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Yr 3 Medicine > Rheumatology > Flashcards

Rheumatology Flashcards

1
Q

What features in a patient history support a diagnosis of RA?

A

Family history of RA
Younger (30 - 50 yrs)
MCP + PIP pain + swelling
Multiple small joint swellings
Morning Stiffness (>30mins)
Fatigue

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2
Q

Apart from the hands, what other joints are commonly affected in RA?

A

Shoulders
Knees
Wrists

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3
Q

What are the classical examination findings in the hands of patients with RA?

A

Soft tissue swelling + tenderness
Ulnar deviation/Palmar subluxation of MCP
Swan-neck deformity to digits
Rheumatoid Nodules

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4
Q

What are the extra-articular manifestations of RA?

A

3 C’s:
Carpel Tunnel
CVD Risk
Cord Compression

3 A’s:
Anaemia
Arteritis
Amyloidosis (build of amyloid)

3 P’s:
Pericarditis
Pleural Disease
Pulmonary Disease (bronchiectasis/fibrosis)

3 S’s:
Sjogren’s (attacks glands - mucosal/tear leading to dry eyes and mouth)
Scleritis
Splenomegaly (+ neutropenia is FELTY’S SYNDROME)

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5
Q

What investigations help diagnose RA?

A

High RF + anti-CCP
FBC (normocytic anaemia - anaemia of CD)
Inflammatory Markers raised

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6
Q

What are the radiological features of RA in the hands?

A

Loss of joint space
Erosions (Periarticular)
Soft Tissue Swelling
Subluxation

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7
Q

What treatment options are available for RA?

A

1) Methotrexate
2) DMARD combination therapy (sulfasalazine, hydroxychloroquine, leflunomide)
3) Biologics (Adalimumab, etanercept, rituximab)

Acute Flare up: Steroids

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8
Q

What monitoring is required with RA treatments?

A

Regular Blood tests
Pregnancy testing (sulfalazine only is safe in pregnancy)

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9
Q

What tests are needed before starting on RA drug therapy and what contraindications are there?

A

CXR
HIV/TB/Hep B/Hep C status
Bloods

Contraindications:
HIV/Hep B/C
Severe HF
Hx of multiple sclerosis
Cancer

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10
Q

What features distinguish RA from other arthritidies?

A

No DIP involvement
Morning Stiffness > 30 mins
Activity Improves
Resting worsens
Family History
Younger presentation
Small Joints

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11
Q

What features support a diagnosis of Ankylosing Spondylitis?

A

Young man (teens-30s)
Back stiffness
Reduced spine movement
Loss of lumbar lordosis
Reduced chest expansion

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12
Q

What is Schober’s Test and what does a +ve one look like?

A

1) Identify the PSIS on each side
2) Mark the skin in the midline 5cm below PSIS + 10cm above PSIS
3) Ask patient to touch there toes

Distance should increase from 15cm > 20cm

+ve test = Less than 20cm (ankylosing spondylitis)

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13
Q

What symptoms would you ask about if you suspect ankylosing spondylitis?

A

Back pain > 3 months
Morning Stiffness > 30 mins
Buttock pain
Exercise improves it
No improvement with rest
Pain wakes up at night

EAMs:
Anterior uveitis (acutely painful red eye, photophobia, blurred vision)
Psoriasis
IBD
Genitourinary Infection
AV Block
Aortic incompetence

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14
Q

What investigations would further help with the diagnosis of Ankylosing Spondylitis?

A

CRP/ESR could be raised
+ve Schober’s test

Spine X-Ray/ MRI Spine
+ve HLA-B27 (GENETICS)

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15
Q

What gene is common in ankylosing spondylitis?

A

HLA-B27

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16
Q

What are the complications of Ankylosing Spondylitis?

A

Spinal Fractures
Hip Joint Replacement
Spinal Fusion
Osteoporosis
Anterior Uveitis
Increased CVD risk (arrhythmias/CHF/Valvular Disease)
Lung Fibrosis

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17
Q

How do you manage Ankylosing Spondylitis?

A

1) NSAIDs + physio
2) TNF Inhibitors (Adalimumab, Etanercept)
3) IL-17 Inhibitors (Brodalumab)

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18
Q

What features support a diagnosis of gout?

A

> 40 yrs
Male
Sudden, severe, red, tender
Usually one joint, big toe
Tophi nodules

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19
Q

What are the common associations with gout? (Lifestyle and conditions)

A

Smoking
DM II
CHF
Obesity
High Alcohol intake
Diet (red meat)
Kidney Diseases

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20
Q

What investigations help diagnose gout?

A

Serum urate/Uric Acid level
Joint aspiration

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21
Q

What treatment options (acute and chronic) are available for patients for gout?

