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DCE Short Case > Rheumatology > Flashcards

Rheumatology Flashcards

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1
Q

How to differentiation between RA deformities and SLE?

A

Attempt to correct
- if correctable then it is SLE
- Ask pt to push hands into pillow to watch for correction

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2
Q

How to distinguish between RA nodules and tophi and calcinosis?

A

RA nodules
- typically oval or round, firm and subcutaneous
- FOund on extensor surface of forearm, fingers and pressure points such as olecranon bursa
- Appear flesh skin coloured
- Variable size
- generally not movable

Tophi
- Gritty in appearance
- May appear more pale or have a pale / white center
- Found over joints, esp hands and feet, may also be over olecranon bursa

Calcinosis:
- difficult to distinguish from gout, need to be Dx in contex
- Can appear more focal that gouty tohpi
- Needle aspiration reveals Calcium rather than urate

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3
Q

Difference between psoriasis plaques, gotrons papules and SLE rash?

A

psoriasis results in raised erythematous rashy with white scally plaque on top of it on the extensor joint surfaces

Gotrons papules are more discrete appearing lesions over the knuckles predominatly, less so over dorsal aspects of DIP and PIP. Not white and scally

SLE rash is more confluent and affects more of the dorsum of phalanges rather than the knuckles. Not white and scaly like psoriasis

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4
Q

Where to test for skin tightness for systemic sclerosis?

A

Dorsal aspect skin between PIP and MCP. Dont test between DIP and PIP because this is tight in everyone

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5
Q

Nail findings in psoriasis?

A

Pitting (most sensative)
Onycholysis
Horizontal ridging
Nail bed crumbling
Discolouration

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6
Q

RA deformities?

A
  • Mild ulna dieviation of the fingers in early RA
  • MCP vollar subluxation (look from the side)
  • Z deformity of the thumb
  • Swan neck and boutoneirs deformity of the fingers
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7
Q

SLE deformities?

A

Same as RA but correctable

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8
Q

OA deformities? How to distinguish these joint swelling from sinovitis joint swelling?

A

Heberdons and bouchards nodes
- these will be non tender usually, and very boney and firm feeling
- sinovitis is squishy like a bit of putty
- Joint fluid is fluctuant

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9
Q

DIP spared, what conditions?
DIP involved what conditions?

A

DIP spared: RA or SLE
DIP involved: OA, psoriatic, Gout

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10
Q

What are the 4 seronegative spondyloarthoptathies?

A

Psoriatic arthritis
Ank Spond
Enteropathic arthritis
Reactive arthritis

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11
Q

What are the two special tests used in back examination?

A

Schobers
Occiput to wall test

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12
Q

Opening statement for classic hand OA?

A

Asymetric small joint polyarthropathy with involvement of the knees bilaterally.
- Can be symmetrical if severe (ie almost all joints affected)

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13
Q

Opening statement for RA?

A

Symmetrical deforming predominant small joint polyarthropathy with / without signs of disease activity and with or without impaired functioning
- With additional involvment of eg lungs

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14
Q

What are sicca symptoms? what diseases can classically involve sicca symptoms?

A

Sicca symptoms:
- dry eyes
- Dry mouth

These are an integral part of sjrogrens syndrome
Can also occur with other rheumatological disease as an overlap
- RA overlap with Sjrogrens syndrome (10-15% of cases)

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15
Q

RA. What else to examine?

A

Eyes
- dryness (sicca)
- Nodular scleritis
- Pallor
Parotid enlargment (sicca)
Mouth:
- Dryness, caries

Resp:
- Percussion (effusions)
- Ausculatate ( basal predominate ILD)

CVD:
- Pul HTN
- mitral and aortic valve (AR most common)

Abdo:
- splenomegally

Legs / feet
- Valgus knees
- Foot drop, MTP, achilies tendon nodules

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16
Q

Ank spond. What else to examine?

