Rheumatology Flashcards
1
Q
Rheumatoid Arthritis
Functions of Synovium (4)
A
Maintenance of intact tissue surface
Lubrication of cartilage
Control of synovial fluid volume and composition (neutrophils in acute flares)
Nutrition of chondrocytes within joints
2
Q
Rheumatoid Arthritis
Effect on joint (4)
A
Erosion into corner of bone
Thinning of cartilage
Inflamed tendon sheath
Inflamed synovium spreading across joint surface
3
Q
Rheumatoid Arthritis
Definition (2)
A
A chronic symmetric polyarticular inflammatory joint disease
The rheumatoid synovial fluid contains neutrophils in acute flares and can cause bone and cartilage destruction
4
Q
Rheumatoid Arthritis
Autoimmunity (4)
A
Evidence of autoimmunity can be present many years before onset of clinical arthritis
Autoantibodies such as RFs and anti-citrullinated protein antibodies are associated with RA
The autoantibodies recognise either joint antigens or systemic antigens
Autoantibodies activate a complement
5
Q
Rheumatoid Arthritis
Cells involved in disease perpetuation (4)
A
Cytokine networks involving TNF-am IL-6 and B-cells participate in disease perpetuation
Osteoclasts and fibroblast-like synoviocytes mediate bone and cartilage destruction
Inflammatory cytokines promote angiogenesis and autoantibody production and activate leukocytes
IL-6 mediates systemic effects
6
Q
Rheumatoid Arthritis
Signs + symptoms
A
Typical presentation: symmetrical swollen, painful and stiff small joints, worse in morning and can fluctuate and effect larger joints Tenosynovitis/bursitis Later there is joint damage and deformity: ulnar deviation of fingers and dorsal wrist subluxation, Boutonniere and swan neck finger deformity or Z-deformity of thumbs Pain Immobility Stiffness Systemic symptoms Swelling Tenderness Redness Heat Limitation of movement
7
Q
Rheumatoid Arthritis Systemic consequences (9)
A
Vasculitis Nodules (elbows + lungs) Scleritis Raynaud's Carpal tunnel syndrome Osteoporosis Amyloidosis Anaemia of chronic disease Increased risk of cardiovascular disease as atherosclerosis is accelerated
8
Q
Rheumatoid Arthritis
Investigations (7)
A
Rheumatoid factor (+ve 70%)
Anticyclic citrullinated peptide (anti-CCP) highly specific (98%)
High platelets
High ESR
High CRP
X-ray (LESS)
Ultrasound and mRI better at identifying synovitis
9
Q
Rheumatoid Arthritis
X-ray findings (4)
A
Loss of joint space
Erosions
Soft tissue swelling
Soft bones (osteopenia)
10
Q
Rheumatoid Arthritis
Disease activity score (3)
A
DAS28 used to measure activity
Assesses tenderness and swelling at 28 joints, ESR and patient’s self-reported symptom severity
Aim to reduce score to <3
11
Q
Rheumatoid Arthritis
Treatment (4)
A
Early use of DMARDs and biologics improves long-term outcomes
Steroids: rapidly reduce symptoms and inflammation
NSAIDs: good for symptom relief
Physio and OT
12
Q
Rheumatoid Arthritis
DMARDs (4)
A
1st line
Take 6-12 weeks for symptomatic benefit
Eg. methotrexate, sulfasalazine, ,hydroxychloroquine
Causes: immunosuppression (can result in pancytopenia, increased susceptibility to infection and neutropenic sepsis so regular FBC monitoring required)
13
Q
Rheumatoid Arthritis
Biologics (6)
A
1st anti-TNF adalimumab
Start biologics after failure, intolerance to at least 2 DMARDs
2nd ani-TNF infliximab, etanercept
3rd B cell depletion rituximab
4h anti IL-1 or IL-6 eg. tocilizumab (anti IL-6) or anakinra (anti IL-1)
5th T cell co-stimulator inhibitor eg. abatacept
14
Q
Septic Arthritis
Routes of infection (3)
A
Haematogenous
Eruption of bone abscess
Direct invasion- penetrating wound, athroscopy, indwelling IV
15
Q
Septic Arthritis
Organisms (4)
A
Staph aureus
Streptococci
Neisseria gonococcus
Gram -ve bacilli
16
Q
Septic Arthritis
Pathology (3)
A
Acute synovitis with purulent joint effusion
Articular cartilage attacked by bacterial toxin and cellular enzymes
Complete destruction of articular cartilage
17
Q
