Rheumatology

Question 1

What is the pathology of RA?

Answer 1

synovitis, thickened synovial lining, infiltration by inflammatory cells and generation of new blood vessels

Question 2

RF for RA?

Answer 2

women, family history, HLA-DR4 (genetics)

Question 3

X ray features for RA?

Answer 3

LESS - 
LOSS of joint space
EROSIONS
SOFT tissue swelling
SOFT bones (osteopenia)

Question 4

Hand signs of RA?

Answer 4

ulnar deviation, swan neck deformity, boutonierre deformity

Question 5

Features of RA?

Answer 5

symettrical polyarthritis (typically affects the small joints of hands and feet.)

• morning stiffness >30 minutes
• as deteriorates, larger joints get involved
• positive MCP squeeze test
• weakened joint capsules - deformities, unstable joints, subluxation

Question 6

Name some non articular manifestations of RA?

Answer 6

SYSTEMIC - fever, fatigue, weight loss
EYES - sjogrens, scleritis, episcleritis
NEURO - carpel tunnel, cord compression, polyneuropathy
HAEM - lymphadenopathy, splenomegaly, anaemia
PULM - effusion, fibrosis, nodules
HEART - pericarditis, effusion

Question 7

Ix for RA?

Answer 7

Bloods - FBC/UE/CRP/ESR
ABs - anti CCP/RF antibodies
Xray the affected joints
synovial fluid sample

Question 8

Which antibodies are positive in RA?

Answer 8

RF, anti-CCP

Question 9

Name some poor prognostic RA factors?

Answer 9

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

Question 10

How do you manage RA? give a few treatments?

Answer 10

NSAIDS - reduce pain and stiffness
Paracetamol - pain
Steroids - reduce disease activity. Systemic vs injection
DMARDS - inhibit inflammatory cytokines e.g. synlfasalazine Methotrexate
Biological DMARD - TNFa inhibitor e.g. Infliximab

Question 11

List some side effects of commonly used RA drugs

NSAIDS/prednisolone/methotrexate

Answer 11

NSAIDS - bronchospasm in asthmatics, peptic ulcers, dyspepsia
Prednisolone - cushingoid, osteoporosis, HTN, impaired glucose tolerance
Methotrexate - myelosuppression, liver cirrhosis, pneumonitis

Question 12

Features of ankylosing spondylitis? who is the patient group most commonly affected?

Answer 12

pain and stiffnesss in lower back/buttocks. Pain improves with exercise and there is progressive reduced spinal movement

Commonly affects young men (early 20s)

Question 13

What do you find on examination with a patient with ankylosing spondylitis?

Answer 13

reduced lordosis and increased kyphosis, reduced L spine mobility and reduced spine flexion, chest does not expand as well

Question 14

Ix for ankylosing spondylitis?

Answer 14

Increased ESR/CRP levels
X ray - erosions and sclerosis
MRI - sacroilitis
HLAB27 testing

Question 15

Mx for ankylosing spondylitis?

Answer 15

exercises in the morning for mobility and posture
NSAIDs
TNFa blocking drugs/methotrexate

Question 16

Name some seronegative spondyloarthropathies?

Answer 16

ankylosing sponydilitis
psoriatic arthritis
reactive arthritis
enteropathic arthritis (Chrons/UC)

Question 17

Features of psoriatic arthritis?

Answer 17

asymetrical affect on small DIP hand joints
arthritis mutilans
sacroiliitis
dactylitis

Question 18

Ix for psoriatic arthritis?

Answer 18

routine bloods/ESR

X-ray - pencil cup deformity

Question 19

Mx of psoriatic arthritis

Answer 19

analgesia, NSAIDS, IA corticosteroids, methotrexate

Question 20

What infections can cause reactive arthritis?

Answer 20

GI - shigella, salmonella, campylobacter

STI - chlamydia

Question 21

Features of reactive arthritis?

