investigations and Management

Question 1

How would you investigate for RA?

Answer 1

• Bedside - None
• Bloods - FBC, LFTs, CRP, ESR, RF, Anti-CCP, ACPA
• O - none
• X - Chest X-ray, dorsopalmar x-ray, MRI, USS
• ECG
• S - synovial fluid analysis

Question 2

How would you manage RA?

Answer 2

• Physical actviity
• Acute flare - Steroids
• Remission - 2 DMARDS
  
  • Methorexate
  • Sulfasalzine
• Analgesia - NSAIDs + PPIs
• Biologic therapy

Question 3

How would you investigate suspected gout/pseudogout?

Answer 3

• Bedside
• B - Urate levels, FBC
• O - None
• X - USS, MRI, CT, X-ray
• E - No
• S - Arthocentesis

Question 5

How would you treat someone with gout?

Answer 5

Acute Gout

• NSAIDs
• Colchicine
• Steroids

Chronic Gout

• Treat hyperuricaemia if symptomatic
• Prevention measures

Question 6

What prophylaxic medications would you use for someone with gout?

Answer 6

Medications - >1 attack in 12 months

• Allopurinol
• Febuxostat
• Uricosuric drugs - increase excretion

Question 7

What is the treatment for pseudogout?

Answer 7

• NSAIDs
• I/A Steroids
• No prophylactic therapies

Question 8

How would you investigate for ankylosing spondylitis?

Answer 8

• Bedside - examination, slit lamp
• B - FBC, CRP, ESR, RF, HLA-B27
• O - none
• X - Spine X-ray, MRI
• ECG - no
• S - none

Question 9

How would you manage ankylosing spondylitis?

Answer 9

• Physical therapy
• NSAIDs
• TNF inhibitors
• Intrleukin 17A inhibitors
• Steroid injections

Question 10

What investigations would you consider doing for psoriatic arthritis?

Answer 10

• Bedside - examination
• Bloods - ESR, CRP, RF
• O
• X - x-rays
• ECG - no
• S - no

Question 12

How do you treat PsA?

Answer 12

• DMARDs - Sulfasalazine, Methotrexate, Leflunomide
• Cyclosporine
• Anti-TNF therapy
• Steroids
• Physio + OT
• Axial disease treated similar to AS

Question 13

What tests can be done in the context of suspected reactive arthritis?

Answer 13

• Bloods - ESR, CRP, Infectious serology
• Orifices - Stool culture, chlamydia swab
• X-Ray - look for enthisitis
• ECG - no
• Specific - no

Question 14

How would you treat Reactive Arthritis?

Answer 14

Acute

• NSAID
• Joint injection (if infection excluded)
• Antibiotics - chlamydia infection (contacts as well)

Chronic

• NSAID
• DMARDs

Question 15

How would you manage someone with Enteropathic Arthritis?

Answer 15

• Treatment of bowel disease - can improve arthropathy
• DMARDS - in resistant disease
• Steroids
• Anti-TNF

Question 16

What tests would you do when presented with symptoms associated with PMR?

Answer 16

No specific diagnostic test

Risk factors present - Age > 50, female

• Bloods - FBC, CRP, ESR, ALP, CK
• O - none
• X - none
• E - none
• S - none

Dramatic steroid response

Question 17

How would you manage someone with PMR?

Answer 17

• Prednisolone - 15mg/day - 18-24 months
  
  • Gastric and bone protection due to prolonged use

Question 18

How would you diagnose GCA?

Answer 18

• Bedside - nil
• B - ESR + CRP, ALP, FBC
• O - Nil
• X - Nil
• E - Nil
• S - temporal artery biopsy within 7 days

Diagnosis

• Temporal Artery Biopsy - within 7 days of starting steroids

Question 19

How would you treat someone with suspected GCA?

Answer 19

• High Dose Steroids - Prednisolone 60mg/day - immediately
  
  • Gastric and bone protection in prolonged use
• Low dose aspirin

Question 20

How would you investigate for lupus?

Answer 20

• Bedside
• B - FBC, U+E’s, CRP, ESR, ANA, Anti-dsDNA, Anti-Sm/ro/la, complement
• O - nil
• X - joint x-ray, USS kidney
• ECG - nil
• S - kidney biopsy

Question 21

How would you manage lupus?

Answer 21

• Avoid sun expoure
• Stop smoking
• Immunize
• Steroids +/- immunosuppresant - induce remission
• Hydroxychloroquine - maintain remission

Question 22

What investigations would you do if you suspected Sjogren’s?

Answer 22

• Bedside - urinalysis
• B - Ig, Anti-Ro, Anti-La, ANA, RF, ESR, CRP, FBC
• O - nil
• X - nil
• ECG - nil
• Specifc - Schirmers tear test, Slit lamp/Rose Bengal staining,Biopsy

Question 23

Which Antibodies are most commonly associated with Sjogren’s?

Answer 23

• Anti-Ro - 40%
• Anti-La - 26%
• ANA - 74%
• RF - 38%

Question 24

How wouldd you manage Sjogren’s?

Answer 24

• Treat Sicca - Artificial tears/saliva, frequent drinks, gland stimulation (pilocarpine or cevimeline)
• NSAIDS and Hydroxychloroquine - Arthralgia
• Immunosuppression - Severe disease

Question 25

How would you investigate someone with suspected polymyositis/dermatomyositis?

Answer 25

• B - CK, Aldolase, myoglobin, LDH, AST, ALT, ESR + CRP, ANA, AntiMi2, anti-Jo-1
• O - nil
• X - PET, MRI
• ECG - nil
• S - EMG, Biopsy

Question 26

How would you manage dermato/polymyositis?

Answer 26

• Prednisolone - drug of choice
• Immunosuppression if resistant
• Topical tacrolimus/ hydroxychloroquine for skin disease
• IVIG
• Plasmapheresis

SCREEN FOR MALIGNANCY

Question 27

What antibodies are associated with dermatomyositis?

Answer 27

• Anti-Mi2
• Anti-Jo1

Question 28

What antibodies are implicated in both dermatomyositis and polymyositis?

Answer 28

Anti-synthase antibodies

Question 29

What diseases can dermatomyositis be associated with, and what investigations would you consider doing to look for a cause?

Answer 29

Cancers:

• Imaging e.g. CXR, MRI/CT, Endoscopy etc.

Question 30

What Tests would you do if you suspected vasculitis?

Answer 30

• Bloods - ESR, CRP, FBC, U+E’s, LFTs, ANCA, ANA
• Urinalysis
• CXR
• Renal Biopsy