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Yr 3 Medicine > Rheumatology > Flashcards

Rheumatology Flashcards

1
Q

What features in a patient history support a diagnosis of RA?

A

Family history of RA
Younger (30 - 50 yrs)
MCP + PIP pain + swelling
Multiple small joint swellings
Morning Stiffness (>30mins)
Fatigue

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2
Q

Apart from the hands, what other joints are commonly affected in RA?

A

Shoulders
Knees
Wrists

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3
Q

What are the classical examination findings in the hands of patients with RA?

A

Soft tissue swelling + tenderness
Ulnar deviation/Palmar subluxation of MCP
Swan-neck deformity to digits
Rheumatoid Nodules

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4
Q

What are the extra-articular manifestations of RA?

A

3 C’s:
Carpel Tunnel
CVD Risk
Cord Compression

3 A’s:
Anaemia
Arteritis
Amyloidosis (build of amyloid)

3 P’s:
Pericarditis
Pleural Disease
Pulmonary Disease (bronchiectasis/fibrosis)

3 S’s:
Sjogren’s (attacks glands - mucosal/tear leading to dry eyes and mouth)
Scleritis
Splenomegaly (+ neutropenia is FELTY’S SYNDROME)

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5
Q

What investigations help diagnose RA?

A

High RF + anti-CCP
FBC (normocytic anaemia - anaemia of CD)
Inflammatory Markers raised

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6
Q

What are the radiological features of RA in the hands?

A

Loss of joint space
Erosions (Periarticular)
Soft Tissue Swelling
Subluxation

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7
Q

What treatment options are available for RA?

A

1) Methotrexate
2) DMARD combination therapy (sulfasalazine, hydroxychloroquine, leflunomide)
3) Biologics (Adalimumab, etanercept, rituximab)

Acute Flare up: Steroids

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8
Q

What monitoring is required with RA treatments?

A

Regular Blood tests
Pregnancy testing (sulfalazine only is safe in pregnancy)

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9
Q

What tests are needed before starting on RA drug therapy and what contraindications are there?

A

CXR
HIV/TB/Hep B/Hep C status
Bloods

Contraindications:
HIV/Hep B/C
Severe HF
Hx of multiple sclerosis
Cancer

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10
Q

What features distinguish RA from other arthritidies?

A

No DIP involvement
Morning Stiffness > 30 mins
Activity Improves
Resting worsens
Family History
Younger presentation
Small Joints

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11
Q

What features support a diagnosis of Ankylosing Spondylitis?

A

Young man (teens-30s)
Back stiffness
Reduced spine movement
Loss of lumbar lordosis
Reduced chest expansion

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12
Q

What is Schober’s Test and what does a +ve one look like?

A

1) Identify the PSIS on each side
2) Mark the skin in the midline 5cm below PSIS + 10cm above PSIS
3) Ask patient to touch there toes

Distance should increase from 15cm > 20cm

+ve test = Less than 20cm (ankylosing spondylitis)

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13
Q

What symptoms would you ask about if you suspect ankylosing spondylitis?

A

Back pain > 3 months
Morning Stiffness > 30 mins
Buttock pain
Exercise improves it
No improvement with rest
Pain wakes up at night

EAMs:
Anterior uveitis (acutely painful red eye, photophobia, blurred vision)
Psoriasis
IBD
Genitourinary Infection
AV Block
Aortic incompetence

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14
Q

What investigations would further help with the diagnosis of Ankylosing Spondylitis?

A

CRP/ESR could be raised
+ve Schober’s test

Spine X-Ray/ MRI Spine
+ve HLA-B27 (GENETICS)

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15
Q

What gene is common in ankylosing spondylitis?

A

HLA-B27

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16
Q

What are the complications of Ankylosing Spondylitis?

A

Spinal Fractures
Hip Joint Replacement
Spinal Fusion
Osteoporosis
Anterior Uveitis
Increased CVD risk (arrhythmias/CHF/Valvular Disease)
Lung Fibrosis

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17
Q

How do you manage Ankylosing Spondylitis?

A

1) NSAIDs + physio
2) TNF Inhibitors (Adalimumab, Etanercept)
3) IL-17 Inhibitors (Brodalumab)

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18
Q

What features support a diagnosis of gout?