A

Back exam, then proceed

Eyes:
- acute iritis/uveitis (usually asyumetrical painful red eye)

Lungs:
- ILD (Apical fibrosis)

Heart:
- AR (most common)
- Pul HTN 2nd to ILD

Abdo
- scars and stoma from IBD

Legs:
- achiles tendonitis (dif from SLE entesitis)
- Plantar fascitis

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17
Q

Compare and contrast SIJ involvement in ank spond vs psoriatic?

A

Ank spond very symetrical SIJ
Psoriasis largely asymetrical

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18
Q

Psoriatic joint involvment patterns?

A
  • Mono or oligoarticular asymmetrical small joint arthritis of the hands and feet with sausage fingers (Most common)
  • Symmetrical small joint polyarthritis similar to RA (but neg RF ofc)
  • DIP involvment with psoriatic nail changes
  • Sacroilitis without peripheral joint involvement
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19
Q

Where does gout affect mainly?

A

Feet first (1st MTP) then knees, then hands

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20
Q

Psoriatic arthritis. What else to examine?

A

Back examination
- SIJ inv

Resp:
- ILD

Face:
- Iritis/uveitis - more often bilateral iunsidious onset posterior uveitis comp to other seroneg spond
- Conjuntivitis (common)

CVD:
- Pul HTN
- MR/prolapse, Aortic root dilation / regurg

Abdo:
- IBD related changed (stoma, scars)

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21
Q

Gout opening statement?

Study These Flashcards
A

Deforming asymetrical small joint polyarthropathy with pain to suggest disease activity, with or without functional impairment

22
Q

Gout. Other things to examine?

Study These Flashcards
A

Feet/ knees
- 1st MTP
- Calcaneal tophi
- Knee inv
- Peripheral vascular disease

Ears:
- tophi

Cardio:
- BP
- Cardiomegally, cardiomyopathy

Other:
- lymphadenopathy (evidence of secondary cause of urate production)

23
Q

Hand findings in SLE? Other areas to examine?

Study These Flashcards
A

Hands:
- vasculitis nailbed changes
- Photosensative rash over dorsum of fingers
- Raynauds active
- Sinovitis on palpation with correctable deformity and non errosive

Forearm:
- Livedo reticularis (non specific)
- Purpura (vascuilitis, autoimmune thrombocytopenia)
- Prox myopathy
- Axiliary lymphadenopathy

Hair:
- General alopecia (frontal moreso)
- Alopecia arata

Eyes:
- scleritis and episcleritis (more common in RA than SLE)
- Dry eyes (sicca)
- Pallor (Anaemia chron disease)
- Scleral icterus (autoimmune haem anaemia)

Face:
- malar rash
- Discoid lupus rash (anywhere but usually scalp and ear canals)

Mouth:
- Dyr mouth (sicca)
- Caries

heart:
- Pericardial rub
Pul HTN

Lungs:
-Pleuritis (pleural rub)
-effusions, fibrosis

Abdo:
-Hepatosplen

Legs:
- peripheral neuropathy
- Prox myopathy

24
Q

Limited cutaneosu systemic sclerosis vs diffuse systemic sclerosis?

Study These Flashcards
A

Limited cutaneous affects skin from elbows and kness distally. Less internal organ manifestation compared to diffuse

Diffuse affects all skin and has more internal organ effects (ie ILD, heart disease)

