Rheumatology Flashcards
Presentation of osteoarthritis
Pain and stiffness worst at the end of the day
Pain on movement
Crepitus
Features to look for on exam for osteoarthritis
DIP Heberden’s nodes
PIP Bouchard’s nodes
Pain in stiffness in thumbs, MCP, knees
Limited ROM
Findings on XRay for osteoarthritis
Loss of joint space
Osteophytes
Subchondral cysts
Subarticular sclerosis
Management of osteoarthritis
Weight loss Exercise/physio/walking aids Topical NSAIDs Corticosteroid/hyaluronic acid injections Surgical joint replacement
Presentation of rheumatoid arthritis
Pain/swelling Morning stiffness Deformity Raynaud's/nodules Dyspnoea Peripheral neuropathy Anaemia symptoms Fatigue
Targeted examination for rheumatoid arthritis
Wrist swelling/deviation MCP swelling Ulnar deviation/subluxation Swan neck/boutonnaire's/Z-thumb Palmar erythema Fixed flexion Nodules Temperature Grip strength and functional tests
Diagnosis of rheumatoid arthritis
4 or more Arthritis of 3 or more joints Rheumatoid nodules Morning stiffness Radiographic changes Arthritis of hand joints Positive rheumatoid factor Symmetrical arthritis
Blood findings in rheumatoid arthritis
Low Hb High ESR Rheumatoid factor and anti-CCP antibodies
Which score is used to monitor rheumatoid arthritis?
DAS28
Includes ESR and number of tender and swollen joints
Management of rheumatoid arthritis
PT and OT NSAIDs Methotrexate, sulfasalazine and hydroxychloroquine Infliximab Steroids in acute flares Surgical joint replacement
Side effects of rheumatoid arthritis medication
Methotrexate: pneumonitis, hepatoxicity, oral ulcers
Sulfasalazine: rash, oligospermia, oral ulcers
Hydroxychloroquine: retinopathy
Infliximab: infections
Presentation of ankylosing spondyloarthritis
Young male Low back pain worse at night, morning stiffness relieved by exercise Loss of spinal movements Tendon inflammation and uveitis HLA-B27
Investigations for ank spond
Bloods:ESR, HLA-B27
MRI
Management of ank spond
Exercise
NSAIDs
ANti TNF-a blockers if severe (humira/adalimumab)
Local steroid injections for short term relief
Presentation of psoriatic arthritis
Affects 10-40% of those with psoriasis
Symmetrical polyarthropathy or asymmetrical oligoarthropathy
Skin and nail changes
Onycholysis and dactylitis
Management of psoriatic arthritis
NSAIDs
Methotrexate/sulfsalazine/ciclosporin
Anti TNF-a if severe
Presentation of reactive arthritis
1-4 weeks following urethritis or dysentery
Reiter’s syndrome: urethritis, conjunctivitis, arthritis
Management of reactive arthritis
Rest and splint affected joints
NSAIDs/local steroid injection
Consider methotrexate
Define SLE
Multisystem autoimmune disease characterised by B-cell secretion of autoantibodies to a variety of autoantigens which form immune complexes. More common in females
Syndromes commonly associated with SLE
Sjogrens
Antiphospholipid
Autoimmune thyroid disease
Features of SLE (4 required for diagnosis)
Discoid rash Lupus nephritis Arthritis Malar rash ANA +ve Serotitis (pleuritis/ pericarditis) Immunological (antidsDNA/ Anti-SM) Photosensitivity Haemolytic anemia/leukopenia Oral ulcers Neurological (seizures/psychosis)
Which drugs can induce SLE
Procainamide
Hydralazine
Diltiazem
Isoniazid
Haematological findings in SLE
Normocytic anaemia or haemolytic anaemia High ESR but normal CRP Low platelets and WBC ANA +ve Anti-dsDNA +ve Anti SM +ve Low C3 and C4
Management of SLE
Acute flares: IV cyclophosphamide and high dose prednisolone
Maintenance: NSAIDs, steroids, methotrexate or azathioprine, warfarin for hypercoagulability
Sunscreen
Presentation of anti-phospholipid syndrome
Coagulation defect
Livedo reticularis
Obstetric (recurrent miscarriage)
Thrombocytopenia
What is psoriasis characterised by
Epidermal proliferation
Inflammatory infiltration of the dermis and epidermis by TNF-alpha, activated T-cells, macrophages and dendritic cells
Risk factors psoriasis
Stress Skin trauma Drugs (lithium, NSAIDs) Alcohol/smoking Obesity Family history
