Misc Flashcards
Where do patients with osteoarthritis of the hip most commonly report pain?
Groin
Diabetic neuropathic arthropathy is most likely to affect which of the following areas?
A. Knee. B. Mid-foot. C. 1st metatarsophalangeal joint D. Elbow. E. Ankle.
B is the correct answer
Best indicator of future erosive joint disease in RA
A. swollen joint count
B. tender joint count
C. weight loss
D. CRP
Answer is D
Difference between inclusion body myositis and polymyositis
a) bilateral ptosis
b) weak long finger flexors
c) weak deltoids
d) weak quadriceps
e) truncal weakness
Answer is B
M>F
Distal then proximal
There may be weakness of the wrist and finger muscles & atrophy of the quadricep muscles
• Atrophy or shrinking of the forearms is characteristic
• Dysphagia occurs in approximately 50% of IBM cases
Anti-synthetase syndrome
Anti-Jo
Raynauds
Speckled ANA
Lung disease
Severity and type of pulmonary involvement determines outcome of disease
• Prednisone + steroid sparing agents (eg azathioprine or methotrexate) used for treatment of myositis, efficacy not substantiated in RCT
• In the case of severe pulmonary involvement pulse IV cyclophosphamide recommended
Patient with well-managed rheumatoid arthritis (on methotrexate and statin), presents for review, describing increasing lethargy. Nil evidence of active joint inflammation – oral ulcers on examination. Bloods show pancytopenia. Drug of choice?
- Folic acid
- Folinic acid
- Cholestyramine
- GCSF
Answer is folinic acid.
It is readily converted to other reducedfolicacid derivatives (e.g. tetrahydrofolate)
Since it does not require the action of dihydrofolate reductase for its conversion, its function as a vitamin is unaffected by inhibition of this enzyme by drugs such as methotrexate
Thus can be useful in treatment of MTX overdose
A patient presents with backpain. Which feature is most suggestive of spinal canal stenosis?
– A. Pain on prolonged weight-bearing – B. Paraesthesia on weight-bearing – C. Osteoarthritic changes on X ray – D. Loss of deep tendon reflexes – E. Loss of vibration sense in feet
Answer is B.
Most common symptom = discomfort in buttock, thigh or leg on standing or walking that is relieved by rest and not produced by vascular insufficiency
• Generally relieved by lying down or sitting
• Adopting a posture of flexion at the waist, leaning over a shopping trolley/church pew/bending forward when walking (simian stance)
27 year old male presents with an 18 month history of back pain, heel pain and a swollen knee. Has restriction in spinal flexion, is HLA-B27 positive and CRP is 25.
In addition to physiotherapy, what is the most appropriate initial pharmacologic management?
A. Prednisone B. Naproxen C. Methotrexate D. Etanercept E. Salazopyrin
Answer B. If sx still persist, then D.
Which of the following cells is most important in the pathogenesis of vasculitis in temporal arteritis? A. Multinucleate giant cell. B. Macrophage. C. CD8+ T cell. D. CD4+ T cell. E. Dendritic cell
Answer is D
Which of the following cells is most likely to cause bony erosions in patients with rheumatoid arthritis? A. T-Lymphocyte. B. B-Lymphocyte. C. Osteoclast. D. Osteoblast. E. Plasma cells.
C.
Osteoblasts and stromal cells produce M-CSF and RANKL & induce proliferation of osteoclast precursors
Stimulation of cells by inflammation leads to ostecolast activation
Arthritis in which of the following joints is most suggestive of haemachromatosis? A. Knee. B. Ankle. C. Distal interphalangeal. D. Metacarpophalangeal. E. Metatarsophalangeal
D MCP
Particularly 2nd and 3rd MCP
Next text iron studies
A 49-year-old female presents with a five week history of symmetrical polyarthralgia. The following laboratory results are obtained:
(ANA) positive, titre: 1/80, pattern: speckled
(ENAs) negative
(anti-dsDNA) 7 IU/mL [0-5]
(anti-CCP) positive
Anti-filaggrin antibody positive Rheumatoid factor (RF) < 20 [0-20]
Which of the following is the most likely diagnosis? A. Rheumatoid arthritis. B. Systemic lupus erythematosus. C. Mixed connective tissue disease. D. Viral polyarthritis. E. Osteoarthritis.