25
Scleroderma hand examine and other examination?
Hands: - Calcinosis - Finger tip ulcers (including old ulcers) - Tight skin - Fixed flexion deformities with limited ROM Small joint arthritis and tendon friction rubs General insepction: - Bird facies - Weight loss (malab from esophageal dysmotility) Arms: - Oedema early, skin thickening / tight late Head: - Allopecia, loss of eye brows - Microstomia (three fingers cant fit) Neck muscle wasting Dyspohagia - RIG or PEG tube, sarcopenia Chest: - Roman chest plate - Heart - Pul HTN, pericarditis, CCF - Lungs - Fibrosis, chronic reflux changes, infections Legs: - SKin lesions, vasculiutis Other: - BLOOD PRESSURE - Urinalysis - Stool examination (steatorrhoea - Temperature
26
Describe erosions in: RA, OA, Gout, PsA, SpA?
RA - Juxta-articular, MCP, radial aspect OA - loss of joint space with gull wing appearance (also other 3x features of AO on XR) Gout - Punched out / moth eaten with sclerotic overhang PsA - pencil in cup SpA - Bone formation at tendon / ligamentous insertions
27
What are the 4x XR findings of OA?
Joint space narrowiung (affecting DIP and othes joints) Subchjondral cysts Subchondral sclerosis Osteophytes
28
In which conditions does periarticualr osteopenia occur?
Any inflammatory arthritis. Classically associated with RA
29
Further investigations for RA?
Hand XR Bloods: RF and anti CCP + CRP and ESR CXR, HRCT and PFTs ECG and TTE CCP is more useful for Dx as RF can be negative (CCP and RF can both be negative however this makes RA less likely) - RF is prognostic indicators. Suggest more aggressive erosive disease
30
Investigations in Psoriatic arthritis?
Hand XR +/- SIJ XR Bloods - HLAB27 suggestive but not Dx. Predicts axial inv - ESR and CRP (disease activity)
31
OA further Ix?
Hand XR + Knee and hip XR - nil specific bloods tests (ESR and CRP may be mildly elevated in flare)
32
Gout further Ix?
Hand XR Joint aspiration (joint urate >>>>> serum urate) Blood tests - urate level (may be normal during flare, always elevated 2-3 weeks post flare) Prognostication: - Serum urate target <0.36 or <0.3 if tophi or XR changes - Tophi will not resolve unless urate WNL (slow process) Cardiac ivestigations Renal function investigations Metabolic syndrome Ix
33
Ank spond Ix?
Bloods: - HLAB27 (if neg does not exclude but much less likely) SIJ XR Tests for other systems if think they are involved (ie hear, lungs, bowels (IBD))
34
SLE Ix?
Dx - anti dsDNA, ANA, Anti smith - Anti smith and anti dsDNA most spec for SLE. Negative ANA means very unlikely (very sensative) - Anti U1 RNP - myopsitis overlap - Anti Ro and anti La - sjrogrens overlap Disease activity - ESR >CRP disproportionate, Low C3,4, raised ds DNA Ix for other systems involved (ie heart or lungs) - Renal: urine MCS, ACR, PCR, sediment. Renal Bx - Haem: FBE with dif, Low complement - ENdo: OP screening, vit D - Caridovascular - APLS, TTE for pul HTN
35
Idiopathic inflam myopathy Ix?
Diagnosis - many antibodies - Anti Mi2 - DM (good prognosis) - Ant SRP - PM - Antisynthetase abs - Jo 1, PL 7, PL 1 Disease activity - CK, trop, ESR and CRP Manifestations - MDA 5 - agressive ILD - TIFF 1 and NXP 2 - paraneoplastic syndrome - Muscle biopsy - necrotic fibers - XR - calcification in affected muscles - MRI high sens, low spec
36
Haematological complications of RA?
Anaemia of chronic disease Cold immune haemolytic anaemia DLBCL Secondary amyloidosis Feltys syndrome (RA, neutropenia, Splenomagally)
37
Management of RA?
Non pharm - PT and ex - Deformity correction devices - Smoking ceasation Pharm - SYmptom control: NSAID, steroids - DMARD: MTX (first line), Sulfasalazine (2nd), leflunamide (3rd), hydroxychloroquine - Biologic - Anti TNFa (infliximab), Anit IL1 (anakinra), Anti IL 67 (tocalizumab), Anti CD20 (ritux), JAK inhibitor (tofacitinib) - Cardio RF modification - OP screening and mnx
38
Management of OA?
