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Scott's Notes > Rheumatology > Flashcards

Rheumatology Flashcards

1
Q

Monoarthritis differentials?

A

Osteoarthritis
Septic arthritis
Crystal arthritis
Trauma -> haemarthrosis

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2
Q

Oligoarthritis differentials? (<5)

A 
Osteoarthritis
Crystal arthritis
Ankylosing spondylitis
Psoriatic arthritis
Reactive arthritis
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3
Q

Polyarthritis differentials?

A

Symmetrical:
Rheumatoid arthritis
Osteoarthritis
Viral (Hepatitis)

Asymmetrical:
Reactive arthritis
Psoriatic arthritis

Either:
SLE
Sarcoid
Endocarditis

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4
Q

What would you send a joint aspiration for?

A

WCC
Gram stain and culture
Polarised light microscopy

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5
Q

What blood tests might you send for in a rheumatoid patient?

A 
FBC, UnE, ESR, CRP, urate
Culture
Abs: RF, ANA, lots
HLA-B27 
Viral serology/urine chlamydia PCR for reactive arthritis
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6
Q

What are the Xray findings of OA?

A

Loss of joint space
Subchondral sclerosis
Subchondral cysts
Osteophytes

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7
Q

What are the Xray findings of RA?

A 
Loss of joint space
Soft tissue swelling
Periarticular osteopaenia
Deformity 
Subluxation
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8
Q

What are the Xray findings of gout?

A

Normal joint space
Soft tissue swelling
Periarticular erosions

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9
Q

Back pain red flags?

A 
Age under 20 or over 50
Any Hx malignancy
Sphincter disturbance
Neurological impairment
Systemic illness
Infection
Thoracic pain
Morning stiffness
Acute onset in elderly people
Nocturnal pain
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10
Q

What are the causes of back pain?

A

Degenerative: Spondylosis, vertebral collapse, stenosis
Mechanical: Strain, pregnancy, trauma, disc prolapse, spondylolisthesis
Inflamm: AnkSpon, Pagets
Neoplasm: Mets or myeloma
Infection: TB, osteomyelitis, abscess

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11
Q

What is the management approach towards backpain?

A

Conservative: Max 2 days bedrest, education, physio, psychosocial, warmth

Medical: NSAIDs first line, cocodamol if C/I’d, short term diazepam if muscle spasms, joint injections

Surgical: Decompression, microdiscectomy (for prolapse)

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12
Q

What HLA type is seen in RA?

A

HLA DR4/DR1

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13
Q

What are the features of RA?

A

ANTI CCP ORF

Arthritis - symmetrical polyarthritis of MCPs, PIPs and feet

Nodules - Elbows and lungs

Tenosynovitis - De Quervains

Immune - AIHA, vasculitis, amyloid

Cardiac- pericarditis and pericardial effusion

Carpal tunnel syndrome

Pulmonary - Fibrosing alveolitis (lower zones), Pleural effusions (exudative), nodules

Opthalmic - 2ary Sjogrens, episcleritis

Raynauds

Felty’s - RA + splenomegaly + neutropaenia

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14
Q

What are the hand features of RA?

A

Affects the MCP, PIPs of hands and feet.
Morning stiffness which improves with exercise

Swan neck
Boutonniere (PIP flexion)
Z-thumb
Ulnar deviation of fingers
Dorsal subluxation of ulnar styloid
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15
Q

What investigations would you do for RA?

A

Bloods: anaemia, thrombocytopaenia, ESR, CRP, RF + in 70%, Anti-CCP + in 98%
Radiography, USS, MRI

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16
Q

What is the management of RA?

A 
Conservative
Refer
Exercise
PT
OT

Medical:
NSAIDs
Steroids
DMARDS (1st line) -methotrexate, sulfasalazine, hydroxychloroquine
Biologics - Anti-TNF(Infliximab, Etanercept, Adalimumab), Rituximab (CD20 mAb)

Also manage CV risk, osteoporosis and gastric ulcers

Surgical:
Ulna stylectomy
Joint prosthesis

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17
Q

What are the side effects of the DMARDs used for RA management?

A

Metho - Pulm fibrosis, hepatotoxicity, ac panc
Sulfasalazine - SJS, hepatotoxicity, ac panc
Hydroxychloroquine - retinopathy, seizures

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18
Q

What is the difference between podagra and tophi?

A

Podagra - monoarthritis in (usually) great toe MTP

Tophi - Urate deposits in pinna and tendons

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19
Q

What are the renal manifestations of gout?

A

Interstitial nephritis

Radiolucent stones

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20
Q

What are the causes of gout?

A

Drugs: diuretics, NSAIDs, pyrazinamide
Increase cell turnover states
EtOH excess
Purine rich foods

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21
Q

What are the investigations for gout?

