Rheumatology Flashcards by John Darlington

Why is establishing the travel history for a rheumatology history important?

TB arthritis
- rare but important

TB history
- immunosuppressive drugs

G.I infections causing reactive arthritis

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Why is it important to establish use of anticoagulation in a rheumatology history?

A lot of drugs are given by injection

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What does anterior uveitis suggest?

Seronegative disease

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Where will S.I joint damage/ involvement radiate to? how does this contrast with hip involvement?

S.I = buttocks

Hip = groin

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Will gout give you a high CRP?

Yes very high

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How can you differentiate between a pre-patella bursitis and an intra-articular effusion?

Often there will be a history of cellulitis
Knee will move
Fluid will not be felt in joint
Large degree of swelling around the knee

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What is the standard treatment for septic arthritis?

2 weeks IV antibiotics
4 weeks oral
Wash out

*remember to take aspirate prior to antibiotics

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Why do you want U&Es in someone suspected with gout?

Renal function is one of the biggest predictors of gout

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Name 2 main investigations wanted in septic arthritis?

Blood cultures

Joint aspiration

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What are rheumatoid nodules heavily associated with?

Anti - CCP

Smoking

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Name two other conditions which are not RA that cause a RH factor increase?

Hep C
Lupus
Sjorgens

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In suspected septic arthritis, what tests do you want done on a joint aspiration?

Gram staining
Culturing
Crystal cytology

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What bloods do you want to request in someone with suspected septic arthritis?

FBC 
CRP 
U&Es 
Blood cultures
Lactate

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How is methotrexate delivered, and what are some important considerations?

Once weekly.
Subcut
With folic acid

CXR should be ordered prior to starting it.

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Outline the broad tests done to diagnose a rheumatological arthropathy:

Bloods:

FBC
LFTs (toxicity of drugs)
U&Es (Toxicity of drugs)
CRP/ ESR
Rh factor
Anti- CCP
Anti-nuclear (further testing if positive)

Imaging:

x-rays
MRI of joints
ultrasound (monitoring)

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What are the characteristic findings found on x-ray of RA:

Loss of joint space
Bony erosion
Soft tissue swelling
Osteopenia

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What substance should people on methotrexate avoid?

Alcohol

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What DMARD is safe during pregnancy? and list some common/ serious complications of the drug:

Sulfasalazine

*caution in use with aspirin as 5-ASA

Oligospermia
Stevens -Johnson syndrome
Pneumonitis
Myelosuppression

How would you monitor RA?

Disease Activity Score of 28 joints (DAS-28)

Ultrasound

CRP

How do you monitor psoriatic arthritis? and what score is considered high disease activity?

DAPSA-64

A score of >28 is high disease activity

What are some important differentials to consider in GCA?

Myositis

Malignancy
- lung cancer

Myeloma
- always do a myeloma screen

What investigations should be done into GCA?

Bloods:

FBC
CRP/ ESR (ESR >50)
TFTs
Glucose
Bone profile (myeloma)

Orifices:
- Bence jones protein

X-rays:

Temporal US
CXR (malignancy)

Special tests:
- temporal artery biopsy

What is the management for GCA?

40-60mg prednisolone

*if visual defects then IV methylprednisolone for 3 days

Name two examinations that can be done into ankylosing spondylitis:

Schober’s test

mark 5cm below L5 and 10cm above.
bend over and if less than <5cm increase (20cm in length) then this is positive

Occipital to wall distance

List the investigations that should be done into Ankylosing spondylitis:

X-ray of lumber spine and S.I joints MRI of lumber and S.I joints HLA B27

Name the criteria needed for ankylosing spondylitis:

Sacrolitis on imaging + >1 other seronegative feature or HLA B27 + >2 other seronegative feature

What score is used to assess how ankylosing spondylitis is affecting the patient?

BASDAI score

What is the management of Ankylosing Spondylitis?

1st line: - NSAIDS - Physiotherapy 2nd line: - Biological therapies (anti- alpha, Anti IL-17)

What investigations should be done into Sjogren's syndrome?

Schirmer's test Anti- Ro Anti- La Salivary gland biopsy (rarely done)

What antibody in Sjogren's syndrome is associated with lymphoma?

Anti - Ro antibody

List some of the signs and symptoms of polymyositis and dermatomyositis and the investigations:

Signs and symptoms: - Proximal muscle weakness - Symmetrical - Groton's papules (if dermatomyositis) - dysphagia - fever Investigations: - Creatine kinase (raised) - CRP/ ESR - Anti - Jo-1 - Anti- Mi2 antibodies - ANA - EMG - Muscle biopsy (lymphocyte infiltration) - malignancy screening

What are the radiological findings of sacroiliitis:

X-ray: - Sclerosis of endplates - especially iliac side - Widening of the joint space MRI: - Marrow oedema - Synovitis and capsulitis - Enthesitis (thickening of ligaments) Later: - subchondral lesions - foci erosions

What antibodies are associated with systemic sclerosis?

ANAs Anti-centromere: limited cutaneous type Anti SCL-70: diffuse type

What is the general management for SLE?

Sun cream NSAIDs Hydroxychloroquine - typically used when NSAIDs is not enough

What disease is also known as the pulseless disease - list some other signs and symptoms of it and how is it diagnosed?

Takayasu's disease - large vessel vasculitis - usually aorta causing aneurysms which swell and compress - fever - malaise - arm claudication - CT or - MRI angiogram

How does methotrexate work and List the common side effects of methotrexate and list some parameters which should be monitored throughout the treatment:

Inhibits dihydrofolate reductase - preventing cellular replication Myelosuppression - anaemia Lung fibrosis - dry cough Mucositis - oral ulcers/ G.I upset Liver fibrosis - FBC - U&Es - LFTs *1-2 weekly to begin with then 2-3 times monthly there after **taken with folic acid the day before

Highlight some adverse effects of steroids:

Mood behaviour - insomnia - confusion - psychosis Diabetes Osteoporosis Skin thinning/ bruising/ ulceration Immunosuppression Metabolic changes - hypokalaemia

Name the 4 major DMARDs and side effects for them:

Methotrexate - lung fibrosis - liver hepatiis Hydroxychloroquine - Retinopathy Sulfasalazine - Steven's johnson syndrome - myelosuppression - pneumonitis Leflunomide - peripheral neuropathy - G.I upset

Which drug requires a TMPT level prior to administration? and list two autoimmune conditions it is used for and non-autoimmune condition:

Azathioprine 1. Inflammatory bowel disease 2. Myasthenia gravis 1. Eczema

Name the key skin findings in SLE and highlight key characteristics of them:

Mallar rash: - across cheeks and bridge of nose. Spare nasal labia folds Discoid rash: - run exposed area, well demarcated, pigmented and becomes hyperkeratotic Livedo reticularis - vessel formation Raynaud's

List the key antibody tests to conduct into SLE:

Anti- Nuclear Antibodies Anti Double stranded DNA - Anti - Extractable nuclear Antigens - anti - smith Complement studies - low

Which antibody is associated with dermatomyositis?

Anti- Jo-1

Which two antibodies are associated with Sjogren's syndrome?

Anti Ro and Anti- La

p-ANCA is also associated with other conditions other than vasculitis, what are they?

Ulcerative colitis PSC Crohns (rarer)