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77 Cards in this Set
- Front
- Back
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Define arthritis, osteoarthrosis and arthralgia. |
Arthritis = Synovitis = inflamm of synovium - red, hot, swollen, painful, immobile Osteoarthrosis = non-inflammatory degredation of cartilage and subchondrial bone. No/minimal Synovitis Arthralgia = Aches and pains from periarticular soft tissue (tendinitis, bursitis, enthesitis). No Synovitis |
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What cells line the intima of synovial joints? |
Fibroblasts and Macrophages |
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What do you Look for in a hand exam? |
General inspection then... Look at ELBOWS, FOREARMS and HANDS!! Rash / Skin changes Scars Swelling and masses Colour changes Deformities - ulnar deviation, subluxation Nails - oncholysis? pitting? discolouration Muscle bulk/wasting Finger fixed flexion Clubbing Z-deformity Boutinniere or Swan necking |
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What do you Feel for in a hand exam? |
Feel across each joint - DIP, PIP, MCP, wrist Feel the elbow and surrounds for nodules or dry skin Feel temperature Feel pulses - radial and ulna Feel for fluid in the joint, subluxations, dislocations, joint fusions, crepitus, pain Assess nerves - sensation on thenar and hypothenar and back of hand - enquire if same on both sides. |
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What do you Move in a hand exam? |
Isolate and move all joints in all directions - identify dislocation, pain, fusions, range of movement. Identify power of fingers and wrist Identify power of thumb in all 4 planes using a pen Passive and active ab/adduction |
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What special tests do you do in a hand exam? |
Opposition - thumb to each finger individually Make a fist Pinch my finger or pick up a pen Grip my finger Prayer sign - reveals finger fixed flexion and wrist extension Inverted prayer sign (Phalen's) - hold for 30s to identify median nerve palsy Oppositon strength of fingers - hold piece of paper btwn thumb and finger and tug of war. Carpal tunnel test - tap on wrist in full extension and ask about shooting pain/needles in hand (Tinel's test) |
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Describe Swan neck and Boutinniere's |
Swan neck = flexion of DIP and extension of PIP Boutinniere's = ext of DIP and flexion of PIP |
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Modifiable risk factor for RA? |
Smoking. |
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Which cells are of particular importance in RA? |
TH1 cells |
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Joint Sx of RA? |
Symmetrical arthralgia - PIPs, MCP, wrist, shoulder, ankles, knees, MTP Inflammatory - hot, red, swollen joints, sore in the morning and better with movement Doesn't effect DIPs Sub-acute/insidious onset |
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Systemic Sx and complications of RA? |
Nodules - on elbows/hands particularly Pulmonary - fibrosis, pleuritis - effusion Cardiac - pericarditis, valvular disease Ocular - scleritis Neurologic - nerve entrapment, peripheral neuropathy Vasculitis - PVD, stroke, MI Palmar erythema Osteoporosis Malignancy - lymphoma Infection |
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Ix for RA? |
Bloods - autoantibodies: RF and anti-CCP. CRP, ESR, platelets (thrombocytosis) Imaging - X-rays (generally only show Sx at late stages of RA) US and MRI for fluid and structures (nerves, synovitis, erosions) |
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Mx of RA? |
Education - don't smoke! 1st line Meds - prednisolone (short course) + MTX or hydroxychloroquine (Plaquinel) or Sulfasalazine or Leflunomide. 2nd line Meds - Anti-TNF - adalimumab, infliximab, etanercept. Or Abatacept. Or Rituximab. |
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Side effects of drug Rx? |
Reduced immunity - infections and cancer Reduced healing GI problems - N/V/D Liver damage Cytopaenias Pregnancy - teratonergic |
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Dx this - Pt presents with dry eyes and dry mouth, swollen parotid gland, Raynauds, some arthralgia and fatigue. |
Sjogrens Syndrome. Exocrine glandular dysfunction (lacrimal, parotid) DDx - SLE |
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What Ix help to Dx a Pt with Sjogrens? |
Antibodies - SSA (Ro) and SSB (La) Test eye fluid production Test saliva production Biopsy parotid gland - lymphocytic infiltration Hypergammaglobulinaemia |
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How does Sjogrens differ from SLE when all of the Sx are basically shared? |
Antibodies SSA (Ro) and SSB (La) not part of SLE No photophobia in Sjogrens |
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Tx for Sjogrens? |
Tx the Sx. Eye drops (cyclosporine), oral pilocarpine, chewing gum, NSAIDs for joints. |
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Bad complications of Sjorgrens? |
