Rheumatology

Question 1

lumps on fingers in osteoarthritis

Answer 1

Herbedens nodes = DIP joints

Bouchard’s nodes = PIP joints

Question 2

management of osteoarthritis:
1. Non-medical options (2)
2. Medical/surgical options

Answer 2

1. Weight loss (if overweight)
   Physiotherapy

2.Medical/surgical options
Analgesia (first line= paracetamol or topical NSAIDs)
Intra-articular steroid injections
joint replacement surgery

Question 3

antibodies associated with rheumatoid arthritis (2)

Answer 3

1. Anti-CCP antibodies- sensitivity 70%, specificity 90-95%
2. Rheumatoid Factor- sensitivity 70%, lower specificity

Question 4

Hand deformities associated with Rheumatoid Arthritis (4)

Answer 4

1. z-shaped deformity (thumb)
2. Swan-neck deformity
3. Boutonniere’s deformity
4. Ulnar deviation at the MCP joints

Question 5

Rheumatoid Arthritis:
1. investigations for synovitis
2. scoring system
3. First line options for management
4. Initial type of biologic

Answer 5

1. Ultrasound of joints
2. DAS28
3. Methotrexate, Leflunomide, Sulfasalazine
4. TNF inhibitor

Question 6

35yF with asymmetric pain and stiffness in the fingers, skin rash and nail changes
1. Diagnosis?
2. Nail changes?
3. Name for inflammation of an entire digit?
4. Screening tool?
5. most severe form with osteolysis and telescoping of the digits?

Answer 6

1. Psoriatic arthritis
2. Nail changes: nail pitting + oncholysis (separation of the nail from the nailbed)
3. Dactylitis
4. Psoriasis epidemiological screening tool (PEST)
5. Arthritis Mutilans

Question 7

42yM with knee pain and swelling two weeks after having gastroenteritis
1. Diagnosis?
2. Classic triad of features?
3. Associated gene?
4. most important differential?
5. most common triggers?
6. Investigation to exclude other causes?

Answer 7

1. Reactive arthritis
2. Arthritis + conjunctivitis + urethritis/balanitis
3. HLA B27
4. Septic Arthritis- would usually have a fever with this
5. Gastroenteritis and sexually transmitted infection (chlamydia)
6. Joint Aspiration

Question 8

Ankylosing spondylitis:
1. Associated gene ?
2. Main symptoms in the back?
3. Worse morning/evening or movement/rest?
4. Name the test
5. XRay findings in late disease?
6. MRI finding in early disease?

Answer 8

1. HLA B27
2. pain and stiffness
3. Worse in the morning, worse after rest
4. Schober’s test
5. Bamboo spine
6. Bone Marrow Oedema

Question 9

SLE:
1. presenting features can include (7)
2. Initial antibody test?
3. Specific antibody tests?
4. first line in mild disease?
5. biologic used in severe disease, targeting B cells?

Answer 9

1. malar rush which spares nasolabial folds and is worse with sunlight, hair loss, joint pain, splenomegaly, hair loss, SOB, lymphadenopathy, myalgia
2. initial antibody test= Anti nuclear antibodies
3. Specific antibody tests: Anti-Double stranded DNA + Anti-Smith
4. first line in mild disease= Hydroxychloroquine
5. Biologic used in severe disease= Rituximab

Question 10

30yF with skin lesions on her face and patches of hair loss. Symptoms are worse with sunlight

1. Diagnosis
2. diagnostic investigation?
3. Treatment options? (4)
4. Rarely lesions can become which cancer?

Answer 10

1. Discoid Lupus erythematous
2. Skin biopsy
3. management:
   1- sun protection
   2- topical steroids
   3- intralesion steroid injections
   4- hydroxychloroquine
4. Squamous Cell Carcinoma

Question 11

Reynaud’s phenomenon:
1. 3 stages of colour changes?
2. what % have an underlying disease?
3. most associated connective disease?
4. screening blood test for connective tissue disease?
5. test to examine the small blood vessels in the fingers?
6. medical management?

