Rheumatology qs Flashcards
who should take vit d supplements?
vit D 10mcg (pregnant and while breastfeeding), adults 65+, housebound, children 6 month to 5 yrs unless formula fed
PTH/ Ca/ explain?
high PTH, high CA, high ALP, low Po4?
High PH, high ALP, low/ normal Ca?
all normal values?
isolated ALP?
low Ca, PTH release - increased bone release of po4 and Ca. kidneys - activate vit D, reabsorb Ca and excrete.
Calcitonin released when high calcium from thyroid gland.
low Po4 in primarty hyperparathyroid - kidneys excrete it
in secondary - kidneys not functioning as well, leads to higher po4
all normal - osteoporosis
alp - pagets
High PTH, Low Po4, Low Ca, high ALP?
Osteomalacia (low vit D)
Serum 25-hydroxyvitamin D
Less than 25 nmol/L – vitamin D deficiency
25 to 50 nmol/L – vitamin D insufficiency
osteoporosis values ofr PTH, Ca, po4?
normal
explain paget’s
complications?
bloods?
how does osteomalacia present differently?
increased bone turnover. lytic phase, mixed and then sclerotic. risks: kyphosis, hearing loss, heart failure. isolated ALP rise
bone arcoma, high output crdiac failure, deafness
pagets - specific pain worse on weight bearing in pelvis, spine, hip, long bones, frontal bossing/ bowing
vit D deficiency - general aches and pains with Xr showing looser’s zones/ pseudofractures. normal ALP, low po4 and ca.
RA tx summary? flares?
assess disease severity?
poor prognosis?
DMARD and bridging C/S
methotrexate - pneumonitis/ liver cirrhosis
sulfasalazine - oligospermia, rash, interstitial lung disease. caution aspirin cross sensitivity, G6PD. safe in pregnancy and breastfeeding
leflunomide - liver impairment, intestinal lung disease, HTN
hydroxychloroquine
flares - c/s
if 2+ DMARDS have not worked - anti TNF i (risk TB reactivated)
DAS 28
poor: RF na danti ccp +, poor function, HLA Dr4, early erosiions on XR <2 yrs
leflunomide SE?
LEF - liver impairment
LUN- interstital lung disease
HTN
When would you consider stopping bisphosphonates?
75YO+, low risk FRAX, T score -2.5+
methotrexate Se?
acoird prescribing iwth?
pneumonitis, liver and pumonary fibrosis, myelosuppression, mucositis
directions: give folic acid with, contraception for 6 months
CI: aspirin, pregnancy, trimethoprim, co-trim, aspirin
mets patient 3 days after bisphosphonates, patient get body aches, muscle spasms and tingling around lips?
hypocalcaemia due to giving bisphosphonates before correcting vit d/ calcium low before.
bisphosponates reduce bone turnover (shove all ca into bones)
APLS antibodies?/ skin manifestation?
CLOTS:
C- cardiolipin
L -livid reticularis, anti
O- obstretic miscarriage
T - thrombocytopenia
tX: low dose aspirin (primary). secondary: warfarin lifelong 2-3INR. consider adding aspirin
woman on TB medication has arthralgia, but resolves after stopping isoniazid. antibody?
other drugs cusing this?
common sx?
drug induced lupus - anti histone antibody
Fen’s PRetty HISTONED
- phenytoin, procainimide, hydralazine, isoniazid
sc: skin and arthralgia, pleurisy, ds dna negative
CX of drug induced lupus?
Isoniazid, phenytoin, hydralazine, procainamide
Diffuse cutaneous SS:
anti scl 70, renal , HNT, ANA, resp cause death, scleroderma affects trunk and proximal limbs
32F proximal muscle weakness and erythematous, keratotic macules overlying her interphalangeal joints
Gottron’s papules, dermatomyositis - heloptrope, nail fold capillary dilation, proximal muscle weakness, lung disease, ANA, anti JO
raynauds, most common secondary cx? other causes?