Non pharm - Weight loss - Regular ex - Correction of malalignment / deformities Pharm - NSAIDs - intrarticular steroids Surg: - Indication: failure of pharm + salvagable function - Options: TJR vs hemiarthroplasty vs wedge osteotomy - Venous thromboembolism prophylaxis crutial
39
Where to look for psoriatic plaques?
Extensor surfaces of limbs Behind ears Scalp Genitals
40
XR findings in PsA?
Pencil in cup deformities Dactylitis Rays not rows (all joints in one finger affected compared to all MCPs, all PIPs etc)
41
Management of SLE?
Non pharm: - Stop smoking - Ex inc weight bearing Pharm: - HCQ - Steroids for induction and flares - Maintainance therapy - azothioprine (after TPMT testing), MTX (folate supplementation) - Severe disease requires high dose steroids + immunosupression with mycophenylate, cyclophosphamide, ritux, aza, MTX - Lupus Nephritis - mycophenylate + high dose steroids perfered Rx
42
Management of PsA?
Non pharm: - Ex and PT - Orthotics - UV light for skin changes Pharm: - NSAID and emollient for symptom relief - Intra-articular steroids for peripheral arthritis - MTx, sulfasalazine, leflunamide - Severe or persistent disease: -> Anti IL 17/IL 23 (secukinumab, Ustekinumab)
43
Systemic sclerosis Ix?
Autoantibodies: - Anti centromere - CREST (limited) - scl70 / topoisomerase - diffuse, predicts severe lung disease - RNA polymerase III - predicts renal and severe skin disease - U1 RNP - overlap disease (MCTD) Other systems affected: - Heart - TTE ? PHTN, restrictive biventricular failure - Lungs - CXR, HRCT, PFT (ILD) - Renal function - Urine MCS, ACR, PRC, Bx (RIsk greatest with >15mg pred per day)
44
Management of systemic sclerosis?
General: - SKin and nail care - Cold avoidance, keep core temperature warm - Stop smoking - Avoid etoh Raynauds - dihydropyridime Ca Blockers, iloprost Esophagitis - PPI Skin inv: - MTX, mycophenylate Arthritis: - low dose steroid, HCQ ILD: - cyclo, mycophenylate Pul HTN - Pul HTN medications Renal crisis (ACEi (catopril) for renal crisis and systemic HTN
45
What is MCTD?
This is definied as an overlap of SLE, SSc, and polymyuositis - mostly affects females aged 20-40 yrs - Associated with U1 RNP autoantibodies
46
Dermatomyositis skin findings?
Gotrons papules Shall sign Heliotrope rash Photodistributed errythema Raynauds Poikiloderma
47
Systemic manifestations of poly/dermatomyositis?
ILD Prox oesophageal dysfunction Cardic conduciton disease and myocarditis Symmetrical small joint polyarthritis Underlying sold organ malignancy
48
Management of poly/dermatomyositis?
Non pharm: - PT and ex - aspiration precautions - Sun protection Pharm: - steroid for induction - Aza (TPMT testing prior) - IVIG (severe disease) - HCQ (skin disease only) - Malig screening and testing Managment of chron steroid comp CVD testing
49
Medications that cause hyeruricaemia?
Low dose aspirin, Thiazde and loop diuretics, cyclosporin
50
Aspirate findings on Gout, pseudogout?
Gout - needle shapped, negative birefringance (yellow) Pseudogout - rhomboid, positive birefringance (green) Cell count elevated Culture negative (rule out SA)
51
Management of gout?
Acute attack: - NSAID / colchicine 1st line - pred second line - intrarticular steroid if oligo/mono arthritis Do not commence urate lowering therapy at time of acute flare Long term prophylaxis - Colchicine - Weight loss, dietary mod (shellfish, offal, etoh avoid) - Urate lowering therapy -> Xanthine oxidase inhibitors (allopurinol, febuxustat) -> Uricosuric (probenacid) -> Uricase (rasburicase) Interaction between allopurinol and aza
52
Management of seronegative SpA?
Non pharm: - stop sm - Ex program Pharm: - NSAID first line - MTX, sulfa for peripheral arthritis (not effective for axial) - TNF alpha inh second line fvor axial arthritis (exclude HIV and TB first) - IL17 inh (secukinumab)

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