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Rheumatology Flashcards

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1
Q

Describe the signs/symptoms in the joints of rheumatoid arthritis

A
  • Swollen, painful, stiff joints
    • Small joints of hand, wrist, feet and cervical spine
    • Symmetrical
    • Worse in the morning or after prolonged inactivity
  • Digital ulnar deviation
  • Dorsal wrist subluxation (radial)
  • Loss of knuckle guttering
  • Finger deformities
    • Swan neck (PIPJ extention, DIPJ flexion)
    • Boutonniere (PIPJ flexion, DIPJ extension)
    • Z deformity of thumb
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2
Q

Name some extra-articular signs of rheumatoid arthritis

A
  • Skin - rheumatoid nodules, vasculitis, Raynauds
  • Lungs - fibrosis, pleural effusion, nodules
  • Kidneys - amyloid, immune-complexes
  • Liver - hepatomegaly
  • Blood - normocytic anaemia, neutropenia
  • Neuro - peripheral neuropathy
  • Atherosclerosis
  • Eyes - episcleritis/scleritis, dryness
  • Carpal tunnel syndrome
  • Osteoporosis
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3
Q

Describe the diagnostic criteria of RA

A

At least 4 criteria for 6 weeks:

  • Morning stiffness > 1 hour
  • Involvement of hand joints
  • Arthritis >/= 3 joints
  • Symmetrical arthritis
  • Rheumatoid nodules
  • Serum rheumatoid factor
  • X-ray changes
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4
Q

Name some investigations into RA

A
  • Bloods - inc ESR/CRP, dec Hb, dec WCC, inc platelets, inc LFTs (ALP), dec albumin
  • Rheumatoid factor (70%)
  • Anti-CCP antibody (95%)
  • X-ray
    • Soft tissue swelling
    • Loss of joint space
    • Erosions
    • Subluxation
    • Carpal destruction
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5
Q

How is RA managed?

A
  • Regular exercise
  • Physiotherapy
  • Wrist splints
  • NSAIDs (ibuprofen 400mg/8hr) + PPI
  • Steroid injection
  • Glucocorticoids for acute flare ups (prednisolone 7.5mg/d)
  • DMARDs ASAP (methotrexate)
  • Anti-TNF (infliximab)
  • Surgery - joint replacement, tenosynovectomy, carpal tunnel decompression
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6
Q

Name the common DMARDs, their mechanism of action and their side effects

A
  • Hydroxychloroquine - eye exam (ocular toxicity)
  • Methotrexate/anti-tnf - CXR (pulmonary fibrosis)
  • Ciclosporin/mycophenolate - urinanalysis
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7
Q

What advice should be given when prescribing NSAIDs?

A
  • Not to asthmatics, peptic ulcer
  • For relief of symptoms only - not needed all the time
  • Side effects - GI bleeding, headaches/dizziness, hypertension, fluid retention allergic reaction, constipation, diarrhoea
  • Stop taking if experiencing abdo pain or black stools and report to doctor
  • Don’t supplement with other NSAIDs over the counter
  • Smoking and alcohol increase side effect risk
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8
Q

What is the Disease Activity Score?

A

DAS28: A tool used to measure the activity or control of RA. Questions include:

  • Number of swollen joints (/28)
  • Number of tender joints (/28)
  • ESR/CRP value
  • Patient global health score (/10)

Number between 0-10 based on severity of disease activity

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9
Q

Describe the signs/symptoms of psoriatic arthritis

A
  • Asymmetrical oligoarthritis (inflammation affecting 1-4 joints during 1st 6 months)
    • Mainly DIPs
    • Pain, swelling, stiffness, redness, warmth
  • Dactylitis (sausage finger)
  • Nail pitting / oncholysis (nail separation)
  • Enthesitis (inflammation of tendon insertion)
  • Spondylitis (back)
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10
Q

Describe the x-ray features of psoriatic arthritis

A
  • Asymmetrical
  • Osteolysis (pencil in a cup appearance)
  • Proliferative erosions
  • Periosteal reaction
  • DIP disease
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11
Q

How is psoriatic arthritis investigated?

A
  • Bloods - U+Es, LFTs
    • NO rheumatoid factor
  • Hands and feet x-ray
  • US/MRI of achilles tendon
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12
Q

How is psoriatic arthritis treated?

