rheum

Question 1

acute Gout

Answer 1

NSAIDs
colchicine if renal impairment
3rd line steroids oral
4th intraarticular steroids

Question 2

DE QUERVEINS Tendosinovitis

Answer 2

Features
pain on the radial side of the wrist
tenderness over the radial styloid process
abduction of the thumb against resistance is painful
Finkelstein’s test: with the thumb is flexed across the palm of the hand, pain is reproduced by movement of the wrist into flexion and ulnar deviation

Management
analgesia
steroid injection
immobilisation with a thumb splint (spica) may be effective
surgical treatment is sometimes required

Question 3

OSteoporosis frax

Answer 3

FRAX:
history of glucocorticoid use
rheumatoid arthritis
alcohol excess
history of parental hip fracture
low body mass index
current smoking

Question 4

Marfan’s assw what eye condition

Answer 4

eyes: upwards lens dislocation (superotemporal ectopia lentis), blue sclera, myopia

Question 5

rheumatoid arthritis what drugs are safe in pregnancy

Answer 5

sulfasalazine

hydroxychloroquine

Question 6

rheumatoid factor

Answer 6

IgM towards one’s own IgG

Question 7

Marfan’s mutation

Answer 7

Mutation of FBN1 that encodes Fibrillin-1

Question 8

sjogren’s assw with what malignancy

Answer 8

lymphoid malignancy

Question 9

anti-Jo 1:

Answer 9

polymyositis

Question 10

anti centromere antibodies

Answer 10

Limited (central) systemic sclerosis = anti-centromere antibodies

Question 11

Limited cutaneous systemic sclerosis

Answer 11

Raynaud’s may be first sign
scleroderma affects face and distal limbs predominately
associated with anti-centromere antibodies
a subtype of limited systemic sclerosis is CREST syndrome: Calcinosis, Raynaud’s phenomenon, oEsophageal dysmotility, Sclerodactyly, Telangiectasia

Question 12

scl 70 antibodies

Answer 12

Diffuse cutaneous systemic sclerosis

Question 13

Diffuse cutaneous systemic sclerosis

Answer 13

scleroderma affects trunk and proximal limbs predominately
associated with scl-70 antibodies
the most common cause of death is now respiratory involvement, which is seen in around 80%: interstitial lung disease (ILD) and pulmonary arterial hypertension (PAH)
other complications include renal disease and hypertension
poor prognosis

Question 14

Scleroderma

Answer 14

(without internal organ involvement)
tightening and fibrosis of skin
may be manifest as plaques (morphoea) or linear

Question 15

azathioprine

Answer 15

metabolised to the active compound mercaptopurine, a purine analogue that inhibits purine synthesis. A thiopurine methyltransferase (TPMT) test may be needed to look for individuals prone to azathioprine toxicity.

Adverse effects include
bone marrow depression
nausea/vomiting
pancreatitis
increased risk of non-melanoma skin cancer

Question 16

Ankylosing spondylitis - x-ray findings:

Answer 16

subchondral erosions, sclerosis
and squaring of lumbar vertebrae

late:
sacroiliitis: subchondral erosions, sclerosis
squaring of lumbar vertebrae
‘bamboo spine’ (late & uncommon)
syndesmophytes: due to ossification of outer fibers of annulus fibrosus
chest x-ray: apical fibrosis

Question 17

proximal myopathy in combination with mechanic hands

Answer 17

anti-synthetase syndrome.

association with interstitial lung disease - particularly non-specific interstitial pneumonia or NSIP.

Question 18

Mx of Sjogrens

Answer 18

artificial saliva and tears

pilocarpine may stimulate saliva production

Question 19

polyarteritis nodosa

Answer 19

fever, malaise, arthralgia
weight loss
hypertension
mononeuritis multiplex, sensorimotor polyneuropathy
testicular pain
livedo reticularis
haematuria, renal failure
perinuclear-antineutrophil cytoplasmic antibodies (ANCA) are found in around 20% of patients with ‘classic’ PAN
hepatitis B serology positive in 30% of patients

Question 20

Reactive arthritis: features

Answer 20

typically develops within 4 weeks of initial infection - symptoms generally last around 4-6 months
arthritis is typically an asymmetrical oligoarthritis of lower limbs
dactylitis
symptoms of urethritis
eye: conjunctivitis (seen in 10-30%), anterior uveitis
skin: circinate balanitis (painless vesicles on the coronal margin of the prepuce), keratoderma blenorrhagica (waxy yellow/brown papules on palms and soles)

Question 21

biggest cause of gout

Answer 21

decrease in renal urate secretion:
drugs*: diuretics
chronic kidney disease
lead toxicity

