Rheumatology 2 Flashcards
Describe the femoral nerve stretch test
Lie the patient prone
Extend the hip joint with a straight leg
Then bend the knee
If there is pain = trapped femoral nerve
Pain and tenderness over lateral side of thigh
Most common in women aged 50-70
Greater trochanteric pain
High steroid therapy
Previous hip fracture/ dislocation
Gradual or sudden onset
Hip pain
Avascular necorosis
Seen in the third trimester of pregnancy
Groin pain
Limited range of movement of hip
May be unable to weight bear
ESR can be elevated
Transient idiopathic osteoporosis
Hypersensitivity types
I anaphylactic
II cell bound
III immune complex
IV delayed
Hypersensitivity Mechanism
I IgE
II IgG or IgM
III IgG or IgA
IV T cell
Hypersensitivity examples I (2)
I - anaphylaxis, atopy
Hypersensitivity examples II (7)
II - ITP, Goodpasture’s, pernicious anaemia, haemolytic anaemia, RhF, pemphigus/ pemphigoid
Hypersensitivity examples III (3)
III - SLE, post strep GN, extrinsic allergic alveolitis acute
Hypersensitivity examples IV (6)
IV - TB, graft versus host, allergic contact dermatitis, extrinsic allergic alveolitis chronic, scabies, Guillian Barre
What makes lateral epicondylitis worse? (movements)
Wrist extension with the elbow extended
Supination with the elbow extended
Lateral epicondylitis
How long do the sx last for?
6 months to 2 years
Acute pain 6-12 weeks
Lateral epicondylitis Mx (4)
Avoid muscle overload
Simple analgesia
Steroid injection
Physiotherapy
Marfans
AD or AR
Gene + chromosome
AD
FBN1 gene chromosome 15
Tall stature
Long fingers (arachnodactyly)
High arched palate
Pectus excavatum
Scoliosis
Heart: dilatation of aortic sinuses
Lungs: repeated pneumothoraces
Eyes: upward lens dislocation, blue sclera, myopia
Marfan’s
AR type V glycogen storage disease
Muscle pain and stiffness following exercise
Muscle cramps
Myoglobinuria
Low lactate levels during exercise
Mc Ardle’s disease
MTX rules around pregnancy
men and women should avoid pregnancy for 6 months
MTX - what should be taken with it?
5mg once weekly - at least 24 hours post MTX
MTX - which meds should be avoided? (3)
Trimethoprim
Co-trimoxazole
High dose aspirin
Mx MTX toxicity
Folinic acid
OA XR findings (4)
Loss of joint space
Subchrondral sclerosis
Subchondral cysts
Osteophytes
RA XR findings (4)
Loss of joint space
Juxta-articular oseteoporosis
Periarticular erosions
Subluxation
OA Mx
CHECK AGAINST NICE
- Paracetamol + topical NSAIDs (knee and hand for topical NSAIDs)
- PO NSAIDs/ COX2 inhib, opioids, capsaicin cream, intra-articular steroids + PPI
Blue sclera
Deafness secondary to otosclerosis
Dental imperfections
Osteogenesis imperfecta
What is osteomalacia?
Mx
Softening of the bones secondary to low vitamin D
Mx vitamin D supplementation
Osteomalacia findings on XR
Translucent bands (Loosers zones or pseudofractures)
How long does sciatica symptoms last for?
4-6 weeks
What is temporal arteritis?