Other diseases associated with psoriasis
Inflammatory arthritis Inflammatory bowel disease Uveitis Coeliac disease Metabolic syndrome
Management of psoriasis
Remove triggers-discuss control not cure
Mild: calcipotriol and betamethasone cream
Emolliants
Salicyclic acid
Moderate/severe: phototherapy or methotrexate
Biologics if no improvement
Difference between scleroderma and systemic sclerosis
Scleroderma: autoimmune skin fibrosis
Systemic sclerosis: scleroderma + vasculitis
Types of systemic sclerosis
Limited cutaneous systemic sclerosis (CREST): anti-centromere, limited to face hands and feet
Diffuse cutaneous systemic sclerosis: anti-topoisomerase
Presentation of CREST syndrome
Thickening of fingers, tight skin (prayer sign) Telangiectasia Raynaud's GORD Calcinosis on extensor surfaces
Investigations for systemic sclerosis
Bloods
Renal function
Echo
Pulmonary function tests (for interstitial lung disease)
Management of systemic sclerosis
Smoking cessation Methotrexate/mycophenylate Sildenafil for raynauds Prednisone Monitor FBC, renal function and echo
Risk factors for Sjogren’s syndrome
Female, 20s, scleroderma, RA, SLE
Presentation of sjogren’s syndrome
Kerratoconjunctivitis Altered swallow/taste Decreased salivation Parotid swelling Arthralgia
Investigations for Sjogren’s
Schimer’s Test
Test of conjunctival dryness (<5mm in 5 mins)
Check RF ANA anti-RO
Salivary gland biopsy
Management of Sjogren’s
Treat symptoms (eye drops, lozenges, gum, pilocarpine) Treat vasculitis with prednisone or IV IG Avoid dentures over night, avoid anti-cholinergics and anti-histamines
What is polymyositis/dermatomyositits?
Polymyositis is immune-mediated striated muscle inflammation
Dermatomyositis is polymyositis plus cutaneous involvement
Presentation of polymyositis/dermatomyositis
Symmetric progressive proximal muscle weakness
Gottron papules
Shawl sign (rash over shoulders, chest and back)
Heliotrope rash (dusky red periorbital rash)
Investigations for polymyositis/derm
Raised serum creatinine kinase and anti-Jo antibodies
Electromyography
Muscle biopsy
MRI for muscle oedema/fibrosis and checking for malignancy
Management of poly/derm
Screen for malignancy
High dose prednisone for acute flares
Derm manifestations just moisturiser/sunscreen
Azathioprine Methotrexate
IVIG in severe cases
Follow up with rheum and regular assessment of pulmonary and cardiac involvement
Risk factors for gout
Seafood, meat, beer, obesity, diuretics, dehydration
Presentation of gout
Rapid onset pain
50% 1st MTP
Red, hot, swollen, tender
Can be mono or oligo
Investigations for gout
Arthrocentesis (negative birefringent needles)
Raised WBC and serum urate
Xray
Criteria for diagnosis of gout
Monosodium urate crystals in joint fluid and developed within one day Monoarthritis with redness 1st MTP involved Tophi Abnormal swelling on xray
Management of gout
Acute flare: naproxen/colchine/prednisone
Prevention: allopurinol
Lose weight and improve diet
Presentation of polymyalgia rheumatica
Bilateral morning stiffness in neck/shoulders/pelvis
Low grade fever and fatigue
Response to steroids
Associated with giant cell arteritis
Investigations for polymyalgia rheumatica
CRP, ESR, serum electrophoresis (rule out myeloma)
Normal CK
Management of polymyalgia rheumatica
Prednisone Colecalciferol Alendronate Warn patient of GCA symptoms Monitor monthly
Presentation of giant cell arteritis
Headache
Scalp tenderness
Jaw claudication
Monocular blindness
Investigations for GCA
ESR
FBC
Temporal artery biopsy-treat first
Management of GCA
Start prednisone 1mg/kg first if high suspicion of GCA
Begin aspirin 75mg OD when confirmed
Monitor because increased aneurysm risk
Presentation of fibromyalgia
Chronic diffuse pain
Chronic fatigue
Cognitive dysfunction
Sleep and mood disturbance
How to diagnose fibromyalgia/investigate
Diagnosis of exclusion all bloods normal
Tender in 11/18 spots
Management of fibromylagia
Amitriptyline Gabapentin CBT Exercise Education
