Rheum Flashcards
(135 cards)
1
Q
What are red flags forr back pain
A
Age (<20 or >55) Sphincter disturbance Recet / current infection Malignancy Morning stiffness COnstant or progressive pain Neuro disturbance Bilareral / alternating leg pain FLAWS Thoracic back pain Nocrturnal pain
2
Q
Ix for lower back pain
A
MRI only if suspected malignancy / fracture, infection, ask spond
NEVER XR
3
Q
how do you manage lower back pain
A
- conservative: physical acrivity and exercise
- medical: NSAID + PPI
consider group exercise programme, manual therapy, radiofrequency denervation, epidural injections
4
Q
What is Rheumatoid Arthtritis
A
chronic inflammatory disease characterised by SYMMETRICAL DEFORMING POLYARTHRITIS
5
Q
What is epidemiology like in RA
A
smokers
F>M
middle aged
6
Q
genetic associations in RA
A
HLADR4 and HLADR1
7
Q
sx of RA
A
- symmetrical, wollen painful small joints in hands and feet
- ulnar deviation of MCPs and radial deviation at wrist
- Morning stiffness, better with exercise
- limitation of movement
8
Q
which joints are most afected by RA
A
hand: MCP, PIP
wrist
feet: MTP
9
Q
late fts of RA (pathomnemonic=
A
Swan neck
Boutonierre
Z thumb
Ulnar deviation at MCP
trigger finger
10
Q
What is a boutonniere deformity
A
PIP is flexed
DIP is hyperextended
11
Q
What is a swan neck deformity
A
PIP is hyperextended
DIP is flexed
12
Q
What are bedside Ix for RA
A
DAS28 (disease activity score 28)
Squeeze test postive
13
Q
why is the DAS 28 called that?
A
because there are 28 bones in the hand
14
Q
what is the squeeze test
A
discomfort on squeezing across metacarpal (MCP) or metatarsal (MCP) joints
15
Q
Bloods for RA
A
- FBC (anaemia, low PMN, high platelets)
- Raised ESR, CRP
- RhF +
- anti-CCP +
- ANA +
16
Q
which is the most specific and sentitive antibody for RA
A
anti-CCP
17
Q
What antibody correlates severe progressive diseasse?
A
RhF
18
Q
what imaging should you get for RA
A
XR (normal in early)
USS (allows earlier diagnosis of synovitis and erosions)
MRI
CXR
19
Q
Rheumatoid arthritis xray findings
A
o Bone peri-articular erosions (late)
o Osteopenia and juxta-articular osteoporosis
o Narrowing of joint space
oDeformity
o Soft tissue swelling
20
Q
What do you need to monitor in RA
A
CRP
DAS28
Tender and swollen Joint Count
21
Q
How do you manage RA
A
DMARD monotherapy + bridging prednisolone short course
22
Q
non-pharmacological mx of RA
A
physiotherapy
occupational therapy
hand exercise programmed
psychological interventions
treat comobird (obese, htn, dm)
23
Q
What are DMARDD medication examples
A
methotrexate, sulfasalazone
24
Q
what investigations should you get often if on methotrex
A
regular FBC and LFT (risk of myelosuppression and liver cirrhosis)=
25
how do you treat RA flare
CORTICOSTEROD + NSAID
26
what is driving process behind RA
Autoinflamm!
27
Whhat is driving process behind OA
mechanical wear and tear
28
what age group is OA most common
elderlhy
29
what joints are affecte in OA
```
weightberaring joints (knee, hip)
Hands: CMC, DIP, PIP
```
30
what joints are affected in RA
Hands (MCP, PIP)
31
What is pain like in OA
pain following use (because this is mechanical wear!!)
