Rheumatology Flashcards
(46 cards)
1
Q
Questions to ask about a patient with musculoskeletal complaints
A
- inert vs contractile structures (articular/extra-articular)?
- inflammatory vs non-inflammatory?
- duration and distribution?
- extra-articular manifestations/complications?
- could it be referred pain?
2
Q
Describe the capsular pattern of arthritis with reference to the shoulder and hip
A
Shoulder: limited external rotation and abduction
Hip: limited internal rotation and adduction
3
Q
Signs of pain being inflammatory (rather than non-inflammatory)
A
- morning stiffness for > 1 hour
- prominent night-time symptoms
- exercise improves/ rest worsens sx
- good response to NSAIDS
- constitutional symptoms
- systemic manifestations
4
Q
What is the compression test and explain its relevance
A
Slight pressure across carpal/tarsal joints
–> elicits pain in synovitis
5
Q
Etiology of Rheumatoid Arthritis
A
- genetics (HLA)
- sex (females)
- environmental (smoking, stress, infection)
6
Q
Inflammatory cytokines involved in RA
A
- Tumour necrosis factor
- Interleukin-1
- Interleukin-6
7
Q
Typical hx of RA
A
Young female Insidious onset Pain Early morning stiffness of several hours Hands and wrists Constitutional symptoms (fatigue, lethargy, fever)
8
Q
Joint distribution of RA
A
COMMON wrists, MCPJ, PIPJ, MTPJ, knees, ankles LESS COMMON elbows, C1/C2, shoulders, hips RARE crico-arytenoid, temperomandibular
9
Q
Early RA of hands
A
- boggy tender swellings around MCP and PIP
- filling of valleys between MCPs
- spindling of fingers due to fusiform swelling of PIPs
- loss of fist/ loss of grip strength (tenosynovitis)
- swelling over wrist dorsum
- wasting of small hand muscles
10
Q
Advanced RA of hands
A
- Swan neck deformity
- Boutonniere deformity
- Z deformity of thumb
- ulnar deviation
- subluxation and dislocation of MCPJ
11
Q
Poor prognostic signs in RA
A
- early appearance of erosions
- RF/ACPA positivity
- rheumatoid nodules
12
Q
Extra-articular manifestations in RA
A
- Peri-articular: rheumatoid nodules, tenosynovitis
- Eyes: scleritis, sicca
- Lung: pleurisy, fibrosis, nodules
- Cardiac: effusions, atherosclerosis
- Skin: leg ulcers (vasculitis)
- Neurological: carpal tunnel, cervical myelopathy
- Haematological: Anaemia, Felty’s Syndrome
13
Q
Felty’s syndrome
A
- RA
- Splenomegaly
- Neutropenia
- -> susceptible to infection
- -> associated with severe disease
14
Q
Special Investigations for RA
A
- FBC
- ESR/CRP
- RF
- ACPA
- Synovial fluid
- Radiology
15
Q
X-rays of early RA
A
- soft tissue swelling
- peri-articular osteopaenia
- erosions at margins of small joints
[U/S better at picking up erosions and tenosynovitis but time-consuming)
16
Q
Medical Rx of RA
A
- DMARDs: methotrexate (mainstay), sulfasalazine, chloroquine
- Biologics (against TNFa, IL-6, B-lymphocytes)
- Steroids
- Anti-inflammatories (diclofenac, ibuprofen, indomethacin)
- Analgesics (paracetamol, amitriptyline)
17
Q
Indications for joint replacement in RA
A
- pain due to joint damage not responding to medical management
- improvement of function/ restoration of movement
18
Q
Causes of Mono-Arthritis
A
- septic arthritis
- trauma (fracture, internal derangement, haemarthrosis)
- crystal deposition disease
- osteoarthritis
- juvenile idiopathic arthritis
- coagulopathy
- AVN
19
Q
Polyarthritides that can present with mono-articular onset
A
RA JIA Viral arthritis sarcoid reactive arthritis psoriatic arthritis enteropathic arthritis
20
Q
Contents of synovial fluid analysis
A
- gram stain/culture (infection)
- crystals (gout/pseudogout)
- blood (haemarthrosis)
- WCC (2k-50k = inflammatory; >50k = pyarthrosis)
21
Q
Diagnostic studies in monoarthritis
A