A

Polarised light (negative needles)
Hyperuricaemia
X ray: Changes (punched out erosions in juxta articular bone) occur late

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22
Q

What is the management of gout?

A 
Acute: Diclofenac or Indomethacin. 
Colchicine
In renal impairment: Steroids
Chronic: Allopurinol
Weight loss and diet changes
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23
Q

Name four seronegative spondyloarthropathies

A

Psoriatic arthritis
Ankylosing spondylitis
Enteropathic arthritis
Reactive arthritis

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24
Q

What are the common features of seronegative spondyloarthropathies?

A

Axial arthritis and sacroiliitis
Asymmetrical large joint oligoarthritis or monoarthritis
Enthesitis
Dactylitis
Extra articular Fx:Uveitis, rashes, oral ulcers, AR, IBD

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25
Q

What is the presentation of AnkSpon?

A

Gradual onset back pain - SI joints into hip and buttocks, worst in morning relieved by exercise

Progressive loss of all spinal movements

Thoracic kyphosis and neck hyperextension

Enthesitis - Achilles tendonitis and plantar fasciitis

Costochondritis

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26
Q

What is the most common extraarticular manifestation of ankylosing spondylitis?

A

Osteoporosis

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27
Q

How would you come to a diagnosis of AnkSpon?

A

Mostly clinical
HLA-B27 in 95%
DEXA scan and CXR

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28
Q

What is the management of AnkSpon?

A

Conservative: Exercise and physio

Medical: NSAIDs, steroids, anti-TNF therapy, bisphosphonates

Surgery: Hip replacement

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29
Q

What are the different patterns of joint involvement in psoriatic arthritis?

A

All Old Paulines Suck Dick

A - Arthritis mutilans
O - Oligoarthritis (asymmetrical)
P - Polyarthritis (symmetrical)
S - Spinal
D - DIP distal arthritis
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30
Q

What are the other features of psoriatic arthritis?

A

Psoriatic plaques
Nail changes - pitting, hyperkeratosis, onchyolysis
Enthesitis
Dactilitis

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31
Q

What are the X-ray findings of arthritis mutilans?

A

Pencil in cup deformity

32
Q

What is the treatment for psoriatic arthritis?

A

NSAIDs
Sulfasalazine/methotrexate/ciclosporin
Anti-TNF

33
Q

What is reactive arthritis?

A

A sterile arthritis 1-4 weeks after urethritis (chlamydia) or dysentry (campy, sal, shig, yers)

34
Q

What are the features of reactive arthritis?

A 
Asymmetric lower limb oligoarthritis
Anterior uveitis, conjunctivitis
Keratoderma blenorrhagica - plaques on soles/palms
Circinate balanitis
Enthesitis
Mouth ulcers
35
Q

RF

A

Sjogrens
Feltys
RA

36
Q

ANA

A

SLE
AIH
Sjogrens

37
Q

dsDNA

A

SLE

38
Q

Histone

A

Iatrogenic lupus

39
Q

Centromere

A

CREST

40
Q

Ro

A

SLE, Sjogrens

41
Q

La

A

SLE, Sjogrens

42
Q

Sm

A

SLE

43
Q

RNP

A

SLE, Mixed CTD

44
Q

Jo-1

A

Polymyo/Dermatomyositis

45
Q

Scl70

A

Diffuse systemic sclerosis

46
Q

What are the features of Behcets disease?

A 
Turk, Mediterranean, Japanese origin
Recurrent oral and genital ulcerations
Uveitis
Erythema nodosum
Vasculitis
Large joint oligoarthropathy
47
Q

Rx for Behcet’s?

A

Immunosuppression

48
Q

How do we classify sjogrens?

A

Primary (M.F 9:1)

Secondary - RA, SLE, CREST

49
Q

What are the features of Sjogren’s syndrome?

A 
Dry eyes
Xerostomia
Bilateral parotid enlargement
Vaginal dryness
Polyarthritis
Raynauds
Pulm fibrosis
Vasculitis
Myositis
50
Q

How would you investigate and treat Sjogrens?

A

Ix: Schirmer tear test, ANA, Ro, La, RF Abs
Hypergammaglobulinaemia
Parotid biopsy

Rx: Artificial tears, salifa replacement, NSAIDs, immunosuppression

51
Q

What are the features of systemic sclerosis?

A 
CREST
Calcinosis
Raynauds
Oesophageal dysmotility
Sclerodactyly
Telangectasia
52
Q

What is the difference between limited and diffuse sclerosis?

A

Skin involvement in limited SS is confined to the hands, face and feet

53
Q

How might you investigate systemic sclerosis?