pain improves with rest
unilateral
systemically well
32
what is pain like in RA
morning stiffness
pain improves with use
bilateral
systemic unwell
33
what are XR findings in OA
```
LOSS
loss of joint space
osteophytes
subchondral sclerosis
subchondral cysts
```
34
what is the aetiology of gout
```
monosodium urate (MSU) crystal deposition in and around the joints
this causes erosive arthritis
```
35
what can precipitate a gout attack
infection
alcohol
starvation
surgery
diuretics
36
who is gout common in
men
| with HTN, IHD, metabolic syndrome
37
what are causes of gout
1. Increased urate intake or production:
- Increased dietary intake of purines – shellfish, anchovies, red meat
- Increased nucleic acid turnover (e.g. lymphoma, leukaemia, severe psoriasis)
- Increased synthesis of urate e.g. Lesch-Nyhan syndrome
2. Decreased Renal Excretion
- Idiopathic
- Dehydration/starvation
- Alcohol excess
- Drugs (e.g. DIURETICS: THIAZIDES, loop diuretics (furosemide) ciclosporin, alcohol, low-dose salicylates)
* Note: aspirin 75-150mg does not have significant effect on plasma urate levels
- Renal dysfunction: CKD
38
S/S gout
-sudden excruciating MONOARTHRITIS --> wake up feeling like toe is on fire (usually on first MTP aka podogra)
- Tophi (urate deposits in pinna and tendons)
- symptoms of urate urolithiasis (renal calculi symptoms)
39
what ix should you get in gout
- bloods: FBC (raised WCC), U&Es, Serum urate (during acute response-->urate excretion increases so may be normal), Raised ESR/CRP
- synovial fluid aspirate: needle shaped monosodium urate crystals seen. NEGATIVELY birefringent under polarised light microscopy
- xray: early (joint effusions), late (punched out erosions)
40
how do you manage gout ACUTE ATTACK
ACUTE attack: Colchine, NSAID (+PPI)
if renal impairment: steroids
follow up in 4-6 weks
41
what are contreaindications of NSAIDS
warfarin
Peptic Ulcer Disease
Heart failure
CRF
42
How do you manage CHRONIC gout
Conservative: Weight loss, avoid alcohol, alter diet and intake of high purine foods (red meat, liver, kidneys, shellfish, yeast extracts)
| Urate lowering therapy: allopurinol (xanthine oxidase inhibitor)
43
what is psudogout caused by
calcium pyrophosphate crystals
44
what joints ar affected by pseudogout
BIGGER joints (knee, wrist, hip)
45
What will needle aspiration show for pseudogout
positively birefringent, needle shaped crystals
46
how do you manage pseudogout
analgesia
NSAIDS
steroids
47
what are the four seronegative spondyloarthropathies
psoriatic arthritis
enteropathic arthritis
alkylosing spondylitis
reactive arthritis
48
what are seronegative spondyloarthropathies
inflammatory arthritis affecting spine and saroiliac joints
with NO RhF production
HLA B27 assdociation
49
What is Ankylosing Spondylitis sx
* **insidious onset of back pain >3 months
* relieved by exercise **but not by rest
* **morning stiffness **
* worse at night and ealy morning --> disurbed sleep
* costochondritis (anterior chest pain)
*progressive loss of spinal movement
50
what is ank spond associated with
```
AAAAAA
Anterior uveitis
Apical lung fibrosis
aortic regurg
AV node block
Achilles tendonitis
Amyloidosis
```
51
who will alk spond occur in
YOUNG MEN
52
clinical examination findings in ank spond
* reduced lateral flexion
* reduced forward flexion - Schober's test
* reduced chest expansion
* tender sacroiliac joints
53
what special exam can you do for alk spond
**Schober's test**
1. mark L5 (back dimples)
2. place a finger 5cm above and 5 cm below the mark
3. get them to bend over
4. The distance between the two lines should increase by more than 5 cm when the patient bends as far forward as possible
5. reduced movement -> AS
54
What ix can you get for ALkSpond
XR: sacroiliac joints
MRI (most sensitive)
HLA-B27 testing
ESR, CRP (non specific)
55
what changes do you see on XR / MRI spine for alkspond
sacroilitis: subchondral erosions + sclerosis --> fusion (ankylosis)
bamboo spine (squaring of lumbar vertebrae)
56
how do you manage alkspond
* conservative (exerciis / physio)
* medical: 1st --> NSAID 2nd --> simple analgesics, opiods, 3rd --> anti-TNFa)
* surgical (hip replacement to decrease pain and increase mobility
57
what is psoriatic arthritiis
```
Psoriasis
Nail changes - pitting, onycholysis, subungal hyperkeratosis
Enthesitis
Dactylitis (swollen sausage finger)
Arthritis (usually of DIPJ)
```
58
mx psoriatic arthritis
NSAID > methotrex
59
what is Reiter's / Reactive arthritis
sterile arthrisis 1-4 weeis after urethritis (chlamydia) or dysentry (campylobacter)
60
sx of reactive arthritis