A
  • Physiotherapy
  • Refer to dermatology for psoriasis
  • NSAIDs
  • DMARDs - methotrexate, leflunomide, ciclosporin, azathioprine
  • Anti-TNF (infliximab)
  • Intra-articular steroids
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13
Q

What is reactive arthritis?

A

A sterile inflammatory arthritis precipitated by a distant infection (HLA-B27 associated)

  • Urethritis
  • Acute diarrhoea
  • Chlamydia trachomatis
  • Campylobacter
  • Shigella
  • Salmonella
  • Rubella
  • HIV
  • Hep B/C
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14
Q

Name some signs/symptoms of reactive arthritis

A
  • Reiter’s syndrome = arthropathy (knee, SI joint), conjunctivitis + urethritis/cervicitis
    • ‘Can’t wee, can’t see, can’t climb up a tree’
  • GI - ileitis/colitis
  • Mucocutaenous - oral ulcers, keratoderma blenorrhagium (small hard nodules on soles of feet)
  • General - malaise, fatigue, weight loss
  • Enthesopathy (attachment of tendon/ligament)
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15
Q

How is reactive arthritis investigated?

A
  • Bloods - FBC, U+Es, LFTs, CRP/ESR
  • Aspirate knee - M, C + S
  • Stool culture
  • urethral swabs
  • PCR of early morning urine (chlamydia)
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16
Q

How is reactive arthritis treated?

A
  • Antibiotics
  • NSAIDs
  • Intra-articular corticosteroid injection
  • DMARDs if no improvement
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17
Q

What is ankylosing spondylitis?

A

Autoimmune inflammation of the axial skeleton, typically the SI joint.

  • HLA-B27 associated
  • Predominantly affects males
  • Between 15-40
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18
Q

What are the signs and symptoms of ankylosing spondylitis?

A
  • Chronic dull pain in lower back/gluteal region
    • Worse in the morning
    • Better with exercise
  • Insertional tendonitis (Achilles, intercostal, plantar fascia etc)
  • Synovitis (hip/knee)
  • Uveitis (inflammation of anterior eye chamber)
  • Systemic - weight loss, fatigue, fever
  • Question mark posture in late disease
  • CVS - Aortic regurgitation, cardiomegaly, aortic valve disease
  • Respiratory - upper lobe, bilateral pulmonary fibrosis

Additional features (As) = arthitis, anterior uveitis, aortic regurgitation, AV node block, achilles tendonitis, apical pulmonary fibrosis, amyloidosis and cauda equina

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19
Q

How is ankylosing spondylitis investigated?

A
  • Schober’s test - flexion of lumbar spine (abnormal if < 5cm)
  • Wall-tragus measurement (kyphosis)
  • Bloods - HLA-B27, anaemia, raised inflammatory markers
  • MRI of sarco-iliac joints
    • Erosions
    • Sclerosis
  • X-ray of spine = squaring and ossification
    • Syndesmophyte = longitudinal fibrous band
    • Symmetrical SIJ changes
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20
Q

How is ankylosing spondylitis treated?

A
  • Education - sleeping flat on a firm mattress
  • Exercise and physiotherapy
  • Hydrotherapy
  • Stop smoking
  • NSAIDs / opioids
  • DMARDs
    • Sulfasalazine
  • TNF-alpha blocker (infliximab)
  • Acute flare ups - intra-articular steroid injection
  • Steroid eye drops for uveitis
  • Surgery
    • Joint replacement (hip)
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21
Q

What is SLE?

A

Autoimmune-mediated, systemic inflammation/connective tissue disorder that can affect multiple organs

  • Classically affects women aged 20-40
  • More common in non-white communities
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22
Q

Name some signs and symptoms of SLE

A
  • Rashes
    • Malar - spares nasolabial folds
    • Discoid - erythematous papules with scaling on head/neck
    • Photosensitive
  • Raynauds
  • Oral/nasopharyngeal ulcers (painless)
  • Arthritis > 2 joints (non-erosive)
  • Serositis - pleural / pericardial / peritoneal
  • Renal disease
  • Cardiovascular disease
  • CNS - seizures, psychosis, headache
  • Haematological - haemolytic anaemia, leucopenia, lymphopenia
  • Systemic - weight loss, maliase, fever, myalgia, alopecia
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23
Q