A

Acute:
NSAIDs
Oral/IM Steroids
Colchine

Chronic:
Regular Exercise
Diet Modification
Reduce Alcohol
Smoking Cessation

Urate Lowering Therapy:
Allopurinol
Febuxostat

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22
Q

What does crepitus in a joint represent?

A

Loss of Cartilage

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23
Q

Does OA or RA improve with rest?

A

OA - improves with rest
RA - improves with movement

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24
Q

What are type of joint swellings are and what do these signify?

A

Hard - boney - Heberden’s, Bouchard’s nodes in OA
Soft/non-tender - inflammatory disease

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25
Q

What are the 2 tests for carpel tunnel syndrome?

A

Phalen’s Test:
wrists together flexed with dorsal surfaces of each hand touching each other for 1 minute

Tinel’s Test:
Tap the median nerve with index and middle finger for 30 secs-1min

Should get numbers in lateral 3 digits

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26
Q

What scan is used for osteoporosis and what result is significant?

A

DEXA Scan
T score of > -2.5cm

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27
Q

What patient factors make osteoporosis more likely?

A

Low BMI
Tall

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28
Q

What patient factors can cause low bone density?

A

Genetics
Low testosterone
Thyroid issues
Smoking
Alcohol
Low BMI
Physical inactivity

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29
Q

What disease are associated with osteoporosis?

A

CKD
Cushing’s
Thyrotoxosis
Malabsorption (coeliac e.g.)
RA

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30
Q

What drugs are linked to osteoporosis?

A

LONG TERM STEROID USE
Thyroxine

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31
Q

What score is used to asses fracture risk in osteoporosis/

A

FRAX
High then treatment is required

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32
Q

What is the basics of osteoporosis management?

A

1) Biphosphonates (10yrs use max)
2) s.c. PTH
3) Denosumab

Vit D!

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33
Q

What are some side effects of biphosphonates?

A

Osteonecrosis of jaw
Atypical femur fracture

34
Q

What does the pneumonic SOAP BRAIN stand for in SLE?

A

Serositis (pleurisy, pericarditis)
Oral ulcers
Arthritis
Photosensitivity

Blood disorders (low WCC, lymphopenia)
Renal involvement (glomerulonephritis)
Autoantibodies (ANA +ve)
Immunologic tests
Neurologic disorder (seizures, psychosis)

35
Q

What are the clinical features of SLE?

A

Painful hands (arthritis)
Raynaud’s phenomenon
Alopecia/hair thinning
Pleuritic chest pain/SOB
Butterfly rash
Fatigue
Sunlight Sensitivity

36
Q

What examination findings will you look for in SLE?

A

Malar Rash
Mouth Ulcers
Alopecia

Raynauds (cold hands)
Pain in joints

Pleural Rub
Splenomegaly

37
Q

What investigations would you request for SLE?

A

FBC (anaemia of CD, thrombocytopenia, leukopenia)
Raised ESR/CRP (CRP can be =)
Urine Dip (proteinuria in lupus nephritis)

Autoantibodies:
ANA (Anti-Nuclear Antibodies)
Anti-dsDNA (Anti-double stranded DNA)

Anti-Ro + Anti-La (Sjögren’s syndrome)

Low C3/C4 (compliment proteins)

38
Q

What is the diagnostic criteria for SLE?

A

Constitutional:
Fever

Hematologic:
Leukopenia
Thrombocytopenia
Autoimmune Hemolysis

Neuropsychiatric:
Delirium
Psychosis
Seizures

Mucocutaneous:
Non-scarring alopecia
Oral Ulcers
Discoid Lupus

Serosal:
Pleural/Pericardial Effusion
Pericarditis

MSK:
Joint involvement

Renal:
Protenuria
Kidney biopsy showing lupus nephritis changes

Immunological:
Anti-dsDNA
Anti-Smith Antibody
Low C3/C4
Antiphospholipid antibodies

> 10 = SLE (each category ranges from 2-10 points each)

39
Q

What features would suggest SLE active disease (a flare up)?

A

Symptoms returning or worsening of symptoms already present

Ongoing Fever
Painful/swollen joints
Worsened Fatigue
Rashes
Leg swelling
Pleuritic chest pain

40
Q

What management is available for SLE?

A
  1. Sun protection
  2. Reduce CVS RFs
  3. Hydroxychloroquine (gold standard)
  4. NSAIDs
  5. Azathioprine, Mycophenolate mofetil
  6. Biologics (rituximab, belimumab)

Flares:
Short course of prednisolone

41
Q

What monitoring is required with SLE and it’s treatments long term?