Question 22

Rheumatoid arthritis Mx

Answer 22

DMARD monotherapy plus bridging steroids

methotrexate is the most widely used DMARD. Monitoring of FBC & LFTs is essential due to the risk of myelosuppression and liver cirrhosis. Other important side-effects include pneumonitis
sulfasalazine
leflunomide
hydroxychloroquine

if 2 dmards fail - can try TNFalpha inhibitor
- infliximab

Question 23

Paget’s blood and urine

Answer 23

raised ALP
normal calcium and phosphate

Raised urine hydroxyproline - bone turnover

Question 24

examination of carpal tunnel syndrome

Answer 24

weakness of thumb abduction (abductor pollicis brevis)
wasting of thenar eminence (NOT hypothenar)
Tinel’s sign: tapping causes paraesthesia
Phalen’s sign: flexion of wrist causes symptoms

Question 25

ankylosing spondilitis

Answer 25

if using TNF alpha inhibitors | - radiological progression is NOT changed

Question 26

L3 nerve root compression

Answer 26

loss of thigh sensation reduced knee reflex positive femoral stretch test weakness of quadriceps

Question 27

L4 nerve root compression

Answer 27

Sensory loss anterior aspect of knee Weak quadriceps Reduced knee reflex Positive femoral stretch test

Question 28

L5 Nerve compression

Answer 28

Sensory loss dorsum of foot Weakness in foot and big toe dorsiflexion Reflexes intact Positive sciatic nerve stretch test

Question 29

S1 nerve root compression

Answer 29

Sensory loss posterolateral aspect of leg and lateral aspect of foot Weakness in plantar flexion of foot Reduced ankle reflex Positive sciatic nerve stretch test

Question 30

pseudogout

Answer 30

Features knee, wrist and shoulders most commonly affected joint aspiration: weakly-positively birefringent rhomboid-shaped crystals x-ray: chondrocalcinosis Management aspiration of joint fluid, to exclude septic arthritis NSAIDs or intra-articular, intra-muscular or oral steroids as for gout ``` RF haemochromatosis hyperparathyroidism acromegaly low magnesium, low phosphate Wilson's disease ```

Question 31

Symptoms may be reproduced by deep palpation just below the ASIS (pelvic compression) and also by extension of the hip. There is altered sensation over the upper lateral aspect of the thigh. There is no motor weakness.

Answer 31

? meralgia paraesthetica - lateral cutaneous nerve of thigh compression Burning, tingling, coldness, or shooting pain Numbness Deep muscle ache Symptoms are usually aggravated by standing, and relieved by sitting They can be mild and resolve spontaneously or may severely restrict the patient for many years.

