1. MSK Rheum

Question 1

Pattern of joint involvement in RA:

Answer 1

Hands and feet
Sparing of the DIPs
Larger joint involvement as it progresses

Question 2

Classic signs and symptoms of RA:

Answer 2

Swollen painful joints in hands and feet
Stiffness worse in the morning
Bilateral symptoms

Question 3

25% of patients have ocular manifestations of RA, what are they?

Answer 3

Keratoconjunctivitis sicca
Episcleritis (just erythema)
Scleritis (erythema and pain)
Corneal ulceration
Keratitis

Iatrogenic
Chloroquine retinopathy
Steroid-induced cataracts

Question 4

Investigations for RA:

Answer 4

Rheumatoid Factor
Anti-CCP
ESR and CRP
XR of hands and feet

Question 5

Poor prognostic factors in RA:

Answer 5

RF +ve
Anti-CCP +ve
Poor functional status at presentation
XR showing early erosions
Extra-articular features e.g. nodules
HLA-DR4
Insidious onset

Question 6

Diagnosis of RA:

Answer 6

ACR criteria:
Target population is definite clinical synovitis, without a more fitting diagnosis.

Adding category scores, needs 6/10 to qualify.

Categories are joint involvement, serology, acute phase reactants and duration of symptoms >/<6wks.

Question 7

Monitoring of RA:

Answer 7

CRP and DAS28 score

Question 8

First line management RA:

Answer 8

Monotherapy with DMARD e.g. MTX, leflunomide, sulfasalazine
+ short term bridging treatment with prednisolone

Hydroxychloroquine for mild or palindromic RA.

Question 9

Treatment of RA flare:

Answer 9

intra-articular glucocorticoid injection, or oral
+ ?NSAIDs

Question 10

Second line management of RA, if combinations of DMARDs have been tried:

Answer 10

Biologic drugs:
TNF-alpha inhibitors e.g. infliximab
Rituximab

Question 11

Hydroxychloroquine action and side effects:

Answer 11

Inhibits TLRs

Bull’s eye retinopathy - severe permanent visual loss. More common than previously thought.
+ GI disturbances etc.

Question 12

Methotrexate action and side effects:

Answer 12

Anti-folate mechanism - must take folate too.

Mucositis, pulmonary fibrosis, liver fibrosis, pneumonitis and myelosuppression.

Question 13

Sulfasalazine action and side effects:

Answer 13

Unclear mechanism

Arthralgia, cough, diarrhoea, dizziness, fever, GI discomfort, headache, leucopenia, skin reactions, vomiting

Question 14

Contraindications to methotrexate:

Answer 14

Pregnancy

Trimethoprim or co-trimoxazole - marrow aplasia

High dose aspirin increases risk of toxicity due to decreased excretion

Question 15

Environmental factors in RA (3:)

Answer 15

Smoking
Infection
Hormonal - female sex

Question 16

Extra-articular complications of RA (minus ocular and respiratory):

Answer 16

osteoporosis
ischaemic heart disease
increased infection risk
depression

Rare = Felty’s syndrome (RA + splenomegaly + low wcc) and amyloidosis

Question 17

Respiratory complications of RA:

Answer 17

Pulmonary fibrosis
Pleural effusions
Pulmonary nodules
Bronchiolitis obliterans
MTX pneumonitis
Pleurisy

Question 18

What are the 4 seronegative arthritides?

Answer 18

Psoriatic arthritis
Ankylosing spondylitis
Enteropathic arthritis
Reactive arthritis

Question 19

Define seronegative spondyloarthropathy:

Answer 19

Disease involving the axial skeleton, expressing a variety of extra-skeletal signs and symptoms.