A 
Bloods; anaemia, renal impairment
Abs: Centromere=limited, Scl70/topoisomerase=diffuse
Urine: PCR
Imaging:
CXR - cardiomegaly, bibasal fibrosis
Hands - calcinosis
Ba swallow - impaired motility
HiRes CT
Echo - evidence of pulmonary HTN
54
Q

What is the management of systemic sclerosis?

A

Cons: Exercise and lubricants, handwarmers

Med:
Immunosuppression
Raynauds - CCBs, ACEi, IV prostacyclin
Renal: Intensive BP control
Oesophageal@ PPIs, metoclopramide (prokinetic)
PHT- Sildenafil
55
Q

What are the principal features of polymyositis?

A

Progressive symmetrical proximal muscle weakness with wasting of the shoulder and pelvic girdles

Dysphagia

Myalgia and arthralgia

Often paraneoplastic

56
Q

What are the skin manifestations in dermatomyositis?

A 
Heliotrope rash on eyelids
Malar rash (+ Shawl sign)
Nailfold erythema
Gottrons papules (elbows, knuckles, knees)
Mechanical hands
Retinopathy
Subcut calcifications
57
Q

What are the extramuscular manifestations of dermatomyositis?

A 
Fever
Arthritis
Basal pulm fibrosis
Raynauds
Myocarditis/arrhythmias
58
Q

How would you investigate poly/dermatomyositis?

A 
Muscle enzymes: CK predominantly raised, also AST, ALT, LDH
Anti-Jo1
EMG
Muscle biopsy
malignancy screen
59
Q

Management of polymyositis?

A

Immunosuppresion

60
Q

What are the features of SLE?

A

SOAPBRAIN MD

Serositis -pleuritis/pericarditis
Oral ulcers
Arthritis
Photosensitivity
Blood - pancytopaenia
Renal - proteinuria
ANA
Immunologic - dsDNA, Sm, phospholipid
Neuro - psych, seizures
Malar rash (spares nasolabial folds
Discoid rash
61
Q

How is SLE disease activity monitored?

A

Anti-dsDNA titres
Complement (C3, C4 depletion)
ESR

62
Q

What are some causes of drug induced lupus, and which autoantibody is typical?

A

Procainamide, phenytoin, hydralazine, isoniazid

Anti-histone (100%)

63
Q

What are the features of antiphospholipid syndrome?

A

CLOTS - venous and arterial

Coagulopathy
Livido reticularis
Obstetric complications
Thrombocytopaenia

64
Q

What is the management of SLE/APS?

A

Severe acute flare - IV pred and IV cyclophosphamide

Cutaneous - topical steroids

Maintenance - NSAIDs and hydroxychloroquine

Lupus nephritis - ACEi +-immunosuppression

65
Q

What are the complications of Lupus?

A

Osteoporosis

CV disease

66
Q

Which vasculitides are pANCA associated with?

A

Eosinophilic granulomatosis with polyangiitis

Microscopic polyangiitis

67
Q

Which vasculitides are cANCA associated with?

A

Granulomatosis with polyangiitis

68
Q

What is the Ix and Rx of GCA?

A

ESR and start pred 40-60mg/day PO
ESR and CRP both raised, as is ALP
Temporal artery biopsy within 3 days - beware skip lesions

Taper steroids gradually followed by 2 year course of PPI with bisphosphonate

69
Q

What is the typical presentation of polymyalgia rheumatica?

A 
>50yos
Sever pain and stifness in shoulders, neck and hips
Worse in morning
NO weakness
Constitutional signs may be present
70
Q

Which vasculitis is associated with polymyalgia rheumatica?

A

GCA

71
Q

Which investigations and findings would you see in PMR?

A

Massively raised ESR and CRP
Raised ALP
NORMAL CK

72
Q

What are the features of Takayasu’s arteritis?

A

The pulesless disease

Constitutional symptoms
Weak pulses in upper extremities
Visual disturbances
HTN

73
Q

What are the features of Granulomatosis with Polyangiitis?

A

URT, LRT, Renal

URT - Sinusisit, epistaxis, saddle nose

LRT - Cough, haemoptysis, pleuritis

Renal - Glomerulonephritis, haematuria, proteinuria

cANCA

74
Q

What are the features of Eosinophilic Granulomatosis with Polyangiitis?

A

Late onset asthma
Eosinophilia
Renal disease
pANCA

75
Q

What are the features of Goodpastures disease?

A

Anti-GBM Abs
Rapidly progressive glomerulonephritis
Haemoptysis
Bilateral lower zone infilatrates

76
Q

What are the features and management of fibromyalgia?

A 
Chronic widespread ache and tenderness
Morning stiffness
Fatigue
Poor concentration
Poor sleep
Low mood
Education
CBT
Exercise
Neuropathic pain management
Venlafaxine

Scott's Notes (21 decks)

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