A.
Anti-CCP antibodies potentially important surrogate markers for diagnosis and prognosis in RA
• More sensitive and specific than IgM RF in early and established disease
• may predict development of RA
• are a marker of erosive disease in RA
• may be detected in healthy individuals years before onset of clinical RA
- Which of the following is most likely to exacerbate
gout?
Beer Dairy products High purine vegetables Red meat Fish
Beer > wine
Fructose also a risk fractures
An 82-year-old man presents with difficulty walking due to osteoarthritis in his right hip. When prescribing a cane as a walking aide for him, the most appropriate instruction regarding use of the cane is:
Hold the cane:
A. in the right hand and advance the cane with the right leg.
B. in the right hand and advance the cane with the left leg.
C. in the left hand and advance the cane with the right leg.
D. in the left hand and advance the cane with the left leg.
E. in the right hand and advance the cane after both feet have advanced.
C.
A patient with a painful hip will usually hold stick in contralateral hand
A 56yo man presents with right knee swelling after a long walk. He has a history of obesity and psoriasis of 12 years. Right knee xray shows loss of cartilage in the medial compartment with chondrocalcinosis.
What is the cause of this man’s right knee swelling? • A. Pseudogout • B. OA • C. Gout • D. Psoriatic arthritis • E. Medial meniscal tear
Viscosity: normal • Clarity: normal • WCC: 900mm3 (<200) • Differential: 90% mononuclear • Crystals : occasional extracellular urate crystals
Gout/pseudogout is intracellular not intracellular
Answer is B
Dialysis related amyloid disease >20 years almost 100%
Bone cyst erosions, flexor tenosynovitis, carpal tunnel, erosions
Beta2-microglobulin (b2m) amyloidosis
• common and disabling complication affecting patients undergoing long- term hemodialysis or peritoneal dialysis
• Does not affect individuals with normal or mildly reduced renal function or patients with a functioning renal transplant.
• b2m is a major constituent of amyloid fibrils.
• shown to invade synovial membranes & osteoarticular sites → destructive osteoarthropathies
A year old man is on a statin (80mg simvastatin), thiazide diuretic and other medications. He presents with muscle aches and pains. His blood pressure is poorly controlled, so he is started on diltiazem 180mg controlled release formulation. Four weeks later he develops proximal weakness and muscle aches, and has noted “brownish coloured urine”. The following investigations are performed: Ix: Na 135, K 2.9, Creatinine and Ur Normal AST 150, ALT 258, CK 30 000 What is the most likely diagnosis? A. Hypothyroid myopathy B. Statin myopathy C. Polymyositis D. Diltiazem myopathy E. Hypokalaemic myopathy
B
commoner in females, the elderly, hypothyroidism and with concomitant therapy with cytochrome P450 3A4 metabolised drugs e.g. cyclosporin, erythromycin, and fibrates (particularly gemfibrozil)
28 yo woman who is otherwise well presents with Raynauds of fingers. ANA +ve 1/80 titer. The most likely diagnosis is: A. SLE B. CREST C. Systemic sclerosis D. primary Raynaud's
Answer is D
Abnormal nailfold capilloroscopy in 30 year old woman.
- Systemic sclerosis
- CREST
- Sjogrens
- SLE
- Polymyositis
Majority of patients with SSc have capillary dilatation associated with avascular areas and loss of normal capillary organization.
Answer is 1.
In which part of the vertebral column are syndesmophytes first seen in ankylosing spondylitis? • Cervical • Cervical/thoracic • Thoracic • Thoraco-lumbar • Lumbar
Thoraco lumbar
Sacroiliac joints
• sacroilitis usually first manifestation and is symmetrical and bilateral
• joints widen before they narrow
• subchondral erosions, sclerosis and proliferation on the iliac side of SI joints
• at endstage, the sacroiliac joint may be a thin line or not visible
• Clinically important: criteria for biological treatment
A 44 year old female has a 20 year history of systemic lupus erythematosus. She was previously on cyclophosphamide but is now of prednisolone and hydroxychloroquine for skin manifestations. Past history includes type II diabetes. She now presents with ventricular fibrillation and dies.
