Rheumatology (C38-41) Flashcards
40
A 33 year old man presents to the rheumatology clinic with back stiffness and reduced range of spine movements. O/E he has loss of lumbar lordosis, reduced chest expansion and is positive for Schober’s Test
What features support a diagnosis of Ankylosing Spondylitis in this patient? (2 marks)
- Young adult male
- Back stiffness - affects lower back & sacroiliac joint
- Loss of lumbar lordosis - due to spine fusion
- Reduced chest expansion - restricted chest wall movememt due to inflamm. of costovertebral & sternocostal joints
- Positive Schober’s test
40
What is Schober’s Test? (1 mark)
Assesses spinal mobility
1. With Pt standing straight locate L5 vertebra
2. Point marked 10cm above & 5cm below this level (15cm apart)
3. Pt forward as far as possible
4. Distance between the points is measuredd - length < 20cm indicates a restriction in lumbar movement = ankylosing spondylitis Dx
40
What other symptoms would you ask about? (3 marks)
- Sacroiliac/buttock pain (sacroiliac joint)
- Pain worse with rest & better with activity
- Pain worse at night & may wake them up
- Stiffness takes at least 30 mins to improve in morning
- Associated Sx - enthesitis, chest pain, SOB, dactilytis,
40
What other examination findings might you elicit? (2 marks)
- Enthesitis - eg. achilles tendonitis & plantar fasciitis
- Reduced ROM with flexion & extension
- Pain in back & sacroiliac joints
40
What investigations would further help with the diagnosis of Ankylosing Spondylitis? (2 marks)
- HLA B27 genetic testing
- Xray of spine & sacrum
- MRI of spine - shows bone marrow oedema early in the disease before there are any Xray changes
- Infalmmatory markers (CRP & ESR)
40
What do you know about the genetics associated with Ankylosing Spondylitis? (2 marks)
- HLA B27 gene
- More common in males
- X-linked
- 90% of AS Pts have gene BUT <10% of ppl with gene will get AS
40
What are the complications of Ankylosing Spondylitis? (4 marks)
- Reduced ROM of spine
- Pain & Stiffness
- Chest pain related to the costovertebral & sternocostal joints
- Enthesitis (inflammation of the entheses, where tendons or ligaments insert into bone)
- Dactylitis (inflammation of the entire finger)
- Vertebral fractures (presenting with sudden-onset new neck or back pain)
- SOB relating to restricted chest wall movement)
40
What treatment options are available for Pts for Ankylosing Spondylitis? (3 marks)
- NSAIDs
- Anti-TNF meds (adalimumab, infliximab, entanercept)
- Monoclonal antibodies againts IL-17 (secukinumab or ixekizumab)
- JAK inhibitor (upadacitinib)
- Intra-articular steroid injections
- PT, exercise/mobilisation, avoid smoking, bisphosphonates fro oseoporosis
- Surgery for severe joint deformity
41
A 53 year old man presents to ED with a painful red and swollen right big toe
What features support a diagnosis of gout in this patient? (1 mark)
Podagra - painful, red & swollen big toe
* Monoarthropathy
* Asymmetrical
41
What other clinical findings might you elicit? (2 marks)
- Reduced ROM of toe
- Gouty tophi
- Hot joint
41
What are the common causes and associations of gout? (4 marks)
- High purine diet (red meat & seafood)
- Obesity
- Male
- FHx - of high uric acid levels
- Alcohol
- Diuretics
- CVD
- Kidney disease
41
What investigations help with making a diagnosis of gout? (2 marks)
- Blood test (post-flare up) - raised serum urate levels
- Joint aspiration & light microscopy - fluid shows monosodium urate crystals (needle-shaped) & negatively birefringent of polarised light
- X-ray
41
What treatment options (acute & chronic) are available for patients for gout? (3 marks)
Acute flares
1. NSAIDs (naproxen) - with PPI for gastroprotection
2. Colchicine - if NSAIDs can’t be used (eg. kidney impairment, heart disease)
3. Oral steroids (prednisolone)
Chronic
* Prophylaxis of flare not started until weeks after the acute attack
* Prophylaxis with xanthine oxidase inhibitors (allopurinol, febuxostat) which lower the uric acid level
* Once XOi initiated, it is continued during an acute attack