Septic Arthritis Risk factors (8)
A
Pre-existing joint disease (especially RA) Diabetes Immunocompromised Chronic renal failure Recent joint surgery Prosthetic joints IVDU Age >80
18
Q
Septic Arthritis
Signs + symptoms (2)
A
Knee affected in >50% of cases
Acutely inflamed joint
19
Q
Septic Arthritis Differential diagnoses (4)
A
Acute osteomyelitis
Trauma
Rheumatic fever
Gout
20
Q
Septic Arthritis
Investigations (4)
A
Urgent joint aspiration for synovial fluid microscopy and culture
X-ray (but may be normal)
CRP (but may be normal)
Blood cultures (guidance for antibiotics)
21
Q
Septic Arthritis
Treatment (3)
A
Antibiotics: flucloxacillin/clindamycin , vancomycin if MRSA, cefotaxime if gonococcal or gram -ve
Antibiotics for 2 weeks IV, 2-4 weeks orally
Orthopaedics: arthocentesis, lavage and debridement
22
Q
Ankylosing Spondylitis
Definition (3)
A
Seronegative arthritis
Chronic inflammatory disease of the spine and sacroiliac joints
Typical patient is a man <30
23
Q
Ankylosing Spondylitis
Signs + symptoms (6)
A
Gradual onset of low back pain, worse at night, with spinal morning stiffness relieved by exercise
Pain radiates from sacroiliac joints to hips/buttocks and usually improves towards the end of the day
Associated with osteoporosis
Progressive loss of spinal movement, hence reduced thoracic expansion
Acute iritis in 1/3 and may lead to blindness
Enthesitis (inflammation of site of tendon/ligament insertion into bone): achilles tendonitis, plantar fasciitis
24
Q
Ankylosing Spondylitis
Examination (3)
A
Schober’s test
Lateral neck flexion
Kyphosis
25
Ankylosing Spondylitis
| Investigations (7)
MRI
X-ray: sacroiliitis earliest feature, erosions, sclerosis
Vertebral syndesmophytes (often T11-L1 initially): bony proliferations due to enthesitis between ligaments and vertebrae
FBC (normocytic anaemia)
High ESR
High CRP
HLA B27 +ve
26
Ankylosing Spondylitis
| Treatment (6)
Physiotherapy to maintain posture and mobility
NSAIDs (ibuprofen/naproxen) to relieve symptoms
TNF-a blockers: adalimumab, etanercept ,infliximab
Local steroid injections for temporary relief
Surgery eg. hip replacement/spinal osteotomy
Consider bisphosphonates for increased risk of spinal fractures
27
Gout
| Signs + symptoms (3)
Typically acute monoarthropathy with severe joint inflammation
>50% occur at MTP of big toe
Other common joints: ankle, foot, small joints of hand, wrist, elbow or knee
28
Gout
| Pathology (4)
Caused by deposition of monosodium urate crystals in and near joints
Often precipitated by trauma, surgery, starvation, infection or diuretics
High plasma urate
In the long term, urate deposits (tophi eg. in pinna, tendons, joints) and renal disease (stones, interstitial nephritis) may occur
29
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Gout
Differential diagnoses (4)
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Septic arthritis
Haemarthrosis
Pseudogout
Palindromic RA
30
Gout
| Aetiology (6)
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Hereditary
High dietary purines
Alcohol excess
Diuretics
Leukaemia
Also associated with cardiovascular disease, hypertension,diabetes and chronic renal failure
```
31
Gout
| Investigations (3)
Polarised light microscopy of synovial fluid: negatively bifringent urate crystals (needle-shaped)
Increased serum urate
Radiographs only show soft-tissue swelling in the early stages, later 'punched out' erosions in juxta-articular bone
32
Gout
| Treatment of acute attack (3)
High-dose NSAIDs (symptoms should subside in 3-5 days)
Steroids may be used
Rest, ice and elevation
33
Gout
| Treatment as prophylaxis (4)
Start if >1 attack in 12 months, tophi or renal stones
Aim is to reduce attacks and prevent damage caused by crystal deposition
Allopurinol (titrate up until plasma urate <0.3mmol/l)
Use of allopurinol may trigger an attack so wait until 3 weeks after an acute episode
34
Pseudogout
| Signs + symptoms (2)
