Rheumatology

Question 1

X ray findings of osteoarthritis

Answer 1

Loss of joint space

Osteophytes formation

Subchondral cysts

Subchondral sclerosis

Question 2

Heberdens and Bouchard nodes, what and where

Answer 2

Osteoarthritic signs
Bouchard is PIP inflamation
Heberdens is DIP inflamation

Question 3

What is the difference in the joints affected by rheumatoid vs osteoarthritis

Answer 3

Osteoarthritis affects large weight bearing joints, and in the hand often CMC and DIP. Often asymmetrical

Rheumatoid is symmetrical and can affect smaller joints. SPARES DIP CLASSICALLY

Question 4

How does pain and stiffness differ after resting (e.g in the morning) in RA vs OA

Answer 4

In RA, it can last over 30 mins, and is worse after rest
In OA, it usually lasts less after rest and is worse after use (e.g a long day)

Question 5

Joints affected more commonly in RA

Answer 5

Smaller: wrist, ankle MCP and PIP

DIPs are SPARED in RA!

Question 6

Associated symptoms of RA

Answer 6

Fatigue, weight loss, flu like illness and muscle aches

Question 7

Serology for RA and what is better

Answer 7

Rheumatoid factor: 70% of RA patients have

Anti CCP- more sensitive and more specifc

Check for CRP and ESR also

Question 8

What scores can be used to monitor RA

Answer 8

DAS28 and HAQ

Question 9

What features are poor prognostic indicators in RA

Answer 9

Younger onset,
Male
More joints affected
Seropositive for RF and anti CCP

Question 10

What is 1,2 and 3rd line mx of RA

Answer 10

1- DMARD alone e.g methotrexate,sulfasalazine or hydroxychloroquine (hydroxy is mildest)
2- 2 DMARD combined
3- Methotrexate + biological- TNF inhibitor

Question 11

Give two examples of anti-TNF drugs

Answer 11

Infliximab and adalimumab

Question 12

Side effect profile of methotrexate

Answer 12

Mouth ulcers and mucocitis
Liver toxicity
Myelosuppressipn leading to leukopenia
Teratogenic

Question 13

Side effect of sulfasalazine

Answer 13

Male infertility

Question 14

Side effects of anti TNF drugs

Answer 14

Vulnerable to infection
Reactivation of TB and Hep B

Question 15

What percentage of people with psoriasis get psoriatic arthritis

Answer 15

10-20%

Question 16

Signs of psoriatic arthritis

Answer 16

Nail pitting
Oncholysis - separation of nail from nail bed
Dactylisis - full inflamation of digit
Enthesitis- inflamation of enthuses, where tendon inserts on bone

Question 17

What are the most common causes of reactive arthritis

Answer 17

Chlamydia and gonorrhoea

Question 18

What are the associations seen in reactive arthritis

Answer 18

Can’t see, can’t pee can’t climb a tree

Anterior uveitis
Bilateral conjunctivitis
Circinate balantis

Question 19

What joints does ankylosimg spondylitis affect

Answer 19

Vertebrae and sacroiliac joints

Question 20

What percentage of people with AS have the HLA-b27 gene

Answer 20

90%

Question 21

Investigations for AS

Answer 21

Baseline bloods
ESR and CRP
HLA-B27 genetic test
X ray of spine - shows bamboo spine due to fusion of vertabra

Question 22

Common associations with AS

Answer 22

Chest pain
Enthesitis - leads to Achilles tendinitis and plantar fasciitis
Ant uveitis
Heart block
IBD

Question 23

What test is used for spinal mobility and AS

Answer 23

Schobers test:
Find L5 and mark 10cm above and 5 below
Ask patient to touch toes, and if distance between marks is less than 20cm, suggests lumbar restriction

Question 24

Auto antibodies seen in SLE

Answer 24

ANA (more detail)
Anti double stranded DNA

Anti smith antibodies (type of extractable nuclear antigen)

Question 25

First line treatment for mild SLE

Answer 25

Hydroxychloroquinine and NSAID

Question 26

Clinical picture of giant cell arteritis

Answer 26

Sever unilateral headache Scalp tenderness Jaw claudication Blurred or double vision