Answer 11

1. White -> blue -> red
2. 10-20%
3. associated connective tissue disease= Systemic sclerosis
4. screening blood test for connective tissue disease= Antinuclear Antibodies
5. Nailfold capillaroscopy
6. Prophylactic nifedipine

Question 12

CREST syndrome:
1. abbreviations?
2. which antibodies are checked initially in suspected connective tissue disease?
3. antibodies in limited cutaneous systemic sclerosis?
4. antibodies in diffuse cutaneous systemic sclerosis?

Answer 12

1. Calcinosis, Reynaud’s, Esophageal dysmotility, Sclerodactyly, Telangiectasia
2. Antinuclear antibodies (ANA) are checked initially in suspected connective tissue disease
3. anti-centromere antibodies= antibodies in limited cutaneous systemic sclerosis
4. anti-scl-70 antibodies= antibodies in diffuse cutaneous systemic sclerosis

Question 13

65yF with one month of shoulder and pelvic girdle pain and stiffness, worse in the morning
1. diagnosis?
2. abnormal blood tests?
3. treatment?
4. additional medications to protect against the side effects of treatment?

Answer 13

1. Polymyalgia rheumatica
2. Abnormal bloods: raised CRP, raised ESR, raised plasma viscosity
3. initial treatment= Prednisolone 15mg OD
4. additional medications to protect against the side effects of treatment:
   - bisphosphonates
   - calcium and vit D
   - proton pump inhibitors

Question 14

72yo with right sided temporal headache with scalp tenderness and aching in his jaw whilst chewing

1. Diagnosis
2. associated condition?
3. key complication?
4. key blood test?
5. definitive test?
6. initial treatment?

Answer 14

1. giant cell arteritis (temporal arteritis)
2. associated condition= polymyalgia rheumatica
3. key complication= loss of vision
4. key blood test= ESR (usually >50mm/hour)
5. definitive test= temporal artery biopsy
6. high dose prednisolone (40-60mg/day)

Question 15

52yF with pain and weakness in the thighs, shoulders and upper arms. There is a purplish rash on the eyelids
1. Diagnosis?
2. Rash on the hands?
3. Similar diagnosis without skin changes?
4. Initial blood test?
5. Antibodies (3)
6. definitive investigation?
7. What else to consider in new cases?
8. first line treatment?

Answer 15

1. dermatomyositis
2. Gottron lesions
3. Polymyositis
4. Creatine Kinase
5. Antibodies:
   Anti-jo-1 antibodies (polymyositis)
   anti-mi-2 antibodies (dermatomyositis)
   antinuclear antibodies
6. muscle biopsy
7. Possible underlying cancer
8. Corticosteroids

Question 16

Sjogren’s:
1. affected structures
2. may be secondary to? (2)
3. associated antibodies? (2)
4. test for dry eyes?
5. treatment to halt disease progression?

Answer 16

1. Exocrine glands
2. systemic lupus erythematous or rheumatoid arthritis
3. Antibodies: Anti-Ro, Anti-La
4. Schirmer test
5. Hydroxychloroquine

Question 17

Saddle-shaped nose, nose bleeds, sinusitis, cough/wheeze/haemoptysis, glomerulonephritis
1. Diagnosis
2. type of disease?
3. blood test for this type of disease?
4. general treatments? (2)

Answer 17

1. GPA (Wegener’s granulomatosis)
2. Vasculitis (small/medium-sized)
3. Anti-nuclear cytoplasm antibodies (ANCA)
4. general treatments: Steroids + immunosuppressants

Question 18

Behcet’s disease:
1. presentation
2. associated gene?
3. special test?
4. Disease pattern?
5. topical treatment for mouth ulcers?
6. other causes of mouth ulcers? (7)

Answer 18

1. recurrent episodes of oral and genital ulcers and episodes of knee pain and swelling
2. HLA B51
3. Pathergy test
4. relapsing-remitting disease pattern
5. Steroids (soluble betamethasone tablets)
6. other causes of mouth ulcers:
   simple aphthous ulcers (common)
   IBD (Crohn’s)
   Coeliac disease
   vitamin deficiency (B12, folate, iron)
   Herpes simplex virus
   hand, foot and mouth
   squamous cell carcinoma

Question 19

gout:
1. What blood test is raised?
2. what is seen on aspirated fluid?
3. first line for acute flare?
4. tx in renal impairment? main side effect?
5. prophylactic treatment?