Acute monoarthropathy typically of larger joints in elderly patients
Usually spontaneous and self-limiting but can be provoked by illness, surgery or trauma
35
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Pseudogout
Risk factors (3)
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Old age
Hyperparathyroidism
Haemochromatosis
36
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Pseudogout
Investigations (2)
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Polarised light microscopy of synovial fluid shows weakly positive bifringent crystals (rhomboid shaped calcium pyrophosphate dihydrate crystals)
X-ray (soft tissue calcium deposits)
37
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Pseudogout
Treatment (2)
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Treatment of acute attack: cool packs, rest, aspiration and intra-articular steroids
Treatment as prophylaxis: NSAIDs may prevent acute attacks
38
Enteric Arthropathy
| Associations (3)
Inflammatory bowel disease
GI bypass
Coeliac and Whipples disease
39
Enteric Arthropathy
| Treatment (2)
Arthropathy often improves with the treatment of bowel symptoms
DMARDs for resistant cases
40
Psoriatic Arthritis
| Epidemiology (1)
Occurs in 10-40% with psoriasis and can present before skin changes
41
Psoriatic Arthritis
| Signs + symptoms (5)
```
Symmetrical polyarthritis
DIP joints
Asymmetrical oligoarthritis
Spinal (similar to ank spond)
Thickened nails with pits/ridges
```
42
Psoriatic Arthritis
| Investigations (1)
X-ray: erosive changes with deformity
43
Psoriatic Arthritis
| Treatment (5)
```
NSAIDs
DMARDs: methotrexate, sulfasalazine
Biologics if failure or intolerance of at least 2 DMARDs
Adalimumab 1st
Then 2nd anti-TNF etnarcept/infliximab
```
44
Reactive Arthritis
| Pathology (4)
Sterile arthritis
Typically affects lower limb
1-4 weeks after urethritis (chlamydia) or dysentery (campylobacter, salmonella)
May be chronic or relapsing
45
Reactive Arthritis
| Extra-articular symptoms (3)
Iritis
Keratoderma blenorrhagia (brown plaques on soles and palms)
Mouth ulcers
46
Reactive Arthritis
| Investigations (4)
High ESR and CRP
Culture stool if diarrhoea
Infectious serology
Sexual health review
47
Reactive Arthritis
| Treatment (4)
NSAIDs
Local steroid injections
Consider sulfasalazine/methotrexate if symptoms >6 months
Treating the original infection may make little difference to arthritis
48
Systemic Sclerosis
| Definition (1)
Multisystem autoimmune condition, also known as scleroderma
49
Systemic Sclerosis
| Pathology (2)
Vascular features: widespread vascular damage involving small arteries, arterioles and capillaries, initial endothelial damage with release of cytokines causing vasoconstriction, the damage also produces widespread obliterative arterial lesions and subsequent chronic ischaemia
Fibrotic features: fibroblasts synthesis collagen, causing fibrosis in the lower dermis of the skin as well as the internal organs
50
Systemic Sclerosis
| Signs + symptoms (7)
Raynaud's
Tight skin over face, small mouth and beaky nose
Telangiectasia
Oesophageal dysmotility/stricture
Intestinal malabsorption, hypomotility
Thickened skin
Lung disease (pulmonary hypertension in limited and pulmonary fibrosis in diffuse)
51
Systemic Sclerosis
| Limited cutaneous systemic sclerosis (4)
70% of cases
CREST: Calcinosis (subcutaneous tissues)< Raynaud's, Esophageal dysmotility, Sclerodactyly (swollen tight digits)< Telangiectasia
Skin involvement is limited to the face, hands and feet
Pulmonary hypertension
52
Systemic Sclerosis
| Diffuse cutaneous systemic sclerosis (5)
30% of cases
Diffuse skin involvement
Raynaud's
Early organ fibrosis (lung, cardiac, GI and renal) occurs with general symptoms of lethargy, anorexia and weight loss
Renal involvement can cause an acute hypertensive renal crisis
53
Systemic Sclerosis
| Investigations (9)
FBC: normocytic anaemia
U&E + creatinine: raised in AKI