TX?
scleroderma (most common)
rheumatoid arthritis, SLE
leukaemia
cold agglutinins
use of vibrating tools
drugs: oral contraceptive pill,
cervical rib
tx: nifedipine, refer to secondary care
impaired kidney function, rash on nose, 2 weeks joint paina and swelling
SLE
most commonc ardaic manifestation - percarditis
After a five year period for oral bisphosphonates (three years for IV zoledronate), who should be reassessed for OP tx?
high risk group:
75+, CS, previous fractures, high FRAX, T score <2.5 after tx
Tx of bisphosphonates
which one is better if severe GI SE?
osteoporosis MX
when would you start bisphosphonate tx straight away?
For C/S induced OP when to start?
after 5 yrs when do you stop?
prevention and treatment of osteoporosis
hypercalcaemia
Paget’s disease
pain from bone metatases
change alendronate to risendronate if severe GI effects
bisphosphonates po 5 yrs or iv 3 yrs and reassess # risk. corect ca/vit D before
straight away: Postmenopausal women, and men age ≥50, who have had osteoporotic vertebral # or
hip # 75+
or C/s 7.5mg od 3 months
C/s induced , <65 if T score is <-1.5, start or repeat in 1-3 yrs
if high risk - do FRAX and DEXA. start if DEXA <2.5
5 yrs after: stop if patient <75YO, low FRAX, T score -2.5+
Middle ages man with known Hep B, presents with livedo reticularis and altered sensation in hands and legs?
Polyarteritis nodosa
W/L, HTN, polyneuropath, testicular pain, hematuria, renal failure, ANA,
Gout tx? if on warfarin and eldery?
warn SE of dicofenac?
If HTN?
targets for URT?
NSAID until 2 days after sx have resolved.
diclofenac - diarrhoea (most common)
Colchicine if on warfarin/ elderly
start Allopurinol after 1st ep 2 weeks after or when patient is not in pain
allopurinol - 100mg (low if egfr) until urate <360
lower target if patient has recurrent tophi
2nd line - febuxostat
if HTN - consider losartan. consider giving vit C
Ra TX?
2nd line?
methrotrexate with or without CS bridging
other DMARD: leflunomide, sulfazalazine, hydroxychloroquin
if trialled 2 with inadequate, trial anti TNF
flare: C/S im/ po
patient with Ra, has reactivation of TB. what medication has he been started on?
ertanecept
84YO F, CKD 4, previous NOF. DEXA is -4.5
CI bisphosphonates IV infusion (GFR <35),
trial denosumab
Features of MArfans?
tall, blue sclera, Aortic dissection, AR, anaeyrusm, repeated pneumeces, myopia, pes excavatum,
Strongest association with sojrens? antibody?azahi
Rheumatoid A (50%) and ANA, anti Ro (70%)
SLE med safe for pregnancy? SE?
azathioprine
SE:bone marrow depression (do fbc if infection),
N+V,
pancreatitis
increased risk of non-melanoma skin cancer
causes of dactylitis?
spondyloarthritis: e.g. Psoriatic and reactive arthritis
sickle-cell disease
other rare causes include tuberculosis, sarcoidosis and syphilis
Common cx of reactive A?
presentation
men - post sti cx
all sexes - post dysentery, e.coli
AF: dactylitis, keratoderma blennhoragica
pain distal to lat epicondyl pain in the lateral forearm that is worse on straightening the wrist or fingers
radial tunnel syndrome
1.hip pain pregnant lay pain in groin and medial thigh with a waddling gait?
- burning sendation over anterolateral thigh?
- positive femoral nerve stretch
- 50 yO woman pain in lateral thigh, anterior groin pain with tendrness on greater trochanter
- chronic steroid use, gradual hip pain?
- pubic symphysis dysfunction
- meralgia parasthetica
- referred lumbar pain
- IT sdrom/ greater trochanteric pain
- AVN hip
drug cx of gout?
diuretics, pyrazinamide, alcohol, cytotoxic agents, thiazides, aspirin
RA on methotrexate now unwell, sore throat, low Hb, platelets and WBC. cx?
prescribed co-trimoxazole (trimethoprim)
