Rheumatology Flashcards
What are the differences between inflammatory and degenerative arthritis:
- Pain- relieved or worsened by exercise?
- Stiffness
- Swelling- bony/synovial>
- Examination of joint
- Patient demographic
- Joint distribution
- Response to NSAIDs
Inflammatory:
- Pain relieved with exercise
- Stiffness - prolonged morning stiffness >30mins
- Synovial
- Joint looks hot, red, swollen
- Young
- Hands and feet
- Good response to NSAIDs
Degenerative:
- Pain is worsened by exercise
- Morning stiffness <30 mins
- Bony swelling
- No inflammation
- Older people
- Hands- base of thumb, DIPJ
- Poor response to NSAIDs
What are the classic findings on examination of hands in rheumatoid arthritis?
Boutonierre deformity: PIP flexion, DIP extension
Swan neck deformity: PIP extension, DIP flexion
Ulnar drift
Rheumatoid nodules
What other organs may be affected in a patient with rheumatoid arthritis?
Lungs- fibrosis/interstitial lung disease, pleural effusion
Heart- pericardial effusion
Kidney- nephrotic syndrome
Rheumatoid nodules in skin
Haem: Felty’s syndrome = RA + splenomegaly + neutropenia
Neuro- peripheral neuropathy
What investigations would you do on a patient with rheumatoid arthritis and what would you see?
Blood tests- FBC, U&E, CRP
Rheumatoid factor, Anti-CCP
X ray- LESS- loss of joint space, erosions, soft tissue swelling, soft bone swelling
How do you treat rheumatoid arthritis- first line, flare ups, maintenance?
First line- NSAIDs
Flare ups- Steroids- oral or intra-articular/ IM
Maintenance: DMARDs- methotrexate, azathioprine
What adverse effects can you get from methotrexate and what needs to be monitored in the blood?
FBC, U&E and LFTs Pancytopenia AKI Hepatotoxicity Pulmonary fibrosis/pneumonitis- cough, SOB
What needs to be co-prescribed with methotrexate and what medication needs to be avoided?
Folic acid 5mg
Avoid trimethoprim- folate antagonist
What signs in the hands may you see in a patient with osteoarthritis?
Heberden’s nodes and Bouchard’s nodes - proximal
What investigations will you do in a patient with osteoarthritis?
Blood tests- FBC, U&E, CRP - rule out inflammation
X ray- LOSS: loss of joint space, osteophytes, subchondral sclerosis and subchondral cysts
How do you treat osteoarthritis- conservative, pharmacological (maintenance + flare ups), surgical
Conservative- weight loss, physio, walking aids, exercise, footwear
Pharmacological- paracetamol, NSAIDs (not great response), opioids, patches. Flare ups- IA steroid injections
Surgery= osteotomy - cut bone away, joint replacement
What investigations would you do in a man presenting with a swollen, red, hot, painful big toe who has a background of chronic kidney disease and has recently been eating lots of seafood? (3)
Gout
Blood tests- FBC, U&Es, clotting, LFTs
X rays- tophi- punched out erosions in bone
Joint aspiration - negatively birefringent needle shaped urate crystals
How would you treat gout? What would change if the patient had CKD/gastric ulcer?
Acutely: NSAIDs, colchicine. If they can’t have either of these due to CKD/gastric ulcer= intra-articular, oral steroids
Prophylaxis: allopurinol
What type of crystals are deposited in gout v pseudo gout?
Gout: urate crystals
Pseudogout: calcium pyrophosphate
What would you see on joint aspirate in a patient with pseudo gout?
Rhombord shaped crystals, positively birefringent
A patient approximately in his 20’s comes to see you in clinic. He is complaining of back pain which goes down to his buttock. the pain is worse when he is sat at a desk all day and gets better when he does exercise. He also says he’s noticed his eyes being a bit sore occasionally over the last few months as well. What IMAGING would you want to do given the diagnosis and what might you see on it?
X ray - bamboo spine or syndesmophytes- calcification
Also would do blood tests- FBC, U&Es, CRP - raised, HLA B27
Ank spond
A patient approximately in his 20’s comes to see you in clinic. He is complaining of back pain which goes down to his buttock. the pain is worse when he is sat at a desk all day and gets better when he does exercise. He also says he’s noticed his eyes being a bit sore occasionally over the last few months as well. What would you look for in the blood test given the diagnosis?
HLA B27 +
What symptoms and signs (and on examination) are associated with ankylosing spondylitis?
Back pain radiating to buttocks and hips, relieved by exercise
Can also affect shoulders
Extra-articular: uveitis- red, sore eye, blurred vision and pulmonary fibrosis, dactylics
Reduced forward flexion on examination
What are the treatment options in ankylosing spondylitis?
Physio
NSAIDs
Steroids oral- short term
Biologics eg. infliximab
What signs/symptoms might you see in a patient with psoriatic arthritis?
Joint pain and swelling commonly on hand DIP joints Stiffness Dry rash on extensor surfaces Nail pitting and onycholysis Dactylitis
What might you see on X ray of the hands of a patient with psoriatic arthritis?
Erosion, ‘pencil in cup’ deformity
How do you treat psoriatic arthritis?
NSAIDs
DMARDS eg. methotrexate
TNF alpha inhibitors if DMARDs don’t work eg infliximab
What is the most common cause of reactive arthritis?
Infection
Chlamydia is the most common cause
What is the classic triad that patients with reactive arthritis will present with?
Arthritis + conjunctivitis + urethritis (can’t see, can’t pee, can’t climb a tree’)
What dermatological condition is associated with reactive arthritis? What do they look like?
Keratoderma blenorragica- waxy brown pustules on palms and soles
How do you treat reactive arthritis?
NSAIDs for pain
Treat the underlying infection eg. chlamydia
Steroids for flare ups
DMARDS eg methotrexate if long term
What condition is enteropathic arthritis classically associated with?
IBD/ coeliac disease