ALWAYS - Xray - FBC and Diff - Uric acid (may be low in acute gout!) SELECTED - blood/urine cultures - clotting profile - ESR RARELY - serology (RF, ANF)
22
Q
Diagnositic studies in chronic monoarthritis
A
- arthroscopy
- MRI
- bone scan
23
Q
Aetiology of Osteoarthritis
A
- Primary - localised/generalised
- Developmental - DDH, Perthe’s, SUFE
- Traumatic - fx, occupational strain, internal derangement)
- Inflammatory (septic arthritis, TB, RA)
- Metabolic (crystal arthritis, haemochromatosis, alkaptonuria)
- Endocrine (acromegaly, DM, hypothyroidism, obesity)
24
Q
Symptoms of OA
A
Mechanical pain
Stiffness 15-30 minutes
Muscle spasm
25
Joints of OA
```
COMMON
DIP, PIP, 1st carpometacarpal,
acromioclavicular,
knees, hips,
spine, 1st MTP
ATYPICAL
wrists, elbow, gleno-humeral,
ankles, MCPs, MTP 2-5
```
26
Signs of OA
1. Swelling of OA joints - firm, bony
2. Tenderness at joint margin
3. Crepitus
4. Warmth
5. Osteophytes
6. Limitation of function and mobility
7. Periarticular muscle atrophy
27
Radiology of OA
1. typical joint involvement
2. loss of joint space
3. osteophyte formation (spurs)
4. subchondral sclerosis
5. bone cysts
6. malalignment/ deformity
7. gull wing sign in PIP and DIP
28
Treatment of OA
1. Weight loss
2. Exercise
3. Heat/massage
4. Simple analgesics
5. NSAIDS
6. Intra-articular corticosteroids
7. Osteotomy
8. Arthroplasty
9. Dietary supplements
29
Indications for arthroplasy in OA
1. severe unresponsive pain (cannot stand in place for 20-30 minutes)
2. loss of joint function
30
Important crystals in arthropathies
Uric acid --> gout
Calcium pyrophosphate --> pseudogout
Calcium hydroxyapatite --> calcifying peri-arthritis
31
Where does uric acid come from
10-30% dietary purines
| 60-90% liver
32
Where is uric acid excreted
75% renal
| 25% intestinal
33
Define gout
inflammatory reaction in synovial joints and/or periarticular tissues due to deposition of urate crystals due to hyperuricaemia
34
Aetiology of Hyperuricaemia
PRIMARY
1. overproduction (enzyme abnormalities)
2. decreased secretion (low GFR, tubular issues)
3. combination of above
SECONDARY
1. Drugs (reduce renal excretion)
2. Overproduction
3. Underexcretion
35
Drugs causing hyperuricaemia
```
Cyclosporine
Alcohol
Nicotinic Acid
Thiazides
Lasix
Ethambutol
Aspirin
Pyrazinamide
```
36
Secondary overproduction of uric acid
```
Purine rich foods
Myelo/Lymphoproliferative disorders
Psoriasis
Obesity
Fructose ingestion
```
37
Secondary underexcretion of uric acid
```
keto-acidosis
lactate acidosis
renal disease
polycystic kidneys
lead nephropathy
hyperparathyroidism
hypothyroidism
```
38
DDX for Gout
1. cellulitis
2. septic arthritis
3. pseudogout
39
Diagnosis of Gout
1. Serum uric acid (may be normal)
2. Synovial fluid microscopy (crystals under polarised light)
3. XRay: Soft tissue swelling
40
Common sites of gout tophi
```
Olecranon
1st MTPJ
Earlobes
Tendons
Peri-articular
```
41
Mx of acute gout
1. Colchecine 0.5mg stat and then 2-3 times daily
2. NSAID eg. voltaren, indocid, other (check renal function)
3. Corticosteroids: prednisone 0.5mg/kg
42
Mx of interval/chronic gout
1. remove precipitating factors
| 2. determine kidney function
43
Indications for uric acid lowering therapy
1. >3 acute attacks per year
2. tophi
3. bony/cartilage destruction on X-ray
4. gout with renal disease
5. uric acid kidney stones
6. uric acid >0.54mmol/l
44
Uric acid lowering drugs
1. uricosuric: probenecid
2. xantine oxidase inhibitors: allopurinol
3. other: lisinopril, losartan, oxypurinol, uricase, citrosoda
45
Probenecid contraindications
1. kidney stones
| 2. renal impairment
46
Side effects of allopurinol
1. skin reactions
2. GIT symptoms
3. bone marrow suppression
4. precipitate acute gout