Describe the criteria for diagnosing ankylosing spondylitis

A
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24
Q

Describe the criteria for diagnosing SLE

Study These Flashcards
A

SOAP BRAIN MD

  • Serositis (pleurits, pericarditis)
  • Oral ulcers
  • Arthritis
  • Photosensitivity
  • Blood - anaemia, leukopenia, thrombocytopenia
  • Renal - protein
  • ANA
  • Immunology - dsDNA
  • Neurology - psych, seizures
  • Malar rash
  • Discoid rash
25
How is SLE investigated?
* Bloods * ANA / ENA / ds DNA antibody * FBC - dec neutrophils, dec lymphocytes, inc ESR, dec C3/C4 * NB: not necessarily raised CRP * Urine dip - inc urea, inc creatinine, protein
26
What is anti-phospholipid syndrome?
A hypercoagulable state caused by antiphospholipid antibodies * Can be secondary to SLE * Causes thrombosis and obstetrical complications * Miscarriage, pre-eclampsia, congenital heart block * Treated with hydroxychloroquine
27
What advice should be given to someone with SLE?
* Rest as appropriate * Avoid over-exposure to sunlight * Wear sun cream (\> SPF 30) * CVS risk factors * BMI * Smoking / alcohol * Exercise * Take calcium / vit D supplements to maintain bone health * Avoid oestrogen pill
28
What pharmacological treatment is recommended for SLE?
* NSAIDs * Hydroxychloroquine (if uncontrolled by NSAIDs) * Risk of retinopathy (need annual opthalmology check) * Prednisolone for severe episodes * Azathioprine, methotrexate, ciclopsorin if not controlled by HCQ * Rituximab
29
What is Wegener's Granulomatosis / GPA?
A systemic vasculitis that affects small and medium sized blood vessels. This typically affects the lungs, kidneys and ENT.
30
Name some clinical features of Wegeners
* Kidneys - glomerulonephritis * Nose - saddle-nose, pain, stuffiness, nosebleeds * Ears - conductive/sensorineural hearing loss * Oral cavity -ulcers, strawberry gingivitis * Eyes - scleritis, conjunctivits, uveitis * Lungs - nodules, cavitis. infiltrate, haemorrhage * Arthritis * Chronic sinusitis
31
How is Wegeners investigated?
* CXR - nodules, cavities, infiltrate * Urine dip - microscopic haematuria, red cell casts * Biopsy of kidney/sinus - granulomatous inflammation of arterial walls * Nasal/oral inflammaion * Bloods * ANCA * FBC * CRP/ESR
32
What is the criteria for diagnosing Wegeners?
33
How is Wegeners treated?
* Cyclophosphamide for induction * Azathioprine, methotrexate, trimethoprim for remission maintenance * Rituximab * Prednisolone for acute flare ups
34
What are the signs and symptoms of dermatomyositis/polymyositis?
* Muscle weakness * Symmetrical * Diffuse * Starts proximally * Breathlessness (diaphragmatic weakness) * Skin * Gottron's papules = erythematous papules over MC/IPJ * Macular rash over back (shawl sign) * Heliotrope / lilac rash over eyelids * Telangiectasia (spider veins) * Mechanics hands * Raynauds
35
What is dermatomyositis?
Inflammation of the skin and muscles that can also affect the joints, oesophagus, lungs and heart
36
How is dermatomyositis/polymyositis investigated?
* Inc creatine kinase / ALP * Alteration in electromyograph activity * Muscle biopsy / skin biopsy * Malignancy markers - FBC, CXR, CRP, abdo US, PSA * Anti-Mi-2 antibodies
37
Describe the signs and symptoms of polymyalgia rheumatica
* Symmetrical aching and morning stiffness in shoulders and proximal limb muscles for \> 1 month * Polyarthritis * Tenosynovitis (carpal tunnel) * Depression * Fatigue * Fever * Weight loss
38
How is PMR investigated?
* Inc ALP * Inc ESR
39
How is PMR treated?
* Prednisolone * Decrease dose slowly * Bisphosphonates
40
Name some signs and symptoms of Giant Cell Arteritis/temporal arteritis?
* Headache * Worse with chewing/brushing hair * Scalp and temporal artery tenderness * Jaw claudication * Sudden blindness in one eye * Prominent/pulsatile temporal artery
41
How is GCA investigated?
* Inc ESR/CRP * Inc platelets * Inc ALP * Dec Hb * Temporal artery biopsy * Fundoscopy - pale swollen optic disc * Visual acuity