A

> 40 yrs
Male
Sudden, severe, red, tender
Usually one joint, big toe
Tophi nodules

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19
Q

What are the common associations with gout? (Lifestyle and conditions)

A

Smoking
DM II
CHF
Obesity
High Alcohol intake
Diet (red meat)
Kidney Diseases

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20
Q

What investigations help diagnose gout?

A

Serum urate/Uric Acid level
Joint aspiration

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21
Q

What treatment options (acute and chronic) are available for patients for gout?

A

Acute:
NSAIDs
Oral/IM Steroids
Colchine

Chronic:
Regular Exercise
Diet Modification
Reduce Alcohol
Smoking Cessation

Urate Lowering Therapy:
Allopurinol
Febuxostat

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22
Q

What does crepitus in a joint represent?

A

Loss of Cartilage

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23
Q

Does OA or RA improve with rest?

A

OA - improves with rest
RA - improves with movement

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24
Q

What are type of joint swellings are and what do these signify?

A

Hard - boney - Heberden’s, Bouchard’s nodes in OA
Soft/non-tender - inflammatory disease

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25
What are the 2 tests for carpel tunnel syndrome?
Phalen's Test: wrists together flexed with dorsal surfaces of each hand touching each other for 1 minute Tinel's Test: Tap the median nerve with index and middle finger for 30 secs-1min Should get numbers in lateral 3 digits
26
What scan is used for osteoporosis and what result is significant?
DEXA Scan T score of > -2.5cm
27
What patient factors make osteoporosis more likely?
Low BMI Tall
28
What patient factors can cause low bone density?
Genetics Low testosterone Thyroid issues Smoking Alcohol Low BMI Physical inactivity
29
What disease are associated with osteoporosis?
CKD Cushing's Thyrotoxosis Malabsorption (coeliac e.g.) RA
30
What drugs are linked to osteoporosis?
LONG TERM STEROID USE Thyroxine
31
What score is used to asses fracture risk in osteoporosis/
FRAX High then treatment is required
32
What is the basics of osteoporosis management?
1) Biphosphonates (10yrs use max) 2) s.c. PTH 3) Denosumab Vit D!
33
What are some side effects of biphosphonates?
Osteonecrosis of jaw Atypical femur fracture
34
What does the pneumonic SOAP BRAIN stand for in SLE?
Serositis (pleurisy, pericarditis) Oral ulcers Arthritis Photosensitivity Blood disorders (low WCC, lymphopenia) Renal involvement (glomerulonephritis) Autoantibodies (ANA +ve) Immunologic tests Neurologic disorder (seizures, psychosis)
35
What are the clinical features of SLE?
Painful hands (arthritis) Raynaud's phenomenon Alopecia/hair thinning Pleuritic chest pain/SOB Butterfly rash Fatigue Sunlight Sensitivity
36
What examination findings will you look for in SLE?
Malar Rash Mouth Ulcers Alopecia Raynauds (cold hands) Pain in joints Pleural Rub Splenomegaly
37
What investigations would you request for SLE?
FBC (anaemia of CD, thrombocytopenia, leukopenia) Raised ESR/CRP (CRP can be =) Urine Dip (proteinuria in lupus nephritis) Autoantibodies: ANA (Anti-Nuclear Antibodies) Anti-dsDNA (Anti-double stranded DNA) Anti-Ro + Anti-La (Sjögren's syndrome) Low C3/C4 (compliment proteins)
38
What is the diagnostic criteria for SLE?
Constitutional: Fever Hematologic: Leukopenia Thrombocytopenia Autoimmune Hemolysis Neuropsychiatric: Delirium Psychosis Seizures Mucocutaneous: Non-scarring alopecia Oral Ulcers Discoid Lupus Serosal: Pleural/Pericardial Effusion Pericarditis MSK: Joint involvement Renal: Protenuria Kidney biopsy showing lupus nephritis changes Immunological: Anti-dsDNA Anti-Smith Antibody Low C3/C4 Antiphospholipid antibodies >10 = SLE (each category ranges from 2-10 points each)
39
What features would suggest SLE active disease (a flare up)?
Symptoms returning or worsening of symptoms already present Ongoing Fever Painful/swollen joints Worsened Fatigue Rashes Leg swelling Pleuritic chest pain
