Rheumatology 2 Flashcards by H JP

Describe the femoral nerve stretch test

Lie the patient prone
Extend the hip joint with a straight leg
Then bend the knee
If there is pain = trapped femoral nerve

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Pain and tenderness over lateral side of thigh
Most common in women aged 50-70

Greater trochanteric pain

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High steroid therapy
Previous hip fracture/ dislocation
Gradual or sudden onset
Hip pain

Avascular necorosis

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Seen in the third trimester of pregnancy
Groin pain
Limited range of movement of hip
May be unable to weight bear
ESR can be elevated

Transient idiopathic osteoporosis

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Hypersensitivity types

I anaphylactic
II cell bound
III immune complex
IV delayed

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Hypersensitivity Mechanism

I IgE
II IgG or IgM
III IgG or IgA
IV T cell

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Hypersensitivity examples I (2)

I - anaphylaxis, atopy

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Hypersensitivity examples II (7)

II - ITP, Goodpasture’s, pernicious anaemia, haemolytic anaemia, RhF, pemphigus/ pemphigoid

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Hypersensitivity examples III (3)

III - SLE, post strep GN, extrinsic allergic alveolitis acute

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Hypersensitivity examples IV (6)

IV - TB, graft versus host, allergic contact dermatitis, extrinsic allergic alveolitis chronic, scabies, Guillian Barre

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What makes lateral epicondylitis worse? (movements)

Wrist extension with the elbow extended
Supination with the elbow extended

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Lateral epicondylitis
How long do the sx last for?

6 months to 2 years
Acute pain 6-12 weeks

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Lateral epicondylitis Mx (4)

Avoid muscle overload
Simple analgesia
Steroid injection
Physiotherapy

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Marfans
AD or AR
Gene + chromosome

AD
FBN1 gene chromosome 15

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Tall stature
Long fingers (arachnodactyly)
High arched palate
Pectus excavatum
Scoliosis

Heart: dilatation of aortic sinuses
Lungs: repeated pneumothoraces
Eyes: upward lens dislocation, blue sclera, myopia

Marfan’s

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AR type V glycogen storage disease
Muscle pain and stiffness following exercise
Muscle cramps
Myoglobinuria
Low lactate levels during exercise

Mc Ardle’s disease

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MTX rules around pregnancy

men and women should avoid pregnancy for 6 months

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MTX - what should be taken with it?

5mg once weekly - at least 24 hours post MTX

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MTX - which meds should be avoided? (3)

Trimethoprim
Co-trimoxazole
High dose aspirin

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Mx MTX toxicity

Folinic acid

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OA XR findings (4)

Loss of joint space
Subchrondral sclerosis
Subchondral cysts
Osteophytes

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RA XR findings (4)

Loss of joint space
Juxta-articular oseteoporosis
Periarticular erosions
Subluxation

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OA Mx
CHECK AGAINST NICE

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Paracetamol + topical NSAIDs (knee and hand for topical NSAIDs)
PO NSAIDs/ COX2 inhib, opioids, capsaicin cream, intra-articular steroids + PPI

Blue sclera
Deafness secondary to otosclerosis
Dental imperfections

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Osteogenesis imperfecta

What is osteomalacia? Mx

Softening of the bones secondary to low vitamin D Mx vitamin D supplementation

Osteomalacia findings on XR

Translucent bands (Loosers zones or pseudofractures)

How long does sciatica symptoms last for?

