Rheumatology Flashcards
What is the general assessment method for rheumatological complaints?
Gait Arms Legs Spine
What should be examined when a patient with back pain presents?
Look at back statically and with AP and lat flexion and extension Push on spine and sacroilliac joints Neuro exam of lower limbs (sensation, reflexes, power) Consider PR for tone Examine nerve root pain (straight leg test) Signs of generalised disease and abdo exam
What investigations could be considered in back pain and why?
MRI (prolapse, cord compression, inflammation, tumour) FBC, ESR, CRP (infection, tumour, myeloma) Serum/urine electorphoresis (myeloma) PSA (tumour) U+E and ALP (pagets)
In what different ways can RA present with joint pains?
Typical - small joint swelling, stiffness and pain sparing DIP, worse in the morning Sudden onset widespread Palindromic - moving around various joints either polyarthritis or monoarthritis Persistent monoarthritis
What systemic features can be present in RA?
Lung and elbow nodules Fatigue Fever Weight loss Pericarditis Pleurisy Lymphadenopathy Fibrosing alveolitis Raynauds Carpel tunnel syndrome Peripheral neuropathy Episcleritis Scleritis Keritoconjuctivits sicca
What are the typical hand deformities of RA? Where else may they occur?
Ulnar deviation Boutonnieres Swan neck deformities
What is the eponomous conditions associated with RA?
Feltys syndrome - RA + splenomegally + neutropenia Caplans syndrome - RA lung nodules + coal workers pneumoconiosis
What blood tests are used in RA? Which is sensitive and which is specific?
RF - 70% sensitivity Anti CCP - 98% specificity
What do xrays show on RA?
Loss of joint space Juxta-articular osteopenia Marginal erosions Soft tissue swelling
What scale is used to monitor progress in RA? What is the aim?
Disease Activity Score 28 Swelling or tenderness at 28 joints including PIP, MCP, knees, shoulders, elbows and wrists. ESR and patients reported severity as,so considered. Aim is a score of
Acute treatment options for RA
NSAIDs Steroids - IM, oral, interarticular
What disease modifying treatments are appropriate for RA?
Methotrexate Hydroxychloroquinine Sulfasalazine
When should biological agents be used in RA? Which can be used?
Failure to respond to dmards with DAS28 >5.1 1st line - TNFalpha inhibitors - infliximab 2nd line - B cell depletors - rituximab 3rd line - IL1/IL6 inhibition - tocilizumab OR tcell disruptors - acatacept
Side effects of methotrexate
Hepatic failure Pneumonitis Oral ulcers
Side effects of sulfasalazine
Rash Decreased sperm count Oral ulcers
Side effects of hydroxychloroquinine
Irreversible retinopathy with blindness
What other autoimmune condition often occurs secondary to rheumatoid arthritis?
Sjogrens syndrome
What is sjogrens syndrome?
Autoimmune reaction against glands
Symptoms of sjogrens?
Dry eyes (keratoconjunctivitis sicca) Corneal ulceration Dry mouth Dental caries Dry vagina Dry skin Raynauds Arthralgia Fatigue
What test is used for keratoconjunctivitis sicca?
Schirmers tear test
What autoantibodies are raised in sjogrens?
ANA Anti ro Anti la
Treatment options for sjogrens?
Artificial tears Saliva replacement Hydroxychloroquinine for arthralgia or fatigue Corticosteroids for severe exacerbations
What is antiphospholipid syndrome?
Autoantibodies against phospholipids on apoptotic bodies
Signs and symptoms of antiphospholipid syndrome
Arterial and venous thrombi Recurrent miscarriage
Positive blood tests in antiphospholipid syndrome
Lupus anticoagulant test persistantly positive
Treatment options for antiphospholipid syndrome
If thrombus formation warfarin When pregnant aspirin and sc heparin
Signs and symptoms of fibromyalgia
Constant pain above and below waist Aching Tender trigger points Fatigue Depression Sleep disturbance Associated IBS Headaches
Treatment of fibromyalgia
Reassurance Exercise Depression treatment Pain relief
Good pain relief meds in fibromyalgia
Amitriptyline Gabapentin Nsaids
What is the pathological mechanism of gout?
Hyperuricaemia leads to intra articular sodium urate crystals in cartilage. Stress (dehydration, surgery, alcohol) triggers shedding of crystals into joint resulting in inflammation,
Broad categories of causes of hyperuracemia. Which is a more common cause of gout?
Impaired excretion (90%) Increased production
Causes of impaired excretion of uric acid causing hyperuricaemia and gout
CKD Thiazides Aspirin Lead toxicity Htn Dehydration
Causes of hyperuricaemia due to increased urate produciton
High protein diet Age Lactic acid (alcohol, exercise) Obesity Cell turnover (polycythaemia vera, leukaemia, tumour lysis, psoriasis)
Acute presentation of gout? Commonly effected joints?
