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Year 6 - MBBS COPY > Firms: Rheum > Flashcards

Firms: Rheum Flashcards

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1
Q

What are the key parts to a rheum hx?

A

PC - joint pain, stiffness, swelling

SHx - functionality, job, driver, smoking, drug compliance

SRV - skin, eyes, renal, constitutional, fatigue

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2
Q

What does the timing of the stiffness indicate?

A

Early morning, within ~half an hr, inflammatory

Worsens throughout the day infers more degenerative

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3
Q

What is the DAS28?

A

Disease Activity Score - 28 Joints

Number swollen and tender, inflam marker, global assessment

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4
Q

How does the DAS28 score translate to disease activity?

A

> 5.1 Active
<3.2 Low
<2.6 Remission

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5
Q

Which is arguably the most important aspect of rheum exams?

A

Looking

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6
Q

Talk through the hand exam

A

LOOK
Elbows, hands, skin, nails, palms, finger pulps

FEEL
Pulses, muscle bulk, snuffbox, tendon thickening, sensation, temp, squeeze MCPs then individually each MCP PIP DIP and wrists, sensation

MOVE
Active prayer and reverse, passive wrist flexion/extension, extend fingers, splay, push hands down, thumb, fists

FUNCTION
Power grip, pincer grip, pick up small object/do up button/hold pen, Tinel’s, Phalen’s, Froment’s, Finkelstein’s

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7
Q

What are you looking for in the elbows?

A

Psoriatic plaques, rheumatoid nodules, olecranon bursa, gout tophi

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8
Q

Where else should you look if you’re suspicious of gout?

A

The pinna of the ear

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9
Q

What are your looking for in the hands?

A

Hands: swelling, loss of alignment, muscle wasting, scars, symmetry

Skin/nails: pitting, ridging, nail fold vasculitis

Palms/finger pulps: palmar erythema and scars from carpal tunnel release

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10
Q

Boutonniere deformity @ PIP and DIP

A

Flexion @ PIP

Extension @ DIP

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11
Q

Swan neck deformity @ PIP and DIP

A

Extension @ PIP

Flexion @ DIP

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12
Q

What do nail signs suggest?

A

Clubbing - cardio, resp, gastro

Pitting - psoriasis

Koilinychia - iron def

Leukonychia - liver disease

Splinters - vasculitis

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13
Q

How do you test sensation in the hands?

A

Median - over thenar eminence

Ulnar - over hypothenar eminence

Radial - thumb and index webspace

Plus can do C678 dermatomes

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14
Q

Describe Phalen’s test

A

If you suspect carpal tunnel, perform reverse prayer for 60s or squeeze wrist and force into flexion for 30s, pos if any tingling/numbness

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15
Q

SEs of colchicine

A

Nausea, vomiting, diarrhoea

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16
Q

Which three qs do you always ask at the start of the GALS screen?

A

Pain and stiffness, dressing, stairs

  1. Do you have any pain or stiffness in your muscles, joints or back?
  2. Can you dress yourself completely w/o any difficulty?
  3. Can you walk up and down the stairs w/o any difficulty?
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17
Q

GALS: What are you looking for in the gait?

A

Smoothness, symmetry, ability to turn quickly

NB: heal to toe and tip toe walking is more neuro looking for cerebellum problems

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18
Q

GALS: What are you looking for during inspection?

-From Behind-

A

Trapezius and gluteal muscle bulk size and symmetry

Spinal alignment

Level iliac crests

Popliteal obv swelling

Hindfoot abnormalities

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19
Q

GALS: What are you looking for in the spine?

-From Side-

A

Cervical lordosis

Thoracic kyphosis

Lumbar lordosis

Schober’s test

Knee flexion/hyperextension

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20
Q

What does Schober’s test assess?

A

Lumbar flexion by placing two fingers on adjacent vertebrae and asking the pt to touch their toes and come back up again

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21
Q

GALS: What are you looking for in the arms?

-From Front-

A

Muscle bulk and symmetry

Elbow extension in anatomical position

Cervical spine lateral flexion each side

Open jaw wide and move side to side

Elbow flexion w hands behind head

Crude hand exam inc fists, thumb to each finger, power grip and squeeze across MCPs

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22
Q

What is TMJ pain often a/w?

A

RA and inflam joint disease

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23
Q

What else does putting hands behind head w elbow back test?

A

Humeral movement and functionality

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24
Q

GALS: What are you looking for in the legs?

