MSK (Rheum and T&O)

Question 1

pattern of joints affected in RA

Answer 1

symmetrical polyarthritis

Question 2

which joints are usually spared in RA?

Answer 2

DIP

Question 3

characteristics of inflammatory joint pain

Answer 3

worse in the morning, improves with exercise

Question 4

which joints are usually affected in primary nodal osteoarthritis

Answer 4

distal interphalangeal joints (DIP)

Question 5

most specific antibody for RA

Answer 5

anti-citrullinated peptide Ab

Question 6

investigations for suspected RA

Answer 6

Acute phase markers
CRP and ESR will usually be high if there is ‘active’ disease

Serological tests
Rheumatoid factor (antibody specific for IgG Fc)
~60-70 % sensitivity and specificity for RA
Anti-cyclic citrullinated peptide antibodies (‘anti-CCP’ antibodies or ‘ACPA’)
~60-70% sensitivity and ~95% specificity for RA

Radiology
US or MRI can demonstrate synovitis and early erosive damage
X rays are most useful for monitoring erosive changes

Other blood tests
FBC, U&E, LFTs will be required prior to initiating drug treatment

Question 7

who is involved in the MDT of a pt with RA?

Answer 7

Rheumatology consultant

General practitioner

Rheumatology nurse specialist
Hand therapist
Occupational therapist
Physiotherapist
Podiatrist
Psychology/counselling services
Surgeon

Question 8

management of RA

Answer 8

1. analgaesics
2. NSAIDs, hydroxychloroqine
3. DMARDs- eg. methotrexate/ sulfazalazine (started early in the course of the disease)
4. plus steroid (flares can do IM, interarticular or oral)
5. anti-TNF therapy (for pts who have active disease despite DMARDs)
6. physiotherapy

Question 9

what deformities can occur as RA progresses?

Answer 9

ulnar deviation
palmar subluxation of metacarpophalangeal joints
Boutonniere deformity (flexion of PIP, hyperextension of DIP)
Swan neck deformity (hyperextension of PIP, flexion of DIP)
inflammation of flexor tendon sheath-> carpal tunnel syndrome

Question 9

features of psoriatic arthritis?

Answer 9

symmetrical or asymmetrical polyarthritis
onycholysis with brown discoloration of the nails
arthritis mutilans in severe disease

Question 9

common joints affected in RA

Answer 9

small joints of the hands and feet except DIP

proximal interphalangeal joints
metacarpophalangeal joints
metatarsophalangeal joints
wrists

Question 10

clinical of osteoarthritis

Answer 10

worse on movement
over 60
heberdens nodes on DIP
Bouchard node on PIP
boney swelling
hips and knees common

Question 11

radiological features of osteoarthritis

Answer 11

Loss of joint space
Osteophytes
Subchondral sclerosis
Subchondral cysts

Question 12

most common causative organism of septic arthritis

Answer 12

staph aureus

Question 13

management of septic arthritis

Answer 13

joint aspiration for MC&S
emperical antibiotics ASAP
- eg. flucloxacillin, gentamycin and benpen
immobilise the joint

Question 14

causes of reactive arthritis

Answer 14

sterile arthritis following an attack of dysentry (campylobacter, salmonella, shigella, yersinia) or urethritis (chlamydia, ureaplasma)

They are gram-negative organisms, with a lipopolysaccharide component within their cell wall

Question 15

clinical features of reactive arthritis

Answer 15

acute, asymmetric lower limb arthritis 1-4 weeks following infection
conjunctivitis
enthesitis (plantar facitiis or achilles tendonitis)
ciricinate balanitis (painless, superficial penile ulcer)
keratoderma blenorrhagica (painless red plaques on soles or palms)
nail dystrophy
mouth ulcers

Question 16

what is Reiters disease

Answer 16

triad of urethritis, arthritis and conjunctivitis

features of reactive arthritis

Question 17

management of reactive arthritis

Answer 17

1. NSAIDs
2. local steroid injection for symptomatic control
3. treat underlying cause

Question 18

pathophysiology of reactive arthritis

Answer 18

CD4 T cell sensitisation of bacterial antigens

antigens disseminate systemically to joint (sterile) causing T cell activation and inflammation of the joint

Question 19

what are the crystals of pseudogout

Answer 19

calcium pyrophosphate

Question 20

underlying conditions that may result in pseudogout

Answer 20

hypothyroidism
hyperparathyroidism
wilsons
haemachromatosis

Question 21

Xray findings of pseudo gout

Answer 21

chondrocalcinosis (calcification of hyline cartilage)

Question 22

what is seen under polarised light in gout vs pseudogout?