40
What management is available for SLE?
1. Sun protection 2. Reduce CVS RFs 2. Hydroxychloroquine (gold standard) 3. NSAIDs 4. Azathioprine, Mycophenolate mofetil 5. Biologics (rituximab, belimumab) Flares: Short course of prednisolone
41
What monitoring is required with SLE and it's treatments long term?
Blood Pressure (CVS risk) Urinalysis U+Es FBCs LFTs Steroids: Hyperglycaemia (blood glucose monitoring) DMARDs: FBC (bone marrow suppression)
42
What are some complications of SLE?
CVD Infection (from disease and drugs used) Anaemia of CD Pericarditis Pleuritis ILD Lupus Nephritis
43
What is the typical presentation of Giant Cell Arteritis (GCA)?
Older white patients (50yrs+) Unilateral headache (temple/forehead) Jaw claudication Scalp tenderness Burred/double vision Temporal artery inflamed with reduced or absent pulsation
44
What investigations can be used to aid your diagnosis of GCA?
Raised ESR (CRP) Temporal artery biopsy (necrotising arteritis)
45
How is GCA treated? What if there is visual disturbance?
Oral prednisolone for 2 weeks then titre down + aspirin 75mg + PPI (protective w/ steroids) Symptomatic/visual disturbance: IV methylprednisolone
46
What is Polymyalgia rheumatica?
Inflammatory condition causing pain/stiffness in shoulders, pelvic girdle and neck
47
What is the typical presentation in polymyalgia rheumatica?
Older white patients Sudden onset (<2weeks) of pain/stiffness in shoulders, neck, pelvic girdle Reduced ROM but normal strength Worse in morning or after rest Weight loss/fatigue/fever GCA association Carpel tunnel
48
How is diagnosis of polymyalgia rheumatica made?
Clinical presentation Raised ESR/CRP
49
How is polymyalgia rheumatica treated?
Daily prednisolone 15mg RAPID IMPROVEMENT WITHIN DAYS IF NOT: WRONG DIAGNOSIS
50
What signs will be present in psoriatic arthritis?
Psoriasis plaques Nail pitting Oncholysis (separation of the nail from nail bed) Dactylitis (inflammation of finger) Enthesitis (entheses - point of tendon insertion into bone)
51
How do you treat psoriatic arthritis?
1. NSAIDs 2. DMARDs (methotrexate) 3. Anti-TNF (etanercept, infliximab, adalimumab)
52
What is reactive arthritis and how does it present? How can we treat it?
Synovitis following infection elsewhere (dysentery, urethritis, cervicitis) CAN'T SEE (Conjunctivitis) CAN'T WEE (Urethritis) Raised inflammatory markers Normal joint aspiration Treat underlying infection NSAIDs if needed
53
What is enteropathic arthritis and how can it be treated?
EIM of IBD TNF-i (etanercept, infliximab, adalimumab) treat arthritis and IBD DMARDs (NSAIDs can flare IBD)
54
What is Raynaud's phenomenon and what does the colour of the hand represent?
Vasospasm of digits Painful episodes lasting minutes White - inadequate blood flow Blue - venous stasis Red - re-warming hyperaemia
55
What diseases/meds are associated with Raynaud's phenomenon?
SLE Sjogren's Scleroderma Polymyositis B Blockers
56
What is the treatment for Raynaud's?
1. Avoid smoking 2. Keep warm (cold triggers it) 3. Ca channel blockers
57
How will a patient with vasculitis present?
Dependant on what organ is involved MSK: Arthralgia Myalgia CNS: Headaches CVS: Pericarditis Angina Resp: Haemoptysis Dyspnoea Cough/Chest pain GI: Abdo pain Diarrhoea Renal: Haematuria General: Fatigue Fever Night sweats Weight loss Anaemia
58
What could vasculitis show on examination?
Necrotic skin ulcers Purpura Abdo: Tenderness Organomegaly Cardiopulmonary: Crackles Pleural rubs
59
What investigations would you order with suspected vasculitis?
CRP/ESR^ Urine Dip (GLOMERULONEPHRITIS) Anti-neutrophil cytoplasmic antibodies (ANCA) CXR
60
What are some conditions that can cause secondary vasculitis?
Malignancy (blood) Connective Tissue Disorders Infection (viruses) Drugs
61
What is the management for vasculitis?
1. Rule out infection. Stop offending medication 2. Corticosteroids 3. Cyclophosphamide, Rituximab
62
What are the small-vessel vasculitis and describe them briefly?
