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61 Cards in this Set
- Front
- Back
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joint pain and ferritin >1000 - which two diagnoses? |
haemochromatosis
still's disease |
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gout def
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inflammatory arthritis associated with hyperuricaemia.
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gout epidemology/risk factors that increase uric acid levels
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male>female, older adults
common in maoris serum uric acid increases in age, obesity, alcohol, high protein diet, DM, HTN!!!, hyperlipidaemia, FHx thiazide diuretics, ASPIRIN low dose! |
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who gets polyarticular gout?
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elderly on diuretics or started on allopurinol too soon after attack
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gout - investigation
(diagnostic test, helpful tests, what else important to check) |
diagnostic: joint fluid microscopy
helpful: serum urate level (rule out if in lower half of normal) important: creatinine for urate nephropathy |
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gout - treatment of acute attack
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mainstay: NSAIDS
24-48 hours high dose until symptoms improved, then another week in reduced dose if renal impairment/hx of peptic ulcers: colchicin |
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gout - how to reduce urate acid levels in the first place?
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reduce alcohol (especially beer)
avoid offal, some fish,m shellfish, spinach - reduces urate level by 15% |
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gout - how to decide when to start drug treatment for hyperuricaemia?
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mainstay: allopurinol
only if attacks frequent and severe if dietary measures unsuccessful if NSAIDs/colchicin difficult to tolerate start allopurinol only >1 month after acute attack under NSAID cover. |
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pseudogout def
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inflammatory arthritis caused by calcium pyrophosphate deposits in hyaline and fibrocartilage
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pseudogout vs gout clinical
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same appearance, but more commonly affecting knee wrist and elderly women
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pseudogout associations in young people
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haemochromatosis
wilson's hyperparathyroidism alkaptonuria |
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pseudogout - diagnosis, what needs to be excluded?
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diagnostic: joint fluid microscopy (rhomboid weakly positive birefringence)/Xray features (chondrocalcinosis)
infection needs to be excluded |
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pseudogout - treatment
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as for gout.
joint aspiration is usually very effective in reducing pain. |
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reactive arthritis def
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reactive arthritis is a sterile synovitis which occurs following an infection
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reactive arthritis clinical features
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triad: urethritis, arthritis, conjunctivitis (reiter's syndrome)
lower limb, asymmetric arthritis days-weeks after infection acute anterior uveitis may occur skin lesions resembling psoriasis may occur |
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reactive arthritis associated organisms
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salmonella, shigella, yersinia, chlamydia, ureaplasma
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reactive arthritis - treatment
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culture for infection and treat
NSAIDs local corticosteroid infections |
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how to test for carpal tunnel syndrome
(clinical, diagnostic test) |
median nerve:
look for thenar wasting ABduction of thumb ( exclusively innervated by median nerve) sensation medial three fingers pressure test (30 seconds - after 16 seconds tingling) diagnostic: nerve conduction study |
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carpal tunnel syndrome - treatment
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mainstay: surgical decompression
in mild cases, wrist splint and local steroid injection |
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Rheumatoid arthritis def
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RA is a chronic, symmetric polyarthritis of unknown cause with systemic involvement.
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RA - clinical features
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F>M 3:1 , 30-50 (although any age possible)
pain, stiffness joints symptoms worse in morning and better with gentle exercise tiredness |
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RA - pattern of joints involved
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small joints: MCP, DIP, PIP
elbow, wrist, shoulder, knee 10% only acute monoarthritis, but 50% of these progress to full disease |
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RA - complications
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septic arthritis
amyloidosis ruptured tendon baker's cyst spinal cord compression |
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RA - involvement of hand joints
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ulnar deviation
flexion deformity (boutonniere) extension deformity (swan neck) carpal tunnel finger drop (little/ring) |
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RA - shoulder, elbow
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shoulder painful arch
elbow fixed flexion deformity, later flexion lost and difficulties feeding |
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RA - knees, feet
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MTP, hammer toe
knee: massive effusions, baker's cysts with rupture if recurrent effusions. varus/valgus deformity and secondary osteoarthritis |
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extra articular manifestations of RA
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subcutaneous nodules
lungs: nodules, serositis (effusions), pleural nodules, fibrosing alveolitis, bronchiolitis obliterans CVS: vasculitis, pericardial effusions neuro: neuropathies (vasculitis of vasa vasorum), carpal tunnel eyes: scleritis, eye perforation renal: amyloidosis (renal failure) leg ulcers, sepsis normocytic-normochromic anaemia |
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felty syndrome
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neutropenia and splenomegaly in RA
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RA diagnostic criteria (American College of Rheumatology)
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diagnosis: based on criteria
4 of 7: 1. morning stiffness >1h 2. arthritis >3 joints 3. arthritis of hand joints and wrist (first three must be for > 6 weeks) 4. symmetrical arthritis 5. subcutaneous nodules 6. positive serum rheumatoid factor 7. typical radiological changes |
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RA investigations (helpful)