Anticentromere antibodies (ACAs) associated with limited systemic sclerosis
Anti-Scl70 associated with diffuse systemic sclerosis
RhF +ve in 30%
ANA +ve in 95%
CXR + HRCT to investigate lung involvement
Barium swallow to investigate oesophageal dysmotility
Anti-Ro antibodies
54
Systemic Sclerosis
| Treatment (4)
Monitor BP and renal function (regular ACE-i reduces risk of renal crisis)
Raynaud's: hand warmers, nifedipine or other oral vasodilators
Immunosuppression eg. cyclophosphamide
Moisturise affected skin
55
Polymyositis
| Definition (2)
Rare disorder of unknown cause
| Inflammation of striated muscle, causing proximal muscle weakness
56
Polymyositis
| Signs + symptoms (7)
```
Proximal muscle weakness
Myalgia +/- arthralgia
Dysphagia
Dysphonia
Respiratory weakness
Fever
Malaise
```
57
Polymyositis
| Investigations (6)
Serum creatinine kinase elevated
Elevated ESR + CRP
Electromyography (EMG) shows fibrillation potentials
Muscle biopsy confirms diagnosis
MRI: muscle oedema and inflammation
Screen for malignancy (CX, mammography, pelvic/abdo US) as may be paraneoplastic phenomenon
58
Polymyositis
| Treatment (2)
Prednisolone
| If resistant: azathioprine, methotrexate
59
Dermatomyositis
| Definition (1)
Polymyositis with skin involvement
60
Dermatomyositis
| Signs + symptoms (4)
Features of polymyositis
Macular rash
Lilac-purple (heliotrope) rash on eyelids often with oedema
Roughened red papules over knuckles
61
Dermatomyositis
| Investigations (5)
```
High CK
High ESR + CRP
EMG shows fibrillation potentials
Muscle biopsy
Screen for malignancy
```
62
Dermatomyositis
| Treatment (3)
Prednisolone
If resistant: azathioprine, methotrexate
For skin: hydroxychloroquine or topical tacrolimus
63
Systemic Lupus Erythematosus
| Definition (2)
Multisystemic autoimmune disease in which autoantibodies are made against autoantigens eg. ANA
Much more common in women (particularly of child-bearing age)
64
Systemic Lupus Erythematosus
| Signs + symptoms (9)
Malar rash (butterfly)
Discoid rash (erythematous raised patches)
Photosensitivity
Oral ulcers
Non-erosive arthritis (>2 peripheral joints, similar to RA)
Serositis: pleuritis, pericarditis
Renal disorder: proteinuria, cellular casts
CNS disorder: seizures or psychosis
Haematological disorder: haemolytic anaemia or leukopenia or thrombocytopenia
65
Systemic Lupus Erythematosus
| Investigations (6)
```
95% are ANA +ve
Anti-dsDNA (highly specific)
40% are RF +ve
Anti-Sm antibody
Bloods: FBC, U&E, LFT, CRP + urinalysis
High ESR
```
66
Systemic Lupus Erythematosus
| Treatment (5)
Topical steroids for rashes
High factor sunblock creams
NSAIDs and hydroxychloroquine as maintenance for joint and skin symptoms
Azathioprine/methotrexate or low dose steroids
Severe: rituximab
67
Vasculitis
| Definition (2)
Inflammatory disorder of blood vessel walls, causing destruction (aneurysm/rupture) or stenosis
Can affect the vessels of any organ, presentation depends on which
68
Vasculitis
| Categories (5)
Large: giant cell arteritis , Takayasu's arteritis
Medium: polyarteritis nodosa, Kawasaki disease
Small ANCA +ve: glomerulonephritis, Wegener's granulomatosis
Small ANCA -ve: Henoch-Schonlein purpura, Goodpasture's syndrome
Malignancy associated
69
Vasculitis
| Signs + symptoms (7)
Systemic: fever, malaise, weight loss, arthralgia
Skin: purpura, ulcers
Eyes: episcleritis, scleritis, visual loss
Pulmonary: haemoptysis, dyspnoea
Cardiac: angina/MI (coronary arteritis)
GI: pain/perforation
Renal: hypertension, haematuria, proteinuria, casts, renal failure
70
Vasculitis
| Investigations (6)
```
High ESR
High CRP
ANCA (often +ve)
High creatinine if renal failure
Urinalysis: protein + haematuria
Angiography +/- biopsy: diagnostic
```
71
Vasculitis
| Treatment (2)
Steroids
| Azathioprine may be useful as steroid sparing
72
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Fibromyalgia
Risk factors (5)
