MSK diseases

Question 1

What is rheumatoid arthritis?

Answer 1

Chronic
autoimmune
systemic illness
characterised by synovial joint inflammation leading to symmetrical peripheral arthritis and extra-articular symptoms.

Question 2

In arthritis, we see chronic inflammation of synovial lining of what

Answer 2

joints, tendon sheafs, and bursa

Question 3

Synovial inflammation of tendons increase risk of what

Answer 3

tendon rupture

Question 4

What is the pattern of rheumatoid arthritis, crucially?

Answer 4

It’s symmetrical

Question 5

Which joints would arthritis tend to affect, broadly speaking?

Answer 5

smaller ones

Question 6

Risk factors for rheumatoid arthritis?

Answer 6

smoking and obesity

Question 7

When does rheumatoid arthritis most commonly develop?

Answer 7

middle age

Question 8

Which gender is rheumatoid arthritis most common in?

Answer 8

2-3 times more common in women than men

Question 9

Disease course of rheumatoid arthritis?

Answer 9

relaxing and remitting, or severe and progressive

Question 10

Positive antibodies/immunoglobulins predict worse disease. What is the autoantibody present in 70% of all rheumatoid arthritis cases?

Answer 10

rheumatoid factor

Question 11

What does rheumatoid factor antibody/immunoglobulin actually do?

Answer 11

Causes immune system activation against the patient’s own IgG, therefore systemic inflammation.

Question 12

What are the two antibodies in rheumatoid arthritis?

Answer 12

rheumatoid factor and anti-CCP antibodies

Question 13

Out of rheumatoid factor and anti-CCP antibodies, which is more sensitive and often pre-dates onset of symptoms?

Answer 13

anti-CCP

Question 14

Speed of onset of rheumatoid arthritis?

Answer 14

Varies:
Can be rapid: overnight
or
Gradual: over months

Question 15

What are the three joint symptoms of rheumatoid arthritis?

Answer 15

stiffness
pain
swelling

nb not heat or red

Question 16

On palpation of the joints, in rheumatoid arthritis, what would you find?

Answer 16

tenderness and synovial thickening, hiving them a ‘boggy’ feeling

Question 17

Which joint in the finger is rarely affected rheumatoid arthritis?

Answer 17

distal interphalangeal joint

Question 18

distal interphalangeal joint affected by arthritis is most likely due to?

Answer 18

more likely to represent Heberden’s nodes due to osteoarthritis

Question 19

rheumatoid arthritis symptoms are worse when, and improve when?

Answer 19

worse with rest, and improve with activity.
Worse in the morning therefore

Question 20

How to distinguish between symptoms of inflammatory arthritis (e.g. rheumatoid arthritis) or mechanical arthritis like osteoarthritis?

Answer 20

Inflammatory is best with activity, worse with rest.
The opposite is true for mechanical problems- worse with activity. This is a crucial point to make clear.

osteoarthritis is wear and tear

Question 21

Hand signs in advanced disease of rheumatoid arthritis?

Answer 21

thumb = z
swan like fingers
maybe ulnar deviation

Question 22

What are rheumatoid nodules?

Answer 22

Firm, painless lumps under the skin, especially on the elbows and fingers

Question 23

You see a patient with persistent synovitis. Where do you refer them?

Answer 23

Urgent rheumatology referral (to be seen within 3 weeks).

Question 24

You’ve seen a patient with persistent synovitis, and you’ve referred them for urgent rheumatology. What do you consider?

Answer 24

Consider an NSAID and arrange baseline bloods.

Question 25

What investigations would you tick when ordering a baseline blood test, for someone just presenting with rheumatoid arthritis?

Answer 25

rheumatoid factor anti CPP antibodies Inflammatory markers like CRP and ESR maybe x-rays for bone changes or ultrasound to detect synovitis

Question 26

Why would you check for ESR in bloods for rheumatoid arthritis?

Answer 26

it's erythrocyte sedimentation rate. ESR. It means how fast red blood cells in unclotted blood settle down. In inflammation, red blood cells clump closer together and settle faster.

Question 27

What is the diagnosis for rheumatoid arthritis based on? Actually think about this.

Answer 27

Clinical findings- hence why examination is so important, as well as systemic signs and blood results such as seeing antibodies anti CCP and rheumatoid factor

Question 28

What two things are used to monitor success of treatment of rheumatoid arthritis?

Answer 28

DAS28 (Disease activity score on 28 joints)- assigning points for: swollen joints, tender joints, and the ESR/CRP result and CRP

Question 29

How to manage rheumatoid arthritis initially?

Answer 29

short term steroids (oral or intramuscular)... at initial presentation.

Question 30

Treatment of rheumatoid arthritis?

Answer 30

cDMARDs such as methotrexate, leflunomide, or sulfasalazine - mono or as a combo also biologic therapies.

Question 31

You can use biologic therapies for rheumatoid arthritis. What do they cause, increase risk of, and what suffix do they tend to end in?

Answer 31

immunosuppression infection and cancer 'mab'

Question 32

How often is methotrexate given?

Answer 32

Once a week, WITH folic acid once a week (Methotrexate interferes with folate metabolism)

Question 33

Why does button-hole deformity occur in the hands for rheumatoid arthritis?

Answer 33

when extensor tendon splits

Question 34

What deviation occurs in the fingers for rheumatoid arthritis?

Answer 34

Ulnar deviation

Question 35

How are blood vessels affected with rheumatoid arthritis?

Answer 35

vasculitis, which can encourage atheromatous plaques. (cardiovascular disease)

Question 36

Commonality in cause of symptoms in skin and visceral organs in rheumatoid arthritis?

Answer 36

rheumatoid nodules

Question 37

Advanced symptoms of rheumatoid arthritis (rarely seen due to treatment)?

Answer 37

pericarditis pulmonary fibrosis pericarditis pleural effusion anaemia carpal tunnel raynauds

Question 38

Structure of articular cartilage:

Answer 38

first layer = chondroblasts which produce collagen. We also see lubricin (produced by chondrocytes) which acts as a layer for boundary lubrication. Next layer(s) = full of chondrocytes for aggrecan (attracts water) Throughout it, the collagen orientation changes. (near bone = vertical)

Question 39

Purpose of synovial fluid

Answer 39

provides nutrients and takes away waste product, to cartilage

Question 40

Main constituents of synovial fluid?

Answer 40

hyaluronic acid, and lubricin