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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
What is the presentation of AnkSpon?
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
26
What is the most common extraarticular manifestation of ankylosing spondylitis?
Osteoporosis
27
How would you come to a diagnosis of AnkSpon?
Mostly clinical HLA-B27 in 95% DEXA scan and CXR
28
What is the management of AnkSpon?
Conservative: Exercise and physio Medical: NSAIDs, steroids, anti-TNF therapy, bisphosphonates Surgery: Hip replacement
29
What are the different patterns of joint involvement in psoriatic arthritis?
All Old Paulines Suck Dick ``` A - Arthritis mutilans O - Oligoarthritis (asymmetrical) P - Polyarthritis (symmetrical) S - Spinal D - DIP distal arthritis ```
30
What are the other features of psoriatic arthritis?
Psoriatic plaques Nail changes - pitting, hyperkeratosis, onchyolysis Enthesitis Dactilitis
31
What are the X-ray findings of arthritis mutilans?
Pencil in cup deformity
32
What is the treatment for psoriatic arthritis?
NSAIDs Sulfasalazine/methotrexate/ciclosporin Anti-TNF
33
What is reactive arthritis?
A sterile arthritis 1-4 weeks after urethritis (chlamydia) or dysentry (campy, sal, shig, yers)
34
What are the features of reactive arthritis?
``` Asymmetric lower limb oligoarthritis Anterior uveitis, conjunctivitis Keratoderma blenorrhagica - plaques on soles/palms Circinate balanitis Enthesitis Mouth ulcers ```
35
RF
Sjogrens Feltys RA
36
ANA
SLE AIH Sjogrens
37
dsDNA
SLE
38
Histone
Iatrogenic lupus
39
Centromere
CREST
40
Ro
SLE, Sjogrens
41
La
SLE, Sjogrens
42
Sm
SLE
43
RNP
SLE, Mixed CTD
44
Jo-1
Polymyo/Dermatomyositis
45
Scl70
Diffuse systemic sclerosis
46
What are the features of Behcets disease?
``` Turk, Mediterranean, Japanese origin Recurrent oral and genital ulcerations Uveitis Erythema nodosum Vasculitis Large joint oligoarthropathy ```
47
Rx for Behcet's?
Immunosuppression
48
How do we classify sjogrens?
Primary (M.F 9:1) | Secondary - RA, SLE, CREST
49
What are the features of Sjogren's syndrome?
``` Dry eyes Xerostomia Bilateral parotid enlargement Vaginal dryness Polyarthritis Raynauds Pulm fibrosis Vasculitis Myositis ```
50
How would you investigate and treat Sjogrens?
Ix: Schirmer tear test, ANA, Ro, La, RF Abs Hypergammaglobulinaemia Parotid biopsy Rx: Artificial tears, salifa replacement, NSAIDs, immunosuppression
51
What are the features of systemic sclerosis?
``` CREST Calcinosis Raynauds Oesophageal dysmotility Sclerodactyly Telangectasia ```
52
What is the difference between limited and diffuse sclerosis?
Skin involvement in limited SS is confined to the hands, face and feet
53
How might you investigate systemic sclerosis?
``` 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
What is the management of systemic sclerosis?
Cons: Exercise and lubricants, handwarmers ``` Med: Immunosuppression Raynauds - CCBs, ACEi, IV prostacyclin Renal: Intensive BP control Oesophageal@ PPIs, metoclopramide (prokinetic) PHT- Sildenafil ```
55
What are the principal features of polymyositis?
Progressive symmetrical proximal muscle weakness with wasting of the shoulder and pelvic girdles Dysphagia Myalgia and arthralgia Often paraneoplastic
56
What are the skin manifestations in dermatomyositis?
``` Heliotrope rash on eyelids Malar rash (+ Shawl sign) Nailfold erythema Gottrons papules (elbows, knuckles, knees) Mechanical hands Retinopathy Subcut calcifications ```
57
What are the extramuscular manifestations of dermatomyositis?
``` Fever Arthritis Basal pulm fibrosis Raynauds Myocarditis/arrhythmias ```
58
How would you investigate poly/dermatomyositis?
``` Muscle enzymes: CK predominantly raised, also AST, ALT, LDH Anti-Jo1 EMG Muscle biopsy malignancy screen ```
59
Management of polymyositis?
Immunosuppresion
60
What are the features of SLE?
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
How is SLE disease activity monitored?
Anti-dsDNA titres Complement (C3, C4 depletion) ESR
62
What are some causes of drug induced lupus, and which autoantibody is typical?
Procainamide, phenytoin, hydralazine, isoniazid Anti-histone (100%)
63
What are the features of antiphospholipid syndrome?
CLOTS - venous and arterial Coagulopathy Livido reticularis Obstetric complications Thrombocytopaenia
64
What is the management of SLE/APS?
Severe acute flare - IV pred and IV cyclophosphamide Cutaneous - topical steroids Maintenance - NSAIDs and hydroxychloroquine Lupus nephritis - ACEi +-immunosuppression
65
What are the complications of Lupus?
Osteoporosis | CV disease
66
Which vasculitides are pANCA associated with?
Eosinophilic granulomatosis with polyangiitis | Microscopic polyangiitis
67
Which vasculitides are cANCA associated with?
Granulomatosis with polyangiitis
68
What is the Ix and Rx of GCA?
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
What is the typical presentation of polymyalgia rheumatica?
``` >50yos Sever pain and stifness in shoulders, neck and hips Worse in morning NO weakness Constitutional signs may be present ```
70
Which vasculitis is associated with polymyalgia rheumatica?
GCA
71
Which investigations and findings would you see in PMR?
Massively raised ESR and CRP Raised ALP NORMAL CK
72
What are the features of Takayasu's arteritis?
The pulesless disease Constitutional symptoms Weak pulses in upper extremities Visual disturbances HTN
73
What are the features of Granulomatosis with Polyangiitis?
URT, LRT, Renal URT - Sinusisit, epistaxis, saddle nose LRT - Cough, haemoptysis, pleuritis Renal - Glomerulonephritis, haematuria, proteinuria cANCA
74
What are the features of Eosinophilic Granulomatosis with Polyangiitis?
Late onset asthma Eosinophilia Renal disease pANCA
75
What are the features of Goodpastures disease?
Anti-GBM Abs Rapidly progressive glomerulonephritis Haemoptysis Bilateral lower zone infilatrates
76
What are the features and management of fibromyalgia?
``` 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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