42
Name some causes of gout
* Diuretics - reduced renal excretion * Obesity / hyperlipidaemia * Hyperparathyroidism * High purine intake * Red meat, beer, offal * Ischaemic heart disease * Renal impairment * Hypothyroidism * Drugs - pyrazinamide / ethanol
43
Name some precipitants of gout
* Trauma * Starvation * Alcohol * Surgery * Infection
44
Describe some clinical signs and symptoms of gout
Urate crystals deposited in synovium, connective tissues and kidneys * Pain, redness and swelling of the joint * MTP of big toe * Knee * Elbow * Ankle * Olecranon bursitis * Tophus deposits in digits, ear, bursae, tendon sheaths * Nephropathy * Uric acid stones in urinary tract
45
How is gout diagnosed?
* Synovial fluid analysis * Polarised light microscopy * Gram stain / culture (exclude infection) * Serum urate (not always inc) * CRP/ESR, FBC * X-ray * Soft tissue swelling * Opacities * Erosions
46
How is gout managed?
* NSAIDs (CI in renal disease) * Corticosteroids * Lifestyle changes * Avoid fasting * Reduce alcohol intake * Reduce food high in purines * Lose weight * Avoid aspirin * Allopurinol (3 weeks after attack) 100-300 mg/day * Adjust with urate levels
47
What is Sjogrens syndrome?
Chronic autoimmune disorder, characterised by lymphocytic infiltration exocrine glands resulting in dry mucous membranes * More common in females * Between 30-60 years * Can be secondary to RA or SLE
48
What are the clinical features of Sjogrens
* Dry mucous membranes - mouth, eyes, vagina, resiratory tract * Mouth - difficulty eating, dental caries, candidal infections * Repiratory tract - hoarseness, infections * Dry skin * Eyes - corneal ulcers, keratoconjunctivitis * Signs and symptoms of a secondary cause * Arthralgia * Parotid gland swelling * Raynauds * Lymphadenopathy
49
How is Sjogrens investigated?
* Routine bloods tests - anaemia * Inc amylase and inflammatory markers * +ve ANA and RF * +ve anti-Ro and anti-La * Schirmer test (strips of filter paper) - dry eyes * Can perform biopsy of salivary gland or lower lip
50
How is Sjogrens managed?
* Education * Promotion of oral hygiene * Artifical tears/lubricating gels * Artifical saliva sprays/mouthwashes * Pilocarpine - stimulate saliva and tear production * Hydroxychloroquine if skin/joint problems * Analgesia * Emollients for dry skin
51
Name the important immunological blood tests and what they diagnose
* Rheumatoid factor (IgM) - 70% RA, 90% Sjogrens * Anti-CCP antibody - RA * ANA - SLE, 75% Sjogrens * Anti-ds DNA - SLE * Extractable Nuclear Antigens * Anti-Ro - Sjogrens * Anti-La - Sjogrens * Anti-Jo1 - polymyositis * ANCA - vasculitis * ACLA - anti-phospholipid syndrome
52
Name some examples of seronegative arthropathies
* Reactive arthritis * Ankylosing spondylitis * Psoriatic arthritis * Enteropathic arthritis
53
What test may be useful before starting azathioprine/mecaptocurine?
Serum TPMT - enzyme that is involved in the metabolism of azathioprine * If deficient - can develop severe and life-threatening bone marrow toxicity
54
What is GCA/temporal arteritis?
* Large vessel vasculitis * Segmental granulomatous inflammation of external carotid artery and branches * Superficial temporal * Opthalmic * Maxillary * Pain over thickened, tender, non-pulsatile temporal arteries * Visual loss / amaurosis fugax (25%) * Jaw claudication * Associated with PMR
55
What are the main 4 features of anti-phospholipid syndrome?
CLOT * Clotting disorder (thrombosis) * Livedo reticularis * Obstetric complications * Recurrent 1st trimester miscarriage * Thrombocytopenia 30% of SLE
56
Describe the difference between RA and OA in terms of: * Symmetry * Morning stiffness * Agrravating and relieving factors * Age of onset * Speed of deterioration * Systemic involvement
57
How is GCA diagnosed?
* Raised ESR * Temporal artery biopsy
58
How is GCA managed?
Prednisolone 60mg/day until ESR decreases

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