Rheumatology Flashcards
Polymyalgia Rheumatica
Generalised ache, tenderness, morning stiffness in shoulders/proximal limbs, mild poly arthritis, tenosynovitis, carpal tunnel, fatigue, weight loss, depression
Ix: CRP, ESR, plasma viscosity
Tx: pred 10-15mg -dramatic respond in 4days, reduce dose + gastric and bone protection for long term steroid use
Causes of monoarthritis
Septic arthritis
Gout/pesudogout
OA
Trauma eg haemarthrosis
Symmetrical polyarthropathies
RA
OA
viral
Asymmetrical polyarthropathies
Reactive arthritis
Psoriatic arthritis
X-RAY features of OA
LOSS Loss of joint space Osteophytes Subarticular sclerosis Subchondral cysts
X-RAY features of RA
Justa-articular osteopaenia
Soft tissue swelling
Joint deformity
Loss of joint space
X-RAY features of gout
Peri articular erosions
Normal joint space
Soft tissue swelling
Features of OA
Affects larger joint eg hip, knee
Crepitus, worse and end of day
Stiffness after rest, joint instability
Pain at rest
Features of OA hand
Heberedens nodes at DIP
Bouchards nodes at PIP
Mainly affected DIP
OA management
Exercise and weight loss Paracetamol and topical NSAIDS Oral NSAID/ codeine +PPI Topical capsaicin Intra articular steroids/hylauronic acid injections Heat/cold patches, TENS Joint replacement
Septic arthritis
Acute inflamed joint
Often in pre-existing joint disease eg OA, or DM, immunosupressed
Needs urgent synovial fluid microscopy and culture
Start empirical ABx after aspiration
Commonly staph
If v bad may have to refer to ortho for lava get and debridement
Features of RA
Symmetrical Swollen, stiff, painful small joints, worse in morning MCP/MTP, PIP, wrist Tenosynovitis or bursitis Atlanta-axial subluxation
Features of RA hand
Ulnar deviation Dorsal wrist subluxation Boutonnière and swan neck deformity Z thumb Extensor tendon rupture
Extra articular features of RA
Nodule - lungs and elbows Lymphadenopathy Vasculitis Lungs: fibrosising alveolitis, obliterative bronchiolitis, pleural/pericardial effusion Raynauds/carpal tunnel Peripheral neuropathy Splenomegaly (Epi)scleritis Keratocnojunctivitis Wicca Osteoporosis
RA Ix
RF - higher title=worse disease ACPA/antiCCP Anaemia of chronic diseas X-RAY USS/MRI
RA treatment
Calculate DAS28
early DMARDS/biologicals
Gout presentation and features
Acute monoarthropathy
MTP of big toe, ankle, foot, hand, wrist, elbow
Monosodium urate crystals
Precipitated by trauma, starvation, infection, duirecfics
Ax with renal disease
Causes of gout
Diabetes Diuretics Leukemia Chemo Dietary routines Alcohol excess
Gout Ix
Microscopy of synovial fluid - negatively bifringent urate crystals
Raised serum urate but can be normal
Treatment of acute gout
High dose NSAID eg diclofenac
If CI Cochicine
Steroids
Gout prevention
Address lifestyle
Start prophylaxis if >1 attack/year or tophi, renal stones
Allopurinol at least 3w after acute episode. Titration against plasma urate
Cover with 6w NSAID or 6m colchicine when starting
Don’t stop in acute gout attack
Febuxosta is alternative
Pesudogout
Calcium pyrophosphate Tends to be larger joints than gout Usually self limiting Ax w/ hyperparathyroidism, haemochromatosis Microscopy - positive bifringent Rest, NSAIDs or steroids
Ankylosing Spondyltiis
30yr old man
Low back pain, morning stiffness, worse at night, better with exercise
Radiates to hips/buttocks
Loss of spinal movement
Question mark spine - neck hyperextension+kyphosis
Extra articular features of ank spond
Enthusiastic eg Achilles tendonitis, plantar fasciitis Acute iritis Osteoporosis Aortic valve incompetence Pulmonary fibrosis
Ankylosing spondylitis Ix
Clinical diagnosis X-ray - sacroilitis, bamboo spine Normocytic anaemia Raised ESR, CRP HLA B27
Ankylosing Spondylitis Tx
Exercise Physic NSAIDS TNF alpha blockers Steroid injection Bisphosphonates
Psoriatic arthritis
DIP, spinal (like AS)
X-RAY - erosive pencil in cup
Synovial sand nail changes
Can present before skin psoriasis
Reactive arthritis
Sterile arthritis
Lower limbs 1-4weeks after chlamdyia, campylobacter, shigella
+- iritis, keratoderma, brown patches on soles and palms, balanitis, mouth ulcers, enethesis
No specific treatment, just manage joints and treat cause
CREST syndrome/ limited cutaneous systemic sclerosis
Limited to face, hands and feet
ACA (anti centromere)
Pulmonary hypertension
ACE, cyclophosphamide
Diffuse cutaneous systemic sclerosis
All skin Organ fibrosis Scl70 antibodies/anti RNA Needs regular echo and spirometeery Terrible prognosis
ACE, cyclophosphamide
Polymyositis/dermatomyositis
Proximal muscle weakness and striated muscle inflammation Myalgia and arthralgia Dysphagia, dysphonia Autoimmune but can be paraneoplastic Purple rash on eyelids (heliotrope) Macular 'shawl' rash Test muscle enzymes Prednisolone
SLE
Anti ANA, anti dsDNA Low C3, C4 Lymphadenopathy Fatigue Malagia Fever Rash - discoid/malar
Cyclophosphamide, prednisolone
Anti phospholipid syndrome
Ax with SLE
CLOTS: coagulation, livedo recticularis, obstetric, thrombocytopenia
Give low dose aspirin/warfarin
Polyarteritis nodosa
Necrotising vasculitis causes aneurysms and thrombosis
Ulcers and rash
Causes significant renal impairment
Cyclophosphamide