A

Blood Pressure (CVS risk)
Urinalysis
U+Es
FBCs
LFTs

Steroids:
Hyperglycaemia (blood glucose monitoring)

DMARDs:
FBC (bone marrow suppression)

42
Q

What are some complications of SLE?

A

CVD
Infection (from disease and drugs used)
Anaemia of CD
Pericarditis
Pleuritis
ILD
Lupus Nephritis

43
Q

What is the typical presentation of Giant Cell Arteritis (GCA)?

A

Older white patients (50yrs+)
Unilateral headache (temple/forehead)
Jaw claudication
Scalp tenderness
Burred/double vision
Temporal artery inflamed with reduced or absent pulsation

44
Q

What investigations can be used to aid your diagnosis of GCA?

A

Raised ESR (CRP)
Temporal artery biopsy (necrotising arteritis)

45
Q

How is GCA treated? What if there is visual disturbance?

A

Oral prednisolone for 2 weeks then titre down
+ aspirin 75mg
+ PPI (protective w/ steroids)

Symptomatic/visual disturbance:
IV methylprednisolone

46
Q

What is Polymyalgia rheumatica?

A

Inflammatory condition causing pain/stiffness in shoulders, pelvic girdle and neck

47
Q

What is the typical presentation in polymyalgia rheumatica?

A

Older white patients
Sudden onset (<2weeks) of pain/stiffness in shoulders, neck, pelvic girdle
Reduced ROM but normal strength
Worse in morning or after rest

Weight loss/fatigue/fever
GCA association
Carpel tunnel

48
Q

How is diagnosis of polymyalgia rheumatica made?

A

Clinical presentation
Raised ESR/CRP

49
Q

How is polymyalgia rheumatica treated?

A

Daily prednisolone 15mg

RAPID IMPROVEMENT WITHIN DAYS
IF NOT: WRONG DIAGNOSIS

50
Q

What signs will be present in psoriatic arthritis?

A

Psoriasis plaques
Nail pitting
Oncholysis (separation of the nail from nail bed)
Dactylitis (inflammation of finger)
Enthesitis (entheses - point of tendon insertion into bone)

51
Q

How do you treat psoriatic arthritis?

A
  1. NSAIDs
  2. DMARDs (methotrexate)
  3. Anti-TNF (etanercept, infliximab, adalimumab)
52
Q

What is reactive arthritis and how does it present? How can we treat it?

A

Synovitis following infection elsewhere
(dysentery, urethritis, cervicitis)

CAN’T SEE (Conjunctivitis)
CAN’T WEE (Urethritis)
Raised inflammatory markers
Normal joint aspiration

Treat underlying infection
NSAIDs if needed

53
Q

What is enteropathic arthritis and how can it be treated?

A

EIM of IBD

TNF-i (etanercept, infliximab, adalimumab) treat arthritis and IBD
DMARDs
(NSAIDs can flare IBD)

54
Q

What is Raynaud’s phenomenon and what does the colour of the hand represent?

A

Vasospasm of digits
Painful episodes lasting minutes

White - inadequate blood flow
Blue - venous stasis
Red - re-warming hyperaemia

55
Q

What diseases/meds are associated with Raynaud’s phenomenon?

A

SLE
Sjogren’s
Scleroderma
Polymyositis

B Blockers

56
Q

What is the treatment for Raynaud’s?

A
  1. Avoid smoking
  2. Keep warm (cold triggers it)
  3. Ca channel blockers
57
Q

How will a patient with vasculitis present?

A

Dependant on what organ is involved

MSK:
Arthralgia
Myalgia

CNS:
Headaches

CVS:
Pericarditis
Angina

Resp:
Haemoptysis
Dyspnoea
Cough/Chest pain

GI:
Abdo pain
Diarrhoea

Renal:
Haematuria

General:
Fatigue
Fever
Night sweats
Weight loss
Anaemia

58
Q

What could vasculitis show on examination?

A

Necrotic skin ulcers
Purpura

Abdo:
Tenderness
Organomegaly

Cardiopulmonary:
Crackles
Pleural rubs

59
Q

What investigations would you order with suspected vasculitis?

A

CRP/ESR^
Urine Dip (GLOMERULONEPHRITIS)
Anti-neutrophil cytoplasmic antibodies (ANCA)
CXR

60
Q

What are some conditions that can cause secondary vasculitis?

A

Malignancy (blood)
Connective Tissue Disorders
Infection (viruses)
Drugs

61
Q

What is the management for vasculitis?

A
  1. Rule out infection. Stop offending medication
  2. Corticosteroids
  3. Cyclophosphamide, Rituximab
62
Q

What are the small-vessel vasculitis and describe them briefly?

