Rheumatology Flashcards
pain in first 15 degrees of arm abduction?
supraspinatus
pain in 60-120 degrees of arm abduction
glenohumeral joint , deltoid
pain in final 10 degrees of arm abduction?
ACJ
what joints are commonly affected in OA
DIP (heberdens nodes), 1st MCP (thumb base), knees also PIP (bouchards nodes)
cardinal signs of arthritis (5)
pain, stiffness, swelling, deformity, loss of function
x ray features of OA
osteophytes, loss of joint space, sub articular sclerosis (dense lesion), subchondral cysts (lucent lesions)
describe the presentation of RA
symetrical small joints
morning stiffness lasting over 1 hour
spares DIP
which joints does RA commonly affect
MCP and PIP
wrist
MPJ (base of big toes) and ankle
PIP flexion with DIP hyperextension - what deformity?
Boutonniere
PIP extension with DIP flexion - what deformity?
swan neck
list extra articular features of RA (by system)
neuro: radiculopathies, CTS
resp: nodules, fibrosis, effusions
cardio: pericarditis, myocarditis, valve disease, increased risk of CVD
Derm: rheumatoid nodules, palmar erythema
heam: felty’s (neutropenia, anaemia, splenomegaly), pernicious anaemia, anaemia of chronic disease, iron deficiency, haemolytic, microscytic, vasculitis (and raynaud’s)
opthal: sjogren’s, keratoconjunctivitis, episcleritis, keratitis, uveitis
investigations in RA and imaging findings
ESR, CRP, platelets, ferritin, anti-ccp, RF (all raised)
x ray: soft tissue swelling, sub articular osteopenia (lucency), subluxation, joint space narrowing
MRI and USS - synovitis and erosions
how can you measure RA progression
DAS 28 (disease activity score) >5.1 = active and <3.2 = controlled
management of RA
DMARD (methotrexate) within 3 months of sx
- needs PFT’s, LFTs and FBC monitoring and folic acid
2nd line - infliximab (TNF alpha), rituximab (B cell)
- need infection screen and contraception
corticosteroids in acute flares
what disease are people with RA more prone to
lymphoma and CVD (atherosclerosis)
what joints does gout commonly affect?
1st MTP (base of thumb) knee, elbow, wrist
where do tophi commonly form in gout?
pinna (ear)
what does thenar wasting suggest?
median nerve pathology
what does hypothenar wasting suggest?
ulnar nerve pathology (ulnar claw)
investigations in gout
needle aspiriation of synovial fluid- negatively bifrimget needle shaped crystals
gram stain and culture
uric acid
xray
management of gout
NSAIDs (colchicine if cant have nsaids)
allopurinol Px
risk factors for pseudogout
elderly, illness, dehydration, surgery, steroid use
investigations in pseudogout
synovial fluid aspiration - positively bifringent rhomboid shaped crystals and neutrophils
chondrocalcinosis on x ray and linear opacification of articular cartilage
what clinical presentation os specific to seronegative arthropathy?