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rheuma factor+CCP
Xray aspiration if effusion resent |
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RA management (how to diagnose, initial treatment, when to refer)
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establish diagnosis clinically
NSAIDs to control symptoms if >6weeks induce remission with single IM methylprednisolone 60-120mg if relapses give second IM dose and refer to rheumatologist for DMARD |
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RA - DMARD
(when to use, how to use) |
use early 6 weeks - 6 months
in CCP+RF pos patient use from beginning use before erosisons appear on xray |
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RA DMARD first choice I
(dose, side effect, monitoring) |
methotrexate weekly (2.5mg - 7.5mg, max 15 - 25mg)
+/- folate works in 1-2 months nausea, vomiting monitor FBC and LFT |
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RA DMARD first choice II
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sulfasalazine
leucopenia, thrombocytopenia |
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RA DMARD TNF-alfa blocker
(when to start) |
after two other DMARDs have been tried
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RA NSAIDs use
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try several to find the best for individual patient
each should be tried for at least a week if >65 or GI symptoms prominent, use PPI S/R preparations (e.g diclofenac 75mg) or suppository can be given in addition to daytime therapy paracetamol/codeine can be used in addition |
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ankylosing spondilytis def
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inflammatory disorder of the spine affecting mainly male
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akylosing spondylitis clinical features
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late-teen/early twenties boys
episodes of buttock pain an stiffness worse in morning and relieved by exercise may present with monoarthritis (knee) uveitis |
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ankylosing spondylitis xray features
(earliest sign) |
blurring of upper lower vertebral rings at thoracolumbar junction (enthesitis)
syndesmophytes bony ankylosis |
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ankylosing spondylitis treatment
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daily exercise
NSAIDs to control pain and to facilitate exercise TNF-alpha blocking agents effective in severe disease |
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polymyositis def
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rare disorder of unknown etiology with inflammation of striated muscle causing proximal muscle weakness
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polymyositis clinical features
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all ages, F>M
insidious/acute proximal muscle weakness systemic features: malaise, fever pain/tenerness uncommon involvement of pharyngeal, laryngeal, resp muscle can occur (dysphagia 50%) lung fibrosis |
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polymyositis investigations
(diagnostic, prognostic marker, what further investigation if new diagnosis in adult) |
diagnostic: CK+EMG+biopsy
anti-Jo1 predicts worse prognosis (lung fibrosis) search for malignancy |
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polymyositis treatment
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prednisolone
bed rest + physiotherapy |
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fibromyalgia clinical features
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middle-aged women overworked
"ache all over" sleep disturbance painful trigger points |
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fibromyalgia diagnosis
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dignosis of exclusion
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fibromyalgia treatment
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aerobic exercise
psychologist referral amitryptiline low dose bedtime trigger point injection/NSAIDs sometimes helpful |
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psoriatic arthritis def
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groupt of arthritides in people with psoriasis or with family history of psoriasis
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psoriatic arthritis clinical features
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skin psoriasis can be present/absent
most common DIP joints (but also RA similar or AS similar, however HLA-B27 or RF negative) nail dystrophy arthritis mutilans 5% |
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psoriatic arthritis xray appearance
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erosive arthritis
erosions central nor juxta-articular "pencil in cup appearance" |
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relapsing polychondritis def
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rare inflammatory disorder of cartilage
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relapsing polychondritis clinical features
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tenderness, inflammation, destruction of cartilage
ear, nose, larynx, trachea seronegative polyarthritis episcleritis systemic features: fever, malaise |
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De Quervain's tendosynovitis
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pain and swelling around radial styloid where abductor pollicis longus tendon.
local tenderness Pain worsened on flexion of thumb into palm Rx: steroid injection, surgery |
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flexor tendosynovitis
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pain when gripping
trigger finger tendon nodule palpable in distal palm Rx: steroid injection, surgery |
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adult-onset still's disease def
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variant of RA
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adult onset still's disease clinical features
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16-35 yr
fever with salmon-pink rash, arthralgia, lymphadenopathy and serositis (pleural/pericardial effusions) |
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adult onset Still's disease diagnosis
(diagnostic, autoantibodies) |
diagnostic: clinical
all autoantibodies, RF, negative FERRITIN > 1000's |
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TNFalfa blockers and surgery
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stop 2-4 weeks before major surgery
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gonococcal arthritis
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septic arthritis secondary to gonorrhoe
febrile, pustules on limbs polyarthritis culture from genital tract usually positive blood cultures initially positive joint culuture can be negative urgent treatment with penicillin, ciprofloxacin or doxycicline |
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RA - radiological features in early disease
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soft tissue swelling
periarticular osteopenia erosions larger joints: marked narrowing of joint space atlantoocipital: forward subluxation C1 on C2 |
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crystallopathy - microscopy findings
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gout: negative birefringence, needle shaped crystals
pseudogout: positive birefringence, rhomboid shaped |
