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Y3 Medicine > 9 - Rheumatology Histories and Exams > Flashcards

9 - Rheumatology Histories and Exams Flashcards

1
Q

What are the main symptoms of rheumatological disease?

A
  • Pain
  • Swelling
  • Stiffness
  • Fatigue
  • Weakness
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2
Q

What questions do you need to ask in the history if someone is complaining of pain?

A

What?

Why?

When?

How bad?

Where?

Who? (patient’s social support, mental health etc)

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3
Q

Why do many patients with arthritis develop chronic pain?

A

Central sensitisation of pain processing cells in dorsil horn

Pain can come from synovium, joint capsule, subchondral bone, peri-articular muscle

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4
Q

How can you tell if pain is articular or peri-articular in origin?

A

If peri-articular usually only triggered by certain movements but articular is all movements

e.g Tennis elbow pain is felt on resisted wrist extension

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5
Q

How can the pattern of pain in joints help to make a diagnosis?

A

Certain rheumatological diseases have characteristics that make them more likely

e.g if the spine is involved not likely to be RA, more likely to be ankylosing spondylitis

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6
Q

What are some causes of acute and chronic monoarthritis?

A
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7
Q

What are some causes of acute and chronic polyarthritis?

A
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8
Q

What are the differentials for arthritis of the DIPJs?

A
  • OA (most common cause and often Herbeden’s nodes)
  • Psoriatic arthritis (will be nail dystrophy)
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9
Q

When a patient presents complaining of stiffness, what are some questions you need to ask?

A

Stiffness is a feeling of difficulty moving a joint

  • Early morning stiffness? (> or < 30 minutes)
  • Generalised or loalised?
  • Worse after resting?
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10
Q

When a patient presents with joint swelling, what are some questions you need to ask?

A
  • How rapidly did it come on?
  • How long goes the swelling last?
  • Does the swelling occur parallel to joint line indicating true joint swelling or does it cross the joint line?
  • Is the swelling bony?
  • Does the swelling extrude any material?
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11
Q

Fill in this table to distinguish the differences between mechanical and inflammatory diseases.

A
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12
Q

After taking a history of the presenting complaint, what other areas of the history do you need to explore?

A

ALWAYS CHECK EXTRAARTICULAR SYMPTOMS

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13
Q

What are constitutional symptoms?

A

Symptoms that are not disease specific e.g fever, weight loss, fatigue, and lymphadenopathy but can indication underlying inflammatory disease, infection or neoplasia

Common in: AS, Primary vasculitis, GCA

Uncommon in: RA and PsA. SLE has fever but not others

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14
Q

What rheumatological diseases are the following extra articular symptoms and signs associated with?

A
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15
Q

What rheumatological diseases are the following extra articular symptoms and signs associated with?

A
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16
Q

What are the basics of an MSK exam?

A
  • Introduction
  • GALS
  • Look
  • Feel
  • Move (Active and Passive)
  • Special tests
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17
Q

How do you perform a GALS assessment?

A
  • Introduction and gain consent
  • Screening questions
  • Gait
  • Arms
  • Legs
  • Spine
  • Regional exam of a joint if any problem detected
  • Thank patient and ask if they need any help dressing
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18
Q

How do the following gaits present?

  • Antalgic
  • Trendelenberg
  • Sensory ataxia
  • Cerebellar ataxia
  • Hemiplegic
  • Festinant
  • Waddling
  • Psychogenic
A
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19
Q

How do you perform a hand examination for an OSCE?

A
  • Introduce and gain consent
  • Hands on pillow and ask if any pain
  • Inspect distal to proximal on dorsum, palmar and elbows. Look at thenar/hypothenar
  • Feel
  • Move
  • Neurovascular
  • Function
  • Special tests
20
Q

What would indicate a positive Tinel’s and Phalen’s test?

A

Test for carpal tunnel syndrome (can be caused by arthritis)

Tinel’s: tap on carpal tunnel with your index and middle finger for 30-60 seconds. If irritation in thumb and radial two figners it is positive for median nerve irritation

Phalen’s: hold wrist in forced flexion for 60 seconds, if symptoms develop then positive

21
Q

What is the sensory and motor supply of the median nerve to the hand?

A

Sensory: see image

Motor:

  • All anterior forearm except FCU and medial two FDP
  • LOAF (lateral two lumbricals, opponens pollicis, APB, FPB)
22
Q

How would a median nerve palsy present?

A

- Weakness of thumb opposition and abduction

  • Numbness in median nerve distribution (palmar sparing if lesion at wrist)
  • Late thenar muscle wasting

(If damage in arm will have weak finger flexion but be able to flex ring and little finger)

23
Q

What is the sensory and motor supply of the ulnar nerve?

A

Sensory: see image (not just fingertips on back)

Motor:

  • FCU
  • Medial FDP
  • Interossei and adductor pollicis
24
Q

How will an ulnar nerve palsy present?

A
  • Wasting of hypothenar
  • Numbness in distribution of ulnar nerve
  • Froment’s test
  • Claw Hand in low lesion
25
Q

What are some important blood tests to order if you suspect rheumatological disease and why are they abnormal?

