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Rheum Flashcards

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1
Q

Extra articular features of rheumatoid arthritis

A

CVD is the most common cause of death in RA

  • Episcleritis and scleritis
  • Pleural effusions and fibrosis
  • Pericarditis (restrictive or constrictive)
  • Splenomegaly (Felty’s syndrome)
  • Nephrotic syndrome
  • Carpal tunnel
  • Anaemia
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2
Q

Mx of rheumatoid arthritis

A

MDT - physio, OT
Analgesia, NSAIDs (w PPI)
Steroids with acute flare
DMARDs

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3
Q

DMARD examples

A
  • Methotrexate (inhibits purine synth)
  • Azathioprine

also
• Cyclosporin
• sulfasalazine
• gold

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4
Q

Tell me about Methotrexate

A 
Once weekly DMARD
Inhibits purine synthesis
Must take folic acid replacement
Regular FBC and LFTs
Risk of myelosuppression
agranulocytosis
Avoid pregnancy
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5
Q

causes of anaemia in rheumatoid arthritis

A
  • Anaemia of chronic disease
  • Bleeding from NSAIDs
  • Bone marrow suppression from DMARDs
  • Megaloblastic anaemia
  • Haemolytic anaemia (Autoimmune)
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6
Q

Ehlers Danlos syndrome inheritance

A

absence of collagen autosomal dominant trait, but up to 50% of patients can present as a de novo mutation

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7
Q

features of Ehlers danlos

A
  • skin hyperelasticity
  • hypermobility of joints
  • easy brusing

velvety skin , atrophic scarring
Aortic root dilatation and MR

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8
Q

types of ehlers danlos

A
  • Most common is hypermobile EDS (mainly joints)
  • Next most common is classical, where skin is mostly affected

These account for >90%

• Another type is vascular type, higher risk of internal haemorrhage (risk of reduced life expectancy)

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9
Q

Joint pain and photosensitive rash

A

SLE

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10
Q

Limited systemic sclerosis features

A
  • Calcinosis
  • Raynaud’s
  • oEsophageal dysfunction
  • Sclerodactyly
  • Telangiectasia
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11
Q

Diffuse systemic sclerosis

A
  • CREST
  • Cardio:
  • hypertension
  • coronary artery disease

• Lung:

  • pulmonary hypertension
  • pulmonary fibrosis.

• Kidney

  • glomerulonephritis
  • scleroderma renal crisis
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12
Q

Antibodies for limited cutaneous systemic sclerosis

A

cutaneous=centromere
Anti-centromere antibodies

Antinuclear antibodies (ANA) are positive in most patients with systemic sclerosis but not specific

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13
Q

Antibodies for diffuse cutaneous systemic sclerosis

A

Anti-Scl-70 antibodies (also associated with more severe disease)

Antinuclear antibodies (ANA) are positive in most patients with systemic sclerosis but not specific

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14
Q

Management of Reynaud’s

A

Nifedipine

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15
Q

SLE features mnemonic

A
  • Serositis – Pleurisy, pericarditis
  • Oral ulcers
  • Arthritis
  • Photosensitivity rash
  • Blood disorders (Neutropenia , thrombocytopenia, lymphopenia, anaemia)
  • Renal involvement (Lupus nephritis)
  • Antinuclear antibodies
  • Immunologic phenomena
  • Neurologic disorder
  • Malar rash
  • Discoid rash
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16
Q

Myasthenia Gravis antibodies

A

Acetylcholine Receptor Antibodies (80%)

Muscle-specific serum kinase antibodies (10%) (MUSK)

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17
Q

Ehler’s Danlos vs Marfans

Study These Flashcards
A

multisystemic disorders that primarily affect the soft connective tissues

EDS - skin hyperextensibility, atrophic scarring, joint hypermobility and generalized tissue fragility

MFS - aortic root dilation/dissection, ectopia lentis and bone overgrowth

18
Q

Ankylosing spondylitis investigations

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A
  • CRP and ESR may be raised (normal doesn’t exclude)
  • HLA B27 +ve in 90% of AS, but +ve in 10% gen pop

Xray of sacroiliac joint
• sacralilitis (erosion / sclerosis)
• sqauring of sacroiliac joint
• bamboo spine is late sign

19
Q

Examination of Ankylosing spondylitis

Study These Flashcards
A

• Reduced flexion in the lumbar spine
——–> Schober’s test - measure 10cm vertically, then normal is >15cm following maximal forward flexion of the spine
• Increased extension at cervical spine
——–> Increased occiput to wall distance
• Reduced chest expansion
• Reduced rotation

20
Q

What is Felty’s syndrome??