Increased risk of malignant lymphoma - MALT and B-cell Foetal heart block Otherwise longevity unaltered. |
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Pt presents with 5/7 Hx of pain and swelling in L mid-foot which is hot and swollen, non-tender. DDx? |
Gout, Pseudogout Trauma - damage OA Psoriatic arthritis Vascular complication - DVT? Septic arthritis SLE, Sjogrens Peripheral spondyloarthritis |
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Which of those DDx are mono- or polyarthritic? |
Mono: Gout, Trauma, Infection (Septic arthritis), Pseudogout, OA, psoriatic arthritis, reactive arthritis, ankylosing/peripheral spondyloarthritis Poly: RA, SLE, OA, psoriatic, ankylosing/peripheral spondyloarthritis, |
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Which joints of hand and signs on inspection indicates psoriatic arthritis? |
DIPs. Nails have dimples and/or onkylysis. |
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What Ix are important to do for a presentation of acute onset monoarthritis? |
Aspirate the joint!! Check for infection by culture and staining. Check for WCCs (low=OA, high=infection/gout), protein, colour, viscosity, Check for crystals by biferingence micro Bloods for uric acid, FBP, CRP, ESR If suspect autoimmune - bloods for antibodies and ESR/CRP |
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What must you always do when a Pt presents with acute monoarthritis? |
ASPIRATE THE JOINT!! |
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What are some seronegative Spondyloarthropathies? |
PsA Ankylosing Spondylitis Reactive arthritis Enteropathic arthritis |
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Which are symmetrical or asymmetrical: A) PsA B) Ankylosing spondylitis C) Reactive arthritis D) Enteropathic arthritis |
A) Asymmetrical B) Symmetrical C) Asymmetrical D) Symmetrical |
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What antibody is most assoc withspondyloarthropathies? |
HLA B27 - particularly specific for ankylosing spondylitis! |
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Dx criteria for ankylosing spondylitis? |
Lower back pain >3/12 (plus morning stiffness) Pain reduces with exercise and responds to NSAIDs Reduced range of movement in lumbar Radiographic sacroiliitis an/or spondylitis Reduced chest expansion |
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What age and sex group does ankylosing spondylitis affect? |
20-40yo Males While RA is generally later >50yo and Females |
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Ankylosing spondylitis affects with joints? |
Sacroiliac Vertebrae Shoulders Hips Peripheral joints uncommon |
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Ix for Axial spondyloarthropathy? |
Schobers test (flexion) Lateral spine flexion, extension Measure Occiput to wall and Tragus to wall Chest expansion measure Feel for pain in joints |
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Features of peripheral spondyloarthropathy? |
Uveitis (inflam of vascular area of eye) Psoriasis Chrons/UC Preceding infection HLA B27 raised sacroiliitis on imaging dactylitis arthritis FHx Enthesitis (inflam where tendon/ligament enters bone) |
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Sx of psoriatic arthritis? |
Nail pitting and onkylysis Dactylitis Rash Asymmetrical arthritis - random involvement Starts as monoarthritis graduates to poly |
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Differentiate PsA from RA and ankylosing spondylitis |
Features PsA RA AS Sex Either Females Males Location random Small jnts Spine lge jnts, lower limbs Number 1-many Symmetr Symmetr HLA B27 10-25% 95% RF rare 75% rare DIP Common Rare Rare Systemic Rash, nails Nodules Sicca Sx |
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What does PsA do to bone? Name of common feature on X-ray? |
Erodes bone (as does RA and AS). AS erodes then reforms with poor quality... X-Ray show 'Pencil and Cup' deformities |
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What 2 features would suggest Reactive Arthritis over other arthropathies? |
Sudden onset Associated with an infectious trigger |
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Is the synovitis sterile or not in reactive arthritis? |
It IS sterile. Occurs after peripheral infection --> get dysregulated immune response --> immune sys then targets other areas of body |
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What common infections can result in Reactive Arthritis? |
Enteric - Salmonella, Shigella, C difficile, Campylobacter jejuni UTI/STI - Chlamydia trachomatis |
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Reactive arthritis (aka Reiters disease) is associated with what 3 Sx? And what other Sx also present? |
Urethritis Conjunctivitis Arthritis Also get rash's over body and tongue |
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Tx for Reactive arthritis? |
Antibiotics if infection active NSAIDs GCs DMARDs for chronic |
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Tx for Spondyloarthropathies in general? |
