reactivation of TB and Hep B
What percentage of people with psoriasis get psoriatic arthritis
10-20%
Signs of psoriatic arthritis
Nail pitting
Oncholysis - separation of nail from nail bed
Dactylisis - full inflamation of digit
Enthesitis- inflamation of enthuses, where tendon inserts on bone
What are the most common causes of reactive arthritis
Chlamydia and gonorrhoea
What are the associations seen in reactive arthritis
Can’t see, can’t pee can’t climb a tree
Anterior uveitis
Bilateral conjunctivitis
Circinate balantis
What joints does ankylosimg spondylitis affect
Vertebrae and sacroiliac joints
What percentage of people with AS have the HLA-b27 gene
90%
Investigations for AS
Baseline bloods
ESR and CRP
HLA-B27 genetic test
X ray of spine - shows bamboo spine due to fusion of vertabra
Common associations with AS
Chest pain
Enthesitis - leads to Achilles tendinitis and plantar fasciitis
Ant uveitis
Heart block
IBD
What test is used for spinal mobility and AS
Schobers test:
Find L5 and mark 10cm above and 5 below
Ask patient to touch toes, and if distance between marks is less than 20cm, suggests lumbar restriction
Auto antibodies seen in SLE
ANA (more detail)
Anti double stranded DNA
Anti smith antibodies (type of extractable nuclear antigen)
First line treatment for mild SLE
Hydroxychloroquinine and NSAID
Clinical picture of giant cell arteritis
Sever unilateral headache
Scalp tenderness
Jaw claudication
Blurred or double vision
How to diagnose giant cell arteritis
Clinical features present (headache, scalp tenderness and jaw claudication)
Raised ESR (>50mm/hr)
Temporal artery biopsy
What is found on temporal artery biopsy for GCA
Multinuckeated giant cells
Initial mx of GCA
High dose steroids - pred 30-60mg per day
What antibodies are seen in sjogrens
Anti-Ro and Anti-la
What test can be used to check for sjogrens
Shirmer test- folded filter paper under eyelid
Tears should travel at least 15 mm, <10mm is significant
What does the FRAX tool tell us
Probability of fragility fracture over the next ten years
What scores do we use from DEXA scan, and what is significant
T scores
More than -1 is normal
-1 to -2 is osteopenia
Less than -2.5 is osteoperosis
Less than -2.5 with a fracture is sever osteoperosis
First line treatment for osteoperosis
Bisphosphonates- aledondric acid 70mg once a week oral
What is denosumab and what is it used for
MAB to osteoclasts, prevents bone resorption
Side effects of bisphosphonates
Reflux and oesophageal erosion- take on empty stomach and sit up for 30 minutes
Atypical fractures
Osteonecrosis of jaw
What condition js linked with polymalgia rheumatics
Giant cell arteritis
Clinical picture of polymalgia rheumatica
Bilateral shoulder pain that radiates to elbow
Bilateral pelvic girdle pain
Stiffness that lasts for more than 45 minutes in the morning
Interferes with sleep
What is the initial treatment for poly myalgia rheumatica
15mg prednisolone per day and review after 1 week and 3/4 weeks
ANA and anti-dsDNA- for sle what is more specific and what is more sensitive
What does this mean
ANA is the most sensitive and shoukd be used first: if positive then they almost definitely have sle
Anti-dsDNA is the most specific. Anyone who is negative does have it
what anti bodies are found in drug induced lupus
ana and anti histome antibodies positive
Common causes of drug induced lupus
Procainmide
Hydralazime
Isonisiaz
Phenytoin
Diffused systemic sclerosis
Features
Antibodies
Scleroderma of trunk and proximal limbs
ILD and pulmonary hypertension
ED
Had anti scl-70 antibodies
Limited systemic sclerosis/ CREST
Features
Antibodies
Raynauds
Scleroderma of face and and distal limbs
anti centromere antibodies
What is CREST
Calcinosis
Raynauds
Oesophageal dysmotility
Sclerodactly
Telangestacis
Unilateral or bilateral psoriatic arthritis and ra
Ra is symmetrical psoriatic not
Risk factors for septic arthritis
Age
Immunosuppressive
Prosthetic joint
Joint instrumentation (injections or arthroscopy)
Underlying joint damage already
Transient bacterial is
Ix for septic arthritis
Bloods; baseline FBC, u and e for AKI, CRP and ESR whic will be raised for inflamation. Clotting screen for haemarthrosis and serum Uris acid to assess for gout. Blood culture
Plain x ray
Joint aspiration is gold standard- should be done before abx given
Joint aspiration in septic arthritis findings
Cell count - WCC >50000 is worrying
Gram stain
Culture
Polarised light microscopy
Gram positive cocci in clusters suggests what on joint aspirate
Septic arthritis due to s aureus
What criteria is used for a hot joint
Kosher criteria
Fever over 38
Non weight bearing
Raised ESR
Raised WCC
Managment of septic arthritis
Conservative - analgesia and splinting
Medical - IV flucloxacillin for two weeks followed by oral for 2-4 weeks
Joint wash out
What to do if a prosthetic joint is thought to be septic
Must be aspirated by an ortho surgeon