Study These Flashcards
A

combination of

  • rheumatoid arthritis
  • neutropenia
  • splenomegaly

(RaNS)

21
Q

Methotrexate counselling

Study These Flashcards
A

Take weekly

Blood test for blood, liver and kidneys - Before+during treatment

CXR before treatment

Not advised if
• pregnant/trying or breastfeeding
• severe liver, kidney, or blood disease
• active infection
• mouth, stomach or duodenal ulcer
• due to have a "live" vaccine

Folic acid weekly, day after your methotrexate

Drug contraindications (NSAIDs, trimethoprim, cotrimoxazole, )

22
Q

Big red flag to look out for in Sjogrens

Study These Flashcards
A

Weight loss, due to 40-60X increased risk of lymphoid malignancies

23
Q

Antiphospholipid antibodies and important blood test to remember

Study These Flashcards
A
  • Anti-Cardiolipin Antibody (ACL)

* paradoxically raised APPT

24
Q

disease scoring system for rheumatoid arthritis

25
Extra articular features of rheumatoid arthritis
* CVD is the most common cause of death in RA * ILD * Felty's with RA splenomegaly and neutropenia
26
Associated conditions w Ankylosing spondylitis
* Atlanto-axial subluxation * Anterior uveitis * Apical fibrosis * Aortic regurgitation * Amyloidosis (renal) * Achilles involvement (enthesitis) ``` Most common is • IBD (50%) • Acute anterior uveitis (35%) • Psoriasis (10%) • Increased CV risk ```
27
Patient with RA on methotrexate presents with peripheral oedema, facial oedema and frothy urine
nephrotic syndrome
28
uhthoff's phenomenon
worsening of MS symptoms from heat
29
Lhermitte's sign
sudden electric shock down back of neck and spine then radiates to arms and legs triggered by bending head forwards
30
most common heart problem associated with active lupus
Pericarditis
31
Examination for Myasthenia Gravis
• Ocular myasthenia ----->Sustained upgaze and repeated blinking • Limb weakness ----->Lift arms to 90deg, check shoulder ab- and adduction. Then move one arm up and down 20 times, and retest ab- and adduction • Central/bulbar involvement ----->Power of head/neck flexion and extension (fatigue this movement as above) Ask the patient to take a deep breath and count out loud as many numbers as they can
32
Age of patients who get diagnosed with Myasthenia Gravis
* Young women (20-35) - usually generalised/acute | * Older men (60-75)- prominent oculobulbar involvement
33
Most important initial investigation in suspected myasthenia gravis
FVC Progressive decline or low (<1.5L) then make ITU aware and measure 4hrly
34
Management of Myasthenia Gravis
``` Conservative • Patient education • Patient alert card • MDT • Optometry • SALT ``` Medical • Pyridostigmine • Low dose PO steroid • Steroid sparing with Azathioprine (check TPMT levels) ACUTELY • IVIG and/or plasma exchange • Steroids (methylpred or pred) -uptitrate slowly as can make worse Surgical • Thymectomy (can cause remission in 80%!) even if they don't have thymoma
35
Classic causes of reactive arthritis
``` Typically preceded by 4-8 weeks by infection of : • Chlamydia • Salmonella • Campylobacter • Streptococcus ``` Gonococcal can cause but more likely to cause Septic arthritis HLA B27 is +ve in 50% of Reactive A
36
Management of reactive arthritis
* Rule out other causes * ESR >30 is worse prog * HLA B27 is +ve in 50% of Reactive A * Typically self-limiting without steroids * BASHH recommends Tx infection (but not "lengthy" course, unlike some trusts)
37
Most common conditions associated with Ankylosing Spondylitis
``` Most common is • IBD (50%) • Acute anterior uveitis (35%) • Psoriasis (10%) • Increased CV risk ```
38
Ankylosing spondylitis differentials
* Rule out cancer red flags * IBD-related spondyloarthropathy (Which came first?) * Mechanical back pain (improves with rest) * Lumbar spinal stenosis (Typically >60y) * RA (predom periph)
39
New name for pseudogout
* Acute calcium pyrophosphate deposition arthritis (CPPD) * 50% of adults develop radiographic changes typical of CPPD by the age of 80 * linear opacification of articular cartilage
40
Drugs that can induce gout
* Aspirin * Diuretics * Immunosuppressant agents * Xylitol * (and renal impairment)
41
What further investigation to offer for Myasthenia Gravis
Bedside tests like • Ice pack test to reverse fatigable ptosis • FVC to check not in respiratory compromise • Measure severity on MG composite scale • Speech and language input • Ask for optometry input if ophthalmeplegia Bloods • Acetylcholine Receptor Antibodies (80%) • Muscle-specific serum kinase antibodies (10%) (MUSK) • ?Lambert Eaton - Voltage gated calcium channel • Thyroid antibodies as 10% also have autoimmune thyroid disease Electromyography EMG • Decrement on repetitive stimulation CT to look for thymoma Can offer tensilon test, but not if signif cardiac cormorb
42
When would you speak to ITU about patient with myasthenia
* Looks unwell * Can't finish sentence * Can't lift head off pilow * Can't manage secretions * Can no longer count up to 20 in one breath * Low or declining FVC

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