Answer 19

1. uric acid is raised in gout
2. monosodium urate crystals (needle shaped) negatively biferingent of polarised light
3. NSAIDs are first line e.g. ibuprofen or naproxen
4. colchicine in renal impairment, main side effect is diarrhoea
5. prophylactic tx= Allopurinol

Question 20

70yo with a hot, swollen, stiff and painful knee

1. Diagnosis?
2. differential to exclude?
3. what is in the joint?
4. appearance of joint fluid microscopy?
5. first line medication?

Answer 20

1. Pseudogout
2. septic arthritis
3. calcium pyrophosphate crystals
4. rhomboid shaped crystals that are positively bifringent of polarised light
5. NSAIDs

Question 21

Osteoporosis:
1. risk assessment tool?
2. investigation?
3. T score for diagnosis?
4. guidelines for deciding whether to treat?
5. first-line treatment?
6. monoclonal antibody option?

Answer 21

1. FRAX tool
2. DEXA scan
3. < -2.5
4. NOGG guidelines
5. Bisphosphonates= first line. vitamin D and calcium supplementation should be offered to all women unless the clinician is confident they have adequate calcium intake and are vitamin D replete
6. Denosumab

Question 22

osteomalacia:
1. cause?
2. abnormal electrolytes?
3. abnormal liver test?
4. abnormal hormone?
5. treatment?

Answer 22

1. vitamin D deficiency
2. low serum calcium + low serum phosphate
3. raised ALP
4. raised parathyroid hormone (PTH)
5. treatment dose vitamin D

Question 23

68yM with bone pain, deformity, pathological fractures and hearing loss

1. Diagnosis
2. name for well-defined osteolytic lesions on XR?
3. classical skull XR?
4. key abnormal blood test?
5. main treatment?

Answer 23

1. Paget’s disease of the bome
2. Osteoporosis circumscripta
3. ‘cotton wool’ appearance
4. raised ALP
5. Bisphosphonates

Question 24

examples of medium vessel vasculitis

Answer 24

Buerger’s disease
Kawasaki disease
Polyarteritis nodosa

Question 25

examples of large vessel vasculitis

Answer 25

giant cell arteritis Takayasu's arteritis

Question 26

examples of small vessel vasculitis

Answer 26

Wegener's granulomatosis (GPA) Henoch-Schonlein Purpura Churg-Strauss disease

Question 27

what types of vasculitis present with skin findings?

Answer 27

medium and small vessel disease

Question 28

management of Buerger's disease

Answer 28

Management is with smoking cessation ± vasoactive medication (such as nifedipine). If there is critical ischaemia the patient requires hospital admission, vasoactive medication and debridement of gangrenous tissue.

Question 29

Trochanteric bursitis (greater trochanteric pain syndrome) 1. Presentation 2. Management

Answer 29

1. pain over lateral side of hip/thigh, tenderness of palpation of the greater trochanter 2. The management is mostly conservative and involves adequate analgesia. This may involve steroid injections. Physiotherapy is useful for stretching and strengthening exercises. Only as a last resort and in selected cases is bursectomy (removal of the inflamed bursa) considered.

Question 30

Ostemyelitis: 1. most likely causative organisms 2. imaging modality of choice 3. Management

Answer 30

1. Staph. aureus is the most common cause except in patients with sickle-cell anaemia where Salmonella species predominate 2. MRI is the imaging modality of choice, with a sensitivity of 90-100% 3. management: flucloxacillin for 6 weeks clindamycin if penicillin-allergic

Question 31

1. what are the seronegative spondyloarthropathies? 2. what antibody is associated with them?

Answer 31

1. ankylosing spondylitis, psoriatic arthritis, reactive arthritis, enteropathic arthritis (associated with IBD) 2. HLA B27