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MUSCULOSKELETAL - Rheumatology & bone > Rheumatology and Bone Disease I and II > Flashcards

Rheumatology and Bone Disease I and II Flashcards

1
Q

What is rheumatology?

A

Deals with joints, bone and muscle disease
Diseases normally inflammatory - usually autoimmune
Arthritis

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2
Q

Systemic features of rheumatology?

A

Fever, skin rash, pain and stiffness, heart and lung involvement, neurological problems

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3
Q

Joint pain:

A

Inflam… TABLE

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4
Q

TABLE

A

TABLE

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5
Q

Rheumatoid arthritis features?

A 
Disease of synovial joints
Affects 1% population
Autoimmune, systemic inflam illness
Symmetrical joint inflam and deformity
Extra articular features - makes it systemic
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6
Q

Rheumatoid arthritis pain features?

A 
Early morning stiffness
Stiffness after rest
Ease with use/exercise
Swelling
Flu like symptoms
Anti-inflam drugs: NSAIDs e.g. ibuprofen may be helpful
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7
Q

What is inflammation?

A

Red
Hot
Painful
Swollen

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8
Q

What can rheumatoid arthritis lead to?

A

Progressive joint deformity

  • Z thumb deformity
  • Boggy swelling
  • Spares DIPJs
  • Swelling and subluxation of MCPJs
  • Ulnar deviation
  • Swan-neck deformity
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9
Q

Extra-articular features of rheumatoid arthritis?

A

Lungs:

  • Nodules
  • Lung fibrosis
  • Pleural effusions
  • Increased lung cancer

CV:

  • Pericardial inflam/effusions
  • Myocarditis
  • Valve inflam

Kidneys:
- Amyloidosis

Skin:

  • Rheumatoid nodules
  • Vasculitis

2ndry Sjogren’s syndrome

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10
Q

What is commonly found via blood tests with you have rheumatoid arthritis?

A

Anaemia
High/low platelets
High inflam markers - C reactive protein, erythrocyte sedimentation rate
Auto-antibodies: up to 75% positive for RF and/or anti-CCP

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11
Q

What is found on x-rays from early and late rheumatoid arthritis?

A

Early:
Osteopenia around joints (thinning)
Soft tissue swelling

Late:
Erosions
Joint space narrowing
Subluxation/dislocation
Fusion (ankylosis)
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12
Q

Tx of rheumatoid arthritis?

A

Immediate relief:

  • NSAIDs
  • Steroids - injected into joint/intra-muscular/iv/oral

Control of disease (immunosuppressive):

  • DMARDS (Disease modifying anti-rheumatic drugs)
    e. g. methotrexate (= 1st choice drug)

Biological drugs (SC or IV injecs)

  • Anti TNF (Tumour necrosis factor) e.g. infiximab
  • B cell depletion e.g rituximab
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13
Q

How to first treat rheumatoid arthritis?

A

Methotrexate first and hydroxychloroquine later

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14
Q

Side effects of rheumatoid arthritis drugs?

A

Infec - all increase risk, for biological drugs: reactivation of TB
Bone marrow toxicity: low white cell count/low platelets/pancytopenia
Hepatotoxic: abnormal liver tests (rise in enzymes)
Gastric upset: nausea, diarrhoea
Skin rashes

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15
Q

When to stop taking DMARDs/biological drugs?

A

For course of antibiotics and for up to 2 weeks after as they are immunosuppressed

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16
Q

Features of methotrexate (DMARD)?

A

Weekly dose: 15-25mg/week
Never co-prescribe trimethoprim/septrin = risk of severe bone marrow suppression: all anti-folate drugs

Lung complications: pneumonitis, fibrosis
Renally excreted: reduce dose/stop or contact doctors if pt develops new renal impairment

Contra-indicated in men and women pre-conception
Nausea, mouth ulcers

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17
Q

When is methotrexate never co-prescribed?

When is it contraindicated?

A

Never co-prescribed trimethoprim/septrin = risk of severe bone marrow suppression: all anti-folate drugs
Contra-indicated in men and women pre-conception

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18
Q

Features of biological drugs?

A

Greater infection risk

  • Stop 2 weeks before surgery
  • Restart 2 weeks later or when wound’s healing
  • Ask pt if on biological drug
  • Contact doctor

Reactivation of TB/Hep B and C
Contraindicated if pt develops cancer
May cause/exacerbate MS

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19
Q

Rheumatoid neck features?

A

Erosive change at C1/C2
Leads to subluxation at the atlanto-axial level or subaxial levels or both
Instability can lead to neurological deficit from spinal cord compression
= problem with intubation or positioning a pt in the dental chair

20
Q

What occurs to the neck in rheumatic neck?

A

Atlas (C1)
Axis (C2) with dens
Erosive change disrupts ligament = does not hold bone in place = bone moves backwards into spinal cord = compression of spinal cord = numbness in fingers (difficulty doing buttons)

21
Q

What to do if a pt has rheumatoid arthritis?

A

Ask about neck pain
Ask if know about rheumatoid neck
When positioning pt, check no new neck pain develops or neurological symptoms such as pins and needles…..