Henoch-Schonlein Purpura/ IgA Vasculitis: IgA deposits in vessels in children Purpura + IgA nephritis Microscopic Polyangiitis: Glomerulonephritis Diffuse alveolar haemorrhage (haemoptysis) Granulomatosis with Polyangiitis (Wegner's granulomatosis): Nose bleeding Sinusitis Cough Wheeze Haemoptysis Glomerulonephritis Eosinophilic Granulomatosis with Polyangiitis (Churg-Strauss): HIGH Eosinophils Severe asthma in middle age
63
What are the medium-vessel vasculitis and describe them briefly?
Polyarteritis Nodosa: Renal impairment HTN Skin nodules MI/stroke Post HEP B Kawasaki Disease: Children under 5yrs Widespread erythematous maculopapular rash Bilateral conjunctivitis Strawberry tongue
64
What are the large-vessel vasculitis and describe them briefly?
Giant Cell Arteritis Takayasu’s Arteritis: Limb claudication Pulseless limbs
65
What is systemic sclerosis? What investigations would you ask for?
Increased fibroblast activity resulting in abnormal connective tissue growth causing vascular damage and fibrosis ANA +ve X-ray hands (calcinosis) CXR/PFT ECG/Echo
66
What are the 2 types of systemic sclerosis?
**Limited Scleroderma**: Calcinisis (white calcium deposits on fingertips) Raynaud's Esophageal dysmotility Sclerodactyly (hand skin tightening/ reduced ROM) Telangiectasia (dilated blood vessels in skin, on the face) Anti-centromere antibodies **Diffuse Scleroderma**: Sudden onset of skin thickening Proximal to elbows/knees Systemic/pulmonary arterial HTN Anti-Scl-70 antibodies
67
What is the management for systemic sclerosis?
Psychological support Ca antagonist/sidenafil for Raynaud's Methotrexate - skin thickening ACE-i Prednisolone - flares
68
What are the common symptoms of Sjögren's syndrome?
Fatigue Dry Mouth Dry eyes Myalgia Arthralgia Raynauds Huge Parotid glands
69
What investigations are there for Sjogren's and how do we manage it?
Schirmer Test - measures tear volume Anti-Ro Salivary gland biopsy Artificial tears/saliva Vaginal lubricants
70
What is hypermobility spectrum disorder and how does it present? What treatment is available?
Joints moving beyond normal limits due to laxity of ligaments, capsules + tendons Pain is from micro trauma? Pain around joints (worsening after activity) +ve Beighton score Strengthening exercises to reduce subluxation
71
What is the aetiology of OA?
Loss of articular cartilage accompanied by new bone formation and capsular fibrosis Resulting from overuse, excessive loading, injury and genetics
72
What are the risk factors for getting OA?
Female Obesity Age Trauma/joint malalignment
73
What are the commonly effecting joints in OA?
Hip Knees Spine DIP Carpometacapral joint (thumb)
74
What do x-rays show with OA?
Loss of joint space Osteophytes (bone spurs) Subarticular sclerosis (increased bone density across joint line) Subchondral cysts (fluid-filled holes in bone)
75
What are signs of OA in the hands?
Heberden's nodes (DIP) Bouchard's nodes (PIP) Squaring at the base of the thumb (CMC)
76
What treatment is available for OA?
1) Strengthening + ROM exercises 2) Paracetamol 3) NSAIDs short spells (topical best) 4) Surgical joint replacement
77
What is the pathophysiology behind fibromyalgia?
Disorder of central pain processing Pain in all 4 quadrants of the body Heightened response to not harmful stimuli Reduced REM sleep found??!! maybe this causes heightened response + pain
78
What are the symptoms and signs of fibromyalgia?
Joint/muscle stiffness Fatigue Unrefreshed sleep Numbness Headache IBS Depression/Anxiety Poor concentration
79
What is the typical presentation of fibromyalgia?
Female 40s Chronic fatigue + joint tenderness post emotional/physical stimuli
80
How can we manage fibromyalgia?
1. Education (helps symptoms most) 2. Sleep advice + ^exercise 3. Low dose amitrypytiline/pregabalin 4. CBT
81
What is the triad of Felty's syndrome?
Rheumatoid arthritis Splenomegaly Neutropenia
82

Yr 3 Medicine (11 decks)

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