Rheumatology Flashcards
Revise Important Concepts and Information for Rheumatology Year III MBBS Monash University.
What are the 5 causes of symmetrical deformity polyarthropathy of the hands?
- Gout
- OA
- ## Psoriatic arthritisAutoimmune:
- Lupus (SLE)
- RA
What are the 5 signs of active synovitis in the hand?
- Joint line tenderness
- Ulnar styloid tenderness
- Stress tenderness
- Effusion
- Bogginess
What are the key findings in X-Ray of a hand of a person with RA?
- EROSION
- DIP is spared
- Joint space narrowing
- Peri-articular osteopaenia
- Concentric
4 Main findings in an X-Ray of a hand of a pt. with OA?
- Joint space narrowing
- Osteophyte
- Subchondral sclerosis
- Cysts
- DIP Not spared
A pt came with widespread joint pain. What do ask in Hx taking?
- STIFFNESS
- Swelling
- Worse in the morning/evening? For how long?
- Is it better or worse with movement?
If a pt. came with widespread joint pain, after taking Hx, what Ix would you order?
- FBE: ?anaemia, ?CRP
- autoantibodies: ANA. anti-CCP, RhF
- U & E, serum uric acid
- ESR & CRP
- Plain XR: ?OA, ?Psoriatic arthritis
What test is considered ‘the gateway for detecting autoimmune disease’?
What are the percentages of +ve in each one of these:
a. SLE
b. Systemic sclerosis
c. Autoimmune hepatitis
d. RA
e. Sjogren’s syndrome
f. Normal person
Anti-nuclear antibody (ANA): +ve by immunofluorescence in:
a. SLE: >95%
b. Systemic sclerosis: 64%
c. Autoimmune hepatitis: 75%
d. RA: 30%
e. Sjogren’s syndrome: 68%
f. Normal person: 0 -2%
In ANA, what pattern of staining is consistent with:
a. SLE
b. mixed connective tissue disease
c. Systemic sclerosis
d. Limited systemic sclerosis
a. Homogenous
b. Speckled
c. Nucleolar
d. Centromere
What is the specific test:
a. to detect RA?
b. to detect conn. tissue diseases? PM DM SLE RA Systemic sclerosis Sjogren's syndrome
a. anti-cyclic citrullinated peptide Ab (anti-CCP, ~96% specificity)
b.
PM & DM - anti-Jo-1 (esp. for PM) & anti Mi-2
SLE dsDNA (~60% sensitivity, highly specific) anti-La (15%) anti-SM ( 20-30%) anti RNP
RA: RhF
Systemic sclerosis: anti-Scl70
Sjogren’s syndrome:???
What does each of this test for?
a. anti-dsDNA
b. anti Jo-1
c. anti Ro
d. anti La (SSB)
e. anti scl70
f. anti-SM
a. anti-dsDNA: SLE
b. anti Jo-1: Polymyocitis
c. anti Ro: SLE, Sjogren’s syndrome, systemic sclerosis
d. anti La (SSB): Sjogren’s syndrome [SLE - 15%]
e. anti scl70: diffuse systemic sclerosis
f. anti-SM: SLE; need to check for vasculitis, p-ANCA (?microscopic polymyositis)
What blood test would you do to confirm polymyocitis?
anti Jo-1; possibly CK
In a lupus-suspected patient, what questions would you ask? Name four.
The American College of Rheumatology: from 11 Diagnostic Criteria
- Malar rash
- Photosensitivity
- Discoid rash
- Reynaud’s phenomenon (white, blue, red)
What are the organs commonly affected in SLE?
Everything! e.g. mouth, skin joints, brain, kidney, heart.
What are the 11 diagnostic criteria to diagnose SLE?
- Malar rash
- Discoid rash
- Serositis: pleurisy or pericarditis
- Oral ulcers
- Arthritis
- Photosensitivity
- Blood - haem. disorder
- Renal disorder
- ANA +ve
- +ve ds-DNA
- Neurological disorder: seizure, psychosis
The presence of anti Jo-1 autoantibodies is most specific for:
a) polymyositis
b) ankylosing spondylitis
c) SLE
d) CREST Syndrome
e) Sjogren’s syndrome
a) Polymyositis
What is the gold standard Ix of osteoporosis?
What is the T-score for osteoporosis Dx?
Gold standard: DEXA Bone scan
T- score: 0: better than reference
0 to -1: BMD - Top 84% (no osteoporosis evidence)
-1 to -2.5: Osteopenia
< -2.5: osteoporosis (repeat DEXA in 2 years)
In osteoporosis screening, what is/are the test(s) that should be included in Ix?
- Vit. D
- Ca2+
- PTH
- Thyroid f(x)
- ESR, CRP
- U & E (?renal failure)
What are the four classes of drugs used to treat osteoporosis?
