Rheumatology Flashcards
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
Why is it important to establish use of anticoagulation in a rheumatology history?
A lot of drugs are given by injection
What does anterior uveitis suggest?
Seronegative disease
Where will S.I joint damage/ involvement radiate to? how does this contrast with hip involvement?
S.I = buttocks
Hip = groin
Will gout give you a high CRP?
Yes very high
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
What is the standard treatment for septic arthritis?
2 weeks IV antibiotics
4 weeks oral
Wash out
*remember to take aspirate prior to antibiotics
Why do you want U&Es in someone suspected with gout?
Renal function is one of the biggest predictors of gout
Name 2 main investigations wanted in septic arthritis?
Blood cultures
Joint aspiration
What are rheumatoid nodules heavily associated with?
Anti - CCP
Smoking
Name two other conditions which are not RA that cause a RH factor increase?
Hep C
Lupus
Sjorgens
In suspected septic arthritis, what tests do you want done on a joint aspiration?
Gram staining
Culturing
Crystal cytology
What bloods do you want to request in someone with suspected septic arthritis?
FBC CRP U&Es Blood cultures Lactate
How is methotrexate delivered, and what are some important considerations?
Once weekly.
Subcut
With folic acid
CXR should be ordered prior to starting it.
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)
What are the characteristic findings found on x-ray of RA:
Loss of joint space
Bony erosion
Soft tissue swelling
Osteopenia
What substance should people on methotrexate avoid?
Alcohol
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
- Inflammatory bowel disease
- Myasthenia gravis
- 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)