```
```
Female (10:1 F:M)
Middle aged
Low household income
Divorced
Low educational status
```
73
Fibromyalgia
| Associations (4)
Chronic fatigue syndrome
IBS
Chronic headache syndromes
Found in 25% with RA, SLE, AS
74
Fibromyalgia
| Signs + symptoms (10)
Pain that is chronic (>3 months)
Pain that is widespread in the absence of inflammation
Pain on palpation of min. II/18 tender points, eg. suboccipital muscle insertions, post. greater trochanter
Morning stiffness
Fatigue
Poor concentration
Low mood
Sleep disturbance
Allodynia (pain in response to non-painful stimulus)
Hyperaesthesia (exaggerated perception of pain in response to a mildly painful stimulus)
75
Fibromyalgia
| Investigations (2)
All normal
| Just exclude other causes of pain/fatigue eg. RA, vasculitis, hypothyroidism, myeloma
76
Fibromyalgia
| Treatment (5)
Education on coping strategies and inform about relapsing and remitting course
CBT
Long-term graded exercise programmes
No response to NSAIDs or steroids as no inflammation
Low dose TCAs (eg. amitriptyline/pregabilin) + tramadol
77
Raynaud's Syndrome
| Definition (1)
Peripheral digit ischaemia due to paroxysmal vasospasm, precipitated by cold/emotion
78
Raynaud's Syndrome
| Aetiology (8)
```
Idiopathic- Raynaud's disease
Underlying cause- Raynaud's phenomenon
Connective tissue disease- SLE, RA, systemic sclerosis, dermato/polymyositis
Occupational- vibrating tools
Obstructive- obstruction, atheroma
Blood- thrombocytosis, polycythaemia rubra vera
Drugs- B blockers
Hypothyroidism
```
79
Raynaud's Syndrome
| Signs + symptoms (2)
Fingers/toes ache and change colour
| Pale (ischaemia) --> blue (deoxygenation) --> red (reactive hyperaemia)
80
Raynaud's Syndrome
| Investigations (1)
Rule out causes
81
Raynaud's Syndrome
| Treatment (3)
Keep warm
Stop smoking
Nifedipine
82
Sjogren's Syndrome
| Definition (3)
Chronic inflammatory autoimmune disorder
Primary: mostly females in 4th-5th decade
Secondary: associated with connective tissue disease such as RA, SLE, systemic sclerosis
83
Sjogren's Syndrome
| Pathology (1)
Lymphocytic infiltration and fibrosis of exocrine glands, especially lacrimal and salivary glands
84
Sjogren's Syndrome
| Signs + symptoms (10)
```
Reduced tear production (dry eyes, keratoconjunctivitis sicca)
Reduced salivation
Parotid swelling
Other glands affected causing vaginal dryness, dry cough, dysphagia
Raynaud's
Lymphadenopathy
Vasculitis
Peripheral neuropathy
Fatigue
```
85
Sjogren's Syndrome
| Investigations (5)
```
Anti-Ro
Anti-La
ANA usually +ve
RhF may be +ve
Biopsy shows focal lymphocytic aggregation
```
86
Sjogren's Syndrome
| Treatment (3)
Treat sicca symptoms eg. hypromellose (artificial tears), frequent drinks
NSAIDs + hydroxychloroquine for arthralgia
Immunosuppressants in severe systemic disease
87
Juvenile Idiopathic Arthritis
| Criteria for diagnosis (3)
Age of onset <16
Duration of disease >6 weeks
Presence of joint swelling or 2 of the following: painful/limited joint movement, tenderness, warmth
88
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Juvenile Idiopathic Arthritis
Clinical subtypes (3)
```
```
Pauciaticular/oligoarticular (55%)- 4 or less joints
Polyarticular (25%)- 5 or more joints
Systemic onset (20%
```
89
Juvenile Idiopathic Arthritis
| Pauciarticular Type 1 (7)
```
Always before age 5, peak 1-3
Girls:Boys 8:1
Presentation: limp rather than pain
Mainly LL joints
Knee > ankle > hand/elbow
+ve ANA in 40-75%
Chronic uveitis in 20% of cases (95% if female <2 years), asymptomatic in 50%
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90
Juvenile Idiopathic Arthritis
| Pauciarticular Type 2 (5)
```
Age: after 8-9
Girls:Boys 1:7
Presentation: limp
Mainly LL joints: knee, ankle, hip can be affected early
Acute iridocyclitis in 10-20%
```
91
Juvenile Idiopathic Arthritis
| Pauciarticular Type 3 (6)
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Any age during childhood