- Biphosphonate [1st line: alendronate]
- SERM [raloxifene]
- strontium renalated
- Recomb. PTH/ HRT] e.g. Teriparatide
Amy is a 66 years old female, with a Hx of osteoporosis, fracture, and thrombosis (DVT) complicated by pumnonary embolism.
Which of the following drugs is best used in her case?
a) PTH
b) HRT
c) Biphosphonate
d) SERM
e) Strontium
b) Hormone replacement therapy (HRT)
What are the patterns of joints involvement in gout?
All!
Monoarthropathy (Podagra)
Oligoarthropathy
Polyarthropathy
Amary is 18 years old, female, with swollen right knee.
Based on your differentials, which Ix would you do?
- Always remember that we need to exclude septic artritis!
- as age is 18 y/o, unlikely OA, RA, etc.
- Fine needle aspiration (need to exclude septic arthritis!)
- CRP, ESR
- FBE
Extra: if suspect septic arthritis, give fluclox or vancomycin.
What are the 5 indications to lower uric acid (a.k.a to undergo uric acid lowering therapy)
- Multiple episodes of acute gout attack/year
- Tophi (or chronic arthritis on exam)
- Nephropathy (e.g. kidney/renal stones)
- Polyarticualr gout
- Extremely high levels of serum uric acid (>12 mg/dl), constantly.
What are the drugs used to treat the Sx of gout?
- NSAIDs (strong): diclofenac 5mg tid
- if CI (e.g. peptic ulcer), use colchicine 0.5mg qid
- Steroid: to be used if patient has renal impairment.
What does these means (on prescription)?
b.i.d
q.d.
t.i.d
q.i.d
q_h
b. i.d - bis in die (latin): 2x/day
q. d. - quaque die (latin): 1x/day
t. i.d - ter in die (latin): 3x/day
q. i.d - quarter in die (latin): 4x/day
q_h - q= quaque. h = hours
e.g. 2 caps q4h = 2 capsules every 4 hours
What are the drugs used to lower uric acid?
- Allupurinol
- Probenacid (not to be used in acute setting, no effect)
- Febuxostate - new kid on the block
What are the extra-articular manifest of ankylosing spondylitis?
- enthesis
- acute iritis
- aortic regurgitation
In ankylosing spondylitis, what is.are the blood test(s) that can be done?
What will be the expected result(s)?
- FBE (normocytic anaemia)
- Increased ESR
- Increased CRP
- +ve HLA B27
Name 6 systemic Comx of steroids.
acute: Acute: PVD Psychosis hyperglycaemia insomnia HTN Skin changes myopathy "rebound" inflammation
acute and chronic: immunosuppression (poor wound healing)
Chronic:
Cushing’s syndrome
Osteoporosis
[Diatebes]
Mr. A is currently on methotrexate. Name 3 tests you could order to monitor this drug.
- FBE
- ?bone marrow over suppression - LFTs
- can irritate liver (methotrexate SE) - U&E {& GFR):
- check for methotrexate build up in body fluid {mathotrexate does NOT affect kidney!}
How dies inflammation causes osteoporosis?
In all inflammation (chronic) –activates–> increase in cytokines (IL-1, IL-6, etc.) - very important link! –activates–> RANK ligand –activates–> oeteoclast (bone eater) –activates–> systemic osteoporosis
What are the contraindications of HRT?
Divide into 1. CVD, 2. DVT & PE, 3. Malignancy
- CVD:
- cerebrovascular disease
- Previous: stroke, PVD, AMI - DVT & PE:
- RF: FHX, T2DM, HTN, Clotting Hx - Malignancy:
- uterine + cervical cancer
Pain
Weakness
Stiffness
Tenderness
a) Match
i) polymyalgia,
ii) polymyositis rheumatica
iii) fibromyalgia, to above description.
b) What abnormality will the blood test shows in each of this condition?
1) PMR: STIFFNESS, increased ESR and CRP.
2) PMC: WEAKNESS, increased CK
3) FML: TENDERNESS & PAIN, all normal blood test
What are the three drugs used to control gout Sx (a.k.a. acute gout)?
- NSAIDs (diclofenac)
- Colchicine
- Steroids
Where do gout usually affect?
In a pt. with gout, what does the polarised light microscopy of synovial fluid show?
- Joints, kidneys, skin
2. Negative birefringence urate crystals.
What does +ve p-ANCA and c-ANCA means?
p-ANCA: microscopic polyangiitis
c-ANCA: Wegener’s granulomatosis
What test is to be done to confirm the Dx of Lupus?
dsDNA
Anti-centromere Ab - what does the +ve finding means?
Limited systemic sclerosis
What is the CREST Syndrome?
C - calcinosis (subcut. tissue) R - Reyanud's E - Oesophageal + gut dysmotility S - Sclerodactyly T - Telangiactasia
In what condition is the CREST Syndrome found?
Limited systemic sclerosis
What I can be done to confirm limited systemic sclerosis?
anti-centromere Ab.