A

Henoch-Schonlein Purpura/ IgA Vasculitis:
IgA deposits in vessels in children
Purpura + IgA nephritis

Microscopic Polyangiitis:
Glomerulonephritis
Diffuse alveolar haemorrhage (haemoptysis)

Granulomatosis with Polyangiitis (Wegner’s granulomatosis):
Nose bleeding
Sinusitis
Cough
Wheeze
Haemoptysis
Glomerulonephritis

Eosinophilic Granulomatosis with Polyangiitis (Churg-Strauss):
HIGH Eosinophils
Severe asthma in middle age

63
Q

What are the medium-vessel vasculitis and describe them briefly?

A

Polyarteritis Nodosa:
Renal impairment
HTN
Skin nodules
MI/stroke
Post HEP B

Kawasaki Disease:
Children under 5yrs
Widespread erythematous maculopapular rash
Bilateral conjunctivitis
Strawberry tongue

64
Q

What are the large-vessel vasculitis and describe them briefly?

A

Giant Cell Arteritis

Takayasu’s Arteritis:
Limb claudication
Pulseless limbs

65
Q

What is systemic sclerosis? What investigations would you ask for?

A

Increased fibroblast activity resulting in abnormal connective tissue growth causing vascular damage and fibrosis

ANA +ve
X-ray hands (calcinosis)
CXR/PFT
ECG/Echo

66
Q

What are the 2 types of systemic sclerosis?

A

Limited Scleroderma:
Calcinisis (white calcium deposits on fingertips)
Raynaud’s
Esophageal dysmotility
Sclerodactyly (hand skin tightening/ reduced ROM)
Telangiectasia (dilated blood vessels in skin, on the face)

Anti-centromere antibodies

Diffuse Scleroderma:
Sudden onset of skin thickening
Proximal to elbows/knees
Systemic/pulmonary arterial HTN

Anti-Scl-70 antibodies

67
Q

What is the management for systemic sclerosis?

A

Psychological support
Ca antagonist/sidenafil for Raynaud’s
Methotrexate - skin thickening
ACE-i

Prednisolone - flares

68
Q

What are the common symptoms of Sjögren’s syndrome?

A

Fatigue
Dry Mouth
Dry eyes
Myalgia
Arthralgia
Raynauds
Huge Parotid glands

69
Q

What investigations are there for Sjogren’s and how do we manage it?

A

Schirmer Test - measures tear volume
Anti-Ro
Salivary gland biopsy

Artificial tears/saliva
Vaginal lubricants

70
Q

What is hypermobility spectrum disorder and how does it present? What treatment is available?

A

Joints moving beyond normal limits due to laxity of ligaments, capsules + tendons

Pain is from micro trauma?

Pain around joints (worsening after activity)
+ve Beighton score

Strengthening exercises to reduce subluxation

71
Q

What is the aetiology of OA?

A

Loss of articular cartilage accompanied by new bone formation and capsular fibrosis

Resulting from overuse, excessive loading, injury and genetics

72
Q

What are the risk factors for getting OA?

A

Female
Obesity
Age
Trauma/joint malalignment

73
Q

What are the commonly effecting joints in OA?

A

Hip
Knees
Spine
DIP
Carpometacapral joint (thumb)

74
Q

What do x-rays show with OA?

A

Loss of joint space
Osteophytes (bone spurs)
Subarticular sclerosis (increased bone density across joint line)
Subchondral cysts (fluid-filled holes in bone)

75
Q

What are signs of OA in the hands?

A

Heberden’s nodes (DIP)
Bouchard’s nodes (PIP)
Squaring at the base of the thumb (CMC)

76
Q

What treatment is available for OA?

A

1) Strengthening + ROM exercises
2) Paracetamol
3) NSAIDs short spells (topical best)
4) Surgical joint replacement

77
Q

What is the pathophysiology behind fibromyalgia?

A

Disorder of central pain processing
Pain in all 4 quadrants of the body
Heightened response to not harmful stimuli
Reduced REM sleep found??!! maybe this causes heightened response + pain

78
Q

What are the symptoms and signs of fibromyalgia?

A

Joint/muscle stiffness
Fatigue
Unrefreshed sleep
Numbness
Headache
IBS
Depression/Anxiety
Poor concentration

79
Q

What is the typical presentation of fibromyalgia?

A

Female 40s
Chronic fatigue + joint tenderness post emotional/physical stimuli

80
Q

How can we manage fibromyalgia?

A
  1. Education (helps symptoms most)
  2. Sleep advice + ^exercise
  3. Low dose amitrypytiline/pregabalin
  4. CBT
81
Q

What is the triad of Felty’s syndrome?

A

Rheumatoid arthritis
Splenomegaly
Neutropenia

82
Q
A

Yr 3 Medicine (11 decks)

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