4-6 weeks

What is temporal arteritis? Characteristic histology

Large vessel vasculitis overlapping with PMR Skip lesions

Temporal arteritis Age Onset Sx (5)

>60yo Rapid < 1 month Headache Jaw claudication Tender, palpable temporal artery Visual symptoms 50% have PMR Other: Lethargy, low grade fever, anorexia, night sweats, depression

Temporal arteritis Ix (3)

Raised ESR >50 CRP raised Biopsy - skip lesions

Temporal arteritis Mx (1) If visual symptoms (2)

High dose PO pred if no visual symptoms If visual symptoms IV methylprednisolone Urgent ophthalmology review - same day Bisphosphonates are required

Mx of patient with fragility fractures >=75yo <75

=>75yo who have had a fragility fracture without DEXA can be started on bisphosphonates If under 75, then arrange a DEXA and use FRAX assessment which determines whether someone should have a bisphosphonate

Name 6 RF that the FRAX assessment tool uses

Alcohol RA Steroid use FH of fracture BMI Smoking

Name 6 medications that can worsen osteoporosis other than steroids

Aromatose inhibitors eg anastrazole Heparin long term Glitazones PPIs Antiepileptics SSRIs

What is the Z score on a DEXA scan?

Bone mass adjusted for age, gender and ethnicity

T score interpretation

> -1 = normal -1 to - 2.5 = osteopaenia < - 2.5 = osteoporosis

When does the risk of osteoporosis with steroid use rise significantly?

7.5mg/day for 3 months or more

Mx of patient's at risk of steroid induced osteoporosis Who gets immediate bone protection (2) and who requires a DEXA? (1)

Bone protection if: 1. >65yo 2. Prev fragility fracture DEXA 1. <65

How to interpret a DEXA result with patients at risk of steroid induced osteoporosis

T score >0 - reassure 0 to -1.5 repeat scan in 1-3 years > - 1.5 bone protection

Osteoporosis management (5)

Vit D and calcium supplementation should be offered to all women unless replete 1. Alendronate - common SE GI 2. Risedronate or etidronate 3. Strontium ranelate and raloxifene (if bisphosphonates are not tolerated) 4. Denosumab

Raloxifene MOA Can worsen what symptoms? Increased risk of? Decreased risk of?

selective oestrogen receptor modulator can worsen menopausal symptoms increased risk of VTE decrease breast ca

Strontium ranelate Who can prescribe? Increased risk of

Secondary care Increased risk of CVD and VTE

How often in denosumab given?

Every 6 months SC injection

How often is ibandronate given?

Every month

Name four RF for Paget's disease of the bone

Male Increasing age Northern latitude FH

Stereotypical presentation for Paget's disease of the bone

Older male with bone pain and isolated raised ALP

Bowing of the tibia Bossing of skull Thickened vault Early mixed lytic/sclerotic lesions later

Paget's

Blood results Paget's ALP, Ca, phos

ALP raised Normal Ca + phos

Mx Paget's

Bisphosphonates - PO risdronate or IV zoledronate

Paget's complications (5)

Deafness Sarcoma Fractures Skull thickening High output cardiac failure

Vasculitis Affects medium sized arteries with necrotizing inflammation which can lead to aneurysms forming

polyarteritis nodosa (PAN)

Polyarteritis nodosa Gender Age Associated with which condition

Middle aged men Hep B

Polyarteritis nodosa Features (9) Antibodies Associated with which condition

Fever, malaise arthralgia Weight loss HTN Mononeuritis multiplex, sensorimotor polyneuropathy Testicular pain Livedo reticularis Haematuria Renal failure ANCA 20% of pts Hep B serology +ve in 30% of pts

PMR Age Onset Symptoms Ix Rx and dose

>60 Rapid onset <1 month Morning stiffness in proximal limb muscles Low grade fever, anorexia, depression, mild polyarthralgia, night sweats ESR >40 CK and EMG normal Rx pred 15mg OD

What is polymyositis? Which type of cell is it mediated by? Associations (1) Gender and age

Inflammatory disorder causing symmetrical proximal muscle weakness. T cell mediated Associated with malignancy Middle aged females

Polymyositis features (6)

Proximal muscle weakness Dysphagia Dysphonia Raynauds Respiratory muscle weakness Interstitial lung disease

Polymyositis Blood test (4) Antibodies

Elevated CK, LDH, AST and ALT Anti-Jo1

Rheumatology 2 Flashcards

(57 cards)