Rheumatology

Question 1

Adhesive capsulitis frozen shoulder

what rotation is affected

Answer 1

external rotation is affected more than internal rotation or abduction
both active and passive movement is affected

Question 2

ANCA associated vasculitis

Answer 2

granulomatosis with polyangiitis
eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome)
microscopic polyangiitis

Question 3

Other features - the ‘A’s
Ankylosings sponditlitis

Answer 3

Apical fibrosis
Anterior uveitis
Aortic regurgitation
Achilles tendonitis
AV node block
Amyloidosis
and cauda equina syndrome
peripheral arthritis (25%, more common if female)

Question 4

Ankylosings sponditlitis investigation

Answer 4

Plain x-ray of the sacroiliac joints is the most useful investigation in establishing the diagnosis.

Question 5

Plain x-ray of the sacroiliac joints is the most useful investigation in establishing the diagnosis.

3S seen on scan

Answer 5

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 6

Avascular necrosis of the hip investigation of choice

Answer 6

MRI is the investigation of choice
it is more sensitive than radionuclide bone scanning

Question 7

compression of the ulnar nerve as it passes through the cubital tunnel. tingling and numbness of the 4th and 5th finger which starts off intermittent and then becomes constant.

Answer 7

Cubital tunnel syndrome

Question 8

pain on the radial side of the wrist
tenderness over the radial styloid process
abduction of the thumb against resistance is painful

Answer 8

De Quervain’s tenosynovitis

Question 9

De Quervain’s tenosynovitis effects

Answer 9

occurs when he extensor pollicis brevis and abductor pollicis longus tendons is inflamed.

Question 10

dirutics that cause gout

Answer 10

diuretics: thiazides, furosemide

Question 11

drugs causing gout other than dirutics

Answer 11

ciclosporin
alcohol
cytotoxic agents
pyrazinamide
aspirin: it was previously thought that only high-dose aspirin could precipitate gout.

Question 12

gout synovial fluid analysis

Answer 12

needle shaped negatively birefringent monosodium urate crystals under polarised light

Question 13

Hydroxychloroquine Adverse effect

Answer 13

bull’s eye retinopathy - may result in severe and permanent visual loss

Question 14

Marfan’s syndrome

caused by defect in

Answer 14

FBN1 gene on chromosome 15 that codes for the protein fibrillin-

Question 15

Methotrexate adverse effects

Answer 15

mucositis
myelosuppression
pneumonitis
the most common pulmonary manifestation
similar disease pattern to hypersensitivity pneumonitis secondary to inhaled organic antigens
typically develops within a year of starting treatment, either acutely or subacutely
presents with non-productive cough, dyspnoea, malaise, fever
pulmonary fibrosis
liver fibrosis

Question 16

OA Xray

Answer 16

X-ray: radiologically there are osteophytes and joint space narrowing. Often signs may be visible on X-ray, before symptoms develop

Question 17

presents in childhood
fractures following minor trauma
blue sclera
deafness secondary to otosclerosis
dental imperfections are common

Answer 17

Osteogenesis imperfecta

adjusted calcium, phosphate, parathyroid hormone and ALP results are usually normal in osteogenesis imperfecta

Question 18

most common organism in Osteomyelitis

Answer 18

Staph. aureus is the most common cause except in patients with sickle-cell anaemia where Salmonella species predominate

Question 19

dexa scan

Answer 19

T score
> -1.0 = normal
-1.0 to -2.5 = osteopaenia
< -2.5 = osteoporosis

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 20

joint aspiration: weakly-positively birefringent rhomboid-shaped crystals

Answer 20

Pseudogout

Question 21

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

Answer 21

Pseudoxanthoma elasticum

Question 22

RA Preganncy safe drugs

Answer 22

sulfasalazine and hydroxychloroquine are considered safe in pregnancy

Question 23

late features of rheumatoid arthritis and unlikely to be present in a recently diagnosed patient.

Answer 23

Swan neck and boutonniere deformities

Question 24

Rheumatoid arthritis: prognostic features

Answer 24

Poor prognostic features
rheumatoid factor positive
anti-CCP antibodies
poor functional status at presentation
X-ray: early erosions (e.g. after < 2 years)
extra articular features e.g. nodules
HLA DR4
insidious onset

Question 25

Early x-ray findings RA

Answer 25

loss of joint space juxta-articular osteoporosis soft-tissue swelling periarticular erosions subluxation

Question 26

most common organism for septic arthtiris

Answer 26

most common organism overall is Staphylococcus aureus he BNF currently recommends flucloxacillin or clindamycin if penicillin allergic antibiotic treatment is normally be given for several weeks (BNF states 4-6 weeks)

Question 27

Sjogren's syndrome think dry

Answer 27

dry eyes: keratoconjunctivitis sicca dry mouth vaginal dryness arthralgia Raynaud's, myalgia sensory polyneuropathy recurrent episodes of parotitis renal tubular acidosis (usually subclinical)

Question 28

Features arthralgia elevated serum ferritin rash: salmon-pink, maculopapular pyrexia

Answer 28

Still's disease in adults

Question 29

the treatment of choice for SLE

Answer 29

Hydroxychloroquine

Question 30

temporal artery biopsy in temporal arteritis

Answer 30

skip lesions may be present

Question 31

Ehler-Danlos syndrome is an autosomal dominant connective tissue disorder that mostly affects

Answer 31

type III collagen. This results in the tissue being more elastic than normal leading to joint hypermobility and increased elasticity of the skin.

Question 32

repeated cramping, rhabdomylisus, myoglobinuri AFTER SHORT bouts of excercise

Answer 32

McArdle's disease autosomal recessive type V glycogen storage disease

Question 33

Azathioprine - check what befpre STARTTING

Answer 33

Azathioprine - check thiopurine methyltransferase deficiency (TPMT) before treatment

Question 34

Bone pain, tenderness and proximal myopathy (→ waddling gait)

Answer 34

osteomalacia bloods low vitamin D levels low calcium, phosphate (in around 30%) raised alkaline phosphatase (in 95-100% of patients)

Question 35

Bisphosphonates inhibit

Answer 35

Bisphosphonates inhibit osteoclasts

Question 36

What organism is most likely to be present in the fluid IN REACTIVE ARTHTIRIS

Answer 36

Reactive arthritis: develops after an infection where the organism cannot be recovered from the joint

Question 37

feature of ankylosing spondylitis more recognised as a feature

Answer 37

Syndesmophytes (ossification of outer fibres of annulus fibrosus) are a feature of ankylosing spondylitis

Question 38

EYE SYMPTOM IN marfans

Answer 38

=upwards lens dislocation (superotemporal ectopia lentis) blue sclera myopia

Question 39

Repeated cramping, rhabdomyolysis and myoglobinuria after short bouts of exercise can point towards

Answer 39

Repeated cramping, rhabdomyolysis and myoglobinuria after short bouts of exercise can point towards McArdle's diseas

Question 40

Denosumab

Answer 40

Denosumab - RANKL inhibitor

Question 41

cANCA pANCA

Answer 41

cANCA = granulomatosis with polyangiitis; pANCA = eosinophilic granulomatosis with polyangiitis + others The major target for pANCA is myeloperoxidase (MPO)