Monoarthropaty, sudden agonising pain swelling and redness Usually lasting one week 1st MTPJ, ankle, wrist, finger, knee
Chronic presentation of gout
Tophi Chronic joint pain Kidney stones
Investigations in gout
Xray Serum urate Joint fluid asperation
What are tophi?
In gout Smooth red tender lumps filled with white fluid Found on joints, ears and achilles tendon
Treatment of acute gout attack
NSAIDs Colchicine Intraarticular corticosteroids
Big side effect of colchincine
Diarrheoa
Chronic treatment of gout
Dietary advice (decrease alcohol, cholesterol and spinach) Allopurinol if >3 attacks per year, tophi or renal calculi
Mechanism of allopurinol? What should be considered?
Blocks xanthine oxidase May induce acute attack so cover with colchicine
Risk factors for septic arthrits
Pre existing joint disease Diabetes Immunocompramised Joint replacement Ivdu
Typical organisms for septic arthritis
Staph aureus Neisseria gonorrheoa
Presentation of septic arthritis
Single joint Acute swelling redness and pain Systemic symptoms in about 50%
Tests in septic arthritis?
Aspiration with ms and c Fbc Blood cultures
Treatment of septic arthritis
Iv abx
Definition of chronic kidney disease”
Impaired renal function for more than three months based on abnormal structure or function OR GFR
Stages of CKD
1 - normal gfr, evidence of damage 2 - gfr 60-89, evidence of damage 3 - gfr 30-59 with or without damage 4 - gfr 15-29 with of without damage 5 - gfr
What is renal failure?
GFR
What is evidence of damage when assessing ckd?
Proteinuria Haematuria Abnormal anatomy Systemic disease
Causes of CKD
DM HTN Idiopathic Glomerulonephritis Pyleonephritis Adult polycystic kidney disease Renovascualr disease
What should be tested on a patient with suspected ckd?
Dipstick for urine Diabetes Htn Cvd Recurrent UTI For multi system disorders For structural disease
What element of history is important in a patient with a chronic kidney disease?
FHx
What symptoms may a ckd patient present with?
Uremia Ankle swelling Dysponea Oligourea Amenorrhea and impotance
Signs of ckd
Htn Fluid overload Purporia Ballotable kidney
Signs and symptoms of uremia
Anorexia Pruritus Uremic frost Vomiting Restless leg Fatigue Yellow tinged skin Pericarditis
Blood tests to run in a ckd patient
Glucose Fbc - anaemia U+es
What would a kidney with ckd usually look like on uss? What may cause them to be the opposite?
Usually small Infiltrative disorders like amyloidosis or myleoma
What tests should be done on urine with ckd?
Dipstick, ms and c, acr / pcr
When should a ckd patient have a biopsy?
Rapidly progressive or unclear cause in a large kidney
Complications of ckd
Cvd Anaemia Acidosis Bone mineral disorders Non bone calcifications Secondary and tertiary hyperparathyroidism
What bone mineral disorders occur with ckd?
Low calcium Osteomalacia Osteitis fibrosa cystica
What is osteitis fibrosis cystica
Low vit d so high pth so low calcium so bone reabsorption and cyst formation (2ndry hyperparathyroidism complication)
Treatment options in ckd?
Treat reversible cause Limit progression Symptom control Renal replacement therapy
How may reversible causes be treated in ckd?
Stop nephrotoxic drugs Control dm Relieve obstruction
How can ckd progression be slowed?
Lower bp Treat proteinuria with acei Prevent renal bone disease with calicum supplementation and vit d analoges Modify cvd risk with aspirin and statins
What treatment options are available for ckd anaemia?
Iron, b12 folate Epo
What treatment options are available for ckd oedema ?
Frusemide Fluid reatriction
When should renal replacement therapy be considered?
Symptomatic (pericaridits, encephalopathy, volume overload) Biochemical disturbance (acidosis, hyperkalaemia)
Why should preparation occur for rrt in ckd? When?
Mrtality higher if not preplanned When egfr
Types of rrt in ckd
Haemodialysis Haemofiltration Peritoneal dialysis Transplantation
Different between haemodialysis and haemofiltration
Heamodialysis - diffusion over semi permiable membrane Haemofiltration - pressure driven
Benefits of haemodialysis
Days off Low reposibility See others
Problems with haemodialysis
Hypotension, Time consuming Many meds Fistual issues
Benefits of peritoneal dialysis
Perform overnight Perform at home Better initial preservation of kidneys Less fluid and food restrictions
Problems with peritoneal dialysis
Peritonitis Adhesions Infections Eventually degraeds Leaks into scrotum Herniation
Benefit of haemofiltration
Fluids replaced so more haemo dynamically stable thus good on itu
Problems with kidney transplantation
Immunosupression Rejection Surgical problems