Exercise!!! NSAIDs DMARDs - sulfasalazine, leflunomide, MTX, anti-TNF therapies Biologics - abatacept, rituxumab, toclizumab... Antibiotics for Reactive Arthritis |
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Clinical features of Dermato-myositis? |
Increasing upper and lower proximal weakness of limbs symmetrically (and pain). Increased fatigue Erythema around neck (Shaul sign) Heliotrope (periorbital blue hue) Thickened/red/dry skin on extensor surfaces (Gottron's papules) - joints of hand, elbow and knees (Gottron's sign). Breathing difficulties due to ILD - SOB |
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DDx for Sx of myositis? |
Metabolic - DM, Vit D, Ca Endocrine - Hypothyroid, Infection Vascular - stenosis, etc Drug induced - statins, antimalarials Genetic - muscular dystrophy Inflamm - Scleroderma, SLE, myositis, polymyalgia rheumatica, inclusion body myositis Neural - myasthenia gravis, motor neuron disease, MS Cancer |
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Ix for Pt presenting with ?myositis? |
Rule out DDx: Neural and MSK exams. Cardio and vascular exams Bloods: FBP, TFTs, Vit D, BSL, Ca, U&Es, ESR, CRP, CK, LFTs, ANA Imaging - MRI, EMG, muscle biopsy. CXR / CT chest for lung fibrosis / ILD |
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MRI shows what feature for myositis? |
Diffuse oedema in muscle due to persistent inflammation |
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Following a Dx of myositis, what follow up is vital? |
Cancer checks critical as myositis carries a sig increased risk of malignancy!! |
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Sx of polymyositis? |
Increasing muscle weakness (and pain) Raynaud's low grade Fever Fatigue SOB with exertion Wasting of quads Dry coarse skin on finger tips and lateral of fingers (mechanics hands) Esophageal dysmobility and dysphagia |
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What differentiates dermato- from polymyositis? |
Poly does not have derm aspect (Gottron's papules) - ie No 'Shaul' rash across neck, no rash across extensor surfaces (MCP/PIP/DIP, elbows). Poly has no heliotrope. Poly has only dry cracked skin on fingers. Poly can have dysphagia/dysmotility of esophagus and Raynaud's |
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Systemic complications of polymyositis? |
Lungs - ILD, fibrosis Cardiac - HF Cancer - lung, non-Hodgkins Lymphoma, bladder ... |
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Ix important for myositis's? |
CK!! MRI EMG Biopsy with histopathology Antibodies - Anti-Jo-1 Ab and Anti-Mi-2 Ab |
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Name 2 types of large, medium, small and ANCA-associated vasculitis's |
Large - Giant cell and Takyasu Medium - Polyarteritis Nodosa and Kawasaki disease Small: Immune complex vasculitis's - IgA vasculitis, Cryoglobulinaemic vasculitis ANCA-associated vasculitis's - Wegners and Churg-Strauss |
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What age groups to Giant cell and Kawasaki vasculitis occur? |
Giant cell - >60yo Kawasaki - children <10yo |
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General Sx of vasculitis? |
Think cancer. Fever, night sweats, fatigue, wt loss, arthralgias. Glomerulonephritis Mesenteric ischaemia Alveolar haemorrhage Visual disturbance with GCA |
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Ix for Vasculitis? |
Exam - tenderness?, vision, etc Bloods - Hb, ESR, CRP, alb, urine MCS and ACR, ANCA testing Biopsy! Angiography or US |
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Tx for Vasculitis? |
High dose short-term steroids. Pred. 3-6 months Plus immunosuppresant for 3-6 mon |
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Sx of Giant cell arteritis? |
General Sx - wt loss, fatigue, fever, night sweats, Headache, tender forehead/scalp, visual loss/disturbance (diplopia, amaurosis fugax), jaw claudication, tongue pain |
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What other immunological disease is strongly associated with GCA? |
Polymyositis rheumatica |
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What causes visual disturbances by GCA? |
Ischaemic optic neuropathy Retinal artery occlusion |
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4 types of ANCA vasculitis |
Microscopic polyangitis - vasculitis in kidneys, skin, nerves, lungs Wegners - vasculitis + granulomatous inflam of lung, sinuses, nose, ears, eyes Churg-Strauss - vasculitis + granulomatous inflam + asthma + eosinophilia ANCA glomerulonephritis |
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Sx of SLE? |
Fever, Fatigue, Wt loss - from cytopaenia's Photophobic malar rash across face Discoid lupus - rash pigments skin Vasculitis Asymmetric Arthritis Raynaud's Alopecia Recurrent miscarriage Nephritis Serositis - pericarditis, pleuritis, peritonitis |
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Ix for SLE? |