Answer 22

gout:
negatively birefringent needle shaped crystals

psuedogout:
positively birefringent rhomboidal crystals

Question 23

what are the crystals in gout

Answer 23

monosodium urate (MSU) crystals

Question 24

management of anklyosing spondylitis

Answer 24

NSAIDs and spinal exercises

Question 25

associated features of ankylosing spondylitis

Answer 25

anterior uevitis- sudden onset pain, blurred vison and photophobia conjunctivitis- red, itchy eyes plantar faciitis, achillies tendonitis

Question 26

what is GCA associated with

Answer 26

polymyalgia rheumatica

Question 27

back pain red flags

Answer 27

<20y >50yrs sphincter disturbance history of malignancy neurological disturbance leg pain

Question 28

features of feltys syndrome

Answer 28

Extraarticular features of seropositive RA [SANTA] splenomegaly Arthritis neutropenia thrombocytopenia anaemia

Question 29

Investigations for RA

Answer 29

Bedside: squeeze test/ hand examination bloods: FBC (anaemia), CRP, ESR (inflammation) Abs- ANA, anti CCP and RF Imaging Xray for basline USS for synovitis MRI

Question 30

features of seronegative spondyloarthropathies

Answer 30

PEARL HEADS Psoriatic arthrtis Eneropathic arthritis Ank spond Reactive arthritis HLA B27 Enthesitis Axial, asymmetrical, oligoarthritis Dactylitis Seronegative (no RF)

Question 31

associated complications of ankylosing spondylitis

Answer 31

AAAAAA Anterior uveitis Apical lung fibrosis Aortic regurgitiation AV node block Achilles tendonitis Amyloidosis

Question 32

Name of a grading system for ankylosing spondylitis

Answer 32

New york criteria

Question 33

management of Ank spond

Answer 33

Conservative: Physiotherapy/ exercise Medical: NSAIDS --> aTNF (etanercept) --> aIL17 (secukinumab) surgical: hip replacement

Question 34

systemic features of connective tissue disease

Answer 34

rash hair loss fatigue fever chest pain cough Raynauds

Question 35

features of limited systemic sclerosis (CREST syndrome)

Answer 35

Calcinosis Raynauds Esophogeal dysmotility Sclerodactyle Telangectasia

Question 36

features of polymyositis

Answer 36

Inflammation of striated muscle o Progressive symmetrical proximal muscle weakness (associated myalgia & arthralgia) o Wasting of shoulder and pelvic girdle o Dysphagia, dysphonia, respiratory weakness

Question 37

features of dermatomyositis

Answer 37

§ Periorbital heliotrope rash on eyelids ± oedema § Gottron’s papules: knuckles, elbows, knees § Mechanics hands: painful, rough skin cracking of fingertips § Macular rash (shawl sign +ve: over back and shoulders) § Nailfold erythema § Retinopathy: haemorrhages and cotton wool spots § Subcutaneous calcifications

Question 38

Investigations for suspected myositis

Answer 38

bloods: CK raised LFTs- raised ALP, AST and LDH myositis pannel- anti Jo1, anti mi2, anti-srp CLAAA CK LDH ALP AST Antibodies- anti jo anti mi anti srp EMG biopsy (diagnostic) Malignancy screen- as can be a feature of a paraneoplastic syndrome

Question 39

Management of GCA

Answer 39

immediate steroids 40-60mg ESR and temporal artery biopsy visual symptoms --> IV methylprednisolone

Question 40

common areas of muscle wasting in polymyositis

Answer 40

shoulder pelvic girdle muscles

Question 41

causes of peripheral muscle wasting

Answer 41

Neuro LMN disease: ALS cervical myelopathy

Question 42

side effects of methotrexate

Answer 42

anaemia leukopenia and infections thromboctyopenia pulmonary fibrosis GI upset skin changes

Question 43

pathophysiology of sjogrens

Answer 43

autoimmune destruction and fibrosis of exocrine glands resulting in dry mouth, dry eyes (and also dry vagina) anti-Ro and anti-La commonly associated

Question 44

management of acute gout

Answer 44

STOP allopurinol 1. strong NSAID eg. indomethacin 2. colchicine if NSAIDs CI 3. intra articular sterid injections prevention of future attacks lifestyle changes- reduce ETOH, wt loos, avoid purine rich food allopurinol low dose aspirin

Question 45

features of bechets

Answer 45

oral and genital ulcers occular involvement- anterior/ posterior uveitis, retinal vascular lesions

Question 46

Conditions associated with carpal tunnel syndrome/ positive tinels test

Answer 46

RA demyelination Pregnancy cardiac failure hypothyroidism

Question 47

what is the function of the ACC

Answer 47

prevents anterior translocation of the tibia at the knee

Question 48

which nerve is responsible for claw hand deformity?

Answer 48

ulnar

Question 49

which nerve is responsible for wrist drop?

Answer 49

radial (Rist-Radial)