Rheum Long Flashcards
(39 cards)
1
Q
Scleroderma Hx
A
- Derm
- Raynauds, skin tightening - Arthritis
- Rheumatoid distribution, Carpel tunnel - GI
- Dysphagia, reflux, diarrhea - Renal
- HTN, CKD, SRC - Resp
- ILD, PHTN, pleurisy - Cardiac
- Pericarditis, arrhthymias, dilated cardiomyopathy -CCF - Other
- Erectile dysfunction, hypothyroid, non melanoma skin cancers
2
Q
DDX of Scleroderma
-Non associated with Raynauds or ANA
A
Eosinophilic fascitis
Morphea
Nephrogenic systemic fibrosis
Diabetic cheiroarthopathy
3
Q
CREST
A
Calcinosis (deposits in subcut tissue at ends of fingers) Raynaud's Esophageal involvement Sclerodactyly Telangiectasia
4
Q
Ix for Systemic Sclerosis
A
- Basic Bloods:
- FBE (Anaemia), ESR, Folate and B12 (malabsorption) - Special Bloods:
- Ig - (Hyper IgG in 50%), ANA, Anti-Scl 70 (diffuse), Anti centromere (limited) - Imaging
- CXR, HRCT - Special tests:
- Gscope and oesophageal manometry
- PFTs
- TTE
- RHC
5
Q
Tx for Systemic Sclerosis
A
- Reflux - PPI
- Raynauds - CCB, Prazocin, methyldopa, iloprost
- Dry eyes
- Malabsorption (ensure no SIBO), supplements
- ILD - Cyclophosphamide
- PHTN - Endothelin recepton antagonist, phosphodiesterase inhibitors, Prostanoids
- HTN - ACEi
6
Q
Extra articular manifestations of RA
A
- Skin - Raynauds, leg ulcers
- Eyes - Dry eyes, scleritis, episcleritis, scleromalacia perforans, cataracts
- Sore throat, horeseness, neck pain 0 Suggests cricoaryteroid disease
- Recurrent headaches at base of skull and arm tingling - thinck C1/2 sublaxation - Lungs - ILD, pleural effusion, pleuritis
- Cardiac - Pericarditis, valvular disease atherosclerosis
- Renal - Drug use, amyloid
- CNS - PN, mononeuritis multiplex, cord compression, entrapment neuropathy
- Haeme - Anaemia, Felty’s (RA, leukopenia, splenomegaly)
- Systemic - fever, weight loss, fatigue
- Vasculitic - digital arteritis, ulcers, PG
7
Q
MTX Side effects
A
Hepatic and pulmonary toxicity
Leukopenia
Thrombocytopenia
8
Q
SSZ Side effects
A
Rash Nausea Haematological abnormalities Abnormal LFTs Reversible oligospermia
9
Q
HCQ Side effects
A
Nausea
Pigmentation
Bull’s eye retinopathy
10
Q
LEF Side effects
A
Diarrhea
Alopecia
Derranged LFTs
11
Q
Causes of Arthritis and Nodules
A
RA (Seropositive)
SLE
Rheumatic fever (Jacoud’s arthritis)
Amyloid Arthropathy (usually associated with MM)
12
Q
DDX for deforming symmetrical chronic polyarthropathy
A
RA PSoriatic arthritis or seronegative arthropathy Chronic tophaceous gout Primary generalised OA SLE
13
Q
Investigations to assess activity of RA
A
ESR or CRP
Hb - severity of normocytic anaemia correlates with activity
Anto CCP and RF titres
PResence of progressive erosions on serial XRs
14
Q
DDx for raised ESR in RA
A
Active disease
Sjogrens
Amyloidosis
Infection
15
Q
Tx of RA
A
General Principles
- Education
- PT - exercise and splinting of joints to prevent deformity
- OT
- Smoking cessation
- Rest of inflamed joints
- Anti inflammatories
- CVS risk modification
Induce Remission
-DMARDS or biologics
Acute flare Mx
-Steroids, PO or intraarticular
Surgery
- Joint replacements - Hip, shoulder, knee
- Arthroplasty and relief of contractures
16
Q
Risk factors for destructive disease in RA
A
High titre RF or positive anti CCP Constitutional Sx Insidious onset Erosions early on XR Rheumatoid nodules early HLA DR4
17
Q
Rules for the use of biologics for RA
A
- Failure of at least 6 months of treatment with traditional DMARDs
- Tx must include MTX and combinations of HCQ, SSZ, or LEF
18
Q
Monitoring for disease activity during review of RA patient
A
Fatigue Morning stiffness Weight loss Functional limitations Acute phase reactants (ESR and CRP)
19
Q
OA MX
A
Non pharm
- Exercise: Stretching and mobility exercises to help maintain ROM; Aquatic exercise; exercise bike; Supervised or group exercise is better for reduction in pain
- Gait aids: SPS, knee braces, foot orthoses
- LoW: most important modifiable RF
- Complimentary meds: Glucosamine, fish oil, chondroitin equal to placebo
Pharm
- NSAIDS/Paracetamol
- Topical NSAID/Capsaicin
- Intraarticular steroids for acute flare
- Opioids topical or oral (increased risk of CVS, fractures, and mortality compared to NSAIDs)
- Duloxetine - superior than placebo
Surgery
20
Q