A
26
Q

What are the advantages and disadvantages of the following inflammatory markers

  • ESR
  • CRP
  • PV
A

ESR and PV looks at immunoglobulins and fibrinogen

27
Q

What auto-antibody tests should you order if you suspect a patient has RA?

A

- Rheumatoid Factor (RF is antibody against Fc region of human IgG)

- Anti-CCP/ACPA (more specific for RA)

28
Q

Antinuclear antibodies are produced against nuclear antigens. You order these tests if you suspect an autoimmune disease. What are the following ANA’s associated with?

  • Anti-dsDNA
  • AntiRO and AntiLa
  • Anti centromere and anti Scl70
  • Anti Jo-1
A
29
Q

What is HLA-B27?

A

Class 1 surface antigen associated with ankylosing spondylitis, iritis, juvenile arthritis

30
Q

Apart from taking blood tests for autoantibodies, HLA-B27 and general bloods, what other investigations can you do for a suspected rheumatological disease?

A

- Urinalysis: proteinuria and haematuria could be present in SLE/Vascultitis

- Joint aspiration: synovial fluid aspiration to look at crystals and rule out sepsis

- Radiology (US, XR, MRI, DEXA for osteoporosis): look for common radiological features

- Biopsy: such as temporal artery biopsy for GCA, muscle biopsy for polymyositis, lymph node biopsy to rule out TB/lymphoma in SLE

- NCS and EMG: confirm peripheral nerve entrapment and record spontaneous muscle activity

31
Q

What medical specialities are on a rheumatic MDT?

A
  • Rheumatologist
  • Rheumatology nurse specialist
  • Physiotherapist
  • OT
  • Orthotist
  • Dietician
  • Orthopaedic surgeon
  • Psychologist
32
Q

What are some causes of positive ANA?

A
  • Auto-immune rheumatic diseases e.g. SLE, RA, Sjogren’s sydrome
  • Chronic liver disease
  • Chronic infection
  • Malignancy
  • Drug-induced e.g. minocycline
33
Q

What are some mono, oligo and poly-arthritis?

A
34
Q

What drugs are used to treat RA and therefore what monitoring is needed?

A

1st Line:

  • DMARDs like methotrexate, sulfasalazine and hydroxychloroquine

- Steroid cover with Prednisolone for 3 months until start to work

  • Need to monitor FBC and LFT

2nd Line:

  • Biologics (see image)
  • Need to do pretreatment screening for TB, Hep B/C and HIV
35
Q

What are the side effects of the following DMARDs used for RA treatment:

  • Methotrexate
  • Leflunomide
  • Sulfasalazine
  • Hydroxychloroquine
A

Methotrexate: nausea, oral ulcers, hepatitis, hair thinning, pneumonitis (do pretreatment CXR), teratogenic, bone marrow suppression

Leflunomide: teratogenic, GI upset, hypertension, hepatitis, oral ulcers, bone marrow suppression

Sulfasalazine: GI upset, rash, hepatitis, oral ulcers, decreased sperm count

Hydroxychloroquine: retinopathy so pre treatment and annual eye screening

36
Q

What DMARDs are completed contraindicated in pregnancy and breast feeding?

A
  • Methotrexate
  • Leflunomide
  • Cyclophosphamide
37
Q

What advice is given to patients started on DMARDs?

A
  • Patient nurse-led education on side effects
  • Annual flu and pneumovax
  • Avoid live vaccinations with more immunosuppressive DMARDs
38
Q

What are the mechanism of action of the following biologics used for RA treatment?

  • Infliximab/Adalimumab/Etanercept
  • Rituximab
  • Tocilizumab
A

- TNF-a inhibitor which is 1st line biologic

- CD20 inhibitor so B-cell depletion

- IL-6 inhibitor used in combination with methotrexate if TNF-a inhibitor has failed. Measure for hypercholesterolaemia

39
Q

What are some of the side effects of biologics?

A

- Reactivation of Hep B and TB so make sure to screen

- Immunosuppression so risk of infection

- Malignancy risk

40
Q

What are some biologics that can be used to treat AS and psoriatic arthritis?

A

IL-17A antagonists

41
Q

What are some biologics that can be used to treat Crohn’s and enteropathic arthritis?

A

IL-12/23 inhibitors

42
Q

What are the side effects of azathioprine, ciclosporin and cyclophosphamide?

A
43
Q

Vitamin D and Calcium are also co-prescribed for osteoporosis. Oral bisphosphonates like alendronic acid can also be used. If these are not tolerated, what other drugs can be given?

A
  • IV bisphosphonate e.g zoledronic acid
  • Subcutaneous denosumab
44
Q

What gout medication should be avoided in renal failure?

A
  • Allopurinol
  • Colchicine
45
Q

When starting a patient on steroids for PMR, what information should you give then?

A
  • No long lasting damage to muscles or joints / excellent prognosis
  • Rapid improvement in symptoms with corticosteroids
  • Likely to need treatment for 1-2 years
  • Relapse common but responds to re-starting/ increasing dose of steroids
  • Side effects of long-term steroids
46
Q

What other investigation for GCA can you do apart from temporal artery biopsy?

A

Temporal Artery US

Y3 Medicine (24 decks)

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