What is the most likely underlying reason for this presentation?
A. Pericarditis and tamponade
B. Coronary artery disease
C. Libman sacks endocarditis
D. Viral myocarditis
E. Coronary vasculitis
F. Antiphospholipid syndrome with large pulmonary embolus
B
Erosive disease DIP
Psoriatic arthritis
Sjogrens
Symptomatic management e.g. fake tears
A 27 year-old woman with psoriatic arthritis comes to her routine clinic appointment. She is well controlled on sulfasalazine 2g BD. At this appointment she mentions that she is keen to get pregnant in the next twelve months.
The most appropriate management of her arthritis is:
Add prednisolone 10mg daily
Continue her current treatment
Stop sulfasalazine and commence hydroxychloroquine 200mg BD Stop sulfasalazine and commence prednisolone 10mg daily
Stop sulfasalazine and treat flares with prednisolone
continue current Rx
Anti Mi 2
dermatomyositis
Anti Jo1
anti-synthetase
Management of inflammatory myopathies
Prednisone (DM>PM>IBM)
AZA/MMF/MTX
Cyclosporin/ritux
IVIG
Scleroderma skin patterns
- Below knees and hands; below knees and feet
* If upper arms, thighs, abdomen → diffuse
Increased risk of IPF and scleroderma renal crisis
Scl-70
RNA polymerase III
scleroderma renal crisis
Th/To
risk of pHTN
Is extent of skin disease predictor of severity of lung disease in scleroderma?
No
How to monitor lung function in ILD
PFT
Who to treat in ILD scleroderma?
FVC <70% or extent on HRCT 20%
Cyclosphosphamide or MMF
RA DAS score aim?
<2.6
Is triple therapy as good as MTX and Mab in RA?
Triple therapy as good as MTX/biology i.e. MTX/SSZ/HCQ = infliximab/MTX
JAK inhibitor meds
Tofacitinib.
Beware shingles, HCHOL
Abatacept is what class?
Fusion protein of CTLA4 and Fc portion of IgG1
TNF alpha meds
infliximab/etanercept/adalumimab/certolizumab
IL 6 inhibitor
Tociluzumab
IL12/23
Ustekinumab
Only for refractory CD
Vedoluzimab
integrin a4b7
RA drugs in pregnancy
HCQ, SSZ, AZA, prednisone
How to get rid of lefluamide
Cholestyramine
IL-17
sekukinumab
il-1
anakinra
drug induced lupus causes?
Procainamide, minocycline, diltiazem, penicillamine isoniazid, quinidine, methyldopa, Hydralazine, TNF inhibitor
Which antibiotic to avoid in SLE
Sulphonamides
Lupus nephritis classes to Rx
Class III (focal), IV (diffuse), V (membranous) Dont treat I(minimal),II (mesangial proliferative), VI (advanced sclerosing
SLE Rx
HCQ, pred, AZA, cyclosporin ritux
Most specific marker of SLE
anti -sm
Most useful antibody to monitor progress in SLE
Anti-dsDNA
Speckled
SLE, Sjogrens, MCTD, RA, polymyositis, scleroderma
Homogenous
SLE, MCTD, Drug induced lupus
Nucleolar
MCTD, Scleroderma
Centromere
Scleroderma,CREST
Haglund’s deformity
Exophytic area above ankle
APL in pregnancy
• APL ab +ve
o Asymptomatic: Aspirin
o Prior obstetric morbidity: aspirin + prophylactic LMWH
o Prior thrombosis: therapeutic LMWH, continue 6/12 post partum
In a patient with rheumatoid arthritis, which clinical feature is most strongly correlated with the risk of future joint erosions? A. Length of early morning stiffness. B. Number of tender joints. C. Number of swollen joints. D. Severity of joint pain. E. Amount of weight loss.
C.
A 52 year old female, has poorly controlled seropositive rheumatoid arthritis. She presents for management of an ulcer, which despite regular dressing has not healed.