can't see
can't pee
can't cliimb a tree
so: conjunctivitis, urethritis, oligoarthritis in LL
also circinate balanitis, keratoderma blenorrhagicum
61
ix Reactive arthritis
raised ESR, CRP
stool culture if diarrhoea
urine test chlamydiia
62
mx Reactive arthritis
NSAIDS
| PO steroids
63
Behcet's disease in whom
mediterranean, turkish, japanese
64
S/S behcet disease
recurrent oral and genital ulceration, uveitis, erythema nodosum, VTE
65
Sjogren syndrome sx
dry eyes
bilateral parotid swelling
decreased salivation, xerostomia
vaginal dryness
66
ix for Sjogrens
Schirmer's test
| Antibodies (anti Ro, anti La, RhF)
67
Mx sjogrens
artificial tears, saliva replacement
| NSAID/hydroxychloroquine
68
SLE symptoms
```
SOAP BRAIN MD
seroritis
oral ulcers
arthritis
photosnsitivity
blood counts all low
renal damage (proteinuria, haematuria)
ANA high
immunological (anti dsDNA, AIHA)
neurological (psych sx, seizures)
```
69
what condition does antiphospholipid syndrome often occur with
occurs with SLE in 30% of cases
70
How does APS present
Thrombi
Thrombocytopoenia
Antibodies
Also:
livedo reticularis
recurrent miscarriage
71
how do you manage APS
low dose aspirin if no prior VTE
| warfarin if prior VTE
72
what antibodies are raised in APS
anti-cardiolipin
| lupus anticoagulant
73
what antibodies ix must you do if suspecting lupus
ANA (most sensitive, poorly specific)
anti-dsDNA
anti-smith
RhF
74
how do you monitor SLE disease
anti-dsDNA titers (marker of disease activity)
C4 reduction (moderate activity) > C3 wrduction (very active lupus)
ESR lvels
75
how do you mansage SSLE
FLARES: prednisolone + IV cyclophosphamide
MAINTAINANCE: hydroxychloroquine + DMARD
76
what are the five fts of limited systemic sclerosis
```
CREST
calcinoosis
raynauds
oesophageal dysmotility
sclerodacyly
telangectasia
```
77
what are fts of diffuse scleroderma
diffuse skin involvement beyond wrists, up the arms
diffuse organ fibrosis:
- GI (GOR, aspiration, dysphagia, anal incontinence)
- Lung (fibrosis, pul HTN)
- cardiac (arrythmia)
- renal (acute HTN crisis)
78
antibodies for systemic sclelrosis
Limited: anti-centromere
Diffuse: anti-SCL70, anti topoisomerase
79
what is polymyositis
inflammation of skeletal muscle
80
polymyositis sx
progressive proximal muscle weakness
with myalgia and arthralgia
wasting of shoulder and pelvic girdle
dysphagia, dysphonia, resp weakness
81
what can trigger polymyositis
paraneoplastic tumour
82
whhat is dermatomyositis
polymyositis + skin signs
83
what skin signs do you get with dermatomyositis
priorbital heliotrope rash (worse in sunlight)
gottron's papules
mechanic hands (painful rough skin)
84
what ix do you gt for myositis
```
RAISED CK (1000s)
AST, ALT, LDH raised
EMG
Biopsy (definitive)
Antibodies (anti-Jo1, Anti-Mi2, anti-SRP)
MALIGNANCY screen
```
85
give examples of two large vessel vasculitis
GCA
| Takayasu
86
give examples of two medium vessel vasculitis
Polyarteritis nodosa
| Kawasaki disease
87
give examples of two small vessel vasculitis
Churg strauss
Wegeeners granulomatosis
HSP, goodpastures
88
What antibody with Churg Strauss?
pANCA
89
what antibody with Wegeners
cANCA
90
sx of GCA
scalp tenderness
jaw cladication
headache
amarosis fugax (ischaemic optic neuropathy)
91
ix GCA
USS temporal artery (halo sign)
if USS negativem, get a temporal artery biopsy
Raised ESR
92
how do you manage GCA
PO prednisolate immediately (before ix)
93
what do you give for GCA if visual sx
IM methylpred
94
how does takayasu arteritis present
```
Asian females
20-40yo
weak/unequal limb pulses
HTN
large vessel blockage
```
95
how does Polyarteritis nodosa present
```
young male adult
systemic symptoms
rash
melaena, abdo pain
renal: HTN
liver dysfunction (HBV)
```
96
How do you manage polyarteritis nodosa
prednisolone + cyclophosphamide
97
How does Wegeners prsent
URT: rhinitis, epistaxis, saddle nose
LRT: haeemoptysis, cough
renal: RPGN, nephritic syndorme
98
Chung strauss sx
eosiniophilia
asthma
vascultisi
99
what meds can you give for chronic pain
All diabetics get peripheral (neuropathy)
amytryptiline
duloxetine
gabapentine
pregabalin
100
first line mx for neuropathic pain
amytriptyline and pregabalin
101
first line mx diabetic neuropathy
duloxetine
102
first line trigeminal neuralgia c
carbamazepine
103
what is stills disease
| + what are its findings on blood test
type of inflammatory arthritis presenting with FAR:
Fever (SPIKES in the evenings)
arthralgia
Rash (salmon pink maculopapular)
negative RF, ANA
high ferritin
104
mx stills diseae
NSAID
| add srteroid after one week
105
How does pseudogout present on X ray?