22
Q

How does RA impact OH?

A

Poor hand/neck/shoulder func = impair OH
Immuno-suppressive drugs may compound this
RA pts have co-existent osteoporosis = bisphosphonates

Increasing evidence that gingivitis/caries may trigger RA

23
Q

Juvenile idiopathic arthritis (JIA) features?

A 
Inflam arthritis before 16yrs old
40% grow out of it by adulthood
Jaw underdevelopment:
- TMJ inflam = altered mandibular growth
- Malocclusion (class II)
- Pain, biomechanical problems
24
Q

Spondyloarthropathy types?

A

Ankylosing spondyloarthropathy
Psoriatic arthritis
Enteropathic artihritc (crohns/UC)
Reactive arthritis

25
Q

What is Spondyloarthropathy associated with?

A

HLA B27

26
Q

What is ankylosing spondyloarthropathy?

A

Calcification in spine = severe limitation of movement
Inflam spinal pain
Progressive new bone formation
Rigid fused neck (fracture risk) or atlanto-axial subluxation

27
Q

Common features of spondyloarthropathy?

A

Enthesitis:
- Inflam of junction between tendon/ligament and bone

Dactylitis:

  • Sausage finger/toe
  • Combination of joint and tendon sheath inflam

Skin/nail psoriasis

Inflam eye disease = iritis

Inflam bowel disease = UC/crohns

28
Q

Psoriatic arthritis signs?

A

Nail pitting
Dactylitis
Distal joints can be effected

29
Q

Osteoarthritis features?

A

Degenerative process, with exaggerated repair response
= Pain, stiffness, deformity, reduced joint movement and joint instability
Increases with age
Occupation/hobbies increase risk
Cartilage erosion
E.g footballers - knees

30
Q

X-ray features in osteoarthritis?

A

Loss of joint space
Osteophytes
Sub0chondral sclerosis

31
Q

OA tx?

A

Physiotherapy/exercise
Weight loss
Paracetamol, co-codamol, NSAIDs
Surgery: for uncontrolled pain, joint failure

32
Q

What is gout?

A

Hot, red, swollen, painful arthritis
Urate crystals precipitate out from bloodstream into joints/soft tissues
Induces intense neutrophil-led inflam response

33
Q

Why do you get gout?

A 
Pt has high serum urate
Causes of high urate:
- Genetic 
- Renal impairment
- Diuretics
- Dehydration
- High alcohol/fructose/red meat
- Part of metabolic syndrome - central obesity, diabetes, high BP and chol
34
Q

Tx of gout?

A

Acute: NSAIDs, Colchicine, steroids

Prevent future attacks: Urate lowering drugs (allopurinol and febuxostat)

35
Q

Features of CT diseases?

A

Group of rare auto-immune systemic diseases
Can be life threatening, usually due to organ involvement e.g. renal failure, lung fibrosis, myocarditis

Associated with auto-antibodies
More common in women

36
Q

CT diseases examples?

A 
Systemic lupus erythematosus
Scleroderma
1 sjogren's
Polymyositis
ALL ASSOCIATED WITH Anti-nuclear antibody (ANA)
37
Q

Common features of CT disease?

A

Raynauds - vasoconstriction finger and toes in response to cold
Mouth ulcers
Cardio resp disease

38
Q

SLE features? (lupus)

A

Non-erosive arthritis
Butterfly rash on face around nose
Photosensitivity

39
Q

Sclerodema features?

A

Progressive skin thickening and tightening
Severe raynaud’s = leads to digital ulcers, oral tethering, telaniesctasia (red dots on lip/face), nose beaking
Can be limited to hands, feet and face (LcSSc)
Or widespread (diffuse systemic scelorsis - DcSSc)

40
Q

Define Primay Sjogren’s

A

Primary = occurs on its own without an associated rhumatic illness but with its own systemic manifestations

41
Q

Define Secondary Sjogren’s

A

Occurs with a rheumatic illness eg RA, SLE

Associated with other auto-immune disorders including interstitial lung disease, auto-immune liver disease etc

42
Q

Primay Sjogren’s features?

A

Dry eyes and mouth
Associated with Ro and La antibodies
High immunoglobulins, high ESR, positive RF
Fatigue, joint pain
Atrophic, shrunked parotid gland, glossitis
Rare complications:
- Vasculitis
- Renal involvement (renal tubular acidosis)
- Neurological - peripheral neuropathy
- Primary biliary cirrhosis
- Lymphoma

43
Q

Polymyositis and dermatomyositis features?

A

Inflam of muscles
Weakness of arms and thighs
Painless wasting of muscles
Associated with lung fibrosis

44
Q

What differs polymyositis from dermatomyositis?

A 
Polymyositis = muscles only
Dermatomyositis = Muscles and skin, photosensitivity/purple rash around eyes (heliotrope rash), internal malignancy
45
Q

Tx for CT disease?

A

NSAIDS/steroids
DMARDS
Cytotoxic drugs for life-threatening complications
Biological drugs

MUSCULOSKELETAL - Rheumatology & bone (2 decks)

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