What is the most likely underlying pathology for the ulcer?
A. Infection
B. Pressure
C. Vasculitis
D. Venous insufficiency
E. Neuropathic
C
HTN in gout
Among patients with hypertension, the concurrent administration of an ACEi or an ARB, particularly losartan, can minimize the diuretic-induced rise in plasma urate concentration
negative birefringement
gout monosodium urate
Rx Gout uric acid levels
Maintain serum urate concentration (<3.6 mmol/L).
If gouty tophi, aim lower <3.0
Allopurinol hypersensitivity syndrome
Erythematous rash, fever, hepatitis, eosinophilia and acute renal failure
Use febuxostat
Which of the following is most likely to involve the enthesis? A. Reactive arthritis B. Rheumatoid arthritis C. Osteoarthritis D. Pseudogout E. Ankylosing spondylitis
E
A 23 year old man presents with arthritis, tenosynovitis of his right hand and pustules on his right forearm. What is the most likely diagnosis? A. Reactive arthritis B. Ankylosing spondylitis C. Enteropathic arthritis D. Gonococcal arthritis E. Psoriatic arthritis
D
Scleroderma hand Xray findings
Radiographs of the hands in scleroderma may reveal soft tissue calcificiations (calcinosis cutis) and resorption of the distal phalangeal tufts (acro-osteolysis)- this is what is shown above. Articular erosions, joint space narrowing and demineralization are less common findings.
Adult onset Stills disease
classic triad of persistent high spiking fevers, joint pain, and a distinctive salmon-colored bumpy rash. Tests for rheumatoid factor and anti-nuclear antibodies are usually negative and serum ferritin is elevated. Use IL drugs e.g. anakinra
Which of the following is the most likely initial site of involvement in primary osteoarthritis of the knee? A. Medial tibiofemoral cartilage. B. Lateral tibiofemoral cartilage. C. Patellofemoral cartilage. D. Intercondylar cartilage. E. All of the above.
A
Knee pain experienced principally when walking downstairs is most likely to reflect pathology in which of the following knee structures? A. Medial compartment. B. Lateral compartment. C. Retropatellar compartment. D. Suprapatellar bursa. E. Lateral meniscus.
C
A 47 year old male with a 20 year history of Type I diabetes mellitus and nephropathy presents with stiffness of the upper limbs. On examination he has diffuse skin and flexor tendon thickening of the hands with no pulp loss or digital infarction. What is the most likely diagnosis? A. Limited systemic sclerosis B. Amyloidosis C. Diabetic cheiroarthropathy D. Extensive sclerosis E. Calcinosis cutis
C
Adhesive capsulitis
Pain on active movement, no pain on passive movement
When aspirating a small effusion in the knee joint, where should the needle be inserted (see below)?
A. 1 cm medial to the junction of the upper and middle third of the patella.
B. 3 cm medial to the lower pole of the patella.
C. 1 cm medial to the mid point of the patella tendon.
D. 1 cm lateral to the lower pole of the patella.
E. 3 cm lateral to the junction of the upper and middle third of the patella.
A
Which is not associated with p-ANCA?
PAN
Associations with chronic Hep C
Bullous pemphigoid
Lichen planus
Cutaneous porphyria tarda
Cryoglobulinaemia
Not associated with autoimmune thyroiditis
Behcets Disease
Behçet’s syndrome is a systemic vasculitis with an unknown aetiology, which affects small and large vessels (venous and arterial).
More than 60% of patients are HLA-B51, and there is an increased prevalence in the Mediterranean countries.
It is commonly associated with mucocutaneous manifestations (scarring oro-genital ulceration, erythema nodosum), ocular disease, gastrointestinal involvement and neurological features. Venous thrombosis is a common complication.
Test with pathergy test (reaction to non-allergic thing)
Young male, with dark urine and muscle cramps after exercise. Renal function normal, CK normal, but urine with myglobin. What is the underlying cause?
Exertional muscle cramps with myoglobinuria suggests McArdle’s disease, a glycogen storage disease. Suggest muscle biopsy for diagnosis.