CHONDROCALCINOSIS (deposits of calcium along joint line)
| otherwise may mimic OA
106
what are heberden and bouchard nodes
```
Heberden = swollen DIP
Bouchard = swollen pip
```
in Osteoarthrtis
107
what is cervical spondylosis
degeneraton of cervical spine
impinges onto spinal cord > compresses nerve root and anterior spinal cord
causes DEGENERATIVE CERVICAL MYELOPATHY
108
sx DEGENERATIVE CERVICAL MYELOPATHY
pain in neck and arms
numbness in neck and arms
loss of motor function (digital dexterity)
109
signs DEGENERATIVE CERVICAL MYELOPATHY
LMN in upper limbs
| UMN in LL (including autonomic dysfunction)
110
what sign is POSITIVE In DEGENERATIVE CERVICAL MYELOPATHY
Hoffman
111
management of DEGENERATIVE CERVICAL MYELOPATHY
urgent neurosurgery referral
| needs IV methylpred + decompression
112
what will you find when examining a patient with GCA
swelling and erythema over temporal artery
thickened, non pulsatile temporal artery
reduction in visual acuity
113
what are the two types of gout
PODAGRA = acute attack, excruciating pain swelling and hot 1st MTP
Chronic TOPHACEOUS GOUT = chronic disease, depositon of TOPHI in joints, tendons, pinna
114
whhat dietary advice should you gve to someone with gout
avoid meat, alcohol, prolonged fasting
| lose weight
115
what does XR show in gout
punched out erosions "RAT BITES" and reduced joint space
116
classic presentation of POLYMYALGIA RHEUMATICA
PAIN and STIFFNESS in shoulders, neck, hips (NO weakness)
>> pain worse on walking
>> stiffness worse in morning, resolves during the day
OVER 50s
Min 2 weeks of sx
117
what are blood markers like in POLYMYALGIA RHEUMATICA
raised ESR, CRP
| normal CK
118
how do you manage POLYMYALGIA RHEUMATICA
PO prednisolon
119
descriibe pattern of muscle weakness in polymyositis
PROXIMAL FIRST (distal is much later)
Difficulty getting up from chair, lifting objects, brushnig hair
fine motor coord is usually spared until later
120
what does the face look like in scleroderma
beak nose
| microstomia (puckered mouth)
121
describe presentation of polyarteritis nodosa
```
systemically unwell
skin rash
GI melaena, abdo pain
renal HTN
liver involvement HBV
```
122
what is classiical 2 signs to distinguissh polyarteriitis nodos
- ROSARY BEAD SIGN on renal angio
| - HBV
123
What antibody is characteristic of goodpastures
anti GBM
124
what meds can cause DRUG INDUCED LUPUS
Hydralazine PIMP
```
Hydralazine
Procainamide
Isoniazid
Minocycline
Phenytoin
```
125
which antibody is present in virtually 100% of pts with driug induced lupus
aanti-histone antibody
126
when must you reassess the necessity or oral biphosphinates
assess after five years
127
how do you reassess the need for biphosphonates
FRAX score and DEXA scan
128
what conditions would you stop biphosphonates for
if T score >-2.5
low risk
BUT REVIEW IN 2 YEARS
129
how do you manage paget's disease
bisphosphonate (either oral risedronate or IV zoledronate)
130
what does joint aspirate show in RA
```
yellow cloudy fluid
high WCC (PMN)
```
131
what is Carpal tunnel syndrome
compression of median nerve in the carpal tunnel.
132
symptos of carpal tunnel
* pain/pins and needles in thumb, index, middle finger
* unusually the symptoms may 'ascend' proximally
* patient shakes his hand to obtain relief, classically at night
133
examination findings for carpal tunnel
* weakness of thumb abduction (abductor pollicis brevis)
* wasting of thenar eminence (NOT hypothenar)
* Tinel's sign
* Phalen's sign
*
134
tinel vs phalens
Tinel's sign: tapping causes paraesthesia
Phalen's sign: flexion of wrist causes symptoms
135
treatment of carpal tunnel syndrome
mild-moderate symptoms: 6-week trial of conservative treatments -->
* corticosteroid injection
* wrist splints at night
severe symptoms or symptoms persist with conservative management -->
surgical decompression (flexor retinaculum division)