Bloods - FBP for cytopaenias TFTs, creatinine, ESR, CRP, C3/C4 (low levels = SLE) Antibody tests - ANA (non-specific) - Anti-Smith Ab and Anti-dsDNA v specific for SLE |
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Tx for SLE? |
Lifestyle - avoid sun, stop smoking, exercise for fatigue/joints, immunizations Pharma - topical steroids, NSAIDs, for arthritis, Antimalarials Glucocorticoids Immunosuppressants - Cyclophosphamide, MTX, azathioprine, mycophenylate Rituxumab Abatacept Anti-TNFs, Anti-IL6 |
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Does SLE shorten lifespan? |
Yes. 15y survival 79% |
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Cause of death in SLE? |
Infection complications CV event - eg DIC, stroke... Disease flare - end organ damage / vascular damage |
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Describe Raynauds phenomenon |
Episodic, reversible digit ischaemia. Vasoconstriction causes pallor --> venostasis (blue cyanotic) --> reactive hyperaemia (erythema). Prolonged episode can cause necrosis and gangrene |
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Scleroderma, aka Systemic sclerosis, is split into diffuse cutaneous (dcSS) and limited cutaneous (lcSS). Describe features of each. |
dcSS: GORD and oesophageal problems, malignant HTN - retinopathy and renal failure. ILD --> pulmonary HTN. Myocardial fibrosis and arrhythmia's lcSS is defined by CREST: Calcnosis, Raynauds, Oesophageal dysmobility, Sclerodactyly, Talangectasia. Also - pulmonary HTN |
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Which connective tissue diseases are associated with Raynaud's? |
SLE, Sjogrens, Polymyositis, Scleroderma/Systemic sclerosis. |
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Causes of Raynaud's? |
Cold, Anxiety, SNS, occlusive vascular diseases (atherosclerosis), Buerger's, vibratory trauma, drugs, polycythaemia, cryoglobulinaemia |
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Effect of scleroderma on skin and joints? |
Skin - puffyness, tightens skin, darker pigment Bone - synovitis and erosive arthritis. Distal tuft reabsorption |
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Tx for scleroderma? |
Tx the Sx. Raynauds - avoidance of triggers. CCBs, ARBs, SSRIs, amputations of digits Pulmonary HTN - ET-1 R blocker (bosentan), sildenafil (inhalant) GIT - PPIs, antibiotics, TPN feeding, surgery Lungs - Prednisolone, cyclophosphamide, rituxumab, azathioprine Arthritis - analgesics, NSAIDs, steroids, MTX, Plaquenil Myositis - steroids + MTX or azathioprine or... |
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What organs are affected by scleroderma? |
Skin - pigment, puffy and tight Vessels - Raynauds, occlusions from cell debris Joints - arthritis/arthralgia Muscles - weakness and inflamm Heart - pericardial and myocardial fibrosis, constrictive pericarditis + tamponade and arrhythmia Lungs - ILD, fibrosis, pulm HTN GIT - oesophageal dysmobility and dysphagia, GORD, fibrosis and atrophy of GIT wall = no peristalsis, gastric antral vascular ectasia Renal - malignant HTN and renal failure, glomerulonephritis Eyes - retinopathy |
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How do these drugs work and for what diseases are they prescribed? A) Prednisolone B) Anti-malarial (hydroxychloroquine) |
A) works by inhibiting pro-inflammatory genes and increasing anti-inflam genes. Used for flares of RA, SLE, vasculitis's, scleroderma, PsA B) works by impairing Ag processing = less T cells activated and less cytokines released. Used for RA and SLE |
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How do these drugs work and for what diseases are they prescribed? C) Adalimumab D) Sulfasalazine |
C) TNFa antibody. Used for spondyloarthropathies, RA (2nd-line), SLE D) works by inhibiting neutrophils, B cells and T cells. Used for RA, spondyloarthropathies. |
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How do these drugs work and for what diseases are they prescribed? E) Azathioprine F) Methotrexate |
E) works by blocking purine synthesis = reduced cell formation. Need TPMT genetic screen before prescribing! Used for SLE, RA, vasculitis F) works by suppressing folic acid processing = reduced inflam cell number. Used for RA, SLE, spondyloarthropathies, scleroderma, chronic vasculitis, PsA, polymyositis |
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How do these drugs work and for what diseases are they prescribed? G) Leflunomide H) Abatacept |
G) works by inhibiting pyramidine synthesis = reduced T-cells. Used for RA, SLE, spondyloarthropathies H) works by preventing APC from activating T-cells. Used for RA, SLE, Spondyloarthropathies |
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How do these drugs work and for what diseases are they prescribed? I) Cyclosporin A J) Mycophenylate |
I) Works by inhibiting T-cell prolif. Used for RA and PsA J) calcineurin inhibitor. Used for SLE, polymyositis, vasculitis |
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Describe Haberdens and Bouchard's Nodes |
Haberdens = Nodes in the DIP - DISTAL!! Bouchards = Nodes in the PIP - PROXIMAL! |