-Lying Down-

A

Passive knee flexion, hip flexion, hip internal rotation

Patellar tap looking for a large effusion

Sweep/bulge test looking for smaller effusions

Crude foot exam inc callus formation and squeeze across MTPs

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25
Which rotation at the hip do you perform as part of the GALS screen?
Internal
26
How do you record an unremarkable GALS in the notes?
GALS: NAD
27
What does REMS stand for?
Regional Examination of the Musculoskeletal System
28
Hx for Ank Spond
Fatigue, lower back stiffness > pain, early morning and after sitting then relieved by activity Plus quick SRV
29
What should you do if you lose your thought in a hx?
Summarise
30
Ix for Ank Spond
Bloods inc HLA-B27, xray, MRI
31
What would you find on MRI of ank spond?
Sacroiliitis
32
Mx for Ank Spond
Early intervention w physio and NSAIDs then consider steroids and biologicals
33
What is the ACR and EULAR 2010 RA diagnostic cut off?
6 points to dx RA & <6 labelled as undifferentiated inflammatory arthritis
34
Outline the rheumatoid arthritis ACR and EULAR 2010 classification criteria
Tbc
35
Felty’s Triad
RA, Splenomegaly, Neutropenia
36
Hand Hx
Hand dominance, weakness, tingling, pregnant, rheumatoid, prev surgery
37
RFs for Gout
Age Male Injury CVD HTN CKD Diabetes Obesity Thiazide Lead FHx Diet Alcohol
38
Mx of Gout vs Pseudogout
Bloods: FBC, U+Es, Uric Acid Acute Tx: NSAIDs, Colchicine, Steroids Chronic Tx: lose wt, inc water dec alcoholic and fizzy drinks, low purine diet + allopurinol w initial NSAID cover if gout>pseudo
39
How can SLE be diagnosed?
>=4 Serositis Oral Ulcer Arthritis Photosensitivity Blood Disorder Renal Disorder Anti Nuclear Abs Immuno Disorder Neuro Disorder Malar Rash Discoid Rash
40
What is Hatchet sign?
The limited erosion of the lateral aspect of the humeral head found in ank spond
41
What do the lumbricals of the hands do?
Flex at MCP + Extend at IPJ
42
Which inflammatory conditions are more common in males>females? (2)
PSC + Ank Spond
43
What do OA hands look like?
Heberden’s @ DIP Bouchard’s @ PIP Base of Thumb Squaring
44
Psoriatic Arthritis
Psoriasis Nail Changes: onycholysis, pitting, subungual hyperkeratosis, discolouration Small joint arthritis involving both the PIP and DIP joints Dactylitis
45
Which antibody is most specific for RA?
Anti-CCP
46
Ix for RA
O/e: tender, stiff, swollen, number and type of joint involved, DIP sparing Bloods: acute phase markers, anti-CCP, rheumatoid factor Imaging: early disease may show synovitis on US/MRI but x-rays monitor joint damage over time - loss of joint space, bony erosions, periarticular osteopenia, joint deformities
47
Mx of RA
1. Analgesics 2. NSAIDS 3. Steroids 4. DMARDs - conventional (methotrexate), biological (anti-TNF), targeted (JAK inhibitors) Conventional: Methotrexate Sulphasalazine Hydroxychloroquine Biological: Anti-TNF IL-6 Receptor - toclizumab, sarilumab Anti-CD20 (target B cells) - rituximab CTLA4-Ig (targets T cell activation) - abatacept Targeted: JAK Inhibitors
48
Anti-TNF
Etanercept Adalimumab Certolizumab Golimumab Infliximab
49
JAK Inhibitors
Tofacitinib Baricitinib Upadacitinib Filgotinib
50
What is characteristic of the spondyloarthritides?
HLA B27 Arthritis Sacroiliitis Iritis Dactylitis Enthesitis
51
What is the ASAS classification of axial spondyloarthritis?
Aged <45 w at least 3mnths of back pain Must have sacroiliitis on imaging plus one other feature or HLA B27 plus two other features
52
What drug won’t work for axial spondyloarthritis?
Conventional DMARDs
53
Mx of Ank Spond
1. Analgesics 2. NSAIDS 3. DMARDs - biological (anti-TNF and IL-17 blocker) + targeted (JAK inhibitors)
54
What is the ASAS classification of peripheral spondyloarthritis?
Aged <45 w peripheral features only Must have arthritis/enthesitis/dactylitis plus one/two other features
55
Psoriatic Arthritis X-ray
Loss of joint space Erosions Bony proliferation Osteolysis Spurs
56
Mx of Psoriatic Arthritis
1. Analgesics 2. NSAIDS 3. DMARDs - conventional (methotrexate), biological (anti-TNFα or anti-IL17), targeted (JAK inhibitor or apremilast)