Answer 21

typically affects knees/ankles/feet
CIRCINATE BALANITIS RASH
acute anterior uveitis
plantar fasciitis

Question 22

What is reiters syndrome?

Answer 22

urethritis, reactive arthritis, conjunctivitis

Question 23

Ix of reactive arthritis?

Answer 23

clinical diagnosis

synovial fluid aspirate - sterile, high neutrophils

Question 24

Mx of reactive arthritis?

Answer 24

NSAIDS, local corticosteroid injections

Question 25

What is enteropathic arthritis?

Answer 25

large joint asymmetrical oligoarthritis occuring in patients with UC/CD. parrallels the activity of the IBD.

Question 26

What sort of crystals are in joints with gout?

Answer 26

intra-articular sodiium urate crystals (due to hyperuricaemia)

Question 27

Causes of hyperuricaemia?

Answer 27

reduced excretion - CKD/thiazide diuretics/HTN | increased production - high purine turnover/polycythemia/leukaemia

Question 28

Features of gout?

Answer 28

commonly affects MTP joint in big toe. Significant pain, swelling, erythema.

Question 29

Precipitating factors for an attack of gout?

Answer 29

diet/alcohol/thiazide diuretic/dehydration

Question 30

Ix for gout?

Answer 30

joint fluid microscopy - long needle shaped crystals (-ve bifringent under polarised light) X ray - joint effusion, punched out erosions Serum uric acid raised

Question 31

Acute management of gout?

Answer 31

NSAIDS, colchicine (SE = diarrhoea), IA corticosteroids

Question 32

Chronic management of gout?

Answer 32

``` allopurinol (xanthine oxidase inhibitor) low purine diet stop thiazide diuretics reduce alcohol reduce weight ```

Question 33

What antibodies are positive in SLE?

Answer 33

ANA, dsDNA

Question 34

Blood results in SLE?

Answer 34

FBC (anaemia), UE, Cr, raised ESR, normal SLE, low C3 and C4. Positive ANA and dsDNA antibodies IgG deposition in kidneys

Question 35

Multisystem features of SLE

Answer 35

MSK - arthralgia/myalgia GENERAL - tired, fever, depressed, weight loss SKIN - butterfly rash, vasculitis, alopocia, UV sensitivity BLOOD - anaemia, leucopenia, thrombocytopenia LUNGS - pleural effusions HEART - pericarditis, myocarditis KIDNEYS - glomerulonephritis

Question 36

Mx of SLE?

Answer 36

``` NSAIDS, chloriquine/hydroxychloroquine corticosteroids immunosuppressant - azathioprine rituximab (anti - CD20) ```

Question 37

Features of antiphospholipid syndrome?

Answer 37

thrombosis, recurrent miscarriages Arteries - TIA/stroke/MI Placenta - recurrent miscarriages Other - migraine, thrombocytopenia, renal impairment, accelerated atheroma

Question 38

Mx of antiphospholipid syndrome?

Answer 38

lifelong anti-coagulation

Question 39

What causes systemic sclerosis?

Answer 39

autoimmune activation, proliferation of fibroblasts and production of connective tissue = thickened vascular walls

Question 40

Features of systemic sclerosis?

Answer 40

CREST SYNDROME | calcinosis, raynauds, oesophagus, sclerodactyl, telangiectasia

Question 41

What is polymyositis?

Answer 41

inflammation and necrosis of skeletal muscle fibres

Question 42

Features of polymyositis?

Answer 42

symmetrical progressive weakness, muscle wasting of proximal muscles, difficulty squatting, NO pain

Question 43

Ix for polymyoisitis?

Answer 43

muscle biopsy = shows muscle inflammation and necrosis increased CK, ESR normal Positive anti JO abs MRI

Question 44

Mx of polymyositis?

Answer 44

prednisolone

Question 45

Features of polymyalgia rheumatica?

Answer 45

Pt with GCA. Abrupt stiffness and pain in the neck and shoulder muscles. malaise/fever/weight loss. AION