Extraarticular manifestations of Ank Spond
A
Uveitis
AR
Symptoms of cauda equina (late)
Upper lobe interstitial lung disease (Late)
21
Q
Diagnosis of Axial Spondyloarthritis
A
- Age < 45
- > 3 months of back pain
- HLA B27 positive + 2 or more of:
-Inflammatory back pain
-Enthesitis
-Uveitis
-Dactylitis
-IBD
-Family Hx of SPA or HLA B27
Elevated CRP
-REsponse to NSAIDs - Sacroilitis on XR or MRI
22
Q
Mx of axial spondyloarthritis
A
- Exercise program for flexibility
- NSAIDs - reliev Sx and slow radiographic progression
- Anti TNF alpha if not responsive to NSAIDs
- ?Surgical options
23
Q
ARA criteria for SLE
A
Need 4 out of 11
- Malar rash - sparing the nasolabial folds
- Discoid rash
- Photosensitivity rash
- Oral Ulcers
- Arthritis affecting 2 or more peripheral joints
- Serositis - pleurisy, pericarditis
- Renal disorder - Proteinuria > 0.5 g/day or cellular casts
- Neuro disorder - Seizures, psychosis
- Haeme - haemolytic anaemia, leukopenia, lymphopenia, thrombocytopenia
- Immunological disorder - dsDNA, anti-Sm, positive APLS ab
- ANA >1:160
24
Q
SLE Hx
A
- General Sx: Nausea, weight loss, malaise, thrombosis
-MSK: arthralgia, arthritis, myalgia, myositis
-Derm: rash, alopecia, oral and nasal ulcers
-Fever
-Neuro psych Sx - delirium, dementia, seizures, chorea, neurpathy, stroke, headache, MS like symptoms, anxiety, depression
-Renal - haematuria, oedema, renal failure
-Resp - pleurisy
-CVS - pericarditis, myocarditis, valvular lesions, CAD
HAeme - anaemia, lymphadenopathy
-GI - diarrhea, pseudo bowel obstruction, perforation
-APLS Symptoms
-Sicca symptoms
25
KEy Symptoms for SLE
```
Apthous ulcers
Serositis
Raynauds
Alopecia
Photsensitivity rash
Dry eyes and mouth
Thrombosis
miscarriage
Nephritis
```
26
Features of MCTD
- OVerlapping features of SLE, SS, and polmyositis
- High anti U1RNP
- PErcardial effusion
- Raynaud's, swollen hands, fatigue and arthritis
- PAH is main cause of death
27
Major causes of death in SLE
Infection
Renal failure
Lymphoma
AMI
28
Mx of SLE
General
- Sun protection and avoidance
- Rest and NSAIDs for arthralgia and myalgia
- Cease smoking
Suppressing disease activity
- HCQ (Skin and joint)
- Steroids if serious disease manifestation
- AZA/MMF/Cyclophosphamide -Renal Lupus
- MTX - Joints
- Raynaud's: CCB
- Ritux/Belimumab - on special access scheme for some patients
Managing Disease complications
- CVS modification
- Thrombosis and hypercoagulability
- Bone health
- Routine Pap smears - risk of cervical dysplasia
29
General Vasculitis Sx to ask on Hx
```
Fatigue
fever
myalgia
arthralgia
Vasculitic skin rashes - palpable purpura
Renal disease
HTN
GI symptoms
```
30
GPA Hx specifics
Ganulomatosis with polyangiitis
- Nasal congestion/Rhinorrhea
- Bloody nasal discharge
- Cough (initially dry, but may progress to hemoptysis)
- Breathlessness
- Renal involvement
31
GCA Hx specifics
- PMR Sx
- Bitemporal headache
- Visual disturbance - diplopia, visual loss
- Jaw claudication
- Scalp tenderness
32
PAN Hx specifics
Hep B risk factors
USually multi system involvement
-e.g. foot drop, abdo pain, chest pain
33
EGPA Hx specifics
- Asthma
- PEripheral eosinophilia
- Allergic rhinitis/nasal polyps
- Eczema
- Cough and breathlessness
- PNS - symmetrical PN or mononeuritis multiplex
34
Mixed essential cryoglobulinemia Hx specifics
Small vessels due to RF bound to IgG
- Palpable purpura
- Raynauds
- Arthritis
- Neuropathy
- Hep C is common
35
Levido reticularis DDx
```
Cholesterol atheroembolism
APLS
Vasculitis
Atrial myxoma
Bacterial endocarditis
TTP
```
36
IX for vasculitis
```
ESR
Renal function - GPA, MPA, PAN
LFTs- usually derranged in GPA and PAN
Urine MCS, casts, RBC morphology
CXR - bilateral diffuse interstial abnormality in GPA, peripheral fluffy patchy infiltrative pattern in EGPA
c-ANCA and anti PR3 antibodies- GPA
p-ANCA - EGPA and consider sural nerve Bx
MPA - p-ANCA and REnal Bx
PAN - Angiography/Bx
```
37
Tx of GPA
High dose steroids
Cyclophosphamide
Bactrim adjunct
Ritux if above fails
38
PAN Mx
High dose pred
Cyclophosphamide - 90% go into remission
If associated with Hep B - Interferon alpha or antivrial vidarabine is helpful to lead to remission
39
EGPA MX
Steroids alone effective
| MAy need other immunosuppression if not