Girls:Boys 4:1
Presentation: asymmetric UL + LL arthritis, dactylitis
Chronic iridocyclitis in 10-20%
Can be very destructive arthritis
Family history of psoriasis in 40%
```
92
Juvenile Idiopathic Arthritis
| Pauciarticular Extended Arthritis (1)
30% of those presenting with pauciarticular JIA can go on to develop more severe polyarticular course
93
Juvenile Idiopathic Arthritis
| Polyarticular Rheumatoid Factor -ve (4)
Any age, often early
Girls:Boys 9:1
Presentation: constitutional (fever, malaise), hepatosplenomegaly, anaemia, growth abnormalities
Symmetric large and small joints (knees, wrists, ankles, MCPs, PIPs, neck)
94
Juvenile Idiopathic Arthritis
| Polyarticular Rheumatoid Factor +ve (5)
```
Late childhood 12-16 years
Girls:Boys 7:1
Presentation: constitutional (fever, malaise, weight loss), anaemia, nodules
Similar to adult RA
Erosions on X-ray
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95
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Juvenile Idiopathic Arthritis
Systemic Onset (6)
```
Most serious short and long term morbidity and mortality
Extra-articular features (fever in evenings but normal in morning, rash on trunk/thighs, lymph nodes, hepatosplenomegaly, abdo pain, pericarditis)
Arthritis only in 75% wtihin 3-12 months of onset of fever, effects wrists, knees, ankles, cervical spine, hips and TMJ
20% of JIA
Age: 4-6
AKA Still's Disease
96
Juvenile Idiopathic Arthritis
| 1st line therapy (2)
NSAIDs
| Joint steroid injections
97
Juvenile Idiopathic Arthritis
| 2nd line therapy (1)
Methotrexate
98
Juvenile Idiopathic Arthritis
| 3rd line therapy (3)
Anti-TNFa (eg. adalimumab, infliximab)
Anti-IL-6 for systemic arthritis (eg. tocilizumab)
Anti IL-1 receptor for systemic (eg. anakinra)
99
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Osteoporosis
Bone metabolism (7)
```
Continuous turnover of bone
Osteoblasts: bone building
Osteocytes: regulate osteoblasts + osteoclasts
Osteoclasts: bone resorption
Low extracellular Ca stimulates parathyroid hormone which promotes resorption
Vit D converted to calcitriol in response to elevated PTH
Calcitriol increases calcium absorption in the gut and kidneys, stimulates osteoclasts
100
Osteoporosis
| Epidemiology (1)
1/3F and 1/5M have an osteoporotic fracture at some point
101
Osteoporosis
| Aetiology (8)
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Age
Hypothyroidism
Hypo/hyperparathyroidism
Cushings
Malabsorption
Myeloma
Rheumatic diseases
Drugs (steroids, warfarin, PPIs)
```
102
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Osteoporosis
Risk factors (6)
```
```
Steroids
RA
Alcohol excess
Low BMI
Smoking
Premature menopause + early menarche
```
103
Osteoporosis
| Signs + symptoms (3)
Asymptomatic until fracture occurs
Fracture on low impact/minor trauma
Commonly fracture neck of femur if older or Colles fracture if younger/fitter
104
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Osteoporosis
Differential diagnoses (2)
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Osteomalacia
| Myeloma
105
Osteoporosis
| Investigations (2)
DEXA scan hip and spine: T score based on bone mass, normal >-1, osteopenia -1 to -2.5, osteoporosis
106
Osteoporosis
| Treatment (7)
Fracture prevention if T score
107
Polymyalgia Rheumatica
| Epidemiology (2)
>50 0
| F:M 2:1
108
Polymyalgia Rheumatica
| Signs + Symptoms (6)
```
Subacute (<2 weeks) onset
Shoulder +/- pelvic girdle stiffness but no weakness
Anaemia
Weight loss
Fever
Depression
```
109
Polymyalgia Rheumatica
| Investigations (2)
FBC: normochromic, normocytic anaemia
ESR: >50
110
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Polymyalgia Rheumatica
Differential diagnoses (3)
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Recent onset RA
Hypothyroidism
Osteoarthritis
111
Polymyalgia Rheumatica
| Treatment (1)
Oral prednisolone with PPI and bisphosphonate as treatment is prolonged