57
Which organisms cause reactive arthritis?
GU: chlamydia GI: shigella, salmonella, yersinia, campylobacter, e coli
58
SLE
Mild: rash, arthritis, lymphadenopathy Mod: pleurisy, pericarditis, cytopenia Sev: renal and CNS involvement
59
What are the SLICC criteria for diagnosing SLE?
Must have biopsy proven lupus nephritis w positive ANA or dsDNA OR Must have four criteria including at least one clinical and one immunological
60
Mx of SLE
Minimise the use of prednisolone and add steroid sparing agents: hydroxychloroquine for skin and joint involvement, azathioprine, mycophenolate, rituximab, tacrolimus, cyclophosphamide for sev disease
61
Ix of CTD
Screen with ANA then dsDNA, ENA, cytoplasmic to confirm dx
62
How do you monitor treatment efficacy in SLE?
ESR dsDNA C3/C4
63
Primary Sjogren’s Syndrome
It involves inflam destruction of exocrine glands particularly the lacrimal and salivary
64
What should you counsel a young female with anti-Ro or anti-La abs about?
If she does get pregnant they can cross the placenta and cause fetal heart block
65
Where does the skin involvement in CREST not progress beyond?
Forearms/Calves
66
Comps of LCSS
Pulmonary HTN Plus: ILD, renal crisis, extensive gut disease (all more common in DCSS)
67
Ix for Scleroderma
Dx: ANA, anti-centromere for LCSS, anti-scl70 for DCSS Comps: ECG/echo, CXR/CT, U+Es/urinalysis
68
Mx of Raynaud’s
Consrv: avoid cold environments, keep whole body warm, gloves Medical: nifedipine, sildenafil, IV iloprost
69
Ix for Dermatomyositis
CK ANA Myositis Ab Panel MRI Involved Muscle Electromyogram Muscle Biopsy
70
Ix for GCA
Acute Inflam Markers Temporal Artery US +/- Biopsy FDG PET Scan
71
Mx of GCA
Immediate PO Prednisolone 40-60mg 4w + urgent ophthal review If visual sx: add IV methylprednisolone 500mg If persistent/relapsing disease: add an IL6 blocker
72
ANCA
cANCA: a/w abs to proteinase 3 occurring in pts w GPA pANCA: a/w abs to myeloperoxidase occurring in pts w eGPA and microscopic polyangiitis
73
Ddx of Purpuric Rash
Infection: meningococcal septicaemia + haemorrhagic fevers Inflammation: HSP Thrombocytopenia: ITP
74
What could you give pts who are unable to tolerate wkly alendronate?
Annual IV Zoledronate OR Biannual S/C Denosumab
75
How many wks after an acute attack of gout should you wait before starting allopurinol?
3wks
76
What are the RFs for CPPD?
Inc Age Hyperparathyroidism Haemochromatosis Hypophosphataemia
77
What is the typical pt w PMR?
Elderly pt w bilateral morning stiffness in shoulder and hip girdles + pain - weakness but pain makes raising arms, getting out of a chair and going up the stairs difficult
78
Ix for PMR
Raised ESR/CRP Plus rule out ddx: RA - anti-CCP; Myositis - CK; Malignancy - FLAWS, bloods, serum electrophoresis, urinary bence jones protein, CT CAP
79
Mx of PMR
Start prednisolone 15mg/d PO and expect a dramatic response within 1wk then wean 1mg/mnth
80
What is the most specific antibody for SLE?
Anti-Smith Anti-dsDNA
81
Tx of Raynaud’s Syndrome
Nifedipine Primrose Oil Sildenafil Epoprostenol Sympathectomy
82
What ab is a/w drug-induced SLE?
Antihistone
83
What should be performed annually in pts w diffuse systemic sclerosis? (2)
Echo + Spirometry
84
What ab is a/w mixed CTD?
Anti-U1-RNP
85
Which NSAID carries the lowest cardiovascular risk?
Naproxen
86
Ix for Myositis
Inc muscle enzymes in plasma ie ALT AST LDH CK and aldolase; EMG shows fibrillation potentials; MRI shows oedema if acute; autoabs anti-M2 and anti-Jo1 if acute and ILD; muscle biopsy confirms the dx
87
Tx of Myositis
Prednisolone If resistant: immunosuppressives/cytotoxics If skin disease: hydroxychloroquine/topical tacrolimus
88
Ddx of DIP Involvement
OA + Psoriatic Arthritis
89
What are the three best tests for monitoring activity in SLE?
Anti-dsDNA Complement ESR
90
Which DMARD causes azoospermia?
Sulfasalazine
91
Which DMARD causes retinopathy?
Hydroxychloroquine

Year 6 - MBBS COPY (35 decks)

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