dactylitis
presentation and signs in ank spond
enthesitis and synovitis (esp achilles tendon), morning stiffness, reduced forward lumbar flexion (Schober’s test <5cm), tender sacroiliac joints, reduced chest expansion, anterior uveitis, IBD (UC), aortic regurge
investigations in ank spond
HLA b27 testing
MRI
Xray: sacroiliitis, erosions, sclerosis, vertebral syndesmophytes, bamboo spine
absence of ANA and RF
what drug may help in ank spond
TNF alpha blockers - enteracept
what joints does psoriatic arthritis affect and what does imaging show
DIP
erosions and pencil in a cup appearance on x ray (Mutilans)
what is reiters syndrome
conjunctivitis, urethritis, arthritis
what is reactive arthritis
sterile mono/oligoarthritis 1-4 weeks following STI/GI infection
what must you do to rule out septic arthitis
aspitiation and culture
what signs are highly predictive of a connective tissue diease
mouth ulcers
raynauds
list the signs and symptoms of SLE
SOAP BRAIN MD Serositis (pleuritis/pericarditis) Oral ulcers Arthritis - non erosive, >2 peripheral joints Photosensitivity Blood - anaemia, leucocytopenia, thrombocytopenia Renal - proteinuria ANA +ve Immunological (anti DNA, anti sm, anti phospholipid, low complement) Neuro - seizures, psychosis, depression Malar rash (in acute cutaneous) Discoid rash (chronic cutaneous)
systemically unwell, raynauds, thrombosis
list the drugs which cause SLE
isoniazid, hydralazine, chlorpromazine, phenytoin, methyl dopa
management of acute and chronic SLE
IV cyclophosphamide and prednisolone
hydroxychloroquine an steroids for maintenance
diagnosis of antiphospholipid syndrome
CLOT
Coagulation - thrombosis (cerebral and renal)
Livedo reticularis
Obstetric complications
Thrombocytopenia (low platelets, raised APTT)
antibodies (anti cardiolipin, lupus anticoagulant) present 12 weeks apart
what antibodies are present in sjogren’s (implications for fetus)
ANA, RF (very high), ESR, anti ro and anti la cause fetal heart block
investigations in sjrogrens
antibodies (RF, ANA, anti ro and anti la)
schirmer’s test, sialometry, salivary gland biopsy
ESR
management of sjogren’s and review
annual - risk of lymphoma and vasculitis
dental review
artificial tears and saliva
describe the limited cutaneous form of systemic sclerosis
CREST - subcutaneous calcinosis, raynauds, oesophageal and gut dysmotility, Sclerodactyly (face and hands only), telangiectasia
organ fibrosis - pulmonary HTN
anti centromere Abs
describe the diffuse cutaneous form of systemic sclerosis
scleroderma on arms face legs and trunk
fibrosis of organs
renal crisis: accelerated HTN, headache, oliguria
describe polymyositis and investigations
pelvic girdle weakness (cant get out of chair)
dysphagia - pharyngeal weakness
interstitial lung disease
muscle breakdown: CK, ALT, AST, LDH, biopsy
Anti Jo
describe dermatomyositis and investigations
Rash over neck and back - shawl sign
gottron’s papules over MCP
systemic symptoms
anti Mi2 and muscle biopsy
what is behcet’s disease and management
oral and genital ulcers
non erosive arthritis
eye and skin lesions
1-2 years steroids
example of large vessel vasculitis
Giant cell arteritis, takyasus
example of medium vessel arteritis
polyarteritis nodosa, kawasakis
example of small vessel vasculitis (and descriptions)
ANCA positive:
polyangiitis (glomerulonephritis and pulmonary hemorrhage
Churg strauss (eosinophilia, granulomatous inflammation, vasculitis - asthma, sinusitis, mononeuritis multiplex, haemoptysis, haematuria)
granulomatosis polyangiitis (ENT, lungs, kidneys - C-ANCA P3)
ANCA negative:
cryoglobulinemia
HSP - abdo pain, rash, arthritis, nephrotic syndrome
goodpasture’s - glomerulonephritis and pulmonary hemorrhage
what is polymyalgia rheumatica associated with?
GCA
presentation of PMR
bilateral pain and stiffness in arms and legs
cant brush hair/ get out of chair
where does GCA affect
aorta, cerebral arteries, temporal artery
investigations in GCA
ESR and biopsy
ANCA , C3, C4
what is takayasu’s arteritis and how does it present
granulomatous inflammation of aorta and its branches in asian women under 40 stenosis, occlusion, aneurysm, stroke unequal BP/absent pulses = occlusion need CT angiography
what is polyarteritis nodosa and presentation
vasculitis causing tissue ischaemia
associated with hepatitis B
what must you screen regularly is on hydroxyxhloyquine
eyes - maculopathy
what is fibromyalgia associated with and how can you assess it
hypermobility
beighton score /9
- knees, elbows, finger, thumb, trunk
diagnosis of fibromyalgia
11/18 tender points