Characteristic histology
Large vessel vasculitis overlapping with PMR
Skip lesions
Temporal arteritis
Age
Onset
Sx (5)
> 60yo
Rapid < 1 month
Headache
Jaw claudication
Tender, palpable temporal artery
Visual symptoms
50% have PMR
Other:
Lethargy, low grade fever, anorexia, night sweats, depression
Temporal arteritis Ix
(3)
Raised ESR >50
CRP raised
Biopsy - skip lesions
Temporal arteritis Mx (1)
If visual symptoms (2)
High dose PO pred if no visual symptoms
If visual symptoms IV methylprednisolone
Urgent ophthalmology review - same day
Bisphosphonates are required
Mx of patient with fragility fractures
>=75yo
<75
=>75yo who have had a fragility fracture without DEXA can be started on bisphosphonates
If under 75, then arrange a DEXA and use FRAX assessment which determines whether someone should have a bisphosphonate
Name 6 RF that the FRAX assessment tool uses
Alcohol
RA
Steroid use
FH of fracture
BMI
Smoking
Name 6 medications that can worsen osteoporosis other than steroids
Aromatose inhibitors eg anastrazole
Heparin long term
Glitazones
PPIs
Antiepileptics
SSRIs
What is the Z score on a DEXA scan?
Bone mass adjusted for age, gender and ethnicity
T score interpretation
> -1 = normal
-1 to - 2.5 = osteopaenia
< - 2.5 = osteoporosis
When does the risk of osteoporosis with steroid use rise significantly?
7.5mg/day for 3 months or more
Mx of patient’s at risk of steroid induced osteoporosis
Who gets immediate bone protection (2) and who requires a DEXA? (1)
Bone protection if:
1. >65yo
2. Prev fragility fracture
DEXA
1. <65
How to interpret a DEXA result with patients at risk of steroid induced osteoporosis
T score >0 - reassure
0 to -1.5 repeat scan in 1-3 years
> - 1.5 bone protection
Osteoporosis management (5)
Vit D and calcium supplementation should be offered to all women unless replete
- Alendronate - common SE GI
- Risedronate or etidronate
- Strontium ranelate and raloxifene (if bisphosphonates are not tolerated)
- Denosumab
Raloxifene
MOA
Can worsen what symptoms?
Increased risk of?
Decreased risk of?
selective oestrogen receptor modulator
can worsen menopausal symptoms
increased risk of VTE
decrease breast ca
Strontium ranelate
Who can prescribe?
Increased risk of
Secondary care
Increased risk of CVD and VTE
How often in denosumab given?
Every 6 months SC injection
How often is ibandronate given?
Every month
Name four RF for Paget’s disease of the bone
Male
Increasing age
Northern latitude
FH
Stereotypical presentation for Paget’s disease of the bone
Older male with bone pain and isolated raised ALP
Bowing of the tibia
Bossing of skull
Thickened vault
Early mixed lytic/sclerotic lesions later
Paget’s
Blood results Paget’s
ALP, Ca, phos
ALP raised
Normal Ca + phos
Mx Paget’s
Bisphosphonates - PO risdronate or IV zoledronate
Paget’s complications (5)
Deafness
Sarcoma
Fractures
Skull thickening
High output cardiac failure
Vasculitis
Affects medium sized arteries with necrotizing inflammation which can lead to aneurysms forming
polyarteritis nodosa (PAN)
Polyarteritis nodosa
Gender
Age
Associated with which condition
Middle aged men
Hep B
Polyarteritis nodosa
Features (9)
Antibodies
Associated with which condition
Fever, malaise arthralgia
Weight loss
HTN
Mononeuritis multiplex, sensorimotor polyneuropathy
Testicular pain
Livedo reticularis
Haematuria
Renal failure
ANCA 20% of pts
Hep B serology +ve in 30% of pts
PMR
Age
Onset
Symptoms
Ix
Rx and dose
> 60
Rapid onset <1 month
Morning stiffness in proximal limb muscles
Low grade fever, anorexia, depression, mild polyarthralgia, night sweats
ESR >40
CK and EMG normal
Rx pred 15mg OD
What is polymyositis?
Which type of cell is it mediated by?
Associations (1)
Gender and age
Inflammatory disorder causing symmetrical proximal muscle weakness.
T cell mediated
Associated with malignancy
Middle aged females
Polymyositis features (6)
Proximal muscle weakness
Dysphagia
Dysphonia
Raynauds
Respiratory muscle weakness
Interstitial lung disease
Polymyositis
Blood test (4)
Antibodies
Elevated CK, LDH, AST and ALT
Anti-Jo1
