Rheumatology Flashcards
What features in the history would you expect to see in a patient with gout?
Severe pain in a single joint (usually big toe) Acute onset (typically <24 hours, often overnight) with episodes lasting 1-2 weeks
What features would you expect to see on examination of a patient with gout?
Tender, red, hot, swollen joint
Tophi (chalky deposits) typically in the digits or over the elbow
Marked swelling with red, shiny skin
What investigations would you carry out in a patient with suspected gout?
Baseline LFT and renal function Serum rate levels X-ray of symptomatic joints Screen patients for cardiovascular risk factors Synovial aspirate (in secondary care)
What criteria scoring system is used to diagnose gout?
The Nijmegen criteria (score >7 = 80% chance of gout)
Describe the factors and scores used in the Nijmegen criteria
Male sex: 2
Previous reported arthritis attack: 2
Onset within 1 day: 0.5
Joint redness: 1
First metatarsophalangeal joint involvement: 2.5
Hypertension/>1 cardiovascular risk factor: 1.5
Serum uric acid >0.35mmol: 3.5
How is a definitive diagnosis of gout made?
Identification of urate crystals in synovial fluid or tophi aspirate
Name 3 key differential diagnoses for gout
Septic arthritis Pseudo-gout (secondary to chondrocalcinosis) Psoriatic arthritis (severe psoriasis can cause elevated urate).
When would you refer a patient with suspected gout?
You are unsure if they have septic arthritis/other differential
Patient is resistant to treatment
Mechanism of action of allopurinol
Xanthine oxidase inhibitor (XO prolongs activity of 6-mercptopurine)
When is urate lowering therapy indicated?
Patients with tophi, erosions or recurrent gout attacks (>2/year), renal impairment, nephrolithiasis or on diuretics
Which patients should allopurinol doses be reduced in?
Elderly patients
Patients with impaired renal function
Patients with impaired hepatic function
Mechanism of action of Benzbromarone
Uricosuric - urate excretion therapy
Why can benzbromarone only be used in hospital?
Rare side effect of hepatotoxicity
Guidelines state that serum urate levels should be ?? to achieve rapid clearance of urate crystals and ?? to achieve adequate maintenance
<0.3mmol/L
<0.36mmol/L
How long should you wait after starting urate lowering therapy to recheck serum urate levels, and why?
2 weeks, as 50% of gout patients will have normal urate levels during an attach due to the effect of inflammation on urate excretion
What is the prophylactic treatment used to prevent gout flares?
Allopurinol 100mg daily increased by 100mg every 4 weeks until target serum uric acid reached, side effects occur or maximum dose is reached
What are the side effects of colchicine?
Diarrhoea, colic
What patients is colchicine contra-inidicated in?
Patients with renal or hepatic impairment who are taking a P-glycoprotein inhibitor or a strong CYP34A inhibitor
What medication should be used to treat gout in patients intolerant of colchicine?
Low dose NSAIDs
What lifestyle changes can be made to prevent gout attacks?
Reduce/remove diuretics
Reduce alcohol intake to within recommended limits
Gradual weight loss to ideal body weight
Avoid sweetened, sugary beverages and rich foods
What features would you expect to see in the history of someone with a connective tissue disorder?
Photosensitive skin rash Polyarthritis/polyarthralgia affecting small joints Pleurisy Pericarditis Muscle pain/weakness Dyspnoea Severe Raynaud's Seizures/focal neurological defects Psychosis Mouth ulcers Dry mouth, dry eyes Hair loss Recurrent miscariage
What features would you expect to see on examination a patient with a connective tissue disorder?
Skin rash Synovitis Mouth ulcers Scarring alopecia Sclerodactyly Raynaud's (with digital ulceration) Telangiectasia Pleural or pericardial effusion
What investigations would you perform in a patient with suspected connective tissue disease?
FBC & ESR (will show raised ESR, anaemia, leukopenia and thrombocytopenia)
Immunology (will show ANA +++, anti dsDNA +, extricable nuclear antigen (ENA) +
When should you consider referral of a patient with suspected connective tissue disorder
Patient with several (<4) symptoms
Patient with signs and have a + ANA and sDNA antibody