Question 27

How to diagnose giant cell arteritis

Answer 27

Clinical features present (headache, scalp tenderness and jaw claudication) Raised ESR (>50mm/hr) Temporal artery biopsy

Question 28

What is found on temporal artery biopsy for GCA

Answer 28

Multinuckeated giant cells

Question 29

Initial mx of GCA

Answer 29

High dose steroids - pred 30-60mg per day

Question 30

What antibodies are seen in sjogrens

Answer 30

Anti-Ro and Anti-la

Question 31

What test can be used to check for sjogrens

Answer 31

Shirmer test- folded filter paper under eyelid Tears should travel at least 15 mm, <10mm is significant

Question 32

What does the FRAX tool tell us

Answer 32

Probability of fragility fracture over the next ten years

Question 33

What scores do we use from DEXA scan, and what is significant

Answer 33

T scores More than -1 is normal -1 to -2 is osteopenia Less than -2.5 is osteoperosis Less than -2.5 with a fracture is sever osteoperosis

Question 34

First line treatment for osteoperosis

Answer 34

Bisphosphonates- aledondric acid 70mg once a week oral

Question 35

What is denosumab and what is it used for

Answer 35

MAB to osteoclasts, prevents bone resorption

Question 36

Side effects of bisphosphonates

Answer 36

Reflux and oesophageal erosion- take on empty stomach and sit up for 30 minutes Atypical fractures Osteonecrosis of jaw

Question 37

What condition js linked with polymalgia rheumatics

Answer 37

Giant cell arteritis

Question 38

Clinical picture of polymalgia rheumatica

Answer 38

Bilateral shoulder pain that radiates to elbow Bilateral pelvic girdle pain Stiffness that lasts for more than 45 minutes in the morning Interferes with sleep

Question 39

What is the initial treatment for poly myalgia rheumatica

Answer 39

15mg prednisolone per day and review after 1 week and 3/4 weeks

Question 40

ANA and anti-dsDNA- for sle what is more specific and what is more sensitive What does this mean

Answer 40

ANA is the most sensitive and shoukd be used first: if positive then they almost definitely have sle Anti-dsDNA is the most specific. Anyone who is negative does have it

Question 41

what anti bodies are found in drug induced lupus

Answer 41

ana and anti histome antibodies positive

Question 42

Common causes of drug induced lupus

Answer 42

Procainmide Hydralazime Isonisiaz Phenytoin

Question 43

Diffused systemic sclerosis Features Antibodies

Answer 43

Scleroderma of trunk and proximal limbs ILD and pulmonary hypertension ED Had anti scl-70 antibodies

Question 44

Limited systemic sclerosis/ CREST Features Antibodies

Answer 44

Raynauds Scleroderma of face and and distal limbs anti centromere antibodies

Question 45

What is CREST

Answer 45

Calcinosis Raynauds Oesophageal dysmotility Sclerodactly Telangestacis

Question 46

Unilateral or bilateral psoriatic arthritis and ra

Answer 46

Ra is symmetrical psoriatic not

Question 47

Risk factors for septic arthritis

Answer 47

Age Immunosuppressive Prosthetic joint Joint instrumentation (injections or arthroscopy) Underlying joint damage already Transient bacterial is

Question 48

Ix for septic arthritis

Answer 48

Bloods; baseline FBC, u and e for AKI, CRP and ESR whic will be raised for inflamation. Clotting screen for haemarthrosis and serum Uris acid to assess for gout. Blood culture Plain x ray Joint aspiration is gold standard- should be done before abx given

Question 49

Joint aspiration in septic arthritis findings

Answer 49

Cell count - WCC >50000 is worrying Gram stain Culture Polarised light microscopy

Question 50

Gram positive cocci in clusters suggests what on joint aspirate

Answer 50

Septic arthritis due to s aureus

Question 51

What criteria is used for a hot joint

Answer 51

Kosher criteria Fever over 38 Non weight bearing Raised ESR Raised WCC

Question 52

Managment of septic arthritis

Answer 52

Conservative - analgesia and splinting Medical - IV flucloxacillin for two weeks followed by oral for 2-4 weeks Joint wash out

Question 53

What to do if a prosthetic joint is thought to be septic

Answer 53

Must be aspirated by an ortho surgeon