WCS82 + Rheumatology Teaching clinic

Question 1

Ddx for monoarthritis

Answer 1

Septic arthritis
Crystal arthritis
Hemarthrosis
OA
JIA
Coagulopathy
Avascular necrosis of the bone
Monoarticular presentation of polyarticular diseases (RA, JIA, viral, SpA, PsA)

Question 2

Polyarticular disease presenting with monoarticular onset sometimes

Answer 2

RA
JIA
Viral arthritis
Spondyloarthritis (reactive, psoriatic, IBD associated)

Question 3

What does a history of using steroids suggest the etiology of arthritis to be

Answer 3

infection

osteonecrosis

Question 4

What does a history of using anticoagulants or bleeding disorders suggest the etiology of arthritis to be

Answer 4

hemarthrosis

Question 5

What does a history of previous acute attacks of self limiting arthritis suggest the etiology of arthritis to be

Answer 5

crystal arthritis

inflammatory arthritis syndrome

Question 6

Indications for synovial fluid analysis

Answer 6

• suspect septic arthritis
• suspect crystal arthritis
• suspect hemarthrosis
• differentiate inflammatory from mechanical arthritis

Question 7

what do you send synovial fluid for

Answer 7

• gross examination (appearance, color, viscosity)
• microscopy (cell count, differential count, polarized light)
• microbiology (gram smear, culture, tb)

Question 8

negative and positive birefringence and shape of gout and pseudogout

Answer 8

gout needle shaped, negative birefringence (yellow)

pseudogout rhomboid shaped, positive birefringence (blue)

Question 9

arthroscopy use

Answer 9

diagnostic

• direct vision to articular surface for assessment of degree of cartilage damage
• synovial biopsy for equivocal cases

therapeutic

• debridement of damaged cartilage
• removal of loose bodies
• temporary pain relief

Question 10

most likely microoarganism for septic arthritis

Answer 10

gram positive

staphylococcus aureus

Question 11

route of infection for septic arthritis

Answer 11

1. hematogenous
2. osteomyelitis
3. adjacent soft tissue infection
4. iatrogenic
5. penetrating trauma

Question 12

risk factors for septic arthritis

Answer 12

• extremes of age
• chronic arthritic syndromes
• prosthetic joint
• intraarticular injection or arthrocentesis
• parenteral drug use
• sexual activity
• chronic systemic illness
• chronic skin infection

Question 13

Ix for septic arthritis

Answer 13

• synovial fluid aspiration
• blood for blood culture, CBC, ESR, CRP, electrolytes, LRFT
• septic workup (throat swab, nasal swab, urine, (stool))
• plain xray/ MRI

Question 14

3 stages of gout

Answer 14

• asymptomatic hyperuricemia
• acute gouty attack with intercritical gout
• chronic tophaceous gout

Question 15

where can tophi be found? what is implied if there is tophus

Answer 15

periarticular tissues, helix of ears, tendon sheaths, (larynx, tongue, heart)
imply gout is chronic

Question 16

radiological description of gout

Answer 16

punched out erosion (mouse bite erosion)

Question 17

Causes of hyperuricemia

Answer 17

• dietary excess
• overproduction of urate by cells
• • primary (idiopathic, HGPRT deficiency, hyperactive PRPP synthase)
• • secondary (myeloproliferative/lymphoproliferative disorders, hemolysis, psoriasis, glycogen storage diseases)
• underexcretion of urate by RENAL and gut
• • primary idiopathic
• • secondary (decreased renal function, metabolic acidosis, dehydration, diuretics, hypertension, hyperparathyroidism, drugs - salicylates, lead nephropathy)

Question 18

Acute gouty attack treatment

Answer 18

• oral indomethacin/ etoricoxib
• colchicine
• intraarticular steroid injection

Question 19

urate lowering therapy drugs

Answer 19

xanthine oxidase inhibitor
- allopurinol
- febuxostat
uricosuric agents
- probenecid
- sulphinpyrazone

Question 20

adverse drug reaction associated with allopurinol

Answer 20

SCAR severe cutaneous adverse reaction

• TEN toxic epidermal necrolysis
• vasculitis

Question 21

adverse drug reaction associated with probenecid

Answer 21

nephrotic syndrome

Question 22

adverse drug reaction associated with urate lowering therapy

Answer 22

• bm suppression
• hepatitis
• allopurinol - SCAR, vasculitis
• probenecid - nephrotic syndrome