Question 32

antiphospholipid syndrome

Answer 32

``` Features venous/arterial thrombosis recurrent fetal loss livedo reticularis thrombocytopenia prolonged APTT other features: pre-eclampsia, pulmonary hypertension ``` Associations other than SLE other autoimmune disorders lymphoproliferative disorders phenothiazines (rare)

Question 33

sulfasalazine cautions + adverse effects

Answer 33

G6PD deficiency allergy to aspirin or sulphonamides (cross-sensitivity) Adverse effects oligospermia Stevens-Johnson syndrome pneumonitis / lung fibrosis myelosuppression, Heinz body anaemia, megaloblastic anaemia may colour tears → stained contact lenses

Question 34

which TB drug causes lupus

Answer 34

isoniazid

Question 35

weak external rotation of shoulder

Answer 35

adhesive capsulitis

Question 36

Anti-ribonuclear protein (anti-RNP)

Answer 36

mixed connective tissue disease

Question 37

Rheumatoid arthritis XR changes

Answer 37

Early x-ray findings loss of joint space juxta-articular osteoporosis soft-tissue swelling Late x-ray findings periarticular erosions subluxation

Question 38

Rheumatoid arthritis associations

Answer 38

respiratory: pulmonary fibrosis, pleural effusion, pulmonary nodules, bronchiolitis obliterans, methotrexate pneumonitis, pleurisy ocular: keratoconjunctivitis sicca (most common), episcleritis, scleritis, corneal ulceration, keratitis, steroid-induced cataracts, chloroquine retinopathy osteoporosis ischaemic heart disease: RA carries a similar risk to type 2 diabetes mellitus increased risk of infections depression Less common Felty's syndrome (RA + splenomegaly + low white cell count) amyloidosis

Question 39

Temporal arteritis features

Answer 39

Temporal arteritis is large vessel vasculitis overlaps with polymyalgia rheumatica (PMR). Features typically patient > 60 years old usually rapid onset (e.g. < 1 month) headache (found in 85%) jaw claudication (65%) visual disturbances secondary to anterior ischemic optic neuropathy tender, palpable temporal artery around 50% have features of PMR: aching, morning stiffness in proximal limb muscles (not weakness) also lethargy, depression, low-grade fever, anorexia, night sweats

Question 40

Temporal arteritis Ix Rx

Answer 40

Investigations raised inflammatory markers: ESR > 50 mm/hr (note ESR < 30 in 10% of patients). CRP may also be elevated temporal artery biopsy: skip lesions may be present note creatine kinase and EMG normal Treatment high-dose prednisolone - there should be a dramatic response, if not the diagnosis should be reconsidered urgent ophthalmology review. Patients with visual symptoms should be seen the same-day by an ophthalmologist. Visual damage is often irreversible

Question 41

Usually gradual onset Unilateral or bilateral leg pain (with or without back pain), numbness, and weakness which is worse on walking. Resolves when sits down. Pain may be described as 'aching', 'crawling'. Relieved by sitting down, leaning forwards and crouching down Clinical examination is often normal Requires MRI to confirm diagnosis

Answer 41

Spinal stenosis

Question 42

bone protection in long term steroids

Answer 42

T score Management Greater than 0 Reassure Between 0 and -1.5 Repeat bone density scan in 1-3 years Less than -1.5 Offer bone protection

Question 43

initially intermittent tingling in the 4th and 5th finger may be worse when the elbow is resting on a firm surface or flexed for extended periods later numbness in the 4th and 5th finger with associated weakness

Answer 43

Cubital tunnel syndrome Due to the compression of the ulnar nerve.

Question 44

chronic pain: at multiple site, sometimes 'pain all over' lethargy cognitive impairment: 'fibro fog' sleep disturbance, headaches, dizziness are common

Answer 44

fibromyalgia polymyalgia rheumatica presents similar but with fevers and weight loss

Question 45

low: calcium, phosphate raised: alkaline phosphatase

Answer 45

osteomalacia

Question 46

The classic laboratory finding is a raised creatinine kinase (CK) and the Anti-Jo-1 antibody

Answer 46

The hallmark of polymyositis is weakness and/or loss of muscle mass in the proximal musculature, and absent skin involvement. ``` proximal muscle weakness +/- tenderness Raynaud's respiratory muscle weakness interstitial lung disease: e.g. fibrosing alveolitis or organising pneumonia dysphagia, dysphonia ```

Question 47

anti ro

Answer 47

assw congenital heart block | assw SLE and sjogrens

Question 48

Osteoarthritis

Answer 48

- paracetamol + topical NSAIDs (if knee/hand) first-line

Question 49

Repeated cramping and myoglobinuria after short bouts of exercise

Answer 49

McArdle's disease Overview autosomal recessive type V glycogen storage disease caused by myophosphorylase deficiency this causes decreased muscle glycogenolysis ``` Features muscle pain and stiffness following exercise muscle cramps myoglobinuria low lactate levels during exercise ```

Question 50

Pseudoxanthoma elasticum

Answer 50

inherited condition (usually autosomal recessive*) characterised by an abnormality in elastic fibres Features retinal angioid streaks 'plucked chicken skin' appearance - small yellow papules on the neck, antecubital fossa and axillae cardiac: mitral valve prolapse, increased risk of ischaemic heart disease gastrointestinal haemorrhage

Question 51

negatively birefringent crystals in joint aspiration

Answer 51

gout

Question 52

Oral ulcers + genital ulcers + anterior uveitis

Answer 52

Behcet's ``` assw DVT aseptic meningitis arthritis abdo pain/diarrhoea/colitis erythema nodosum ```

Question 53

DIP involvement arthritis

Answer 53

psoriatic

Question 54

hydroxychloroquine SE

Answer 54

retinopathy

Question 55

bone pain, typically in the skull or proximal femur cutaneous nodules recurrent otitis media/mastoiditis tennis racket-shaped Birbeck granules on electromicroscopy

Answer 55

Langerhans cell histiocytosis is a rare condition associated with the abnormal proliferation of histiocytes. It typically presents in childhood with bony lesions.

Question 56

erythematous, raised rash, sometimes scaly may be photosensitive more common on face, neck, ears and scalp lesions heal with atrophy, scarring (may cause scarring alopecia), and pigmentation

Answer 56

Discoid lupus erythematosus benign disorder younger females. rarely progresses to systemic lupus erythematosus (in less than 5% of cases). Discoid lupus erythematosus is characterised by follicular keratin plugs and is thought to be autoimmune in aetiology Management topical steroid cream oral antimalarials may be used second-line e.g. hydroxychloroquine avoid sun exposure