Rheumatology

Question 1

What is the ideal first line treatment of inflammatory arthritis?

Answer 1

DMARD therapy within 3 months of symptom onset

Question 2

What are the indications for methotrexate?

Answer 2

Rheumatoid arthritis
Psoriatic arthritis
Connective tissue diseases
Vasculitis

Question 3

What are the adverse effects of methotrexate?

Answer 3

Leucopaenia/thrombocytopaenia
Hepatitis/cirrhosis
Pneumonitis
Rash
Mouth ulcers
Nausea/diarrhoea
Teratogenic

Question 4

What precautions should be taken when someone is on methotrexate?

Answer 4

Limit alcohol intake
Monitor FBC and LFTs

Question 5

What are the side effects of sulfasalazine?

Answer 5

Nausea
Rash
Mouth ulcers
Neutropaenia
Hepatitis
Reduced sperm count

Question 6

What precautions should be taken whem someone is on sulfasalazine?

Answer 6

Monitor FBCs and LFTs

Question 7

When is hydroxychloroquine used?

Answer 7

Connective tissue disorders
Rheumatoid arthritis

Question 8

What is the key side effect of hydroxychloroquine?

Answer 8

Rarely causes retinopathy

Question 9

What are the criteria for starting an RA patient on biologic?

Answer 9

High disease activity score
Not treated with 2 DMARDs

Question 10

What are the adverse effects of biologics?

Answer 10

Increased risk of infection (especially TB)

Question 11

What is the treatment for an acute episode of gout?

Answer 11

Colchicine
NSAIDs
Steroids

Question 12

Which urate lowering drugs are used in the prophylaxis of gout?

Answer 12

Allopurinol
Febuxostat
Uricosurics

Question 13

What are the adverse effects of allopurinol?

Answer 13

Rash (vasculitis)
Azothioprine interaction
Rarely marrow aplasia

Question 13

What are the adverse effects of allopurinol?

Answer 13

Rash (vasculitis)
Azothioprine interaction
Rarely marrow aplasia

Question 14

What are the risk factors for rheumatoid arthritis?

Answer 14

Female
Family history (HLA-DR4 mediated)
Triggers
- Infection
- Stress
- Cigarette smoking

Question 15

What is the clinical presentation of rheumatoid arthritis?

Answer 15

Symmetrical pain and swelling in peripheral synovial joints
Early morning stiffness lasting longer than 60 mins
Positive pressure test
Trigger finger
Carpal tunnel syndrome
Palindromic rheumatism
Poor grip strength

Question 16

What is the management of rheumatoid arthritis?

Answer 16

START DMARD THERAPY WITHIN 3 MONTHS OF SYMPTOM ONSET
Care by rheumatologist
NSAIDs and steroids as adjuncts
Stop smoking
Osteoporosis screening
Immunisations

Question 17

What are the risk factors for osteoarthritis?

Answer 17

Genetic
Age
Female
Obesity
Biomechanical

Question 18

What qualifies as generalised osteoarthritis?

Answer 18

Either spinal or hand plus 2 other regions

Question 19

What are the symptoms of osteoarthritis?

Answer 19

Pain made worse with activity
Morning stiffness lasting less than 60 mins
Inactivity gelling
Joint instability
Poor grip if thumb affected
Pain in hip OA may radiate to the knee or groin or from the lower back

Question 20

What are the signs in osteoarthritis?

Answer 20

Joint line tenderness
Crepitus
Joint effusion
Bony swelling
Deformity
Limited motion
Heberden’s and Bouchard’s nodes
Knee OA:
- Varus and valgus deformities
- Baker’s cysts (outpouching in popliteal fossa)

Question 21

What is the difference between Heberden’s and Bouchard’s nodes?

Answer 21

Heberden’s nodes affect the DIPs and Bouchard’s nodes affect the PIPs

Question 22

What are the signs of osteoarthritis on an x-ray?

Answer 22

Marginal osteophytes
Joint space narrowing
Subchondral sclerosis
Subchondral cysts

Question 23

What is the management of osteoarthritis?

Answer 23

Lifestyle changes
Physiotherapy
Occupational therapy
Analgaesia
Steroid injections
Joint replacement

Question 24

Who is typically affected by gout?

Answer 24

Males more than females Post-menopausal in females Age 20-80

Question 25

What are the clinical features of acute gout?

Answer 25

Usually monoarthropathy Settles in 10 days without treatment Abrupt onset (overnight) May have normal uric acid

Question 26

What are the clinical features of chronic tophaceous gout?

Answer 26

Chronic joint inflammation Often associated with diuretic use High serum uric acid Tophi May get acute attacks

Question 27

What investigations would you run if you suspected gout?

Answer 27

Serum uric acid (elevated) Inflammatory markers (elevated) Polarised microscopy of synovial fluid Renal investigations X-rays

Question 28

What is the treatment for acute gout?

Answer 28

NSAIDs Colchicine Steroids

Question 29

What are the methods of preventing future episodes of acute gout?

Answer 29

Xanthine oxidase inhibitors - Allopurinol - Febuxostat Urosuric drugs - Sulfinpyrazone - Probenecid - Benzbomarone Start 1 week after an acute attack Lifestyle modifications

Question 30

What is the treatment for pseudogout?

Answer 30

NSAIDs Colchicine Steroids Rehydration

Question 31

What are the risk factors for SLE?

Answer 31

Female Chinese and black ethnicity Childbearing age Can be triggered by an infection

Question 32

Which auto antibodies would you test for if you suspected SLE?

Answer 32

ANA (positive MAY suggest SLE) Anti-dsDNA (elevated) APLS Complement (low) Anti-Ro Anti-Sm

Question 33

What is the treatment for SLE?

Answer 33

Vaccines Sun protection Hydroxychloroquine in all patients Short steroid courses in flare ups Imunosuppression

Question 34

What are the key features of an inflammatory spondyloarthropathy?

Answer 34

Worse with rest/better with activity Early morning stiffness for more than 30 mins

Question 35

What are the key features of a mechanical spondyloarthropathy?

Answer 35

Worse with activity/better with rest Worse in the evening

Question 36

What is the typical presentation of ankylosing spondylitis?

Answer 36

Affects men more than women Age 20-30 Morning joint or back stiffness Back or buttock pain that improves with activity Back or joint pain at night that wakes patient up Positive Schober's test Thoracic kyphosis and hyperextension of neck