Question 23

When should urate lowering therapy be considered

Answer 23

• Recurrent and troublesome acute attacks
• Evidence of tophi or chronic joint damage
• In the presence of renal disease
• The patient is young, the uric acid level is high, and
there is a family history of renal or heart disease
• Evidence of primary purine overproduction and
hyperexcretion

Question 24

common sites for chondrocalcinosis

Answer 24

knees, acetabulum, TFCC

Question 25

CPPD disease causes

Answer 25

primary - hereditary - sporadic secondary to metabolic disease - hyperparathyroidism - hypothyroidism - gout - hemachromatosis - ageing - hypomagnesemia - hypophosphatemia

Question 26

Causes of hemarthrosis

Answer 26

- trauma - anticoagulants - hemophilia

Question 27

3 steps p/e for bones and joints

Answer 27

look feel move

Question 28

Radiological findings of OA and RA

Answer 28

OA Loss - loss of joint space, osteophytes, subchondral cyst, subchondral sclerosis RA (in carpal bones, ulnar head, mcp, pip) Less - loss of joint space, erosion, soft tissue swelling, soft bones osteopenia

Question 29

OA treatment

Answer 29

Non pharma - lifestyle modification - physio - fluid aspiration pharma - NSAID/coxib (paracetamol if dm or renal impairment) - local injection of steroids and hyaluronic acid

Question 30

before injecting steroids to joint what must you exclude first

Answer 30

septic arthritis

Question 31

What infection gives reactive arthritis

Answer 31

- post-streptococcal | - Reiter's syndrome

Question 32

When should systemic treatment be considered over intraarticular injections Points to note in i/a injection (duration, technique)

Answer 32

Magic number 3 systemic treatment if >= 3 joints symptomatic at most 3 injections per joint per year, avoid reinjection within 3 months aseptic technique

Question 33

complications of i/a injection

Answer 33

- septic arthritis - microcrystal induced arthritis (steroids) - fat atrophy over site of injection - diabetic decompensation

Question 34

Polyarthritis in elderly with constitutional symptoms, RF and CCP negative first exclude:

Answer 34

paraneoplastic arthritis

Question 35

atlanto-axial subluxation suggests which arthritis

Answer 35

RA

Question 36

Blood test for RA

Answer 36

ESR, CRP, RF, antiCCP

Question 37

Views for Xray hands RA

Answer 37

AP view, Ball catching view

Question 38

Approach for interpreting hand xray ABCDs

Answer 38

Alignment Bone (Mineralization, periarticular osteopenia, osteophytes, erosions, fractures) Cartilage (joint spaces, calcifications) Distribution (pattern of involvement, symmetry) Soft tissues (swelling, calcifications)

Question 39

Views for xray knees

Answer 39

AP standing lateral skyview

Question 40

Clinical hand deformities in RA

Answer 40

- ulnar deviation of fingers with subluxation of mcp - boutonniere deformity - swanneck deformity - z deformity of the thumb

Question 41

Newly dx RA further investigations

Answer 41

- screening for DM, lipid - hep status - g6pd status - cxr, Lung function test - MSK USG, MRI

Question 42

USG hands views

Answer 42

transverse, longitudinal

Question 43

DMARDs for RA anchoring drug: other first line DMARDs: bridging agent

Answer 43

anchoring: MTX others: sulphasalazine, leflunomide, hydroxychloroquine bridging agent: prednisolone

Question 44

which DMARDs for RA are not compatible with pregnancy and which is compatible

Answer 44

mtx and leflunomide not compatible, hydroxychloroquine compatible

Question 45

Biologics for RA

Answer 45

- TNF antagonist - infliximab, etanercept, adalimumab, golimumab - B-cell inhibitors - rituximab - antiIL6 - tocilizumab - Tcell costimulation inhibitor - abatacept

Question 46

RA associated morbidities

Answer 46

- osteoporosis (RA and steroid induced) - CV risk (RA and NSAID) - lymphoma (RA and antiTNF) - infection (steroid) - GI and renal complications (NSAID)